Introduction: Masturbation is a common sexual activity among people of all ages throughout life. It has been traditionally prohibited and judged as immoral and sinful by several religions. Although it is no longer perceived as a negative behavior, masturbation is often omitted in the diagnostic inquiry of patients with sexual problems.

Aims: The aims of this study are to increase the awareness of clinicians to the importance of including questions regarding masturbatory habits in the process of sexual history taking, to analyze cases of male sexual dysfunction (SD) associated with unusual masturbatory practices, and to propose a practical tool for clinicians to diagnose and manage such problems.

Methods: A clinical study of four cases that include a range of unusual masturbatory practices by young males who applied for sex therapy is described. An intervention plan involving specific questions in case history taking was devised. It was based on detailed understanding of each patient's masturbatory practice and its manifestation in his SD.

Main outcome measures: Effects of identifying and altering masturbatory practices on sexual function.

Results: The four men described unusual and awkward masturbatory practices, each of which was associated with different kinds of SD. The unlearning of the masturbatory practices contributed notably to improvement of their sexual function.

Conclusions: The four cases in this study indicate that the detailed questioning of masturbatory habits is crucial for a thorough assessment and adequate treatment of sexual problems in men. We propose specific questions on masturbatory behavior as well as a diagnostic and therapeutic flowchart for physicians and sex therapists to address those problems.