Patient Presentation
A 3-year-old female came to clinic for followup after seeing an urgent care provider for possible urinary tract infection 3 days previously. The parent had complained that the child had been putting her hands in her genital area more frequently or “holding herself.” The provider had noticed some vulvar and vaginal irritation and had started her on antibiotics for possible urinary tract infection. Her mother had continued to see the behavior and was concerned. During the visit the child sat on a child-sized chair and would put her hand in her genital area and did some rocking back and forth. The mother said that this was the behavior she was worried about and had also videotaped it. The video showed the child at a table during a meal performing the same behavior. The pediatrician noted that the child did not seem distressed or worried when performing the behavior. The mother agreed and said that she seemed calmer. The mother noted that she was always aware/awake during the episodes as well and would stop the behavior her name was called out, a hand was put on her arm or otherwise distracted. The mother denied any concerns for child maltreatment. The past medical history was negative for any renal problems and the family history was negative for genital or renal problems. The review of systems showed no specific urinary frequency or dysuria, fever, or malodorous urine or vaginal discharge. Stooling was normal.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. She had some mild vaginal irritation. The hymen was intact and no other lesions including bruises or rashes were noted in the genital area, abdomen or legs.

The diagnosis of vaginal irritation and childhood masturbation was made. “It can be difficult to tell if there was irritation which started her touching herself which then continued, or if she was touching herself which caused some irritation,” the pediatrician explained. “Either way, improving her hygiene will help the irritation,” she explained. The pediatrician also went on to explain the normal self exploration and stimulation that young children perform, and how the mother could explain to the child that this is normal but people don’t do this in public. The antibiotics were also stopped.

Discussion
“Childhood masturbation (CM) is defined as self-stimulation of the genitalia in a prepubescent child.” CM is normal sexual behavior and can be noted at all ages including infancy. It becomes very common after puberty. It is one of the most common sexual behaviors. CM can resemble the same adult masturbatory activity including flushing, sweating, muscular contracting and breath holding or tachypnea. However in younger children these changes are not recognized, are interpreted differently or infants and young children may also have different activities. “…(1)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 (range form 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.”

In young children CM is part of their curiosity of the world and in this case in exploring their own and other’s bodies (i.e. viewing genitalia) and in discovering pleasurable sensations. Sexual behaviors in puberty and post-pubertal youth and adults is more intentional with sexual arousal and/or orgasm as goals. Some parents especially worry that the behaviors are abnormal or excessive. There is no specific definition of normal or excessive and these are left to interpretation. Normative behavior is based on cultural, group or societal expectations with the idea that they support health or at least do not hinder it. For example, as children mature and reach school age, they are less likely to do CM activities in public as they have learned that certain behaviors are not acceptable in public. If the CM causes distress for the child, is outside the developmental range for the child’s age, or there are concerns for child maltreatment, or there are multiple behavioral problems, then simple normative CM may not be the only diagnosis to consider. In children with psychological stress, CM can be a regulating mechanism. It can also be a stimulatory activity for children with severe lack of external stimulation in their lives.

CM can occur in children who are victims of abuse. No specific behavior is pathognomonic of abuse and for many victims there are no symptoms at all. However sexualized behavior is one of the common symptoms of child abuse. Examples of inappropriate sexual behaviors include:

• Putting mouth on breasts or genitals
• Masturbating with objects
• Inserting objects into vagina/anus
• Inserting tongue while kissing
• Imitating sexual sounds
• Undressing with other people
• Wanting to participate in sexual acts or imitating sexual intercourse including with dolls or toys
• Wanting to see inappropriate video or television

Parental and societal views of CM are different and should be respected. Discussing normal growth and development of the child including their own sexuality usually normalizes the behavior and understanding for families. Based on the family’s beliefs, the child’s age and education, the child (and family) can be educated about their sexuality and taught to masturbate in a private location similar to other private activities such as elimination. Some people have strong feelings about the term masturbation and alternatives include self-stimulation or gratification.

Reasons that CM comes to attention can be attributing it to abdominal pain, seizures, dystonia, movement disorders, urinary tract infections, vaginal discharge or vaginitis, diaper rash, phimosis, balanitis, pinworms, eczema and lichen sclerosus. Sometimes it can be difficult to tell if the CM caused genital trauma which in turn leads to the child complaining of pain or holding or rubbing their genitals, or if it is the other way around. Videotaping the behavior can help with diagnosis as the behavior can be reviewed by the clinician and family together.

Learning Point
The key element which distinguishes CM from other differential diagnostic entities is that it ceases with distraction. Children are awake during the behavior.

Questions for Further Discussion
1. Describe common sexual behaviors in young children. A review can be found here
2. What is differential diagnosis of vulvovaginitis? A review can be found here

Related Cases

Disease: Childhood Masturbation | Sexual Health Issues | Child Behavior Disorders

Symptom/Presentation: Behavior Problems | Dysuria | Vaginal Discharge

Specialty: General Pediatrics | Child Abuse and Neglect | Psychiatry and Psychology

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Health and Child Behavior Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Mallants C, Casteels K. Practical approach to childhood masturbation – a review. European Journal of Pediatrics. 2008;167(10):1111-1117. doi:10.1007/s00431-008-0766-2

Strachan E, Staples B. Masturbation. Pediatr Rev. 2012;33(4):190-191. doi:10.1542/pir.33-4-190

Wilkinson B, John RM. Understanding Masturbation in the Pediatric Patient. J Pediatr Health Care. 2018;32(6):639-643. doi:10.1016/j.pedhc.2018.05.001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa