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brief report
471
Ann Saudi Med 30(6) November-December 2010 www.saudiannals.net
Childhood masturbation was reported by Still
in 1909.1 It is characterized by self-stimu-
lation of the genitalia frequently associated
with unusual posture and movement, sweating, flush-
ing, tachypnea, and typically begins in infancy and
early childhood.2 Masturbation is a normal behavior
in adolescence, occuring in 90% to 94% of males and
50% to 60% of females at some point in their lives;
maturation of sex hormones predisposes to the activ-
ity.3-5 Previous reports on infants and early childhood
masturbation are sparse with no attempts to identify
the role of sex hormones in such a situation, despite the
evidence that sex hormones are known to predispose
to adolescentmasturbation behavior.5,6 In infants and
young children, unusual postures and movements oc-
cur during masturbation and may be misdiagnosed as
Infantile and early childhood masturbation:
Sex hormones and clinical profile
Heitham K. Ajlouni,a Azhar S. Daoud,b Saleh F. Ajlouni,c Kamel M. Ajlounib
From the aSaint Michael’s Medical Center, Seton Hall University, New Jersey, USA, bNational Center for Diabetes, Endocrinology and Genetics,
Amman, Jordan, cKing Hussein Medical Center, Jordan
Correspondence: Professor Kamel Ajlouni · The National Center for Diabetes, Endocrinology and Genetics, PO Box (13165) Amman 11942
Jordan · ajlouni@ju.edu.jo · Accepted: July 2010
Ann Saudi Med 2010; 30(6): 471-474
PMID: **** DOI: 10.4103/0256-4947.72271
BACKGROUND AND OBJECTIVES: Few studies have explored the hormonal triggers for masturbation in infants
and young children. Thus, we aimed to study the sex hormones and clinical profiles of masturbating infants and
young children.
METHODS: This case-control study involved infants and young children who masturbate and were referred to
three pediatric neurology clinics between September 2004 and 2006 (n=13), and a similar control group. All
children underwent basic laboratory investigations prior to referral. Other tests included electroencephalogra-
phy (n=8) and brain neuroimaging (n=9). We measured dehydroepiandrosterone sulfate, 17-hydroxyprogester-
one, free testosterone, estradiol, dehydroepiandrosterone, sex hormone-binding globulin (SHBG), and andro-
stenedione in all participants.
RESULT: The median age at the first incident was 19.5 months (range, 4-36 months); the median masturbation
frequency, 4 times/day; and the median duration of each event, 3.9 min. The subjects masturbated in both prone
(n=10) and supine positions (n=3); two subjects used the knee-chest position. All subjects showed facial flush-
ing; 6, friction between the thighs; 5, sweating; 9, sleeping after the event; and 12, disturbance on interruption.
EEG was abnormal in one of eight subjects tested, and neuroimages were normal in all of nine subjects exam-
ined. The case and control groups had comparable levels of all sex hormones, except estradiol, which showed
significantly lower levels in the case group (P=.02).
CONCLUSION: Masturbation in children seems to be associated with reduced estradiol levels, but not with
other sex hormones. Further studies are needed to confirm our findings.
seizures, movement disorders, abdominal pain, colic, or
other neurologic or medical problems.7-10 Extensive un-
warranted investigations may be performed.10-12 To o ur
knowledge, assessment of the levels of sex hormones as
a possible predisposing factor has not been carried out
before. e purpose of this study was to describe the
clinical characteristics of masturbatory behaviors in 13
children referred to three different child neurology clin-
ics in Jordan, to assess their sex hormones levels, and to
compare these with that of a control group.
METHODS
is was a prospective study of all infants and young
children referred to the participating pediatric neurol-
ogy clinics between September 2004 and 2006, diag-
nosed as having gratification disorder. A data collec-
brief report CHILDHOOD MASTURBATION
472 Ann Saudi Med 30(6) November-December 2010 www.saudiannals.net
tion sheet was developed which included information
on demographic characteristics, a detailed history on
the features of the movements during masturbation,
clinical examination, neurodevelopment assessment, as
well as the levels of sex hormones (dehydroepiandros-
terone sulfate (DHEAS), 17-hydroxyprogesterone
[17OHP], free testosterone, estradiol, dehydroepi-
androsterone (DHEA), sex hormone-binding globulin
[SHBG], and androstenedione). All hormone levels
were determined using commercially available kits as
follows: DHEAS and 17OHP were measured by RIA,
DHGA by immunoradiometric assay (Immunotech
Marseille, France), free testosterone by RIA (Biosource
Europe S.A., Belgium), estradiol by a micropar-
ticle enzyme immunoassay using an AXsym machine
(Abbott Labs, IL, USA), SHBG by an enzyme immu-
noassay using a Cobas machine (Roche Diagnostics,
Mannheim, Germany), and androstenedione by an
enzyme immunoassay (DSL, Dallas, TX, USA). To
assess the role of sex hormones in this condition, 13
age- and sex-matched controls were selected from chil-
dren attending the same clinics for reasons other than
masturbation. Blood samples were obtained from all
controls and assessed for sex hormones using the same
techniques as for the cases. e mean levels of the sex
hormones were compared between cases and controls
using the two-sample independent t test. Other tests
performed included EEG (n=8), brain CT scan (n=8),
and brain MRI (n=1). Five of the children were wrong-
ly diagnosed as having epilepsy and were on a mainte-
nance antiepileptic drug treatment prior to referral to
our clinics. Basic blood tests included complete blood
count, serum electrolytes, and liver and kidney profiles.
Echocardiography was performed on all children be-
fore the referral. e ethics committees of the three in-
stitutes approved the study protocol. A verbal consent
was obtained from the parents of all participants.
RESULTS
irteen infants and young children exhibiting mas-
turbation were enrolled in this study. Table 1 shows
the characteristic features of events associated with
masturbation. Antiepileptic drugs were given to five of
the children, but did not have in any clinical benefit. A
comparison of sex hormone levels between all cases and
controls is shown in Table 2. Table 3 shows the cor-
responding values in female cases. As shown in Tables
2 and 3, estradiol levels were found to be significantly
lower in cases as compared to controls (P=.03). ere
was no difference in the levels of all other sex hormones
between the two groups. e mean estradiol level was
also found to be lower in male cases (9.3 pg/mL) as
compared to male controls (14.3 pg/mL) (not reported
in the tables), but the difference was not statistically
significant (P=.50), possibly due to the small sample
size.
DISCUSSION
Masturbation is considered to be a common normal be-
havior in adolescents. e physiological and hormonal
Table 1. Characteristic features of events associated with masturbation in 13 Jordanian children.
Patient Sex Age of onset Color change Posture Duration Frequency
1 F 6 mo Flushing Prone, supine 5 Min 3/day
2 F 6 mo Flushing Knee-chest 2 Min 20/day
3 M 18 mo Flushing Prone 5 Min 2/day
4 M 36 mo Flushing Prone 5 Min 3/day
5 F 12 mo Flushing Friction of thighs 5 Min 5/day
6 M 36 mo Flushing Prone 5 Min 2/day
7 F 36 mo Flushing Prone 10 Min 2/day
8 F 42 mo Flushing Supine 3 Min 3/day
9 F 13 mo Flushing Prone 3 Min 3/day
10 F 20 mo Flushing Prone 4 Min 4/day
11 F 18 mo Flushing Prone 5 Min 6/day
12 F 4 mo Flushing Prone, knee-chest 4 Min 10/day
13 F 12 mo Flushing Prone 5 Min 3/day
brief report
CHILDHOOD MASTURBATION
473
Ann Saudi Med 30(6) November-December 2010 www.saudiannals.net
Table 2. Hormonal profile of children exhibiting masturbation.
Status N Mean SD
P
Age (years)
Control 13 2.02 0.91
.15
Case 13 2.67 1.28
DHEAS (µg/dL)
Control 13 6.59 12.54
.54
Case 13 4.37 3.43
17OHP (nmol/L)
Control 13 2.83 2.29
.75
Case 13 2.55 1.94
Free
testosterone
(pg/mL)
Control 13 0.31 0.14
.87
Case 13 0.31 0.15
17-estradiol
(pg/mL)
Control 13 19.46 8.50
.03
Case 13 12.31 6.73
DHEA (ng/mL)
Control 13 1.28 0.97
.89
Case 13 1.23 0.67
SHBG (nmol/L)
Control 13 71.43 24.00
.20
Case 13 86.07 32.27
Androstene-
dione (ng/mL)
Control 13 0.14 0.16
.95
Case 13 0.15 0.19
Table 3. Hormonal profile of female children exhibiting masturbation, Jordan 2009.
Status N Mean SD
P
Age (years)
Control 10 1.78 0.86
.27
Case 10 2.34 1.19
DHEAS (µg/dL)
Control 10 2.27 1.74
.12
Case 10 4.54 3.80
17OHP (nmol/L)
Control 10 3.39 2.55
.56
Case 10 2.77 2.04
Free
testosterone
(pg/mL)
Control 10 0.28 0.12
.40
Case 10 0.34 0.16
17-estradiol
(pg/ml)
Control 10 21.78 6.38
.02
Case 10 13.20 7.51
DHEA (ng/ml)
Control 10 0.97 0.30
.24
Case 10 1.29 0.74
SHBG (nmol/l)
Control 10 72.88 27.82
.52
Case 10 82.42 34.54
Androstene-
dione (ng/ml)
Control 10 0.16 0.17
.94
Case 10 0.16 0.21
changes that occur during such activity have been well-
documented.5 However, in infants and young children,
masturbation can be difficult to recognize due to the
absence of genital manipulation, as well as the variable
manifestations of this behavior.3 Childhood masturba-
tion, if unrecognized, may lead to considerable parental
anxiety, unnecessary investigations, and inappropriate
and potentially harmful therapies.2-12 e paroxysmal
tightening of the thighs, rocking pelvic movements or
other rhythmic activities, mechanical pressure applied
to the supra-pubic area, grunting, facial flushing, irreg-
ular breathing, and sweating during the event, may be
misinterpreted as abdominal pain, urinary symptoms,
or epileptic seizures.8-12 In our subjects, masturbation
was previously misdiagnosed in many of the cases as
a seizure disorder, dystonia, or abdominal pain, result-
ing in extensive diagnostic testing in the majority of
our children, as well as initiation of many unnecessary
medications. is demonstrates that even for an expe-
rienced movement disorder specialist, the distinction
between paroxysmal movement disorders and mastur-
batory behavior can be difficult to make,10 if the fact
that these infants and young children are responsive to
all stimuli during masturbation is missed. In a previous
study, 8 of 12 patients with similar characteristics had
been treated with different antiepileptic medications.3
Our diagnosis was made on the basis of the Fleisher
and Morrison study9 that reported the frequency of an
event to vary from 1/week to 12/day, with a mean fre-
quency of 16/week, and a median of 7/week. e mean
duration of the event was 9 minutes (median 2.5 min-
utes, range 30 seconds to 2 hours).9 e median fre-
quency of events in our study was 4/day, and the medi-
an duration of the event was 3.9 minutes. e female-
to-male ratio was 3:1 in our study. Varied ratios have
been reported in other studies.6,9,13 Consistent with
our findings, masturbation has been reported to start
in most children before 2 years of age.6 Since Jordan
is a sexually conservative country with no formal sex
education, childhood masturbation may create more
parental concern than in Western societies, and the re-
ferral rate may differ. Ten (77%) of our children did not
attend any follow-up visits after their parents were in-
formed about the diagnosis of childhood masturbation,
possibly due to the concern of stigmatization. e eti-
ology of childhood masturbation and its predisposing
factors are still controversial and poorly understood.
Childhood masturbation has been linked to emotional
deprivation, which may in turn lead to more self-stimu-
lation.14 It may also be associated with sexual abuse.14 A
possible correlation of childhood masturbation to the
duration of breast-feeding has also been reported: mas-
brief report CHILDHOOD MASTURBATION
474 Ann Saudi Med 30(6) November-December 2010 www.saudiannals.net
1. Still GF. Common disorders and diseases of
childhood. London, United Kingdom: Oxford Uni-
versity Press; 1909. p. 336-80.
2. Yang ML, Fullwood E, Goldstein J, Mink
JW. Masturbation in infancy and early child-
hood presenting as a movement disorder: 12
cases and a review of the literature. Pediatrics
2005;116:1427-32.
3. Leung AK, Robson WL. Childhood masturba-
tion. Clin Pediatr (Phila) 1993;32:238-41.
4. Nechay A, Ross LM, Stephenson JB, O’Regan
M. Gratification disorder (infantile masturba-
tion): A review. Arch Dis Child 2004;89:226-6.
5. Nelson WE. Nelson Textbook of Pediatrics.
USA: Saunders Company; 1996.
6. Unal F. Predispsing factors in child-
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7. Bower B. Fits and other frightening or
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tiation between epilepsy and non-epileptic par-
oxysmal events in the first year of life. Arch Dis
Child 1995;73:342-4.
9. Fleisher DR, Morrison A. Masturbation mim-
icking abdominal pain or seizures in young girls.
J Pediatr 1990;116:810-14.
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paroxysmal dystonia or dyskinesia in a young
girl. Mov Disord 1995;10:518-20.
11. Livingston S, Berman W, Pauli LL. Mastur-
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1975;14:232-4.
12. Wulff CH, Ostergaard JR, Storm K. Epi-
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13. Bradley SJ. Childhood female masturbation.
Can Med Assoc J 1985;132:1165-6.
14. McCray GM. Excessive masturbation of
childhood is a symptom of tactile deprivation?
Pediatrics 1978;62:277-9.
turbation was found to be significantly associated with
weaning, but not with pacifier usage.6
To our knowledge, this is the first study to examine
the role of sex hormones in masturbation behavior in
children. e finding of a significantly lower level of es-
tradiol in cases as compared to controls is interesting,
but should be interpreted with caution. Further studies
need to be conducted to conform our results.
REFERENCES
