Dealing with the capricious, fickle, disloyal phallus

With considerable interest, I read Dr Jack Chang’s BCMJ blog post about the taboos surrounding cosmetic surgery for men, specifically the taboos about issues relating to penis size. I appreciate Dr Chang’s recommendation that genital cosmetic surgery needs to be accompanied by some form of educational support. In my close to 3 decades of clinical experience in the areas of sexual medicine and sexual rehabilitation, there were three areas of importance to discuss. 

First, an explanation that the phallus, and the female clitoral function, are largely under the control of the autonomic nervous system. They are “not conscious” body functions; as with functions like heart rate, respiratory rate, or digestion, we do not have willful command over them. Unlike a hand or foot, which may be commanded to do this or that, neither the male nor the female genitalia can “perform” to desired expectations in any reliable manner in the presence of even a modest state of anxiety. 

Focusing on the male, in safe and relaxed conditions, the autonomic nervous system’s parasympathetic branch activates the relaxation of the smooth muscles of the erectile and spongy structures of the penis and the arteries supplying blood to those tissues. This permits a rush of blood to enter and inflate the penile erectile chambers. A somewhat similar process of congestion occurs in the relevant female organs.

In contrast, when the sympathetic nerve pathways are activated in what one’s brain visualizes as an unsafe, anxious situation, the penile arteries and erectile tissues become contracted, causing blood to exit and the erectile chambers of the penis and clitoral structures are emptied. 

Genital structures are in fact innocent, though they may appear to be capricious or fickle or disloyal, as when the penis does not stay erect and respond to our wishes. They only respond to the type of signal they receive from the two competing activities of the autonomic nervous system. If the brain perceives any form of real or imagined danger, the sympathetic nerves rule, with all the consequences. When anxieties settle, the parasympathetic nerves take control and let nature take its desired path. 

Second, discussion is needed to assist the patient and his partner to enjoy an essentially anxiety-free sexual relationship. It has to be pointed out that the act of intercourse is only one of many ways to enjoy sexual pleasures. Unfortunately, it is the most anxiety-generating sexual act. What if the fickle penis loses its erect stage at the wrong time? What if ejaculation occurs too early in the act, with the associated loss of erection? What if the partner is clearly dissatisfied? What if unwanted pregnancy occurs as a result of this act, what if infections are transmitted in this act? Even thinking about these potential problems will trigger the sympathetic nervous system to create negative consequences. 

When I was involved in the Sexual and Reproductive Rehabilitation program at the UBC Faculty of Medicine, I proposed the term sensuous adoration of the body. This includes mutual caressing and playing with and kissing each other’s body, including the genital structures, without any anxiety about behavior, and lets nature take its parasympathetic course. The sensuous adoration eventually may include, as one choice, a try at a low-anxiety act of intercourse. This, however, requires the third discussion. 

It will be necessary to encourage the couple to know what their desired experience is during the various sexual practices. Knowing what would feel best, each partner should have the courage to offer guidance to their partner and be strong enough to accept guidance. Again, anxiety levels will then drop to a minimum and desired experiences will be reached under parasympathetic protection. 

As Dr Chang points out, cosmetic surgery is not a solution on its own. By taking the taboo or the feelings of shame out of the conversation about sexual issues, we can empower the mental health of the individual and their partner.
—George Szasz, CM, MD

Suggested reading
McCorry LK. Physiology of the autonomic nervous system. Am J Pharm Educ 2007;71:78.

Siegel A. The fickle phallus. Our greatest wealth is health. Accessed 19 May 2023.


This post has not been peer reviewed by the BCMJ Editorial Board.

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