Self-exploration and masturbation are a normal part of development but are not discussed often because they are challenging topics for parents and pediatricians. Most children will engage in some sexual behavior before puberty, and after puberty the practice is even more common. In one report, 90% to 94% of males and 50% to 60% of females recalled masturbating at some point during their childhood. Given that this behavior is so common, it is essential that pediatricians be able to distinguish normal behavior from pathologic behavior, including behavior that is suggestive of an alternative medical diagnosis or abuse.Children follow a progression of appropriate sexual behavior based on age and developmental level. Common early sexual behaviors include touching one’s genitals in private or in public, attempting to touch others’ genitals, showing one’s genitals to others, or attempting to view others while they are naked. These actions represent an extension of curiosity-seeking behavior and immature understanding of interpersonal barriers, in addition to discovery of pleasurable sensations. Typically, these early sexual behaviors diminish by 5 years of age, once the child has a better understanding of cultural norms and has received explanation from his or her parents about social norms and exhibiting these behaviors in private.When a child reaches puberty, sexual behaviors become more intentional with the goal of producing sexual arousal or orgasm. This behavior typically occurs in private, because by this age children are aware of cultural norms and interpersonal boundaries. When masturbation or other public sexualized behavior occurs past early childhood, this behavior may suggest poor awareness of social reality and warrants further evaluation for developmental delays or autism spectrum disorders.It is well documented that sexual behaviors also can be related to a variety of environmental factors, including physical abuse, sexual abuse, and neglect. The cultural background of parents and their interpretation of these behaviors are important factors in determining how this issue is presented to a pediatrician. No one behavior is pathognomonic of abuse or behavioral problems. However, actions that are intrusive, inflict harm, involve insertion of foreign objects, imitate adult sexual acts, or are coercive of other children raise concern and merit more extensive evaluation.Excessive masturbation that is not easily redirected may be related to family dysfunction or stress, underlying developmental disability, mental health issues, understimulation in the home, or possible neglect or physical or sexual abuse.The Child Sexual Behavior Inventory is a good tool to help distinguish developmentally appropriate sexual behavior from pathologic behavior in children ages 2 to 12 years. If behavior is assessed to be within normal limits, the clinician should proceed with parental reassurance and instructions on redirection of behavior and establishment of clear boundaries. However, behavior that is determined to be outside of age-appropriate norms should trigger more comprehensive assessment and treatment, and make the clinician consider evaluation for mental health problems or developmental delay, or suggest referral to child protective services, depending on the particulars of the case.Because many parents are naive to the prevalence of early childhood sexual behavior, masturbation may be misinterpreted as a seizure disorder or movement disorder in younger children. Conversely, medical conditions that result in genital itching such as vaginitis, vaginal discharge, lichen sclerosus, diaper rash, pinworms, or eczema may be interpreted as sexual behavior. A careful history and physical examination are essential. In a very young child, videotaping the behavior will help the clinician in making a diagnosis.Comments: Before the 20th century, masturbation was thought to be secondary to a neuropsychiatric disorder. We have come a long way since then in understanding that masturbation is a normal demonstration of sexual exploration commonly seen in preschool-age children. However, it can still be a challenging topic to discuss with parents. Although there is no specific evidence base concerning masturbation, survey studies and the use of the Child Sexual Behavior Inventory have provided observational information about prevalence rates and norms.Masturbation includes stereotypical positioning and pressure on the genitalia, which may result in an altered breathing pattern, can be variable in duration, and stops with distraction. Studies have shown that parents with higher educational levels, who are more likely to co-sleep with their children, exhibit family nudity, and view masturbation as normal are more likely to report these behaviors and discuss them openly. Hence, it is important to discuss routinely with parents who do not fit these demographic characteristics that these behaviors are common, or when parents bring up concerns indirectly, because they may have hidden worries.Some parents may misinterpret these behaviors as signs of enhanced sexuality or suggestions that the child has been abused. Anticipatory guidance is essential to reassure parents regarding the normalcy of masturbation based on the age and specific behaviors that are demonstrated.
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Mar 30, 2016
Danielle Chung + 4
Open Access
