Electronic Journal of Human Sexuality, Volume 2, March 19, 1999

www.ejhs.org

PENILE AUGMENTATION SURGERY

APPENDIX #1
QUESTIONNAIRE

Todays date____________     Code_____________
Introduction deleted

Please complete this questionnaire to the best of your ability.  Do not write your name so this
can remain anonymous.  Thank you for your help with this research.

1. Age_________

2. What is your race? (Circle one)

 White  Black  Asian   Hispanic            Other______________

3. What was the highest grade level you completed in school? __________

4. How many years of college (undergraduate) did you complete? __________

5. How many years of graduate school did you complete? __________

6. What degrees or certifications do you hold?__________________________

7. What is your occupation or profession?_____________________________

8. What is you estimated annual income? $____________________________

9. What is your religious background? (Circle one)

 Catholic  Protestant  Jewish  Muslim  Buddhist  Athiest  Agnostic

 Other__________________________________    None

10. How often do you attend religious services? (Circle one)

 One or more times weekly      Approx. once a month

 One or two times yearly         Never

11. How old were you the first time you knew about:
  Age                                            Age
 _____Masturbation                  _____Homosexuality
 _____Orgasm                          _____Clitoris
 _____Penile lengthening           _____Pregnancy
 _____Menstruation                  _____Penile enlargement Surgery
 _____Sexual intercourse

12. Did you have a course in school that dealt with human sexuality?
   Yes   No

 12A. If yes, was this course given in (Circle one):

  Elementary school (K-6)    Junior high school (7-9)

  High school (10-12)          Junior College         Univ./College

 12B. What percent of the information was NEW to you?   ________percent

13. Which number on the scale best describes both your behaviors and fantasies. (Circle the
number you feel is most appropriate)
     1                   2               3               4                       5              6                7
Opposite sex                              Equal same sex                                              Same sex
interests only                              and opposite interests                                     interests only

14. Please circle one of the following to define yourself:
 Heterosexual     Bisexual     Homosexual   Other________________________

15. How important is sex to you? (Circle most appropriate answer)
 Very important   Slightly important   Somewhat important   Not at all important

16. How would you rate your general health? (Circle a number)
 Great   1  2  3  4  5    Very Poor

17. Do you exercise on a regular basis?(Circle one) Yes   No
 17A. If yes, how frequently? ____________________

 17B. What types of exercise do you do?___________________________

18. What other cosmetic surgeries, of any kind, have you undergone?
_____________________________________________________________________________________
_______________________________________________________________________

BEFORE YOUR SURGERY...

19. Using the scale below, how would you rate your self concept or self worth before surgery?
(Circle one number)
        1                   2              3           4           5
        very good                   neutral            very poor

20. How did you perceive your FLACCID penis size before surgery?(Check one)
   _____Much larger than average
   _____Somewhat larger than average
   _____Average
   _____Somewhat smaller than average
   _____Much smaller than average

21. How did you perceive your ERECT penis size before surgery?(Check one)
   _____Much larger than average
   _____Somewhat larger than average
   _____Average
   _____Somewhat smaller than average
   _____Much smaller than average

22. What were the dimensions of your penis before surgery (in inches)?
  FLACCID: Length________ Circumference_________

  ERECT: Length________ Circumference_________

23. How many hours of counseling or therapy did you have in the year before your surgery?
(Fill in a number)   _____times per day
       _____times per week
       _____times per month
       _____times per  year
       _____Not applicable

23A. What percentage of the counseling was regarding penis size? _________%

24. How frequently did you engage in sexual activities, with or without a partner, before your penile enlargement surgery?
(Fill in a number)       _______times per day
                                _______times per week
                                _______times per month
                                _______times per year
                               _______Never did

25. List your three most frequent sexual activities on the lines below.
 1)____________________________________________________
2)____________________________________________________ 3)____________________________________________________

26. In general, would you say your overall sexual satisfaction (self-defined) BEFORE SURGERY
was: (
Check one)   _____Very much above average
                     _____Somewhat above average
                    _____About average
                    _____Somewhat below average
                    _____Very much below average

27. How long before surgery, did you consider a penile augmentation?
    ______weeks_______months______years

28. Why did you decide to change the size of your penis?__________________________________________________
_____________________________________________________________________________________________

29. Who else knew about your plans to get a penile enlargement or lengthening?
__________________________________________________________

30. Approximately, how long did you spend talking with your doctor BEFORE the day of the
surgery?
(Fill in numbers)  _____minutes_____hours    _____Never did

31. Approximately, how long did you spend talking with your doctor on the day of the
surgery?
(Fill in numbers)   _____minutes_____hours  _____Never did

32. How frequently, on average, did you masturbate before your penile enlargement surgery?
(Fill in a number)    ______times per day
                             ______times per week
                             ______times per month
                             ______times per  year
                             ______Not applicable

33. How frequently, on average, did you engage in sexual relations with members of the opposite sex before surgery ?
(Fill in a number)     ______times per day
                               ______times per week
                               ______times per month
                               ______times per  year
                               ______Not applicable

34. How often did you engage in sexual relations with members of your same sex  before
surgery ?(Fill in a number)
        ______times per day
        ______times per week
        ______times per month
        ______times per  year
        ______Not applicable

ABOUT YOUR PENILE ENLARGEMENT SURGERY....

35. How long has it been since your first penile enlargement surgery?
 _____weeks_____months_____years  DATE:_____________________________

36. List other penile enlargement surgeries, DATES and Doctor’s name
_____________________________________________________________________________________
_________________________________________________________________________________________

37. Which surgery did you have performed? (Circle your first surgical procedure)

Penile Lengthening only                                        Fat Injection into Penis (liposuction)

Autologous fat and lengthening                             Dermal Fat graft and lengthening
(Fat liposucked and inserted into penis)               (Skin and fat from under buttocks)

Pedical Fat graft and lengthening                          Don’t know
(Skin and fat from the stomach)

Other_____________________________________________

38. What is the name of the doctor who performed your first penile enlargement surgery?_________________________

39. Your age at time of initial penile enlargement surgery_______________

40. What city/state/country did you live in at the time of your penile enlargement surgery?__________________________

41. What city/state did you have the penile surgery in?__________________________________

42. How do you feel the PRE-OPERATIVE procedures rated(e.g. meeting with doctor, nurse or technician, videos shown, medical testing, informational packets)? (Circle the appropriate number)
  Best 1  2  3  4  5  Worst

 Describe procedures___________________________________________________________________________
___________________________________________________________________________________________

43. How do you feel the FOLLOW-UP procedures rated? (Circle the appropriate number)
 Best 1  2  3  4  5  Worst

 Describe the procedure ________________________________________________________________________
___________________________________________________________________________________________

44. What would you say was your estimated time of recovery?(Your life was back to normal)
Fill in a number.
  ______days  _______weeks _______months ______Never was

45. Did your recovery time match the time your doctor predicted?
   Yes    No

 If not, describe the difference_________________________________
 ______________________________________________________

AFTER THE SURGERY...

46. Did the surgical procedure match what you expected?            Yes  No
 Explain________________________________________________
______________________________________________________

47. Did you experience any infection or other problems after your penile augmentation surgery?
     Yes   No
 Explain________________________________________________
______________________________________________________

48. How do you perceive your FLACCID penis size after surgery?(Check one)
   _____Much larger than average
   _____Somewhat larger than average
   _____Average
   _____Somewhat smaller than average
   _____Much smaller than average

49. How do you perceive your ERECT penis size after surgery?(Check one)
   _____Much larger than average
   _____Somewhat larger than average
   _____Average
   _____Somewhat smaller than average
   _____Much smaller than average

50. Did the penile enlargement live up to the expectations of how you wanted your penis to look?

 LENGTH:  Yes   No

 THICKNESS:  Yes   No

 PROPORTION: Yes   No

 AESTHETICS: Yes    No
 (Scarring, curvature, lumpiness, etc.)

 FUNCTION: Yes   No

 Explain your answers _____________________________________
______________________________________________________
______________________________________________________

51. What other procedures have you used to enhance your results?(weights, stretching,
etc.)_______________________________________________
__________________________________________________________

52. What are the dimensions of your penis, currently (in inches)?
  FLACCID: Length________ Circumference_________

  ERECT: Length________ Circumference_________

53. Did you feel the surgery was successful?(Circle a number)
            1                  2                3              4                   5
   very successful                                                   very UNsuccessful

54. How long did you wait after surgery before you showed your penis to someone other than
a medical professional?
(Fill in a number)   _______days_______months_______years

55. Who was that person? (Circle all that apply)  Male  Female  Friend  Relative  Lover Other__________________

56. How many hours of counseling or therapy have you had in the last year?
  (Fill in a number)
       _____times per day
       _____times per week
       _____times per month
       _____times per  year
       _____Not applicable

56A. What percentage of the counseling was regarding penis size?__________%

ABOUT YOUR SEXUALITY AFTER SURGERY...

57. Using the scale below, how would you rate your self concept or self worth AFTER surgery?
(Circle one number)

                   1           2        3         4            5
            very good           neutral            very poor

58. How frequently have you engaged in sexual activities, with or without a partner, since your penile enlargement surgery and after healing?
(Fill in a number)
         _______times per day
         _______times per week
         _______times per month
         _______times per year

59. In general, would you say your overall sexual satisfaction (self-defined) after surgery has been
(Put a check next to your answer):
      _____Very much above average
      _____Somewhat above average
      _____About average
      _____Somewhat below average
      _____Very much below average

60. Did the surgical procedure change your erection in any way?(angle, shape, firmness, size, scarring)  Yes   No
  If yes, please describe.______________________________________
 ______________________________________________________

61. How long after your penile surgery did you attempt masturbation?(Fill in a number)
  _____days_____weeks_____months_____years     Never did_________

62. After surgery, did you experience pain during masturbation?(Circle one)
   Yes   No

 62A. If yes, how long after surgery did it go away?______________

63. How often do you masturbate since your penile enlargement surgery?
(Fill in a number)
       _______times per day
       _______times per week
       _______times per month
       _______times per year
       _______Never did

64. How long after your penile surgery did you attempt sexual intercourse?
(Fill in a number)  _____days_____weeks_____months_____years     Never did______

65. After surgery, did you experience pain during sexual intercourse?
   Yes   No

65A. If yes, how long after surgery did it go away?______________

66. How often have you engaged in sexual relations with members of the opposite sex after
surgery ?
(Fill in a number)
         _______times per day
         _______times per week
         _______times per month
         _______times per year
         _______Never did

67. How often have you engaged in sexual relations with members of your same sex  after surgery ?(
Fill in a number)
           _______times per day
           _______times per week
           _______times per month
           _______times per year
           _______Never did

68. Did you notice any difference in penile sensation after your surgery?(Circle one)
    Yes   No
 Explain________________________________________________
______________________________________________________
 

69. Did you notice any difference in ejaculation after your surgery?(Circle one)
   Yes   No
 Explain________________________________________________
______________________________________________________

70. How long were you told, by your doctor, to wait before attempting...
      Masturbation__________
      Oral sex______________
      Vaginal sex___________
      Anal sex_____________
      Never told____________

71. Rate your first doctor on this satisfaction scale? (Circle one)
    1 = very satisfied   5 = very UNsatisfied

 A. Initial contact:
  1  2  3  4  5

 B. Interview:
  1  2  3  4  5

 C. Surgery:
  1  2  3  4  5

 D. Follow up:
  1  2  3  4  5

72. If you had life to live over again, would you have the penile augmentation surgery?
   Yes   No

73.  Circle the more important aspect of penis size.
   Length    Girth

74. If you could magically “grow” the penis of your dreams, how long would your ideal penis be?
 __________ inches

75. How thick would your penis be? _________ inches in circumference

76. How many people do you know who have had a penile augmentation surgery?_____________

77. How many people do you know who are considering penile augmentation surgery?_____________

78. Would you suggest the procedure you went through to a friend?
  Yes   No
 Explain________________________________________________________________________________________

79. What advice would you give to future patients? ______________________________________________________________________________________________
___________________________________________________________________________________________

80. Where did you find the doctor who performed your surgery (Advertisement, Referral, etc.)?_______________________

81. What was the cost of the penile augmentation surgery? $____________

82. How much was spent on other costs (travel, hotel, taxis)? $___________

83. Please list any other elective surgeries you have considered.
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________

Please return this questionnaire in the enclosed stamped envelope to:  (deleted)

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