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In a previous blog, I examined Body Dysmorphic Disorder (BDD). At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed. BDD sufferers can think about their perceived defect for hours and hours every day. The International Classification of Diseases (ICD-10) criteria for BDD is:
* Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom(s), even though repeated investigations and examinations have identified no adequate physical explanation, or a persistent preoccupation with a presumed deformity or disfigurement.
* Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormality underlying the symptoms.
One particular body part that has been the focus of some research in the BDD field is that of genitalia. Many men obsessively worry about the size of their penis and think it is too small. This is perfectly normal and the worry or concern is highly unlikely to be a symptom of BDD. In a 2004 issue of the Postgraduate Medical Journal, British psychiatrist Dr David Veale reported that although there are broad similarities between the genders in BDD, there are some differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Dr. David Sarwer (writing in a 2006 issue of Plastic and Reconstructive Surgery) asserted that the rate of body dysmorphic disorder should be examined among patients re-questing atypical procedures and cites the example of those individuals requesting genital surgery.
Back in 2008, Channel 4 in the UK had a television series called Penis Envy. The first episode ('The Perfect Penis') featured a US psychology student who paid $4000 to have his penis lengthened by cutting the ligament in his pubis. Such actions might be indicative of BDD but the programme didn’t explore this facet. Following such operations, men then have to spend the following weeks suspending a weight from their penis for at least eight hours a day. For all the financial and physical burdens faced, the average increase in length is only 0.5-3cm (with official statistics being closer to 0.5cm than 3cm). Other methods of increasing genital size include the injection of silicon into the penis (although this is dangerous and can result in a silicon embolism). Dr. Stephen Snyder was interviewed about (so-called) ‘Penile Dysmorphic Disorder’ (PDD) in an online Psychology Today article. He was quoted as saying:
“I don't know of any statistics on [PDD]. Anxiety or insecurity about penis size is extremely common in men. It would be difficult to determine how frequently the more serious condition of penis-focused BDD occurs. People with BDD tend to avoid mental health specialists…It's much more likely I think that a man with penile BDD will purchase penis enlargement equipment or consult a surgeon than consult someone like me…Some people seem to have an innate tendency for obsessive thinking. Why some of these people develop BDD, and others OCD or Anorexia Nervosa is unknown…A man who begins to obsess about the size of his penis may begin to compulsively and repeatedly measure his erections, and to avoid dating because he's convinced he'll be humiliated. Then the whole thing can spiral out of control, until ultimately he's online studying penis enlargement techniques”.
A 2006 study led by Dr. J. Lever and published by Psychology of Men and Masculinity reported that in an online survey of over 52,000 participants, most male participants rated their penis as average (66%) and only 22% as large and 12% as small. Among the female participants, around 85% of women were satisfied with their partners’ penile size, while only 55% of men were satisfied, with 45% wanting to be larger (and 0.2% to be smaller). More recently, Dr. Warren Holman highlighted the case of ‘Sam’, a 17-year-old white male from a middle-class Jewish family living in Midwest USA with penile dysmorphic disorder (in a 2012 issue of Social Work in Mental Health). As Dr. Holman reported:
“Sam had stopped attending school several weeks earlier, and on many days would not even leave his home. He said he wanted to remain at home and away from school because, ‘My penis is shrinking and people can tell.’ Sam reported he had had his anxiety about his penis for about a year, but until recently had been able to reason himself out of it…Sam was well related, and his mental status was unremarkable except for his belief about his penis”.
Dr. Holman believed that Sam’s conviction that his penis was shrinking (and people could tell) suggested three possible diagnoses (i.e., social phobia; BDD and/or delusional disorder of the somatic type; or schizophrenia). Holman eventually reached the conclusion that Sam’s beliefs were due to BDD although did say that it “may be in a prodromal phase of schizophrenia”. Sam was treated via a form of psychodynamic counseling (which much to the disappointment of Holman ultimately failed perhaps because of initial misdiagnosis).
In 2007, British urologists Dr. Kevan Wylie and Dr. Ian Eardley published a review on penile size in BJU International. They summarized all of the studies on penile size that have examined flaccid penis length, stretched penis length, erect penis length, flaccid penis girth and erect penis girth. They reported that:
“Stretched penile length in these studies was typically 12–13 cm, with an erect length of 14–16 cm. For girth, there was again remarkable consistency of results, with a mean girth of 9–10 cm for the flaccid penis and 12–13 cm for the erect penis…Concern over the size of the penis, when such concern becomes excessive, might present as the ‘small penis syndrome’ [SPS], an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis”.
However, they did also assert that more research was required on the effects of race and age on penile length. Wylie and Eardley speculate that SPS (or ‘locker room syndrome’ as they also call it) originates in childhood following the sight of their father’s, elder sibling’s and/or older friend’s penis. This appears to have support from a 2005 study (also published in BJU International). Dr. N. Mondaini and Dr. P. Gontero surveyed men who thought they had a small penis at an andrology clinic and reported that nearly two-thirds said their SPS had begun in childhood (63%) with the rest saying it began in adolescence (37%). Dr. K. Wylie and Dr. I Eardley also examined the treatment options of men with SPS and also examined the evidence of commercial penis extending techniques. They concluded that:
“It is recommended that the initial approach to a man who has SPS is a thorough urological, psychosexual, psychological and psychiatric assessment that might involve more than one clinician…Conservative approaches to therapy, based on education and self-awareness, as well as short-term structured psychotherapy [cognitive-behavioural therapy] are often successful, and should be the initial interventions in all men. Of the physical treatments available, there is poorly documented evidence to support the use of penile extenders. More information is need on the outcomes with these devices. Similarly, there is emerging evidence about the place of surgery and there are now several reports suggesting that dividing the suspensory ligament can increase flaccid penile length”.
References and further reading
Goodman, M.P. (2009). Female Cosmetic Genital Surgery. Obstetrics and Gynecology, 113, 154-159.
Holman, W.D. (2012). “My Penis Is Shrinking and People Can Tell”: A Confusing Case of Apparent Body Dysmorphic Disorder. Social Work in Mental Health, 9, 319-335
Morrison, T.G., Bearden, A., Ellis, S.R. & Harriman, R. (2005). Correlates of genital perceptions among Canadian post- secondary students. Electronic Journal of Human Sexuality, 8. Located at: http://www.ejhs.org/volume8/GenitalPerceptions.htm
Lever, J., Fredereicjk, D.A. & Peplau, L.A. (2006). Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men and Masculinity, 3,129-143.
Mondaini, N. & Gontero, P. (2005). Idiopathic short penis: myth or reality? BJU International, 95, 8–9.
Sarwer, D.B. (2006). Body Dysmorphic Disorder and cosmetic surgery. Plastic and Reconstructive Surgery, December, 168e-180e.
Snyder, S. (2011). When size obsession gets out of hand. Psychology Today, June 11. Located at: http://www.psychologytoday.com/blog/sexualitytoday/201106/when-size-obs…
Sondheimer, A. (1988). Clomipramine treatment of delusional disorder-somatic type. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 188-192.
Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.
Wylie, K.R. & Eardley, I. (2007). Penile size and the ‘small penis syndrome’. BJU International, 99, 1449–1455.
