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Eur J Pediatr (2008) 167:11111117

DOI 10.1007/s00431-008-0766-2


Practical approach to childhood masturbationa review

Charita Mallants & Kristina Casteels

Received: 23 February 2008 / Accepted: 14 May 2008 / Published online: 25 June 2008
# Springer-Verlag 2008

Abstract The aim of this article is to review the literature

for information that could guide the clinical practitioner in
the assessment and management of childhood masturbation.
The boundary between normal and abnormal or deviant
masturbation in children remains unclear. Besides the link
with sexual abuse, other environmental factors and individual factors, as well as psychiatric disorders, are
mentioned in relation to masturbation and sexual behaviour
in general in children. However, evidence-based information is missing and, therefore, a safety management
approach is advised when a clinician is confronted with
childhood masturbation. We conclude that normal psychosexual development, as well as environmental and individual factors, should be considered in the assessment and
management of childhood masturbation.
Keywords Childhood masturbation . Normal sexual
behaviour . Psychiatric problems . Epilepsy . Abdominal pain
Childhood masturbation
Child Sexual Behaviour Inventory
DSM-IV Diagnostic and Statistical Manual of Mental
Disorders4th edition
World Health Organization
C. Mallants
Department of Child and Adolescent Psychiatry,
University Hospital Gasthuisberg,
Herestraat 49,
3000 Leuven, Belgium
K. Casteels (*)
Department of Paediatrics, University Hospital Gasthuisberg,
Herestraat 49,
3000 Leuven, Belgium



International Statistical Classifications of

Diseases and Related Health Problems
(WHO 1992, 1993)
Child Behavior Checklist

In clinical practice, one is sometimes confronted with
parents who are worried about the masturbatory activity of
their children and seek advice. Childhood masturbation
(CM) is defined as self-stimulation of the genitalia in a
prepubescent child [19]. Most information on CM is found
in case reports and in studies on normal sexual behaviour,
using questionnaires filled in by parents or teachers, or
retrospective self-reports [10, 18, 20, 23, 29]. The Child
Sexual Behaviour Inventory (CSBI), first described by
Friedrich in 1991, has often been used to measure and
describe sexual behaviours in children and for the assessment of sexually abused children [3, 9]. However, there is
little epidemiological information on normal childhood
sexual behaviour. Comparative studies are hindered by
cultural and time differences. This lack of information
makes it difficult for the clinical practitioner to assess CM.
In this article, the literature is reviewed in order to guide
the clinician in the assessment and management of
childhood masturbation.

Review of the literature

Prior to the 20th century, masturbation was commonly
held to be the progenitor of neuropsychiatric disorders. In


the psychoanalytical view of Sigmund Freud, masturbation was believed to contribute to neurasthenia and
hysteria. As late as 1912, he maintained that masturbation
resulted in organic and psychic harm. Felix Gattel, a pupil
of Freud, recognised in 1898 that masturbation was
common in young girls. This entity, however, was
neglected for almost a century [8, 12, 21]. With the
increasing awareness of sexual abuse in the 1980s and
1990s, one has focussed predominantly on the negative
expressions of sexual behaviour of children [17]. Nowadays, the attitude towards the sexuality of children is more
relaxed [5].
Definition and clinical features
CM is defined as self-stimulation of the genitalia in a
prepubescent child [19]. It is not included in the DSM-IV,
the Diagnostic and Statistical Manual of Mental Disorders
(4th edition) of the American Psychiatric Association [2],
which means that it is not classified as a (specific)
psychiatric disorder. The WHO places (excessive) CM
under the title Other specified behavioural and emotional
disorders with onset usually occurring in childhood and
adolescence (F98.8) in the ICD-10, the International
Statistical Classification System of Diseases and Related
Health Problems [35].
CM can resemble the masturbatory activity of adults,
with associated physiologic changes and accompanying
symptoms, such as sweating, flushing, tachypnoea and
muscular contraction, but these changes are less well
recognised in infants and toddlers. In very young children,
CM often does not involve manual stimulation of the
genitalia, which hampers the differential diagnosis. Common features of CM in infants are: (1) episodes of
stereotyped posturing of the lower extremities and/or
mechanical pressure on the perineum or suprapubic area,
(2) associated intermittent (quiet) grunting, irregular breathing, facial flushing and diaphoresis, (3) variable duration of
the episode (lasting from a few seconds to several hours)
and variable frequencies of episodes (ranging from once in
a while to almost continuously), (4) no alteration of
consciousness, (5) cessation with distraction, (6) the
episodes cannot be explained by abnormalities on physical
and other diagnostic (technical, laboratory) examinations
[36, 37].
CM in infants and toddlers has often been mistakenly
attributed to abdominal pain, epilepsy, paroxysmal dystonia
or dyskinesia, and prompted unnecessary diagnostic tests
and medical treatments [7, 36]. Misdiagnosis seems to be
more likely when the infant seems unhappy during the
activity or when the infant stares and makes rhythmic
movements resembling epilepsy [23]. The stereotyped

Eur J Pediatr (2008) 167:11111117

posturing and the pressure applied in the suprapubic area

often suggest abdominal pathology.
A lack of awareness by the clinical practitioner could
result in anxiety for the parents and unnecessary investigations for the child. The diagnosis of CM, thus, depends
upon awareness, a careful interrogation and video recording. One of the most important features of CM is that the
child stops if he/she is distracted [4].
Sometimes, masturbation can co-occur with a somatic
problem. Excessive masturbation after epilepsy surgery and
in mesial temporal lobe epilepsy is described [24]. A good
physical examination also remains important because local
irritation in the genital area can initiate or maintain
masturbation [37]. In the study of nal on predisposing
factors in CM, 22 children (36.1%) started to masturbate as
a reaction to a genitourinary disease such as urethral
infection, parasitic disease or nappy dermatitis [33].
Normal psychosexual development and childhood
Although there are no major changes in physical sexual
development between birth and puberty, the psychosexual
development begins in infancy [9]. Children often explore
and experiment in their prepubescent years, in contrast to
what the psychoanalytical tradition initially argued [18]. An
infant starts to explore the world around him, as well as his
or her own body. The discovery of certain pleasurable areas
can be fascinating and can lead to masturbation because a
young child reacts to instinctual drives and looks for
pleasure [28].
In a study of Friedrich, the frequencies of a lot of
different sexual behaviours in 1,114 2- to 12-year-old
children were rated by their mothers (by means of the
CSBI and the CBCL). Friedrich excluded children with a
history or suspicion of sexual abuse in order to compose a
normative sample. His results were consistent with earlier
research and showed that a broad spectrum of sexual
behaviours appears in children with varying frequencies.
Self-stimulation is one of the most frequently seen sexual
behaviours (Table 1). More intrusive behaviours are rather
rarely seen in normal children. Sexual behaviour also
shows an inverse relationship with age, with the overall
frequency peaking at year 5 for both boys and girls. After
this age, there is a decline in overt sexual behaviour for
both sexes. This decline does not seem to be a continuous
phenomenon, but seems to occur in phases, corresponding
to preschool years (25 years), middle childhood (6
9 years) and prepuberty (1012 years). This can be
explained by socialisation: an infant learns to adapt to the
social and cultural norms. Normally developing children
learn to become discrete and selective in the display of

Eur J Pediatr (2008) 167:11111117


Table 1 Frequencies of some sexual behaviours for the three age groups in boys and girls [10]
25 years old

Touches sex parts in public

Touches sex parts at home
Masturbates with hand
Masturbates with toy/object
Rubs body against people

69 years old

1012 years old













certain behaviours. Friedrich labels behaviour as more

developmentally related if it has been reported by at least
20% of the respondents (e.g. touching sex parts at home
is more developmentally related for 25-year-olds; very
interested in opposite sex is more developmentally
related for 1012-year-olds) [9, 10].
So, CM is a common and developmentally related
behaviour. Overt CM, however, can be labelled as normal
in 25-year-olds, but should diminish with increasing age.
Epidemiology of masturbation
As already stated, masturbation belongs to the normal
spectrum of sexual behaviours in children and may be
observed at any age in childhood [10, 29]. There is one
published case of masturbation in utero and, in the
literature, there are several reports on infantile masturbation
[7, 22]. There seems to be a gradual rise in masturbation in
the prepubescent years, from about 10% at the age of 7 to
about 80% at the age 13 [26]. Masturbation occurs in 90
94% of males and 5060% of females at some point in their
lives [19]. However, general conclusions on sex differences
concerning CM are difficult to form [33]. Girls are more
frequently the subject of case reports, but social and cultural
factors (and, thus, referral bias) and anatomical differences
may play a role in these reported sex differences [7, 33, 37].
Solitary masturbation is more common than masturbation in
a group or dyadic masturbation [18].
Normal versus abnormal childhood masturbation
The term normal behaviour can have several meanings:
statistical normality (behaviour that appears in a general
population), behaviour that promotes health or, at least,
does not harm the well-being or health of an individual.
Normative behaviour indicates what is considered to be
the norm in a given society, culture or group. Terms such as
abnormal, pathological and problematic are used to
describe behaviour which indicates that something has
happened to disrupt or change expected sexual behaviour or
the natural development process. The term deviant is

more frequently used to describe sexual behaviour outside

social norms or legislation [15].
One could wonder if CM is always normal and
developmentally related or if there are conditions in which
CM has to be considered as abnormal.
First of all, it has to be mentioned that the definition of
normal sexual behaviour depends on the social, cultural and
familial context, which hampers distinguishing between
normal and abnormal sexual behaviour in children [13].
The sexual behaviour in a particular child has to be
compared with a representative normative sample (for a
review of normal sexual behaviour in children, we refer to
the publications of Friedrich et al. (1998) for an American
sample and to Schoentjes et al. (1999) for a Dutch-speaking
sample [10, 29]).
Observable CM or masturbation in public, for instance,
can be considered as normal in an infant or toddler, but not
for a child at the age of 12. The child should have learned
the culturally appropriate rules by then, unless there is an
underlying individual-bounded, pedagogical or other explanation [10, 29].
Heiman et al. investigated the considerations on normal
sexual behaviour in children in four professional groups
who, in some way, come into contact with questions of
sexual behaviour. All groups judged sexual acts involving
oral, vaginal or anal penetration of children before puberty
to be abnormal behaviour [13]. Schoentjes et al. performed
a study in a representative, normative sample of 917 2- to
12-year-old Dutch-speaking schoolchildren. They found
that a number of behaviours are very unusual and rarely
endorsed in the three age categories. They are best labelled
as intrusive, aggressive (e.g. with pain) or more imitative of
adult sexual behaviour (e.g. puts mouth on other child/
adult sex parts, puts tongue in mouth when kissing,
puts objects in vagina or rectum) [29]. We refer to
Table 2 for the figures. In the literature, one proposes to
consider this behaviour as abnormal [17, 20].
Also, excessive or obsessive CM is considered as
abnormal. The term excessive is not clear-cut defined
in the literature and still leaves much space for personal
interpretation. Lngstrm et al. studied the genetic influen-


Eur J Pediatr (2008) 167:11111117

Table 2 Rank order of endorsement frequencies for shared items of the CSBI versions [29]


CSBI [29]
Schoentjes et al. 1999

CSBI [9]
Friedrich et al. 1991

CSBI [10]
Friedrich et al. 1998


Puts mouth on another child/adult sex parts

Ask others to engage in sex acts
Puts objects in vagina/rectum
Masturbates with object
Imitates the act of sexual intercourse
Puts tongue in mouth when kissing





ces on problematic masturbatory behaviour. He defined

problematic CM as a score of 1 or more out of 4 on a
masturbatory problem index constructed from the summed
scores of CBCL items plays with own sex parts in public
and plays with own sex parts too much [16]. Lindblad et
al. found, in a normative sample of 2- to 6-year-old children
at a day care centre in Sweden, that 1.2% of the children
masturbated sometimes and 2.4% often or daily [20]. Up to
now (as far as we know), there is no hard evidence for a
negative outcome (e.g. evolution to a (psychiatric) disorder
or a pathological development of the child etc.) of
excessive/obsessive CM. However, excessive CM is seen
in sexual abuse [14]. Case reports have described infants
who masturbated almost continuously but, over time, the
masturbatory activity diminished and these children developed normally [7]. nal re-examined his CM group after 2
years (34 girls and 16 boys; mean age at the time of study:
48.724.5 months): 39 children (78%) had completely
recovered and 11 children (22%) continued to masturbate.
He found that children who began to masturbate earlier and
masturbated more frequently continued to masturbate [32].
This finding is confirmed in the study of Casteels et al.: five
girls who started to masturbate in their first year of life were
re-examined after 4 years. One of them still masturbated
frequently (when bored or tired), two others from time to
time (when stressed) and one had completely stopped.
Psychomotor development was normal after 4 years [4].
Relationship of childhood masturbation to psychiatric
and developmental disorders
As mentioned before, CM is, in the first place, developmentally related behaviour. However, children with an
interfering problem develop interest towards the genital
area earlier than expected [33]. nal studied predisposing
factors in CM in Turkey (61 CM children versus two
control groups consisting of 61 age- and gender-matched
children of the outpatient clinics and 43 biological siblings
of the study group children). In children with CM, sleep
difficulties were more frequent (p<0.001) and breastfeeding
was used for a shorter period than in controls (p<0.05). A
specific event associated with the beginning of CM was

reported in 52 children (85.2%). This was a stressful life

event, such as weaning, the birth of a sibling or separation
from the parents in 30 children (49.1%). Masturbation in
these children seems to be a regulating mechanism to
canalise negative emotions. Indeed, other case reports
described infants who masturbated when they were angry,
anxious or bored [7]. Self-stimulation is also described in
children with a severe lack of external stimulation, such as
organically impaired or psychotic children, or some
orphanage children [19, 28]. Family stress and the lack of
affection fostered more self-stimulation in three of the five
patients described by Fleischer and Morrison, but not in the
CM children of Casteels et al. [4, 7].
CM sometimes seems to have a function, namely, a
mechanism to cope with negative emotions. Does this mean
that CM is seen more often in children with emotional
problems? Schoentjes et al. found, in their normative
sample, that internalising behaviour scores (e.g. anxiety,
depression) as well as externalising behaviour scores (e.g.
aggression) on the CBCL1 is significantly related to sexual
behaviour (CSBI) and each accounted for about 10% of the
variance (respectively, F=85.4, R2=0.096, P<0.00001, and
F=124, R2=0.133, P<0.00001). This suggests that children
with serious emotional or behavioural problems tend to
exhibit a broader range of behaviours, including excessive
sexual behaviour. The authors advise clinicians who are
confronted with unusual sexual behaviours in children,
such as intrusive, aggressive or excessive sexual behaviour,
to look for an underlying behavioural or emotional problem
in that child [29].
Lngstrm et al. studied the relative importance of
genetic and environmental factors for problematic masturbatory behaviour among non-referred pre-pubertal twins
(401 monozygotic and 248 dizygotic same-sex twin pairs

The CBCL (Achenbach Child Behavior Checklist) is a widely used

screening measure of childrens behaviour. The version for 2- to 3year-olds has 99 items and the version for 4- to 18-year-olds has 113
items. A 3-point scale is used and the child is rated by his parents over
the previous 6 months. The CBCL assesses internalising (depression,
anxiety, somatic concerns and withdrawn behaviour) and externalising
(aggression, delinquency and hyperactivity) behaviours [1].

Eur J Pediatr (2008) 167:11111117


aged 79 years). He confirmed that the prevalence of

problematic child masturbatory behaviour was low and was
associated with other emotional and behavioural problems.
The degree of problematic child masturbatory behaviour
resemblance was higher within monozygotic twin pairs as
compared to dizygotic same-sex twin pairs. Model fitting
indicated that genetic factors substantially influenced the
studied behaviours (77%, 95% CI=996%), although the
family environment also played a role [16].
In one study on the clinical outcome of CM, 52% of the
CM sample had psychiatric co-morbid disorders, such as
oppositional defiant disorder, pica, encopresis, nocturnal
enuresis, sleep disorder, conduct disorder and attentiondeficit and hyperactivity disorder [32]. However, until now,
there are no studies that have examined a possible
correlation between (abnormal) masturbation in children
and (specific) psychiatric disorders. This is, however, an
important issue because there is a possibility that sexual
problem behaviour may persist from childhood into
adulthood and can even develop into sexual delinquency.
Neurological or psychiatric disorders with, e.g. decreased
impulse control or obsessive-compulsive personality traits
could influence the development of problematic sexual
behaviour [16].
Children with autism or mental retardation are more
susceptible to self-stimulatory behaviour. Wing [34] suggested that masturbation in young children is seen more
often in children with autism than in normal infants.
Children with autism can also exhibit socially unacceptable
sexual behaviours because the core features of autism can
hinder the normal socialisation process [25]. Mentally
retarded children are also an exception concerning normal
socialisation: the stages of their psychosexual development
may be reached at a later chronological age [30].
Abnormal CM is not included in the DSM-IV as a
psychiatric disorder, and there is no evidence available for a
meaningful discriminative validity for this diagnosis [2,
27]. CM has to be considered as a normal and developmentally related sexual behaviour in children. However,
age-inappropriate public CM and excessive/obsessive,
intrusive, aggressive and adult-imitative forms are very
uncommon in a normal population and are, therefore,
considered as abnormal, and also because a significant link
is seen between abnormal CM and other emotional and
behavioural problems, such as sexual abuse.

examined 45 different studies on sexual abuse and found

that, although there is no single symptom that characterises
the majority of sexually abused children, sexualised
behaviour is one of the most common symptoms. One in
three of the children who had been the victims of abuse
showed no symptoms at all. Sexualised behaviour refers to
expressed and often recurring sexual behaviour which takes
over other activities and becomes a central aspect of a
childs everyday life and to which others react with
concern: it often involved excessive or public CM,
sexualised games with dolls, seductive behaviour, inserting
objects in the anus/vagina, sexual knowledge not commensurate with the childs age and desire for sexual stimulation
by others [14]. Sexually abused children have higher scores
than normative controls on the Sexual Problems Scale of
the CBCL [3]. Case reports and controlled studies also
showed that sexually abused victims exhibit more inappropriate sexual behaviours than physically abused children
and non-abused psychiatrically hospitalised children [3, 6].
Sexually abused offenders tend to have engaged prematurely in masturbation, around 2.5 years earlier than the
non-abused offenders. Masturbation starts less than 1 year
after the sexual abuse [31]. It also has to be noted that, in
most cases of sexual abuse, there are no abnormal physical
findings [3].
Besides sexual abuse, other environmental factors should
also be taken into account. Mothers with a higher
educational level seem to report more sexual behaviour in
their children, maybe because they feel more comfortable
with it or because they are more observing [10, 29]. On the
other hand, family stress may impair the parents ability to
provide affectionate (physical) contact with their child,
which, in turn, may foster more self-stimulation in the
child. Family nudity and sexuality is also related to greater
sexual behaviour in children at all age levels, probably
because of the greater openness, honesty and disclosure
about this subject [9, 10]. In the normative sample of
Schoentjes et al., separated and divorced parents reported
significantly higher levels of sexual behaviour in their
children, but this relationship did not account for more than
1% of the explained variance [29].

Correlation with environmental factors

Assessment of childhood masturbation

Similar to other areas of child development, sexual

behaviour is influenced by environmental factors, at the
level of the society as well as at the level of the family.
Masturbation and other sexual behaviours are frequently
associated with sexual abuse [17]. Kendall-Tackett et al.

The diagnosis of CM is especially difficult to make in very

young children. When parents seek advice for the strange
behaviour of their child, the clinician should include CM in
his/her differential diagnosis. A careful interrogation of the
behaviour and video recording can determine the diagnosis

Guidelines for the assessment and management

of childhood masturbation


Eur J Pediatr (2008) 167:11111117

and prevent further anxiety for the parents and unnecessary

investigations for the child. One of the most important
features of CM is that the child stops if he or she is
distracted [4].
Once the diagnosis is made, the meaning of this
behaviour should be explored because this will guide the
management of a particular child. In practice, a good
assessment of CM should include a thorough interrogation
of the childs development, with special attention devoted
to the regulation of sleep, feeding, affective state and
behaviour, and of symptoms of genitourinary problems.
Environmental factors such as cultural practices, family
history, infantparent relationship, sibling relationships and
current environmental stresses should be assessed. A good
physical examination remains important in order to exclude
local irritation and, if present, signs of sexual abuse.
Age-inappropriate public CM and excessive/obsessive,
intrusive, aggressive and adult-imitative forms are very
uncommon in a normal population and are, therefore,
considered as abnormal, and also because a significant link
is seen between abnormal CM and other emotional and
behavioural problems, such as sexual abuse. Special
attention has to be paid in these cases.
We refer to the following for guidelines for the
interpretation and consecutive management of CM:

conversation on how to pay more attention to the

b. When the child masturbates when bored, interesting/
educative toys and (related) activities can be offered.
4. Since there is no significant causal relation between
CM and sexual abuse, not all children should be further
investigated by a forensic team. However, the absence
of physical findings does not prove the absence of
sexual abuse; the clinician should be aware of this.
Only children who exhibit overall sexualised behaviour
and who show inappropriate sexual behaviours should
be referred. Evidence or suspicion, based on the
interrogation, also is an indication for referral.
5. CM, in combination with other emotional and/or
behavioural problems, or CM in a child that does not
function well (e.g. at school, socially, developmentally), is best referred to a psychiatrist or psychologist.
Schoentjes et al. advise clinicians who are confronted
with unusual sexual behaviours in children, such as
intrusive, aggressive or excessive sexual behaviour, to
look for an underlying behavioural or emotional
problem in that child.

1. Medical conditions that predisposes to CM should be

assessed and treated, e.g. sleeping problems, insufficient breastfeeding, genitourinary problems etc.
2. If public CM is inappropriate for age, the clinician
should explore why this child has not yet adapted to the
social rules (socialisation):

When there is no evidence of other problems, the clinical

practitioner can focus on parental education and guidance.
This helps the parents change from viewing their childs
behaviour as evidence of disease to considering it as a
harmless, non-painful habit. The term masturbation may be
offensive to parents who are not familiar or comfortable with
the concept of sexuality in infants and prepubescent children.
Referring to the episodes as self-stimulation or gratification may be more acceptable in such families [23, 36].
Attempts to stop the behaviour immediately are likely to
be frustrating and prohibition or punishment of the
behaviour tends to reinforce it [11]. It is better to ignore
this behaviour or to distract the child during his or her
masturbatory activity [7, 33]. When possible, the child
should also receive sex information, appropriate for their
age. In this way, he/she will learn what is socially accepted
and what is not. Although (overt) CM often ceases
eventually spontaneously, further follow-up is advised.

a. Is it a parenting (pedagogical) problem? Did the

parents teach their child how to behave in a socially
acceptable way? Did they give sexual education?
b. Does the calendar age fit with the mental age of the
c. Is there a reason why the child does not understand/
comprehend appropriate social behaviour or why
the child is more susceptible to compulsive behaviour (e.g. autism)?
Psycho-education should be given, if necessary, by an
expert in mental retardation or autism.
3. Assessing the pedagogical and affective climate of the
a. When the presence of environmental stresses is
followed by (a rise in) CM, it can be seen as a way
of canalising negative emotions. Psycho-education
can then be an opportunity for parents to help their
child to cope in another way with these negative
emotions (anxiety, anger, unhappiness). A lack of
parental attention as an underlying cause can open a

Management of childhood masturbation

Summary and conclusion

The boundary between normal and abnormal/deviant
childhood masturbation (CM) remains unclear, as well as
the relationship between abnormal/deviant CM and psychopathology. In the past, CM was linked too often to
sexual abuse. Other environmental factors, such as depri-

Eur J Pediatr (2008) 167:11111117

vation, were mentioned, but individual factors were rarely

highlighted. More empirical information on a cultural
normative sample of CM and the correlation between CM
and psychopathology is needed to guide the clinician in his
or her assessment and management of CM. Until more
information is available, a safety policy is recommended, in
which environmental and individual factors are taken into
account during the assessment of CM. When there are
arguments for co-morbid problems, the child should be
referred to a child psychiatrist or a multidisciplinary team.
If the CM seems to be a solitary problem, the clinical
practitioner can reassure the parents and give appropriate
advice and guidance.

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