Studies on self-esteem of penile size in young Korean military men

Hwancheol Son^1,4, Hanjoo Lee², Jung-Sik Huh³, Soo Woong Kim⁴, Jae-Seung Paick⁴

1Department of Urology, Seoul Municipal Boramae Hospital, Seoul, Korea
²Department of Neuropsychiatry, Seoul National University College of Medicine, Seoul, Korea
³Department of Urology, Cheju National University College of Medicine, Jeju, Korea
⁴Department of Urology, Seoul National University College of Medicine, Seoul 110744, Korea

Keywords: penis; self esteem; MMPI; psychology

Abstract

Aim: To investigate the flaccid and stretched penile sizes of young Korean males and their complexes or pride about their penile size. Methods: After an explanation and agreement to the purpose and methods of this study, 123 Korean men in their early 20's visiting the Jinhae Military General Hospital were included in the study. The flaccid penile length, flaccid mid-shaft circumference, stretched length and pre-pubic bone fat pad depth were measured in a warm comfortable environment. The accuracy the subjects assessed their penile size was investigated by asking them to rate their penile size, as 'very small', 'small', 'normal', 'large' or 'very large'. All subjects were asked to complete the Minnesota multiphasic personality inventory (MMPI) test. Results: The mean flaccid length, flaccid circumference, stretched length and fat pad depth of the 123 subjects were (6.9 0.8) cm, (8.5 1.1) cm, (9.6 0.8) cm and (1.1 0.4) cm, respectively. The answer distribution on penile size was 1 (0.8 %) 'very small', 29 (23.6 %) 'small', 86 (69.9 %) 'normal', 6 (4.9 %) 'large' and 1 (0.8 %) 'very large'. Subjects who underestimated their penile size showed significantly higher scores on the hypochondriasis (Hs), depression (D) and psychasthenia (Pt) subscales of the MMPI than those in the Unbiased Group (P<0.05). Conclusion: In consultation, with a patient requesting penile augmentation, the urologist should consider the psychologic attitude of the patient to his penile size.

1 Introduction

Most men would like to have a larger penis regardless of age or background. This desire is demonstrated by phallism and religion and by more active interventions, such as penile augmentation and the injection of prosthetic materials. Penile augmentation is growing in popularity in Korea. More than 1000 cases of penile augmentation have been reported by a single Korean urologist [3], however,it is claimed that penile augmentation is still in its experimental stage and its indicationshave not yet been clearly established and many complications were reported [2, 3].

When considering penile augmentation, the emotional comfort and satisfaction are as important as the actual physical enlargement of the penis.

It is important to take into consideration the dilemma the patient must have experienced until he finally decided to visit aurologist and the patient's motivation for the procedure. Hence, the psychological aspects of the patient's attitude towards penile size become crucial. In a recent study, one of thepresent authors (Son H.) [4] reported that young Korean males had a tendency to underestimate their penile size. Penile augmentation operation is becoming popular in Korea, but not enough is known about the psychologic aspects of a Korean male's attitude to the penile size. In this study, we aimed at investigating the psychological attitude of men to their penile size at their early 20's.

2 Materials and methods

This study was reviewed and sanctioned by the Main Executive Board of Jinhae Military General Hospital. After an explanation and agreement to the purpose and methods of this study, 123 Korean men visiting the General Hospital were included in the study.

The average age of the subjects was 21.7 (range 19~27) years.

The flaccid penile length was measured in a warm quiet room. The penile length was defined as the distance from the pubo-penile skin junction atthe dorsum to the tip of the glans. The suprapubic fat thickness was defined as the thickness of the fad-pad when the examiner firmly compressed up to the pubis symphysis at the pubo-penile junction. The stretched length was measured after maximum penile stretching at the first attempt. A rigid ruler was used, except for the penile circumference, to avoid measurement error due to penile curvature. The mid-shaft circumference was measured with a tape.

The accuracy the subjects assessed their penile size was investigated by asking them to rate their penile size as 'very small', 'small', 'normal', 'large' or 'very large'. Subjects were asked to complete the MMPI questionnaire in a quiet place.

There were two subject groups: the Underestimated Group, who misperceived their penile size as small despite an actual stretched penile size at or above the average and the Unbiased Group who properly perceived their penile size.

Data were presented as meanSD. The student t-test was used for the analysis and P<0.05 was considered significant.

3 Results

In the 123 subjects, the mean flaccid penile length was (6.9 0.8) cm, mean flaccid circumference (8.5 1.1) cm, mean stretched length (9.8 0.8) cm and mean suprapubic fat thickness (1.1 0.4) cm (Table 1). The distribution of answers about penile size was: 1 (0.8 %) 'very small', 29 (23.6 %) 'small', 86 (69.9 %) 'normal', 6 (4.9 %) 'large' and 1 (0.8 %) 'very large'.

Table 1. Penile dimensions in 123 subjects (MeanSD, n=123).

The accuracy in assessing the penile length was determined based on the mean lengthSD (Table 2). Among the 30 subjects who answered 'very small' and 'small', 5 had a penis smaller than meanSD, 24 within meanSD and 1 larger than meanSD. Among the 7 subjects who answered 'very big' and 'big', 4 had a stretched penis length longer than meanSD and no one had a length less than meanSD.

Table 2. Self-esteem of penile size and stretched length.

No subject showed any result indicating psychologic disease. Those who underestimated their penile size showed statistically higher scores on the hypochondriasis (Hs) scale (P<0.05) and psychasthenia (Pt) scale (P<0.01) than those who properly estimated their penile size. On the other hand, those who thought their penile size was big showed statistically higher scores on the hysteria (Hy) scale (P<0.05, Figure 1).

Figure 1. Minnesota multiphasic personality inventory (MMPI) clinical scale of each group according to self-esteem of penile size. The 10 clinical scales of the MMPI are hypochondriasis (Hs), depression (D), hysteria (Hy), psychopathic deviate (Pd), masculinity-Femininity (Mf), paranoia (Pa), psychasthenia (Pt), schizophrenia (Sc), hypomania (Ma) and social introversion (Si).

The Underestimated Group (n=8) misperceived their penile size as small or very small in spite of having an actual penile size at or above average, and showed significantly higher scores than the Unbiased Group (n=43) on the three subscales of the MMPI: Hs (66.39.5 vs 58.510.1), depression (D) (63.49.9 vs 53.111.1) and Pt (59.93.9 vs 49.57.8) (P<0.05, Figure 2).

Figure 2. Minnesota multiphasic personality inventory (MMPI) clinical scales of the Underestimated and Unbiased Groups. The 10 clinical scales of MMPI are hypochondriasis (Hs), depression (D), hysteria (Hy), psychopathic deviate (Pd), masculinity-femininity (Mf), paranoia (Pa), psychasthenia (Pt), schizophrenia (Sc), hypomania (Ma) and social introversion (Si).

It is hard to measure erect penile length, although some use injection [5-7], audiovisual aids [5] or manual stimulation [4, 5] to erect the penis, these methods are inconvenient, stressful and time consuming. Furthermore, there are ethical problems associated with inducing erection especially in children. In one study [8], Subjects have measured their own penil length, however, this may be inaccurate. Moreover, despite efforts to erect the penis, some subjects fail to erect due to unfavorable psychological status [4].

Stretched penile length measurement offer a good alternative to erect penile length measurement, as the former correlates well with the erect length [4, 5, 9]. However, it is evident that stretched penile length is dependent upon factors like the stretching force or number of stretchings. To avoid this kind of problems, in this study one researcher measured all penile lengths with a maximal constant stretching force at one attempt. Different to the comparison of flaccid penile length results (6.9 cm0.8 cm in this study vs. 6.1 cm1.3 cm in a previous study), the mean value (9.6 cm0.8 cm) of the stretched penile length in this study was very close to that (9.6 cm1.2 cm) of a previous study in subjects of a similar age [4]. Thus, stretched penile length measurements produce consistent results as long as the maximal constant stretching force-one attempt method is used. The stretched length measurement can also be accurately used in children [10].

In the self-esteem of penile size, we asked the subjects to extimate their 'just' and not the 'flaccid' or 'erect' penile size. Multiple questions about multiple parameters or status of penis (volume, length, circumference, flaccid state, erect state, etc.) may produce misunderstanding to the subjects. As the major penile status is flaccid, men commonly experience their penile size at the flaccid state. However, the real penile size is the erect penile size and the erect penile length showed a higher correlation with the stretched length than with the flaccid length [4,7]. In this study, data of flaccid length showed a relatively higher SD. The statistical analysis with flaccid length (data not shown) was similar to that with stretched length, but showed a dubious statistical correlation (P<0.1)

The MMPI is the most widely used and studied personality inventory in the world. At present, over 100 translated versions of the MMPI have been published in 45 countries [11]. Though the primary goal of the MMPI concerns psychiatric diagnostic criteria, it is also used to deduce characteristics of the public by the assumption that the concept of pathologic classification can be used to explain the normal behavior. Therefore, we often use the tool to screen the perception and psychologic status of urology outpatients.

In this study, among the 123 subjects only 7 (5.7 %) answered that they thought their penis were large, but 30 (24.4 %) thought their penis small. It confirmed the results of previous study [4] that young men tended to underestimate their penile size. Those who underestimated their penile size small or very small showed significantly higher scores on the Hs (P<0.05) and Pt scales (P<0.01) of the MMPI.

Persons with high scores on the Hs scale believe that they have some kind of disease and tend to dwell on their vague somatic symptoms. They are likely to have many complaints and have negative attitudes to psychological or physical treatment. They also tend to escape their responsibilities, avoid confronting difficult problems or manipulate other people using their somatic symptoms [11].

Elevations on the Pt scale are suggestive of people who are anxious, apprehensive, perfectionistic, tense and with a wide variety of fears. High scores on this scale tend to show inordinate self-consciousness and introspection and exaggeration of the negative implications of minor flaws. They tend to enlarge minor problems making them major sources of concern and dissatisfaction. They may be rigid and moralistic and set high standards for both themselves and others and have difficulty to overlook minor mistakes or defective states of affairs. In addition, they are likely to show excessive concerns over bodily functions, especially with respect to the circulatory, digestive or urinary organs [11].

Those who thought they had a large penile size showed significantly higher scores on the Hy scale of the MMPI. Persons with significantly high scores on the Hy scale are in denial and have high suggestibility. They tend to cope with their stresses or avoid their responsibility by expressing their somatic symptoms. They are over-exhibitional, extroversive, superficial, unsophisticated and ego-centric. They tend to deny all problems, and to show specific somatic problems in stressful conditions and to be immature, suppressive and simple. They demand specific solutions for problems and avoid self-investigation. Women with a high Hy scale and a low masculinity-femininity scale tend to uproariously show sexual or sensual behaviors [11]. Likewise, of the 7 subjects who believed their penile size was big, 6 answered that they have had 4 or more sexual partners.

The Underestimated Group showed significantly higher scores on the three subscales of the MMPI (i.e. Hs, D and Pt) than those of the Unbiased Group. The mean scores of the three subscales of the Underestimated Group were elevated over 60 (except the score of Pt which is 59.9), indicating a mild deviation from the normal population (Table 3). From these results we infer that those who belong to the Underestimated Group are more prone to the psychopathological features implied by these scales than those of the Unbiased Group.

Table 3. Raw scores of Minnesota multiphasic personality inventory of Underestimated Group. Diagnostic implication: PD (personality disorder), Anx D (anxiety disorder), SOM (somatoform disorder).

Persons with high scores on the D scale usually show depressive emotional and cognitional features. These individuals become easily depressed under adverse circumstances. Many of them show an underlying negative attitude toward themselves, their world and their future. Such a person is likely to be confronting difficulties in daily life with a sense of pessimism, helplessness and hopelessness. High scores on the D scale are usually characterized by a lack of self-esteem, self-confidence or self-efficacy. In addition, they may show excessive signs of worry, anxiety, guilty or a self-critical attitude over minor problems. These features may be exaggerated when confronting difficulty situations. Those who show mild elevations in the D scale may become easily self-critical under stress [11].

Based on these considerations, the elevations in the Hs, D and Pt scales in the Underestimated Group indicate that they are more prone to the negative features of the three subscales as mentioned above. This result suggests that those who underestimate their penile size as small, possibly have a stronger tendency to be easily preoccupied with somatic concerns and to exaggerate physical complaints to express psychological distress or conflict than those who do not manifest a perceptual distortion of penile size. Compared to those in the Unbiased Group, individuals in the Underestimated Group may also be more subject to excessive concerns over personal minor flaws and may unduly exaggerate their negative aspects. In addition, their general affective tones are expected to be more vulnerable to depressive or anxious moods.

However we are clear about the limitations of this finding and are very cautious about making generalizations. In order to specify distinctive patterns of MMPI deviation in connection with the underestimation of penile size, more extensive studies are needed involving a large number of male subjects from various populations. However, even though our findings on individual profiling should be regarded as no more than a preliminary in the diagnostic sense, it is indeed worthwhile to note that most of those who underestimated their penile size show an MMPI profile deviation from the normal.

Underestimating one's penile size or the wish to enlarge penile size does not seem to be a purely physical matter. It may frequently be the case that such perceptual distortions or compensational efforts to change one's physical appearance reflect underlying feelings of dissatisfaction. Penile enlargement operations may be motivated by a psychological difficulty rather than the awareness of a bodily defect or physical distress. This study was also carried out to explore such relationships between the perceptual distortion and the underlying psychological background. In our somatizing hypothesis of penile size perception, complaining about one's penis possibly stems from underlying dissatisfaction related to the masculine sexual role, which may be disguised and expressed through physical dimensions, such as penile size. This aspect should be examined by a more elaborate study, one that includes various psychological variables (e.g. one's own psychological response to sexual performance, confidence in one's masculinity, etc.) and male subjects from diverse populations in terms of demographics, such as age and marital state.

The penile augmentation surgery is not contraindicated in patients having a normal size penis, as it is a kind of aesthetic surgery. The patient must finally decide whether to have the operation. However, it is advisable to be aware of the psychological background of such decisions, as a patient may have hidden psychological tendencies and pathologies. There are problems that cannot be solved by surgery alone. Alter [12] recommended that doctors should understand a patient's motive and psychological status and his expectations of the operation before deciding penile augmentation, and maintained that those with severe depression, psychologic disease or an unrealistic attitude should not receive augmentation surgery. Wessells et al. [2] reported that among 12 patients who underwent reoperation because of complications, 7 complained about the shape of their penis. Also in Korea, in a report of 13 penile augmentation cases using dermal adipose tissue transplantation, 5 patients said that the result was 'neutral' or 'unsatisfied' [13]. Hence, urologists should be careful about selecting subjects for operation by close consultation and observation, otherwise the result of surgical intervention may be problematic both for doctors and patients.

In conclusion, more Korean young males think their penile size being small and subjects who underestimate their penile size have a psychological tendency toward high Hs, D and Pt scales by the MMPI test. Subjects who think their penile size is large have a psychological tendency towards high Hy scale. We hope that the results of our study will help in understanding a man's attitude to penile size and the attitude of a patient requesting penile augmentation.

References

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Correspondence to: Jae-Seung Paick, M.D., Department of Urology, Seoul National University Hospital, Yongun-dong, Jongro-gu, Seoul, 110744, Korea.
Tel: +82-2-760 2422, Fax: +82-2-742 4665
E-mail: jspaick@snu.ac.kr
Received 2003-06-05  Accepted 2003-07-08