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Aesthetic Surgery Journal
2018, 1– 11
© 2018 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjy108
www.aestheticsurgeryjournal.com
Genital Rejuvenation
Preliminary Report
Nonsurgical Medical Penile Girth
Augmentation: A Retrospective Study of
Psychological and Psychosexual Outcomes
Gemma Sharp, PhD; and Jayson Oates, FRACS
Abstract
Background: Although interest in penile augmentation procedures is increasing, there is a significant lack of research into the psychological and
psychosexual outcomes of these procedures.
Objectives: To investigate the psychological and psychosexual outcomes of nonsurgical medical penile girth augmentation.
Methods: This retrospective study involved a mixed method approach. Twenty-five men who had undergone a nonsurgical medical penile girth
augmentation between 1 and 12 months prior (mean, 6.6 months) completed an online questionnaire containing measures of procedure motivation,
procedure satisfaction, genital self-image, penile-focused body dysmorphic disorder symptoms, self-esteem, and sexual relationship satisfaction. Six of
these men elected to complete in-depth one-to-one semi-structured phone interviews to further explore the psychological impacts of the procedure.
Results: In the online questionnaire, most men were satisfied with their penile size, appearance, and function after penile girth augmentation. The men
also reported statistically significant improvements in their genital self-image (P < 0.001) and self-esteem (P = 0.008), and a reduction in penile-focused body
dysmorphic disorder symptoms (P = 0.002) at the time of completing the questionnaire compared to recalled pre-procedural levels. The in-depth interviews
yielded 3 themes surrounding penile augmentation outcomes: (1) high satisfaction with increased penis girth; (2) increased self-confidence, particularly in
situations in which the penis would be seen, such as a locker room; and (3) increased sexual confidence, but some mixed impacts on sexual relationships.
Conclusions: Most men appear to be satisfied with their nonsurgical medical penile girth augmentation results, and they also seem to experience
improvements in their overall self-esteem.
Level of Evidence: 4
Editorial Decision date: April 16, 2018.
In society, men with larger penises tend to be viewed as
more “powerful” and “masculine,” and this message is
propagated in our mainstream media.1,2 As a result, men
who perceive their penises to be smaller than average may
become concerned that they are less “manly” than their
peers. Several studies indicate that a sizeable percentage of
men are dissatisfied with their penis size.2-4 For example,
a large-scale study found that 45% of men desired a larger
penis, in particular, those men who perceive their penis to
be either smaller than average (91%) or average (46%).2
However, most studies suggest that men who have size
Dr Sharp is a Post-Doctoral Research Fellow and Clinical Psychologist
Registrar, School of Public Health and Preventive Medicine, Monash
University, Melbourne, Victoria, Australia (the studies presented in
this manuscript were undertaken while she was based at the School
of Occupational Therapy and Social Work, Curtin University, Perth,
Western Australia, Australia). Dr Oates is a facial plastic and cosmetic
surgeon in private practice in Subiaco, Western Australia, Australia.
Corresponding Author:
Dr Gemma Sharp, School of Public Health and Preventive Medicine,
Monash University, 553 St Kilda Road, Melbourne, Victoria,
Australia 3004.
E-mail: gemma.sharp@monash.edu
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2 Aesthetic Surgery Journal
concerns are actually in the normal population size range.5
Nevertheless, men are increasingly seeking medical solu-
tions for their supposedly inadequate genitals.2
There is a wide range of medical penile augmentation
methods, both surgical and nonsurgical, all of which are
still considered to be controversial.6-8 The literature to date
suggests that current surgical techniques are often associ-
ated with relatively low satisfaction and high complication
rates.6,7 Penile augmentation using injectable materials,
particularly aimed at enhancing penile girth, may represent
a safe noninvasive alternative for men seeking to enhance
their penile size, although further rigorous research is
needed.9 Nevertheless, a variety of injectable materials
has been reported in the literature, including liquid inject-
able silicone,10,11 autologous fat,12,13 polymethylmethacry-
late,14,15 and hyaluronic acid (HA),16,17 but no filler has yet
been approved by the US Food and Drug Administration
for use in the penis.18 The research to date suggests that
HA fillers are associated with the few side effects and yield
high satisfaction rates.7,19 However, they do not offer a
permanent size enhancement owing to slow reabsorption
over time.9 A study of 41 men who underwent penile girth
enhancement using HA filler found that patient satisfaction
scores were 3.71 ± 0.46 (range: 0-4) at 1 month post-proce-
dure and 3.34 ± 0.53 at 18 months, with no adverse reac-
tions.17 Similar satisfaction results after 5 years have also
been reported for glans penis augmentation using HA.16
Beyond these relatively simplistic measures of satisfac-
tion with procedural outcomes, however, there are very
limited data on broader outcomes. A procedure that aims
to improve function and appearance can influence multi-
ple domains of life functioning, including physical, sexual,
and psychological,20 but these domains have received very
little attention from researchers. With respect to psycho-
logical functioning, an important factor to consider in the
field of cosmetic interventions is body dysmorphic disor-
der (BDD), the most common psychological disorder in
individuals who seek cosmetic procedures.21 This disorder
involves a preoccupation with a slight or perceived flaw
in physical appearance, which has a significant negative
impact on social, occupational, and general life function-
ing.22 This preoccupation prompts some individuals to
undergo cosmetic procedures in an attempt to correct their
perceived physical defect. In fact, between 5% and 15%
of cosmetic surgery patients meet criteria for BDD,22 and
this diagnosis appears to be even more common in male
patients than female patients.23 However, rather than an
alleviation of their psychological distress after cosmetic
intervention, individuals with BDD usually experience no
change or a worsening of their symptoms after undergoing
cosmetic treatment.24 Thus, BDD is generally considered to
be a contraindication to cosmetic treatment.21
The prevalence of BDD in men seeking penile augmen-
tation is not yet known.25 So called “penile dysmorphobia”
has been reported in a limited number of studies involving
surgical methods of penile augmentation.26-28 Unexpectedly,
some studies reported high surgical satisfaction rates for
patients with penile dysmorphobia, while Li et al26 reported
a low overall surgical satisfaction rate at 35%, which was
even lower in patients with penile dysmorphobia at 27%.
However, the diagnosis of penile dysmorphobia in all stud-
ies did not appear to be based on any validated screening
measure or structured diagnostic interview for BDD, and
so we cannot be certain whether these men actually had a
diagnosis of BDD prior to surgery or the effects the proce-
dure had on their BDD symptoms.
Research also suggests that men experience improve-
ments in their self-esteem and confidence, particularly in
sexual situations, after surgical penile augmentation.28,29
However, these results were similarly based on non-vali-
dated measures, often single items, which cannot capture
the complexity of psychological constructs such as self-es-
teem. Furthermore, quantitative questionnaires in general
are somewhat limited in their capacity to provide in-depth
and complex understandings of men’s life experiences after
undergoing penile augmentation. In-depth interviews with
patients are an essential source of information, as it is pos-
sible to explore why patients are satisfied/dissatisfied with
the procedure, and also the patients themselves can identify
the specific areas of their lives impacted by the procedure
and what these impacts are. Without this information, med-
ical practitioners may unintentionally overlook outcomes
that their patients consider to be highly important. To our
knowledge, no interview studies have been published with
men who have undergone penile augmentation procedures.
Thus, in the current study, we sought to examine the
psychological and psychosexual outcomes in men who
had already undergone a penile girth augmentation, using
a unique mixed method approach. First, for the quanti-
tative component of the study, we aimed to investigate
the effects of girth augmentation on penile-focused BDD
symptoms, genital self-image, overall self-esteem, and sex-
ual relationship satisfaction, using validated measures in a
questionnaire. Second, for the qualitative component, we
aimed to explore in-depth, via interview, the impacts on
girth augmentation on men’s lives, particularly surround-
ing the issues of psychological and sexual well-being.
METHODS
Quantitative Phase
Participants and Procedure
A sample of adult men in Australia who had undergone
a penile girth augmentation procedure from May 2016 to
August 2017 were recruited from April 2017 to August 2017
through private clinics in Sydney and Perth, Australia. None
of the men who underwent the procedure had a micropenis,
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Sharp and Oates 3
defined as a stretched penis measuring less than 7 cm.30,31
The penile girth augmentation method employed in this
study, using a HA-based gel, has been previously described9
and example procedure results are shown in Figure 1. Men
were contacted by clinic staff, who were not involved in the
patient’s treatment, via email or phone text message and were
provided with a weblink to study information. Interested
patients then clicked on the weblink at the end of the study
information to access an online questionnaire. Participation
in the questionnaire was completely anonymous and confi-
dential, and completion of the questionnaire was considered
to be informed consent, according to the Australian National
Health and Medical Research Council.32 Only the first author
(G.S.), a researcher who was completely independent of the
patient’s treatment, had access to the online portal contain-
ing the completed survey data. This was important, as the
second author (J.O.), a facial plastic and cosmetic surgeon,
performed the penile augmentation procedure on some of
the study participants. Ethical approval to conduct the ques-
tionnaire was obtained from the Flinders University Social
and Behavioural Research Ethics Committee.
Inclusion criteria for the study were: (1) undergone
a HA injectable penile girth augmentation at least one
month prior; (2) aged 18 or over; (3) proficient in English;
and (4) agreeable to contact with the clinics. Of the 80
men eligible to participate in the study, 25 completed the
online questionnaire, resulting in a response rate of 31.3%.
This rate was slightly higher than previous penile aug-
mentation research14 and corresponded to other cosmetic
intervention studies.33 As the participants completed the
survey anonymously, analysis of any potential differences
in characteristics between men who chose to participate
and those who did not could not be conducted. A blank
copy of the survey is available online as Supplementary
Material at www.aestheticsurgeryjournal.com.
Survey participants were between 1 and 12 months post-
girth augmentation procedure (mean, 6.6 months; median,
8 months). Participant age ranged from 23 to 69 years
(mean, 39.6; SD, 13.7 years). Most participants (76.0%,
n = 19) self-identified as Caucasian/White (1 “Arab,” 5 no
response). The majority (56.0%, n = 14) self-identified as
exclusively heterosexual (2 predominantly heterosexual, 1
equally heterosexual and homosexual, and 3 exclusively
homosexual, 5 no response), and most were involved in
a relationship at the time of completing the questionnaire
(76.0%, n = 19). The most common highest level of educa-
tion achieved by participants was trade/certificate/diploma
(36.0%, n = 9), followed by an undergraduate university
degree (24.0%, n = 6), high school (12.0%, n = 3), and
postgraduate university degree (8.0%, n = 2). Some partic-
ipants (20.0%, n = 5) had previously undergone a cosmetic
procedure of some kind that included rhinoplasty (n = 2),
chin implant (n = 1), male breast reduction (n = 1), “body
lift” (n = 1), and Botulinum toxin injections (n = 1).
Furthermore, 28% (n = 7) had previously tried another
method of penile augmentation that included penis pumps
(n = 2), extenders/stretchers (n = 2), autologous fat trans-
fer (n = 1), girth enhancement using a non-HA material
(n = 1), “penile implant” not otherwise specified (n = 1),
and platelet rich plasma injection (n = 1).
Measurements
The questionnaire included measures of demographic
information, followed by details of the penile augmentation
AB
Figure 1. (A) Pre-injection photograph of a 34-year-old man who was concerned about “shrinkage” of his penis, which
measured 11.0 cm in girth. (B) Post-injection photograph obtained 1 week after 10 mL injection of a hyaluronic acid (HA)-
based gel to increase penile girth, which now measured 13.5 cm.
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4 Aesthetic Surgery Journal
procedure and motivations for and satisfaction with the
procedure. Participants were then asked to rate their cur-
rent levels of genital self-image, penile-focused BDD symp-
toms, and self-esteem and sexual relationship satisfaction.
Next, they were asked to recall their levels of genital
self-image, penile-focused BDD symptoms, and self-es-
teem and relationship satisfaction before undergoing girth
augmentation so that any perceived changes in these out-
comes from prior to augmentation to the time they com-
pleted the questionnaire could be measured.
Motivations for Penile Augmentation and Procedure
Details
Participants were first asked to recall their reasons for under-
going a girth augmentation in an open-ended response. These
were rated by two independent raters, and four categories
were agreed upon, namely, “self-perception,” “psychologi-
cal distress,” “sexual function/pleasure,” and “appearance.”
Participants were then asked to provide the month and year
of their girth augmentation. They were also asked whether
they had tried any other method of penile enhancement and
any other cosmetic procedures in their lifetime and to pro-
vide details of these procedures if applicable.
Satisfaction With Penile Augmentation
Satisfaction with the girth augmentation procedure was
measured using 3 items. The items addressed current sat-
isfaction with penile size, appearance, and function on a
7-point Likert-type scale ranging from 1 (extremely dissat-
isfied) to 7 (extremely satisfied). In addition, they were
asked whether they had had any complications and to pro-
vide details where relevant.
Male Genital Self-Image
Men’s perceptions of their genitals or genital self-image
were measured using the 7-item Male Genital Self-Image
Scale (MGSIS).34 Participants rated their level of agreement
with each item (eg, “I am satisfied with the appearance
of my genitals,” “I am not embarrassed about my gen-
itals”) on a 4-point Likert-type scale (1 = Strongly dis-
agree to 4 = Strongly agree). The 7 items were summed
to generate an overall score ranging from 7 to 28 with
higher scores indicating more positive genital self-image.
The reported internal consistency for this scale was high
(Cronbach’s α = 0.93)34 and was similar in the present
study (Cronbach’s α recalled = 0.92, current = 0.93).
Penile-Focused Body Dysmorphic Disorder
Penile-focused BDD symptoms were measured using the
9-item Cosmetic Procedure Screening Scale for Penile
Dysmorphic Disorder (COPS-P), which follows the Diagnostic
and Statistical Manual of Mental Disorders 4th edition
(DSM-IV) criteria for BDD, with a focus on penile concerns.35
Participants rated their level of symptomatology for each item
(eg, “To what extent does the size or appearance of your penis
currently cause you distress?,” “To what extent do your con-
cerns about the size or appearance of your penis currently
interfere with your social life?”) on a 9-point Likert-type scale
(0 = Not at all to 8 = Extremely/Very Severely). The 9 items
were summed to generate an overall score ranging from 0 to
72 with higher scores indicating greater preoccupation and
distress surrounding the penis and thus a greater likelihood of
a diagnosis of BDD. In accordance with Veale et al,35 an overall
score of 40 was used to discriminate men with penile-focused
BDD from those with less severe small penis anxiety.31 This
scale has demonstrated high internal consistency (Cronbach’s
α = 0.94),35 and this was slightly lower in the present study
(Cronbach’s α recalled = 0.89, current = 0.86).
Self-Esteem and Relationships
Self-esteem and relationship satisfaction were measured
using the 14-item Self-Esteem and Relationship (SEAR)
questionnaire.36 This questionnaire consisted of two
domains: Sexual Relationship (8 items) and Confidence (6
items), and within the Confidence domain, there were 2
subscales: Self-Esteem (4 items) and Overall Relationship
(2 items). Participants rated the frequency with which they
agreed with each item (eg, Sexual Relationship Domain:
“I felt confident about performing sexually,” Confidence
Domain - Self Esteem Subscale: “I felt like a whole man,”
Confidence Domain - Overall Relationship Subscale: “I was
satisfied with our relationship in general”) on a 5-point
Likert-type scale (1 = Almost never/never to 5 = Almost
always/always). The items were summed within domains/
subscales as well as an overall score and transformed to
a 0 to 100 scale (as described in Cappelleri et al36) with
higher scores indicating a more favorable response. The
total and domains/subscales have demonstrated good
internal consistency previously (Cronbach’s α = 0.76 to
0.93)36 and were higher in the present study (Cronbach’s α
recalled = 0.81 to 0.95, current = 0.84 to 0.92).
Data Analysis
The data were analyzed using IBM SPSS (version 24.0;
IBM SPSS, Inc, Chicago, IL). Paired samples t-tests (two-
tailed) were used to examine changes in participants’
current ratings for genital self-image, penile-focused BDD
symptoms, and self-esteem and relationships satisfaction
compared to their recalled ratings before their procedure.
Missing values in the data set were handled with pair-wise
deletion. A value of P < 0.05 was considered to be statis-
tically significant.
Qualitative Phase
Participants and Sampling
Participants were a sub-sample of the men who completed
the quantitative questionnaire and indicated interest in
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Sharp and Oates 5
further research by providing contact details in a sepa-
rate section at the end of the questionnaire. Participants
were sent an email or text message by the first author
(G.S.) with information about a phone interview study.
Interested participants completed a written consent form
and consent was reconfirmed verbally at the start of each
interview. Ethical approval to conduct the interview study
was obtained from the Flinders University Social and
Behavioural Research Ethics Committee. Of the 12 men
who were invited to participate in the interview study, 6
responded and consented to participate (50.0%), similar
to interview response rates for a study involving women
undergoing cosmetic genital surgery.37 Interview partic-
ipants were between 1 and 14 months post-augmenta-
tion procedure (mean, 7.3 months; median, 7 months),
and ranged in age from 30 to 58 years (mean, 42.7; SD,
10.2 years). All participants self-identified as Caucasian/
White. Most identified as exclusively heterosexual (66.7%,
n = 4), and the remainder identified as exclusively homo-
sexual. Similarly, 66.7% (n = 4) were involved in a rela-
tionship at the time of the interview. Half had achieved
an undergraduate university degree (50.0%, n = 3),
with the remainder nominating trade/certificate/diploma
qualification (33.3%, n = 2) and postgraduate degree
(16.7%, n = 1). Two participants (33.3%) had previously
undergone a cosmetic procedure in their lifetime, which
included a chin implant (n = 1) and Botulinum toxin
injections (n = 1).
Data Collection and Analysis
The first author (G.S.), a female clinical and research
psychologist, conducted all six one-to-one interviews
with participants in July and August 2017. The first
author was not involved in the treatment of any of the
participants. A qualitative phenomenological approach
was used to gain an in-depth understanding of the effects
of penile girth augmentation on men’s psychological and
sexual well-being. An interview guide was developed
containing questions similar to a study conducted by the
first author investigating the psychological outcomes of
cosmetic genital modification procedures in women.37
The first author adopted a semi-structured interview
approach to provide flexibility to briefly diverge from key
interview questions to explore issues of importance to
individual participants. The interviews began with con-
firmation of participant demographic information. The
next section of questions involved the exploration of par-
ticipant motivations to undergo the procedure. This was
followed by exploration of societal influences that may
have potentially impacted participant attitudes towards
their penis size and decision to have an augmentation.
The final section of the interview involved exploring par-
ticipant satisfaction with the outcomes and any effects
girth augmentation had on their lives, including on their
sexual relationships and psychological well-being. This
same framework was used in all interviews. As it was
not possible to do justice to all themes in this paper, the
three themes related to satisfaction and outcomes were
included owing to the focus on psychological and psy-
chosexual outcomes in this paper.
The phone interviews were between 20 and 54 minutes
in duration (mean, 31.8 minutes; median, 28 minutes).
These interviews were audio recorded and transcribed
verbatim. As previously described by Braun and Clarke,38
the transcriptions were analyzed using inductive thematic
analysis. The extracts were read multiple times so the first
author (G.S.) was familiar with the interview data and then
coded for important features. The codes were confirmed
with the second author (J.O.). The first author examined
similar codes to generate themes and represented these
visually as a thematic mind map on paper. The thematic
map was discussed with the second author and revised
until a consensus was reached.
RESULTS
Quantitative Phase
Motivations and Satisfaction
The men provided a range of reasons for seeking penile
girth augmentation. As seen in Table 1, the most common
motivation was to improve their self-perception. The next
most common reasons were to address psychological dis-
tress related to penis size, and to improve sexual function/
enjoyment for themselves and/or a partner, and, finally, to
improve the appearance of their penis.
After penile girth augmentation, the majority of par-
ticipants reported that they were either “slightly,” “mod-
erately,” or “extremely” satisfied with the size (n = 20,
80.0%), appearance (n = 19, 76.0%), and function
(n = 19, 76.0%) of their penis after augmentation
(Table 2). Three participants (12.0%) utilized a final com-
ments section at the end of the questionnaire to provide
reasons for dissatisfaction (ie, scores less than 4 on the
7-point Likert-type scale), and these included an unnat-
ural look to their penis (n = 2), girth size increase not
being as large as expected (n = 1), and prominent look of
the foreskin due to lack of circumcision (n = 1). Only a
minority of participants (n = 2, 8.0%) reported post-pro-
cedure complications that included infection, swelling,
and pooling of filler.
Psychological Outcomes
As seen in Table 3, the participants reported significant
changes in their genital self-image, penile-focused BDD
symptoms, and the self-esteem subscale of the SEAR meas-
ure. More specifically, the participants reported increased
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6 Aesthetic Surgery Journal
genital self-image and self-esteem, as well as less severe
BDD symptoms at the time of completing the question-
naire compared to their recalled levels prior to penile aug-
mentation. It must be noted that the recalled ratings from 2
participants (8.0%) would have potentially met diagnostic
criteria for BDD before undergoing penile augmentation,
and this reduced to zero participants for their current
ratings (after augmentation). Furthermore, these 2 par-
ticipants both rated their satisfaction with the size, appear-
ance, and function of their penis after augmentation in
the satisfied range (ie, scored 5 and above on the 7-point
Likert-type scales).
Table2. Participant Satisfaction With Penile Girth Augmentation Outcomes (n=25)
Variable Extremely
satisfied
n (%)
Moderately
satisfied
n (%)
Slightly
satisfied
n (%)
Neither satisfied or
dissatisfied
n (%)
Slightly
dissatisfied
n (%)
Moderately
dissatisfied
n (%)
Extremely
dissatisfied
n (%)
Size satisfaction 9 (36.0) 6 (24.0) 5 (20.0) 0 (0.0) 1 (4.0) 3 (12.0) 1 (4.0)
Appearance
satisfaction
7 (28.0) 8 (32.0) 4 (16.0) 0 (0.0) 2 (8.0) 4 (16.0) 0 (0.0)
Function satisfaction 10 (40.0) 4 (16.0) 5 (20.0) 3 (12.0) 2 (8.0) 1 (4.0) 0 (0.0)
Table3. Comparisons of Participant Recalled Ratings Before Penile Girth Augmentation and Current Ratings on Psychological and Psychosexual
Outcome Measures (n=25)
Measure Range Before
mean (SD)
Current
mean (SD)
P value Cohen’s d
Genital self-image 7-28 17.7 (4.7) 21.9 (4.0) <0.001 0.96
Penile-focused body dysmorphic disorder 0-72 21.9 (14.7) 11.9 (11.1) 0.002 0.77
Self-esteem and relationship* 0-100 69.8 (21.7) 78.0 (18.0) 0.091 0.41
D1: Sexual relationship* 0-100 71.1 (22.2) 76.8 (18.2) 0.240 0.28
D2: Confidence* 0-100 68.1 (24.1) 79.5 (19.5) 0.065 0.52
S1: Self-esteem 0-100 67.5 (25.9) 80.6 (17.9) 0.008 0.59
S2: Overall relationship* 0-100 71.9 (22.7) 72.9 (28.6) 0.809 0.04
D, domain; S, subscale. *n= 12 for these analyses, as participants needed to be involved in a relationship both before augmentation and at the time of questionnaire completion to allow for
comparison.
Table1. Participant Motivations for Penile Girth Augmentation by Theme (n=25)
Theme Example n (%)* n (%) as sole
reason
Self-perception “Just wanted more size to feel better about myself.”
“To feel more confidence in myself.”
8 (32.0) 4 (16.0)
Psychological distress “Primarily have always been conscious of my size”
“I knew that Ilacked girth for many years. From girls telling me, and seeing for myself. Ijust wanted to feel normal
and not ashamed or anxious of it. It was occupying about 80% of my thoughts that Iwas inadequate, and useless.”
7 (28.0) 6 (24.0)
Sexual function/ pleasure “I wanted to make my partner feel very full and very stretched.”
“So it…feels tighter when having sex.”
7 (28.0) 2 (8.0)
Appearance “So it looks bigger.”
“It’s always nice to feel you fill out a pair of underwear or swimmers better.”
6 (24.0) 1 (4.0)
Combination “Partner has had multiple children so trying to increase her pleasure along with mine. Not quite satisfied with nat-
ural size. Increase confidence, self-image and pleasure.”
“Self-esteem. Feeling comfortable in public change rooms.”
7 (28.0)
*Percentages do not sum to 100%, as participants provided motivations that were coded into multiple themes.
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Sharp and Oates 7
Qualitative Phase
High Overall Post-Procedure Satisfaction
Participants were generally very satisfied with the improve-
ments in the aesthetics of their penis after girth augmenta-
tion, which sometimes even exceeded their expectations.
I think that the result that I’ve ended up with is
fantastic. I absolutely love it…. But also the length
of the penis. It’s much longer now when it’s flac-
cid obviously. It doesn’t really retract much at all.
(Participant 2, aged 40, 7 months post-augmentation)
Some noted that although their penis was not “perfect,”
they were still satisfied with the perceived improvement
in appearance.
P: It’s slightly skewiff, so it’s slightly sort of not as
perfect as it used to be.
I : So it’s got a bit of a kink in it now?
P: Got a bit of a kink, yes….but I feel great with it.
It’s fantastic. (Participant 6, aged 47, 1-month
post-augmentation)
Increased Self-Condence From Less Worry
All participants reported an increase in their self-con-
fidence as a result of their increased penile girth. Some
added that they were not necessarily lacking in self-con-
fidence prior to the procedure. However, after the proce-
dure, they no longer had to worry about their penis size.
I just stopped thinking about it [my penis]. It was
no longer an issue obviously because I’d solved that
issue so therefore I suppose, you find yourself not
thinking about it. I guess I have to say there is def-
initely a confidence factor. (Participant 2, aged 40,
7 months post-augmentation)
I didn’t feel like I had no confidence at all, but I feel
like I have a bit more confidence now. (Participant 5,
aged 30, 7 months post-augmentation)
Participants consistently provided examples of feeling
more confident and comfortable in non-sexual situations
where their naked penis (eg, locker/change room) or the
outline of their penis (eg, wearing a swimsuit) would be
visible to others. Prior to the procedure, these situations
would have provoked some anxiety in the participants.
[Feeling] a little bit more comfortable, especially in
the change room. I was very conscious before and…I
was always covered [up] so I don’t really worry that
much anymore when naked. I’m not worried about
people seeing my penis. (Participant 3, aged 47,
14 months post-augmentation)
I don’t think twice about if I had to change in a
[locker] room, that’s really not an issue or coming
out of a pool or any sort of thing like that I don’t have
to worry about. I always know that I look good naked
I guess…I think, for anybody, that would increase
confidence too on a day to day basis. (Participant 5,
age 30, 7 months post-augmentation)
Individual Differences in Impacts on Sexual
Relationships
Most participants reported that they were more confident
to initiate sex and felt that their partner’s pleasure was
increased. If not involved in a relationship at the time of
the interview, participants predicted that future partners
would experience greater sexual enjoyment as a result of
their penile enhancement.
P: Probably just more confident in bed, that’s prob-
ably the best change….I venture there [the bed-
room] a bit more often.
I : So you feel like you can initiate sex a bit more often?
P: Yes. (Participant 1, aged 58, 14 months
post-augmentation)
P: I definitely think it would be a lot better for my
future partner.
I : Sure. So you’re likely to increase her sexual pleas-
ure you think?
P: I’d say so, yes. (Participant 4, aged 34, 1 month
post-augmentation)
However, one participant noted that as he had been in a
very long-term relationship with his female partner, he did
not think the impact on his sex life was so obvious.
Well, suppose I’ve been with the same one [rela-
tionship] for twenty-five years so probably not
to an extent. (Participant 3, aged 47, 14 months
post-augmentation)
Another participant stated that he actually felt more
pressure in sexual situations than he did before his aug-
mentation procedure. This perceived pressure was from
prospective male sexual partners as his penis was now so
large and thus more appealing to other men.
So now sometimes I can have performance issues
and confidence issues because it’s like there’s a much
more obvious focus on my penis from other guys…
They see how big it is when it’s flaccid and then say
“Oh great. That’s incredible. Let’s get going [have
sex].” And then I think “…I hope I can perform” and
then those [doubting] thoughts start to process…So
a bigger penis has actually probably caused me to
have more performance issues now than I had before.
(Participant 2, aged 40, 7 months post-augmentation)
DISCUSSION
As the first study to conduct an in-depth exploration of
the psychological and psychosexual outcomes of penile
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8 Aesthetic Surgery Journal
girth augmentation, using both quantitative and qualita-
tive approaches, we have provided several new insights.
We have shown that men are generally satisfied with the
outcomes of their nonsurgical medical penile girth aug-
mentation. We also found, for the first time, that they
report statistically significant improvements in their gen-
ital self-image, overall self-esteem, and a reduction in
penile-focused BDD symptoms after having a girth aug-
mentation procedure. Through our qualitative analysis,
we discovered that men appear to relate improvements in
their overall self-confidence to a decrease in anxiety about
their penis being viewed by other people such as peers and
partners. We also report, for the first time, that although
girth augmentation can have positive effects on some
men’s sexual relationships, it can also have less desirable
effects too.
In terms of motivations to undergo girth augmentation,
the men reported in the quantitative phase that they were
motivated by a range of reasons to undergo penile girth
augmentation, with the most common being to improve
their overall perception of themselves. This finding sup-
ported previous research that self-worth in men can be
influenced by the perceived “adequacy” of their geni-
tals,39 and when a man feels his penis is “inadequate,” he
may seek a medical solution in an attempt to improve his
self-worth. Our results suggested that 8% of men poten-
tially fulfilled the diagnostic criteria for BDD (focused
on their penis) prior to penile augmentation, which may
have motivated these individuals to seek augmentation.
Notably, our study was the first to employ a validated BDD
screening measure in a penile augmentation setting. Our
BDD prevalence is similar to that found in patient cohorts
seeking other forms of cosmetic treatments.21 However,
our study was reliant upon men’s recall of their psycholog-
ical state prior to their procedure and so may potentially
be an underestimate of BDD prevalence, considering that
20% of the men had undergone another form of cosmetic
procedure in their lifetime, indicating dissatisfaction with
multiple body parts. This investigation of BDD should be
replicated in patients prior to penile augmentation and
also involve a structured diagnostic interview as confirma-
tion of BDD diagnosis.
The vast majority of participants were satisfied with the
size, appearance, and function of their penis after girth
augmentation in the quantitative study phase, including
the 2 men whose recalled scores for pre-augmentation
potentially met diagnostic criteria for BDD. The satisfac-
tion rates were generally higher than for surgical augmen-
tation methods,6,7 but slightly lower than reported in other
injectable penile girth augmentation studies.14,17 However,
unlike these other studies, our assessment of satisfaction
was conducted anonymously and independently of the
treatment team. Importantly, we also collected reasons for
dissatisfaction with outcomes, which are often overlooked
in this area of research.8 Dissatisfactions reported in our
study focused on aesthetic concerns and unmet expecta-
tions for girth increase. The complication rate was low
in our study (8%), but the fact that the patients them-
selves nominated the complications they experienced,
rather than the medical practitioner, may have contrib-
uted to the slightly higher complication rate compared to
other HA-based girth augmentation methods.17 The men
involved in the qualitative study phase all expressed high
satisfaction, with some commenting that their expecta-
tions for size increases were exceeded.
The men also experienced significantly improved
genital self-image and a reduction in BDD symptoms in
the quantitative study phase, compared to their recalled
levels prior to augmentation, thus indicating an overall
improvement in their attitudes and distress surrounding
their penis. The men who indicated that they would have
potentially met diagnostic criteria for BDD prior to aug-
mentation, according to their recalled scores, no longer
met criteria after their procedure. This was unexpected,
as BDD symptoms usually do not improve or worsen after
cosmetic treatment, and so BDD is usually considered to
be a contraindication.21,24 However, a small prospective
study involving women who underwent labial reduction
surgery also found that almost all patients no longer had
BDD 3 months post-surgery.40 This may be a point of dif-
ferentiation for cosmetic genital procedures in which there
may be more definite functional reasons motivating the
individual to undergo the procedure than for other more
aesthetically focused procedures, such as rhinoplasty. It
is also possible that even for individuals who do feel sat-
isfied with the body part that was the focus of the cos-
metic procedure, their preoccupation may shift to another
body part and the diagnosis of BDD remain. Clearly, fur-
ther research investigating BDD in penile augmentation
patients is required and medical practitioners should con-
tinue to screen their patients for this disorder and refer to
mental health practitioners when needed.
The improvements in attitudes towards their penis
also appeared to translate to significant improvements
in overall self-esteem in the quantitative phase. A desire
to increase self-esteem is a common motivation for cos-
metic intervention in general,41 including in our study,
but research suggests that improved self-esteem does not
always occur after treatment or the increase is only mod-
est.33,41,42 However, our findings were in accordance with
2 other penile augmentation studies,28,29 although these
studies were reliant upon single-item non-validated mea-
sures and focused particularly on sexual self-esteem. It may
be the case that improvements to the penis, in particular,
may impact a man’s overall sense of self more strongly
than improvements to other body parts (eg, nose, chin).
The men’s reports from the qualitative interviews sup-
ported and expanded on the quantitative findings. All men
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Sharp and Oates 9
mentioned an increase in self-confidence that they linked
to no longer having to be anxious about their penis being
seen by others. It may have been the case that these men
had concerns that dated back to childhood or adolescence,
potentially with negative comments being made by family
members and peers.5 Certainly, some men reported receiv-
ing negative comments about their penis and the resulting
psychological distress as a motivating factor for penile aug-
mentation in the quantitative phase of the study. Thus, an
increase in penis size would have likely been a relief and
allowed these men to feel more comfortable in situations
in which their penis was visible, such as a change room.
Unlike the improvements in self-esteem after augmen-
tation, there were no significant improvements in men’s
perceptions of their sexual relationship or relationships as
a whole in the quantitative phase. Notably, not all men in
the sample were involved in a relationship either before or
after their augmentation procedure, and so the sample size
was reduced for this analysis. Nevertheless, sexual rela-
tionship satisfaction is influenced by multiple factors, both
emotional and relational aspects of sexual interactions,43
and so it may be unrealistic to expect enhancements in this
area of life after an increase in penile girth size alone. Thus,
sexual relationship quality may be an important issue for
clinicians to discuss with prospective penile augmenta-
tion patients to check that their expectations are realistic.
A man who expects a greatly improved relationship with
his partner after augmentation may be disappointed with
his procedural outcomes.42 Nevertheless, the qualitative
data suggested that men may experience improvements
in particular aspects of their sexual relationships, includ-
ing increased confidence to initiate sex with a partner and
increased sexual enjoyment for their partner. Although
some previous quantitative studies have included simple
satisfaction ratings for the patient’s partner, which were
usually similar to the patient’s own satisfaction levels,16,17
future research could involve in-depth interviews with
partners to further explore the effects of penile augmenta-
tion on sexual relationships.
Another novel finding from the qualitative study phase
was that transitioning to a larger penis size could actually
lead to some men feeling more anxious about their sexual
performance. This issue may be particularly important in
men who have sex with men, as was the case in our study,
as men who have larger penises tend to be sought after as
the “top” or anal penetrative partner.1 Thus, establishing
and maintaining an erection may be more important in the
“top” role than the anal receiving partner (“bottom” role).1
A penile augmentation procedure may mean that a man
who used to have a smaller penis and was traditionally
a receiving partner is now expected to be the penetrative
partner, which may generate some anxiety around hav-
ing to perform the more dominant sexual role. Although
the majority of men in our study identified as exclusively
heterosexual, this may be an important issue for clinicians
to consider when consulting with bisexual or homosexual
penile augmentation patients.
The present study should be interpreted with some lim-
itations in mind. First, owing to the retrospective design
of the study, we relied upon participant recall of their psy-
chological state prior to augmentation. It may have been
difficult for men to accurately remember their attitudes
towards their penis before their augmentation procedure,
which was longer than 12 months prior for some partici-
pants. Clearly, our preliminary findings addressing psycho-
logical outcomes of penile augmentation presented here
should be further investigated using a prospective con-
trolled study design, which is our in-progress work.
Second, we did not collect any data on the physical out-
comes of the girth augmentation, such as girth measure-
ments before and after the procedure, as we did not expect
the men themselves to accurately recall these measure-
ments. Further, owing to the anonymous data collection,
which was performed independently of the treating clin-
ics via the first author (G.S.), we could not match men’s
responses with their clinical records. Nevertheless, the fact
that the treating medical practitioners were not involved
in data collection in any capacity, thus potentially reduc-
ing response bias,44 is a significant strength of our study.
Our previous research suggests that an injection total of
15 to 25 mL of HA will usually result in a girth increase
of approximately 2.5 cm when flaccid and 1.3 cm when
erect.9 An important consideration is that a larger increase
in penile girth size may not necessarily translate to greater
psychological benefits for the patient, and so a broad range
of outcomes, physical, psychological, and sexual, should
be examined in future outcome studies.
A third limitation of our study was that the sample size
was relatively small for the quantitative phase, particu-
larly the sexual relationship analysis, as not all men were
involved in relationships before or after augmentation.
As a result, we did not have sufficient statistical power to
detect small effects. Smaller sample sizes in psychosocial
research in cosmetic surgery settings are a noted common
issue,33 particularly with more sensitive procedures such
as penile augmentation.45 The qualitative phase involved a
smaller group of men; again, however, qualitative research
is not intended to yield a “representative” sample like a
quantitative study.46 Instead, coherence of themes among
participants is important, and that was evident in our qual-
itative phase. It is possible that there was a bias in our
sample toward men who were more satisfied with their
girth augmentation outcomes. However, 12% of men felt
sufficiently comfortable, potentially owing to the anony-
mous and independent nature of the data collection, to
specifically outline the reasons for their dissatisfaction
with procedural outcomes. Previous research suggests
that individuals who participate in questionnaire studies
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10 Aesthetic Surgery Journal
on intense topics are actually less likely to have had an
extremely positive or extremely negative experience.46,47
CONCLUSION
Notwithstanding these limitations, our study results have
provided novel insights into the psychological and psy-
chosexual outcomes of penile girth augmentation, using
a unique mixed method approach, and thus provided an
important platform for future research. We showed that
men perceive that nonsurgical medical penile girth aug-
mentation has a positive effect on their attitudes toward
and distress surrounding their penis, as well as on their
overall self-esteem. Some men added in the interviews that
they no longer felt anxious in situations in which their
penis could potentially be viewed by others. There were
no overall positive effects on men’s sexual relationships;
however, the men who were interviewed generally indi-
cated that they were more confident to initiate sex with a
partner. Our study results will potentially assist clinicians
in their discussions with men who are concerned about
their penis size and are seeking penile augmentation.
Acknowledgements
Sincere thanks are extended to all of the men who partici-
pated in this study.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Disclosures
Dr Sharp served as a paid research consultant on this study,
but derived no benefit from the clinical outcomes presented.
Dr Oates performed penile girth augmentation procedures on
some of the study participants.
Funding
The authors received no financial support for the research,
authorship, or publication of this article.
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