Childhood Masturbation
Alexander K.C. Leung, M.B.B.S., F.R.C.P.C., F.A.A.P., F.R.C.P.
Wm. Lane M. Robson, M.D., F.R.C.P.C.
Introduction
asturbation is a topic
that has long perplexed
~ V and interested physicianss
and laypeople alike. &dquo;Masturba-
tion&dquo; refers to the self-stimulation
of the genitalia, often to achieve an
orgasm. The term &dquo;masturbation&dquo;
is derived from the Latin words
manus, meaning &dquo;hand,&dquo; and stu-
pratio, meaning &dquo;defilement.&dquo; Pre-
sumably, the derivation stems
from the observation that mastur-
bation is the stimulation of the
genitalia by the hand of an indi-
vidual for the purpose of sexual
gratification and is a practice that
historically has been considered
to be unhealthy.
Masturbation in children is an
almost universal phenomenon. As
long as it is not excessive and is
performed in private, masturba-
tion is considered to be a normal
and healthy activity. Masturbation
is often a concern for parents be-
cause of the long history of associ-
ated religious and cultural taboos.
Parental misconceptions about
masturbation and inappropriate
reactions to this activity may lead
to unnecessary anxiety and guilty
feelings in children and parents.
Department of Pediatrics
University of Calgary
Alberta Children’s Hospital
Calgary, Alberta, Canada
Address correspondence to: Alexander K.C.
Leung, M.D., Alberta Children’s Hospital,
1820 Richmond Road SW, Calgary, Alberta,
Canada T2T 5C7
238
(Edin), F.R.C.P. (Glasg), F.R.C.P.I.
Child-care providers are in a
unique position to educate chil-
dren and parents about normal
sexual development and to help
prevent or correct any misconcep-
tions regarding masturbation. In
spite of the prevalence of mastur-
bation, there is little written in the
pediatric literaturethis topic.
on
The purpose of this article is to
familiarize the reader with the sub-
ject and to recommend an ap-
proach to counseling parents and
children on masturbation.
Epidemiology
Approximately 90% to 94% of
males and 50% to 60% of females
masturbate at some point in their
lives. 1-4
Masturbation is practiced at all
ages and has been observed in
utero.&dquo; It is most common at about
4 years of age and again in adoles-
cence. The highest incidence is
among males between 16 and 20
years of age, of whom 88% mastur-
bate.6 In males, the incidence de-
creases after the age of 20 years,
whereas in females the incidence
increases until middle a~e.77
Masturbation is less common in
individuals with lower educational
backgrounds’ and in those with 3
strong religious beliefs.3
The frequency of masturbation
varies considerably. Some individu-
als masturbate only occasionally,
no more than a few times a year,
whereas others masturbate several
times a week.4 In general, females
masturbate less often than males.’
Etiology
Sexual arousal occurs early in
life. Penile erections in neonates
occur spontaneously during sleep
and in response to genital manipu-
lation.’ Similarly, vaginal secre-
tions in response to stimulation
have been observed in female in-
fants.’ In one study, a majority of
male infants less than 20 weeks of
age were noted to have 5 to 40
penile erections per day.9
Early random touching of the
genitalia results from the general
exploration of the body by the in-
fant. Masturbatory activity is gener-
ally initiated as a response to the
learned pleasure associated with
such touching of the genitalia. The
interest in the genitalia may disap-
pear as other aspects of the infant’s
environment are discovered.
About the age of 3 to 4 years,
the child learns that stimulation of
the genitalia will consistently pro-
vide a pleasurable sensation. Mas-
turbation may then continue as a
lifelong pleasurable experience
unless the individual is otherwise
distracted or the activity is sup-
pressed. Masturbatory activity is in-
tensified during adolescence, a
period usually associated with an
increased sex drive.
Excessive masturbation may be a
symptom of emotional deprivation
and may develop subsequent to ac-
tual or perceived withdrawal of pa-
rental affection.l° Masturbation has
been noted subsequent to parental
absence, divorce, and death, as well
as following the birth of a new sib-
ling.l° Masturbation may be used to
release anxiety or tension, particu-
larly regarding conflicting feelings
toward parents. Some children will
masturbate to comfort themselves
when they are frightened.&dquo; Frus-
tration, boredom, loneliness,
poor self-esteem, lack of peer re-
lationships, conflict with parents,
and too much pressure in school
are common causes of stress which
older children and adolescents may
try to relieve through masturba-
tion.12
Compulsive masturbation or
masturbation in public usually sug-
gests a serious emotional
more
problem. However, some children
may unknowingly masturbate in
public when they are preoccupied
or are daydreaming.&dquo;
In a small number of cases, local
genital irritation is a contributing
or indirect cause of masturbation
in preschool children, especially in
girls. 13,14 Local genital irritation
may result from tight clothes, vulvo-
vaginitis, balanitis, diaper rash, phi-
mosis, or parasitic infestation.14,15
Clinical Manifestations
The most forms of
common
masturbation are manual stimula-
tion, genital stimulation against
objects, muscular tension, and, in
adolescents and adults, genital
stimulation with the use of special
devices. 14 These methods are not
mutually exclusive. The primary
site of genital stimulation for the
majority of males is the penis and
for the majority of females is the
glans clitoris
In infancy and early childhood,
masturbation is usually practiced
by rubbing the thighs together
and, sometimes, by rocking the
body against a pillow or another
object 14 Rhythmic body move-
ments and pelvic thrusts have been
observed in older infants.&dquo; Rhyth-
mic manipulation of the genitalia
by the hand rarely occurs before
the age of 21i2years. During mastur-
bation, the child may appear to be
in a trance, with a flushed face,
glassy stare, and audible breathing.
If an orgasm develops, it may be
followed by general relaxation, pal-
lor, and sweating. 14 In some cases,
the child may appear exhausted
and fall asleep.14,17 Orgasms due to
masturbation are rare in children
less than 2~- years of age.3,lS
In older children, adolescents,
and adults, manual stimulation of
the genitalia is the most common
technique of masturbation for
both sexes. Most males masturbate
by holding the penis in their hand
and then stroking the penis up and
down or in a &dquo;milking&dquo; motion. 15
Most females masturbate by rub-
bing or massaging the clitoris or
labia with one or more fingers.
Digital stimulation of the vagina is
practiced by approximately 20% of
females.’5 The breast and nipples
may be stimulated simultaneoUSly.4
In both sexes, anal masturbation is
an uncommon form of sexual stimu-
lation.19 Masturbation in children
can be achieved by genital stimula-
tion against objects, such as by rub-
bing or pushing against a pillow,
mattress, towel, or bed cover.
Individuals who masturbate ex-
perience sexual excitement and
pleasure. In the male, this is mani-
fested as penile erection, and in
the female, as vaginal vasoconges-
tion and secretion and breast and
vulval engorgement. The sexual ex-
citement may be accompanied by
tachycardia, tachypnea, skin flush-
ing, mydriasis, and increased blood
pressure. The majority of older chil-
dren and adults can produce an or-
gasm through masturbation. 20
The first ejaculation of a male is
usually due to masturbation, rather
than to a nocturnal ejaculation (wet
dream) or CoitUS.21
Masturbation is accompanied by
fantasies in about 75% of the males
and 50% of the females who mastur-
bate.12 Both sexes may develop their
own fantasies, or they may rely on
erotic books, pictures, or films.
Most masturbatory activity is
carried out in private. Less com-
monly, males masturbate in front
of friends. Mutual masturbation
may be practiced by sexually expe-
rienced individuals.
Laboratory Findings
Plasma levels of pregnenolone,
dehydroepiandrosterone, andro-
stenedione, testosterone, and dihy-
drotestosterone are significantly
elevated in males immediately fol-
lowing masturbation. The most
marked changes are observed in the
plasma levels of pregnenolone and
dehydroepiandrosterone.22 The
plasma luteinizing hormone level re-
mains unchanged before and after
masturbation.22
Increased vaginal vasoconges-
tion, as measured by both vaginal
pressure pulse and pooled blood
volume, has been demonstrated in
females during masturbation.23
Nonspecific electrocardiographic
changes may be observed, such as in-
creases in the amplitudes of the QRS
complex, T wave, and ST segment
There are no significant or specific
changes in the electroencephalo-
gram (EEG) during masturbation.25
Some authors report low-voltage
rapid activity during the early
stages of arousal, followed during
orgasm by high-voltage paroxys-
mal, three-per-second waves which
are mixed with rhythmic muscular
discharges.26 Other authors report
finding interhemispheric asymme-
try in the parietal areas. 21
Differential Diagnosis
Masturbatory activity in infancy
and early childhood may be mani-
fested as an active stereotyped
j
239
 movement, stiffening of the body,
and staring appearance, followed
by exhaustion and sleep. These fea-
tures may be mistaken for epi-
lepsy.14,l7,28 The following points help
to distinguish epilepsy from mas-
turbation : In epilepsy, the onset is
generally abrupt, spontaneous, and
involuntary, whereas in masturba-
tion, the onset is volitionaJ.28 With
epilepsy, the child is unconscious,
whereas with masturbation, there
is no alteration of consciousness.
The rocking movement which is
characteristic of masturbation is
rarely observed during an epileptic
seizure.28 An epileptic seizure may
occur in any location, whereas mas-
turbatory activity is usually per-
formed in private .2’ Epilepsy and
masturbation may coexist. Jacome
and Risk029 reported a male patient
with generalized epilepsy whose
automatisms during episodes of ab-
sence were manifested only as com-
pulsive masturbation.
In infancy and early childhood,
masturbatory posturing may in-
volve stiffening of the lower ex-
tremities or mechanical pressure
applied to the suprapubic area,
and this may be mistaken for ab-
dominal pain.30
Complications
There is no scientific basis for
the myths that masturbation may
lead to acne, warts, hair on the
palm, poor physical health, physi-
cal deformities, deafness, blind-
ness, insanity, mental retardation,
epilepsy, impotence, sterility, sex-1
ual perversion, or homosexuality. 1
Masturbation does not interfere
with contemporary or later sexual
responsiveness. There is clinical
evidence that adolescents of both
sexes who repress their sexual feel-
ings and who never masturbate
may have subsequent difficulty
adapting to adult sexuality.9’
240
Notwithstanding the prevalence
in the developed world of a liberal
attitude toward sexuality, guilt over
masturbation still remains a signifi-
cant factor in the psychosexual de-
velopment of many individuals.&dquo;
In one study, over two thirds of
individuals with a history of mas-
turbation indicated that they felt
guilty.32 If a child feels shame, fear,
or guilt as a consequence of mas-
turbation, this may adversely affect
future sexual adjustment.33
In general, masturbation in pri-
vate is harmless. Excessive mastur-
bation, however, may interfere
with regular activities and school
work and may lead to soft-tissue
injury to the genital area.34
Management
Parents should be reassured
that masturbation is common in
children of both sexes and that
this activity is harmless. Masturba-
tion in private should be ignored
to prevent unnecessary anxiety.
Scolding, threatening, and sham-
ing are not appropriate. Overreac-
tion or punishment may lead to
increased sexual preoccupation or
regression. If feelings of guilt or
shame develop, they may carry
over into adult life and affect fu-
ture sexual adjustment.
Some parents may have religious
or moral beliefs that do not tolerate
masturbation. These parents should
be advised not to shame, frighten, or
threaten their children about mas-
turbation. These approaches may
lead to permanent emotional and
sexual difficulties. Rather, these par-
ents should employ mild types of
inhibition, such as advising their
children that their family does not
believe in such activity.ll Whatever
the religious or moral beliefs of the
parents, it is important for the par-
ents to talk openly about masturba-
tion and other aspects of sexuality
to their children. This approach will
foster a healthier attitude toward
sexuality and will open the door to
discussions about other important
topics, such as contraception1 and
sexually transmitted diseases.&dquo;
Children should receive sexual
counseling appropriate for their age.
Sexual education programs should
include information concerning
masturbation. Children should be
counseled that individuals who mas-
turbate are normal, as are those who
choose not to masturbate.
In a small number of cases, local
irritative factors, such as balanitis
or vulvovaginitis, may be a causa-
tive factor and should be treated.
Excessive masturbation may be
an indication of boredom, anxiety,
frustration, or emotional depriva-
tion and suggests a need for in-
creased attention and other kinds of
stimulation. This should be man-
aged by providing additional oppor-
tunity for social interaction and play
and by giving the child adequate
love, affection, and attention.
Masturbation in public is not ap-
propriate and suggests either a lack
of parental guidance or a signifi-
cant behavioral disorder. Children
should be taught that masturbation
in public is unacceptable behavior.
Repeated masturbation in public
suggests the need for consultation
with a child psychologist.
Conclusion
Masturbation in children is an
almost universal phenomenon.
Masturbation that is not excessive
and that is performed in private is
a normal and healthy activity.
Acknowledgments
The authors would like to thank
Ms. Kathy Campbell-Brown and
Mrs. Paula Pang for their expert
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241