1. Background
Childhood masturbation is defined as the self-stimulation of the genital area in a child, accompanied by physiologic changes, and symptoms, such as muscular contraction, flushing, sweating, and tachypnea (1). Genital stimulation is proposed to be a normal part of childhood development. Penile erection and vaginal lubrication appear soon after birth as a physiological reflex associated with bladder tension or similar events. They can also be observed in a later period of development when infants play with their genitals with curiosity and try to explore their bodies (2).
Childhood masturbation is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a psychiatric disorder (3). However, Excessive Childhood Masturbation is classified as “Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence” in International Classification of disease (ICD-10) (4).
According to the National Center on Sexual Behavior of Youth, excessive masturbation is an example of inappropriate sexual behavior in children at the age of 12 years old or younger (5).
Masturbation and other sexual behaviors are frequently related to sexual abuse (1). Kendall-Tackett et al. reported that sexualized behavior was one of the most common symptoms that characterize the majority of the children who had been the victims of sexual abuse (6).
Sexualized behavior often included excessive or public masturbation, sexualized games with dolls, tempting behavior, putting objects into the anus/vagina, desire for sexual stimulation by others, and disproportionate sexual knowledge with the child’s age. These behaviors often recur and become a central aspect of a child’s everyday life, and others worry about the child’s behavior (6).
Childhood masturbation causes parental distress of various degrees in different societies (2). In Iran, masturbation is a taboo; and the Iranian culture generally deplore the idea of children as sexual beings.
Although the concept of childhood masturbation was recognized in 1909, (7) there is little published on childhood masturbation and its predisposing factors. The results of the study by Unal showed that in children with masturbation, sleep difficulties were more frequent and breast-feeding was shorter than in controls. In 85.2% of children, the onset of masturbation was associated with a stressful life event, such as weaning, the birth of a sibling, or separation from the parents (2).
2. Objectives
The present study aimed to investigate the prevalence of pathological childhood masturbation in outpatient children and adolescent psychiatric clinic in Ahvaz. In this study, the meaning of pathological masturbation was “the activity that is excessive; interfere with child’s normal activities, the child cannot be distracted easily from it, or the activity indicates that the child is under stress about something and is trying to comfort him/herself”.
3. Methods
This is a descriptive cross-sectional study conducted over 24 months from 2015 to 2017. In this interval, 600 children with the age range of 2 - 12 years were brought to an outpatient child and adolescent psychiatric clinic in Ahvaz with different complaints.
Among these patients, the chief complaint of 67 parents was excessive masturbation in their children.Some of these children were referred by a pediatrician, gynecologist, neurologist or dermatologist. A child and adolescents psychiatrist took history about the behavioral patterns during masturbation, the situations in which masturbation was observed, the behavior start time, the length of time that each episode lasts, the rate at which the behaviors occur, and how this issue interfered with daily activities, education, and communication of the children. Mothers who had children under six years old were solely interviewed. Mothers with older children were interviewed with their children.
The psychiatrist suspected a neurological disorder, gynecological disease, metabolic disease, dermatitis referred the patient to the relevant specialist (based on the patients’ need) for a thorough examination. Also, the child and adolescents psychiatrist with a clinical psychologist watched videos of the episodes of masturbation recorded by their families (since a video could correctly diagnose childhood masturbation, parents were asked to record a video of children during masturbation). The diagnosis of comorbid psychiatric disorders was performed by the child and adolescent psychiatrist following the DSM-5 criteria.
The inclusion criteria were the age range of 2 - 12 years and completion of the informed consent by parents. The exclusion criteria were the absence of a parent or primary caregiver who had detailed information about the life of a child and his/her activities; therefore, the impossibility of taking a precise history .[a1] Two children were excluded from the study because they were brought to the clinic by their aunt or grandmother; therefore, taking a precise history was impossible.
3.1. The Study Instrument
- The clinical interview was conducted using DSM-5 by a child and adolescent psychiatrist
- Parents were asked to complete a questionnaire to obtain demographic features, including ethnicity, education, age, and birth order.
3.2. Ethical Considerations
All the parents signed a written informed consent before participating in the study; they were informed of their right to refuse from participating in the study. All the personal information was kept confidential.
3.3. Data Analysis
Data were analyzed using descriptive statistics. Statistical analyses were carried out using SPSS V. 16 software.
4. Results
Among 600 children who were brought to the psychiatric clinic with different complaints, 65 had pathological masturbation. This means the prevalence of pathological masturbation was 10.8% in the clinical setting.
The mean age of children with pathological masturbation was 5 years and 7 months (± 2 years and 3 months). Of these children, 55.4% were girls and 44.6% were boys. Frequencies of the participants’ demographic features are listed in Table 1. Self-stimulation started in a girl after urethral infection and in a boy after constipation. One girl started to masturbate after watching a porn movie.
Table 1.Demographic Features of Children with Pathological Masturbation (N = 65)
| Frequency (%) or Mean ± SD | |
|---|---|
| Mother education | |
| Diploma | 15 (23.07) |
| Associate degree | 13 (20) |
| Bachelor | 37 (56.92) |
| Father education | |
| Diploma | 10 (15. 38) |
| Associate degree | 24 (36.92) |
| Bachelor | 31 (47.69) |
| Birth order | |
| Firstborn | 32 (49.23) |
| Second child | 27 (41.53) |
| Third child | 6 (9.23) |
| Mother age | 33.32 ± 4.06 |
| Father age | 36.75 ± 4.22 |
The most common behaviors during masturbation were genital manipulation with hand, and rubbing the genitalia against other objects. Other behaviors included water pressure, rhythmic contraction and relaxation of thigh muscles, sleeping on stomach and genitalia, during wearing tights, knocking genital to the wall (Table 2).
Table 2.Behaviors During Masturbation (N = 65)
| Behaviors during masturbation | Frequency (%) |
|---|---|
| Genital manipulation with hand | 38 (58.46) |
| Rubbing of the genitalia against other objects | 12 (18.46) |
| Genital manipulation with hand / rubbing against other objects | 4 (6.15) |
| Masturbation with water pressure | 4 (6) |
| Masturbation while wearing tights | 1 (1.53) |
| Knocking genital to wall and sleeping on stomach | 1 (1.53) |
| Rhythmic contraction and relaxation of thigh muscles | 3 (4.61) |
| Sleeping on stomach and genitalia | 2 (3.07) |
Parents reported the situations in which their children masturbated based on time, place, or emotional state. As can be seen, 33.84% of children were reported to masturbate most of the time. The most common emotional states before masturbation were boredom (23.07%) and then agitation (12.3%). And the most common location was in the toilet (6.15%) (Table 3).
Table 3.The Situations in Which Masturbation Was Observed
| The Situations in Which Masturbation Was Observed | Frequency (%) |
|---|---|
| Based on time | |
| Often/Most of the time | 22 (33.84) |
| Bedtime | 8 (12.30) |
| When the child is alone /bedtime | 10 (15.38) |
| The parent did not emphasize on a specific time | 25 (38.46) |
| Based on location | |
| In toilet | 4 (6.15) |
| In front of the television | 1 (1.53) |
| In school | 1 (1.53) |
| The parent did not emphasize on a specific location. | 59 (90.76) |
| Based on emotional states before masturbation | |
| Excitement (When the child is excited) | 57.69) |
| Agitation (When the child is agitated) | 8 (12.30) |
| Boredom (When the child is bored) | 15 (23.07) |
| Fear (When the child is afraid) | 2 (3.07) |
| Anxiety (When the child is anxious) | 1 (1.53) |
| Tired (When the child is tired) | 1 (1.53) |
| No emotional state was reported | 33 (50.76) |
In 76.88% of children, pathological masturbation co-occurs with other psychiatric disorders. The most prevalent psychiatric disorder was ADHD with comorbid psychiatric disorders; ADHD and anxiety were the second and third, respectively (Table 4).
Table 4.Comorbid Psychiatric Disorders with Pathological Masturbation
| Comorbid Disorders | Frequency (%) |
|---|---|
| Anxiety | 10 (15.38) |
| Attention Deficit Hyperactivity Disorder | 16 (24.61) |
| ADHD with comorbid psychiatric disorders (including anxiety, communication disorder, LD, Tic, OCD and mood disorder) | 21 (32.30) |
| Obsessive-Compulsive Disorder | 1 (1.53) |
| Mental Retardation | 1 (1.53) |
| Depression | 1 (1.53) |
| None | 15 (23.07) |
5. Discussion
The purpose of the present study was the pathological analysis of childhood masturbation. According to our results, 10.8% of participants had pathological masturbation.
The children stimulated their genitals more commonly by hand, rubbing the genitalia against other objects and water pressure. The less common ways of masturbation included masturbating while wearing tights, knocking genital to wall, sleeping on stomach and genitalia, rhythmic contraction, and relaxation of thigh muscles. This finding is consistent with previous studies (10-14), even though the studies are somewhat different. In the present study, our subjects were in the age range of 2 - 12 years; however, most previous studies were about infantile self-stimulation. For example, Hansen and Balslev (10) reported some distinct patterns of hand activities in infantile masturbation, including grasping of toys, furniture or clothing, chorea-like “piano playing” hand movements, pressure over the diaper/genital region, and bimanual manipulation of items.
Other features of masturbation in infants were unusual apparent dystonia (11), rocking and adducting thighs (12), sitting with legs crossed over, rhythmic contraction and relaxation of thigh muscles accompanied by pelvis rocking movements (13), stiffening legs and made rubbing motions, and stereotypical movements when sitting (14).
Episodes of masturbation accompanied by distance and withdrawal (14), grunting, scratching or squeezing chest and staring (11, 14), irregular breathing (12, 13), tongue licking, lip-smacking, eye-rolling, and shakiness (11, 12), facial flushing (13, 14) diaphoresis (11, 13), pallor and giggling (11). Masturbation did not involve genital manipulation with hand in none of the mentioned studies (10-14).
In our study, 33.84% of children were reported to masturbate most of the time. Others masturbated when they were exited, agitated, bored, afraid, anxious, or tired. Some case reports showed that infants masturbated when they were upset (12) angry, anxious (15), or stressed (14).
Childhood masturbation is sometimes a mechanism to cope with negative emotions and the children attempt to comfort themselves by masturbation when they are stressed about something (2). Our findings indicated that 76.88% of children with pathological masturbation have comorbid psychiatric disorders, including ADHD, anxiety, communication disorder, LD, tic, OCD, mood disorder, and MR. Unal found that 52% of samples with childhood masturbation have comorbid disorders, including Oppositional Defiant Disorder (ODD), ADHD, pica, encopresis, nocturnal enuresis, sleep disorder, and conduct disorder (16). This difference between two studies may be due to different definitions of pathological masturbation, features of subjects, or methodological differences in the diagnosis of psychiatric disorder.
Schoentjes et al. reported that internalizing and externalizing behavior scores on the Child Behavior Checklist (CBCL) is significantly associated with sexual behavior. Children with serious behavioral and emotional problems tent to show a broader range of behaviors, including excessive sexual behavior on the CBCL (9). It is also probable that, comorbidity of psychiatric disorders in children, prevent the effective parenting by parents.
Some children masturbated when they were bored or alone. This is consistent with the studies described self-stimulation in children with a severe lack of external stimulation (8, 17). The most common situations in which children are likely to masturbate included in front of the television, in the toilet, and bed. In the study conducted by Nechay et al. (2004), masturbation occurred in any situation in some children. The car seat was the most common specific location followed by sleeping, boredom, watching television, and being in a baby walker. The least common situations were lying on the floor, being in the high chair, and during nappy changing (11).
In our study, self-stimulation started in one girl after urethral infection, which confirms that local irritation in the genital area can initiate or maintain masturbation (18). Vulvovaginitis, urinary tract infections, or dermatitis cause perineal discomfort and may exacerbate the masturbatory behavior but may also be the result of the behavior. In these cases, an exact genital examination should be performed, and medical therapy should be performed if need be (19).
One boy started to masturbate after constipation, failure to control bowel, and anal surgery. Unal also reported that 36.1% of children started to stimulate their genitals after a genitourinary disease, such as urethral infection, parasitic disease, or nappy dermatitis (2).
One girl started to masturbate after watching a porn movie. In this regard, sexual behavior was found to be associated with parental attitudes toward sexuality (20, 21). It has been reported that more explicitness, honesty, and disclosure about this issue in the family are related to more sexual behaviors in children (20, 21). In terms of gender differences, our findings indicated that the number of girls who were brought in was more than boys (55.4% versus 44.6%). Girls also were the subject of reports more frequently (10, 12-15). These sex differences could be due to the anatomical differences or social and cultural factors (2, 15).
In the current study, most of the children’s mothers had bachelor’s degrees (the highest educational level in this sample). The finding was similar to previously published studies, finding the sexual behavior was related to maternal education (9, 20). Educated mothers probably felt more comfortable with report their children’ sexual behavior or probably because they were more observant of their children (20).
In conclusion, low awareness of specialists can cause anxiety in parents and unnecessary examinations on children. Correct diagnosis of childhood masturbation could happen by awareness, a precise history, and watching a video of the behavior.
Awareness about this problem, its behavioral patterns, the situations in which masturbation occurs, and its comorbid disorders can facilitate the diagnosis of the problem and prevent the unnecessary tests and treatments. Physical examination is important because local irritation in the genital area could be involved in the initiation or continued masturbating.
5.1. Limitations
The subjects were selected by convenience sampling; therefore, the findings should be generalized to other groups with caution.
