Klam 4 and Andrew P. This review 1 considers data from multiple domains, e. Alterations to the brain's motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use.
In the interim, a simple diagnostic protocol for assessing patients with porn-induced sexual dysfunction is put forth. Trends in Sexual Dysfunction—Unanswered Questions Up until the last decade, rates of ED were low in sexually active men under 40, and did not begin to rise steeply until thereafter [ 1 , 2 ].
In contrast, recent studies on ED and low sexual desire document a sharp increase in prevalence of such dysfunctions in men under In —, it was administered to 13, sexually active men in 29 countries [ 5 ]. The first group, in —, were aged 40— The second group, in , were 40 and under. Based on the findings of historical studies cited earlier, older men would be expected to have far higher ED rates than the negligible rates of younger men [ 2 , 7 ].
However, in just a decade, things changed radically. In the last few years, research using a variety of assessment instruments has revealed further evidence of an unprecedented increase in sexual difficulties among young men. A study on Canadian adolescents reported that A study by this same group assessed sexual problems in adolescents 16—21 years in five waves over a two-year period. For males, persistent problems in at least one wave were low sexual satisfaction The researchers noted that over time rates of sexual problems declined for females, but not for males [ 11 ].
A study of new diagnoses of ED in active duty servicemen reported that rates had more than doubled between and [ 12 ]. Rates of psychogenic ED increased more than organic ED, while rates of unclassified ED remained relatively stable [ 12 ]. A cross-sectional study of active duty, relatively healthy, male military personnel aged 21—40 employing the five-item IIEF-5 found an overall ED rate of The researchers also noted that sexual dysfunctions are subject to underreporting biases related to stigmatization [ 14 ], and that only 1.
Traditionally, ED has been seen as an age-dependent problem [ 2 ], and studies investigating ED risk factors in men under 40 have often failed to identify the factors commonly associated with ED in older men, such as smoking, alcoholism, obesity, sedentary life, diabetes, hypertension, cardiovascular disease, and hyperlipidemia [ 16 ]. ED is usually classified as either psychogenic or organic.
Psychogenic ED has been related to psychological factors e. However, none of the familiar correlative factors suggested for psychogenic ED seem adequate to account for a rapid many-fold increase in youthful sexual difficulties.
For example, some researchers hypothesize that rising youthful sexual problems must be the result of unhealthy lifestyles, such as obesity, substance abuse and smoking factors historically correlated with organic ED. Yet these lifestyle risks have not changed proportionately, or have decreased, in the last 20 years: Obesity rates in U. Other authors propose psychological factors. Yet, how likely is it that anxiety and depression account for the sharp rise in youthful sexual difficulties given the complex relationship between sexual desire and depression and anxiety?
Some depressed and anxious patients report less desire for sex while others report increased sexual desire [ 22 , 23 , 24 , 25 ]. Not only is the relationship between depression and ED likely bidirectional and co-occurring, it may also be the consequence of sexual dysfunction, particularly in young men [ 26 ].
While it is difficult to quantify rates of other psychological factors hypothesized to account for the sharp rise in youthful sexual difficulties, such as stress, distressed relationships, and insufficient sex education, how reasonable is it to presume that these factors are 1 not bidirectional and 2 have mushroomed at rates sufficient to explain a rapid multi-fold increase in youthful sexual difficulties, such as low sexual desire, difficulty orgasming, and ED?
Kinsey Institute researchers were among the first to report pornography-induced erectile-dysfunction PIED and pornography-induced abnormally low libido, in [ 27 ]. The researchers actually redesigned their study to include more varied clips and permit some self-selection. Since then, evidence has mounted that Internet pornography may be a factor in the rapid surge in rates of sexual dysfunction. A study on high school seniors found that Internet pornography use frequency correlated with low sexual desire [ 29 ].
Another study of men average age Anxiety about sexual performance may impel further reliance on pornography as a sexual outlet. Clinicians have also described pornography-related sexual dysfunctions, including PIED.
For example, in his book The New Naked, urology professor Harry Fisch reported that excessive Internet pornography use impairs sexual performance in his patients [ 32 ], and psychiatry professor Norman Doidge reported in his book The Brain That Changes Itself that removal of Internet pornography use reversed impotence and sexual arousal problems in his patients [ 33 ]. In , Bronner and Ben-Zion reported that a compulsive Internet pornography user whose tastes had escalated to extreme hardcore pornography sought help for low sexual desire during partnered sex.
Eight months after stopping all exposure to pornography the patient reported experiencing successful orgasm and ejaculation, and succeeded in enjoying good sexual relations [ 34 ]. To date, no other researchers have asked men with sexual difficulties to remove the variable of Internet pornography use in order to investigate whether it is contributing to their sexual difficulties. While such intervention studies would be the most illuminating, our review of the literature finds a number of studies that have correlated pornography use with arousal, attraction, and sexual performance problems [ 27 , 31 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], including difficulty orgasming, diminished libido or erectile function [ 27 , 30 , 31 , 35 , 43 , 44 ], negative effects on partnered sex [ 37 ], decreased enjoyment of sexual intimacy [ 37 , 41 , 45 ], less sexual and relationship satisfaction [ 38 , 39 , 40 , 43 , 44 , 45 , 46 , 47 ],a preference for using Internet pornography to achieve and maintain arousal over having sex with a partner [ 42 ], and greater brain activation in response to pornography in those reporting less desire for sex with partners [ 48 ].
Again, Internet pornography use frequency correlated with low sexual desire in high school seniors [ 29 ]. Two studies deserve detailed consideration here. The first study claimed to be the first nationally-representative study on married couples to assess the effects of pornography use with longitudinal data. The marriages most negatively affected were those of men who were viewing pornography at the highest frequencies once a day or more.
Assessing multiple variables, the frequency of pornography use in was the second strongest predictor of poor marital quality in [ 47 ]. The second study claimed to be the only study to directly investigate the relationships between sexual dysfunctions in men and problematic involvement in OSAs online sexual activities. This survey of men reported that lower overall sexual satisfaction and lower erectile function were associated with problematic Internet pornography use [ 44 ]. Finally, a significant percentage of the participants Our review also included two papers claiming that Internet pornography use is unrelated to rising sexual difficulties in young men.
However, such claims appear to be premature on closer examination of these papers and related formal criticism. The first paper contains useful insights about the potential role of sexual conditioning in youthful ED [ 50 ]. However, this publication has come under criticism for various discrepancies, omissions and methodological flaws.
For example, it provides no statistical results for the erectile function outcome measure in relation to Internet pornography use. Additionally, the researchers investigated only hours of Internet pornography use in the last month. A better predictor is subjective sexual arousal ratings while watching Internet pornography cue reactivity , an established correlate of addictive behavior in all addictions [ 52 , 53 , 54 ].
There is also increasing evidence that the amount of time spent on Internet video-gaming does not predict addictive behavior. A second paper reported little correlation between frequency of Internet pornography use in the last year and ED rates in sexually active men from Norway, Portugal and Croatia [ 6 ]. Yet, based on a statistical comparison, the authors conclude that Internet pornography use does not seem to be a significant risk factor for youthful ED.
This paper has been formally criticized for failing to employ comprehensive models able to encompass both direct and indirect relationships between variables known or hypothesized to be at work [ 59 ]. Incidentally, in a related paper on problematic low sexual desire involving many of the same survey participants from Portugal, Croatia and Norway, the men were asked which of numerous factors they believed contributed to their problematic lack of sexual interest.
Again, intervention studies would be the most instructive. However, with respect to correlation studies, it is likely that a complex set of variables needs to be investigated in order to elucidate the risk factors at work in unprecedented youthful sexual difficulties.
First, it may be that low sexual desire, difficulty orgasming with a partner and erectile problems are part of the same spectrum of Internet pornography-related effects, and that all of these difficulties should be combined when investigating potentially illuminating correlations with Internet pornography use.