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Sexual Functioning and Behavior of Men with Body Dysmorphic Disorder Concerning Penis Size Compared with Men Anxious about Penis Size and with Controls: A Cohort Study

Sexual Functioning and Behavior of Men with Body Dysmorphic Disorder Concerning Penis Size... ORIGINAL RESEARCH—PSYCHOLOGY Sexual Functioning and Behavior of Men with Body Dysmorphic Disorder Concerning Penis Size Compared with Men Anxious about Penis Size and with Controls: A Cohort Study David Veale, MD, FRCPsych,* Sarah Miles, MSc,* Julie Read, MA,* Andrea Troglia, PsyD,* † ‡ Kevan Wylie, FRCP, FRCPsych, FECSM, and Gordon Muir, FRCS *Institute of Psychiatry, Psychology and Neurosciences, Kings College London, South London and Maudsley NHS Foundation Trust, London, UK; Porterbrook Clinic, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK; King’s College Hospital, NHS Foundation Trust, London, UK DOI: 10.1002/sm2.63 ABSTRACT Introduction. Little is known about the sexual functioning and behavior of men anxious about the size of their penis and the means that they might use to try to alter the size of their penis. Aim. To compare sexual functioning and behavior in men with body dysmorphic disorder (BDD) concerning penis size and in men with small penis anxiety (SPA without BDD) and in a control group of men who do not have any concerns. Methods. An opportunistic sample of 90 men from the community were recruited and divided into three groups: BDD (n = 26); SPA (n = 31) and controls (n = 33). Main Outcome Measures. The Index of Erectile Function (IEF), sexual identity and history; and interventions to alter the size of their penis. Results. Men with BDD compared with controls had reduced erectile dysfunction, orgasmic function, intercourse satisfaction and overall satisfaction on the IEF. Men with SPA compared with controls had reduced intercourse satisfaction. There were no differences in sexual desire, the frequency of intercourse or masturbation across any of the three groups. Men with BDD and SPA were more likely than the controls to attempt to alter the shape or size of their penis (for example jelqing, vacuum pumps or stretching devices) with poor reported success. Conclusion. Men with BDD are more likely to have erectile dysfunction and less satisfaction with intercourse than controls but maintain their libido. Further research is required to develop and evaluate a psychological intervention for such men with adequate outcome measures. Veale D, Miles S, Read J, Troglia A, Wylie K, and Muir G. Sexual functioning and behavior of men with body dysmorphic disorder concerning penis size compared with men anxious about penis size and with controls: A cohort study. Sex Med 2015;3:147–155. Key Words. Small Penis Anxiety; Body Dysmorphic Disorder; Sexual Function; Small Penis Syndrome Introduction cultural beliefs, which might indicate penis size as of importance, might leave men fearful of negative or men, penis size is often considered a sign evaluation when their penis is exposed in sexual of masculinity and sexual prowess. Social and situations leading to impaired sexual function. © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 148 Veale et al. Small penis anxiety (SPA) (also known as “small retrospective case series the diagnosis of BDD may penis syndrome”) has been described in the litera- be associated with a poor outcome in most cos- ture in men who are dissatisfied or excessively metic procedures [6,14–17]. worried about their penis size which is in the Penis size is considered important to homo- normal range [1]. This definiton excludes men sexual men in terms of how they construct their with a micropenis [2]. Some men experiencing sense of self [18], how they construct masculinity excessive worry or shame about penis size may and that they recognize a notion of “bigger is meet criteria for a diagnosis of Body Dysmorphic better” when defining an ideal male partner [19]. Disorder (BDD) [3]. Individuals with BDD are Homosexual men’s perceptions of size are signifi- excessively preoccupied with a perceived defect in cantly related to sexual positioning as those with their appearance that is either not observable to smaller perceived size more often assume the others or appears only slight. The individual nor- anally submissive sexual position [20]. Grove mally performs repetitive behaviors (e.g., checking et al. [21] subsequently reported that 86% of or comparing) in response to the concerns. They their men had measured their penile size. While must also experience clinically significant distress penis size is important among the male homo- or impairment in social, occupational, or other sexual community, previous research has indi- important areas of functioning. BDD in specialist cated that homosexual men have a vulnerability psychiatric settings is associated with a high rate of to body dissatisfaction in comparison with het- suicide ideation and completed suicide [4,5]. It is erosexual men [22,23] often chronic with an onset during adolescence Recent research investigated the phenomenol- but can take 10 years before obtaining adequate ogy of men with BDD exclusively or mainly treatment [4,5]. The preoccupation in BDD is related to penile size [24,25]. Results found that most commonly on the face. Occasionally in men men with BDD concerning their penis reported it is focused on their penis size [4,5]. It was greater shame and interference in relationships hypothesized that BDD and SPA would interfere compared with men with small penis anxiety and in sexual behavior and reduce the frequency of controls. The shame provoking situations that are sexual behavior more than in men without con- avoided can be broadly categorized into (i) display- cerns because they are generally more impaired. ing a flaccid penis in public situations (for example Individuals with BDD commonly seek cosmetic in changing rooms) and (ii) displaying a flaccid or procedures with the hope that the appearance an erect penis with a sexual partner. Most of the of their perceived flaw(s) can be significantly safety seeking behaviors can be divided into either improved [6,7]. A number of surgical case studies threat detection (e.g., measuring the size or com- have described men seeking phalloplasty augmen- paring) and avoidance or camouflage (e.g., chang- tation as having BDD related to the penis [8–10]. ing one’s posture to avoid their penis being seen). Penile length augmentation can include suspen- Furthermore, men with BDD were found to score sory ligament release; prepubic liposuction; penile higher on symptoms of general psychopathology disassembly and cartilage transplant; girth aug- (e.g., low mood, general anxiety and quality of life) mentation can include lipoinjection; dermal graft; in comparison with men with small penis anxiety temporalis fascia transfer; saphenous vein grafts or no concern. However, little is known about and injection of synthetic materials which have whether or not the perceived shame of a small been comprehensively reviewed in the literature penis affects sexual functioning and behavior. The [11]. People with BDD may also perform D.I.Y same dataset used in the study on phenomenology (do it yourself) surgery—an attempt to correct and characteristics of such men was used in this their perceived physical flaw(s) themselves [12]. study [25]. Thus some men preoccupied by their penis size have injected Vaseline in to their penis [13]. Aims Reports of penile augmentation in men with BDD have not been based on any structured diagnostic Given the severity of BDD and SPA and the interview for BDD or a validated screening scale. limited existing research on BDD exclusively or Therefore, some of the participants reported may mainly related to the penis, this study sought to not meet criteria for BDD. Cosmetic phalloplasty investigate the sexual functioning and behavior of is regarded as experimental for men with small men with BDD relating to penis size and whether penis anxiety without any adequate outcome mea- or not they could be differentiated from men with sures or evidence of safety [11]. Furthermore, in SPA and those who are unconcerned about their Sex Med 2015;3:147–155 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Sexual Functioning in Small Penis Anxiety 149 Main Outcome Measures penis size. Our hypothesis was that men with BDD concerning small penis size were more likely to All participants completed the following question- experience erectile dysfunction and overall poor naires online. sexual satisfaction compared with men with small penis anxiety and men unconcerned with penis Demographic Information size. Information was collected on age, marital status, ethnic origin, employment status and sexual ori- entation. Methods The study consisted of a group cohort design com- Penis Size paring men with BDD exclusively or mainly Penile length was measured in order to exclude related to their penis against men with SPA and men who had a micropenis by an urologist using a controls who did not report any concerns with standard disposable medical measuring tape. their penis size. Sexual History Participants were asked about their sexual orienta- Participants tion; the age when they first had intercourse; the All men were recruited from one of three sources: number of sexual partners they had had in their (i) by email to staff and students at King’s College lifetime; the number of sexual partners lasting 3 London (n = 36), (ii) by email to a database of months or longer; the age they first started to volunteers at the Institute of Psychiatry, Kings masturbate; the frequency of masturbation; the College London (n = 10) and (iii) by a link on the frequency of accessing pornography and the fre- website “Embarrassing Bodies” (n = 44). Embar- quency of sexual intercourse per month. rassing Bodies is an informative television program aired on Channel 4 in which members of International Index of Erectile Function (IIEF) [26] the public present to a doctor with physical and The IIEF is a 15-item self-report scale that has five medical concerns (often rare or unusual). The subscales: erectile function (score range 0–30), program has its own website on which members of orgasmic function (range 0–10), sexual desire the public can both learn about the body and (range 0–10), intercourse satisfaction (range 0–15), related illnesses as well as post queries to profes- and overall satisfaction (range 0–10). Across all 5 sionals. The authors approached the producers subscales, a higher score indicates higher levels of who organized for an advertisement and study sexual functioning. Cronbach’s alpha for the total contact details to be posted on the website. scale was 0.90, and alpha values for each of the 5 In total, 90 participants were included in the subscales ranged from 0.70 to 0.90, indicating study. The inclusion criteria for taking part were good internal reliability. After 4 weeks, test-retest that men had to be aged 18 or above and proficient reliability coefficients ranged from 0.64 to 0.84, in English in order to provide consent and com- indicating high positive correlation. plete online survey questionnaires. Our exclusion criteria were men who: Structured Clinical Interview for DSM-IV (SCID) [27] 1. Had a micropenis (defined as 6 cm or less in the The SCID was used in order to determine whether flaccid state) [2] or not the men worried about their penis size met 2. Had a penile abnormality (e.g., Peyronie’s criteria for a diagnosis of BDD. DSM-IV was used disease, hypospadias, intersex, phimosis) as the study commenced before publication of 3. Had any had penile or prostatic surgery (which DSM-5. Those in SPA group were defined as may affect penis size). expressing worries about their penis size but not 4. Had any condition associated with length loss meeting criteria for BDD. or “acquired short penis,” secondary to a disease or an intervention. e.g., prostate radia- Interventions tion, prostate cancer hormonal treatment, dia- Participants were asked if they have made any pre- betes with severe penile atrophic damage. vious attempt to alter the size or shape of their The Queen Square NHS Research Ethics Com- penis; what type of procedure they have used; the mittee granted ethics permission for the comple- degree of cosmetic success of the procedure (on a tion of the research (Reference 11/LO/0803). scale of 0–8, where 0 was “very much worse” and 8 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. 150 Veale et al. was “very much improved”) and how much the one way ANOVAs were run to compare continu- procedure(s) reduced their preoccupation with ous variables across the three groups. All tests were their penis size and self-consciousness (on the two tailed. Where one comparison is made, alpha same a scale of 0–8). levels were set at 0.05, however where multiple post hoc comparisons were made for mean age, a Bonferroni correction was used to reduce type 2 Procedure error; as comparisons were made between three Advertisements for participants sought to recruit groups, the standard alpha value of 0.05 was men to a study that was interested in their beliefs divided by 3 to given a new alpha value of 0.017. and concerns about their penis size. After complet- ing the questionnaires online, men who expressed any concerns or worries about their penis size were Results interviewed with the SCID by a research psy- chologist either face to face or over the telephone, All the participants were identified as being in the when they were unable to come to the clinic [27]. normal range for penis size. None were close to a Participants then came to an outpatient urology micropenis and therefore none were excluded for department for an examination to exclude a this reason. The flaccid length measurements in all micropenis or other abnormalities. On arrival, par- the participants were between 7 cm and 13 cm. ticipants completed a consent form and were then Men with BDD were significantly older than given privacy in an air-conditioned consulting men with SPA and controls (Table 1). Of those room at a constant temperature (21°C) at sea level. with a concern about penis size there were no Using a disposable tape measure, each participant differences between the age at which men with was measured in the flaccid state from pubis to BDD and SPA first started to think their penis was distal glans (bone-to-tip). small or the age at which penis size became a Twelve men were unable to attend the clinic. In significant problem for them. However, men with order to exclude a micropenis (that would exclude BDD did seek help for their size related concern at them from the study), they were sent standardized a significantly older age than men with SPA. There instructions guided with a tutorial video compiled were no significant differences between the groups by expert urologists, on how to administer self- for marital status, employment status, or ethnicity. measurement and email the results to the research- There were no significant differences between ers and to report any penile abnormalities (e.g., groups for the frequencies who have had any pre- curvature). In addition the SCID was conducted vious sexual experience, mean age of first sexual over the telephone. experience, mean number of previous sexual part- ners or long term sexual partners, or their frequen- Statistical Analysis cies of sexual intercourse per month (Table 2). The Data were analyzed using SPSS v20. Fisher’s Exact median number of sexual partners is reported as Tests were run to calculate differences in categori- well as the mean because the range of frequencies cal variable frequencies across groups. As from 0 to 600 could be considered misleading. Kolmonogorov–Smirnov, skew and kurtosis tests The groups also did not differ on their ages and indicated that the data were normally distributed, frequencies of masturbation or pornography use. Table 1 Demographic comparisons between BDD, SPA and control groups at baseline Small penis BDD group anxiety group Control group Comparison n 26 31 33 Mean age, (SD) 42.04 (10.01) 31.77 (10.61) 32.42 (13.06) F (2, 88) = 7.02, P = 0.001 BDD × SPA t (55) =−3.73, P < 0.001, d = 0.98 BDD × Control t (57) =−3.10, P = 0.003, d = 0.91 SPA × Control t (62) = 0.218, P = 0.828, d = 0.01 Mean age men started to think 16.46 (9.18) 15.39 (3.64) n/a t (55) =−0.565, P = 0.574 their penis was small, (SD) Mean age penis size became a 19.00 (9.18) 18.08 (4.30) n/a t (55) =−0.452, P = 0.653 significant problem, (SD) Mean age sought help for size 30.35 (12.12) 23.61 (11.83) n/a t (55) =−2.06, P = 0.046 related concern, (SD) Sex Med 2015;3:147–155 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Sexual Functioning in Small Penis Anxiety 151 Table 3 shows scores between groups from each IIEF subscale. There was a significant effect of group on erectile dysfunction, orgasmic function, intercourse satisfaction and overall satisfaction after controlling for participant age. There were no differences in sexual desire between the groups. Post hoc analyses show that participants with BDD had significantly higher erectile dysfunction than controls. BDD participants had significantly lower orgasmic function than those with SPA and controls. Both BDD and SPA participants had lower intercourse satisfaction than controls. Overall satisfaction was significantly lower in men with BDD in comparison with the SPA and control group. Significantly more men with BDD or SPA had both previously attempted to alter the size of their penis (Table 4). No controls reported any previous attempts to alter their size. There were no signifi- cant differences between BDD and SPA groups for both how many times they had attempted to alter the size of their penis, and the procedures they had tried. Reported frequencies were low, between 1 and 3, and the most commonly reported proce- dures tried were “exercises,” specifically “jelqing.” Reported success rates of all procedures tried were low. Discussion This is the first study to investigate the sexual functioning and behavior of men with BDD related to their penis size in comparison with men with SPA and controls in the community. We con- firmed our hypothesis that the BDD group would have difficulties in sexual functioning but not their sexual desire. It was a chronic problem of over 20 years in the BDD group and about 10 years in the SPA group. Differences also occurred between the groups in the frequency of attempts to alter their penis size or appearance. Men with no concerns made no attempts to alter their size whereas men with BDD or SPA did. Up to 80% of the SPA group had used a procedure such as “jelqing.” This is a squeezing and stroking motion performed to force blood flow to the tip of the penis, hypotheti- cally lengthening it. “Stretching” exercises can include tying weights to the penis. Two men had used a vacuum pump, which is a device used to draw blood up through the penis by creating a vacuum around it. Only one man had an “extender” stretching device which has been evalu- ated in one uncontrolled study [28]. Of note is that the success rates of the attempts were low and this © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. Table 2 Sexual history of BDD, SPA, and control participants Small penis BDD group anxiety group Control group Comparison Measure n = 26 n = 31 n = 33 ANCOVA/Fisher’s Exact Test Previous sexual experience, n (%) 23 (88.5) 30 (96.8) 32 (97) Fisher’s Exact Test P = 0.432 Mean age at first sexual experience (SD) 17.17 (5.80) 19.13 (5.78) 18.66 (2.77) n/a Mean number of previous sexual partners (SD) 22.15 (29.37) 35.90 (94.15) 36.16 (105.00) F (2, 86) = 1.60, P = 0.209 Median number of previous sexual partners 12.50 6.00 12.50 Mean number of long-term sexual partners (SD) 3.12 (2.76) 2.13 (1.50) 2.94 (2.95) F (2, 86) = 0.823, P = 0.443 Mean frequency of sexual intercourse per month (SD) 2.88 (4.66) 5.29 (7.78) 6.58 (6.58) F (2, 86) = 0.700, P = 0.499 Mean frequency of pornography access per month (SD) 11.69 (11.45) 13.87 (12.94) 15.00 (12.12) F (2, 86) = 0.219, P = 0.804 Mean age at first masturbation (SD) 14.46 (5.84) 12.58 (3.01) 12.76 (2.17) F (2, 86) = 2.73, P = 0.071 Mean frequency of masturbation per month (SD) 14.54 (11.63) 16.68 (9.91) 20.58 (15.73) F (2, 86) = 1.21, P = 0.304 Belief penis damaged through masturbation, n (%) 3 (11.5) 5 (16.1) 4 (12.1) Fisher’s Exact Test P = 0.859 (0 “not at all”—10 “convinced”) Sexual Orientation, n (%) Heterosexual 19 (73.1) 22 (71.0) 26 (78.8) Fisher’s Exact Test P = 0.790 Homosexual 7 (26.9) 9 (29.0) 7 (21.2) 152 Veale et al. supports previous research [11]. Increased adver- tising for solutions to increase penis size may be responsible for these findings. A simple search on Google will give hundreds of results for “solu- tions” to increase penis size; however the evidence for their efficacy is unproven and unlikely. However, such “solutions” are often risky, and cli- nicians should educate their patients to avoid any “solutions” that have no evidence base and develop an effective psychological therapy for such men. There may be a disproportionate number of homosexual men who are at risk of developing SPA or BDD [23,24]. However there was no significant difference in sexual identity across the groups perhaps because of the perceived importance of penis size to women by heterosexual men [29]. The frequency of homosexual men was however relatively high in all three groups. There may be a bias in the recruitment of homosexual men who may have been more interested than heterosexual men in volunteering for our study. It may there- fore be important to replicate the study in exclu- sively homosexual men. One might expect the mean age of men losing their virginity to be higher for those with BDD influenced by their higher avoidance of intimacy. The non-significant finding could also be explained by the BDD and SPA group concerns having been initiated during or post first sexual experience, although one can only hypothesize at this point this could be further researched in future. It is surprising that there was no significant dif- ference between the groups’ mean numbers of sexual partners and frequency of sexual intercourse per month although this may be a Type 2 error. One might have expected men with BDD who were concerned about their penis size to have had less sexual partners and a lower frequency of sexual intercourse per month given their higher reported avoidance and safety-seeking behaviors in com- parison with controls. Men with penis size con- cerns could be engaging in as many sexual encounters as men without concerns for a number of different reasons. For example, men with penis size concerns might seek sexual encounters (i) in order to seek more opportunities to compare the size of their penis with others (if homosexual) as a form of “checking,” (ii) in order to seek acceptance or reassurance from others that their size is adequate—another safety-seeking behavior or (iii) their sexual drive could over-ride psychosocial processes that reduce the functioning of these men in other important areas of life. Indeed, the IIEF scores do indicate that men with penis size con- Sex Med 2015;3:147–155 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Table 3 International Index of Erectile Functioning scores BDD group SPA group Control group Comparison Pairwise comparisons 1. BDD × SPA 2. BDD × Controls Mean (SD) Mean (SD) Mean (SD) Measure n = 26 n = 31 n = 33 ANCOVA 3. SPA × Controls Erectile dysfunction 13.46 (11.32) 18.70 (10.36) 24.45 (7.08) F (2, 86) = 8.17, P = 0.001 1. Mean diff. = 5.28, S.E = 2.78, P = 0.183 2. Mean diff. = 11.04, S.E = 2.76, P < 0.001 3. Mean diff. = 5.75, S.E. = 2.49, P = 0.069 Orgasmic function 5.31 (3.95) 8.10 (2.60) 9.45 (1.15) F (2, 86) = 16.47, P < 0.001 1. Mean diff. = 3.08, S.E = 0.782, P = 0.001 2. Mean diff. = 4.43, S.E = 0.776, P < 0.001 3. Mean diff. = 1.35, S.E = 0.699, P = 0.170 Sexual desire 5.73 (2.76) 6.17 (1.88) 6.81 (1.94) F (2, 86) = 2.35, P = 0.102 — Intercourse satisfaction 3.81 (4.71) 5.93 (4.79) 9.61 (5.10) F (2, 86) = 8.25, P = 0.001 1. Mean diff. = 1.60, S.E = 1.40, P = 0.762 2. Mean diff. = 5.28, S.E = 1.39, P = 0.001 3. Mean diff. = 3.68, S.E = 1.25, P = 0.012 Overall satisfaction 2.42 (2.59) 3.77 (2.21) 5.61 (2.47) F (2, 86) = 14.81, P =< 0.001 1. Mean diff. = 1.85, S.E. = 0.610, P = 0.010 2. Mean diff. = 3.66, S.E = 0.678, P < 0.001 3. Mean diff. = 1.81, S.E. = 0.683, P = 0.028 Sexual Functioning in Small Penis Anxiety 153 Table 4 Interventions tried to alter the size or appearance of the penis, and their success rates Small penis Control BDD group anxiety group group Measure n = 26 n = 31 n = 33 Comparison Previous attempt to alter the shape or size of the penis, n (%) 11 (42.3) 10 (32.3) 0 (0) Fisher’s Exact Test P < 0.001 Mean number of procedures tried (SD) 1.75 (0.75), 1.36 (0.67) n/a t (20) = .−1.29, P = 0.211 Type of procedure n (%) Exercises 2 (18.2) 8 (80) Pump 2 (18.2) 0 (0) n/a Fisher’s Exact Test P = 0.083 Elastic stretching device 1 (9) 0 (0) Viagra 1 (9) 0 (0) Multiple procedures 5 (45.5) 2 (20) Mean cosmetic success of procedure (0–8) (SD) 2.67 (2.31) 5.00 (1.87) n/a t (20) = 1.58, P = 0.166 Mean reduced preoccupation with size concern following 1.67 (2.08) 4.17 (2.40) n/a t (20) = 1.53, P = 0.170 the procedure (0–8)(SD) cerns do not differ in their sexual functioning, that includes men, with which to compare their desire or satisfaction. Men with a concern may be size? Again, this hypothesis would need to be utilizing their higher levels of safety-seeking investigated through further research. behaviors such as hiding their penis (e.g., in a dark It is possible that some of the non-significant setting) in order to feel more comfortable engag- findings may have been influenced by the size and ing in sexual intercourse. Furthermore, modern recruitment of an opportunistic sample. Our technology such as internet dating sites could be sample may not be representative of men who increasing opportunities for men to find sexual present to urologists, sexual heath or psychiatric partners without the social interactions that might services who may be more depressed or presenting have previously hindered their ability to build a with sexual dysfunction, which may be less stigma- sexual relationship. In fact, two men with BDD tizing and a more medical problem. Equally sexual from the current sample did freely comment that dysfunction may be a moderating factor affecting websites and mobile phone applications which are outcome in those with BDD or SPA. The sample aimed at finding “quick fix sexual encounters” had may be more representative however of men in the made them feel that any humiliation felt from community who are searching for solutions to comments on their penis size could be short lived penis size concerns on the Internet. Therefore, when engaging in purely one-time sexual encoun- this study will need to be replicated in a clinical ters. However, these are of course all only hypoth- setting to determine if our sample is representa- eses, and further research is required to investigate tive. DSM-5 has added a further criterion in BDD these possibilities. for repetitive behaviors (including comparing a It is of interest that the current sample did not feature) but this is unlikely to have made any sig- differ in levels of pornography access or masturba- nificant difference to the composition of our tion. For example, previous findings indicated that sample diagnosed as BDD. Further research the majority of men with penis size concerns are should investigate homosexual and heterosexual comparing their size with images they see in por- men separately in a larger sample. However large nography, which contributes to the maintenance clinical samples (heterosexual or homosexual) with of their BDD as a safety-seeking behavior. There- BDD and SPA are hard to recruit, as such men are fore concerned men may not be watching pornog- avoidant of seeking help and highly stigmatized. raphy purely for sexual gratification. However, of However, non-significant findings may also truly note, internet statistics now report that pornogra- indicate that sexual functioning and behavior are phy websites are among the most frequently not strong predictors of penis size concerns. visited sites worldwide [30], and therefore it is Our sample judged their own interventions of conceivable that watching pornography may not exercises and vacuum pumps to be unsuccessful. be linked to the psychopathology of small penis Further research is now needed to consider spe- anxiety and rather is now considered the “norm.” cific interventions that may help such men. Cos- It may also be of interest to know the type of metic phalloplasty is not indicated [11]. There are pornography viewed by heterosexual men—for evidence-based treatments for BDD for other example, are men with BDD or SPA more likely bodily features, namely cognitive behavior therapy than men with no concerns to access pornography (CBT) and a selective serotonin reuptake inhibitor © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. 154 Veale et al. 9 Perovic SV, Byun J-S, Scheplev P, Djordjevic ML, Kim J-H, [31–34], but they have not been adapted or evalu- Bubanj T. New perspectives of penile enhancement surgery: ated for men with penis size concerns. Men with Tissue engineering with biodegradable scaffolds. Eur Urol SPA might be helped by psycho-education and 2006;49:139–47. counselling but again there are no randomized 10 Spyropoulos E, Christoforidis C, Borousas D, Mavrikos S, Bourounis M, Athanasiadis S. Augmentation phalloplasty controlled trials to evaluate any intervention. surgery for penile dysmorphophobia in young adults: Consid- Overall, the clinical implications of the findings erations regarding patient selection, outcome evaluation and are that professionals should be made increasingly techniques applied. Eur Urol 2005;48:121–8. aware of the presentation of men with penis size 11 Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Man- agement of men complaining of a small penis despite an actu- concerns, the great lengths that such men may go ally normal size. J Sex Med 2013;10:294–303. to change their size, and how they might adapt 12 Veale D. Outcome of cosmetic surgery and “D.I.Y” surgery in their approach to such patients. It is important that patients with body dysmorphic disorder. Psychiatry Bull professionals act by validating clients body image 2000;24:218–21. 13 Rosecker Á, Bordás N, Pajor L, Bajory Z. Hungarian “jail- concerns and developing a psychological interven- house rock”: Incidence and morbidity of vaseline self-injection tion for these men rather than just focusing on any of the penis. J Sex Med 2013;10:509–15. sexual dysfunction (which is often reported by 14 Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures among persons with body such men). dysmorphic disorder. Ann Plast Surg 2010;65:11–6. 15 Tignol J, Biraben-Gotzamanis L, Martin-Guehl C, Grabot D, Aouizerate B. Body dysmorphic disorder and cosmetic surgery: Acknowledgments Evolution of 24 subjects with a minimal defect in appearance 5 This study presents independent research part-funded years after their request for cosmetic surgery. Eur Psychiatry 2007;22:520–4. by the National Institute for Health Research (NIHR) 16 Phillips KA, Grant J, Siniscalchi J, Albertini RS. 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Tel: +44 203 228 4146; Fax: +44 203 228 in-patient treatment for severe, chronic, resistant obsessive- 5215; E-mail: [email protected] compulsive disorder. Psychiatry Bull 2007;31:49–52. 20 Grov C, Parsons JT, Bimbi DS. The association between penis Conflict of Interest: The authors report no conflicts of size and sexual health among men who have sex with men. interest. Arch Sex Behav 2010;39:788–97. 21 Grov C, Wells BE, Parsons JT. Self-reported penis size and experiences with condoms among gay and bisexual men. Arch References Sex Behav 2013;42:313–22. 22 Morrison MA, Morrison TG, Sager CL. Does body satisfac- 1 Wylie KR, Eardley I. Penile size and the “small penis syn- drome.” BJU Int 2007;99:1449–55. tion differ between gay men and lesbian women and hetero- sexual men and women? A meta-analytic review. Body Image 2 Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: Guidelines for penile augmentation. 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Sexual Functioning and Behavior of Men with Body Dysmorphic Disorder Concerning Penis Size Compared with Men Anxious about Penis Size and with Controls: A Cohort Study

Veale, David; Miles, Sarah; Read, Julie; Troglia, Andrea; Wylie, Kevan; Muir, Gordon
Sexual Medicine , Volume 3 (3) – May 27, 2015
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© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine.
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ORIGINAL RESEARCH—PSYCHOLOGY Sexual Functioning and Behavior of Men with Body Dysmorphic Disorder Concerning Penis Size Compared with Men Anxious about Penis Size and with Controls: A Cohort Study David Veale, MD, FRCPsych,* Sarah Miles, MSc,* Julie Read, MA,* Andrea Troglia, PsyD,* † ‡ Kevan Wylie, FRCP, FRCPsych, FECSM, and Gordon Muir, FRCS *Institute of Psychiatry, Psychology and Neurosciences, Kings College London, South London and Maudsley NHS Foundation Trust, London, UK; Porterbrook Clinic, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK; King’s College Hospital, NHS Foundation Trust, London, UK DOI: 10.1002/sm2.63 ABSTRACT Introduction. Little is known about the sexual functioning and behavior of men anxious about the size of their penis and the means that they might use to try to alter the size of their penis. Aim. To compare sexual functioning and behavior in men with body dysmorphic disorder (BDD) concerning penis size and in men with small penis anxiety (SPA without BDD) and in a control group of men who do not have any concerns. Methods. An opportunistic sample of 90 men from the community were recruited and divided into three groups: BDD (n = 26); SPA (n = 31) and controls (n = 33). Main Outcome Measures. The Index of Erectile Function (IEF), sexual identity and history; and interventions to alter the size of their penis. Results. Men with BDD compared with controls had reduced erectile dysfunction, orgasmic function, intercourse satisfaction and overall satisfaction on the IEF. Men with SPA compared with controls had reduced intercourse satisfaction. There were no differences in sexual desire, the frequency of intercourse or masturbation across any of the three groups. Men with BDD and SPA were more likely than the controls to attempt to alter the shape or size of their penis (for example jelqing, vacuum pumps or stretching devices) with poor reported success. Conclusion. Men with BDD are more likely to have erectile dysfunction and less satisfaction with intercourse than controls but maintain their libido. Further research is required to develop and evaluate a psychological intervention for such men with adequate outcome measures. Veale D, Miles S, Read J, Troglia A, Wylie K, and Muir G. Sexual functioning and behavior of men with body dysmorphic disorder concerning penis size compared with men anxious about penis size and with controls: A cohort study. Sex Med 2015;3:147–155. Key Words. Small Penis Anxiety; Body Dysmorphic Disorder; Sexual Function; Small Penis Syndrome Introduction cultural beliefs, which might indicate penis size as of importance, might leave men fearful of negative or men, penis size is often considered a sign evaluation when their penis is exposed in sexual of masculinity and sexual prowess. Social and situations leading to impaired sexual function. © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 148 Veale et al. Small penis anxiety (SPA) (also known as “small retrospective case series the diagnosis of BDD may penis syndrome”) has been described in the litera- be associated with a poor outcome in most cos- ture in men who are dissatisfied or excessively metic procedures [6,14–17]. worried about their penis size which is in the Penis size is considered important to homo- normal range [1]. This definiton excludes men sexual men in terms of how they construct their with a micropenis [2]. Some men experiencing sense of self [18], how they construct masculinity excessive worry or shame about penis size may and that they recognize a notion of “bigger is meet criteria for a diagnosis of Body Dysmorphic better” when defining an ideal male partner [19]. Disorder (BDD) [3]. Individuals with BDD are Homosexual men’s perceptions of size are signifi- excessively preoccupied with a perceived defect in cantly related to sexual positioning as those with their appearance that is either not observable to smaller perceived size more often assume the others or appears only slight. The individual nor- anally submissive sexual position [20]. Grove mally performs repetitive behaviors (e.g., checking et al. [21] subsequently reported that 86% of or comparing) in response to the concerns. They their men had measured their penile size. While must also experience clinically significant distress penis size is important among the male homo- or impairment in social, occupational, or other sexual community, previous research has indi- important areas of functioning. BDD in specialist cated that homosexual men have a vulnerability psychiatric settings is associated with a high rate of to body dissatisfaction in comparison with het- suicide ideation and completed suicide [4,5]. It is erosexual men [22,23] often chronic with an onset during adolescence Recent research investigated the phenomenol- but can take 10 years before obtaining adequate ogy of men with BDD exclusively or mainly treatment [4,5]. The preoccupation in BDD is related to penile size [24,25]. Results found that most commonly on the face. Occasionally in men men with BDD concerning their penis reported it is focused on their penis size [4,5]. It was greater shame and interference in relationships hypothesized that BDD and SPA would interfere compared with men with small penis anxiety and in sexual behavior and reduce the frequency of controls. The shame provoking situations that are sexual behavior more than in men without con- avoided can be broadly categorized into (i) display- cerns because they are generally more impaired. ing a flaccid penis in public situations (for example Individuals with BDD commonly seek cosmetic in changing rooms) and (ii) displaying a flaccid or procedures with the hope that the appearance an erect penis with a sexual partner. Most of the of their perceived flaw(s) can be significantly safety seeking behaviors can be divided into either improved [6,7]. A number of surgical case studies threat detection (e.g., measuring the size or com- have described men seeking phalloplasty augmen- paring) and avoidance or camouflage (e.g., chang- tation as having BDD related to the penis [8–10]. ing one’s posture to avoid their penis being seen). Penile length augmentation can include suspen- Furthermore, men with BDD were found to score sory ligament release; prepubic liposuction; penile higher on symptoms of general psychopathology disassembly and cartilage transplant; girth aug- (e.g., low mood, general anxiety and quality of life) mentation can include lipoinjection; dermal graft; in comparison with men with small penis anxiety temporalis fascia transfer; saphenous vein grafts or no concern. However, little is known about and injection of synthetic materials which have whether or not the perceived shame of a small been comprehensively reviewed in the literature penis affects sexual functioning and behavior. The [11]. People with BDD may also perform D.I.Y same dataset used in the study on phenomenology (do it yourself) surgery—an attempt to correct and characteristics of such men was used in this their perceived physical flaw(s) themselves [12]. study [25]. Thus some men preoccupied by their penis size have injected Vaseline in to their penis [13]. Aims Reports of penile augmentation in men with BDD have not been based on any structured diagnostic Given the severity of BDD and SPA and the interview for BDD or a validated screening scale. limited existing research on BDD exclusively or Therefore, some of the participants reported may mainly related to the penis, this study sought to not meet criteria for BDD. Cosmetic phalloplasty investigate the sexual functioning and behavior of is regarded as experimental for men with small men with BDD relating to penis size and whether penis anxiety without any adequate outcome mea- or not they could be differentiated from men with sures or evidence of safety [11]. Furthermore, in SPA and those who are unconcerned about their Sex Med 2015;3:147–155 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Sexual Functioning in Small Penis Anxiety 149 Main Outcome Measures penis size. Our hypothesis was that men with BDD concerning small penis size were more likely to All participants completed the following question- experience erectile dysfunction and overall poor naires online. sexual satisfaction compared with men with small penis anxiety and men unconcerned with penis Demographic Information size. Information was collected on age, marital status, ethnic origin, employment status and sexual ori- entation. Methods The study consisted of a group cohort design com- Penis Size paring men with BDD exclusively or mainly Penile length was measured in order to exclude related to their penis against men with SPA and men who had a micropenis by an urologist using a controls who did not report any concerns with standard disposable medical measuring tape. their penis size. Sexual History Participants were asked about their sexual orienta- Participants tion; the age when they first had intercourse; the All men were recruited from one of three sources: number of sexual partners they had had in their (i) by email to staff and students at King’s College lifetime; the number of sexual partners lasting 3 London (n = 36), (ii) by email to a database of months or longer; the age they first started to volunteers at the Institute of Psychiatry, Kings masturbate; the frequency of masturbation; the College London (n = 10) and (iii) by a link on the frequency of accessing pornography and the fre- website “Embarrassing Bodies” (n = 44). Embar- quency of sexual intercourse per month. rassing Bodies is an informative television program aired on Channel 4 in which members of International Index of Erectile Function (IIEF) [26] the public present to a doctor with physical and The IIEF is a 15-item self-report scale that has five medical concerns (often rare or unusual). The subscales: erectile function (score range 0–30), program has its own website on which members of orgasmic function (range 0–10), sexual desire the public can both learn about the body and (range 0–10), intercourse satisfaction (range 0–15), related illnesses as well as post queries to profes- and overall satisfaction (range 0–10). Across all 5 sionals. The authors approached the producers subscales, a higher score indicates higher levels of who organized for an advertisement and study sexual functioning. Cronbach’s alpha for the total contact details to be posted on the website. scale was 0.90, and alpha values for each of the 5 In total, 90 participants were included in the subscales ranged from 0.70 to 0.90, indicating study. The inclusion criteria for taking part were good internal reliability. After 4 weeks, test-retest that men had to be aged 18 or above and proficient reliability coefficients ranged from 0.64 to 0.84, in English in order to provide consent and com- indicating high positive correlation. plete online survey questionnaires. Our exclusion criteria were men who: Structured Clinical Interview for DSM-IV (SCID) [27] 1. Had a micropenis (defined as 6 cm or less in the The SCID was used in order to determine whether flaccid state) [2] or not the men worried about their penis size met 2. Had a penile abnormality (e.g., Peyronie’s criteria for a diagnosis of BDD. DSM-IV was used disease, hypospadias, intersex, phimosis) as the study commenced before publication of 3. Had any had penile or prostatic surgery (which DSM-5. Those in SPA group were defined as may affect penis size). expressing worries about their penis size but not 4. Had any condition associated with length loss meeting criteria for BDD. or “acquired short penis,” secondary to a disease or an intervention. e.g., prostate radia- Interventions tion, prostate cancer hormonal treatment, dia- Participants were asked if they have made any pre- betes with severe penile atrophic damage. vious attempt to alter the size or shape of their The Queen Square NHS Research Ethics Com- penis; what type of procedure they have used; the mittee granted ethics permission for the comple- degree of cosmetic success of the procedure (on a tion of the research (Reference 11/LO/0803). scale of 0–8, where 0 was “very much worse” and 8 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. 150 Veale et al. was “very much improved”) and how much the one way ANOVAs were run to compare continu- procedure(s) reduced their preoccupation with ous variables across the three groups. All tests were their penis size and self-consciousness (on the two tailed. Where one comparison is made, alpha same a scale of 0–8). levels were set at 0.05, however where multiple post hoc comparisons were made for mean age, a Bonferroni correction was used to reduce type 2 Procedure error; as comparisons were made between three Advertisements for participants sought to recruit groups, the standard alpha value of 0.05 was men to a study that was interested in their beliefs divided by 3 to given a new alpha value of 0.017. and concerns about their penis size. After complet- ing the questionnaires online, men who expressed any concerns or worries about their penis size were Results interviewed with the SCID by a research psy- chologist either face to face or over the telephone, All the participants were identified as being in the when they were unable to come to the clinic [27]. normal range for penis size. None were close to a Participants then came to an outpatient urology micropenis and therefore none were excluded for department for an examination to exclude a this reason. The flaccid length measurements in all micropenis or other abnormalities. On arrival, par- the participants were between 7 cm and 13 cm. ticipants completed a consent form and were then Men with BDD were significantly older than given privacy in an air-conditioned consulting men with SPA and controls (Table 1). Of those room at a constant temperature (21°C) at sea level. with a concern about penis size there were no Using a disposable tape measure, each participant differences between the age at which men with was measured in the flaccid state from pubis to BDD and SPA first started to think their penis was distal glans (bone-to-tip). small or the age at which penis size became a Twelve men were unable to attend the clinic. In significant problem for them. However, men with order to exclude a micropenis (that would exclude BDD did seek help for their size related concern at them from the study), they were sent standardized a significantly older age than men with SPA. There instructions guided with a tutorial video compiled were no significant differences between the groups by expert urologists, on how to administer self- for marital status, employment status, or ethnicity. measurement and email the results to the research- There were no significant differences between ers and to report any penile abnormalities (e.g., groups for the frequencies who have had any pre- curvature). In addition the SCID was conducted vious sexual experience, mean age of first sexual over the telephone. experience, mean number of previous sexual part- ners or long term sexual partners, or their frequen- Statistical Analysis cies of sexual intercourse per month (Table 2). The Data were analyzed using SPSS v20. Fisher’s Exact median number of sexual partners is reported as Tests were run to calculate differences in categori- well as the mean because the range of frequencies cal variable frequencies across groups. As from 0 to 600 could be considered misleading. Kolmonogorov–Smirnov, skew and kurtosis tests The groups also did not differ on their ages and indicated that the data were normally distributed, frequencies of masturbation or pornography use. Table 1 Demographic comparisons between BDD, SPA and control groups at baseline Small penis BDD group anxiety group Control group Comparison n 26 31 33 Mean age, (SD) 42.04 (10.01) 31.77 (10.61) 32.42 (13.06) F (2, 88) = 7.02, P = 0.001 BDD × SPA t (55) =−3.73, P < 0.001, d = 0.98 BDD × Control t (57) =−3.10, P = 0.003, d = 0.91 SPA × Control t (62) = 0.218, P = 0.828, d = 0.01 Mean age men started to think 16.46 (9.18) 15.39 (3.64) n/a t (55) =−0.565, P = 0.574 their penis was small, (SD) Mean age penis size became a 19.00 (9.18) 18.08 (4.30) n/a t (55) =−0.452, P = 0.653 significant problem, (SD) Mean age sought help for size 30.35 (12.12) 23.61 (11.83) n/a t (55) =−2.06, P = 0.046 related concern, (SD) Sex Med 2015;3:147–155 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Sexual Functioning in Small Penis Anxiety 151 Table 3 shows scores between groups from each IIEF subscale. There was a significant effect of group on erectile dysfunction, orgasmic function, intercourse satisfaction and overall satisfaction after controlling for participant age. There were no differences in sexual desire between the groups. Post hoc analyses show that participants with BDD had significantly higher erectile dysfunction than controls. BDD participants had significantly lower orgasmic function than those with SPA and controls. Both BDD and SPA participants had lower intercourse satisfaction than controls. Overall satisfaction was significantly lower in men with BDD in comparison with the SPA and control group. Significantly more men with BDD or SPA had both previously attempted to alter the size of their penis (Table 4). No controls reported any previous attempts to alter their size. There were no signifi- cant differences between BDD and SPA groups for both how many times they had attempted to alter the size of their penis, and the procedures they had tried. Reported frequencies were low, between 1 and 3, and the most commonly reported proce- dures tried were “exercises,” specifically “jelqing.” Reported success rates of all procedures tried were low. Discussion This is the first study to investigate the sexual functioning and behavior of men with BDD related to their penis size in comparison with men with SPA and controls in the community. We con- firmed our hypothesis that the BDD group would have difficulties in sexual functioning but not their sexual desire. It was a chronic problem of over 20 years in the BDD group and about 10 years in the SPA group. Differences also occurred between the groups in the frequency of attempts to alter their penis size or appearance. Men with no concerns made no attempts to alter their size whereas men with BDD or SPA did. Up to 80% of the SPA group had used a procedure such as “jelqing.” This is a squeezing and stroking motion performed to force blood flow to the tip of the penis, hypotheti- cally lengthening it. “Stretching” exercises can include tying weights to the penis. Two men had used a vacuum pump, which is a device used to draw blood up through the penis by creating a vacuum around it. Only one man had an “extender” stretching device which has been evalu- ated in one uncontrolled study [28]. Of note is that the success rates of the attempts were low and this © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. Table 2 Sexual history of BDD, SPA, and control participants Small penis BDD group anxiety group Control group Comparison Measure n = 26 n = 31 n = 33 ANCOVA/Fisher’s Exact Test Previous sexual experience, n (%) 23 (88.5) 30 (96.8) 32 (97) Fisher’s Exact Test P = 0.432 Mean age at first sexual experience (SD) 17.17 (5.80) 19.13 (5.78) 18.66 (2.77) n/a Mean number of previous sexual partners (SD) 22.15 (29.37) 35.90 (94.15) 36.16 (105.00) F (2, 86) = 1.60, P = 0.209 Median number of previous sexual partners 12.50 6.00 12.50 Mean number of long-term sexual partners (SD) 3.12 (2.76) 2.13 (1.50) 2.94 (2.95) F (2, 86) = 0.823, P = 0.443 Mean frequency of sexual intercourse per month (SD) 2.88 (4.66) 5.29 (7.78) 6.58 (6.58) F (2, 86) = 0.700, P = 0.499 Mean frequency of pornography access per month (SD) 11.69 (11.45) 13.87 (12.94) 15.00 (12.12) F (2, 86) = 0.219, P = 0.804 Mean age at first masturbation (SD) 14.46 (5.84) 12.58 (3.01) 12.76 (2.17) F (2, 86) = 2.73, P = 0.071 Mean frequency of masturbation per month (SD) 14.54 (11.63) 16.68 (9.91) 20.58 (15.73) F (2, 86) = 1.21, P = 0.304 Belief penis damaged through masturbation, n (%) 3 (11.5) 5 (16.1) 4 (12.1) Fisher’s Exact Test P = 0.859 (0 “not at all”—10 “convinced”) Sexual Orientation, n (%) Heterosexual 19 (73.1) 22 (71.0) 26 (78.8) Fisher’s Exact Test P = 0.790 Homosexual 7 (26.9) 9 (29.0) 7 (21.2) 152 Veale et al. supports previous research [11]. Increased adver- tising for solutions to increase penis size may be responsible for these findings. A simple search on Google will give hundreds of results for “solu- tions” to increase penis size; however the evidence for their efficacy is unproven and unlikely. However, such “solutions” are often risky, and cli- nicians should educate their patients to avoid any “solutions” that have no evidence base and develop an effective psychological therapy for such men. There may be a disproportionate number of homosexual men who are at risk of developing SPA or BDD [23,24]. However there was no significant difference in sexual identity across the groups perhaps because of the perceived importance of penis size to women by heterosexual men [29]. The frequency of homosexual men was however relatively high in all three groups. There may be a bias in the recruitment of homosexual men who may have been more interested than heterosexual men in volunteering for our study. It may there- fore be important to replicate the study in exclu- sively homosexual men. One might expect the mean age of men losing their virginity to be higher for those with BDD influenced by their higher avoidance of intimacy. The non-significant finding could also be explained by the BDD and SPA group concerns having been initiated during or post first sexual experience, although one can only hypothesize at this point this could be further researched in future. It is surprising that there was no significant dif- ference between the groups’ mean numbers of sexual partners and frequency of sexual intercourse per month although this may be a Type 2 error. One might have expected men with BDD who were concerned about their penis size to have had less sexual partners and a lower frequency of sexual intercourse per month given their higher reported avoidance and safety-seeking behaviors in com- parison with controls. Men with penis size con- cerns could be engaging in as many sexual encounters as men without concerns for a number of different reasons. For example, men with penis size concerns might seek sexual encounters (i) in order to seek more opportunities to compare the size of their penis with others (if homosexual) as a form of “checking,” (ii) in order to seek acceptance or reassurance from others that their size is adequate—another safety-seeking behavior or (iii) their sexual drive could over-ride psychosocial processes that reduce the functioning of these men in other important areas of life. Indeed, the IIEF scores do indicate that men with penis size con- Sex Med 2015;3:147–155 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Table 3 International Index of Erectile Functioning scores BDD group SPA group Control group Comparison Pairwise comparisons 1. BDD × SPA 2. BDD × Controls Mean (SD) Mean (SD) Mean (SD) Measure n = 26 n = 31 n = 33 ANCOVA 3. SPA × Controls Erectile dysfunction 13.46 (11.32) 18.70 (10.36) 24.45 (7.08) F (2, 86) = 8.17, P = 0.001 1. Mean diff. = 5.28, S.E = 2.78, P = 0.183 2. Mean diff. = 11.04, S.E = 2.76, P < 0.001 3. Mean diff. = 5.75, S.E. = 2.49, P = 0.069 Orgasmic function 5.31 (3.95) 8.10 (2.60) 9.45 (1.15) F (2, 86) = 16.47, P < 0.001 1. Mean diff. = 3.08, S.E = 0.782, P = 0.001 2. Mean diff. = 4.43, S.E = 0.776, P < 0.001 3. Mean diff. = 1.35, S.E = 0.699, P = 0.170 Sexual desire 5.73 (2.76) 6.17 (1.88) 6.81 (1.94) F (2, 86) = 2.35, P = 0.102 — Intercourse satisfaction 3.81 (4.71) 5.93 (4.79) 9.61 (5.10) F (2, 86) = 8.25, P = 0.001 1. Mean diff. = 1.60, S.E = 1.40, P = 0.762 2. Mean diff. = 5.28, S.E = 1.39, P = 0.001 3. Mean diff. = 3.68, S.E = 1.25, P = 0.012 Overall satisfaction 2.42 (2.59) 3.77 (2.21) 5.61 (2.47) F (2, 86) = 14.81, P =< 0.001 1. Mean diff. = 1.85, S.E. = 0.610, P = 0.010 2. Mean diff. = 3.66, S.E = 0.678, P < 0.001 3. Mean diff. = 1.81, S.E. = 0.683, P = 0.028 Sexual Functioning in Small Penis Anxiety 153 Table 4 Interventions tried to alter the size or appearance of the penis, and their success rates Small penis Control BDD group anxiety group group Measure n = 26 n = 31 n = 33 Comparison Previous attempt to alter the shape or size of the penis, n (%) 11 (42.3) 10 (32.3) 0 (0) Fisher’s Exact Test P < 0.001 Mean number of procedures tried (SD) 1.75 (0.75), 1.36 (0.67) n/a t (20) = .−1.29, P = 0.211 Type of procedure n (%) Exercises 2 (18.2) 8 (80) Pump 2 (18.2) 0 (0) n/a Fisher’s Exact Test P = 0.083 Elastic stretching device 1 (9) 0 (0) Viagra 1 (9) 0 (0) Multiple procedures 5 (45.5) 2 (20) Mean cosmetic success of procedure (0–8) (SD) 2.67 (2.31) 5.00 (1.87) n/a t (20) = 1.58, P = 0.166 Mean reduced preoccupation with size concern following 1.67 (2.08) 4.17 (2.40) n/a t (20) = 1.53, P = 0.170 the procedure (0–8)(SD) cerns do not differ in their sexual functioning, that includes men, with which to compare their desire or satisfaction. Men with a concern may be size? Again, this hypothesis would need to be utilizing their higher levels of safety-seeking investigated through further research. behaviors such as hiding their penis (e.g., in a dark It is possible that some of the non-significant setting) in order to feel more comfortable engag- findings may have been influenced by the size and ing in sexual intercourse. Furthermore, modern recruitment of an opportunistic sample. Our technology such as internet dating sites could be sample may not be representative of men who increasing opportunities for men to find sexual present to urologists, sexual heath or psychiatric partners without the social interactions that might services who may be more depressed or presenting have previously hindered their ability to build a with sexual dysfunction, which may be less stigma- sexual relationship. In fact, two men with BDD tizing and a more medical problem. Equally sexual from the current sample did freely comment that dysfunction may be a moderating factor affecting websites and mobile phone applications which are outcome in those with BDD or SPA. The sample aimed at finding “quick fix sexual encounters” had may be more representative however of men in the made them feel that any humiliation felt from community who are searching for solutions to comments on their penis size could be short lived penis size concerns on the Internet. Therefore, when engaging in purely one-time sexual encoun- this study will need to be replicated in a clinical ters. However, these are of course all only hypoth- setting to determine if our sample is representa- eses, and further research is required to investigate tive. DSM-5 has added a further criterion in BDD these possibilities. for repetitive behaviors (including comparing a It is of interest that the current sample did not feature) but this is unlikely to have made any sig- differ in levels of pornography access or masturba- nificant difference to the composition of our tion. For example, previous findings indicated that sample diagnosed as BDD. Further research the majority of men with penis size concerns are should investigate homosexual and heterosexual comparing their size with images they see in por- men separately in a larger sample. However large nography, which contributes to the maintenance clinical samples (heterosexual or homosexual) with of their BDD as a safety-seeking behavior. There- BDD and SPA are hard to recruit, as such men are fore concerned men may not be watching pornog- avoidant of seeking help and highly stigmatized. raphy purely for sexual gratification. However, of However, non-significant findings may also truly note, internet statistics now report that pornogra- indicate that sexual functioning and behavior are phy websites are among the most frequently not strong predictors of penis size concerns. visited sites worldwide [30], and therefore it is Our sample judged their own interventions of conceivable that watching pornography may not exercises and vacuum pumps to be unsuccessful. be linked to the psychopathology of small penis Further research is now needed to consider spe- anxiety and rather is now considered the “norm.” cific interventions that may help such men. Cos- It may also be of interest to know the type of metic phalloplasty is not indicated [11]. There are pornography viewed by heterosexual men—for evidence-based treatments for BDD for other example, are men with BDD or SPA more likely bodily features, namely cognitive behavior therapy than men with no concerns to access pornography (CBT) and a selective serotonin reuptake inhibitor © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:147–155 on behalf of International Society for Sexual Medicine. 154 Veale et al. 9 Perovic SV, Byun J-S, Scheplev P, Djordjevic ML, Kim J-H, [31–34], but they have not been adapted or evalu- Bubanj T. New perspectives of penile enhancement surgery: ated for men with penis size concerns. Men with Tissue engineering with biodegradable scaffolds. Eur Urol SPA might be helped by psycho-education and 2006;49:139–47. counselling but again there are no randomized 10 Spyropoulos E, Christoforidis C, Borousas D, Mavrikos S, Bourounis M, Athanasiadis S. Augmentation phalloplasty controlled trials to evaluate any intervention. surgery for penile dysmorphophobia in young adults: Consid- Overall, the clinical implications of the findings erations regarding patient selection, outcome evaluation and are that professionals should be made increasingly techniques applied. Eur Urol 2005;48:121–8. aware of the presentation of men with penis size 11 Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Man- agement of men complaining of a small penis despite an actu- concerns, the great lengths that such men may go ally normal size. J Sex Med 2013;10:294–303. to change their size, and how they might adapt 12 Veale D. Outcome of cosmetic surgery and “D.I.Y” surgery in their approach to such patients. It is important that patients with body dysmorphic disorder. Psychiatry Bull professionals act by validating clients body image 2000;24:218–21. 13 Rosecker Á, Bordás N, Pajor L, Bajory Z. 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Sexual Medicine – Pubmed Central

Published: May 27, 2015

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