J is a dynamic and colourful 25-year-old sportsman who has won many accolades in football and athletics. This delightful character was starting to worry me about several uncharacteristic appearances over a period of about eight weeks for relatively trivial complaints, mainly of a musculoskeletal nature.
His problems included headache, neck pain, back pain and groin pain, all of a relatively minor nature with no significant findings on clinical examination. When I confronted him about his general health he admitted to feeling lethargic and uninterested in his beloved sport, claiming that his training program was virtually at a halt. ‘I feel stale, Doctor—just can’t be bothered.’
I advised J that this flat spot was commonplace in super athletes and that a break in routine including a ‘holiday’ to a ‘different’ training resort would be beneficial. Shortly after this consultation a letter was hand-delivered to my mailbox.
I hope I can take a couple of your precious minutes to discuss a subject that’s been a major worry for me for a long time. It is a very awkward and most embarrassing letter to write.
I want to ask you if anything can be done in relation to the size of one’s penis. You’re probably thinking this is the wish of many a young man; however, I do believe I have a very special case.
All I want to know is can anything be done at all, no matter how drastic the measure need be? It has got to such a stage that it is wrecking my whole life. Many times when I let it get the better of me, my self-concept, my thoughts on the future, etc. are almost zero—completely negative.
It is a constant worry and I know it restricts my total personality. I know it does not directly affect my ‘sexual performance’, but I wonder now at 25 whether I will ever be able to accept a wife. I know many would say it is a purely psychological thing.
Doctor, I need to know if there is any chance of doing anything to rectify what I believe is an underdeveloped penis, perhaps due to a lack of male hormones during puberty—I don’t know.
I know the next step is examination and that will be embarrassing but I thought if I could give you a little time to assess the situation it would be better.
Believe me, it has taken a lot of courage to write this and to confide in you.
The problem was now obvious, and so I rang J and told him that I had encountered this situation several times in the past. He should not feel too embarrassed about it and should come along one evening so that we could clarify the problem.
J seemed quite at ease during the consultation. The examination did reveal a normal-sized penis albeit at the lower end of the normal range. On direct questioning he did experience normal heterosexual impulses, and did have erections of 11–12 cm. When I asked him why he thought that he was so ‘small’, he said it was based mainly on comparisons with the other guys in the showers at the change rooms.
I counselled him that his ‘problem’ was a common complaint of men when they compared themselves with others, and one explanation might be that some men with homosexual or bisexual tendencies could be stimulated by the sight of other naked men in the change rooms so that their penises could be observed in the semi-erect state. He understood this and said that such a possibility had crossed his mind.
A knowing, sheepish grin transformed J’s face when I casually said: ‘Now you’ve fallen in love haven’t you? You’ve probably met your match and you’re thinking about getting married and you have some anxiety about your manliness, your sexual performance and your ability to father children’.
‘That would be close to the mark, Doctor, but is it possible to carry out a hormone test to make sure?’
A serum testosterone was ordered because I could see that counselling would not reassure him completely. A normal result made him feel relieved and reassured. He gradually regained his confidence and his normal zest for life.
Now, years later, he is happily married with three children and claims that his sporting activities are as enjoyable as ever.
DISCUSSION AND LESSONS LEARNED
Anxieties about penile size and sexual performance, including the ability to induce conception, are common characteristics of young men, especially when they meet the ‘right woman in their life’.
As general practitioners we should bear this in mind with premarital counselling. One strategy would be to subtly raise the issue by using the third person in an offhanded matter-of-fact manner. For example: ‘. . we find that guys in your situation often worry about their manliness and their ability to be good husbands and lovers’. This approach may trigger open discussion should such an anxiety be significant. Of course most men are able to dismiss this fleeting apprehension, but for the occasional patient such extreme anxiety manifests itself in frequent and apparently trivial attendance at the surgery.