800,000 immigrant votes in New York. Keep the border open. Hata hawafichi kama last year, raundi hii wanataka kuiba live live.
[MEDIA=twitter]1463870153947418631[/MEDIA]
800,000 immigrant votes in New York. Keep the border open. Hata hawafichi kama last year, raundi hii wanataka kuiba live live.
[MEDIA=twitter]1463870153947418631[/MEDIA]
Biden anaona vituko moto moto kweli. He is bleeding support mbaya sana. Euphoria is long gone, buyers remorse is niw deep seated. He is backtracking. Mpaka lamestream fakenews media are acknowledging the facts. Maybe this is why our local democrat supporters ngufu yao ya kusupport biden imegwisha.
[SIZE=6]‘Remain in Mexico’: Biden administration expected to …[/SIZE]
https://www.cnn.com/2021/11/24/politics/border-biden-remain-in-mexico/index.html
2 days agoThe anticipated return of the “Remain in Mexico” policy puts the Biden administration on track to have two major Trump-era policies in place at the US-Mexico border by the end of the year, despite …
In New York the leading lobby groups appear to be Chinese and Indian immigrant groups. New York has 117,500 new Chinese immigrants. If Xi Jinping can get a few of his CCP members elected in New York…
Ni kama Sadiq Khan mayor of London. Pakistanis na Indians ndio wanasema huko London.
In Kenya Isilii has a large Somali population, I don’t need to paint the picture. Somalia can decide who rules Nairobi or even Kenya.
https://www.nytimes.com/2021/11/23/nyregion/noncitizen-voting-rights-nyc.html
[SIZE=7]New York Moves to Allow 800,000 Noncitizens to Vote in Local Elections[/SIZE]
New York City will become the largest municipality in the country to allow legal residents to vote if the legislation is approved as expected in December.
Imagehttps://static01-nyt-com.cdn.ampproject.org/ii/AW/s/static01.nyt.com/images/2021/11/23/nyregion/23nyvoting/23nyvoting-mobileMasterAt3x.jpg
Ydanis Rodriguez, center, a councilman who represents Washington Heights in Upper Manhattan, is the prime sponsor of a bill that would allow noncitizens to vote in local elections.Credit…Thalia Juarez for The New York Times
By Jeffery C. Mays and Annie Correal
Nov. 23, 2021
For decades, lawmakers and immigrant advocates in New York City have pushed for legislation that would allow legal residents who are not citizens to vote in municipal elections, a right they had in school board elections until the boards were abolished in the early 2000s.
[COLOR=rgb(184, 49, 47)]A leading opponent, Joseph Borelli, a Republican councilman who represents Staten Island, went further, saying the bill would “weaken” citizens’ votes.
[COLOR=rgb(184, 49, 47)]“Someone who has lived here for 30 days will have a say in how we raise our taxes, our debt and long-term pension liabilities,” he said. “These are things people who are temporary residents should not have a say in.”
“In the so-called blue states, we are moving toward expansion and that includes expansion of noncitizen voting,” said Joshua A. Douglas, a professor at the University of Kentucky J. David Rosenberg College of Law who studies voting rights and election law. “In the so-called red places, you are moving toward more constrictions on the right to vote, which includes noncitizens. The whole world of voting rights has become one that is more polarized, even more than normal.”
Wameamua mbaya mbaya. Remember they want to make DC a 51st state.
There is also a new angle to this agenda. For Biden to merge the North to China he appears to be selling political seats to the CCP.
If Jinping can control the political power in New York or California si ni hivyo.
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RESEARCH ARTICLE Women’s Preferences for Penis Size: A New Research Method Using Selection among 3D Models Nicole Prause1:yin_yang:*, Jaymie Park1‡ , Shannon Leung1‡ , Geoffrey Miller2:yin_yang: 1 Department of Psychiatry, University of California Los Angeles, Los Angeles, California, United States of America, 2 Department of Psychology, University of New Mexico; Albuquerque, New Mexico, United States of America These authors contributed equally to this work. ‡ These authors also contributed equally to this work. * [email protected] Abstract Women’s preferences for penis size may affect men’s comfort with their own bodies and may have implications for sexual health. Studies of women’s penis size preferences typically have relied on their abstract ratings or selecting amongst 2D, flaccid images. This study used haptic stimuli to allow assessment of women’s size recall accuracy for the first time, as well as examine their preferences for erect penis sizes in different relationship contexts. Women (N = 75) selected amongst 33, 3D models. Women recalled model size accurately using this method, although they made more errors with respect to penis length than circumference. Women preferred a penis of slightly larger circumference and length for one-time (length = 6.4 inches/16.3 cm, circumference = 5.0 inches/12.7 cm) versus longterm (length = 6.3 inches/16.0 cm, circumference = 4.8 inches/12.2 cm) sexual partners. These first estimates of erect penis size preferences using 3D models suggest women accurately recall size and prefer penises only slightly larger than average. Introduction Both men and women often have reported discomfort with the appearance of their genitals. While not as common of a concern as body weight, muscularity, amount of head hair and body hair, or height, penis size was a concern for 68.3% of 200 men in one study [1]. Concerns about genital appearance are unique compared to other concerns about physical appearance. First, only intimate partners generally know the appearance of genitals. In contrast to the penis, body weight, acne, and other features are easily observed, informing feelings of attraction early in interactions. While indicators of penis size include ethnicity [2] and finger length and ratio [3, 4], most proposed cues of penis size, including male height and foot size [5], weight [6, 7], shoe size [8], and age [9], are unreliable. Second, no diet, pill, or exercise regime affects the size or shape of genitals. However, about half of men in one study believed that they could change their penis size through non-surgical means [10]. Little can be done to change the appearance PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 1 / 17 a11111 OPEN ACCESS Citation: Prause N, Park J, Leung S, Miller G (2015) Women’s Preferences for Penis Size: A New Research Method Using Selection among 3D Models. PLoS ONE 10(9): e0133079. doi:10.1371/ journal.pone.0133079 Editor: Heather Hoffmann, Knox College, UNITED STATES Received: February 11, 2015 Accepted: June 22, 2015 Published: September 2, 2015 Copyright: © 2015 Prause et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are available via Figshare ( http://dx.doi.org/10.6084/m9 . figshare.1466782). Funding: These authors have no support or funding to report. Competing Interests: The authors have declared that no competing interests exist. of the penis. Contrary to some public opinion, it also is worth noting that discomfort with the appearance of the penis is not impacted [11], or is positively impacted [12], by viewing sex films. Given that only intimate partner(s) view the penis, the appearance is relatively immutable, and sex films are not causing dissatisfaction, partner perceptions of the penis appearance seem to most likely to impact men’s feelings about the features of their penis. The expectations that men have about women’s penis size preferences appear to drive anxiety and dissatisfaction more than some inborn dissatisfaction. In the first questionnaire to examine the nature of dissatisfaction with the penis directly, three of the ten items concerned a partner’s perception [13]. These included “I will be alone and without a partner” and “I will be laughed at by a partner in a sexual situation”. These anxieties may be unnecessary. For example, while men and women agreed that the “ideal” penis length was longer than what they thought was average, men mistakenly reported that women would find an even longer penis ideal than the women actually did [10]. Furthermore, most men seeking surgery to increase their penis size (e.g., [14, 15]), actually fall within the normal penis size range [16]. Concerns about penis size affect men’s sexual satisfaction and functioning. Of course, penis size need not affect sexual functions like orgasm, sexual drive, or pain experience. However, men who are less satisfied with their penis report more sexual health problems [17]. A smaller penis decreases sexual confidence [18], which may be why penis size is related to sexual function. Another reason penis size may be related to sexual functioning is that anxiety concerning the partner’s response may be calculated as a cost of the relationship, which leads him to experience broad sexual dissatisfaction [19]. The context of the sexual relationship could influence penis size preferences. For example, the goal of the sexual interaction with a one-night partner tends to be pleasure [20]. Women recognize that infection risks are higher from a one-night partner [21]. While women adjust their behaviors for this risk, being less likely to engage in anal sex [22] and more likely to use condoms [23] with one-night partners, such risky behaviors themselves are often experienced as pleasurable [24]. On the other hand, vaginal intercourse always causes tears in the vaginal mucosa [25] especially in the sensitive posterior fourchette [26], so women might prefer a smaller penis less likely to stress their physiology for regular, long-term mates. Thus, women might shift their preferences for penis size depending on the type and duration of sexual relationship. Studies of penis size preference to date have relied on numerical size estimates, vague qualitative descriptions, or 2-D line drawings. For example, some studies have asked participants to specify penis length preferences in centimeters [27]. Another study asked participants to indicate their preference from reading erotic passages with three qualitative penis size options (small, medium, large) [28]. Yet, humans judge sizes most accurately when visual and haptic information are available together [29]. Both sources of data are usually available in sexual interactions. Thus, in this study, three-dimensional (3D) models were used with the hope of increasing accuracy, ecological validity, and external validity. Also, most studies of penis size preference have portrayed or asked about the penis in its flaccid state [30, 31]. This may be problematic, because the relationship between erect and flaccid sizes has been reported as negligible [32, 33] moderate (r = .44 in [34], r = .78 in [35]), and strong (rho = .77 in [6], r = .79 in [32]). It is unclear how well flaccid size reflects erect size. Of course, intercourse can occur only with a sufficiently rigid penis [36]. Thus, it seemed important to characterize preferences for penis size in its erect state. The current study used 3D models of erect phalluses to characterize women’s penis size preferences for the first time. Three-dimensional (3D) printing is just beginning to be used to assess shape perception and categorization. On the one hand, visual 2D information as compared to haptic information (from 3D) result in similar solutions for object similarity [37]. Each mode of information (visual or haptic) also improves categorization in the other domain [38, 39]. 3D printing could Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 2 / 17 allow representation of highly problem-specific, complex structures [39]. Haptic information from 3D objects improved shape identification compared to raised lines alone [40] and improves later performance in the visual domain [41], possibly by improving discriminability [42]. Also, haptic information is robust to differences in perceptual acuity, such as occur with aging [43], which make such stimuli attractive when the visual acuity of participants may vary. This study extends the existing work using 3D stimuli to assess size preferences. This approach also permitted characterization of women’s ability to accurately recall the size of erect phallus models for the first time. When flaccid and “stretched” penis sizes are characterized [44], largely by self-measurement [45], they predict erect size surprisingly poorly. Yet there are relatively few studies of erect penis size. This may reflect cultural taboos against researchers or doctors interacting with men who are in a sexually aroused state. One study had men judge their own erect size in relation to a banknote’s length [46]. Two studies of erect penis sizes provided kits for home measurement [47, 48]. Such self-measurements of length and circumference show fairly good test-retest reliability (r = .68 to .90, [47]). Pharmacologically-induced, physician-measured erections identified an average length of 12.89 cm (SD = 2.91) and circumference of 12.3 cm (SD = 2.9; [32]). These were somewhat shorter in length (M = 14.15, SD = 2.7), yet similar in circumference (M = 12.23, SD = 2.2), compared to a recent, large survey [48]. Women’s penis preferences may vary with their relationship expectations. Women prefer more masculine partners for shorter-term sexual relationships [20]. Women also value intelligence more, and attractiveness less, for long term, as compared to short term, partners [49]. More masculine traits, such as lower voice pitch [50] and (to some extent) larger penis size [51, 52] are correlated with testosterone levels, which also may influence men’s mating goals and attractiveness. Since a larger penis size is perceived as more masculine [53, 54], we predict women will prefer a larger penis for shorter-term sexual relationships. Women likely make penis size judgments partly using their recalled experiences. Yet, it is unclear how accurately women can recall penis size. Exposed to nude male images, women do attend to the genital area [55, 56]. People can generally recall if a penis was described as “large”, “medium”, or “small”, or not described at all [28]. In the current study, women’s ability to recall penis size was tested by match-to-sample recall, both immediately and after a delay of ten minutes. Materials and Methods Stimuli: The penis models Based on previous studies (see above) about the distributions of penis length and circumference, the average American erect penis length was estimated as 6 inches (15.2 cm) and circumference as 5 inches (12.7 cm). Models were created to range +/- 3.0 S.D. across each dimension (see Fig 1). This resulted in length ranging 4.0 inches to 8.5 inches (10.2 cm to 21.6 cm), and circumference (circumference) ranging from 2.5 inches to 7.0 inches (6.4 cm to 17.7 cm), using 0.5-inch (1.3 cm) increments (see Fig 1). This yielded a 10 X 10 matrix of 100 possible sizes. However, such a large choice set could overwhelm participants. We chose to sample 1/3 of this space, yielding 33 models across the range of space. The penis model shape was a cylinder, representing the shaft, topped by a dome, representing the penis head (see Fig 2). Of course, the human penis shaft is comprised of three corpora that could be better represented by a rounded triangle and a more complex glans. Also, no veins, testicles, or other details of the penis were portrayed. These details were not represented for three reasons. First, there are no mathematical descriptions available to accurately represent normal proportions of more complex penile structure. Second, women generally rate male Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 3 / 17 Fig 1. Sizes of printed models. Shading indicates the average penis length and girth in the USA. Bold indicates models used for recall (immediate/delayed, counterbalanced) tests. Units are in inches. doi:10.1371/journal.pone.0133079.g001 Fig 2. Penile Models. A) Computer graphic representation of one of the ‘print files’ used to produce the 3D penis models. B) Examples of (4 of 33) 3D models showing length in inches. A and D represent the largest and smallest models in the set, respectively; B and C represent the two models (counterbalanced) used to test recall for size. doi:10.1371/journal.pone.0133079.g002 Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 4 / 17 nudes as less attractive than heterosexual men rate female nudes [57], so making the penis model more realistic might have provoked negative responses. Third, the study was focused on overall penis size, not penis shape or surface details. While one motivation behind the current study was to improve the ecological validity of the stimuli, these concerns suggested starting with a more simplistic, erect penis model. Dimensions of commercial penile models do not vary systematically, so they were not appropriate for research purposes. Thus, the penis models were printed using a Makerbot Replicator 2 in blue ABS plastic (“Navy wool”; printer files for replications are at http://www . thingiverse.com/thing:518401). Files were created using object-oriented Tinkercad [58] and compiled to.stl formats in G-Replicator [59]. Models were light-weight, sturdy plastic with a smooth surface (see Fig 1). After printing, models were checked by measuring tape to ensure accuracy of length and circumference. None required reprinting for accuracy. The models were identified by randomly assigned letters (e.g., “M”, “CC”) written on the bottom of each. This was done to reduce the influence of “largest” and “smallest” anchors and also to eliminate the need for women to measure or infer specific size. The 33 models were evenly split (11, 11, 11) in a three-tier wire basket to ease women’s ability to find the desired model. Baskets were randomly shuffled between participants to reduce selection bias. Participants Volunteer were recruited by flyers around the California university campus, the neighborhood, and local physicians’ offices. The flyers stated that women were requested to volunteer for a study concerning sexuality. The flyers also stated that participants must be female, at least 18 years old, sexually attracted to men, and would be paid $20. The flyer did not mention penis size preferences. Women volunteered by either phone or an online form requesting a phone call. They completed a phone screening to confirm their eligibility (e.g. being aged 18 or over, being sexually attracted to men) before being scheduled as participants. Procedures Upon a participant’s arrival, the Informed Consent document was provided, and women were given time to study it. Afterwards, they were given a chance to ask questions, then the experimenter asked whether they still wish to participate. If the participant verbally consented, the experimental protocol started. The Informed Consent document stated that continuing at this stage constituted consent. Participants never provided their names. Informed Consent was not documented using identifiable personal information, because it was unclear whether the new procedures might influence participants’ willingness to report their penis size preferences. Next, the participant answered questionnaires (described below) presented on a computer in a private room, using a secure connection, on private laboratory server space scripted by the first author in php5. This took about 50 minutes and included the penis size preference tasks and questionnaires (see below). Computer presentation of questionnaires has been shown to increase the reporting of socially less desirable behaviors [60]. After the questionnaires, she completed a 10-minute computer task (data to be reported elsewhere) assessing attention to sexual images. Afterwards, the participants was debriefed, offered the opportunity to ask questions, and given $20 cash. The study protocol, including Informed Consent protocol, was approved by the University of California, Institutional Review Board. Questionnaire The self-report questionnaires included demographic information (e.g., age, ethnicity, sexual orientation), sexual history (e.g., number of sexual partners, sexual coercion, whether penis Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 5 / 17 size played a role in relationship dissolution(s), etc.), and current sexual functioning (e.g. orgasm rates, ease of lubrication, relationship monogamy status, pain during intercourse). These were used to characterize the sample. Other personality questionnaires were included, such as the Sexual Desire Inventory [61] and the Sociosexual Orientation Scale [62] to characterize the sample. Size preference and recall: Recall accuracy After completing the other questionnaires, the experimenter entered with one of the two test models. Two of the original 33 models were randomly selected and reprinted (indicated in black cells in Fig 2). The experimenter informed the participant that she would be handed a model. She was instructed that she would be asked to try to recall the size of the model after inspecting it. During the inspection, she was asked not to measure the model using any objects in the room, but no instruction was provided regarding how she used her own hands. Then, the experimenter left for 30 seconds (without observing the participant’s inspection process), returned, took the test model from the participant and out of the testing room, and asked the participant to select which penis model (from the 33 described above) was most similar in size to the test model she just handled. The participant recorded the letter code from the bottom of that model into the computer. The delayed-recall task was similar, except this time, the participant did not immediately search for the model. Instead, she was given ten minutes to complete the penis size preference questionnaire (below). The preference questionnaire would increase memory interference, which is desirable for ecological validity as women asked to recall a former partner’s penis size may have sex with other new partners in the delay. After this, the participant was instructed to attempt to locate the second model (from the 33 described above). The test models were counter-balanced, so the recall type (immediate or delayed) would not be confounded with test model size (larger or smaller). Size preference and recall: Penis Size Preferences After completing the immediate recall task, participants answered 15 questions about their penis size preferences. Each involved picking one penis size model from amongst the 33 models available. The option “No answer” also was available for each. For this study, the key questions were to select the model that they believed best reflected the average of men, which size is most likely to carry a sexually transmitted infection, and which size she would prefer for different expected relationship durations. The questions about preferences for different types of partners were a bit more complex. For one-time partners the question was: “Imagine you’re single and you’re out at a restaurant with some friends. You meet an attractive man who is also single. He seems kind, intelligent, funny, and has a great job. You are feeling sexually aroused. He says he’s in town for a conference but he has to fly back home tomorrow afternoon. If you could spend only this one night with him, what size would you want him to be?” For long-term partners the question was: “What would be the ideal size for a husband or serious, long-term boyfriend?” The question regarding shorter-term partners clearly included much more detail. This was done in an attempt to control for intervening variables not of interest. For example, if a woman doubted at all for her safety with an unknown partner, she might select smaller models in the event of sexual assault. Thus, safety cues were included in the characterization. Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 6 / 17 Data analyses Recall error was calculated as the difference of the dimension the participant chose minus the size of the actual sample. Thus, a positive number would indicate that participants chose a model larger than what they were shown. A within-participant ANOVA was calculated with the interaction of dimension (length, circumference) by recall (immediate, delayed. Put another way, the accuracy of recall could be affected by length or circumference being recalled better than the other dimension (dimension factor), by the length of the delay was until they selected a model (recall), or an interaction where length or circumference were recalled better at either the shorter or longer delay. Descriptive data are provided regarding the size that women believed was average and the range women indicated for their “smallest” and “largest” sexual partner. To test whether women’s preferences differ by partner type, an ANOVA with dimension (length, circumference) X partner (one-time, long term) predicting preferred inches was conducted. A custom model was specified without dimension as a main effect, because dimensions were stipulated to be different in the generation of the stimuli. Results Participant demographics and sexual experience All participants (N = 75) were screened to report sexual attraction to men, and ranged in age from 18 to 65. They were California residents, mostly white or Asian, sexually experienced, currently in a sexual relationship, and had sex recently (see Table 1). Twenty-seven percent of women reported that they had ended a relationship due, in part, to a mismatch between their penis size preference and their partner’s penis size (see Table 1). More women cited that the penis was too small as a problem, rather than that the penis was too large. The length and circumference of the model that each woman believed best represented the “average” penis size is presented in Figs 3 and 4 shows every woman’s selection of the “smallest” and “largest” sexual partner with whom she had contact. Recall accuracy Most (N = 48) women selected the exactly correct model (in both length and circumference) at immediate recall (see Fig 5). About half (N = 31) of women selected exactly the correct model at delayed recall. There was a main effect of dimension predicting model selection error (F (1,73) = 11.6, p < .001, ηp 2 = .14): participants slightly underestimated penis length after the recall interval (M = -0.18 inches or -0.46 cm error), but were very accurate recalling penis circumference (M = 0.02 inches or 0.05 cm error). There was no main effect of delay nor dimension X delay interaction despite high power (f = .1, r = .9, 1-β = .97). Given the high accuracy, analyses for preferences were conducted as planned. Does the expected relationship duration affect penis size preference? For the penis size preferences for one-time or long-term partners, 15 women indicated “No answer”. Analyses were conducted on the remaining participants (N = 60). There was a small main effect for expected relationship duration, F(1,59) = 4.4, p = .04, ηp 2 = .07 (see Fig 6), such that participants preferred a slightly larger penis size in one-time (length = 6.4 inches or 16.3 cm, circumference = 5.0 inches or 12.7 cm) partners as compared to long-term partners (length = 6.3 inches or 16.0 cm, circumference = 4.8 inches or 12.2 cm). There was no interaction of dimension (length, circumference) and relationship duration. Using independent t-tests separately predicting length and circumference preferences for partner type resulted in a Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 7 / 17 Table 1. Demographic characteristics of participants. Variable M SD Age 24.7 10.5 Intercourse partners (last 12 months) 3.2 5.3 Intercourse partners (in lifetime) 6.0 9.0 Number of penises touched (lifetime) 6.8 9.0 Na % Sexual orientation (self-identified) Heterosexual 36 57.1 Bisexual 10 15.9 Lesbianb 8 12.7 Asexual 6 9.5 Queer 3 4.8 Did not identify 11 14.7 Racec White 28 37.3 Asian 24 32.0 Hispanic (non-white) 16 21.3 Black 10 13.3 Pain with intercourse None 28 37.3 Mild 20 26.7 Discomforting to excruciating 27 36.0 Frequency of intercourse (last month) Not once 26 35.1 1 to 3 times a month 22 29.3 About once a week 10 13.5 2 or 3 times a week 13 17.6 4 times a week or more 3 4.0 One night stand experience (lifetime) Not once 34 45.3 Once or more 41 54.7 Penis size concernd A lot more 0 0 A little more 11 15 About the same as other women 37 49 A little less 13 18 A lot less 12 16 Relationship ended due to penis size preferencee Penis too large 5 7 Penis too small 15 21 a Numbers may not sum to total due to non-response.; b Recall that participants were required to report attraction to men to participate, thus a “Homosexual/ Lesbian” self-identity did not preclude attraction to men; c Participants were allowed to indicate more than one option. Top 4 endorsed races or ethnicities are included. d Question wording “How much do you think you care about penis size compared to other women?” e Question wording “Have you ever stopped seeing a man because, among other reasons, his penis was too large[small] compared to what you wanted?”, number indicates count endorsing. doi:10.1371/journal.pone.0133079.t001 Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 8 / 17 significant difference for the test of circumference (t(59) = 2.4, p = .02, d = .2) only. Women preferred a larger circumference in one-time partners (M(SD) = 5.0(.1)) relative to long-term partners (M(SD) = 4.8(.1)). As ANOVA corrects for multiple comparisons, it is a more appropriate statistical test for these data. These t-tests are noted for full disclosure of the analyses conducted. Only 16 women selected a model as “most likely to have an STI”, whereas most women declined to select a model. Of the women who did respond, the model selected as most likely to have an STI was significantly larger (M(SD) = 6.2(.3)) than the model women used to indicate their one-night stand (M(SD) = 5.8(.2)) preference, F(1,15) =, p = .01, ηp 2 = .35. This finding did not vary by the dimension (length, circumference). Discussion Women attended one session in the laboratory during which they completed questionnaires about their sexual history and selected among 3D erect penis models to indicate their size preferences for one-time or longer-term partners. The state-space appeared to well-characterize the range of women’s experience, as their “largest” and “smallest” partners did not show evidence of ceiling or floor effects. Women tended to recall the size of the 3D models very well, only underestimating penis length. Women preferred a larger penis size (especially a larger circumference) for one-time partners as compared to long-term partners. While this preference for a larger phallus is above the average penis size, it is only very slightly above the average. Fig 3. Size of model selected by women indicating the “average” penis size. (N = 75, r = .48). doi:10.1371/journal.pone.0133079.g003 Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 9 / 17 While most declined to identify a penis size most likely to carry an STD, women selected even larger phallus sizes as the most likely to be infected with an STD. A delay in model recall did not significantly worsen participant’s recall of the model size. In fact, women were generally very accurate in identifying the same model at both immediate and delayed recall. When they did make errors, they slightly underestimated model length. One possible explanation is that women care more about circumference, so they may attend to it more [63]. Some authors have argued that penis length actually is more important and Fig 4. Largest and smallest penis experiences. No evidence of ceiling or floor effects in women’s choices indicating their largest and smallest sexual partner’s penis size. doi:10.1371/journal.pone.0133079.g004 Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 10 / 17 “healthy” to desire than circumference (e.g., [64, 65]), but others have not replicated this reported pattern. These data are generally consistent with Mautz et al. (2013), which asked women to rate the attractiveness of life-sized, projected, rotating drawings of male figures with flaccid penises of Fig 5. Recalled sizes (immediate and delayed) slightly shorter than actual model with most picking exact model. Note: “0” indicates the exact correct model was chosen. Positive values indicate that the selected model was larger than the target model. doi:10.1371/journal.pone.0133079.g005 Fig 6. Preference for larger penis in one-time relative to long-term relationships. doi:10.1371/journal.pone.0133079.g006 Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 11 / 17 various sizes. Their participants preferred phalluses 2SD above their estimated populationaverage penis size, whereas our participants preferred penises that were only a little above average. This difference may be due to their images depicting flaccid penises, whereas our models depicted erect penises. Since women’s preferences for both relationship types were slightly larger than the average male, the preferred size for the one-time partner was farther from the average. Novelty itself contributes to pleasure [66], so seeking a more novel-sized penis may be consistent with a goal to pursue pleasure primarily in one-time partners. Women may prefer a smaller penis size in a long-term partner compared to a one-time partner for reasons of both physical comfort and a preference for less masculinity in a longer term partner [67]. The difference in pleasure motive is also suggested by genital physiology. A larger circumference might stretch the vaginal opening such that the deep structures (clitoral crura and vestibular bulbs) are more stimulated, and the clitoral glans is more stimulated by penis movement [68]. Also, the vagina is densely packed with pressure-sensitive mechanoreceptors that detect stretch sensations [69]. These appear finely tuned to detect variability in circumference, whereas the vagina is less sensitive to differences in other stimuli such as vibration or warmth [70]. Other studies also found that women prefer a relatively larger penis proportional to body size [31], especially with respect to circumference (e.g., [54]). Given that women typically experience more pleasurable and orgasmic sex in longer-term relationships [71], they might prefer a larger penis for short-term sex partly so the increased physical sensation compensates for the reduced psychological connection. In one notable exception, a preference for general body somatotype did not differ by the relationship duration [brief uncommitted versus long-term partners in 72]. A larger penis could contribute to infection risks, such that a larger penis on more risky one-time partners elevates risk. A larger penis has been associated with higher infection rates amongst men who have sex with men [73]. Also, an increase in friction during intercourse from a condom is associated with the introduction of more bacteria into the vagina [74, 75] and more vulvar erythema [74]. Finally, women report that condoms increase their experience of pain during intercourse [76, 77]. Anything that increases friction during intercourse may promote genital injury, indirectly increasing infection risk. A larger phallus would increase friction relative to a smaller phallus. These potential complications of a larger penis suggest why the human penis has not evolved to be larger. Individual differences among the women were not examined in relationship to their penis size preferences, although various female traits could interact with their sexual health risks. For example, women with wider hips tend to have a higher proportion of one-time sexual partners [78]. While women’s vaginal depth and pelvic muscle tonicity has been characterized [79, 80], these traits have never been related to women’s penis size preferences. Presumably, given the variability in vaginal size and tonicity, some women would experience more tearing with a larger phallus than other depending on the morphology of their particular vagina. Generating haptic stimuli was relatively cost-effective and simple. Free software was available for generating print files. Also, the print files are shared online to allow exact future replications. Undergraduate research assistants were able to create and monitor the work flow. The 3D printer used is now widely, cheaply commercially available. Expanding this model into preferences pertaining to other domains, or even for other penis shape preferences, appears desirable. As a first study using life-sized 3D models of erect penises to investigate preferences, some limitations exist. Models were not perfectly ecologically valid. They were blue to minimize racial skin-color cues. They were made with rigid, odorless plastic. They were a simplified dome-on-cylinder form rather than realistically shaped and textured. The male body was neither described nor portrayed. There were also limitations of self-report approaches. Men and Women’s Preferences for Penis Size PLOS ONE | DOI:10.1371/journal.pone.0133079 September 2, 2015 12 / 17 women appear to have actually become less approving of one-time sexual partners since 2001 [81], which may affect the preferences that they are willing to report regarding such partners. Also, a significant minority (15 of 75) of women chose not to report a preference for penis size in short and long term partners, but did answer both of the recall questions. Perhaps these women did not have a clear preference, consistent with weak penis size preferences reported in some previous studies [54, 65]. This could be viewed as a strength, insofar as women did not feel compelled to answer in cases where they did not feel they had a strong enough basis to generate an answer. Another limitation is sexual inexperience among some participants. Fifteen women in our sample indicated that they had never experienced sexual intercourse. This inexperience could underlie some of the size preferences observed. For example, women generally anticipate more pain with their first intercourse than they actually experience [82], so they may show riskaverse penis size preferences (for shorter length and thinner circumference than they may prefer with experience). Less experienced women may also be less accurate in their size estimates. However, a follow-up analysis showed that having had sexual intercourse (yes or no) did not predict penis size preferences, arguing against this possibility. A related limitation is that the experimental protocol necessarily limited the sample size, and these women were recruited largely near a college campus. There may be other biases in the sample related to the recruitment method and sample size that were not identified. There are several implications of these data for males interested in long-term female partners. Males with a larger penis may be at an advantage when pursuing short-term female partners. Also, this study provides the first data on the accuracy of women’s penis size judgments. Furthermore, women tended to slightly underestimate the length of penis models after a recall delay. Women may misremember specific partners penis attributes as smaller than they really are. This may exacerbate men’s anxieties about their penis size. Men dissatisfied with their penis size have historically benefitted more from counseling than from surgically increasing their penis size [83]. This may help explain why most men seeking surgical interventions for enlarging what they perceive to be a small penis actually have a penis that falls within a normal range [16]. Finally, 3D printing allows greater flexibility and complexity in stimuli and highly accurate replications. This first use of 3D stimuli to assess preferences is promising. 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84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected] 84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
84 Sao Paulo Med J. 2015; 133(2):84-90 ORIGINAL ARTICLE DOI: 10.1590/1516-3180.2013.7710008 Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a cross-sectional pilot study Percepções sobre o tamanho do pênis em homens brasileiros supostamente saudáveis de 40 a 60 anos: um estudo piloto transversal Margareth de Mello Ferreira dos ReisI , Sidney GlinaII, Carmita Helena Najjar AbdoIII Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil ABSTRACT CONTEXT AND OBJECTIVE: Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. DESIGN AND SETTING: Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. METHODS: In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. RESULTS: Seven men (2.3%) reported that they were dissatisfied with their penis size (they thought that it was small), and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). CONCLUSION: The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. RESUMO CONTEXTO E OBJETIVO: Muitos homens buscam tratamento médico com a queixa de que seus pênis são muito pequenos (curtos), quando na verdade não são (não são casos de micropênis). O objetivo do presente estudo foi avaliar a satisfação com o próprio corpo e vida sexual e a prevalência de disfunção erétil entre homens que não estavam buscando aconselhamento médico ou psicológico. TIPO DE ESTUDO E LOCAL: Estudo transversal, em um hospital privado filantrópico em São Paulo, Brasil. MÉTODOS: Neste estudo, 300 homens doadores de sangue, com idade entre 40 e 60 anos, responderam um questionário, em privacidade, sobre sua vida sexual e satisfação com o próprio corpo. Eles também foram rastreados para disfunção erétil por meio do questionário International Index of Erectile Function. RESULTADOS: Sete homens (2,3%) disseram estar insatisfeitos com o tamanho de seus pênis (achavam que era pequeno), e entre estes, um tinha disfunção erétil leve. Entretanto, nenhum deles procurou atendimento médico. Entre esses sete, somente dois estavam com índice de massa corporal normal, três estavam com sobrepeso e dois eram obesos. CONCLUSÃO: A prevalência de insatisfação com o tamanho do pênis foi pequena. Entre os sete homens insatisfeitos, apenas um tinha disfunção erétil, leve, e todos se sentiam potentes. I PhD. Psychologist at Instituto H. Ellis and Researcher at the Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo; and Coordinator of the Postgraduate Course “New Paradigms in Sexual Health” at Faculdade de Medicina do ABC, Santo André, Brazil. IIMD, PhD. Head of the Department of Urology, Hospital Ipiranga, São Paulo, Brazil. IIIMD, PhD. Program of Studies on Sexuality (ProSex), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. KEY WORDS: Erectile dysfunction. Sexuality. Body dysmorphic disorders. Penis. Prevalence. PALAVRAS-CHAVE: Disfunção erétil. Sexualidade. Transtornos dismórficos corporais. Pênis. Prevalência. Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 85 INTRODUCTION The penis is considered to be a symbol of masculinity in many cultures, and the phallus often represents potency, fertility, strength and male power. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.1,2 In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.2 A Google search for “penile enlargement”, on July 2, 2011, retrieved more than 19 million websites, thus showing indirectly that there is great popular interest in gaining increased penis size. Micropenis is a medically described condition of a penis of less than 4 cm (flaccid) or 7 cm (stretched).3,4 This abnormality of penis size is also considered to be 2.5 standard deviations smaller than the mean penile length for a given population.5 “Candidates” for penile augmentation would be those with a length of less than 4 cm (flaccid) or 7.5 cm (erect/stretched).4 Normal penis size has been measured in several studies and is known to be different according to the population observed. In a review by Ghanem et al., average penis length was reported as being 12.3 cm stretched and 12.7 cm erect.6 However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.6,7 They are just esthetically dissatisfied,6 and many surgery clinics (urology and plastic) are probably profiting from this dissatisfaction. While this is an issue still under investigation, this complaint has already being named in the literature as “penis dysmorphophobia”,3,6,7 a condition in which men seek medical treatments believing that their penises are too short.3,7 Some studies have shown that, on measurement, their penises are in fact found to be normal.3,6-9 Once informed that they have no abnormality, approximately 70% of these men give up treatment.7,8 The fact is that their penises are not impairing sexual activity (intercourse), because they are normal sized. What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy (they were not recruited in hospitals or clinics, and they were healthy enough to be blood donors) and who were not seeking diagnoses or self-information on sexual behavior or function. That study10 revealed an opportunity to investigate whether those men were satisfied with their penis size. The present study is thus a specific analysis on the previous database. OBJECTIVE The aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size. METHODS Study design In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling (total length of school attendance). Being heterosexual and in a stable partnership for at least six months, irrespective of marital status (in order to ensure a minimum period of sexual interaction with their partner), were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects. Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.11 They also answered a specific question about their self-perception of erectile dysfunction: “do you feel sexually potent”? They were asked if they had sought for treatment for any problem they might have. The results from this analysis have already been published.10 The men also gave answers to questions about their own perception of aspects of their personal lives and bodies, such as sexual life, length of relationship with their partner, satisfaction, attraction towards their partner, sexually potency, erection and the satisfaction with their own body and penis size. The subjects answered the questionnaires voluntarily while waiting to donate blood (and after being considered able to donate blood by health professionals), and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed. The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 86 Sao Paulo Med J. 2015; 133(2):84-90 dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample. RESULTS As already reported elsewhere,10 among the 300 men included, 236 (78.6%) were aged 49 years or less. The majority (213; 71%) had 4 to 11 years of schooling. The majority (274; 91.3%) were satisfied with their relationships, classifying them as good or excellent, and most (97.3%) felt sexually attracted towards their partners, and answered that their sexual desire was excellent or good (279; 93%). The majority of the men said that they felt comfortable when talking about sex. Twenty of them said they had a curved penis. Although the majority (253) said that they were satisfied with their bodies, most of them were overweight (body mass index, BMI ≥ 25 kg/m2 ; 200). Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent. Men’s profiles Seven subjects (# 15, 26, 102, 171, 209, 227 and 233) were dissatisfied with their penis size. Their profiles (Table 1) are described individually below. Subject # 15: This obese man (BMI 33.56 kg/m2 ) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction (he obtained a satisfactory erection in most of his sexual encounters). This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years. Subject # 26: This overweight man (BMI 26.70 kg/m2 ) thought that he was fat, with a waist that was too large. He desired a bigger Subject # 15 26 102 171 209 227 233 Body mass index 33.5 26.7 23.6 32.3 25.7 22.7 26.2 Satisfied with body? No No Yes No Yes Yes Yes International Index of Erectile Function score 21 30 29 26 27 28 30 Satisfied with relationship? Good Good Great Good Great Moderate Great Attracted to the partner? No Yes Yes Yes Yes Yes Yes Comfortable talking about sex? Not at ease, nor uncomfortable Comfortable Comfortable Not at ease, nor uncomfortable Comfortable Not at ease, nor uncomfortable Comfortable Sexual Desire Moderate High High Good High Moderate Good Sentence 1 Yes Yes No Yes Yes No No Sentence 2 Yes No No No Yes No No Sentence 3 No No No No No No No Sentence 4 No No No Yes No No No Sentence 5 No No No No No No No Sentence 6 No No No No Yes No No Sentence 7 No No No No No No No Sentence 8 No No Yes No No No No Sentence 9 Yes No Yes No Yes Yes Yes Sentence 10 No No No No No No No Sentence 11 Yes Yes Yes Yes Yes Yes No Sentence 12 No No No No Yes No No Sentence 1 - We are liberated people and we feel comfortable about sex; Sentence 2 - A real man does not dwell on things as delicate as feelings and communication; Sentence 3 - All physical contact is sexual or should lead to the sexual act; Sentence 4 - A man is always interested in and constantly willing to have sex; Sentence 5 - A real man performs well in the sexual act; Sentence 6 - Sex is centered on an erect penis and on what you do with it; Sentence 7 - Sex is the same as intercourse; Sentence 8 - A man should be able to make the earth shake under the feet of his partner; Sentence 9 – A good sexual act requires orgasm; Sentence 10 - Men should not listen to women during sex; Sentence 11 - Good sex is spontaneous, without planning and without talking about it; Sentence 12 - Real men do not have sexual problems. Table 1. Data and responses to questions among seven men who were dissatisfied with their penis size Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 87 penis. This man felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function). He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex. Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2 ). He was very satisfied with his partner, to whom he was attracted; he felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex. Subject # 171: This obese man (BMI 32.36 kg/m2 ) was satisfied with his partner and felt attracted to her. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it. Subject # 209: This slightly overweight man (BMI 25.77 kg/m2 ) was highly satisfied with his partner, to whom he felt attracted. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and classified his sexual desire as “high”. He said that he felt “ok” talking about sex. Subject # 227: This man with normal weight (BMI 22.75 kg/m2 ) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function), but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable. Subject # 233: This man was slightly overweight (BMI 26.23 kg/m2 ). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent (he did not have erectile dysfunction according to the International Index of Erectile Function) and his sexual desire was good. He felt “ok” talking about sex. DISCUSSION An Italian study assessed 67 men who visited an andrology clinic complaining of a short penis. The majority were concerned only about the length of the flaccid penis. They were asked to “guess” what a normal penis size would be and, for them, a penis length of 10 cm to 17 cm (12 cm on average) was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.7 Three years later, the Egyptian urologist Shamloul8 also asked his patients what the normal penis size should be, before measuring their size. They estimated that the normal size was 13 cm (range: 11 cm to 17 cm); 94% overestimated the normal penis size. None of them had erectile dysfunction or anatomical abnormalities such as a micropenis. The onset of worries about penis size began during childhood or adolescence for the majority. After an explanatory session about anatomy and sexual intercourse, 86% of the patients agreed that their penis size concerns had been eliminated. The remaining 14% received psychological counseling, after which 84% of these men gave up the idea of seeking enlargement surgery. The data presented here were collected as part of a larger study of ours.10 The results presented here showed that 2.3% of the sample of blood donors said that they were dissatisfied with their penis size. These findings were obtained at a time when it was no longer possible to contact the subjects, who were interviewed at the time when they were in the blood center making their donations. Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”. While simple esthetic problems (such as big or small breasts or noses; or too much or too little hair) can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort (such as “I do not like my nose” or “I feel bad about being bald”), which is something that people can cope with over a long life, or whether it was something that led to distress. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 88 Sao Paulo Med J. 2015; 133(2):84-90 It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation. Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.2,4,12-14 Some of them investigated correlations between penis size and height, BMI or other somatometric parameters, including index finger length.12-14 However, it is still too soon to establish an average penis size for each average height range or any other characteristic, since no significant associations were found. In fact, Lever et al.15 investigated this issue using the internet, with more than 50,000 participants, and found that 12% thought that their penises were small, while 22% thought that their penises were large and 55% said that they were satisfied with their penis size. Among the men who rated their penis size as “average”, 46% wanted it to be larger, and this rate increased to 91% among those who thought that their penises were small. Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.15 Whether this idea would be realistic or not is an issue to be discussed further. As stated by Lever et al.,15 “Addressing the problem of male dissatisfaction with penis size is particularly important in the modern technological age where alteration of the body through cosmetic surgery has become a widespread phenomenon”. Treating penises that are not really small can be considered to be esthetic therapy, rather than functional therapy.3 A recent review on the subject concluded: “Current data regarding the results and complication rate of interventional augmentation procedures are reported mainly in patients without an objective penile-shaft problem, and they are extremely disappointing. There is a need for scientific and methodological research on the outcomes and complication rate of all these procedures”.9 The review points out that, from the surgical point of view, the techniques available fail to show efficacy and the complication rate is high: infections, shortening (instead of increasing the length), curvature and retraction are some of the complications reported. Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.6 agreed that “penile augmentation surgery is still experimental and should be limited to research or university institutions with supervisory ethics committees, where well-informed, properly evaluated and properly counseled patients accept the potential risks of the procedure. Only limited data support the use of stretching devices for penile augmentation”. As shown by the Italian study,7 reassurance about normality can avoid unnecessary treatments. We strongly agree with the idea that psychological evaluation and counseling can help patients before they even consider undergoing procedures that are always risky, such as surgery, or before they start buying useless penis enlargement devices sold through the internet. Rather, it is important to understand the factors that contribute towards penis dissatisfaction.15 The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be (an issue that could be easily be resolved through a medical consultation). All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling. Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,16 commented on penis size saying that “size matters”. He stated that although penis size is a very common concern for men, they do not see each other’s erect penises except in erotic movies. What they see in these films are actors who have been hired precisely on the basis of uncommonly big penises, which are further enhanced through filming techniques such as lighting, camera tricks and other effects. Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Perceptions about penis size among supposedly healthy 40 to 60-year-old Brazilian men: a pilot study. A cross-sectional study | ORIGINAL ARTICLE Sao Paulo Med J. 2015; 133(2):84-90 89 Egyptian study.7,8 The dissatisfaction among those subjects began during childhood and adolescence and, once they had been told that they were within the normal range, most of the men became reassured and gave up the idea of augmentation surgery. What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.15 The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size. Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis (fully stretched manually) was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.5 Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception. On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study (for example, body mass index and dissatisfaction with the body). One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder. CONCLUSION 1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them. REFERENCES 1. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99(6):1449-55. 2. Shaeer O, Shaeer K. Impact of penile size on male sexual function and role of penile augmentation surgery. Curr Urol Rep. 2012;13(4):285-9. 3. Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the ‘efficacy’ and tolerability of a penile-extender device in the treatment of ‘short penis’. BJU Int. 2009;103(6):793-7. 4. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156(3):995-7. 5. Gabrich PN, Vasconcelos JSP, Damião R, Silva EA. Avaliação das medidas do comprimento peniano de crianças e adolescentes [Penile anthropometry in Brazilian child and adolescent]. J Pediatr (Rio J.). 2007;83(5):441-6. 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med. 2013;10(1):294-303. 7. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res. 2002;14(4):283-6. 8. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65(6):1183-5. 9. Vardi Y, Har-Shai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol. 2008;54(5):1042-50. 10. Reis MM, Abdo CH. Prevalence of erectile dysfunction as defined by the International Index of Erectile Function (IIEF) and self-reported erectile dysfunction in a sample of Brazilian men who consider themselves healthy. J Sex Marital Ther. 2010;36(1):87-100. 11. Ferraz MB, Ciconelli JRM. Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa [International index of erectile function: cultural adjust and translation of portuguese]. Revista Brasileira de Medicina. 1998;55:35- 40. Available from: http://www.moreirajr.com.br/revistas.asp?id_ materia=1669&fase=imprime. Accessed in 2014 (Jan 30). 12. Söylemez H, Atar M, Sancaktutar AA, et al. Relationship between penile size and somatometric parameters in 2276 healthy young men. Int J Impot Res. 2012;24(3):126-9. ORIGINAL ARTICLE | Reis MMF, Glina S, Abdo CHN 90 Sao Paulo Med J. 2015; 133(2):84-90 13. Awwad Z, Abu-Hijleh M, Basri S, et al. Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res. 2005;17(2):191-5. 14. Spyropoulos E, Borousas D, Mavrikos S, et al. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485-9; discussion 490-1. 15. Lever J, Frederick DA, Peplau LA. Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men & Masculinity. 2006;7(3):129-43. Available from: http://psycnet.apa . org/index.cfm?fa=buy.optionToBuy&id=2006-09081-001. Accessed in 2014 (Jan 28). 16. Zilbergeld B. The new male sexuality. New York: Bantam; 1999. Sources of funding: None Conflict of interest: None Date of first submission: September 19, 2013 Last received: October 30, 2013 Accepted: January 30, 2014 Address for correspondence: Margareth de Mello Ferreira dos Reis Rua Barata Ribeiro, 237 — 13o andar Bela Vista — São Paulo (SP) — Brasil CEP 01308-000 Tel. (+55 11) 3159-1300 E-mail: [email protected]
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