Childhood Masturbation: A Case Report from Bangladesh

Introduction

Masturbation is a normal sexual behavior, which has been found in 90% to 94% of males and 50% to 60% of females in lifetime.^1-3 However, masturbation in childhood is less commonly addressed in research.^{1, 4} Childhood masturbation (CM) or gratification disorder came into concern since 1909, which was addressed by still and characterized by self-stimulation of genitalia in a prepubescent child.^{1, 2, 4, 5} It characteristically starts at 2 months of age with a peak of incidence at 4 years; is presented as unusual postures and movements; could be misdiagnosed as seizure disorder, movement disorders, abdominal pains, or other neurologic or medical disorders.^{1-4, 6} However, CM often stops if the child could be distracted, which helps clinicians to distinguish it from other differential diagnoses. ⁷ Previous research found that the frequency of CM incident varies from 1 per week to 12 per day and duration varies from 30 s to 2 h. ² It is found to be more in females (3-7 times).^{1, 2, 4} During management of CM, clinicians can focus on parental education and guidance, helping them to change their view to take it into consideration as a harmless and nonpainful habit.^{3, 5} Any attempt to stop it could be frustrating and considered as a punishment for it tends to reinforce it. Thus, ignoring or distracting the child during the episode has been considered as a better option. ⁵ Age- and culture-appropriate sex education could be provided as it often ceases eventually and spontaneously. ⁵

Bangladesh is a country where sex has been merged with plenty of myths and talking regarding sex openly has not been encouraged.^{8, 9} Here we aim to report a case of CM in Bangladesh, so that clinicians consider the diagnosis as a differential, which in turn may reduce the sufferings of the patients and undue anxiety of the caregivers.

Case

Master F, a six-year-old Muslim girl of middle socioeconomic class, with below average body built, however, good intelligence, was presented at a private chamber of a psychiatrist with the complaints of episodic frictions of pubic area with edges of bed, furniture, and other approachable particles for last one and a half years. Sometimes the girl used her bolster for the purpose. She used to perform the activity when she was alone. Her mother noticed the event which was irregular initially. For last six months the frequency had been increasing gradually and at the time of consultation, the girl was found to have such episodes 3 to 4 times per week. The average duration of episodes was about 5 minutes. Previously, the mother consulted with pediatrician and child neurologist, where she was performed routine investigations as well as magnetic resonance imaging of brain and electroencephalogram which revealed no abnormality. Subsequently, she was referred to a psychiatrist. Her mother was so anxious that she could not concentrate on any other activity and she had stopped the child from going to school for the last 3 months.

After taking detailed history, and performing physical and mental state examination, the girl was labeled as a case of CM. Adequate psychoeducation was provided to the mother regarding the disorder as well as its management such as behavior therapy. She was advised to ignore the events, minimizing the attention to masturbatory behaviors, distracting the child with other enjoyable activities, and praising the child for expected behaviors. She was also ensured repeatedly regarding the diagnosis as well as the management methods advised for the girl. However, the mother found it challenging to accept the diagnosis, and also the treatment because the girl was not prescribed any medication. The mother was expecting hospitalization, further investigations, and subsequently enough medications. She also asked the psychiatrist to opine whether the girl required overseas treatment to cure the disorder immediately with medications. She was advised to follow up after a week. The psychiatrist arranged for a combined meeting with the previously consulted pediatrician and child neurologist, mother of the child, and other family members to convince the family regarding the disorder. After that the mother assured to follow the treatment plan.

Discussion

CM is an almost universal phenomenon which should be ignored if it happens privately as it is self-remitting, though the exact etiological formulation is controversial and poorly understood to date.^1-3 Culture of the country and the religious beliefs of the caregivers affect the care being sought significantly. ⁷ Clinicians need to consider views on cultural awareness and about sex and sexuality. ⁷

Bangladesh is a sexually conservative Muslim country where sex has been considered as a covert issue, and masturbation as guilty behavior.^{8, 9} The situation has become more complex due to poor health literacy status of the people. ⁸ In the current case, the mother along with other family members was very anxious regarding the masturbatory behavior of the child which lead to a disgrace for the whole family. The psychiatrist had to struggle to educate them regarding the behavior, treatment, and prognosis. They thought that the child had a serious neurological disease which could be cured by pills. Adequate awareness among the clinicians could increase the reporting of such cases as well as reduce the stigma attached to talking about the sexual problems.

Conclusions

To the best knowledge of authors, this is first reported case of CM in a sexually conservative country, Bangladesh. This article is expected to raise the issue of CM among clinical practitioners other than psychiatrists, which in turn would reduce the sufferings of the patients and anxiety of the caregivers. Early diagnosis could save extensive investigations as well as treatment seeking from multiple consultants of different specialties.