A Structured Review and Critical Analysis of Male Perceptions of the Penis: a Comparison between Heterosexual Men and Men Who Have Sex with Men (MSM)
The penis and penis size have been understood differently across times and cultures (Friedman, 2008). For example, smaller penises have been favoured in some ancient Greek and Roman contexts (see Kimmell, Milrod and Kennedy (Eds), 2014).In contrast, larger penises, in more recent times, have been understood (and with racial overtones) as threatening and animalistic, being made to stand for closeness to brute nature as opposed to culture (Dines, 2007) thus signalling infrahuman status (Hall, 1997).
However, contemporary research into male body image has identified several areas of body dissatisfaction among men (Mellor et al, 2010; Janlowskiet al, 2014; Murray and Lewis, 2014), where penis size, appearance (Lever et al, 2006; Tiggemannet al, 2008; Grovet al, 2010) and overall genital appearance (Liossi, 2003; Jankowski et al, 2014) feature prominently. Body dissatisfaction usually manifests in distorted body size estimation, a discrepancy between ideal versus perceived reality and shame concerning the body (Ogden, 2012). Concerns about penis size compared to other males are associated with adverse psychosocial and sexual outcomes (Tiggemannet al, 2008; Herbenicket al, 2013; Veale et al, 2013). The penis is prized in virtually every culture and metonymic with power (Wylie, 2008) and thus can be a source of anxiety if one is considered under-endowed (Vardi and Lowenstein, 2005). Indeed, Wylie and Eardley have observed a link between dis/satisfaction with the body and penis size, representing a form of body dysmorphia among men with penis sizes within the normal range. Also, evidence suggests that men who have sex with men (MSM) may be more vulnerable than heterosexual men to body dissatisfaction (Morrison et al, 2004; Strong et al, 2000; Tiggemannet al, 2007) and that this may arise from the increased importance of appearance ideals within gay subcultures (Gettleman and Thompson, 1993; Jankowski et al, 2014; Siever, 1994), though evidence of the reverse is discussed in what follows. It is also worth noting that MSM who engage usually in receptive anal sex (known as ‘bottoms’ as opposed to insertive ‘tops’) might downplay/disregard the significance of penis size for themselves (Grovet al., 2010)but not necessarily apropos any sexual partners (Drummond and Filiault, 2007), especially in the case of ‘size queens’ (Bergling, 2013).
This structured narrative review of 26 studies across various nations/continents (American Europe, Asia and Australasia) argues that men’s accounts of the penis represent diverse ways of negotiating normative masculinity, though we note transmen’s appropriation of the penis/phallus in ways that challenge this form of masculinity.1 While there is some convergence between the accounts of heterosexual men and men who have sex with men (MSM) concerning penis size and overall body image, some key distinctions indicate the persistence of a heteronormative masculinity understood as more traditional, which can weigh heavy on heterosexual men and affect their sexual and overall self-esteem as much as MSM. Research into male perceptions of the penis has not been evaluated systematically, and such a study will assist the development of research into male genital body image and differences of sexual identity. Throughout this paper, the term MSM is used rather than ‘gay’ because some men who have sex with men identify as bisexual, heterosexual, fluid or may prioritize other aspects of identity (such as ethnicity) over their sexuality and thus reject this nomenclature. Conversely, not all men who have sex with women are exclusively heterosexual in terms of their sexual/sexualized behaviour. Ward (2015) questions the rigidity of hetero-masculinity in drawing attention to forms of sexualized behaviour ranging from hazing rituals, online personal adverts seeking other men with whom to masturbate (practices that can still objectify women and deride effeminacy), to anonymous sex in public toilets. (See also Humphreys’ (1970) classic study of ‘tea room trade’).
The aim of this paper is to present a structured review and synthesis of research into male perceptions of the penis, the psychosocial and sexual correlates and to provide a comparison of outcomes between MSM and heterosexual men. We are motivated primarily by concern for the self-esteem if not mental health of men who are encouraged to feel anxious about penile dimensions. Thus we want to contribute to questioning of dominant, heteronormative models of masculinity which can inflict emotional harm not just on MSM but also heterosexual men who have been persuaded to invest in/prize such ways of thinking (Connell 1995/2005). Providing an overview of the literature also helps mark limits to the homogenizing view that a small penis is a matter of shame as a symbol of failed masculinity and allows clarification of the conditions under which different men from different cultures might react in varying ways to discourses concerning penis size. Whilst shame and misery might be a dominant story about (smaller) penis size, this story should not be universalized and may occlude other stories and experiences, which we aim to illuminate. The results and discussion below indicate that men variously capitulate to, negotiate with, ignore or challenge discourses of shame.
The key questions addressed in this review concern similarities and differences between straight men and MSM in relation to: (i) subjective estimation of penis size; (ii) ideal penis size compared with perceptions of straight men and MSM and, in some cases, actual measurements; (iii) the importance of genital dis/satisfaction relative to dis/satisfaction with other parts of the body; (iv) genital perceptions and effects on general self-esteem; and (v) psychosocial/sexual outcomes – effects of perceptions of the penis on social and sexual behaviour.
We recognize the contingency of meanings attached to the penis and how, in particular, being well-endowed can operate in gay male cultures as sexual capital often independently of socio-economic power (Green, 2011). However,our findings offer support for Connell’s (1995/2005) theorizing on hegemonic masculinity. This concept refers to a form of masculinity that is prized over others. Simultaneously, it refers to a collection of practices that constitute and are constituted by social, economic, political and cultural structures and institutions and that underpin and normalize relations of (male) domination and (female) subordination but also subordination of other males. Within a hierarchy of esteem, men who embody subordinate masculinities, variously gay, non-white or working class men, find themselves disadvantaged in comparison to white, elite/middle-class, heterosexual men. In distancing themselves from femininity, gayness and low status, the latter are thought to represent the most legitimate form of masculinity marked by success, social esteem, emotional self-control and favourable access to formal political power. As will be seen in the discussion section,the penis and semen are implicated in this power complex and can represent extension and renewal of hegemonic masculinity (Moore, 2002, 2007).
Method
Our study was motivated by a wish to deepen and extend knowledge on how differences in sexual identity affects body and genital image. In particular, we wanted to examine whetherMSM may be more vulnerable than heterosexual men to such body dissatisfaction (Morrison et al, 2004; Strong et al, 2000; Tiggemannet al, 2007). Such knowledge could inform differentiated strategies designed to overcome any lack of genital self-esteem.
Search strategy:
The search strategy was divided into two stages. The first stage involved the identification of existing reviews focusing on male genital perceptions and psychosocial/sexual outcomes. This search was conducted by searching the Cochrane Library and five major databases (PsycINFO, Pubmed, EMBASE, CINAHL and SocIndex). No systematic reviews were identified.
The second stage of the search strategy consisted of a search for English-language primary studies published up until June 2015 on male genital perceptions and psychosocial/sexual outcomes. The following databases were searched: PsycINFO, Pubmed, EMBASE, CINAHL and SocIndex until June 2015. The same search strategy was employed in all databases: (men OR gay men OR bisexual men OR heterosexual men) AND (genital OR penis OR penis size OR penis satisfaction) AND ((body image OR body satisfaction OR body dissatisfaction) OR (masculinity) OR (wellbeing) OR (self-image) OR (self-esteem)). Using the above search strategy, 449 articles (again, up to June, 2015) were identified.
The authors scrutinised all the titles and abstracts returned and identified studies eligible for inclusion based on the review’s inclusion and exclusion criteria (as detailed below). Further searches were conducted of the bibliographies of relevant reviews and publications to identify additional studies for inclusion.
Inclusion and exclusion criteria:
After the removal of duplicates, the titles and abstracts of papers were screened by both authors to assess whether they met the inclusion criteria. For a study to be included it had to:
(i)report genital perceptions, genital satisfaction, genital self-esteem or psychosocial/sexual outcomes associated with genital perceptions;
(ii)provide sufficient detail on the above outcome measures to allow comparison across studies;
(iii)report data on participants who were not part of a sample that had undergone genital surgery;
(iv)report quantitative, qualitative or mixed methods methodology;
(v)written in the English language;
(vi)published in a peer-reviewed journal.
Included studies focused specifically on men’s perceptions of their genital size/appearance, genital satisfaction, genital self-esteem, or psychosocial/sexual outcomes associated with genital perceptions. A wide range of study designs were included, spanning quantitative, qualitative and mixed methods. Exclusion criteria included any study that: was not published in English; was not published in a peer-reviewed journal; did not contain primary data; did not include a sample of male participants; did not include male genital body image as the main focus; focused on clinically diagnosed or post-surgery patients; and was a review article
Data Extraction:
Data were extracted from full texts by the authors and included information about study aims, authors, date of publication, location of study, sample size and composition (including sexual identification), study design, validated outcome measures/tools, and genital perception, image, esteem measures and associated psychosocial/sexual outcomes. Data extraction was reviewed by the authors with a view to highlighting any discrepancies; a discrepancy occurred for only a small number of studies which was resolved by discussion. The search strategies identified 449 articles. Following review of abstracts and titles and the removal of duplicates, 391 articles were excluded and the remaining 58 were considered eligible and retrieved for full text review. Articles were rejected for one or more reasons: no outcome measures on male self-perception of the penis; the article was a review article; the article reported data on males with clinical diagnoses related to the genitals, or on males who had undergone genital surgery; the article contained only objective penis outcome measures; insufficient information regarding measurement of variables; and an absence of original data.
Clinical studies which reported data on participants who had undergone urological surgery (for example, for cancer or hypospadias) or who had received a physical urological diagnosis (e.g., small penis syndrome) or psychiatric diagnosis (e.g., anxiety or depression disorder) were excluded from this review. While it is acknowledged that this is a wide area in the health-related literature, the inclusion of such studies would have made the study samples too heterogeneous. Men who have undergone genital surgery or who have been diagnosed with genital or psychiatric conditions bring with them a range of related experiences and co-morbidities that were outside of the scope of this paper.
The full texts of the 58 articles were then examined by both authors to assess whether the inclusion/exclusion criteria were met. A further 32 articles were excluded for failure to meet the inclusion criteria. A total of 26 articles met the inclusion criteria and have been included in this review. Figure 1 presents a flowchart of study selection at each stage, along with categorical data on excluded studies.
Figure 1. Flow diagram of search and selection strategy of included articles.
Study quality was assessed by authors employing the Timmer et al (2003) checklist for qualitative studies and the National Institute for Health and Care Excellence (United Kingdom) (2007) appraisal checklist for quantitative studies. The Timmeret al (2003) checklist for quantitative studies, which has been demonstrated to have good construct validity, was adapted for this review (three items pertaining to intervention studies were removed) (Roy and Payette, 2012). A total of 16 items were utilised and, as per the guidelines,two points were allocated if the item was fully met, one if partially met and none if not met at all. Up to five extra points were awarded based on study design. A ratio score between 0 and 1 was computed, with 1 representing the highest quality score and zero the lowest.
The National Institute for Health and Clinical Excellence quality appraisal checklist for qualitative studies was used to assess the quality of the qualitative studies in this review (National Institute for Health and Clinical Excellence, 2007). It employs 13 items to assess six components of qualitative studies (aims, design, recruitment and data collection, analysis, findings/interpretation and research implications). Items were scored dichotomously, with total quality scores of ‘++’ where an article has addressed at least 11 out of 13 items,’ +’ for articles addressing 7–10 out of 13 items and ‘ –‘ for articles addressing fewer than seven items out of 13. Quality ratings for each study are presented in Table 1.
Data analysis was undertaken by means of a thematic content analysis, whereby a systematic classification process of coding for themes by the two authors enabled a subjective interpretation of the data (Braun and Clarke, 2006). The following five themes were identified: (1) subjective penis size estimation; (2) ideal penile size versus perceived reality; (3) relative importance of genital image dissatisfaction; (4) genital perceptions and self-esteem; (5) psychosocial/sexual outcomes.
Results
Study characteristics
The findings presented are synthesised from the 26 studies (detailed in Table 1), published between 1995 and 2014, sampling a total of over 37,000 men world-wide. Nine out of the 26 studies had samples that either partially or totally comprised gay/bisexual men (see Table 1). Sample sizes ranged from small-scale studies (Drummond and Filiault, 2007; n=14) to very large-scale surveys (Lever et al (2006) n=25,594). All studies were cross-sectional, 22 were quantitative, three were qualitative and one consisted of a mixed-methods design.
Findings: describing the data
Five themes were identified: (1) subjective penis size estimation; (2) ideal penile size versus perceived reality; (3) relative importance of genital image dissatisfaction; (4) genital perceptions and self-esteem; (5) psychosocial/sexual outcomes. Table 1 presents details of the studies in terms of methodological design, sample composition and demographics, study quality rating, key study characteristics (validated outcome measures) and a summary of results.
Table 1: Study Details and Summary of Results
Study & sample characteristics. / Methods.Relevant validated outcome measures.
Quality rating. / Results summary
- Algarset al, 2011, Finland
Cross sectional
Structured questionnaire.
DFSI (Derogatiset al, (1979), IIEF (Rosen et al, 1997)
Quality: 0.84 / Majority - 68% of men satisfied with penis but 49% wished for a larger one (though all correlations low). Those satisfied reported lower levels of premature or delayed ejaculation, positive erectile function and more sex (kissing, oral, vaginal and anal sex and enjoyment of and satisfaction with sexual intercourse). Sexual body image related to general body image and overall self-esteem. Positive general body image and sense of attractiveness are positively associated with penis size satisfaction (r=.4) and negatively correlated with wishing for larger penis (r=.31). Small penis size affects self-esteem in sexual context.
- Carballo-Dieguezet al, 2004, US (New York)
Cross-sectional
Structured interviews & focus groups.
Adapted Sexual Identity Scale (SIS) (Stern, et al, 1987).
Quality: 0.77 & ‘-‘ / Penis size, height, age and proximity to normative masculinity influence men’s role during sex and could bring about change from normal role. Stigma could be associated with ‘pasivo’ (passive-receptive) role could explain preponderance of men identifying as ‘activo’ (active-insertive).
- Cranney, 2014, Netherlands
Cross sectional
Longitudinal survey