Critique of “Is Pornography Use Related to Erectile Functioning? Results From Cross-Sectional and Latent Growth Curve Analyses” (2019)

Introduction: His correlations say one thing, but Joshua Grubbs says another

The researcher who saddled humankind with “perceived pornography addiction” and claimed it somehow “functions very differently from other addictions,” has now turned his dexterity to porn-induced ED. Joshua Grubbs’s new paper claims there’s no epidemic of youthful ED, boldly concluding its abstract with:

In conjunction with prior literature, we conclude that there is little or no evidence of an association between mere pornography use and ED.

This two-part assertion is disturbingly inaccurate:

  1. In reality, this new Grubbs study actually found that both problematic porn use (porn addiction) and higher levels of porn use were related to poorer erectile functioning in all 3 samples.
  2. As for “prior literature,” 27 studies link porn use or porn addiction to sexual problems and lower arousal to sexual stimuli. In fact, the first 5 studies in that list demonstrate causation, as participants eliminated porn use and healed chronic sexual dysfunctions.

Equally disturbing is the fact that this paper:

  1. largely excluded men with severe erectile dysfunction
  2. excluded sexually inactive men, and
  3. excluded virgins.

In short, most of the young men who constitute the “ED epidemic” (which these authors deny) were omitted from this study. It’s easier to claim you have established that porn use isn’t associated with an ED epidemic, if you refuse to study those who are suffering so severely from porn-induced ED that they aren’t having sex!

As RebootNation founder Gabe Deem said about a similar study: “Using men with healthy erections to study the links between porn and ED is akin to using cancer-free subjects to study the links between smoking and lung cancer.” (Gabe recovered from severe PIED, and now helps other men porn-induced sexual problems.)

Even though this Grubbs-penned study found correlations between poorer sexual functioning and both porn addiction and porn use (while excluding sexually inactive men and thus many men with ED), the paper reads as if it has completely debunked porn-induced ED (PIED). This maneuver comes as no surprise to those who have followed the earlier dubious claims of Dr. Grubbs in relation to his “perceived pornography addiction” campaign.

Note: While the study lists both Joshua Grubbs and Mateusz Gola as authors, Grubbs was responsible for “Acquisition of Data,” “Analysis and Interpretation of Data,” and “Drafting the Article.” Gola jumped in after the fact, helping only with “Revising It for Intellectual Content.” This is Josh Grubbs’s baby.

Let’s examine the problems in the methodology and reported findings:

Red Flag: The 3 groups of sexually active men reported good sexual functioning

Note the average age of each group. Sample 3 contains the age range most affected by porn as it’s rare for 19-year olds (sample 1) to develop PIED, while men in their late 40s to early 60s (sample 2) didn’t grow up using streaming internet porn.

  1. Sample 1: Psychology students: average age 19.8 (N=147)
  2. Sample 2: Online survey: average age 46.5 (N=297)
  3. Sample 3: Online survey: average age 33.5 (N=433)

As the study reported, all 3 groups scored fairly high on erectile functioning (using the IIEF-5) :

In 3 samples of sexually active men who also consume pornography, we found very high levels of erectile functioning. (emphasis supplied)

Again, this constitutes a huge confound as the study omitted virgins, sexually inactive men, and most anyone with severe ED: the very men who have the most porn-related sexual problems. The men excluded from the study represent a significant portion of the population, as there has been a tremendous rise in sexually inactive young men and men men under 40 with ED or problematic low libido.

It’s important to note that the IIEF-5 (pictured above) is intended to assess only men who are engaging in sexual intercourse (sexually active men). If complete porn-induced ED is a porn user’s current destination, many recognizable steps often preceded it, sometimes by years. As such, many porn-related sexual problems (and the men who have them), would be ineligible for assessment using the IIEF-5. Here are common issues reported on porn recovery forums:

This grim reality is supported by at least 5 studies demonstrating porn use apparently causing an array of sexual dysfunctions. Three of the five studies involved men who recovered from porn-induced anorgasmia and low libido, rather than ED. The other two studies contained a mix of patients who healed porn-induced delayed ejaculation and PIED. In addition, a study on treatment-seeking men who compulsively masturbated to porn reported that 71% of them had sexual problems, with 33% reporting delayed ejaculation.

Bottom line: In addition to likely omitting many (or even most) of the young men who constitute the “ED epidemic,” the study did not catch other porn-related sexual problems reported in the literature and by many chronic porn users.

Contrary to Grubbs’s study analysis, both porn addiction and higher levels of porn use were related to poorer erectile functioning

Tips for understanding the numbers in the study’s tables:

Zero means no correlation between two variables; 1.00 means a complete correlation between two variables. The bigger the number the stronger the correlation between the 2 variables. If a number has a minus sign, it means there’s a negative correlation between two things. (For example, there’s a negative correlation between exercise and heart disease. Thus, in normal language, exercise reduces the chances of heart disease. In contrast, obesity has a positive correlation with heart disease.)

Part 1: Porn addiction and erectile functioning

The 4 questions Grubbs used to measure levels of problematic porn use (porn addiction) were:

  1. I believe I am addicted to Internet pornography
  2. I feel unable to stop my use of online pornography
  3. Even when I do not want to view pornography online, I feel drawn to it
  4. I have put off things I needed to do in order to view pornography

A reader of the paper’s Introduction or Discussion sections would likely miss the fact, but both levels of porn use and levels of problematic porn use (porn addiction) were related to lower scores on IIEF-5 (the International Index of Erectile Function), which indicates reduced erectile functioning. Yet, even the authors do admit that porn addiction was related to poorer erectile functioning:

Similarly, there were consistent negative relationships between erectile functioning and problematic pornography use in all 3 samples, although this relationship was of only small to moderate magnitude (r = –0.20 to –0.33) and did not maintain statistical significance in sample 1 after application of the Holm correction.

Remember, a negative signs means lower scores on the IIEF, which means poorer erectile functioning. The results reveal that even in subjects with relatively healthy erectile functioning, porn addiction was significantly related to poorer erections.

Wait a minute you ask, how dare I say significantly related? Doesn’t the the study excerpt above confidently declare that the relationship (–0.20 to –0.33) was only “small to moderate,” meaning it’s no big deal?

As we will explore in greater detail below, Grubb’s use of descriptors varies remarkably, depending upon which Grubbs study you read. If the Grubbs study is about porn use causing ED, then the above numbers represent a meager correlation, tossed aside in his spin-laden write-up.

However, if it’s Grubbs’s most famous study (“Transgression as Addiction: Religiosity and Moral Disapproval as Predictors of Perceived Addiction to Pornography“), where he proclaimed that being religious was the real cause of  “porn addiction,” then numbers smaller than these constitute a “robust relationship.” In fact, Grubbs’s “robust” correlation between religiosity and “perceived pornography addiction” was only 0.30! Yet he audaciously used it to usher in a completely new, and questionable, model of porn addiction. The tables, correlations and details referred to here are found in this section of a longer YBOP analysis.

In the current ED study, it’s vital to note that the strongest correlation between porn addiction and poorer erections (–0.33) occurred in Grubbs’s largest sample. This was the only sample of an average age most likely to report porn induced ED: sample 3, average age: 33.5 (433 subjects).

Part 2: Pornography use and erectile functioning

While the paper consistently downplays the correlations between higher pornography use and poorer erections, correlations were reported in all 3 groups – especially for sample 3, which was the most relevant sample as just explained. Excerpt from study:

However, with the exception of sample 3, there was little evidence of a link between pornography use itself and erectile functioning. In samples 1 and 2, the links between pornography use and erectile functioning were consistently weak and insignificant

Below are the 3 groups, with their average daily minutes of porn viewing and the correlations between erectile functioning amount of use (a negative sign means poorer erections linked to greater porn use):

  1. Sample 1 (147 men): average age 19.8 – Averaged 22 minutes of porn/day. (–0.18)
  2. Sample 2 (297 men): average age 46.5 – Averaged 13 minutes of porn/day. (–0.05)
  3. Sample 3 (433 men): average age 33.5 – Averaged 45 minutes of porn/day. (–0.37)

Fairly straightforward results: the sample that used the most porn (#3) had the strongest correlation between greater porn use and poorer erections, while the group that use the least (#2) had the weakest correlation between greater porn use and poorer erections. Why didn’t Grubbs emphasize this pattern in his write-up, instead of using statistical manipulations to try to make it disappear?

To summarize:

  • Sample #1: Average age 19.8 – Note that 19-year old porn users rarely report chronic porn-induced (especially when only using 22 minutes a day). The vast majority of porn-induced ED recovery stories YBOP has gathered are by men aged 20-40. It generally takes time to develop PIED.
  • Sample #2:  Average age 46.5 – They averaged only 13 minutes per day! With a standard deviation of 15.3 years, some portion of these men were fifty-something. These older men did not start out using internet porn during adolescence (making them less vulnerable to conditioning their sexual arousal solely to internet porn). Indeed, just as Grubbs found, the sexual health of slightly older men has always been better and more resilient over all, than users who began using digital porn during adolescence (such as those with an average age of 33 in sample 3).
  • Sample #3: Average age 33.5 – As already mentioned, sample 3 was the largest sample and averaged higher levels of porn use. Most importantly, this age range is the most likely to report PIED. Not surprisingly, sample  3 had the strongest correlation between higher levels of porn use and poorer erectile functioning (–0.37).

Considering the above links between poorer erections and both greater porn use and porn addiction, it’s shocking how this Grubbs paper reads as if widespread internet porn cannot be related to the documented rise in ED in men under 40. Also, why did Grubbs disregard the robust correlations in the age group most affected by PIED and who reported the greatest porn use? Was he unaware of the age ranges most affected by porn induced sexual problems?

Put simply, if this study had only addressed sample #3 (which was apparently the first sample Grubbs gathered), Grubbs would have been obliged (we hope) to acknowledge porn’s relationship to sexual dysfunction. Instead, two samples outside the target age range, were added after the baseline scores for sample #3 were gathered. This watered down the initial and most relevant findings (sample #3).

Grubbs: If it’s religion causing porn addiction, 0.30 is “robust.” If it’s porn causing ED, 0.37 is “limited evidence.”

As mentioned above, Grubbs has in the past unhesitatingly used weaker correlations than those reported in the current ED study to make very strong and questionable claims in his most highly publicized studies. Grubbs’s claim to fame is his series of “perceived porn addiction” studies, which spawned the scientifically inadequately supported meme that “religion causes porn addiction.” Too intricate to unpack here, YBOP (and actual researchers) have dismantled Grubbs’s unsupported claims elsewhere: article 1, article 2, article 3.

However, before leaving this point, check out the data from Grubbs’s most widely cited paper: “Transgression as Addiction: Religiosity and Moral Disapproval as Predictors of Perceived Addiction to Pornography.” Table 2 below contains data from 2 separate samples. Highlighted below are the correlations between Grubbs’s porn use questionnaire, the CPUI-9 (#1), and Religiosity (#6).

Here’s something to keep in mind when reading all of Grubbs’s perceived-addiction studies: he re-labeled the total CPUI-9 score as “perceived pornography addiction” – even though it was not a perception-of-addiction test. This is confusing, yet highly strategic, as his studies and comments on social media read as if he assessed “belief in porn addiction,” although he did not. So when Grubbs states that religiosity is robustly related to “perceived porn addiction,” he really means that religiosity is merely related to total score the CPUI-9, an unsound questionnaire that assesses neither actual porn addiction nor believing oneself to be a porn addict.

The correlations between total CPUI-9 scores and religiosity: Study 1: 0.25, Study 2: 0.35

  • Average: 0.30

What did Dr. Grubbs say about the 0.30 relationship between “perceived pornography addiction” and religiosity? Why, he claimed it was “robust!”

Results from two studies in undergraduate samples (Study 1, N=331; Study 2, N=97) indicated that there was a robust positive relationship between religiosity and perceived addiction to pornography.

Grubbs considers 0.30 “robust” when it supports his artfully crafted meme that religious folks only “perceive” they are addicted to porn and no one else really has a problem with it.

In the current ED study, how has Grubbs described the correlations between greater porn use and poorer erections, including sample 3 – which had a larger correlation (0.37), than his “religion = porn addiction” study just described?

“Across the 3 samples, we found only very limited support for the notion that mere pornography use itself is related to diminished erectile functioning, which is inconsistent with another popular narrative claiming that such use is likely to drive sexual dysfunction.” (emphasis supplied)

In 2019, Grubbs considers 0.37 as “very limited support” for a link between porn use and poorer erectile functioning. Have Grubbs’s views on statistics evolved in the intervening 4 years or could it be something else?

We suspect bias, and now revisit the above table from Grubbs “Transgression as Addiction study to support our assertion. Above we highlighted the correlations between CPUI-9 scores (perceived porn addiction) and religiosity. Below we highlighted the correlations between CPUI-9 scores (perceived porn addiction) and “hours of porn use”:

The correlations between total CPUI-9 scores (perceived porn addiction) and “hours of porn use”: Study 1: 0.30, Study 2: 0.32

  • Average 0.31

Notice that CPUI-9 scores have a slightly stronger relationship to “hours of porn use” (0.31) than to religiosity (0.30). Put simply, hours of porn is a better predictor “perceived porn addiction” than is religiosity. It’s “porn overuse = porn addiction,” not “religiosity = porn addiction.” Even in Grubbs’s own work.

Yet Grubbs assures us that religiosity is “robustly related to perceived porn addiction” (CPUI-9 scores). If this is the case, then “hours of porn use” are evidently also “robustly related” to scores on the CPUI-9. But that’s not what you glean from reading the Grubbs’s analysis, or from his comments in the press or his Twitter feed.

Indeed, Grubbs sums up his campaign in this extraordinary biased 2016 Psychology Today article, where he falsely asserts that CPUI-9 scores (perceived porn addiction) are not related to the amount of porn used, but only related to religiosity:

Being labeled “porn addict” by a partner, or even by oneself, has nothing to do with the amount of porn a man views, says Joshua Grubbs, assistant professor of psychology at Bowling Green University. Instead, it has everything to do with religiosity…

… Grubbs calls it “perceived pornography addiction.” “It functions very differently from other addictions.” (emphasis supplied)

These are astonishing statements made in direct opposition to his findings. As the tables show, CPUI-9 scores (“perceived porn addiction”) were in fact more related to “hours of use” than to religiosity! Such unsupported assertions led YBOP to publish extensive critiques of Dr. Grubbs’s perceived porn addiction studies.

Now, we must do so again with this current ED paper, where he produced a write-up that dismisses significant correlations (especially in the most at-risk group), omits the numerous studies linking porn to sexual problems, and misrepresents the literature on sexual problems in young men. The picture this paper has painted matches neither his data nor the current state of the literature.

Sample shell game?

To return to the matter of Grubbs’s samples, it’s common knowledge on porn recovery forums that the age group of men currently reporting the most porn-induced sexual problems hovers around late 20s and early 30s. In other words, of Grubbs’s three samples, the sample most suitable for investigating a possible phenomenon of porn-induced sexual dysfunction was sample 3.

Sample 3 (average age 33.5) is not only the closest sample to the ideal age group, but also by far the largest, and therefore most reliable, of his samples.

Interestingly, sample 3 was apparently the earliest of the samples Grubbs collected (spring of 2017). Predictably, sample 3 showed a robust correlation between impaired erectile health and porn use (0.37) and porn addiction (0.33) at baseline – even though many sexually inactive men had been (strategically?) excluded by use of the IIEF.

This raises awkward questions. Why didn’t Grubbs write up his results only about this sample 3, the most at-risk group? Had he done so, this would have been a very different paper…offering solid support for the existence of porn-induced erectile health problems (we would hope).

Was it because Grubbs didn’t like the robust correlations between poorer erectile health and both porn use and porn addiction, which his most relevant, most reliable sample revealed? Why did he obscure his most pertinent results by adding 2 more samples of men from less at-risk age groups?

Longitudinal group saw little change in erectile function, but problematic users may have dropped out

The study claims that in the longitudinal sample (#3) links between porn use/porn addiction didn’t have an impact on erectile functioning over 1 year’s time

In short, self-reported problematic use of pornography was not associated with changes in erectile functioning over a 1-year period, likely due to the lack of change in erectile functioning in the sample overall.

Let’s examine this finding. First, it’s important to know that of the 433 participants in group #3 at baseline, a mere 117 participants had complete data for the entire year (4 data points and 4 intervals). That’s a scant 27% of the original participants, on which Grubbs basis this claim.

Second, it appears likely that the subjects who used the most porn, and had the most problems (addiction), were the ones who tended to drop out of the study. Table 3 reveals a drop in average “hours of porn use” and porn addiction scores occurring with each successful check-in. Either all the men cut down on porn use and felt less addicted, or many of the heavier users with the worst problems dropped out. The latter seems most likely.

For both of these reasons we need to take this study’s longitudinal data with a boulder of salt.

Grubbs uses specious reasoning to suggest that “Moral incongruence”might explain poorer erectile functioning

Grubbs asserts that “Moral Incongruence” may play a role in ED, but he is playing games:

In addition, we note that in the 1 sample (sample 3) in which pornography use itself was related to diminished erectile functioning cross-sectionally, both self-reported problematic use and moral incongruenceregarding pornography use were similarly related to diminished erectile functioning, both of which in addition to the relationship between reported use and diminished erectile functioning. When these findings are considered along with the results from our other 2 samples demonstrating no clear relationship between pornography use and erectile functioning, we urge caution in placing credence on statements of pornography use itself as a causal mechanism in driving ED. (emphasis supplied)

MI (moral incongruence) is always correlated with porn addiction (Grubbs’s 4 questions listed earlier), because people with porn addiction usually want to stop due to negative consequences. Since MI is always related to porn addiction, and poorer erectile functioning always related to porn addiction, MI scores are related to poorer erectile functioning. So, Grubbs’s assertion is an artifact, not a meaningful correlation.

Note: Grubbs has been striving to convince the scientific community for 8 years that porn addiction is really nothing more than so-called “moral incongruence” (or religiosity). That is, disapproval of one’s own own compulsive porn use is the actual problem – not the porn use itself. His crusade rests on the unsupported premise that morally disapproving of one’s compulsive use is unique to porn addicts.

However, this review of the literature points out the obvious. Addicts typically disapprove of their addictions. Here drug addicts cite moral reasons as core motivation for quitting:

Grubbs should ask himself, “Why isn’t there a ‘moral disapproval model’ of meth addiction, or gambling addiction, or cigarette addiction?” The ‘moral disapproval model of porn addiction’ is a red herring spawned by Grubbs himself. It’s created and supported by his own repetitive studies correlating moral disapproval with porn addiction (and those of his fan club), while he ignores dozens of other important variables that better explain problematic porn use (such as inability to quit despite negative consequences).

The reality is that 41 neurological studies show that porn addiction functions very much like other addictions. And even Grubbs’s own studies consistently reveal that “perceived pornography addiction” scores have a lot to do with the amount of porn a man views.

Finally, Dr. Grubbs appears to be closely allied with ardent pro-porners Dr. Nicole Prause and Dr. David Ley. All three often like and retweet each other comments, entering into jovial Twitter convos. All three campaign against the concept of “porn addiction.” Ley and Grubbs have co-authored peer-reviewed papers, and Ley and Prause have vocally championed Grubbs’s perceived addiction studies since the beginning.

So it’s no surprise that Ley and Prause adore this current Grubbs study (at least his write-up, if not the actual correlations). In this Twitter thread, Prause boldly suggests that the “moral disapproval” correlation might mean that erection troubles are really porn-induced….via shame. Grubbs seems to agree with his ally:

Ley and Prause are not objective observers. Both have engaged in multiple documented incidents of harassment and defamation as part of an ongoing “astroturf” campaign to persuade people that anyone who disagrees with their conclusions deserves to be defamed.

Prause appears to be quite cozy with the pornography industry, as can be seen from this image of her (far right) on the red carpet of the X-Rated Critics Organization (XRCO) awards ceremony. According to Wikipedia the XRCO Awards are given by the American X-Rated Critics Organization annually to people working in adult entertainment. It is the only adult industry awards show reserved exclusively for industry members.[1]). (emphasis supplied)

Nicole Prause continues to be obsessed with debunking PIED, having waged a 3-year war against an academic paper on the subject (with Ley’s help), while simultaneously harassing and libeling young men who have recovered from porn-induced sexual dysfunctions and are trying to warn others. See: Gabe Deem #1, Gabe Deem #2, Alexander Rhodes #1, Alexander Rhodes #2, Alexander Rhodes #3, Noah Church, Alexander Rhodes #4, Alexander Rhodes #5, Alexander Rhodes #6Alexander Rhodes #7, Alexander Rhodes #8, Alexander Rhodes #9.

David Ley is not only involved with several of the preceding incidents, he has also published multiple articles attacking porn recovery forums and the concept of porn induced ED, disparaging men who run porn-recovery forums, while using social media to harass men recovering from PIED. In addition, Ley makes money selling two books which deny sex and porn addiction (“The Myth of Sex Addiction,” 2012 and “Ethical Porn for Dicks,” 2016). Pornhub is one of the four back-cover endorsements for the latter on Amazon.com.

Empty claims that a PIED epidemic doesn’t exist

This paper claims several times that there’s not an epidemic of ED, and that porn use is not related to claimed epidemic of ED:

Despite evidence to the contrary, a number of advocacy and self-help groups persist in claiming that internet pornography use is driving an epidemic of erectile dysfunction (ED).

We’ll begin with the first words of the above excerpt: there is no persuasive “evidence to the contrary.”  Let’s examine this purported contrary evidence.

1) Prause and Pfaus, 2015Prause and Pfaus did not support its claims. See a formal critique by researcher Richard Isenberg, MD and a very extensive lay critique:

Prause and Pfaus 2015 wasn’t a study on men with ED. It wasn’t a study at all. Instead, Prause claimed to have gathered data from four of her earlier studies, none of which addressed erectile dysfunction. It’s disturbing that this paper by Nicole Prause and Jim Pfaus passed peer-review as the data in their paper did not match the data in the underlying four studies on which the paper claimed to be based. The discrepancies are not minor gaps, but gaping holes that cannot be plugged. In addition, the paper made several claims that were false or not supported by their data. In addition, both Nicole Prause and Jim Pfaus made false statements to the media about their methodology and findings.

2) Landripet and Štulhofer, 2015 was designated as a “brief communication” by the journal that published it, and the two authors selected only certain data to share, while omitting other pertinent data. As with Prause and Pfaus, the journal later published a critique addressing the weaknesses of Landripet and Štulhofer: Comment on: Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men? by Gert Martin Hald, PhD

As for the claim that Landripet and Štulhofer, 2015 found no relationships between porn use and sexual problems, this is not true, as documented in both this YBOP critique and this review of the literature, co-authored by multiple Navy physicians. Furthermore, Landripet and Štulhofer’s paper omitted three significant correlations, which one of the authors had earlier presented at a European conference.

Equally importantly, in his write-up, why did Grubbs ignore the 27 peer-reviewed studies linking porn use/porn addiction to sexual problems and lower arousal – especially the 5 case studies where men healed problems by quitting porn?

Here’s a similar excerpt where he attempts to press home his same flawed talking point about the state of the literature:

In general, among sexually active pornography-using men, serious erectile problems seem rare, a finding that runs counter to a popular narrative suggesting that pornography use is driving an epidemic of ED.

In fact, as noted above, the 3 samples here were men who are sexually active and whose IIEF (sexual health) scores were pretty good. Put simply, this paper largely excluded men with ED, didn’t include sexually inactive men, and didn’t include virgins. Thus, many of the the men who constitute the “ED epidemic” (which these authors deny) were omitted from this study. And yet, even in this paper both porn addiction and higher levels of porn use were related to poorer erectile functioning. Why go to such pains to deny the truth?

The position of the “medical community”?

Citing nothing to support their assertion, Grubbs and his co-author mistakenly claim that the “medical community” has not conclusively found evidence of an epidemic of ED:

Moreover, given that the medical community has not conclusively found evidence of an increasing rate of ED in young men in recent years, the present work provides additional evidence against the notion that pornography use is driving an epidemic of ED.

The reality?

Historical ED rates: Erectile dysfunction was first assessed in 1940s when the Kinsey report concluded that the prevalence of ED was less than 1% in men younger than 30 years, less than 3% in those 30–45. While ED studies on young men are relatively sparse, this 2002 meta-analysis of 6 high-quality ED studies reported that 5 of the 6 reported ED rates for men under 40 of approximately 2%. The 6th study reported figures of 7-9%, but the question used could not be compared to the 5 other studies, and did not assess chronic erectile dysfunction as had the others. Instead it asked, “Did you have trouble maintaining or achieving an erection any time in the last year?”

At the end of 2006, free, streaming porn tube sites came on line and gained instant popularity. This changed the nature of porn consumption radically. For the first time in history, viewers could escalate with ease during a masturbation session without any wait. What happened to ED rates?

Ten studies since 2010: Ten studies published since 2010 reveal a tremendous rise in erectile dysfunction. This is documented in this lay article and in this peer-reviewed paper co-authored by 7 US Navy physicians – Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016). In the 10 studies, erectile dysfunction rates for men under 40 ranged from 14% to 37%, while rates for low libido ranged from 16% to 37%.

Other than the advent of streaming porn (2006) no variable related to youthful ED has appreciably changed in the last 10-20 years (smoking rates are down, drug use is steady, obesity rates in males 20-40 up only 4% since 1999 – see this study).

The recent jump in sexual problems coincides with the publication of 27 studies linking porn use and “porn addiction” to sexual problems and lower arousal to sexual stimuli. In addition to the studies listed, this page contains articles and videos by over 120 experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who acknowledge, and have successfully treated, porn-induced ED and porn-induced loss of sexual desire.

Current hours of porn use is just one of many variables that may predict porn-induced sexual dysfunctions

Additional variables likely also need to be investigated. This 2016 review highlighted the weakness in correlating only “current hours of use” to predict porn-induced sexual dysfunctions. The amount of porn currently viewed is likely just one of many variables related to the development of porn-induced ED. Others may include:

  1. Ratio of masturbation to porn versus masturbation without porn
  2. Ratio of sexual activity with a person versus masturbation to porn
  3. Gaps in partnered sex (where one relies only on porn)
  4. Virgin or not
  5. Total hours of use
  6. Years of continued use
  7. Age started using porn voluntarily
  8. Escalation to new genres
  9. Development of porn-induced fetishes (from escalating to new genres of porn)
  10. Level of novelty per session (i.e. compilation videos, multiple tabs)
  11. Addiction-related brain changes or not
  12. Presence of hypersexuality/porn addiction (which was robustly related in sample #3)
  13. It might also be fruitful to ask about edging, the harmful practice of masturbating to porn while avoiding climax.

The better way to research this phenomenon, is to remove the variable of internet porn use and observe the outcome, which was done in multiple case studies in which men removed internet porn use and healed. Such research suggests causation instead of correlations based on possibly faulty recall – and open to agenda-driven interpretations like those in the present study. YBOP has documented self-reports of a few thousand men who removed porn and recovered from chronic sexual dysfunctions.

Additional flaws, also present in earlier papers on the subject

Some of the following points come from this earlier critique of Prause and Pfaus 2015. The current paper suffers from most of the same flaws.

  1. Did not assess individuals complaining of erectile dysfunction
  2. Did not ask men to attempt masturbation without porn (the way to test for porn-induced ED)
  3. Did not have men remove porn to see if erectile functioning eventually improved (the only way to know if ED was porn-induced)
  4. Did not ask about years or porn use, age guys started using porn, type of porn, or escalation of use.
  5. Did not ask about delayed ejaculation or anorgasmia (precursors to PIED)
  6. Study only included men who were sexually active (which means they probably didn’t have full blown ED), which would exclude those with such severe ED that they are avoiding sex
  7. Study omitted virgins (including so called “porn virgins” – who can’t manage sex with real partners) and thus all who have not had sex in the last year.

Conclusion

A genuine investigation of porn use and sexual dysfunctions needs to ask subjects to eliminate digital porn use and assess any changes over the subsequent months.

Meanwhile, it is evident that the scientific community can do a more conscientious job of investigating the unfortunate phenomenon of young men in their prime struggling with unprecedented levels of sexual dysfunctions (which often heal simply by giving up today’s ubiquitous digital porn). Researchers can also do a far more responsible job of describing their findings and the state of the literature rather than misleading their readers.

Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019): Excerpt analyzing Prause et al., 2015

Link to original study – Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019)

Excerpt critiquing Prause’s 2 EEG studies: Steele et al., 2013 & Prause et al., 2015 (citation 105 is Steele, citation 107 is Prause):

Evidence of this neural activity signalizing desire is particularly prominent in the prefrontal cortex [101] and the amygdala [102,103], being evidence of sensitization. Activation in these brain regions is reminiscent of financial reward [104] and it may carry a similar impact. Moreover, there are higher EEG readings in these users, as well as the diminished desire for sex with a partner, but not for masturbation to pornography [105], something that reflects also on the difference in erection quality [8]. This can be considered a sign of desensitization. However, Steele’s study contains several methodological flaws to consider (subject heterogeneity, a lack of screening for mental disorders or addictions, the absence of a control group, and the use of questionnaires not validated for porn use) [106]. A study by Prause [107], this time with a control group, replicated these very findings. The role of cue reactivity and craving in the development of cybersex addiction have been corroborated in heterosexual female [108] and homosexual male samples [109].

Comments: The above critique states that Prause’s 2015 EEG replicated the findings from her 2013 EEG study (Steele et al.): Both studies reported evidence of habituation or desensitization, which is consistent with the addiction model (tolerance). Let me explain.

It’s important to know that Prause et al., 2015 AND Steele et al., 2013 had the same “porn addicted” subjects. The problem is that Steele et al. had no control group for comparison! So Prause et al., 2015 compared the 2013 subjects from Steele et al., 2013 to an actual control group (yet it suffered from the same methodological flaws named above). The results: Compared to controls “individuals experiencing problems regulating their porn viewing” had lower brain responses to one-second exposure to photos of vanilla porn. The ACTUAL results of Prause’s two EEG studies:

  1. Steele et al., 2013: Individuals with greater cue-reactivity to porn had less desire for sex with a partner, but not less desire to masturbate.
  2. Prause et al., 2015: “Porn addicted users” had less brain activation to static images of vanilla porn. Lower EEG readings mean that the “porn addicted” subjects were paying less attention to the pictures.

A clear pattern emerges from the 2 studies: The “porn addicted users” were desensitized or habituated to vanilla porn, and those with greater cue-reactivity to porn preferred to masturbate to porn than have sex with a real person. Put simply they were desensitized (a common indication of addiction) and preferred artificial stimuli to a very powerful natural reward (partnered sex). There is no way to interpret these results as falsifying porn addiction. The findings support the addiction model.

Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019): Excerpt analyzing Steele et al., 2013

Link to original study – Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019)

Excerpt critiquing Steele et al., 2013 (citation 105 is Steele et al.)

Evidence of this neural activity signalizing desire is particularly prominent in the prefrontal cortex [101] and the amygdala [102,103], being evidence of sensitization. Activation in these brain regions is reminiscent of financial reward [104] and it may carry a similar impact. Moreover, there are higher EEG readings in these users, as well as the diminished desire for sex with a partner, but not for masturbation to pornography [105], something that reflects also on the difference in erection quality [8]. This can be considered a sign of desensitization. However, Steele’s study contains several methodological flaws to consider (subject heterogeneity, a lack of screening for mental disorders or addictions, the absence of a control group, and the use of questionnaires not validated for porn use) [106]. A study by Prause [107], this time with a control group, replicated these very findings. The role of cue reactivity and craving in the development of cybersex addiction have been corroborated in heterosexual female [108] and homosexual male samples [109].

Comments: Steele et al., 2013 was touted in the media as evidence against the existence of porn/sex addiction. It wasn’t. As the above review by medical doctors explained, Steele et al. actually lends support to the existence of both porn addiction and porn use down-regulating sexual desire. How so? The study reported higher EEG readings (relative to neutral pictures) when subjects were briefly exposed to pornographic photos. Studies consistently show that an elevated P300 occurs when addicts are exposed to cues (such as images) related to their addiction.

In line with the Cambridge University brain scan studies, this EEG study also reported greater cue-reactivity to porn correlating with less desire for partnered sex. To put it another way – individuals with greater brain activation to porn would rather masturbate to porn than have sex with a real person. Shockingly, study spokesperson Nicole Prause claimed that porn users merely had “high libido,” yet the results of the study say the exact opposite (subjects’ desire for partnered sex was dropping in relation to their porn use).

Peer-reviewed critiques of Prause et al., 2015


 

Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019)

Excerpt critiquing Prause’s 2 EEG studies: Steele et al., 2013 & Prause et al., 2015 (citation 105 is Steele, citation 107 is Prause):

Evidence of this neural activity signalizing desire is particularly prominent in the prefrontal cortex [101] and the amygdala [102,103], being evidence of sensitization. Activation in these brain regions is reminiscent of financial reward [104] and it may carry a similar impact. Moreover, there are higher EEG readings in these users, as well as the diminished desire for sex with a partner, but not for masturbation to pornography [105], something that reflects also on the difference in erection quality [8]. This can be considered a sign of desensitization. However, Steele’s study contains several methodological flaws to consider (subject heterogeneity, a lack of screening for mental disorders or addictions, the absence of a control group, and the use of questionnaires not validated for porn use) [106]. A study by Prause [107], this time with a control group, replicated these very findings. The role of cue reactivity and craving in the development of cybersex addiction have been corroborated in heterosexual female [108] and homosexual male samples [109].

COMMENTS: The above critique states that Prause’s 2015 EEG replicated the findings from her 2013 EEG study (Steele et al.): Both studies reported evidence of habituation or desensitization, which is consistent with the addiction model (tolerance). Let me explain.

It’s important to know that Prause et al., 2015 AND Steele et al., 2013 had the same “porn addicted” subjects. The problem is that Steele et al. had no control group for comparison! So Prause et al., 2015 compared the 2013 subjects from Steele et al., 2013 to an actual control group (yet it suffered from the same methodological flaws named above). The results: Compared to controls “individuals experiencing problems regulating their porn viewing” had lower brain responses to one-second exposure to photos of vanilla porn. The ACTUAL results of Prause’s two EEG studies:

  1. Steele et al., 2013: Individuals with greater cue-reactivity to porn had less desire for sex with a partner, but not less desire to masturbate.
  2. Prause et al., 2015: “Porn addicted users” had less brain activation to static images of vanilla porn. Lower EEG readings mean that the “porn addicted” subjects were paying less attention to the pictures.

A clear pattern emerges from the 2 studies: The “porn addicted users” were desensitized or habituated to vanilla porn, and those with greater cue-reactivity to porn preferred to masturbate to porn than have sex with a real person. Put simply they were desensitized (a common indication of addiction) and preferred artificial stimuli to a very powerful natural reward (partnered sex). There is no way to interpret these results as falsifying porn addiction. The findings support the addiction model.

Pro-Porn PhD’s Deny Porn-induced ED by Claiming Masturbation Is the Problem

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John A. Johnson on Steele et al., 2013 (and Johnson debating Nicole Prause in comments section under his Psychology Today article)

Analysis of “Data do not support sex as addictive” (Prause et al., 2017)

Peer-reviewed critiques of Steele et al., 2013

Furthermore, habituation may be revealed through decreased reward sensitivity to normally salient stimuli and may impact reward responses to sexual stimuli including pornography viewing and partnered sex [1, 68]. Habituation has also been implicated in substance and behavioral addictions [73-79].

COMMENTS: In the above excerpt the authors of this review are referring to Steele et al’s finding of greater cue-reactivity to porn related to less desire for sex with a partner (but not lower desire to masturbate to porn). To put another way – individuals with more brain activation and cravings related to porn preferred to  masturbate to porn than have sex with a real person. That’s less reward sensitivity to “partnered sex”, which is “normally salient stimuli”.  Together these two Steele et al. findings indicate greater brain activity to cues (porn images), yet less reactivity to natural rewards (sex with a person). Both are hallmarks of an addiction.


Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019)

Excerpt critiquing Steele et al., 2013 (citation 105 is Steele et al.)

Evidence of this neural activity signalizing desire is particularly prominent in the prefrontal cortex [101] and the amygdala [102,103], being evidence of sensitization. Activation in these brain regions is reminiscent of financial reward [104] and it may carry a similar impact. Moreover, there are higher EEG readings in these users, as well as the diminished desire for sex with a partner, but not for masturbation to pornography [105], something that reflects also on the difference in erection quality [8]. This can be considered a sign of desensitization. However, Steele’s study contains several methodological flaws to consider (subject heterogeneity, a lack of screening for mental disorders or addictions, the absence of a control group, and the use of questionnaires not validated for porn use) [106]. A study by Prause [107], this time with a control group, replicated these very findings. The role of cue reactivity and craving in the development of cybersex addiction have been corroborated in heterosexual female [108] and homosexual male samples [109].

COMMENTS: Steele et al., 2013 was touted in the media as evidence against the existence of porn/sex addiction. It wasn’t. As the above review by medical doctors explained, Steele et al. actually lends support to the existence of both porn addiction and porn use down-regulating sexual desire. How so? The study reported higher EEG readings (relative to neutral pictures) when subjects were briefly exposed to pornographic photos. Studies consistently show that an elevated P300 occurs when addicts are exposed to cues (such as images) related to their addiction.

In line with the Cambridge University brain scan studies, this EEG study also reported greater cue-reactivity to porn correlating with less desire for partnered sex. To put it another way – individuals with greater brain activation to porn would rather masturbate to porn than have sex with a real person. Shockingly, study spokesperson Nicole Prause claimed that porn users merely had “high libido,” yet the results of the study say the exact opposite (subjects’ desire for partnered sex was dropping in relation to their porn use).


Update: Much has transpired since July, 2013.

UCLA did not renew Nicole Prause’s contract (late 2014/early 2015). No longer an academic Prause has engaged in multiple documented incidents harassment and defamation as part of an ongoing “astroturf” campaign to persuade people that anyone who disagrees with her conclusions deserves to be reviled. Prause has accumulated a long history of harassing authors, researchers, therapists, reporters and others who dare to report evidence of harms from internet porn use. She appears to be quite cozy with the pornography industry, as can be seen from this image of her (far right) on the red carpet of the X-Rated Critics Organization (XRCO) awards ceremony. (According to Wikipedia the XRCO Awards are given by the American X-Rated Critics Organization annually to people working in adult entertainment and it is the only adult industry awards show reserved exclusively for industry members.[1]). It also appears that Prause may have obtained porn performers as subjects through another porn industry interest group, the Free Speech Coalition. The FSC subjects were allegedly used in her hired-gun study on the heavily tainted and very commercial “Orgasmic Meditation” scheme. Prause has also made unsupported claims about the results of her studies and her study’s methodologies. For much more documentation, see: Is Nicole Prause Influenced by the Porn Industry?

Sexual Function in 16- to 21-Year-Olds in Britain (2016)

Dismantling David Ley’s Response to Philip Zimbardo: “We Must Rely on Good Science in Porn Debate” (2016)

facts.jpg

Neurocognitive mechanisms in compulsive sexual behavior disorder (2018) – Excerpts analyzing Prause et al., 2015

Link to PDF of full paper – Neurocognitive mechanisms in compulsive sexual behavior disorder (2018).

Excerpt analyzing Prause et al., 2015 (which is citation 87)

A study using EEG, conducted by Prause and colleagues, suggested that individuals who feel distressed about their pornography use, as compared to a control group who do not feel distress about their use of pornography, may require more/greater visual stimulation to evoke brain responses [87]. Hypersexual participants—individuals‘ experiencing problems regulating their viewing of sexual images’ (M=3.8 hours per week)—exhibited less neural activation (measured by late positive potential in the EEG signal) when exposed to sexual images than did the comparison group when exposed to the same images. Depending on the interpretation of sexual stimuli in this study (as a cue or reward; for more see Gola et al. [4]), the findings may support other observations indicating habituation effects in addictions [4]. In 2015, Banca and colleagues observed that men with CSB preferred novel sexual stimuli and demonstrated findings suggestive of habituation in the dACC when exposed repeatedly to the same images [88]. Results of the aforementioned studies suggest that frequent pornography use may decrease reward sensitivity, possibly leading to increased habituation and tolerance, thereby enhancing the need for greater stimulation to be sexually aroused. However, longitudinal studies are indicated to examine this possibility further. Taken together, neuroimaging research to date has provided initial support for the notion that CSB shares similarities with drug, gambling, and gaming addictions with respect to altered brain networks and processes, including sensitization and habituation.

COMMENTS: The authors of the current review agree with six other peer-reviewed papers (1, 2, 3, 4, 5, 6.): Lower EEG readings mean that subjects are paying less attention to the pictures. They were bored (habituated or desensitized). The lead author claims these results “debunk porn addiction”, but other researchers disagree with her over-the-top assertions. You have to ask yourself – “What legitimate scientist would claim that their lone anomalous study has debunked a well established field of study?”

  1. Prause N, Steele VR, Staley C, Sabatinelli D, Proudfit GH. Modulation of late positive potentials by sexual images in problem users and controls inconsistent with “porn addiction”. Biol Psychol. 2015;109:192-9.

 FOR ADDED CONTEXT, THE FULL REVIEW

October 2018, Current Sexual Health Reports

Abstract

Purpose of review: The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD)and provides recommendations for future research specific to the diagnostic classification of the condition.

Recent findings: To date, most neuroimaging research on compulsive sexual behavior has provided evidence of overlapping mechanisms underlying compulsive sexual behavior and non-sexual addictions. Compulsive sexual behavior is associated with altered functioning in brain regions and networks implicated in sensitization, habituation, impulse dyscontrol, and reward processing in patterns like substance, gambling, and gaming addictions. Key brain regions linked to CSB features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens.

Summary: Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addictions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand this phenomenon and resolve classification issues surrounding CSBD.

Introduction

Compulsive sexual behavior (CSB) is a debated topic that is also known as sexual addiction, hypersexuality, sexual dependence, sexual impulsivity, nymphomania, or out-of-control sexual behavior [1-27]. Although precise rates are unclear given limited epidemiological research, CSB is estimated to affect 3-6% of the adult population and is more common in men than women [28-32]. Due to the associated distress and impairment reported by men and women with CSB [4-6, 30, 33-38], the World Health Organization (WHO) has recommended including Compulsive Sexual Behavior Disorder(CSBD)in the forthcoming 11th edition of the International Classification of Diseases (6C72)[39]. This inclusion should help increase access to treatment for unserved populations, reduce stigma and shame associated with help-seeking, promote concerted research efforts, and increase international attention on this condition[40, 41].We acknowledge that over the last 20 years there have been varying definitions used to describe dysregulated sexual behaviors often characterized by excessive engagement in nonparaphilic sexual activities (e.g., frequent casual/anonymous sex, problematic use of pornography). For the current review, we will use the term CSB as an overarching term for describing problematic, excessive sexual behavior.

CSB has been conceptualized as an obsessive–compulsive-spectrum disorder, an impulse-control disorder, or addictive behavior [42, 43]. The symptoms of CSBD are like those proposed in 2010forthe DSM-5 diagnosis of hypersexual disorder [44]. Hypersexual disorder was ultimately excluded by American Psychiatric Association from DSM-5 for multiple reasons; the lack of neurobiological and genetic studies was among the most noted reasons [45, 46]. More recently, CSB has received considerable attention in both popular culture and social sciences, particularly given health disparities affecting at-risk and underserved groups. Despite the considerable increase in studies of CSB (including those studying “sexual addiction,” “hypersexuality,” “sexual compulsivity”), relatively little research has examined neural underpinnings of CSB [4, 36]. This article reviews neurobiological mechanisms of CSB and provides recommendations for future research, particularly as related to diagnostic classification of CSBD.

CSB as an Addictive Disorder

Brain regions involved in processing rewards are likely important for understanding the origins, formation, and maintenance of addictive behaviors [47]. Structures within a so-called ‘reward system’ are activated by potentially reinforcing stimuli, such as addictive drugs in addictions. A major neurotransmitter involved in processing rewards is dopamine, particularly within the mesolimbic pathway involving the ventral tegmental area (VTA) and its connections with the nucleus accumbens (NAc), as well as the amygdala, hippocampus, and prefrontal cortex [48]. Additional neurotransmitters and pathways are involved in processing rewards and pleasure, and these warrant considerations given that dopamine has been implicated to varying degrees in individual drug and behavioral addictions in humans [49-51].

According to the incentive salience theory, different brain mechanisms influence motivation to obtain reward (‘wanting’) and the actual hedonic experience of reward (‘liking’) [52]. Whereas ‘wanting’ may be closely related to dopaminergic neurotransmission in the ventral striatum (VStr) and orbitofrontal cortex, networks dedicated to creating wanting motivations and pleasurable feelings are more complex [49, 53, 54].

VStr reward-related reactivity has been studied in addictive disorders such as alcohol, cocaine, opioid use disorders, and gambling disorder[55-58]. Volkow and colleagues describe four important components of addiction: (1) sensitization involving cue reactivity and craving, (2) desensitization involving habituation, (3) hypofrontality, and (4) malfunctioning stress systems[59]. Thus far, research of CSB has largely focused on cue reactivity, craving, and habituation. The first neuroimaging studies of CSB were focused on examining potential  similarities between CSB and addictions, with a specific focus on the incentive salience theory that is based on preconscious neural sensitization related to changes in dopamine-related motivation systems[60]. In this model, repeated exposure to potentially addictive drugs may change brain cells and circuits that regulate the attribution of incentive salience to stimuli, which is a psychological process involved in motivated behavior. Because of this exposure, brain circuits may become hypersensitive (or sensitized), thereby contributing to the development of pathological levels of incentive salience for target substances and their associated cues. Pathological incentive motivation (‘wanting’) for drugs may last for years, even if drug use is discontinued. It may involve implicit (unconscious wanting) or explicit (conscious craving) processes. The incentive salience model has been proposed to potentially contribute to the development and maintenance of CSB [1, 2].

Data support the incentive salience model for CSB. For example, Voon and colleagues examined cue-induced activity in the dorsal anterior cingulate cortex (dACC) –Vstr –amygdala functional network [1].Men with CSB as compared to those without showed increased VStr, dACC, and amygdala responses to pornographic video clips. These findings in the context of the larger literature suggest that sex and drug-cue reactivity involve largely overlapping regions and networks[61, 62]. Men with CSB as compared to those without also reported higher wanting (subjective sexual desire) of pornography stimuli and lower liking which is consistent with an incentive salience theory[1]. Similarly, Mechelmans and colleagues found that men with CSB as compared to men without showed enhanced early attentional bias towards sexually explicit stimuli but not to neutral cues [2]. These findings suggest similarities in enhanced attentional bias observed in studies examining drug cues in addictions.

In 2015, Seok and Sohn found that among men with CSB as compared to those without, greater activity was observed in the dorsolateral prefrontal cortex (dlPFC), caudate, inferior supramarginal gyrus of the parietal lobe, dACC, and thalamus in response to sexual cues[63]. They also found that the severity of CSB symptoms was correlated with cue-induced activation of the dlPFC and thalamus. In 2016, Brand and colleagues observed greater activation of the VStr for preferred pornographic material as compared to non-preferred pornographic material among men with CSB and found that VStr activity was positively associated with self-reported symptoms of addictive use of Internet pornography (assessed by the short Internet Addiction Test modified for cybersex (s-IATsex) [64, 65].

Klucken and colleagues recently observed that participants with CSB as compared to participants without displayed greater activation of the amygdala during presentation of conditioned cues (colored squares) predicting erotic pictures (rewards) [66]. These results are like those from other studies examining amygdala activation among individuals with substance use disorders and men with CSB watching sexually explicit video clips [1, 67].Using EEG, Steele and colleagues observed a higher P300 amplitude to sexual images (when compared to neutral pictures) among individuals self-identified as having problems with CSB, resonating with prior research of processing visual drug cues in drug addiction [68, 69].

In 2017, Gola and colleagues published results of a study using functional magnetic resonance imaging (fMRI) to examine Vstr responses to erotic and monetary stimuli among men seeking treatment for CSB and men without CSB [6]. Participants were engaged in an incentive delay task[54, 70, 71] while undergoing fMRI scanning. During this task, they received erotic or monetary rewards preceded by predictive cues. Men with CSB differed from those without in VStr responses to cues predicting erotic pictures, but not in their responses to erotic pictures. Additionally, men with CSB versus without CSB showed greater VStr activation specifically for cues predicting erotic pictures and not for those predicting monetary rewards. Relative sensitivity to cues (predicting erotic pictures vs. monetary gains) was found to be related to an increased behavioral motivation for viewing erotic images (‘wanting’), intensity of CSB, amount of pornography used per week, and frequency of weekly masturbation. These findings suggest similarities between CSB and addictions, an important role for learned cues in CSB, and possible treatment approaches, particularly interventions focused on teaching skills to individuals to successfully cope with cravings/urges [72]. Furthermore, habituation may be revealed through decreased reward sensitivity to normally salient stimuli and may impact reward responses to sexual stimuli including pornography viewing and partnered sex [1, 68]. Habituation has also been implicated in substance and behavioral addictions [73-79].

In 2014, Kuhn and Gallinat observed decreased VStr reactivity in response to erotic pictures in a group of participants watching pornography frequently, when compared to participants watching pornography rarely[80].Decreased functional connectivity between the left dlPFC and right VStr was also observed. Impairment in fronto-striatal circuity has been related to inappropriate or disadvantageous behavioral choices irrespective of potential negative outcome and impaired regulation of craving in drug addiction [81, 82]. Individuals with CSBmay have reduced executive control when exposed to pornographic material [83, 84]. Kuhn and Gallinat also found that the gray matter volume of the right striatum(caudate nucleus), which has been implicated in approach-attachment behaviors and related to motivational states associated with romantic love, was negatively associated with duration of internet pornography viewing[80, 85, 86]. These findings raise the possibility that frequent use of pornography may decrease brain activation in response to sexual stimuli and increase habituation to sexual pictures although longitudinal studies are needed to exclude other possibilities.

A study using EEG, conducted by Prause and colleagues, suggested that individuals who feel distressed about their pornography use, as compared to a control group who do not feel distress about their use of pornography, may require more/greater visual stimulation to evoke brain responses [87]. Hypersexual participants—individuals‘ experiencing problems regulating their viewing of sexual images’ (M=3.8 hours per week)—exhibited less neural activation (measured by late positive potential in the EEG signal) when exposed to sexual images than did the comparison group when exposed to the same images. Depending on the interpretation of sexual stimuli in this study (as a cue or reward; for more see Gola et al. [4]), the findings may support other observations indicating habituation effects in addictions [4].In 2015, Banca and colleagues observed that men with CSB preferred novel sexual stimuli and demonstrated findings suggestive of habituation in the dACC when exposed repeatedly to the same images [88]. Results of the aforementioned studies suggest that frequent pornography use may decrease reward sensitivity, possibly leading to increased habituation and tolerance, thereby enhancing the need for greater stimulation to be sexually aroused. However, longitudinal studies are indicated to examine this possibility further. Taken together, neuroimaging research to date has provided initial support for the notion that CSB shares similarities with drug, gambling, and gaming addictions with respect to altered brain networks and processes, including sensitization and habituation.

CSB as an Impulse-Control Disorder?

The category of “Impulse-Control Disorders Not Elsewhere Classified” in DSM-IV was heterogeneous in nature and included multiple disorders that have since been re-classified as being addictive (gambling disorder) or obsessive-compulsive-related (trichotillomania) in DSM-5[89, 90]. The current category in the DSM-5 focuses on disruptive, impulse-control and conduct disorders, becoming more homogeneous in its focus by including kleptomania, pyromania, intermittent explosive disorder, oppositional defiant disorder, conduct disorder, and antisocial personality disorder[90]. The category of impulse-control disorders in the ICD-11includes these first three disorders and CSBD, raising questions regarding the most appropriate classification. Given this context, how CSBD relates to the transdiagnostic construct of impulsivity warrants additional consideration for classification as well as clinical purposes.

Impulsivity may be defined as a, “predisposition towards rapid, unplanned reactions to internal or external stimuli with diminished regard to the negative consequences to the impulsive individual or others” [91]. Impulsivity has been associated with hypersexuality [92]. Impulsivity is a multidimensional construct with different types (e.g., choice, response) that may have trait and state characteristics [93-97]. Different forms of impulsivity may be assessed via self-report or via tasks. They may correlate weakly or not all, even within the same form of impulsivity; importantly, they may relate differentially to clinical characteristics and outcomes [98]. Response impulsivity maybe measured by performance on inhibitory control tasks, such as the stop signal or Go/No-Go tasks, whereas choice impulsivity may be assessed through delay discounting tasks [94, 95, 99].

Data suggest differences between individuals with and without CSB on self-report and task-based measures of impulsivity [100-103]. Furthermore, impulsivity and craving seem to be associated with the severity of symptoms of dysregulated pornography use, such as loss of control [64, 104]. For instance, one study found interacting effects of levels of impulsivity measured by self-report and behavioral tasks with respect to cumulative influences on symptom severity of CSB [104].

Among treatment-seeking samples, 48% to 55% of people may exhibit high levels of generalized impulsivity on Barratt Impulsiveness Scale [105-107]. In contrast, other data suggest that some patients seeking treatment for CSB do not have other impulsive behaviors or comorbid addictions beyond their struggles with sexual behaviors which is consistent with findings from a large online survey of men and women suggesting relatively weak relations between impulsivity and some aspects of CSB (problematic pornography use) and stronger relations with others (hypersexuality) [108, 109]. Similarly, in a study using different measures of individuals with problematic pornography use(mean time of weekly pornography use = 287.87 minutes) and those without (mean time of weekly pornography use = 50.77 minutes) did not differ on self-reported (UPPS-P Scale) or task-based (Stop Signal Task)measures of impulsivity [110].Further, Reid and colleagues did not observe differences between individuals with CSB and healthy controls on neuropsychological tests of executive functioning (i.e., response inhibition, motor speed, selective attention, vigilance, cognitive flexibility, concept formation, set shifting),even after adjusting for cognitive ability in analyses [103]. Together, findings suggest that impulsivity may link most strongly to hypersexuality but not to specific forms of CSB like problematic pornography use. It raises questions about CSBD’s classification as an impulse-control disorder in the ICD-11 and highlights the need for precise assessments of different forms of CSB. This is particularly important since some research indicates that impulsivity and subdomains of impulse-control disorder differ on conceptual and pathophysiological level [93, 98, 111].

CSB as an Obsessive-Compulsive-Spectrum Disorder?

One condition (trichotillomania) classified as an impulse-control disorder in DSM-IV has been reclassified with obsessive-compulsive disorder (OCD) as an obsessive-compulsive and related disorder in DSM-5[90]. Other DSM-IV impulse-control disorders like gambling disorder exhibit significant differences from OCD, supporting their classification in separate categories [112]. Compulsivity is a transdiagnostic construct that involves, “the performance of repetitive and functionally impairing overt or covert behavior without adaptive function, performed in a stereotyped or habitual fashion, either according to rigid rules or as a means to avoid negative consequences”[93]. OCD exhibits high levels of compulsivity; however, so do substance addictions and behavioral addictions like gambling disorder [98]. Traditionally, compulsive and impulsive disorders were construed as lying along opposite ends of a spectrum; however, data suggest the constructs as being orthogonal with many disorders scoring high on measures of both impulsivity and compulsivity [93, 113]. Regarding CSB, sexual obsessions have also been described as time-consuming and interfering and may relate theoretically to OCD or to OCD-related features [114].

Recent studies assessing obsessive-compulsive features using the Obsessive-Compulsive Inventory –Revised (OCI-R) did not show elevations among individuals with CSB [6, 37, 115]. Similarly, a large online survey found aspects of compulsivity only weakly related to problematic pornography use[109]. Together, these findings do not show strong support for considering CSB as an obsessive-compulsive-related disorder. Neural features underlying compulsive behaviors have been described and overlap across multiple disorders [93]. Further studies using psychometrically validated and neuroimaging methods in larger clinical treatment seeking samples are needed to examine further how CSBD may relate to compulsivity and OCD.

Structural Neural Changes among CSB Individuals

Thus far, most neuroimaging studies have focused on functional alterations in individuals with CSB, and results suggest that CSB symptoms are linked to specific neural processes[1, 63, 80]. Although task-based studies have deepened our knowledge about regional activation and functional connectivity, additional approaches should be used.

White-or gray-matter measures have been studied in CSB [102, 116]. In 2009, Miner and colleagues found that individuals with CSB as compared to those without displayed higher superior frontal region mean diffusivity and exhibited poorer inhibitive control. In a study of men with and without CSB from 2016, greater left amygdala volume was observed in the CSB group and relatively reduced resting-state functional connectivity was observed between the amygdala and dlPFC [116]. Reduction of brain volumes in the temporal lobe, frontal lobe, hippocampus, and amygdala were found to be related to the symptoms of hypersexuality in patients with dementia or Parkinson’s disease [117, 118]. These seemingly opposing patterns of amygdala volume relating to CSB highlight the importance of considering co-occurring neuropsychiatric disorders in understanding the neurobiology of CSB.

In 2018, Seok and Sohn used voxel-based morphometry (VBM) and resting-state connectivity analysis to examine gray-matter and resting-state measures in CSB [119]. Men with CSB showed significant gray-matter reduction in the temporal gyrus. Left superior temporal gyrus (STG) volume was negatively correlated with the severity of CSB (i.e., Sexual Addiction Screening Test-Revised [SAST ] and Hypersexual Behavior Inventory [HBI] scores)[120, 121]. Additionally, altered left STG-left precuneus and left STG-right caudate connectivities were observed. Lastly, results revealed a significant negative correlation between severity of CSB and functional connectivity of the left STG to the right caudate nucleus.

While the neuroimaging studies of CSB have been illuminating, little is still known about alternations in brain structures and functional connectivity among CSB individuals, particularly from treatment studies or other longitudinal designs. Integration of findings from other domains (e.g., genetic and epigenetic) will also be important to consider in future studies. Additionally, findings directly comparing specific disorders and incorporating transdiagnostic measures will allow for collection of important information that could inform classification and intervention development efforts currently underway.

Conclusions and Recommendations

This article reviews scientific knowledge regarding neural mechanisms of CSB from three perspectives: addictive, impulse-control, and obsessive-compulsive. Several studies suggest relationships between CSB and increased sensitivity for erotic rewards or cues predicting these rewards, and others suggest that CSB is related to increased cue-conditioning for erotic stimuli [1, 6, 36, 64, 66]. Studies also suggest that CSB symptoms are associated with elevated anxiety [34, 37,122]. Although gaps exist in our understanding of CSB, multiple brain regions (including frontal, parietal and temporal cortices, amygdala, and striatum) have been linked to CSB and related features.

CSBD has been included in the current version oftheICD-11as an impulse-control disorder [39]. As described by the WHO, ‘Impulse-control disorders are characterized by the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person, at least in the short-term, despite consequences such as longer-term harm either to the individual or to others, marked distress about the behaviour pattern, or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning’ [39]. Current findings raise important questions regarding the classification of CSBD. Many disorders characterized by impaired impulse-control are classified elsewhere in the ICD-11 (for example, gambling, gaming, and substance-use disorders are classified as being addictive disorders) [123].

Currently, CSBD constitutes a heterogeneous disorder, and further refinement of CSBD criteria should distinguish between different subtypes, some of which may relate to the heterogeneity of sexual behaviors problematic for individuals [33, 108, 124]. Heterogeneity in CSBD may in part explain seeming discrepancies which are noticeable across studies. Although neuroimaging studies find multiple similarities between CSB and substance and behavioral addictions, additional research is needed to fully understand how neurocognition relates to the clinical characteristics of CSB, especially with respect to sexual behaviors subtypes. Multiple studies have focused exclusively on problematic use of pornography which may limit generalizability to other sexual behaviors. Further, inclusion/exclusion criteria for CSB research participants have varied across studies, also raising questions regarding generalizability and comparability across studies.

Future Directions

Several limitations should be noted with respect to current neuroimaging studies and be considered when planning future investigations (see Table 1). A primary limitation involves small sample sizes that are largely white, male, and heterosexual. More research is needed to recruit larger, ethnically diverse samples of men and women with CSB and individuals of different sexual identities and orientations. For example, no systematic scientific studies have investigated neurocognitive processes of CSB in women. Such studies are needed given data linking sexual impulsivity to greater psychopathology in women as compared to men and other data which suggest gender-related differences in clinical populations with CSB [25, 30]. As women and men with addictions may demonstrate different motivations (e.g., relating to negative versus positive reinforcement) for engaging in addictive behaviors and show differences in stress and drug-cue responsivity, future neurobiological studies should consider stress systems and related processes in gender-related investigations of CSBD given its current inclusion in the ICD-11 as a mental health disorder [125, 126].

Similarly, there is also a need to conduct systematic research focusing on ethnic and sexual minorities to clarify our understanding of CSB among these groups. Screening instruments for CSB have been mostly tested and validated on white European men. Moreover, current studies have focused predominantly on heterosexual men. More research examining clinical characteristics of CSB among gay and bisexual men and women is needed. Neurobiological research of specific groups (transgender, polyamorous, kink, other) and activities (pornography viewing, compulsive masturbation, casual anonymous sex, other) is also needed. Given such limitations, existing results should be interpreted cautiously.

Direct comparison of CSBD with other disorders (e.g., substance use, gambling, gaming, and other disorders)is needed, as is incorporation of other non-imaging modalities (e.g., genetic, epigenetic) and use of other imaging approaches. Techniques like positron emission tomography could also provide important insight into neurochemical underpinnings of CSBD.

The heterogeneity of CSB may also be clarified through careful assessment of clinical features that may be obtained in part from qualitative research like focus group ordiary assessment methods [37]. Such research could also provide insight into longitudinal questions like whether problematic pornography use may lead to sexual dysfunction, and integrating neurocognitive assessments into such studies could provide insight into neurobiological mechanisms. Further, as behavioral and pharmacological interventions are formally tested for their efficacies in treating CSBD, integration of neurocognitive assessments could help identify mechanisms of effective treatments for CSBD and potential biomarkers. This last point may be particularly important because the inclusion of CSBD in the ICD-11 will likely increase the number of individuals seeking treatment for CSBD. Specifically, the inclusion of CSBD in the ICD-11 should raise awareness in patients, providers, and others and potentially remove other barriers (e.g., reimbursement from insurance providers) that may currently exist for CSBD.

Neurocognitive mechanisms in compulsive sexual behavior disorder (2018) – Excerpt analyzing Steele et al., 2013

Link to PDF of full paper – Neurocognitive mechanisms in compulsive sexual behavior disorder (2018).

Excerpts analyzing Steele et al., 2013 (which is citation 68):

Klucken and colleagues recently observed that participants with CSB as compared to participants without displayed greater activation of the amygdala during presentation of conditioned cues (colored squares) predicting erotic pictures (rewards) [66]. These results are like those from other studies examining amygdala activation among individuals with substance use disorders and men with CSB watching sexually explicit video clips [1, 67]. Using EEG, Steele and colleagues observed a higher P300 amplitude to sexual images (when compared to neutral pictures) among individuals self-identified as having problems with CSB, resonating with prior research of processing visual drug cues in drug addiction [68, 69].

COMMENTS: In the above excerpt the authors of the current review are saying that Steele et al’s findings indicate cue-reactivity in frequent porn users. This aligns with the addiction model and cue-reactivity is a neuro-physiological marker for addiction. While Steele et al. spokesperson Nicole Prause claimed that the subjects’ brain response differed from other types of addicts (cocaine was the example given by Prause) – this was not true, and not found anywhere in Steele et al., 2013.


Furthermore, habituation may be revealed through decreased reward sensitivity to normally salient stimuli and may impact reward responses to sexual stimuli including pornography viewing and partnered sex [1, 68]. Habituation has also been implicated in substance and behavioral addictions [73-79].

COMMENTS: In the above excerpt the authors of this review are referring to Steele et al’s finding of greater cue-reactivity to porn related to less desire for sex with a partner (but not lower desire to masturbate to porn). To put another way – individuals with more brain activation and cravings related to porn would rather masturbate to porn than have sex with a real person.  That’s less reward sensitivity to “partnered sex”, which is “normally salient stimuli”.  Together these two Steele et al. findings indicate greater brain activity to cues (porn images), yet less reactivity to natural rewards (sex). Both are hallmarks of addiction.

  1. Steele VR, Staley C, Fong T, Prause N. Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images. Socioaffect Neurosci Psychol. 2013;3:20770.

FOR ADDED CONTEXT, THE FULL REVIEW

October 2018, Current Sexual Health Reports

DOI: 10.1007/s11930-018-0176-z

Abstract

Purpose of review: The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD)and provides recommendations for future research specific to the diagnostic classification of the condition.

Recent findings: To date, most neuroimaging research on compulsive sexual behavior has provided evidence of overlapping mechanisms underlying compulsive sexual behavior and non-sexual addictions. Compulsive sexual behavior is associated with altered functioning in brain regions and networks implicated in sensitization, habituation, impulse dyscontrol, and reward processing in patterns like substance, gambling, and gaming addictions. Key brain regions linked to CSB features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens.

Summary: Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addictions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand this phenomenon and resolve classification issues surrounding CSBD.

Introduction

Compulsive sexual behavior (CSB) is a debated topic that is also known as sexual addiction, hypersexuality, sexual dependence, sexual impulsivity, nymphomania, or out-of-control sexual behavior [1-27]. Although precise rates are unclear given limited epidemiological research, CSB is estimated to affect 3-6% of the adult population and is more common in men than women [28-32]. Due to the associated distress and impairment reported by men and women with CSB [4-6, 30, 33-38], the World Health Organization (WHO) has recommended including Compulsive Sexual Behavior Disorder(CSBD)in the forthcoming 11th edition of the International Classification of Diseases (6C72)[39]. This inclusion should help increase access to treatment for unserved populations, reduce stigma and shame associated with help-seeking, promote concerted research efforts, and increase international attention on this condition[40, 41].We acknowledge that over the last 20 years there have been varying definitions used to describe dysregulated sexual behaviors often characterized by excessive engagement in nonparaphilic sexual activities (e.g., frequent casual/anonymous sex, problematic use of pornography). For the current review, we will use the term CSB as an overarching term for describing problematic, excessive sexual behavior.

CSB has been conceptualized as an obsessive–compulsive-spectrum disorder, an impulse-control disorder, or addictive behavior [42, 43]. The symptoms of CSBD are like those proposed in 2010forthe DSM-5 diagnosis of hypersexual disorder [44]. Hypersexual disorder was ultimately excluded by American Psychiatric Association from DSM-5 for multiple reasons; the lack of neurobiological and genetic studies was among the most noted reasons [45, 46]. More recently, CSB has received considerable attention in both popular culture and social sciences, particularly given health disparities affecting at-risk and underserved groups. Despite the considerable increase in studies of CSB (including those studying “sexual addiction,” “hypersexuality,” “sexual compulsivity”), relatively little research has examined neural underpinnings of CSB [4, 36]. This article reviews neurobiological mechanisms of CSB and provides recommendations for future research, particularly as related to diagnostic classification of CSBD.

CSB as an Addictive Disorder

Brain regions involved in processing rewards are likely important for understanding the origins, formation, and maintenance of addictive behaviors [47]. Structures within a so-called ‘reward system’ are activated by potentially reinforcing stimuli, such as addictive drugs in addictions. A major neurotransmitter involved in processing rewards is dopamine, particularly within the mesolimbic pathway involving the ventral tegmental area (VTA) and its connections with the nucleus accumbens (NAc), as well as the amygdala, hippocampus, and prefrontal cortex [48]. Additional neurotransmitters and pathways are involved in processing rewards and pleasure, and these warrant considerations given that dopamine has been implicated to varying degrees in individual drug and behavioral addictions in humans [49-51].

According to the incentive salience theory, different brain mechanisms influence motivation to obtain reward (‘wanting’) and the actual hedonic experience of reward (‘liking’) [52]. Whereas ‘wanting’ may be closely related to dopaminergic neurotransmission in the ventral striatum (VStr) and orbitofrontal cortex, networks dedicated to creating wanting motivations and pleasurable feelings are more complex [49, 53, 54].

VStr reward-related reactivity has been studied in addictive disorders such as alcohol, cocaine, opioid use disorders, and gambling disorder[55-58]. Volkow and colleagues describe four important components of addiction: (1) sensitization involving cue reactivity and craving, (2) desensitization involving habituation, (3) hypofrontality, and (4) malfunctioning stress systems[59]. Thus far, research of CSB has largely focused on cue reactivity, craving, and habituation. The first neuroimaging studies of CSB were focused on examining potential  similarities between CSB and addictions, with a specific focus on the incentive salience theory that is based on preconscious neural sensitization related to changes in dopamine-related motivation systems[60]. In this model, repeated exposure to potentially addictive drugs may change brain cells and circuits that regulate the attribution of incentive salience to stimuli, which is a psychological process involved in motivated behavior. Because of this exposure, brain circuits may become hypersensitive (or sensitized), thereby contributing to the development of pathological levels of incentive salience for target substances and their associated cues. Pathological incentive motivation (‘wanting’) for drugs may last for years, even if drug use is discontinued. It may involve implicit (unconscious wanting) or explicit (conscious craving) processes. The incentive salience model has been proposed to potentially contribute to the development and maintenance of CSB [1, 2].

Data support the incentive salience model for CSB. For example, Voon and colleagues examined cue-induced activity in the dorsal anterior cingulate cortex (dACC) –Vstr –amygdala functional network [1].Men with CSB as compared to those without showed increased VStr, dACC, and amygdala responses to pornographic video clips. These findings in the context of the larger literature suggest that sex and drug-cue reactivity involve largely overlapping regions and networks[61, 62]. Men with CSB as compared to those without also reported higher wanting (subjective sexual desire) of pornography stimuli and lower liking which is consistent with an incentive salience theory[1]. Similarly, Mechelmans and colleagues found that men with CSB as compared to men without showed enhanced early attentional bias towards sexually explicit stimuli but not to neutral cues [2]. These findings suggest similarities in enhanced attentional bias observed in studies examining drug cues in addictions.

In 2015, Seok and Sohn found that among men with CSB as compared to those without, greater activity was observed in the dorsolateral prefrontal cortex (dlPFC), caudate, inferior supramarginal gyrus of the parietal lobe, dACC, and thalamus in response to sexual cues[63]. They also found that the severity of CSB symptoms was correlated with cue-induced activation of the dlPFC and thalamus. In 2016, Brand and colleagues observed greater activation of the VStr for preferred pornographic material as compared to non-preferred pornographic material among men with CSB and found that VStr activity was positively associated with self-reported symptoms of addictive use of Internet pornography (assessed by the short Internet Addiction Test modified for cybersex (s-IATsex) [64, 65].

Klucken and colleagues recently observed that participants with CSB as compared to participants without displayed greater activation of the amygdala during presentation of conditioned cues (colored squares) predicting erotic pictures (rewards) [66]. These results are like those from other studies examining amygdala activation among individuals with substance use disorders and men with CSB watching sexually explicit video clips [1, 67].Using EEG, Steele and colleagues observed a higher P300 amplitude to sexual images (when compared to neutral pictures) among individuals self-identified as having problems with CSB, resonating with prior research of processing visual drug cues in drug addiction [68, 69].

In 2017, Gola and colleagues published results of a study using functional magnetic resonance imaging (fMRI) to examine Vstr responses to erotic and monetary stimuli among men seeking treatment for CSB and men without CSB [6]. Participants were engaged in an incentive delay task[54, 70, 71] while undergoing fMRI scanning. During this task, they received erotic or monetary rewards preceded by predictive cues. Men with CSB differed from those without in VStr responses to cues predicting erotic pictures, but not in their responses to erotic pictures. Additionally, men with CSB versus without CSB showed greater VStr activation specifically for cues predicting erotic pictures and not for those predicting monetary rewards. Relative sensitivity to cues (predicting erotic pictures vs. monetary gains) was found to be related to an increased behavioral motivation for viewing erotic images (‘wanting’), intensity of CSB, amount of pornography used per week, and frequency of weekly masturbation. These findings suggest similarities between CSB and addictions, an important role for learned cues in CSB, and possible treatment approaches, particularly interventions focused on teaching skills to individuals to successfully cope with cravings/urges [72]. Furthermore, habituation may be revealed through decreased reward sensitivity to normally salient stimuli and may impact reward responses to sexual stimuli including pornography viewing and partnered sex [1, 68]. Habituation has also been implicated in substance and behavioral addictions [73-79].

In 2014, Kuhn and Gallinat observed decreased VStr reactivity in response to erotic pictures in a group of participants watching pornography frequently, when compared to participants watching pornography rarely[80].Decreased functional connectivity between the left dlPFC and right VStr was also observed. Impairment in fronto-striatal circuity has been related to inappropriate or disadvantageous behavioral choices irrespective of potential negative outcome and impaired regulation of craving in drug addiction [81, 82]. Individuals with CSBmay have reduced executive control when exposed to pornographic material [83, 84]. Kuhn and Gallinat also found that the gray matter volume of the right striatum(caudate nucleus), which has been implicated in approach-attachment behaviors and related to motivational states associated with romantic love, was negatively associated with duration of internet pornography viewing[80, 85, 86]. These findings raise the possibility that frequent use of pornography may decrease brain activation in response to sexual stimuli and increase habituation to sexual pictures although longitudinal studies are needed to exclude other possibilities.

A study using EEG, conducted by Prause and colleagues, suggested that individuals who feel distressed about their pornography use, as compared to a control group who do not feel distress about their use of pornography, may require more/greater visual stimulation to evoke brain responses [87]. Hypersexual participants—individuals‘ experiencing problems regulating their viewing of sexual images’ (M=3.8 hours per week)—exhibited less neural activation (measured by late positive potential in the EEG signal) when exposed to sexual images than did the comparison group when exposed to the same images. Depending on the interpretation of sexual stimuli in this study (as a cue or reward; for more see Gola et al. [4]), the findings may support other observations indicating habituation effects in addictions [4].In 2015, Banca and colleagues observed that men with CSB preferred novel sexual stimuli and demonstrated findings suggestive of habituation in the dACC when exposed repeatedly to the same images [88]. Results of the aforementioned studies suggest that frequent pornography use may decrease reward sensitivity, possibly leading to increased habituation and tolerance, thereby enhancing the need for greater stimulation to be sexually aroused. However, longitudinal studies are indicated to examine this possibility further. Taken together, neuroimaging research to date has provided initial support for the notion that CSB shares similarities with drug, gambling, and gaming addictions with respect to altered brain networks and processes, including sensitization and habituation.

CSB as an Impulse-Control Disorder?

The category of “Impulse-Control Disorders Not Elsewhere Classified” in DSM-IV was heterogeneous in nature and included multiple disorders that have since been re-classified as being addictive (gambling disorder) or obsessive-compulsive-related (trichotillomania) in DSM-5[89, 90]. The current category in the DSM-5 focuses on disruptive, impulse-control and conduct disorders, becoming more homogeneous in its focus by including kleptomania, pyromania, intermittent explosive disorder, oppositional defiant disorder, conduct disorder, and antisocial personality disorder[90]. The category of impulse-control disorders in the ICD-11includes these first three disorders and CSBD, raising questions regarding the most appropriate classification. Given this context, how CSBD relates to the transdiagnostic construct of impulsivity warrants additional consideration for classification as well as clinical purposes.

Impulsivity may be defined as a, “predisposition towards rapid, unplanned reactions to internal or external stimuli with diminished regard to the negative consequences to the impulsive individual or others” [91]. Impulsivity has been associated with hypersexuality [92]. Impulsivity is a multidimensional construct with different types (e.g., choice, response) that may have trait and state characteristics [93-97]. Different forms of impulsivity may be assessed via self-report or via tasks. They may correlate weakly or not all, even within the same form of impulsivity; importantly, they may relate differentially to clinical characteristics and outcomes [98]. Response impulsivity maybe measured by performance on inhibitory control tasks, such as the stop signal or Go/No-Go tasks, whereas choice impulsivity may be assessed through delay discounting tasks [94, 95, 99].

Data suggest differences between individuals with and without CSB on self-report and task-based measures of impulsivity [100-103]. Furthermore, impulsivity and craving seem to be associated with the severity of symptoms of dysregulated pornography use, such as loss of control [64, 104]. For instance, one study found interacting effects of levels of impulsivity measured by self-report and behavioral tasks with respect to cumulative influences on symptom severity of CSB [104].

Among treatment-seeking samples, 48% to 55% of people may exhibit high levels of generalized impulsivity on Barratt Impulsiveness Scale [105-107]. In contrast, other data suggest that some patients seeking treatment for CSB do not have other impulsive behaviors or comorbid addictions beyond their struggles with sexual behaviors which is consistent with findings from a large online survey of men and women suggesting relatively weak relations between impulsivity and some aspects of CSB (problematic pornography use) and stronger relations with others (hypersexuality) [108, 109]. Similarly, in a study using different measures of individuals with problematic pornography use(mean time of weekly pornography use = 287.87 minutes) and those without (mean time of weekly pornography use = 50.77 minutes) did not differ on self-reported (UPPS-P Scale) or task-based (Stop Signal Task)measures of impulsivity [110].Further, Reid and colleagues did not observe differences between individuals with CSB and healthy controls on neuropsychological tests of executive functioning (i.e., response inhibition, motor speed, selective attention, vigilance, cognitive flexibility, concept formation, set shifting),even after adjusting for cognitive ability in analyses [103]. Together, findings suggest that impulsivity may link most strongly to hypersexuality but not to specific forms of CSB like problematic pornography use. It raises questions about CSBD’s classification as an impulse-control disorder in the ICD-11 and highlights the need for precise assessments of different forms of CSB. This is particularly important since some research indicates that impulsivity and subdomains of impulse-control disorder differ on conceptual and pathophysiological level [93, 98, 111].

CSB as an Obsessive-Compulsive-Spectrum Disorder?

One condition (trichotillomania) classified as an impulse-control disorder in DSM-IV has been reclassified with obsessive-compulsive disorder (OCD) as an obsessive-compulsive and related disorder in DSM-5[90]. Other DSM-IV impulse-control disorders like gambling disorder exhibit significant differences from OCD, supporting their classification in separate categories [112]. Compulsivity is a transdiagnostic construct that involves, “the performance of repetitive and functionally impairing overt or covert behavior without adaptive function, performed in a stereotyped or habitual fashion, either according to rigid rules or as a means to avoid negative consequences”[93]. OCD exhibits high levels of compulsivity; however, so do substance addictions and behavioral addictions like gambling disorder [98]. Traditionally, compulsive and impulsive disorders were construed as lying along opposite ends of a spectrum; however, data suggest the constructs as being orthogonal with many disorders scoring high on measures of both impulsivity and compulsivity [93, 113]. Regarding CSB, sexual obsessions have also been described as time-consuming and interfering and may relate theoretically to OCD or to OCD-related features [114].

Recent studies assessing obsessive-compulsive features using the Obsessive-Compulsive Inventory –Revised (OCI-R) did not show elevations among individuals with CSB [6, 37, 115]. Similarly, a large online survey found aspects of compulsivity only weakly related to problematic pornography use[109]. Together, these findings do not show strong support for considering CSB as an obsessive-compulsive-related disorder. Neural features underlying compulsive behaviors have been described and overlap across multiple disorders [93]. Further studies using psychometrically validated and neuroimaging methods in larger clinical treatment seeking samples are needed to examine further how CSBD may relate to compulsivity and OCD.

Structural Neural Changes among CSB Individuals

Thus far, most neuroimaging studies have focused on functional alterations in individuals with CSB, and results suggest that CSB symptoms are linked to specific neural processes[1, 63, 80]. Although task-based studies have deepened our knowledge about regional activation and functional connectivity, additional approaches should be used.

White-or gray-matter measures have been studied in CSB [102, 116]. In 2009, Miner and colleagues found that individuals with CSB as compared to those without displayed higher superior frontal region mean diffusivity and exhibited poorer inhibitive control. In a study of men with and without CSB from 2016, greater left amygdala volume was observed in the CSB group and relatively reduced resting-state functional connectivity was observed between the amygdala and dlPFC [116]. Reduction of brain volumes in the temporal lobe, frontal lobe, hippocampus, and amygdala were found to be related to the symptoms of hypersexuality in patients with dementia or Parkinson’s disease [117, 118]. These seemingly opposing patterns of amygdala volume relating to CSB highlight the importance of considering co-occurring neuropsychiatric disorders in understanding the neurobiology of CSB.

In 2018, Seok and Sohn used voxel-based morphometry (VBM) and resting-state connectivity analysis to examine gray-matter and resting-state measures in CSB [119]. Men with CSB showed significant gray-matter reduction in the temporal gyrus. Left superior temporal gyrus (STG) volume was negatively correlated with the severity of CSB (i.e., Sexual Addiction Screening Test-Revised [SAST ] and Hypersexual Behavior Inventory [HBI] scores)[120, 121]. Additionally, altered left STG-left precuneus and left STG-right caudate connectivities were observed. Lastly, results revealed a significant negative correlation between severity of CSB and functional connectivity of the left STG to the right caudate nucleus.

While the neuroimaging studies of CSB have been illuminating, little is still known about alternations in brain structures and functional connectivity among CSB individuals, particularly from treatment studies or other longitudinal designs. Integration of findings from other domains (e.g., genetic and epigenetic) will also be important to consider in future studies. Additionally, findings directly comparing specific disorders and incorporating transdiagnostic measures will allow for collection of important information that could inform classification and intervention development efforts currently underway.

Conclusions and Recommendations

This article reviews scientific knowledge regarding neural mechanisms of CSB from three perspectives: addictive, impulse-control, and obsessive-compulsive. Several studies suggest relationships between CSB and increased sensitivity for erotic rewards or cues predicting these rewards, and others suggest that CSB is related to increased cue-conditioning for erotic stimuli [1, 6, 36, 64, 66]. Studies also suggest that CSB symptoms are associated with elevated anxiety [34, 37,122]. Although gaps exist in our understanding of CSB, multiple brain regions (including frontal, parietal and temporal cortices, amygdala, and striatum) have been linked to CSB and related features.

CSBD has been included in the current version oftheICD-11as an impulse-control disorder [39]. As described by the WHO, ‘Impulse-control disorders are characterized by the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person, at least in the short-term, despite consequences such as longer-term harm either to the individual or to others, marked distress about the behaviour pattern, or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning’ [39]. Current findings raise important questions regarding the classification of CSBD. Many disorders characterized by impaired impulse-control are classified elsewhere in the ICD-11 (for example, gambling, gaming, and substance-use disorders are classified as being addictive disorders) [123].

Currently, CSBD constitutes a heterogeneous disorder, and further refinement of CSBD criteria should distinguish between different subtypes, some of which may relate to the heterogeneity of sexual behaviors problematic for individuals [33, 108, 124]. Heterogeneity in CSBD may in part explain seeming discrepancies which are noticeable across studies. Although neuroimaging studies find multiple similarities between CSB and substance and behavioral addictions, additional research is needed to fully understand how neurocognition relates to the clinical characteristics of CSB, especially with respect to sexual behaviors subtypes. Multiple studies have focused exclusively on problematic use of pornography which may limit generalizability to other sexual behaviors. Further, inclusion/exclusion criteria for CSB research participants have varied across studies, also raising questions regarding generalizability and comparability across studies.

Future Directions

Several limitations should be noted with respect to current neuroimaging studies and be considered when planning future investigations (see Table 1). A primary limitation involves small sample sizes that are largely white, male, and heterosexual. More research is needed to recruit larger, ethnically diverse samples of men and women with CSB and individuals of different sexual identities and orientations. For example, no systematic scientific studies have investigated neurocognitive processes of CSB in women. Such studies are needed given data linking sexual impulsivity to greater psychopathology in women as compared to men and other data which suggest gender-related differences in clinical populations with CSB [25, 30]. As women and men with addictions may demonstrate different motivations (e.g., relating to negative versus positive reinforcement) for engaging in addictive behaviors and show differences in stress and drug-cue responsivity, future neurobiological studies should consider stress systems and related processes in gender-related investigations of CSBD given its current inclusion in the ICD-11 as a mental health disorder [125, 126].

Similarly, there is also a need to conduct systematic research focusing on ethnic and sexual minorities to clarify our understanding of CSB among these groups. Screening instruments for CSB have been mostly tested and validated on white European men. Moreover, current studies have focused predominantly on heterosexual men. More research examining clinical characteristics of CSB among gay and bisexual men and women is needed. Neurobiological research of specific groups (transgender, polyamorous, kink, other) and activities (pornography viewing, compulsive masturbation, casual anonymous sex, other) is also needed. Given such limitations, existing results should be interpreted cautiously.

Direct comparison of CSBD with other disorders (e.g., substance use, gambling, gaming, and other disorders)is needed, as is incorporation of other non-imaging modalities (e.g., genetic, epigenetic) and use of other imaging approaches. Techniques like positron emission tomography could also provide important insight into neurochemical underpinnings of CSBD.

The heterogeneity of CSB may also be clarified through careful assessment of clinical features that may be obtained in part from qualitative research like focus group ordiary assessment methods [37]. Such research could also provide insight into longitudinal questions like whether problematic pornography use may lead to sexual dysfunction, and integrating neurocognitive assessments into such studies could provide insight into neurobiological mechanisms. Further, as behavioral and pharmacological interventions are formally tested for their efficacies in treating CSBD, integration of neurocognitive assessments could help identify mechanisms of effective treatments for CSBD and potential biomarkers. This last point may be particularly important because the inclusion of CSBD in the ICD-11 will likely increase the number of individuals seeking treatment for CSBD. Specifically, the inclusion of CSBD in the ICD-11 should raise awareness in patients, providers, and others and potentially remove other barriers (e.g., reimbursement from insurance providers) that may currently exist for CSBD.

Neurocognitive mechanisms in compulsive sexual behavior disorder (2018)

October 2018, Current Sexual Health Reports

Abstract

Purpose of review: The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD) and provides recommendations for future research specific to the diagnostic classification of the condition.

Recent findings: To date, most neuroimaging research on compulsive sexual behavior has provided evidence of overlapping mechanisms underlying compulsive sexual behavior and non-sexual addictions. Compulsive sexual behavior is associated with altered functioning in brain regions and networks implicated in sensitization, habituation, impulse dyscontrol, and reward processing in patterns like substance, gambling, and gaming addictions. Key brain regions linked to CSB features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens.

Summary: Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addictions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand this phenomenon and resolve classification issues surrounding CSBD.

Introduction

Compulsive sexual behavior (CSB) is a debated topic that is also known as sexual addiction, hypersexuality, sexual dependence, sexual impulsivity, nymphomania, or out-of-control sexual behavior [1-27]. Although precise rates are unclear given limited epidemiological research, CSB is estimated to affect 3-6% of the adult population and is more common in men than women [28-32]. Due to the associated distress and impairment reported by men and women with CSB [4-6, 30, 33-38], the World Health Organization (WHO) has recommended including Compulsive Sexual Behavior Disorder(CSBD)in the forthcoming 11th edition of the International Classification of Diseases (6C72)[39]. This inclusion should help increase access to treatment for unserved populations, reduce stigma and shame associated with help-seeking, promote concerted research efforts, and increase international attention on this condition[40, 41].We acknowledge that over the last 20 years there have been varying definitions used to describe dysregulated sexual behaviors often characterized by excessive engagement in nonparaphilic sexual activities (e.g., frequent casual/anonymous sex, problematic use of pornography). For the current review, we will use the term CSB as an overarching term for describing problematic, excessive sexual behavior.

CSB has been conceptualized as an obsessive–compulsive-spectrum disorder, an impulse-control disorder, or addictive behavior [42, 43]. The symptoms of CSBD are like those proposed in 2010forthe DSM-5 diagnosis of hypersexual disorder [44]. Hypersexual disorder was ultimately excluded by American Psychiatric Association from DSM-5 for multiple reasons; the lack of neurobiological and genetic studies was among the most noted reasons [45, 46]. More recently, CSB has received considerable attention in both popular culture and social sciences, particularly given health disparities affecting at-risk and underserved groups. Despite the considerable increase in studies of CSB (including those studying “sexual addiction,” “hypersexuality,” “sexual compulsivity”), relatively little research has examined neural underpinnings of CSB [4, 36]. This article reviews neurobiological mechanisms of CSB and provides recommendations for future research, particularly as related to diagnostic classification of CSBD.

CSB as an Addictive Disorder

Brain regions involved in processing rewards are likely important for understanding the origins, formation, and maintenance of addictive behaviors [47]. Structures within a so-called ‘reward system’ are activated by potentially reinforcing stimuli, such as addictive drugs in addictions. A major neurotransmitter involved in processing rewards is dopamine, particularly within the mesolimbic pathway involving the ventral tegmental area (VTA) and its connections with the nucleus accumbens (NAc), as well as the amygdala, hippocampus, and prefrontal cortex [48]. Additional neurotransmitters and pathways are involved in processing rewards and pleasure, and these warrant considerations given that dopamine has been implicated to varying degrees in individual drug and behavioral addictions in humans [49-51].

According to the incentive salience theory, different brain mechanisms influence motivation to obtain reward (‘wanting’) and the actual hedonic experience of reward (‘liking’) [52]. Whereas ‘wanting’ may be closely related to dopaminergic neurotransmission in the ventral striatum (VStr) and orbitofrontal cortex, networks dedicated to creating wanting motivations and pleasurable feelings are more complex [49, 53, 54].

VStr reward-related reactivity has been studied in addictive disorders such as alcohol, cocaine, opioid use disorders, and gambling disorder[55-58]. Volkow and colleagues describe four important components of addiction: (1) sensitization involving cue reactivity and craving, (2) desensitization involving habituation, (3) hypofrontality, and (4) malfunctioning stress systems[59]. Thus far, research of CSB has largely focused on cue reactivity, craving, and habituation. The first neuroimaging studies of CSB were focused on examining potential  similarities between CSB and addictions, with a specific focus on the incentive salience theory that is based on preconscious neural sensitization related to changes in dopamine-related motivation systems[60]. In this model, repeated exposure to potentially addictive drugs may change brain cells and circuits that regulate the attribution of incentive salience to stimuli, which is a psychological process involved in motivated behavior. Because of this exposure, brain circuits may become hypersensitive (or sensitized), thereby contributing to the development of pathological levels of incentive salience for target substances and their associated cues. Pathological incentive motivation (‘wanting’) for drugs may last for years, even if drug use is discontinued. It may involve implicit (unconscious wanting) or explicit (conscious craving) processes. The incentive salience model has been proposed to potentially contribute to the development and maintenance of CSB [1, 2].

Data support the incentive salience model for CSB. For example, Voon and colleagues examined cue-induced activity in the dorsal anterior cingulate cortex (dACC) –Vstr –amygdala functional network [1].Men with CSB as compared to those without showed increased VStr, dACC, and amygdala responses to pornographic video clips. These findings in the context of the larger literature suggest that sex and drug-cue reactivity involve largely overlapping regions and networks[61, 62]. Men with CSB as compared to those without also reported higher wanting (subjective sexual desire) of pornography stimuli and lower liking which is consistent with an incentive salience theory[1]. Similarly, Mechelmans and colleagues found that men with CSB as compared to men without showed enhanced early attentional bias towards sexually explicit stimuli but not to neutral cues [2]. These findings suggest similarities in enhanced attentional bias observed in studies examining drug cues in addictions.

In 2015, Seok and Sohn found that among men with CSB as compared to those without, greater activity was observed in the dorsolateral prefrontal cortex (dlPFC), caudate, inferior supramarginal gyrus of the parietal lobe, dACC, and thalamus in response to sexual cues[63]. They also found that the severity of CSB symptoms was correlated with cue-induced activation of the dlPFC and thalamus. In 2016, Brand and colleagues observed greater activation of the VStr for preferred pornographic material as compared to non-preferred pornographic material among men with CSB and found that VStr activity was positively associated with self-reported symptoms of addictive use of Internet pornography (assessed by the short Internet Addiction Test modified for cybersex (s-IATsex) [64, 65].

Klucken and colleagues recently observed that participants with CSB as compared to participants without displayed greater activation of the amygdala during presentation of conditioned cues (colored squares) predicting erotic pictures (rewards) [66]. These results are like those from other studies examining amygdala activation among individuals with substance use disorders and men with CSB watching sexually explicit video clips [1, 67].Using EEG, Steele and colleagues observed a higher P300 amplitude to sexual images (when compared to neutral pictures) among individuals self-identified as having problems with CSB, resonating with prior research of processing visual drug cues in drug addiction [68, 69].

In 2017, Gola and colleagues published results of a study using functional magnetic resonance imaging (fMRI) to examine Vstr responses to erotic and monetary stimuli among men seeking treatment for CSB and men without CSB [6]. Participants were engaged in an incentive delay task[54, 70, 71] while undergoing fMRI scanning. During this task, they received erotic or monetary rewards preceded by predictive cues. Men with CSB differed from those without in VStr responses to cues predicting erotic pictures, but not in their responses to erotic pictures. Additionally, men with CSB versus without CSB showed greater VStr activation specifically for cues predicting erotic pictures and not for those predicting monetary rewards. Relative sensitivity to cues (predicting erotic pictures vs. monetary gains) was found to be related to an increased behavioral motivation for viewing erotic images (‘wanting’), intensity of CSB, amount of pornography used per week, and frequency of weekly masturbation. These findings suggest similarities between CSB and addictions, an important role for learned cues in CSB, and possible treatment approaches, particularly interventions focused on teaching skills to individuals to successfully cope with cravings/urges [72]. Furthermore, habituation may be revealed through decreased reward sensitivity to normally salient stimuli and may impact reward responses to sexual stimuli including pornography viewing and partnered sex [1, 68]. Habituation has also been implicated in substance and behavioral addictions [73-79].

In 2014, Kuhn and Gallinat observed decreased VStr reactivity in response to erotic pictures in a group of participants watching pornography frequently, when compared to participants watching pornography rarely[80].Decreased functional connectivity between the left dlPFC and right VStr was also observed. Impairment in fronto-striatal circuity has been related to inappropriate or disadvantageous behavioral choices irrespective of potential negative outcome and impaired regulation of craving in drug addiction [81, 82]. Individuals with CSBmay have reduced executive control when exposed to pornographic material [83, 84]. Kuhn and Gallinat also found that the gray matter volume of the right striatum(caudate nucleus), which has been implicated in approach-attachment behaviors and related to motivational states associated with romantic love, was negatively associated with duration of internet pornography viewing[80, 85, 86]. These findings raise the possibility that frequent use of pornography may decrease brain activation in response to sexual stimuli and increase habituation to sexual pictures although longitudinal studies are needed to exclude other possibilities.

A study using EEG, conducted by Prause and colleagues, suggested that individuals who feel distressed about their pornography use, as compared to a control group who do not feel distress about their use of pornography, may require more/greater visual stimulation to evoke brain responses [87]. Hypersexual participants—individuals‘ experiencing problems regulating their viewing of sexual images’ (M=3.8 hours per week)—exhibited less neural activation (measured by late positive potential in the EEG signal) when exposed to sexual images than did the comparison group when exposed to the same images. Depending on the interpretation of sexual stimuli in this study (as a cue or reward; for more see Gola et al. [4]), the findings may support other observations indicating habituation effects in addictions [4].In 2015, Banca and colleagues observed that men with CSB preferred novel sexual stimuli and demonstrated findings suggestive of habituation in the dACC when exposed repeatedly to the same images [88]. Results of the aforementioned studies suggest that frequent pornography use may decrease reward sensitivity, possibly leading to increased habituation and tolerance, thereby enhancing the need for greater stimulation to be sexually aroused. However, longitudinal studies are indicated to examine this possibility further. Taken together, neuroimaging research to date has provided initial support for the notion that CSB shares similarities with drug, gambling, and gaming addictions with respect to altered brain networks and processes, including sensitization and habituation.

CSB as an Impulse-Control Disorder?

The category of “Impulse-Control Disorders Not Elsewhere Classified” in DSM-IV was heterogeneous in nature and included multiple disorders that have since been re-classified as being addictive (gambling disorder) or obsessive-compulsive-related (trichotillomania) in DSM-5 [89, 90]. The current category in the DSM-5 focuses on disruptive, impulse-control and conduct disorders, becoming more homogeneous in its focus by including kleptomania, pyromania, intermittent explosive disorder, oppositional defiant disorder, conduct disorder, and antisocial personality disorder[90]. The category of impulse-control disorders in the ICD-11includes these first three disorders and CSBD, raising questions regarding the most appropriate classification. Given this context, how CSBD relates to the transdiagnostic construct of impulsivity warrants additional consideration for classification as well as clinical purposes.

Impulsivity may be defined as a, “predisposition towards rapid, unplanned reactions to internal or external stimuli with diminished regard to the negative consequences to the impulsive individual or others” [91]. Impulsivity has been associated with hypersexuality [92]. Impulsivity is a multidimensional construct with different types (e.g., choice, response) that may have trait and state characteristics [93-97]. Different forms of impulsivity may be assessed via self-report or via tasks. They may correlate weakly or not all, even within the same form of impulsivity; importantly, they may relate differentially to clinical characteristics and outcomes [98]. Response impulsivity maybe measured by performance on inhibitory control tasks, such as the stop signal or Go/No-Go tasks, whereas choice impulsivity may be assessed through delay discounting tasks [94, 95, 99].

Data suggest differences between individuals with and without CSB on self-report and task-based measures of impulsivity [100-103]. Furthermore, impulsivity and craving seem to be associated with the severity of symptoms of dysregulated pornography use, such as loss of control [64, 104]. For instance, one study found interacting effects of levels of impulsivity measured by self-report and behavioral tasks with respect to cumulative influences on symptom severity of CSB [104].

Among treatment-seeking samples, 48% to 55% of people may exhibit high levels of generalized impulsivity on Barratt Impulsiveness Scale [105-107]. In contrast, other data suggest that some patients seeking treatment for CSB do not have other impulsive behaviors or comorbid addictions beyond their struggles with sexual behaviors which is consistent with findings from a large online survey of men and women suggesting relatively weak relations between impulsivity and some aspects of CSB (problematic pornography use) and stronger relations with others (hypersexuality) [108, 109]. Similarly, in a study using different measures of individuals with problematic pornography use(mean time of weekly pornography use = 287.87 minutes) and those without (mean time of weekly pornography use = 50.77 minutes) did not differ on self-reported (UPPS-P Scale) or task-based (Stop Signal Task)measures of impulsivity [110].Further, Reid and colleagues did not observe differences between individuals with CSB and healthy controls on neuropsychological tests of executive functioning (i.e., response inhibition, motor speed, selective attention, vigilance, cognitive flexibility, concept formation, set shifting),even after adjusting for cognitive ability in analyses [103]. Together, findings suggest that impulsivity may link most strongly to hypersexuality but not to specific forms of CSB like problematic pornography use. It raises questions about CSBD’s classification as an impulse-control disorder in the ICD-11 and highlights the need for precise assessments of different forms of CSB. This is particularly important since some research indicates that impulsivity and subdomains of impulse-control disorder differ on conceptual and pathophysiological level [93, 98, 111].

CSB as an Obsessive-Compulsive-Spectrum Disorder?

One condition (trichotillomania) classified as an impulse-control disorder in DSM-IV has been reclassified with obsessive-compulsive disorder (OCD) as an obsessive-compulsive and related disorder in DSM-5[90]. Other DSM-IV impulse-control disorders like gambling disorder exhibit significant differences from OCD, supporting their classification in separate categories [112]. Compulsivity is a transdiagnostic construct that involves, “the performance of repetitive and functionally impairing overt or covert behavior without adaptive function, performed in a stereotyped or habitual fashion, either according to rigid rules or as a means to avoid negative consequences”[93]. OCD exhibits high levels of compulsivity; however, so do substance addictions and behavioral addictions like gambling disorder [98]. Traditionally, compulsive and impulsive disorders were construed as lying along opposite ends of a spectrum; however, data suggest the constructs as being orthogonal with many disorders scoring high on measures of both impulsivity and compulsivity [93, 113]. Regarding CSB, sexual obsessions have also been described as time-consuming and interfering and may relate theoretically to OCD or to OCD-related features [114].

Recent studies assessing obsessive-compulsive features using the Obsessive-Compulsive Inventory –Revised (OCI-R) did not show elevations among individuals with CSB [6, 37, 115]. Similarly, a large online survey found aspects of compulsivity only weakly related to problematic pornography use[109]. Together, these findings do not show strong support for considering CSB as an obsessive-compulsive-related disorder. Neural features underlying compulsive behaviors have been described and overlap across multiple disorders [93]. Further studies using psychometrically validated and neuroimaging methods in larger clinical treatment seeking samples are needed to examine further how CSBD may relate to compulsivity and OCD.

Structural Neural Changes among CSB Individuals

Thus far, most neuroimaging studies have focused on functional alterations in individuals with CSB, and results suggest that CSB symptoms are linked to specific neural processes[1, 63, 80]. Although task-based studies have deepened our knowledge about regional activation and functional connectivity, additional approaches should be used.

White-or gray-matter measures have been studied in CSB [102, 116]. In 2009, Miner and colleagues found that individuals with CSB as compared to those without displayed higher superior frontal region mean diffusivity and exhibited poorer inhibitive control. In a study of men with and without CSB from 2016, greater left amygdala volume was observed in the CSB group and relatively reduced resting-state functional connectivity was observed between the amygdala and dlPFC [116]. Reduction of brain volumes in the temporal lobe, frontal lobe, hippocampus, and amygdala were found to be related to the symptoms of hypersexuality in patients with dementia or Parkinson’s disease [117, 118]. These seemingly opposing patterns of amygdala volume relating to CSB highlight the importance of considering co-occurring neuropsychiatric disorders in understanding the neurobiology of CSB.

In 2018, Seok and Sohn used voxel-based morphometry (VBM) and resting-state connectivity analysis to examine gray-matter and resting-state measures in CSB [119]. Men with CSB showed significant gray-matter reduction in the temporal gyrus. Left superior temporal gyrus (STG) volume was negatively correlated with the severity of CSB (i.e., Sexual Addiction Screening Test-Revised [SAST ] and Hypersexual Behavior Inventory [HBI] scores)[120, 121]. Additionally, altered left STG-left precuneus and left STG-right caudate connectivities were observed. Lastly, results revealed a significant negative correlation between severity of CSB and functional connectivity of the left STG to the right caudate nucleus.

While the neuroimaging studies of CSB have been illuminating, little is still known about alternations in brain structures and functional connectivity among CSB individuals, particularly from treatment studies or other longitudinal designs. Integration of findings from other domains (e.g., genetic and epigenetic) will also be important to consider in future studies. Additionally, findings directly comparing specific disorders and incorporating transdiagnostic measures will allow for collection of important information that could inform classification and intervention development efforts currently underway.

Conclusions and Recommendations

This article reviews scientific knowledge regarding neural mechanisms of CSB from three perspectives: addictive, impulse-control, and obsessive-compulsive. Several studies suggest relationships between CSB and increased sensitivity for erotic rewards or cues predicting these rewards, and others suggest that CSB is related to increased cue-conditioning for erotic stimuli [1, 6, 36, 64, 66]. Studies also suggest that CSB symptoms are associated with elevated anxiety [34, 37,122]. Although gaps exist in our understanding of CSB, multiple brain regions (including frontal, parietal and temporal cortices, amygdala, and striatum) have been linked to CSB and related features.

CSBD has been included in the current version of theICD-11 as an impulse-control disorder [39]. As described by the WHO, ‘Impulse-control disorders are characterized by the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person, at least in the short-term, despite consequences such as longer-term harm either to the individual or to others, marked distress about the behaviour pattern, or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning’ [39]. Current findings raise important questions regarding the classification of CSBD. Many disorders characterized by impaired impulse-control are classified elsewhere in the ICD-11 (for example, gambling, gaming, and substance-use disorders are classified as being addictive disorders) [123].

Currently, CSBD constitutes a heterogeneous disorder, and further refinement of CSBD criteria should distinguish between different subtypes, some of which may relate to the heterogeneity of sexual behaviors problematic for individuals [33, 108, 124]. Heterogeneity in CSBD may in part explain seeming discrepancies which are noticeable across studies. Although neuroimaging studies find multiple similarities between CSB and substance and behavioral addictions, additional research is needed to fully understand how neurocognition relates to the clinical characteristics of CSB, especially with respect to sexual behaviors subtypes. Multiple studies have focused exclusively on problematic use of pornography which may limit generalizability to other sexual behaviors. Further, inclusion/exclusion criteria for CSB research participants have varied across studies, also raising questions regarding generalizability and comparability across studies.

Future Directions

Several limitations should be noted with respect to current neuroimaging studies and be considered when planning future investigations (see Table 1). A primary limitation involves small sample sizes that are largely white, male, and heterosexual. More research is needed to recruit larger, ethnically diverse samples of men and women with CSB and individuals of different sexual identities and orientations. For example, no systematic scientific studies have investigated neurocognitive processes of CSB in women. Such studies are needed given data linking sexual impulsivity to greater psychopathology in women as compared to men and other data which suggest gender-related differences in clinical populations with CSB [25, 30]. As women and men with addictions may demonstrate different motivations (e.g., relating to negative versus positive reinforcement) for engaging in addictive behaviors and show differences in stress and drug-cue responsivity, future neurobiological studies should consider stress systems and related processes in gender-related investigations of CSBD given its current inclusion in the ICD-11 as a mental health disorder [125, 126].

Similarly, there is also a need to conduct systematic research focusing on ethnic and sexual minorities to clarify our understanding of CSB among these groups. Screening instruments for CSB have been mostly tested and validated on white European men. Moreover, current studies have focused predominantly on heterosexual men. More research examining clinical characteristics of CSB among gay and bisexual men and women is needed. Neurobiological research of specific groups (transgender, polyamorous, kink, other) and activities (pornography viewing, compulsive masturbation, casual anonymous sex, other) is also needed. Given such limitations, existing results should be interpreted cautiously.

Direct comparison of CSBD with other disorders (e.g., substance use, gambling, gaming, and other disorders)is needed, as is incorporation of other non-imaging modalities (e.g., genetic, epigenetic) and use of other imaging approaches. Techniques like positron emission tomography could also provide important insight into neurochemical underpinnings of CSBD.

The heterogeneity of CSB may also be clarified through careful assessment of clinical features that may be obtained in part from qualitative research like focus group ordiary assessment methods [37]. Such research could also provide insight into longitudinal questions like whether problematic pornography use may lead to sexual dysfunction, and integrating neurocognitive assessments into such studies could provide insight into neurobiological mechanisms. Further, as behavioral and pharmacological interventions are formally tested for their efficacies in treating CSBD, integration of neurocognitive assessments could help identify mechanisms of effective treatments for CSBD and potential biomarkers. This last point may be particularly important because the inclusion of CSBD in the ICD-11 will likely increase the number of individuals seeking treatment for CSBD. Specifically, the inclusion of CSBD in the ICD-11 should raise awareness in patients, providers, and others and potentially remove other barriers (e.g., reimbursement from insurance providers) that may currently exist for CSBD.

Table 1.Recommendations for neuroscientific studies of Compulsive Sexual Behavior Disorder.

Data

Goal
Behavioral

Self-report

Neurobiological

 

▪ Conduct intercultural studies on larger samples; include more women, ethnic and sexual minorities, economicallydisadvantaged persons and persons with cognitive and physical disabilities

 

Clinical

Behavioral

Self-report

Neurobiological

 

▪ Large, well-powered field trials to assess and validate proposed CSBD diagnostic criteria

▪ Examinethe heterogeneous natureof CSBD

▪ Examine the role of impulsivity and other transdiagnostic constructs in the development and maintenance of CSBD

▪ Assess the relationship between brain structure and function and treatment outcomesfor treatment-seeking individuals with CSBD

 

Clinical

Pharmacological

Neurobiological

 

▪ Identification of efficacious and well tolerated pharmacological and behavioral treatments in randomized clinical trials of individuals with CSBD

 

Neurobiological  

▪ Further examination of structural,functional, neurochemical and other data and their integration

▪ Examine neurobiological mechanisms underlying specific aspects of CSBD including sexual function and dysfunction

 

Genetic  

▪ Conduct genome-wide association studies (GWAS) on CSBD

▪ Examine genetic factors that may serve as vulnerability factors for the development of CSBD

▪ Study environmental and epigenetic influences on processes in CSBD

 

 

Nicole Prause’s efforts to have Behavioral Sciences review paper (Park et al., 2016) retracted

CONTENTS:

  1. “Who’s watching Retraction Watch?” – an update on events.
  2. Background – general
  3. Pre-MDPI history: the Yale Journal of Biology & Medicine, and “Janey Wilson”.
  4. Behavioral Sciences version of Park et al., and Prause’s retraction efforts
  5. Prause uses social media to harass MDPI and researchers who publish in MDPI journals
  6. May, 2018 – Prause creates multiple sock-puppets to edit the MDPI Wikipedia page (and is banned for sock-puppetry & defamation)
  7. May, 2018 – Prause lies about Gary Wilson in emails to MDPI, David Ley, NeuroSkeptic, Adam Marcus of Retraction Watch, and COPE
  8. The exploits of “Janey Wilson” (Prause)
  9. Summary of events

“Who’s watching Retraction Watch?”

(This section was created after sections 2-9 were created.) I was under the impression that people looked to Retraction Watch for responsible, thoroughly vetted articles about research. After my recent experience however, I can only ask, “Who’s watching Retraction Watch?” To whom or what is Retraction Watch accountable for oversight when it engages in irresponsible journalism?

On June 13, Retraction Watch (RW) published an inaccurate and biased account of events surrounding Behavioral Sciences paper Park et al., 2016. Among other distortions, the piece omitted material details about Nicole Prause’s unsuccessful (and unseemly) 3-year campaign to have the paper retracted (documented in the next 8 sections).

Prause, a former academic, apparently contacted RW personnel and fed them the particulars she wanted in print – and RW apparently swallowed them whole and duly published them. My response appears underneath the Retraction Watch article. However, RW edited my comment substantially before it would post it. Here I supply various missing details.

First, my comment is a redacted version of an email I sent to Adam Marcus and Ivan Oransky of RW shortly after the piece appeared. After 3 days of back-and-forth emails, RW eventually posted some of the proposed content (from my email), but demanded that I remove content that revealed the ways in which RW had not performed its journalistic duties.

Here is more of the story.

1) Senior author, and Naval officer, Andrew Doan MD PhD requested that Adam Marcus speak to me for clarification on details surrounding the paper (after Marcus contacted him). Doan did this because he and my other 6 co-authors are Active Duty in the US Navy and “cannot speak about the paper in detail without permission from the public affairs office US Navy.” Marcus chose not to contact me. Instead he ran with everything Prause fed him. From my original email:

I’ve read your piece, “Journal corrects, but will not retract, controversial paper on internet porn.” As the prime objective of Retraction Watch is integrity in publishing, I believe you will want to correct this article in numerous important respects. In its current form it contains many errors and much defamatory misinformation. I regret that you didn’t contact me as Dr. Doan suggested, so that these errors could have been avoided.

2) RW principals Adam Marcus and Ivan Oransky were copied on the May, 2018 MDPI-Prause email exchanges. As I said in one of my emails to RW:

I am deeply concerned about Retraction Watch’s selective use of bits of the MDPI emails that Dr. Prause copied you on. As I was also sent those emails, I know there was a lot of other information in them. The omitted bits included lies and unprofessional attacks on others by Dr. Prause. While Dr. Lin’s metaphor was unfortunate (English is not his first or second language), I think his remark needs to be ‘heard’ in light of the fact that Dr. Prause has been badgering his company directly, and indirectly via COPE, for almost two straight years. His exasperation is easily understood. Giving Dr. Prause a “pass” on her offensive behavior while highlighting his was unkind and, more important, leaves your readers with a very skewed perspective.

It must be noted that RW was not copied on the endless stream of emails, from the previous 3 years, where Prause harassed MDPI, the US Navy, the 7 Navy doctors, The Reward Foundation, the publisher of my book, etc., etc. Nor is anyone privy to her many private emails to COPE and its officers.

3) In the May, 2018 MDPI-Prause email exchanges, Marcus and Oransky were twice given this extensive page documenting Prause’s long history of harassing researchers, authors, medical doctors, therapists, psychologists, a former UCLA colleague, a UK charity, men in recovery, a senior TIME magazine editor, several professors, IITAP, SASH, Fight The New Drug, MDPI, and the head of the academic journal CUREUS. In essence, RW ignored Prause’s documented misbehavior to publish its Prause-inspired hit piece.

4) In a follow-up email asking why RW had failed to post my (redacted) comment, I mentioned to Marcus and Oransky that the core assertion of RW’s hit piece was mistaken:

As things stand, even the premise of your article is false. My affiliation with The Reward Foundation (TRF) was always clearly stated, both in the initial Behavioral Sciences article and in the recent correction (the original PubMed version). The purpose of the newly published correction was to counter Dr. Prause’s incessant defamatory claims that I receive money from TRF, and that I make money from my book (my proceeds for which, in fact, go to the charity).

5) In both my emails to RW, I clearly addressed the second primary assertion in their article:

It is also important to clarify that Dr. Prause’s “77 unaddressed points” claim is untrue. I have the documentation of these points and our team’s responses (and the documentation that 25 of the 77 “points” had nothing to do with the Behavioral Sciences paper).

See this section for more details surrounding Prause’s so-called “77 points,” and her unprofessional involvement with an earlier, much different version of our paper, submitted to Yale Journal of Biology and Medicine.

6) In both my emails to RW, I clearly stated that Prause was lying about the California investigation:

Next, it is crucial to correct Dr. Prause’s false assertion that California’s investigation of her behavior is over and that she has prevailed. It is not over; an investigator has invited me to testify in the coming months (date TBD).

It’s quite telling that Marcus and Oransky

(1) did not correct the RW article’s false assertions and misleading statements,

(2) redacted evidence in my proposed post that they were very aware of Prause’s defamatory statements and long history of harassment and proceeded anyway,

(3) chose not communicate with me prior to publication, even though the paper’s senior author requested they do so,

(4) subtly suggested I was the harasser by falsely stating that the California investigation was complete and decided in Prause’s favor, and by linking to a Daily Beast account of events, and

(5) have not corrected or unpublished their hit piece as irresponsible journalism, nor publicly apologized to the authors and journal whose reputations they smeared without cause.

A few more points about the RW article not covered in my comment. The first paragraph states:

“After publication, critics asked COPE to look at the paper.”

“Critics” plural? It was only one “critic” who emailed either MDPI or COPE: Prause. She emailed the US Navy multiple times, reported the 7 doctors on the paper to their medical boards, and turned to social media to harass me, MDPI, and researchers who publish in MDPI – as part of a long campaign to avoid writing a formal scholarly reply to the paper and instead to try to have it retracted via behind-the-scenes maneuvering and public misinformation.

The article said:

“COPE, which has no enforcement authority, said in an email to the publisher that it would have recommended retraction of the article.”

COPE was only concerned about one issue (based on the “facts” fed to it): consent. COPE said the following:

“should this case have been raised at one of our  COPE forums, we feel the recommendation would have been to consider the retraction of the article on the basis of consent requirements not following expectations”…..

While COPE’s answer is hypothetical, based on whatever “facts” Prause apparently supplied it, the authors and MDPI are truly puzzled by the response. In reality, the US Navy doctors more than complied with their Naval Medical Center – San Diego’s IRB consent rules. The Naval Medical Center San Diego’s IRB policy does not consider case reports of less than four patients in a single article to be human subject research and does not require the patients to consent to inclusion in an article. Although the researchers were not required to obtain consent, for two cases, verbal and written consents were obtained. In the third case where anonymity was unlikely to be compromised, no written consent was obtained.

Incidentally, at Dr. Prause’s insistence, after the paper was published, the actions of the Navy co-authors with respect to this paper were thoroughly reviewed in an independent Navy investigation. Result? I have a copy of the official report by a Navy lawyer affirming that the co-authors complied with all the IRB’s rules.

The RW article also said:

“Among the the [sic] claims is that one of the authors, Gary Wilson, failed to adequately disclose his work with The Reward Foundation,”

This is false. As explained earlier, my affiliation with The Reward Foundation (TRF) was always clearly stated, both in the initial Behavioral Sciences article and in the recent correction (the original PubMed version). The purpose of the newly published correction was to counter Dr. Prause’s incessant defamatory claims that I receive money from TRF, and that I make money from my book (my proceeds for which, in fact, go to the charity).

In the absence of adequate oversight, RW readers may want to be skeptical about ingesting RW’s blog posts without independent investigation. RW seems to be willing to allow itself to be used by agenda-driven forces even when alerted that further investigation is needed.

Background

MDPI is the Swiss parent company of numerous academic journals, including Behavioral Sciences. MDPI does not publish predatory journals. In fact, it was investigated years ago after it was mistakenly placed on a predatory list, and formally determined to be a legitimate publisher. See: http://www.mdpi.com/about/announcements/534. The man (Jeffrey Beall) who made the error eventually deleted his entire operation.

Prause is obsessed with MDPI because (1) Behavioral Sciences published two articles that Prause disagrees with (because they discussed papers by her, among hundreds of papers by other authors), and (2) Gary Wilson is a co-author of Park et al., 2016. Prause has a long history of cyberstalking and defaming Wilson, chronicled in this very extensive page. The two papers:

The second paper (Park et al.) didn’t analyze Prause’s research. It cited findings in 3 of her papers. At the request of a reviewer during the peer-review process, it addressed the third, a 2015 paper by Prause & Pfaus, by citing a scholarly piece in a journal that heavily, accurately criticized the paper. (There was not enough space in Park et al. to address all the weaknesses and unsupported claims in Prause & Pfaus, 2015).

Prause immediately insisted that MDPI retract Park et al., 2016. The professional response to scholarly articles one disapproves of is to publish a comment outlining any objections. Behavioral Sciences’s parent company, MDPI, invited Prause to do this. She declined. It must be noted that Prause attacks Wilson and his website constantly and publicly.

Instead of publishing a formal comment, she unprofessionally turned to threats and social media (and most recently the Retraction Watch blog) to bully MDPI into retracting Park et al., of which I am a co-author with 7 US Navy physicians (including two urologists, two psychiatrists and a neuroscientist). In addition, she informed MDPI that she had filed complaints with the American Psychological Association. She then filed complaints with all the doctors’ medical boards. She also pressured the doctors’ medical center and Institutional Review Board, causing a lengthy, thorough investigation, which found no evidence of wrongdoing on the part of the paper’s authors.

Prause also complained repeatedly to COPE (Committee on Publication Ethics). COPE finally wrote MDPI with a hypothetical inquiry about retraction, based on Prause’s narrative that the “patients weren’t consented.” MDPI thoroughly re-investigated the consents obtained by the doctors who authored the paper, as well as US Navy policy around obtaining consents.

Please note that the Naval Medical Center San Diego’s IRB does not consider case reports of less than four patients in a single article to be human subject research and does not require the patients to consent to inclusion in an article. Although the researchers were not required to obtain consent, for two cases, verbal and written consents were obtained. In the third case where anonymity was unlikely to be compromised, no written consent was obtained.

Incidentally, at Dr. Prause’s insistence, after the paper was published, the actions of the Navy co-authors with respect to this paper were thoroughly reviewed in an independent Navy investigation. Result? I have a copy of the official report by a Navy lawyer affirming that the co-authors complied with all the IRB’s rules.

Accordingly, MDPI declined to retract the paper. This was explained to COPE, without further objection from COPE. As long as researchers comply with their institution’s IRB consent rules (which was the case here), there is no problem. Yet Prause continues to claim falsely that this issue was unresolved and that “the patients were not consented” and retraction is appropriate.

Prause also complained to COPE that I had an undisclosed conflict of interest. Background: I disclosed my affiliation with The Reward Foundation in the paper from the start. This is not a conflict of interest. In 2018, the journal issued a correction that changed the language describing my affiliation to make it crystal clear (even to Prause) that no conflict of interest existed. It mentions my book, the fact that my proceeds from the book go to The Reward Foundation, and the fact that my affiliation is an unremunerated position. Prause has continued to claim (falsely) that I have been accepting thousands of pounds from the charity. Proof that she is mistaken is documented elsewhere on this page.

Pre-MDPI history: The Yale Journal of Biology & Medicine, and “Janey Wilson”

The story of Prause’s efforts relating to the paper that was ultimately published as Park et al. actually begins before the involvement of MDPI and Behavioral Sciences. An earlier, much shorter version of the paper, with the same authors and author affiliations as it had when later submitted to Behavioral Sciences, was first submitted to Yale Journal of Biology and Medicine (YJBM). It’s worth reviewing certain conduct in connection with this paper when it was under consideration by YJBM.

One of the 2 reviewers of the paper gave it a scathing review with 70+ criticisms, and it was duly rejected. Around the time that YJBM rejected the paper, a “Janey Wilson” began harassing my book publisher, Commonwealth Publishing, and the registered charity to which I donate my share of my book’s proceeds. (I am the author of Your Brain On Porn: Internet Pornography and the Emerging Science of Addiction.) A detailed account of “Janey’s” extensive, groundless harassment is set forth at the bottom of this page.

Note: The submission to YJBM was the only place my affiliation with the charity, The Reward Foundation (TRF), could be found, as it was nowhere public. In other words, apart from the Board of TRF and myself, only the YJBM editor and its two reviewers knew about this affiliation. And yet, “Janey” claimed to have evidence of this affiliation, and used my affiliation to fabricate various allegations of wrongdoing by TRF and me. She even filed a nuisance report with the Scottish Charity Regulator, to no avail.

Later, Dr. Prause submitted her scathing YJBM review with 70+ criticisms to a regulatory board (as part of an effort to have the published paper retracted), thus confirming she had indeed provided the YJBM with an unfavorable review of the paper. (Further evidence that she was a YJBM reviewer turned up during the Behavioral Sciences submission process, as recounted below.) Incidentally, Prause’s actions are a clear violation of COPE’s rules for peer reviewers (Section 5 of the “Guidelines on Good Publication Practice”), which require reviewers to keep confidential anything they learn through the review process.

YJBM was informed of (1) the harassing behavior engaged in by “Janey,” (2) “Janey’s” possible true identity, and (3) the fact that “Janey” may have violated COPE’s rules for peer reviewers by making public confidential information about me.

The paper was promptly accepted by YJBM…and then not published in that journal after all, due to the journal’s decision that it was too late to make the requested revisions and still meet the print deadline for YJBM’s special “Addiction” issue.

Behavioral Sciences version of Park et al.

A revised and updated version of the paper was then submitted to the journal Behavioral Sciences. After a few rounds of reviews and further restructuring it was accepted as a review of the literature, with case studies. Its final form was quite different from the original YJBM submission.

During this process, the paper was reviewed by no fewer than 6 reviewers. Five passed it, some with some suggested revisions, and one harshly rejected it (guess who?).

Phase one of this process unfolded as follows: The paper was reviewed twice, one of them the harsh rejection, one favorable. Puzzled by the harsh rejection, Behavioral Sciences sent the paper out for review to 2 other reviewers. These reviewers passed the paper. Behavioral Sciences cautiously rejected the paper but allowed the authors to “revise and resubmit.” As part of this process, the authors were given all of the comments by the reviewers (but not their identities). The reviewers’ concerns were thoroughly addressed, point by point (available upon request).

From these comments, it became evident that the “harsh reviewer” of the Behavioral Sciences paper had also reviewed the paper at YJBM. About a third of the 77 points raised did not relate to the Behavioral Sciences submission at all. They referred to material that was only present in the earlier version of the paper, the one that had been submitted to YJBM.

In other words, the harsh reviewer had cut and pasted dozens of criticisms from a review done at another journal (YJBM), which no longer had any relevance to the paper submitted to Behavioral Sciences. This is highly unprofessional. Moreover, Prause eventually revealed herself as the author of these criticisms in her complaint to the regulatory boards (see above), in which she shared her YJBM review of the obsolete version of the paper.

Incidentally, when Prause was asked to review the paper at Behavioral Sciences she apparently did not reveal that she had already reviewed the paper at another journal. It would have been standard reviewer etiquette to reveal the earlier review.

Let me summarize Prause’s multiple objections to our paper. Again, 25 or so of them had nothing whatsoever to do with the Behavioral Sciences paper Prause had been asked by Behavioral Sciences to review. They referred to its first submission at YJBM. This alone should disqualify the entire review from further consideration.

Yet, we carefully combed through each comment looking for any useful insights, and wrote a comprehensive response to all comments for Behavioral Sciences and its editors. Almost all of the remaining 50 critical comments were either scientifically inaccurate, groundless, or were simply false statements. Some were repetitive. Several complained about the presence of quotations from the 3 patients, even though the paper was submitted as “a review with clinical reports.” Some made claims about some of the sources we cited, but the claims were simply not supported by the papers themselves. More than 10 comments insisted that the doctors were not competent to examine their patients for the case studies(!).

In short, while reviewers’ comments always improve any paper to some degree, there really wasn’t the need to “fix” much of the paper itself in light of Prause’s comments. What we did do was strengthen the paper itself with 50 more citations, lest other readers make any of the same errors.

The paper was rewritten and revised. Next, two more reviewers and a supervisory editor reviewed and passed it with various suggestions, including a suggestion to restructure it as a “review with case studies.” Satisfied that all legitimate concerns had been addressed, Behavioral Sciences published the paper.

Retraction efforts

Immediately Prause began demanding that the paper be retracted. Among other efforts, she sent this unprofessional private email message threatening MDPI with bad press if they refused to retract the paper:

“This was filed August 24, 2016. It is now November 12, 2016….. If I do not hear anything within the next two weeks, we will begin by writing the board of that journal with the  facts of the case. Multiple retraction watchdogs are already aware and waiting to hear that retraction is occurring, but will instead publish about the failure to retract if necessary.”

Here’s another of her private threats to MDPI on Mon, Nov 14, 2016:

“Behavioral Sciences is the definition of a predatory journal and was recognized on Beall’s predatory journal list until you threatened him to remove it. The first media coverage  of this should appear late this week in a national outlet. We gave you every chance to retract this fake paper.”

MDPI disagreed with Prause’s concerns or assessment of the paper, and did not retract the it, pending further investigation of her assertions. The saga continues, and a summary of it appears at the very end of this page.

In any event, after her dubious retraction demands, Prause began defaming MDPI (and its journal Behavioral Sciences) as “predatory” on social media.

Prause uses social media to harass MDPI and researchers who publish in MDPI journals

Out of nowhere Prause attacks MDPI in November, 2017, tweeting an article that has nothing to do with MDPI:

MDPI responds:

This causes Prause to go on a Twitter rampage (a few of her tweets below):

 

MDPI responds to Prause:

CEO of MDPI Franck Vazquez, Ph.D, also responds, as does Prause:

Prause keeps going (MDPI ignores her Twitter tagging):

Has Prause been trying to have MDPI thrown out of PubMed and other indices based on her untruths? Three tweets from August, 2016 – just a few weeks after Park et al., 2016 was published:

Second tweet:

Third tweet:

Another tweet from November, 2017 suggesting Prause is still harassing regulatory agencies about MDPI (https://twitter.com/NicoleRPrause/status/935983476775387136):

From a hit piece containing several false statements by Prause: http://www.patheos.com/blogs/mormontherapist/2016/12/op-ed.html. One article referred to is the review by 7 Navy doctors and me, the other is co-authored by other experts, including Todd Love PsyD – whom Prause has also harassed. Again, MDPI was formally exonerated and removed even before Beall took his list down.

Prause has also tried to interfere with other MDPI journal issues by defaming MDPI:

———-

Here are examples of Prause unprofessionally shaming others for collaborating/publishing with/receiving awards from MDPI:

——

———-

——–

Here Prause plays her favorite card – accusing others of misogyny – without a shred of evidence (just as she has done with me and countless others).

More unfounded accusations of misogyny:

Prause falsely claims the Behavioral Sciences paper she attacked was retracted. This is both defamatory and unprofessional.

The Twitter conversation continues:

After a lengthy, thorough, time-consuming investigation, MDPI decided not to retract the paper, and circulated a draft editorial criticizing Prause’s unprofessional behavior. As soon as Prause was informed, she initiated an unprofessional, untruthful email exchange with MDPI, copying various bloggers she hoped would take her word for things and publish defamatory articles. Retraction Watch has already complied with her demand.

May 24-27, 2018 – Prause creates multiple sock-puppets to edit the MDPI Wikipedia page (and is banned for sock-puppetry & defamation)

In an earlier section we recounted Prause’s harassment of MDPI and its journal Behavioral Sciences. We also chronicled Prause’s long history of employing multiple fake usernames on Wikipedia (which violates its rules) to harass many of the individuals or organizations listed on this page. For example:

Prause’s latest Wikipedia barrage occurred from May 24th to the 27th and involved at least 6 fake usernames (called “sock-puppets” in Wikipedia jargon). The following links take you to all the edits by these particular usernames (“user contributions”):

  1. https://en.wikipedia.org/wiki/Special:Contributions/Suuperon
  2. https://en.wikipedia.org/wiki/Special:Contributions/NeuroSex
  3. https://en.wikipedia.org/wiki/Special:Contributions/Defender1984
  4. https://en.wikipedia.org/wiki/Special:Contributions/23.243.51.114
  5. https://en.wikipedia.org/wiki/Special:Contributions/185.51.228.243
  6. https://en.wikipedia.org/wiki/Special:Contributions/209.194.90.6

The first four usernames edited the MDPI Wikipedia page, while 3 of the 6 edited the Nofap Wikipedia page, the Sex Addiction page and the Pornography Addiction page. All 3 pages are obsessions of Prause. Even Wikipedia recognized the usernames as belonging to the same person because all the names were banned for “sock-puppetry.” We can be sure it was Prause editing the MDPI page because:

1) The most recent batch of emails between MDPI and Nicole Prause started on May 22, with MDPI notifying all involved that one minor technical correction and an editorial would be forthcoming. This enraged Prause who responded with a string of demands and threats, followed by false accusations and personal attacks.

2) The edits began with user NeuroSex whose only edit before May 24th was an unsuccessful attempt to have other Wikipedia pages link to the Nicole Prause Wikipedia page (February, 2018). From the NeuroSex talk page:

Welcome to Wikipedia. Although everyone is welcome to contribute constructively to the encyclopedia, your addition of one or more external links to the page Nicole Prause has been reverted.

3) The Wikipedia content revolves around one of Prause’s ongoing obsessions: discrediting and attempting retraction of the paper co-authored by Gary Wilson and US Navy doctors: Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (Park et al., 2016)

4) All the Wikipedia edits mirror concurrent Prause tweets and her emails to MDPI (many of which Wilson has seen).

5) The sock-puppets claimed to possess private MDPI emails – which they wanted to post to the MDPI Wikipedia page. Here’s what NeuroSex said in her comment. (Note: In her concurrent emails to MDPI, Prause cc’d RetractionWatch, apparently to threaten MDPI with public retaliation.):

I have images that verify each of the claims (e.g., email from the publisher, email from the listed editor, etc.). RetractionWatch and other outlets are considering writing reviews of it as well, but I cannot be sure those will materialize. How is best to provide such evidence that verifies the claims? As embedded image? Written elsewhere with images and linked?

Let’s provide a few examples of the “NeuroSex” edits (lies) related to Gary Wilson and to Park et al., 2016 – followed by Wilson’s comments:

NeuroSex edit #1: Gary Wilson was by <ref>{{cite web|title=paid over 9000 pounds|url=https://www.oscr.org.uk/downloadfile.aspx?id=160223&type=5&charityid=SC044948&arid=236451}}</ref> The Reward Foundation to lobby in the US on behalf of anti-pornography state declarations.

Wilson comment: NeuroSex linked to a redacted document, claiming that Gary Wilson was paid 9,000 pounds by Scotish charity The Reward Foundation. Two days earlier Prause falsely claimed to journal publisher MDPI (and others) that, based on the charity’s recent public filing (with a name redacted, as is standard), expense reimbursements paid to a charity officer were in fact paid to Wilson. Prause has not checked her facts, and she is mistaken (again). Wilson has never received any money from The Reward Foundation. Gary Wilson forwarded Prause’s claim to Darryl Mead, Chair of The Reward Foundation. His response is above:

From: Foundation Reward <_____________@gmail.com>
Sent: Thursday, May 24, 2018 8:17 AM
To: gary wilson
Subject: Re: Concerns raised to the attention of COPE by Nicole Prause. Manuscript ID behavsci-133116

Dear Gary:

I have looked into this. Prause said:

 On 22/05/2018 20:48, Nicole Prause wrote:
> It appears Wilson did receive money from The Reward Foundation.  Attached is The Reward Foundation Annual Report. Per item C6 referring to travel that describes Gary Wilson’s travel totaling 9,027 pounds.
>
> I request that any correction include this financial COI, or time be  allotted to properly demonstrate that this was not a financial  conflict of interest.
>
> Nicole Prause, Ph.D. Liberos <http://www.liberoscenter.com>

This is a reference to our 2016-17 Annual Accounts. A version of the accounts with identity redaction was published by the Office of the Scottish Charity Regulator and can be downloaded at https://www.oscr.org.uk/search/charity-details?number=SC044948#results, copy attached. This redaction process is done by OSCR without input from the named charity.

The relevant section with redaction reads as per this screen shot.

The individual referred to in C6 is Darryl Mead, the Chair of the Reward Foundation. I am that person and I made the claim for reimbursement of travel and other costs.

The original document reads as follows:

 

There is no reference to Gary Wilson in any part of the expenditure for the Reward Foundation because there were no payments to him.

With best wishes,

Darryl Mead

In summary, Prause falsely accused Wilson of receiving funds from The Reward Foundation. She then publicized her lie to MDPI, COPE, RetractionWatch, and others, using the redacted document she submitted (just as NeuroSex lied to Wikipedia in her failed attempt to have her related edits accepted).

Update, 6-7-18: For no reason in particular given that I had not posted and no one cited my work or mentioned me, Prause posted a comment on the ICD-11 about Gary Wilson (must create a username to view comments). In this comment Prause repeats the above lie she stated in an email exchange with MDPI, RetractionWatch, and COPE (and on Wikipedia):

Over the next few days Nicole Prause posted 4 more libelous comments on the ICD-11 attacking Gary Wilson and continuing to falsely assert that he is a paid employee of The Reward Foundation. Darryl Mead, the Chair of The Reward Foundation, eventually responded:

As Expected, Prause rsponded with several more lies and personal attacks.

Update, 6-18-18: Prause created another Wikipedia username to edit the MDPI wikipedia page – https://en.wikipedia.org/wiki/Special:Contributions/185.51.228.245 – and added the following:

In 2016, another MDPI journal, Behavioral Sciences, published a review paper claiming pornography caused erectile dysfunction. Six scientists independently contacted MDPI concerned about fraud and other issues in the article, initiating an independent review by the Committee on Publication Ethics (COPE). COPE recommended retracting the article.[31] The listed paper editor, Scott Lane, denied having served as the editor. Thus, the paper appears not to have undergone peer-review. Further, two authors had undisclosed conflicts of interest. Gary Wilson’s association with The Reward Foundation did not properly identify it as an activist, anti-pornography organization. Wilson also had posted extensively in social media that the study was “by the US Navy”, although the original paper stated that it did not reflect the views of the US Navy. The other author, Dr. Andrew Doan, was an ophthalmologist who ran an anti-pornography ministry Real Battlefield Ministries, soliciting donations for their speaking.[32] Further, the Committee on Publication Ethics determined that the cases were not properly, ethically consented for inclusion. MDPI issued a correction for some of these issues,[33] but has refused to post corrections for others to date as described by Retraction Watch.[31]

Several of the above lies debunked:

  1. There were not 6 scientists – only Prause contacted MDPI.
  2. My association with The Reward Foundation was fully disclosed from the beginning. As explained earlier, my affiliation with The Reward Foundation (TRF) was always clearly stated, both in the initial Behavioral Sciences article and in the recent correction (the original PubMed version). The purpose of the newly published correction was to counter Dr. Prause’s incessant defamatory claims that I receive money from TRF, and that I make money from my book (my proceeds for which, in fact, go to the charity)
  3. I posted that the paper involved 7 US Navy doctors. The Navy had no problems with my comments.
  4. Dr. Andrew Doan is both an MD and a PhD (Neuroscience – Johns Hopkins), is the former of Head of “Addictions and Resilience Research” in the Department of Mental Health at the Naval Medical Center. (He has since been transferred and promoted, and has different responsibilities.) Doan has authored multiple papers on behavioral addiction/pathologies relating to technologies (in some cases with a co-author of the paper you have written about here). In short, he is a qualified senior author. Those other papers can be found here: https://www.ncbi.nlm.nih.gov/pubmed/?term=doan+klam. His non-profit, Real Battlefield Ministries (RBM), did not discuss pornography prior to publication of the paper. Even if RBM had presented on pornography it would not have been a conflict of interest.
  5. As described above, COPE’s decision was hypothetical and did not apply to our paper as the US Navy doctors more than complied with their Naval Medical Center – San Diego’s IRB consent rules. The Naval Medical Center San Diego’s IRB policy does not consider case reports of less than four patients in a single article to be human subject research and does not require the patients to consent to inclusion in an article. Although the researchers were not required to obtain consent, for two cases, verbal and written consents were obtained. In the third case where anonymity was unlikely to be compromised, no written consent was obtained. Incidentally, at Dr. Prause’s insistence, after the paper was published, the actions of the Navy co-authors with respect to this paper were thoroughly reviewed in an independent Navy investigation. Result? I have a copy of the official report by a Navy lawyer affirming that the co-authors complied with all the IRB’s rules.

Prause lies about Gary Wilson in emails to MDPI, David Ley, Neuro Skeptic, Adam Marcus of Retraction Watch, and COPE (May, 2018)

In the May, 2018 email exchanges with MDPI & COPE, Prause copied bloggers who are positioned to damage the reputations of MDPI in the media, if they choose. Ley blogs on Psychology Today and has often served as the Mouth of Prause. Neuro Skeptic has a popular blog that disparages legitimate (and sometimes dubious) research. Adam Marcus writes for Retraction Watch. Prause also copied Iratxe Puebla, who works for COPE, an organization that addresses publication ethics. Already, Adam Marcus of Retraction Watch has taken the bait without adequate investigation.

In her defamatory articles, tweets, and Quora posts Prause has knowingly and falsely stated that I (Gary Wilson) claimed to be “professor in biology” “doctor” or a “neuroscientist.” I was an Adjunct Instructor at Southern Oregon University and taught human anatomy, physiology & pathology at other venues. Although careless journalists and websites have assigned me an array of titles in error over the years (including a now-defunct page on a website that pirates many TEDx talks and describes the speakers carelessly without contacting them) I have always stated that I taught anatomy & physiology. I have never said I had a PhD or was a professor. Prause told the same lie to the email recipients:

PRAUSE EMAIL #1 (5-1-2018)

On Tue, May 1, 2018 at 10:11 PM, Nicole Prause >

Additionally, Mr. Wilson is now using this publication to claim to be a doctor online to unsuspecting patients (attached).

NP

Nicole Prause, Ph.D. Liberos LLC: www.liberoscenter.com

Below is the screenshot Prause uses to “prove” that I have misrepresented my credentials (again, this Gary Wilson page no longer exists). Note: Until Prause produced her “proof,” I had never seen this site and had never communicated with its hosts, never uploaded the page in question and never removed it. Thus I certainly never provided a bio, or claims of “professorship.”

I taught at Southern Oregon University on two occasions. I also taught anatomy, physiology and pathology at a number of other schools over a period of two decades, and was certified to teach these subjects by the education departments of both Oregon and California. I do not seek speaking engagements and have never accepted fees for speaking. Moreover, YBOP accepts no ads, and the proceeds from my book go to a registered charity.

On the “about” page the Keynotes.org website said that it is not an agency and that anyone could upload a video and speaker bio: Keynotes.org is not an agency, but rather, a media site…. Keynotes.org is crowdsourced and fueled by TrendHunter.com, the world’s largest trend spotting website. Again, I’ve never uploaded anything to the site, and I have no idea who uploaded this page (or ordered it removed).

Thus, it is even possible that Prause uploaded this page, with my TEDx talk and a purposely inaccurate bio, in order to fabricate her desired “proof” of misrepresentation – and then removed it. After 5 years of continuous harassment and cyber-stalking, faked documents, libelous assertions, hundreds of tweets, and dozens of usernames with hundreds of comments, nothing would surprise us.

The above screen-shot was part of a larger article by Prause where she falsely claimed that I was fired from Southern Oregon University: March, 2018 – Libelous Claim that Gary Wilson Was Fired. In her article, which was posted on a pornography-related site and Quora, Prause published redacted versions of my Southern Oregon University employment records, falsely stating I was fired and had never before taught at SOU. As with her claims surrounding The Reward Foundation, Prause lied about the true content of what’s in the redacted documents. By the way, David Ley also tweeted the Prause article several times, saying I was fired from SOU (screenshots on the page).

In the end, Prause was permanently banned from Quora for harassing me and the porn-blog site removed Prause’s libelous article.

——————

In an email to MDPI, COPE,  Ley, Neuroskeptic, Adam Marcus of Retraction Watch and others Prause falsely claimed that I had received money from The Reward Foundation.

PRAUSE EMAIL #2 (5-22-2018)

Liberos <http://www.liberoscenter.com> On 22/05/2018 20:48, Nicole Prause wrote:

It appears Wilson did receive money from The Reward Foundation. Attached is The Reward Foundation Annual Report. Per item C6 referring to travel that describes Gary Wilson’s travel totaling  9,027 pounds.

I request that any correction include this financial COI, or time be  allotted to properly demonstrate that this was not a financial  conflict of interest.

Nicole Prause, Ph.D. Liberos

Prause has not checked her facts, and she is mistaken. I have never received any money from The Reward Foundation. I forwarded Prause’s claim to Darryl Mead, Chair of The Reward Foundation, who debunked Prause’s claims: See Above For Documentation.

——————

PRAUSE EMAIL #3 (5-22-2018)

In many of her emails to MDPI (and others), Prause mentioned her “77 criticisms” and falsely claimed that they had not been addressed. This was just the latest:

On Tue, May 22, 2018 at 9:36 AM, Nicole Prause>

I provided a 77 point critique prior to publication that was, true to the predatory journal lists MDPI appeared on, was ignored.

Nicole Prause, Ph.D. Liberos LLC: www.liberoscenter.com

This means Prause was one of two reviewers of the Yale Journal of Biology and Medicine submission – and thus “Janey Wilson.” As explained, many of the 77 so-called problems were carelessly copied and pasted from Prause’s review of the YJBM submission; 25 of them had nothing to do with the Behavioral Sciences submission. In other words, the only reviewer to condemn the paper had cut and pasted dozens of criticisms from a review done at another journal (YJBM), which no longer had any relevance to the paper submitted to Behavioral Sciences. This is highly unprofessional.

Even apart from that glaring irregularity, few of the 77 problems could be considered legitimate. Yet, we carefully combed through each comment mining for useful insights, and wrote a comprehensive response to all comments for Behavioral Sciences and its editors. Almost all of the remaining 50 critical comments were either scientifically inaccurate, groundless, or were simply false statements. Some were repetitive. The authors provided MDPI with a point by point response to each so-called problem.


The exploits of “Janey Wilson” (Prause)

See copies of actual emails below this summary.

Shortly after my book was published in 2015, Prause wrote to my publisher for information, using an alias (“Janey Wilson”). Presuming “Janey” was legitimate, Dan Hind of Commonwealth Publishing advised her that my share of book proceeds went to The Reward Foundation, a registered Scottish charity.

“Janey Wilson” immediately informed the charity that Wilson was “falsely holding himself out publicly as being affiliated with The Reward Foundation,” and saying she had proof. The only way she could have “proof” of this not-yet-public affiliation was if she had seen the academic paper I had co-authored. It’s a violation of publication ethics rules to disclose or misuse information learned through the review process.

“Janey’s” information failed to elicit the desired outrage from The Reward Foundation (as I was indeed affiliated with the Foundation, serving in an unremunerated position as “Honorary Science Officer”). Undaunted, “Janey” then reported The Reward Foundation to the Scottish Charity Regulator for imagined financial and other alleged misdeeds.

The charity was so new that no financial filings had been required yet, so it was not even legally possible for the Reward Foundation to have committed the financial reporting transgressions that “Janey” alleged.

Around the time that “Janey” (1) wrote The Reward Foundation to tell it about my “false” claim of affiliation, and (2) reported the charity itself to the Scottish Charity Regulator, “Janey” also wrote the Edinburgh organization where the charity is domiciled with false claims about me and The Reward Foundation (see below). The Edinburgh entity is called “The Melting Pot.” It’s an umbrella organization that hosts various small enterprises. “Janey” apparently simultaneously posted about this on the redddit/pornfree porn recovery forum – Gary Wilson is profiting from YBOP:

The above is hardly surprising as Prause has employed many sock-puppet identities to post, primarily on porn-recovery forums, about Wilson. For exmaple hundreds of comments by Prause’s apparent avatars can be found at the links below. And, they are but an incomplete collection:

Another reddit/pornfree post that appeared about the same time (Prause deleted her sockpuppet’s username, as she often did after posting):

Janey/Prause made the irrational claim that I was “paying off” The Reward Foundation for a TEDx talk opportunity that occurred years earlier, in 2012. It had been arranged in 2011, years before the charity was conceived of or organized. Obviously, no such subterfuge was needed. I had the right to give my book proceeds to anyone at any point, or put them in my pocket. I chose the Reward Foundation because I respect its balanced, educational objective.

Neither organization (the Scottish Charity Regulator nor the Melting Pot) responded to “Janey,” as she offered no evidence, and wouldn’t identify herself, claiming “whistleblower status” (although, of course, she wasn’t an employee of either, and was not under threat). Had the charity not had a strong, respected relationship with the Melting Pot, and had it already been required to file financial statements with the Scottish Charity Regulator, “Janey’s” malicious claims might have done a lot of damage to the charity’s reputation and initiated a time-consuming, costly audit, etc.

In late 2016, Prause outed herself as “Janey Wilson” when she demanded (repeatedly and unsuccessfully) that Dan Hind of Commonwealth Publishing confirm my connection with the Scottish charity called The Reward Foundation to Prause in writing. Copying both MDPI (the ultimate publisher of the paper discussed earlier) and a publication ethics organization (COPE), Prause told Commonwealth’s Hind that he had already written her to this effect.

However, the only correspondence Hind had with anyone on the subject of Wilson and The Reward Foundation was with “Janey,” and he has stated this in writing (below). Thus, Prause has now outed herself as the former “Janey.” When Hind didn’t respond to Prause’s repeated demands, she then demanded the information via Commonwealth’s web designer – accompanied, as usual, by defamation and threat:

You may wish to encourage the site content owner that you designed to clarify that his author was caught claiming to “donate” proceeds  from a book that actually went into his own pocket. Mr. Hind has failed to respond to inquiries with the Committee on Publication Ethics. I assume you would not want your name entangled in fraud like this in any way.

Prause seems to believe that the fact that my share of book proceeds goes to a Scottish registered charity, which I listed as my affiliation for purposes of two academic papers published in 2016, means that I am somehow pocketing the proceeds (from my own book) – and thus have a conflict of interest, which is purportedly grounds, in her mind, for my paper being retracted. Does any of this make any sense in light of the facts?

In fact, I am not on the Board of the charity, and certainly have no say over the book proceeds it receives as a consequence of my irrevocable donation. Incidentally, my affiliation is now public, as it is mentioned in both papers I published in 2016. In short, there is nothing hidden or improper going on, and no conflict of interest whatsoever – despite Prause’s claims behind the scenes and publicly.

Within days of Nicole Prause (as herself) emailing MDPI to demand that they retract Park et al., 2016, Twitter account “pornhelps” attacked Mary Sharpe of The Reward Foundation. In the tweet @pornhelps all but admits she is Prause:

Prause, a Kinsey grad and former academic, calls herself a neuroscientist, and appears to have started college about 15 years earlier. Not long after this revealing tweet “pornhelps” deleted both its Twitter account and website (pornhelps.com) – as it became apparent to others that Prause often tweeted with this account and helped with the website.

The following sections of Prause page provide examples of Prause and “pornhelps” simultaneously attacking and defaming some of Prause’s favorites targets (men who run porn-recovery forums, porn addiction researchers, TIME editor Belinda Luscombe, who wrote a cover story Prause didn’t approve of):

Update: In May, 2018 Prause falsely claimed to journal publisher MDPI (and others) that, based on the charity’s recent public filing (with a name redacted, as is standard), expense reimbursements paid to a charity officer were in fact paid to me. I forwarded Prause’s claim to Darryl Mead, Chair of The Reward Foundation, who debunked Prause’s claims: See Above For Documentation.

———-

A few of the other emails referred in the “Janey” story:

2015

[“Janey’s” exchange with my publisher]

From: Daniel Hind <dcehind@hotmail.com>
Date: Thu, Mar 26, 2015 at 10:15 AM
Subject: RE: Concern about for-profit posing as non-profit at Melting Pot

I was contacted by someone called Janey Wilson on Saturday. The full exchange between us is cut and pasted below. As you can see I told her that the author’s revenues are paid to the Reward Foundation.

I should have checked with you, I guess. I am sorry if I have created unnecessary complications for anyone.

Dan

——————————–

Date: Thu, 26 Mar 2015 16:59:12 +0000
Subject: Fwd: Wilson text
From: thereturnofthepublic@gmail.com
To: dcehind@hotmail.com

———- Forwarded message ———-
From: Dan Hind <thereturnofthepublic@gmail.com>
Date: Tue, Mar 24, 2015 at 9:33 AM
Subject: Re: Wilson text
To: Janey Wilson <janeywilson68@gmail.com>
The Charity Commission is a register of charities in England and Wales. The Reward Foundation is registered in Scotland.

Here is its listing on the Scottish Charity Register –

https://www.oscr.org.uk//charities/search-scottish-charity-register/charity-details?charitynumber=sc044948

In the UK many responsibilities are devolved to the Scottish Parliament, including the registration of charities, it seems.

I hope this clears up any confusion,

Yours sincerely,

Dan Hind

—–

On Tue, Mar 24, 2015 at 7:15 AM, Janey Wilson <janeywilson68@gmail.com> wrote:

Dear Dan Hind,

Thank you for the information. I would not normally check, but I’m glad I did. That organization actually is not registered in the UK:
http://apps.charitycommission.gov.uk/Showcharity/RegisterOfCharities/registerhomepage.aspx

This is the government registry, so I am not sure where else it could be. You might want to alert your author that they might be contributing to a scam. I cannot buy based on this, and I don’t think anyone else should either.

J

——-

On Mon, Mar 23, 2015 at 4:42 AM, Dan Hind <thereturnofthepublic@gmail.com> wrote:

Dear Ms Wilson,

The author’s income supports the Reward Foundation, a registered charity in the UK.

http://www.rewardfoundation.org/

Yours sincerely,

Dan Hind

—-

On Sat, Mar 21, 2015 at 6:17 AM, Janey Wilson <janeywilson68@gmail.com> wrote:

Hi,

I saw the proceeds from this book are all going to research. Which organization is benefiting? I would like to see if I can list it on my taxes as a deduction.

———

[“Janey’s” exchange with The Melting Pot]

On 25 March 2015 at 12:08 Mohammad Abushaaban <_______________@themeltingpotedinburgh.org.uk> wrote:

Mary – hope you are keeping strong.

I’ve received this strangely out of the blue email from a Janey Wilson…

Do you know this person?

Give it a read and let me know your thoughts.

Thanks

Mo.

———- Forwarded message ———-
From: Janey Wilson <janeywilson68@gmail.com>
Date: 25 March 2015 at 04:09
Subject: Concern about for-profit posing as non-profit at Melting Pot
To: ___________@themeltingpotedinburgh.org.uk

Dear Mohammad Abushaaban,

I write out of concern for The Reward Foundation housed at The Melting Pot, which is posing as a non-profit. In 2012, Mary Sharpe was responsible for selecting TEDX speakers in Glasgow. She made the extremely odd decision to have a massage therapist with no neuroscience background, Gary Wilson, rave about the neuroscience of “porn addiction”. The talk was so poor it is currently under investigation for its pseudoscience by TEDX. Now, Mr. Wilson appears to be paying Mary Sharpe for this opportunity.

Specifically, he is selling a book and all the proceeds of the book are said to be going to The Reward Foundation for “research”:

www.therewardfoundation.org
Yet, Mary Sharpe is not a researcher, has no neuroscience background, and the charity lists no way for any real scientist to apply for these funds. The money appears to be going directly in to her pocket, likely in exchange for her earlier TEDX favor. The charity further has chosen not to openly provide links to their financials.

I have filed this complaint with the Scottish Charity Register as well. I suggest you consider investigating how else Ms. Sharpe might be using pseudo-science to fleece concerned individuals. That hardly seems in line with any of the aspirational goals listed on the Melting Pot website.

J

Mohammad Abushaaban, Business Coordinator

Dynamic resources for social change makers
5 Rose Street, Edinburgh, EH2 2PR
Tel: +44 (0)131 243 2626/3

www.TheMeltingPotEdinburgh.org.uk
Company No: SC291663

 

From: Janey Wilson <janeywilson68@gmail.com>
Date: 22 April 2015 at 17:21
Subject: Re: Concern about for-profit posing as non-profit at Melting Pot
To: Mohammad Abushaaban <_________@themeltingpotedinburgh.org.uk>

I now have documentation that Gary Wilson himself is claiming to be a member of the Reward Foundation. While he is not listed on the new website page (http://www.rewardfoundation.org/who-we-are.html), this represents a rather worse transgression. He claims to “donate” the proceeds of his book to research, which is now going to a charity that has no research plans and of which he is a part. Mary Sharpe may not even be aware he is making these claims, I am not sure, but he has now made them publicly.

——–

As explained above, an earlier and substantially different version of the paper I co-authored with 7 US Navy doctors, Park, et al., was first submitted in March, 2015 to the Yale Journal of Biology and Medicine as part of its “Addiction” issue. This paper was the only place my affiliation with the Reward Foundation could be found at the time of “Janey’s” exchanges, as it was nowhere public. So “Janey” had to have seen the paper sent to YJBM for review.

——-

2016

Prause contacting my publisher, Dan Hind, eventually outing herself as “Janey Wilson”

From: Nikky n__________@gmail.com

Sent: 03 November 2016 21:27
To: Dan Hind; dcehind@hotmail.com
Cc: Dr. Franck Vazquez | CEO | MDPI; Iratxe Puebla; behavsci@mdpi.com; Martyn Rittman; Dr. Shu-Kun Lin; Jim Pfaus
Subject: Re: Book financial beneficiary

Mr. Hind,

We already have a previous email from you verifying that Gary Wilson has sent all the proceeds of his book to the organization he actually is employed by, The Reward Foundation. You may choose not to verify this information for the Committee on Publication Ethics, but the previous email can be supplied to them as well.

Your author failed to disclose his financial conflict of interest in numerous publications now to profit himself while claiming to “donate” the proceeds to the public (and to you). This already is public knowledge that you either can be on record to help expose or profiteer, as you please.

NP

Nicole Prause, Ph.D.

Research: www.span-lab.com

Liberos LLC: www.liberoscenter.com

323.919.0783

———————-

Email to Dan Hind’s web designer:

From: Jamie Kendall <____________@jamiekendall.com>
Sent: 04 November 2016 11:32
To: Daniel Hind
Subject: Fwd: Book financial beneficiary

Hi Dan,

Told them I’d forward whatever this is on to you.

Jamie

Jamie Kendall MA (RCA)

www.jamiekendall.com

Begin forwarded message:

From: Nikky <n_____________@gmail.com>

Subject: Fwd: Book financial beneficiary

Date: 3 November 2016 at 21:31:24 GMT

To: __________@jamiekendall.com

Dear Mr. Kendall,

You may wish to encourage the site content owner that you designed to clarify that his author was caught claiming to “donate” proceeds from a book that actually went into his own pocket. Mr. Hind has failed to respond to inquiries with the Committee on Publication Ethics. I assume you would not want your name entangled in fraud like this in any way.

NP
Nicole Prause, Ph.D.
Research: www.span-lab.com
Liberos LLC: www.liberoscenter.com
323.919.0783


Summary:

  1. March, 2015 an earlier version of Park et al. was submitted to the Yale Journal of Biology and Medicine. The submission to YJBM was the only place my affiliation with the charity The Reward Foundation (TRF), could be found, as it was nowhere public.
  2. Between March 21st and April 22nd of 2015, “Janey Wilson” sent several emails to Dan Hind of Commonwealth Publishing, Mohammad Abushaaban of The Melting Pot Edinburgh (which houses The Reward Foundation), and the Scottish Charity Regulator. All contain unsupported claims of wrongdoing. It seemed likely from the content and distinctive style that “Janey” was actually Nicole Prause – which was later confirmed.
  3. The YJBM was informed of the harassing behavior (engaged in by one of their two reviewers posing at “Janey Wilson”). When it was suggested that Dr. Prause might be behind these bizarre emails and the paper’s initial rejection, the paper was promptly accepted…and then not published after all, based on a claim that it was too late to meet the print deadline for the YJBM’s “Addiction” issue.
  4. An updated version of the paper was then submitted to the journal Behavioral Sciences. Four individuals reviewed the paper with 3 accepting and Prause (as we later discovered) rejecting it with her list of “77 problems”.
  5. Many of her 77 so-called problems were carelessly copied and pasted from Prause’s review of the YJBM submission, as 25 of them had nothing to do with the Behavioral Sciences paper.
  6. Few of the 77 problems could be considered legitimate. The authors provided MDPI with a point by point response to each so-called problem.
  7. Park et al. was revised and re-reviewed by two more reviewers.
  8. As soon as Park et al., 2016 was published, Prause began her campaign to have the paper retracted, sending countless of messages to MDPI, COPE, the Navy, the doctors’ medical boards, and my publisher (and possibly PubMed, the FTC and who knows where else).
  9. MDPI offered Prause the opportunity to publish a formal comment on Park et al, in Behavioral Sciences. Prause declined. If the paper were truly inadequate, it would be a simple matter to discredit it with a formal comment.
  10. In late 2016, Prause outed herself as “Janey Wilson” when she demanded (repeatedly and unsuccessfully) that my publisher confirm my connection with the Scottish charity called The Reward Foundation to Prause in writing. Copying both MDPI (the ultimate publisher of the paper mentioned above) and a publication ethics organization, Prause told Commonwealth’s Dan Hind that he had already written her to this effect. Yet he had only corresponded about the connection with “Janey.”
  11. While vicious in her attacks, and often lying about me and the paper’s content, Prause ultimately came up with only 2 issues that COPE would consider (1) Gary Wilson’s unremunerated position with The Reward Foundation, (2) Consents by the three individuals featured in the case studies.
  12. Although I very much sympathize with COPE, and can easily envision the battering their Committee must have endured, in my view, neither is valid reason for retraction or even for a correction (although such superficial corrections are no big deal), as
    1. My unremunerated connection with The Reward Foundation was plainly not a conflict of interest and my affiliation had already been revealed in the original paper, and
    2. The Navy followed its guidelines for consent (which actually don’t require any written consents for case studies with fewer than 4 patients). Even so, in an abundance of physician-ly caution, full written prior consent was obtained for two individuals. For the third, not enough details to require consent were deemed given in the paper. A US Navy investigation confirmed that the doctors complied with all the IRB’s rules.

Even if some might disagree with me, it is evident that neither of these points involves “fraud” or misconduct, as Prause continues to insist.

What’s going on here?

In 2013 former UCLA researcher Nicole Prause began openly harassing, libeling and cyberstalking Gary Wilson. Within a short time she also began targeting others, including researchers, medical doctors, therapists, psychologists, former UCLA colleagues, a UK charity, men in recovery, a TIME magazine editor, several professors, IITAP, SASH, Fight The New Drug, the academic journal Behavioral Sciences, its parent company MDPI, the head of the academic journal CUREUS, and the journal Sexual Addiction & Compulsivity.

While spending her waking hours harassing others, Prause cleverly cultivated – with zero verifiable evidence – a myth that she was “the victim” of most anyone who dared to disagree with her assertions surrounding porn’s effects or the current state of porn research. To counter the ongoing harassment and false claims, YBOP was compelled to document some of Prause behaviors. Consider the following pages. (Additional incidents have occurred that we are not at liberty to divulge – as Prause’s victims fear further retribution.)

In the beginning Prause employed dozens of fake usernames to post on porn recovery forums, Quora, Wikipedia, and in the comment sections under articles. Prause rarely used her real name or her own social media accounts. That all changed after UCLA chose not to renew Prause’s contract (around January, 2015).

Freed from any oversight and now self-employed, Prause put her name to falsehoods, openly cyber-harassing multiple individuals and organizations on social media and elsewhere. Since Prause’s primary target was Gary Wilson (hundreds of social media comments along with behind the scenes email campaigns), it became necessary to monitor and document Prause’s tweets and posts. This was done for her victims’ protection, and crucial for any future legal actions.

It soon became apparent that Prause’s tweets and comments were rarely about sex research, neuroscience, or any other subject related to her claimed expertise. In fact, the vast majority of Prause’s posts could be divided into two overlapping categories:

  1. Defamatory & ad hominem comments targeting individuals and organizations that she labeled as “anti-porn activists” (often claiming to be a victim of these individuals and organizations).
  2. Support of the porn industry:
    • direct support of the FSC (Free Speech Coalition), AVN (Adult Video Network), porn producers, performers, and their agendas
    • countless misrepresentations of the state of pornography research and attacks on porn studies or porn researchers

This page – Is Nicole Prause Influenced by the Porn Industry? – contains a sampling of tweets and comments related to #2 – her vigorous support of the porn industry and its chosen positions. After years of sitting on the evidence, YBOP is of the view that Prause’s unilateral aggression has escalated to such frequent and reckless defamation (accusing her many victims of “physical stalking her,” “misogyny,” “encouraging her to be raped,” and “being neo-nazis”), that we are compelled to examine her possible motives.

She appears to be quite cozy with the pornography industry, as can be seen from this image of her on the red carpet of the Adult Video Network’s awards ceremony. The AVN is a large, influential porn-industry interest group. It also appears that Prause may have obtained porn performers as subjects through another porn industry interest group, the Free Speech Coalition. The FSC subjects were allegedly used in her hired-gun study on the heavily tainted and very commercial “Orgasmic Meditation” scheme. Prause has also made unsupported claims about the results of her studies and her study’s methodologies.

Analysis of “Does exposure to erotica reduce attraction and love for romantic partners in men? Independent replications of Kenrick, Gutierres, and Goldberg (1989) study 2”

COMMENTS: This new study (abstract below) is being touted as a “failed replication” of a highly cited 1989 experiment, thus proving that porn use has little effect of intimate relationships.

First, it’s absurd to claim that experimental studies can demonstrate if porn viewing really causes negative relationship effects.” Experiments where college-aged guys view a few Playboy centerfolds (as in the study) can tell you nothing about the effects of your husband masturbating to hard-core videos clips day after day for years on end.

In reality, every single study involving males has reported that more porn use linked to poorer sexual or relationship satisfaction. In all, nearly 60 studies link porn use to less sexual and relationship satisfaction. Of these 60 relationship studies 7 are longitudinal studies that control for variables or studies where subjects abstain from porn. To date seven longitudinal relationship studies have been published that reveal the real-life consequences of ongoing porn use. All reported that porn use relates to poorer relationship/sexual outcomes:

  1. Adolescents’ Exposure to Sexually Explicit Internet Material and Sexual Satisfaction: A Longitudinal Study (2009).
  2. A Love That Doesn’t Last: Pornography Consumption and Weakened Commitment to One’s Romantic Partner (2012).
  3. Internet pornography and relationship quality: A longitudinal study of within and between partner effects of adjustment, sexual satisfaction and sexually explicit internet material among newly-weds (2015).
  4. Till Porn Do Us Part? Longitudinal Effects of Pornography Use on Divorce, (2016).
  5. Does Viewing Pornography Reduce Marital Quality Over Time? Evidence from Longitudinal Data (2016).
  6. Are Pornography Users More Likely to Experience A Romantic Breakup? Evidence from Longitudinal Data (2017).
  7. Pornography Use and Marital Separation: Evidence from Two-Wave Panel Data (2017).

On to the 2017 study and its easily dismissed results: Does exposure to erotica reduce attraction and love for romantic partners in men? Independent replications of Kenrick, Gutierres, and Goldberg (1989).

The 2017 study attempted to replicate a 1989 study that exposed men and women in committed relationships to erotic images of the opposite sex. The 1989 study found that men who were exposed to the nude Playboy centerfolds rated their partners as less attractive and reported less love for their partner. As the 2017 findings failed to replicate the 1989 findings, we are told that the 1989 study got it wrong, and that porn use cannot diminish love or desire. Whoa! Not so fast.

The replication “failed” because our cultural environment has become “pornified.” The 2017 researchers didn’t recruit 1989 college students who grew up watching MTV after school. Instead their subjects grew up surfing PornHub for gang bang and orgy video clips.

In 1989 how many college students had seen an X-rated video? Not too many. How many 1989 college students spent every masturbation session, from puberty on, masturbating to multiple hard-core clips in one session? None. The reason for the 2017 results is evident: brief exposure to a still image of a Playboy centerfold is a big yawn compared to what college men in 2017 have been watching for years. Even the authors admitted the generational differences with their first caveat:

1) First, it is important to point out that the original study was published in 1989. At the time, exposure to sexual content may not have been as available, whereas today, exposure to nude images is relatively more pervasive, and thus being exposed to a nude centerfold may not be enough to elicit the contrast effect originally reported. Therefore, the results for the current replication studies may differ from the original study due to differences in exposure, access, and even acceptance of erotica then versus now.

In a rare instance of unbiased prose even David Ley felt compelled to point out the obvious:

It may be that the culture, men, and sexuality have substantially changed since 1989. Few adult men these days haven’t seen pornography or nude women—nudity and graphic sexuality are common in popular media, from Game of Thrones to perfume advertisements, and in many states, women are permitted to go topless. So it’s possible that men in the more recent study have learned to integrate the nudity and sexuality they see in porn and everyday media in a manner which doesn’t affect their attraction or love for their partners. Perhaps the men in the 1989 study had been less exposed to sexuality, nudity, and pornography.

Keep in mind that this experiment doesn’t mean internet porn use hasn’t affected men’s attraction for their lovers. It just means that looking at “centerfolds” has no immediate impact these days. Many men report radical increases in attraction to partners after giving up internet porn. And, of course, there is also the longitudinal evidence cited above demonstrating the deleterious effects of porn viewing on relationships.

Finally, it’s important to note that the authors of this paper are colleagues of Taylor Kohut at the University of Western Ontario. This group of researchers, headed by William Fisher, has been publishing questionable studies, which consistently produce results that on the surface appear to counter the vast literature linking porn use to myriad negative outcomes. Moreover, both Kohut and Fisher played big roles in the defeat of Motion 47 in Canada.

Here are two recent studies from Kohut, Fisher and colleagues at Western Ontario that garnered widespread and misleading headlines:

1) Perceived Effects of Pornography on the Couple Relationship: Initial Findings of Open-Ended, Participant-Informed, “Bottom-Up” Research (2017), Taylor Kohut, William A. Fisher, Lorne Campbell

In their 2017 study, Kohut, Fisher and Campbell appear to have skewed the sample to produce the results they were seeking. Whereas most studies show that a tiny minority of porn users’ female partners use porn, in this study 95% of the women used porn on their own (85% of the women had used porn since the beginning of the relationship). Those rates are higher than in college-aged men, and far higher than in any other porn study! In other words, the researchers appear to have skewed their sample to produce the results they were seeking. Reality: Cross-sectional data from the largest US survey (General Social Survey) reported that only 2.6% of women had visited a “pornographic website” in the last month.

In addition, Kohut’s study asked only “open ended” questions where subjects could ramble on about porn. The researchers read the ramblings and decided, after the fact, what answers were “important” (fit their desired narrative?). In other words, the study did not correlate porn use with any objective, scientific variable assessment of sexual or relationship satisfaction (as did the nearly 60 studies that show porn use in linked to negative effects on relationships). Everything reported in the paper was included (or excluded) at the unchallenged discretion of the authors.

2) Critique of “Is Pornography Really about “Making Hate to Women”? Pornography Users Hold More Gender Egalitarian Attitudes Than Nonusers in a Representative American Sample” (2016),

Taylor Kohut co-authors framed egalitarianism as: Support for (1) Abortion, (2) Feminist identification, (3) Women holding positions of power, (4) Belief that family life suffers when the woman has a full-time job, and oddly enough (5) Holding more negative attitudes toward the traditional family. Secular populations, which tend to be more liberal, have far higher rates of porn use than religious populations. By choosing these criteria and ignoring endless other variables, lead author Kohut and his co-authors knew they would end up with porn users scoring higher on this study’s carefully chosen selection of what constitutes “egalitarianism.” Then the authors chose a title that spun it all. In reality, these findings are contradicted by nearly every other published study. (See this list of over 25 studies linking porn use to sexist attitudes, objectification and less egalitarianism.)

Note: This 2018 presentation exposes the truth behind 5 questionable and misleading studies, including the two studies just discussed: Porn Research: Fact or Fiction?


Abstract

Journal of Experimental Social Psychology

Available online 18 November 2016

Rhonda N. Balzarini, ,Kiersten Dobson1, ,Kristi Chin ,Lorne Campbell

http://dx.doi.org/10.1016/j.jesp.2016.11.003

Highlights

  • Three preregistered, high-powered replications of Kenrick et al. (1989)
  • Exposed men and women in committed relationships to opposite sex erotica
  • After exposure assessed ratings of attractiveness and love for partner
  • Effects of original and replication studies were meta-analyzed
  • Across the three studies we did not find support for the original finding.

Kenrick, Gutierres, and Goldberg (1989; Study 2) demonstrated that men, but not women, in committed relationships exposed to erotic images of opposite-sex others reported lower ratings for their partner’s sexual attractiveness (d = 0.91) and less love for their partner (d = 0.69) than men exposed to images of abstract art. This research has implications for understanding the possible effects of erotica on men in relationships, but has not been replicated. We conducted three preregistered, high-powered close replications, and meta-analyzed the effects of the original and replication studies. We did not find support for the original finding that exposure to attractive images of opposite-sex others affects males’ ratings of their partners’ sexual attractiveness or love for their partner.

Keywords Centerfolds; Erotica; Partner attractiveness; Love; Replication; Reproducibility

This research was supported by a grant awarded to Lorne Campbell by the Social Sciences and Humanities Research Council of Canada [grant number 122848].

Critique of “The 2018 Revision to the Process of Care Model for Evaluation of Erectile Dysfunction” (2018)

 

COMMENTS: At first glance this 2018 paper seemed promising as it recommended that pornography use be added as a part of patient evaluation:

As part of the sexual history, information on sexual habits can be useful, both in diagnosing ED and in selecting the optimal treatment. Sexual habits include frequency of intercourse, predictability, timing, masturbation habits, and use of pornography; these are new to the updated model.

However, the next paragraph gives us this garbage:

Pornography use has become common, and clinicians should be aware that its consumption might represent a factor in the ED report. Well-controlled studies on the impact of pornography on ED are lacking, and the available evidence is conflicting.72,73 A recent study indicated that, rather than use itself, the mode in which pornography is used is related to distress and sexual dysfunction.74 Findings indicated that recreational use of pornography can enhance sexual stimulation, but its use in distressed individuals may contribute to sexual dysfunction.74

Citation 72 is an extensive review of the literature surrounding porn-induced sexual dysfunctions – Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016). However, it appears that the authors didn’t read the paper. Had anyone bothered to read the review they would have discovered that:

  1. There are multiple studies linking porn use to sexual problems and decreased sexual arousal (including studies where men healed sexual problems by eliminating porn), and that
  2. Citation 73 (Landripet & Stulhofer, 2015) is not what it appears to be – as it was critiqued in the above review of the literature.

Worse yet, the authors ignored the findings of these 26 studies to cite a very minor result (citation 74). It comes from a study so dubious that it made YBOP’s Questionable & Misleading Studies page: Profiles of Cyberpornography Use and Sexual Well-Being in Adults (2017). This study categorized porn users into 3 distinct groups:

  1. recreational porn users (75.5%),
  2. highly distressed non-compulsive porn users (12.7%),
  3. compulsive porn users (11.8%).

The two main findings:

  • The “highly distressed non-compulsive porn users” reported more sexual dysfunctions than the other two groups.
  • The “compulsive porn users” reported less sexual satisfaction than the other two groups.

Not exactly earth-shaking, but the authors of the current ED study latched onto “highly distressed non-compulsive porn users” finding as if it were enlightening, ignoring all the other 80 studies published on porn use and sexual function, and sexual and relationship satisfaction. They must have scoured the literature to dig up this cherry-picked item.

But the real reason why YBOP critiqued citation 74 is that it committed a fatal mistake: The study used the ASEX to measure sexual function, and not the standard IIEF. The ASEX doesn’t distinguish between sexual functioning during masturbation (typically to internet porn) and partnered sex, while the IIEF is only for sexually active subjects. As today’s porn users who develop sexual dysfunctions typically experience them during partnered sex, this research is basically useless in understanding porn’s effects on sexual function.

Many of the subjects were rating the quality of their orgasms, arousal and erections while masturbating to porn – not while having sex! Again, most have no problems attaining erections or climaxing to screens – whether due to internet porn’s endless novelty and ready availability of more extreme porn online, or due to the fact that today’s heavy porn users have trained (sensitized) their brains to screen-based arousal, not real people.

Additional information provided in the citation 74 study actually supports this hypothesis, as the compulsive porn users were mostly males and avoided partnered sex:

Sexual behaviors reported by these individuals suggest that their pornography use might be framed into a broader pattern of compulsive sexuality that includes avoidance of sexual interactions with a partner.

Moreover, only 38% of the compulsive porn users had partners. (NOTE: this doesn’t mean that 38% had sex with a partner, as a common symptom of porn addiction is choosing porn over partnered sex). In any case, at least 62% of the compulsive subjects were porn addicts who didn’t have sex with real people. This means that the vast majority of the compulsive porn users in this study were assessing their arousal and erections while masturbating to porn, not while having sex with a partner. Thus, dysfunction rates would be expected to be far lower than if the researchers had only asked porn users who could answer about partnered sex.

Measuring sexual performance in solo porn users creates a huge confound, and the authors of citation 74 were mistaken to claim their results bear any relation to sexual dysfunction studies that use the IIEF. The ASEX that they used measures “apples,” while the IIEF measures “oranges.” Only the latter can reveal sexual dysfunctions during partnered sex – which, again, is where the sexual dysfunctions typically arise first in today’s porn users.

Profits and paid consultants: suppressing the link between porn and ED

Pfizer funded this study to publicize its carefully constructed ED narrative, which ignores the evidence that internet porn is likely the chief culprit of ED in men under 40 today. Instead, the authors of the study want us to believe that porn use “only causes sexual problems in distressed individuals.”

Seven of the paper’s eight authors disclose that they have received money from Pfizer, the maker of Viagra. In fact, one of the authors is a full-time employee of Pfizer. Pfizer also funded the study, and funded editorial and medical writing assistance for the paper, so it’s possible the authors did little but collect their consulting fees. [See “Disclosures” below.]

Makers of sexual enhancement drugs like Pfizer don’t want the general public to consider the growing evidence that internet porn use is causing erectile dysfunction. These drugs used to be sold only to men over 40, because ED was so rare in younger men. But now overuse of internet porn is causing ED in younger men at very high rates. Today, these drug manufacturers are making millions from the sale of their drugs to men who could avert ED by avoiding internet porn, or recover by eliminating its use – if they understood the true risk of internet porn use. Drug manufacturers can’t make money from men quitting internet porn.

This is very disturbing. The lead author of this paper, urologist John Mulhall MD, is also the Editor-in-Chief of The Journal of Sexual Medicine. This suggests that Pfizer is strongly influencing the relevant research on ED, and paying experts in the field to legitimize the narrative it has crafted suppressing the link between internet pornography and erectile health.

Moreover, the Journal of Sexual Medicine’s open access journal published this terribly flawed and biased paper, Prause & Pfaus, 2015, which attempted to debunk porn-induced ED. Prause & Pfaus made multiple unsupported claims in their study and while speaking to the press. Jim Pfaus is on the editorial board of the Journal of Sexual Medicine and spends considerable effort attacking the concept of porn-induced sexual dysfunctions. Co-author Nicole Prause is obsessed with debunking PIED, having waged a 3 year war against this academic paper, while simultaneously harassing & libeling young men who have recovered from porn-induced sexual dysfunctions: see documentation – Gabe Deem #1, Gabe Deem #2, Alexander Rhodes #1, Alexander Rhodes #2, Alexander Rhodes #3, Noah Church.).

If Dr. Mulhall and Pfizer genuinely cared about men’s erectile health, they would be funding, performing and publishing studies on the effects of internet porn on ED.


Abstract

John P. Mulhall, MD, Annamaria Giraldi, MD, PhD, Geoff Hackett, MD, Wayne J.G. Hellstrom, MD, Emmanuele A. Jannini, MD, Eusebio Rubio-Aurioles, MD, PhD, Landon Trost, MD, Tarek A. Hassan, MD, MSc

DOI: https://doi.org/10.1016/j.jsxm.2018.06.005

Background

Erectile dysfunction (ED) is a common condition that may affect men of all ages; in 1999, a Process of Care Model was developed to provide clinicians with recommendations regarding the evaluation and management of ED.

Aim

To reflect the evolution of the study of ED since 1999, this update to the process of care model presents health care providers with a tool kit to facilitate patient interactions, comprehensive evaluation, and counseling for ED.

Methods

A cross-disciplinary panel of international experts met to propose updates to the 1999 process of care model from a global perspective. The updated model was designed to be evidence-based, data-driven, and accessible to a wide range of health care providers.

Outcomes

This article summarizes the resulting discussion of the expert meeting and focuses on ED evaluation. The management of ED is discussed in an article by Muhall et al (J Sex Med 2018;15:XXX-XXX).

Results

A comprehensive approach to the evaluation of ED is warranted because ED may involve both psychological and organic components. The updated process of care model for evaluation was divided into core and optional components and now focuses on the combination of first-line pharmacotherapy and counseling in consideration of patient sexual dynamics.

Clinical Implications

Patient evaluation for ED should encompass a variety of aspects, including medical history, sexual history, physical examination, psychological evaluation, laboratory testing, and possibly adjunctive testing.

Strengths & Limitations

This update draws on author expertise and experience to provide multi-faceted guidance for the evaluation of ED in a modern context. Although a limited number of contributors provided input on the update, these experts represent diverse fields that encounter patients with ED. Additionally, no meta-analyses were performed to further support the ED evaluation guidelines presented.

Conclusion

Comprehensive evaluation of ED affords health care providers an opportunity to address medical, psychological/psycho-social, and sexual issues associated with ED, with the ultimate goal being effective management and possibly resolution of ED. While some or all techniques described in the updated model may be needed for each patient, evaluation should in all cases be thorough.

Key Words:Erectile Dysfunction, Diabetes, Cardio-Vascular Disease, Depression, Hypertension

Disclosures:

J. Mulhall is/has been a consultant for Absorption Pharmaceuticals, AMS, Lilly, Meda, Nexmed, Pfizer Inc, and Vivus and has participated in: scientific studies/trials for AMS, Pfizer Inc, and Vivus; other for Alliance for Fertility Preservation and Association of Peyronie’s Disease Advocates. A. Giraldi is/has been a speaker for Pfizer Inc and Eli Lilly. G. Hackett is a speaker for and adviser to Pfizer Inc, Bayer, and Besins. W.J.G. Hellstrom is/has been a paid consultant and/or speaker for Abbvie, Allergan, Boston Scientific, Coloplast, Endo, Lipocine, Menarini, and Pfizer Inc. E.A. Jannini is/has been a paid consultant and/or speaker for Bayer, Ibsa, Menarini, Otsuka, Pfizer Inc, and Shionogi. E. Rubio-Aurioles is a paid consultant to Pfizer Inc. L. Trost has nothing to declare. T.A. Hassan is a full-time employee of Pfizer Inc.

Funding: This study was funded by Pfizer Inc. Editorial and medical writing assistance was provided by Jill E. Kolesar, PhD, of Complete Healthcare Communications LLC (West Chester, PA, USA), a CHC Group company, and was funded by Pfizer Inc.

2017 Process of Care in ED Expert Panel members: Urologists (John P. Mulhall, USA; Landon Trost, USA; Wayne J. G. Hellstrom, USA); Endocrinologist (Emmanuele A. Jannini, Italy); Sexologist and Urologist (Geoff Hackett, UK); Psychiatrist (Annamaria Giraldi, Denmark); Sexologist (Eusebio Rubio-Aurioles, Mexico).

Critique of “Profiles of Cyberpornography Use and Sexual Well-Being in Adult” (2017)

COMMENTS: The present study is a further analysis of an earlier study that has already been critiqued by YBOP: Cyberpornography: Time Use, Perceived Addiction, Sexual Functioning, and Sexual Satisfaction (2016). Both studies involved the same subjects, with the earlier study reporting that greater porn use was related to both less sexual satisfaction and less sexual dysfunction. The new study added a twist by categorizing the porn users into 3 distinct groups:

  1. recreational porn users (75.5%),
  2. highly distressed non-compulsive porn users (12.7%),
  3. compulsive porn users (11.8%).

In line with the earlier study the current study reported that “compulsive porn users” had both less sexual satisfaction and less sexual dysfunction. As explained in the earlier critique, this finding is inconsistent with nearly every other study on compulsive porn users and sex addicts, which generally report less sexual satisfaction and greater sexual dysfunction. How could more porn use be related to both less sexual satisfaction and less sexual dysfunction?

The most probable answer is the same as for the earlier study by the same team of researchers: This study used the ASEX to measure sexual function, and not the standard IIEF. The ASEX doesn’t distinguish between sexual functioning during masturbation (typically to digital porn) and partnered sex, while the IIEF is only for sexually active subjects. As today’s porn users who develop sexual dysfunctions typically experience them during partnered sex, this research is basically useless in understanding porn’s effects on sexual function.

Many of the subjects were rating the quality of their orgasms, arousal and erections while masturbating to porn – not while having sex. Again, most have no problems attaining erections or climaxing to screens – whether due to the endless novelty and ready availability of more extreme porn online, or due to the fact that today’s heavy porn users have trained (sensitized) their brains to screen-based arousal, not real people.

Additional information provided in the current study actually supports this hypothesis as the compulsive porn users were mostly males and avoided partnered sex:

“Sexual behaviors reported by these individuals suggest that their pornography use might be framed into a broader pattern of compulsive sexuality that includes avoidance of sexual interactions with a partner.”

Moreover, only 38% of the compulsive porn users had partners. (NOTE: this doesn’t mean that 38% had sex with a partner, as a common symptom of porn addiction is choosing porn over partnered sex). In any case, at least 62% of the compulsive subjects were porn addicts who didn’t have sex with real people. This means that the vast majority of the compulsive porn users in these two studies were assessing their arousal and erections while masturbating to porn, not while having sex with a partner. Thus, dysfunction rates would be expected to be far lower than if the researchers had only asked porn users who could answer about partnered sex.

Many guys who use porn solo have no idea that they have sexual dysfunctions during partnered sex. Believing they have abnormally high libidos because they are masturbating so frequently, with erections, they are often baffled when they get with a partner and discover that “it doesn’t work right.” Since the advent of streaming internet porn, rates of sexual dysfunctions have jumped in men, and among problematic porn users, rates of sexual dysfunctions (with partners) are as high as 71%! There’s nothing in this paper to suggest that the cause is underlying “compulsivity” that mysteriously drives them away from partners, rather than simply internet porn addiction itself. (Addicts typically prefer their addictive activity or substance to other activities.)

Measuring sexual performance in solo porn users creates a huge confound, and the researchers were mistaken to claim their results bear any relation to sexual dysfunction studies that use the IIEF. The ASEX that they used measures “apples,” while the IIEF measures “oranges.” Only the latter can reveal sexual dysfunctions during partnered sex – which is where the sexual dysfunctions typically arise first in today’s porn users.

Summary: The peculiar results of greater sexual dissatisfaction and yet less sexual dysfunction are almost certainly due to the fact that the researchers used the wrong instrument to measure sexual dysfunction in porn users, and therefore included a lot of subjects who were not having partnered sex. And drew unsupported conclusions as a consequence.


J Sex Med. 2017 Jan;14(1):78-85. doi: 10.1016/j.jsxm.2016.10.016.

Vaillancourt-Morel MP1, Blais-Lecours S2, Labadie C2, Bergeron S3, Sabourin S2, Godbout N4.

DOI: http://dx.doi.org/10.1016/j.jsxm.2016.10.016

Abstract

Introduction

Although findings concerning sexual outcomes associated with cyberpornography use are mixed, viewing explicit sexual content online is becoming a common activity for an increasing number of individuals.

Aim

To investigate heterogeneity in cyberpornography-related sexual outcomes by examining a theoretically and clinically based model suggesting that individuals who spend time viewing online pornography form three distinct profiles (recreational, at-risk, and compulsive) and to examine whether these profiles were associated with sexual well-being, sex, and interpersonal context of pornography use.

Methods

The present cluster-analytic study was conducted using a convenience sample of 830 adults who completed online self-reported measurements of cyberpornography use and sexual well-being, which included sexual satisfaction, compulsivity, avoidance, and dysfunction.

Main Outcomes Measures

Dimensions of cyberpornography use were assessed using the Cyber Pornography Use Inventory. Sexual well-being measurements included the Global Measure of Sexual Satisfaction, the Sexual Compulsivity Scale, the Sexual Avoidance Subscale, and the Arizona Sexual Experiences Scale.

Results

Cluster analyses indicated three distinct profiles: recreational (75.5%), highly distressed non-compulsive (12.7%), and compulsive (11.8%). Recreational users reported higher sexual satisfaction and lower sexual compulsivity, avoidance, and dysfunction, whereas users with a compulsive profile presented lower sexual satisfaction and dysfunction and higher sexual compulsivity and avoidance. Highly distressed less active users were sexually less satisfied and reported less sexual compulsivity and more sexual dysfunction and avoidance. A larger proportion of women and of dyadic users was found among recreational users, whereas solitary users were more likely to be in the highly distressed less active profile and men were more likely to be in the compulsive profile.

Conclusion

This pattern of results confirms the existence of recreational and compulsive profiles but also demonstrates the existence of an important subgroup of not particularly active, yet highly distressed consumers. Cyberpornography users represent a heterogeneous population, in which each subgroup is associated with specific sexual outcomes.

Key Words: Cyberpornography, Profile Analysis, Sexual Compulsion, Sexual Well-Being, Sexual Dysfunction

Critique of “Cyberpornography: Time Use, Perceived Addiction, Sexual Functioning, and Sexual Satisfaction” (2016)

COMMENTS: This study reported two seemingly contradictory findings in regard to porn use:

  1. More time spent viewing porn correlated with lower sexual satisfaction
  2. More time spent viewing porn correlated with less sexual dysfunction

Wouldn’t it make sense for poorer sexual satisfaction to always be related to more sexual dysfunction? How could more porn use be related to both less sexual satisfaction and less sexual dysfunction?

The probable answer: This study used the ASEX to measure sexual function, and not the standard IIEF. The ASEX doesn’t distinguish between sexual functioning during masturbation (typically to digital porn) and partnered sex, while the IIEF is only for sexually active subjects. This means that many of the subjects were rating the quality of their orgasms, arousal and erections while masturbating to porn – not while having sex. In fact, the demographics suggest a good many were answering as if they were masturbating to porn:

  • The average age was 25
  • 90% of the men regularly used porn
  • Only 35% of the subjects were cohabiting (33% were single; 30% were “dating”)

Internet porn users often experience greater sexual arousal and better erections while using porn. Only very rarely do men who develop porn-induced ED lose sexual function during masturbation sessions with digital porn (although amazingly enough, a few do become that dysfunctional). Most users don’t notice their declining sexual dysfunction due to porn use if they are self-pleasuring because most manage to keep clicking to something hotter or more extreme until they can “get the job done.”

It is with partners that digital porn users typically notice their porn-related sexual dysfunctions, and this happens because they have conditioned their sexual response to screens, fetishes, constant seeking and searching, and endless novelty. Not to partnered sex. The ASEX test (that this research team used) won’t pick up partnered-sex dysfunctions – unless the researchers tell them to apply it only to partnered sex. This research team didn’t do that in this study. (We know because we corresponded with an author.)

This also explains the apparent anomaly, namely that these subjects report low “sexual satisfaction” – when also given a questionnaire that did specify partnered sexual activities. Many porn users today can’t have successful sex with partners, or orgasm with partners, or they report feeling “numb dick” with partners – both oral and intercourse (but have no such problems when only using digital porn). Multiple studies link porn use to sexual problems and lower sexual satisfaction. So far 3 of these studies demonstrate porn use is causing sexual dysfunction – as participants eliminated porn use and healed chronic sexual dysfunctions.

———–

Findings relevant to the Grubbs CPUI

This study also found that porn addiction, as measured by the Grubbs’s CPUI, was very strongly related to the amount of porn viewed. Several lay articles about the Joshua Grubbs studies (“perceived addiction studies”) have claimed that the amount of porn use was unrelated to the scores on on the CPUI. This and other claims surrounding the perceived addiction studies have been debunked by this extensive critique.

A little background. In 2010 Grubbs created a questionnaire to assess porn addiction: the CPUI. In 2013 Grubbs published a study claiming that his actual porn addiction questionnaire had been magically transformed into a “perceived porn addiction” questionnaire (much more here). There is no such as a “perceived addiction” test – for any addiction, including porn addiction, and his test was never validated as such. Anyhow, questions 1-6 of the CPUI-9 assess the signs and symptoms common to all addictions, while questions 7-9 (Emotional Distress) assess guilt, shame and remorse. As a result, “actual porn addiction” closely aligns with questions 1-6 (Compulsivity & Access Efforts).

Compulsivity:

  1. I believe I am addicted to Internet pornography.
  2. I feel unable to stop my use of online pornography.
  3. Even when I do not want to view pornography online, I feel drawn to it

Access Efforts:

  1. At times, I try to arrange my schedule so that I will be able to be alone in order to view pornography.
  2. I have refused to go out with friends or attend certain social functions to have the opportunity to view pornography.
  3. I have put off important priorities to view pornography.

Emotional Distress:

  1. I feel ashamed after viewing pornography online.
  2. I feel depressed after viewing pornography online.
  3. I feel sick after viewing pornography online.

The current study found that the amount of porn used was robustly related to questions 1-6, yet not at all related to questions 7-9. This means that the amount of porn used is a very strong factor in the development of a porn addiction. On the other hand, shame and guilt were not associated with porn use, and have nothing to do with porn addiction. In short “perceived addiction” as a concept is unsupported when one looks closely.


LINK TO STUDY

Cyberpsychol Behav Soc Netw. 2016 Nov;19(11):649-655.

Blais-Lecours S1, Vaillancourt-Morel MP1, Sabourin S1, Godbout N2.

Abstract

Using pornography through the Internet is now a common activity even if associated sexual outcomes, including sexual satisfaction, are highly variable. The present study tested a two-step sequential mediation model whereby cyberpornography time use is related to sexual satisfaction through the association with, in a first step, perceived addiction to cyberpornography (i.e., perceived compulsivity, effort to access, and distress toward pornography) and with, in a second step, sexual functioning problems (i.e., sexual dysfunction, compulsion, and avoidance). These differential associations were also examined across gender using model invariance across men and women. A sample of 832 adults from the community completed self-report online questionnaires. Results indicated that 51 percent of women and 90 percent of men reported viewing pornography through the Internet. Path analyses showed indirect complex associations in which cyberpornography time use is associated with sexual dissatisfaction through perceived addiction and sexual functioning problems. These patterns of associations held for both men and women.

FROM FULL STUDY:

First, even when controlling for perceived addiction to cyberpornography and overall sexual functioning, cyberpornography use remained directly associated with sexual dissatisfaction. Even though this negative direct association was of small magnitude, time spent viewing cyberpornography seems to be a robust predictor of lower sexual satisfaction.

http://www.psy-world.com/asex_print.htm

KEYWORDS: addiction; cyberpornography; gender; sexual functioning; sexual satisfaction

PMID: 27831753

DOI: 10.1089/cyber.2016.0364

Debunking Justin Lehmiller’s “Is Erectile Dysfunction Really on the Rise in Young Men” (2018)

Justin Lehmiller, a regular paid contributor to Playboy Magazine, unconvincingly attempts to debunk the well documented rise in youthful erectile dysfunction with this April, 2018 blog post. Since it was published David Ley and Nicole Prause frequently tweet Lehmiller’s blog post as “proof” that youthful ED rates haven’t changed in the last 30 years. According to Ley and Prause this means that porn use cannot cause sexual problems.

It shouldn’t surprise anyone that Lehmiller is a close ally of Nicole Prause, having featured her in at least ten of his blog posts. ­­­These and many other Lehmiller blogs perpetuate the same false narratives: porn use causes no problems and porn addiction/porn-induced sexual dysfunctions do not exist. Before we address Lehmiller’s sleight of hand attempting to make porn-induced sexual dysfunction disappear, let’s examine the evidence.

Historical ED rates

Erectile dysfunction was first assessed in 1940s when the Kinsey report concluded that the prevalence of ED was less than 1% in men younger than 30 years, and less than 3% in those 30–45. While ED studies on young men are relatively sparse, this 2002 meta-analysis of 6 high-quality ED studies reported that 5 of the 6 reported ED rates for men under 40 were approximately 2%. The 6th study reported figures of 7-9%, but the question used could not be compared to assessments used for the 5 other studies, and did not assess chronic erectile dysfunction. The anomalous study asked, “Did you have trouble maintaining or achieving an erection any time in the last year?” (Yet this inconsistent study is the one that Lehmiller irresponsibly uses for comparison.)

At the end of 2006 the world of online porn changed. Free, streaming porn tube sites came online and gained instant popularity. This changed the nature of porn consumption radically. For the first time in history, viewers could click to new material or escalate to more extreme material with ease during a masturbation session without any wait.

Nine studies published since 2010

Nine studies published since 2010 reveal a tremendous rise in erectile dysfunctions. This is documented in this lay article and in this peer-reviewed paper involving 7 US Navy doctors – Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016). In the 9 studies, erectile dysfunction rates for men under 40 ranged from 14% to 37%, while rates for low libido ranged from 16% to 37%. Other than the advent of streaming porn (2006) no variable related to youthful ED has appreciably changed in the last 10-20 years (smoking rates are down, drug use is steady, obesity rates in males 20-40 up only 4% since 1999 – see this study).

The recent jump in sexual problems coincides with the publication of 26 studies linking porn use and “porn addiction” to sexual problems and lower arousal to sexual stimuli. It’s important to note that the first 5 studies in the list demonstrate causation, as participants eliminated porn use and healed chronic sexual dysfunctions. For some reason, Lehmiller failed to acknowledge the existence of any of this research. In addition to the studies listed, this page contains articles and videos by over 120 experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who acknowledge and have successfully treated, porn-induced ED and porn-induced loss of sexual desire.

Sexual dysfunctions or not, porn use doesn’t heat up the bedroom; nearly 60 studies link porn use to less sexual and relationship satisfaction. As far as we know all studies involving males (which is the majority of studies) have reported more porn use linked to poorer sexual or relationship satisfaction. While a handful of published studies correlate greater porn use in females to neutral (or better) sexual satisfaction, the vast majority most have not. See this list of 35 studies involving female subjects reporting negative effects on arousal, sexual satisfaction, and relationships.

Lehmiller’s sleight of hand

Lehmiller carefully selected two mismatched studies, with data separated by 18 years, in an attempt to convince the reader that ED rates have always been around 8% for men under 40:

1) The “way things were study” from 1992 is the one that asked: “Did you have trouble maintaining or achieving an erection any time in the last year?” Rates of yes to this question were between 7-9%.

2) In contrast, this “modern study” with 2010-12 data is the one that asked whether men had trouble getting or keeping an erection for a period of three or more months during the last year.” This study reported the following rates of sexual functioning problems in 16-21 year old males:

  • Lacked interest in having sex: 10.5%
  • Difficulty reaching climax: 8.3%
  • Difficulty achieving or maintaining an erection: 7.8%

Lehmiller “summarized” these findings for the vision-impaired as he tried to mislead them:

Although these data were collected in different Western countries and the question wording differed, it’s striking how similar the figures are considering that the data were collected 20 years apart. This suggests that perhaps rates of ED aren’t on the rise among young men after all.

Sorry Justin, but the questions are not “worded differently”; they are completely different questions. The 1992 study asked whether over the course of the last year at any point you had trouble getting it up. This includes when you were drunk, sick, just wanked three times in a row, experienced performance anxiety, whatever. I’m surprised it’s only 7-9%. In contrast, the 2010 study asked whether you had a persistent problem of erectile dysfunction over a period of three months or more. This was for 16-21 year olds, not men 39 and under!

As one recovery-forum member observed, Justin Lehmiller’s “science analysis” is Buzzfeed level clickbait, not science journalism.

But you may ask: Why are the ED rates about 8% in the 2010-2012 study, yet 14-37% in the 9 other studies published since 2010?

  1. First, 8% isn’t insignificant, as 8% would translate in a 600%-800% increase for men under 40.
  2. Second, it wasn’t men under 40 – it was 16 to 21 year olds, so virtually none of them should have chronic ED. In the 1940s, the Kinsey report concluded that the prevalence of ED was less than 1% in men younger than 30 years,
  3. Third, unlike the other 9 studies that employed anonymous surveys, this study used face to face in-home interviews. (It’s quite possible that adolescents would be less than fully forthcoming under such circumstances.)
  4. The study gathered its data between August, 2010 and September, 2012. Studies reporting a significant rise in under-25 ED first appeared in 2011. More recent studies on 25-and-under sujects report even higher rates (see this 2014 study on Canadian adolescents).
  5. Many of the other studies used the IIEF-5 or IIEF-6, which assess sexual problems on a scale, as opposed to the simple yes or no (in the past 3 months) employed in Lehmiller’s cherry-picked paper.

Two studies using the exact same questionnaire: 2001 vs. 2011

Before leaving this topic, it would be well to look at some of the most irrefutable research that demonstrates a radical rise in ED rates over a decade using very large samples (which increase reliability). All the men were assessed using the same (yes/no) question about ED, as part of the Global Study of Sexual Attitudes and Behavior (GSSAB), administered to 13,618 sexually active men in 29 countries. That occurred in 2001-2002.

A decade later, in 2011, the same “sexual difficulties” (yes/no) question from the GSSAB was administered to 2,737 sexually active men in Croatia, Norway and Portugal. The first group, in 2001-2002, were aged 40-80. The second group, in 2011, were 40 and under.

Based on the findings of prior studies one would predict the older men would have far higher ED scores than the younger men, whose scores should have been negligible. Not so. In just a decade, things had changed radically. The 2001-2002 ED rates for men 40-80 were about 13% in Europe. By 2011, ED rates in Europeans, ages 18-40, ranged from 14-28%!

What changed in men’s sexual environment during this time? Well, major changes were internet penetration and access to porn videos (followed by access to streaming porn in 2006, and then smartphones on which to view it). In the 2011 study on Croatians, Norwegians and Portuguese, the Portuguese had the lowest rates of ED and the Norwegians had the highest. In 2013, internet penetration rates in Portugal were only 67%, compared with 95% in Norway.

In line with clinical, anecdotal, and experimental evidence

The image below appeared in an analysis of ED posts from MedHelp forums. “Nearly 60% of men posting on the forums were under 24 years old. This was a surprising finding for researchers, as erectile dysfunction is generally considered a condition that strikes older men.”

Graph showing age of forum participants seeking help for ED

An Irish Times poll asked thousands of readers about ED, and the number of men 24-34 with issues was 28%:

Click on graphics from 2015 Irish Times poll to see ED rates, which show higher rates in young men than in men 35-49!

Documented recovery stories

About 2,500 self-reports of recovery from ED and other sexual dysfunctions after quitting internet porn can be found on these pages:

Experts, not employed by Playboy, who recognize and treat porn-induced sexual dysfunctions

Justin Lehmiller may be right in step with a few agenda-driven sexologists, but he’s out of step with professionals who treat men. Since YBOP came online in 2011 over 120 sexual experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who acknowledge and treat porn-induced sexual problems have published articles or appeared on radio and TV. Note: Urologists have twice presented evidence of porn-induced sexual dysfunctions at annual conferences of the American Urological Association.

  1. Video of a lecture: Porn-induced ED (parts 1-4) presented at the American Urologic Association Conference, May 6-10, 2016. Urologist Tarek Pacha.
  2. New findings: Study sees link between porn and sexual dysfunction (2017) – Data from an upcoming study, presented at the 2017 American Urological Association Conference.

List of articles, broadcasts, radio shows, and podcasts that involve sexual experts who confirm the existence of porn-induced sexual dysfunctions:

  1. Too Much Internet Porn May Cause Impotence, urology professor Carlo Foresta (2011)
  2. The Young Turks discuss porn-induced ED (2011)
  3. Porning too much? by Robert Taibbi, L.C.S.W. (2012)
  4. Does Porn Contribute to ED? by Tyger Latham, Psy.D. in Therapy Matters (2012)
  5. Urologist Lim Huat Chye:  Pornography can cause erectile dysfunction for young men (2012)
  6. Director of Middlebury College Health Center, Dr. Mark Peluso, sees rise in ED: blames porn (2012)
  7. Sexual Dysfunction: The Escalating Price of Abusing Porn (2012)
  8. “Addicted to Viagra: They should be at their most virile, but a growing number of young men can’t cope without those little blue pills” (2012)
  9. Hardcore corruption of the human hard disk (2012)
  10. The Dr. Oz Show addresses Porn-induced ED (2013)
  11. Erectile dysfunction increases among young men, sex therapist Brandy Engler, PhD (2013)
  12. Internet Porn and Erectile Dysfunction, by Urologist James Elist, F.A.C.S., F.I.C.S. (2013)
  13. How porn is destroying modern sex lives: Feminist writer Naomi Wolf has an unsettling explanation for why Britons are having less sex (2013)
  14. Pornography & Erectile Dysfunction, by Lawrence A. Smiley M.D. (2013)
  15. Urologist Andrew Kramer discusses ED – including porn-induced ED (2013)
  16. Is Porn Destroying Your Sex Life? By Robert Weiss LCSW, CSAT-S (2013)
  17. Too Much Internet Porn: The SADD Effect, by Ian Kerner PhD. (2013)
  18. Solutions for porn-induced erectile dysfunction, by Sudeepta Varma, MD, Psychiatry (2013)
  19. Dr. Rosalyn Dischiavo on porn-induced ED (2013)
  20. Did porn warp me forever? Salon.com (2013)
  21. Radio Show: Young Psychiatrist Discusses His Porn-induced ED (2013)
  22. Video by Medical Doctor: Causes of ED in young men – includes Internet porn (2013)
  23. Chris Kraft, Ph.D. – Johns Hopkins sexologist discusses porn-induced sexual dysfunctions (2013)
  24. Why A Sex Therapist Worries About Teens Viewing Internet Porn, by Dr. Aline Zoldbrod (2013)
  25. Is “Normal” Porn Watching Affecting Your Manhood? by sexologist Maryline Décarie, M.A. (2013)
  26. ‘Porn’ makes men hopeless in bed: Dr Deepak Jumani, Sexologist Dhananjay Gambhire (2013)
  27. Need porn diet for three to five months to get an erection again, Alexandra Katehakis MFT, CSAT-S (2013)
  28. Just Can’t Get It Up: ZDoggMD.com (2013)
  29. Time-out cures man of Internet porn addiction & ED: CBS video, Dr. Elaine Brady (2013)
  30. Seven Sharp with Caroline Cranshaw – The damage caused by internet porn addiction (2013)
  31. Reality is not enough exciting (Swedish), psychiatrist Goran Sedvallson. urologist Stefan Arver, psychotherapist Inger Björklund (2013)
  32. Why porn and masturbation can be too much of a good thing, Dr. Elizabeth Waterman (2013)
  33. Dan Savage answers question about porn-induced ED (12-2013)
  34. Irish Times: ‘I can’t get stimulated unless I watch porn with my girlfriend’ (2016)
  35. Erection problems from too much porn – Swedish (2013)
  36. Internet porn wrecking conjugal ties in India (Porn-induced ED), Dr. Narayana Reddy (2013)
  37. Pornography was the only one who got Donald aroused: Swedish (2013)
  38. Men who watch too much porn can’t get it up, warns Manchester sex therapist (2014)
  39. What causes erectile dysfunction?, Dr. Lohit K, M.D (2014)
  40. Has Porn Ruined Our Sex Lives Forever? The Daily Dose. (2014)
  41. Suffering from ED? This Reason May Surprise You, by Michael S Kaplan, MD (2014)
  42. Is porn addiction on the rise in Bangalore? (2014)
  43. YBOP review of “The New Naked” by urologist Harry Fisch, MD (2014)
  44. Behind the documentary: Porn-Induced Erectile Dysfunction, Global News Canada (2014)
  45. ‘Generation X-Rated’ (Porn-Induced ED) – Urologist Abraham Morgentaler (2014)
  46. Porn-induced erectile dysfunction in healthy young men, Andrew Doan MD, PhD (2014)
  47. Catastrophic effects of adolescent porn addiction. Wrishi Raphael, MD (2014)
  48. Porn causing erectile dysfunction in young men, by Global News Canada (2014)
  49. LIVE BLOG: Porn-induced erectile dysfunction. Dr. Abraham Morgentaler, Gabe Deem (2014)
  50. Watching porn can cause male sexual dysfunction. Urologists David B. Samadi & Muhammed Mirza (2014)
  51. Looking at porn on the internet could ruin your sex life, doctor says. Harry Fisch, MD (2014)
  52. Online Videos Causing IRL Erectile Problems? by Andrew Smiler PhD (2014)
  53. Do You Masturbate Too Much? Urologist Tobias Köhler, Therapist Dan Drake (2014)
  54. How Online Sexual Stimulation Can Lead to In Real Life Sexual Dysfunction, by Jed Diamond PhD (2014)
  55. Too Much Porn Contributing to ED: Urologist Fawad Zafar (2014)
  56. Is Porn Erectile Dysfunction Fact or Fiction? by Kurt Smith, LMFT, LPCC, AFC (2015)
  57. When porn becomes a problem (Irish Times). Sex therapists Trish Murphy, Teresa Bergin, Tony Duffy (2015)
  58. Porn Addiction, Porn Creep and Erectile Dysfunction By Billi Caine, B.Sc Psych, RN (2015)
  59. Online pornography and compulsive masturbation cause impotence in young, Emilio Loiacono MD (2015)
  60. Counsellors battle ‘plague of pornography’, psychologists Seema Hingorrany & Yolande Pereira, paediatrician, Samir Dalwai (2015)
  61. Tinder and the Dawn of the “Dating Apocalypse”, Vanity Fair (2015)
  62. TEDX talk about porn-induced ED & reclaiming one’s sexuality: “How to Become a Sex God” by Gregor Schmidinger (2015)
  63. Torn on porn: A look at addiction & pornography. Dr. Charlotte Loppie, University of Victoria Professor in the School of Public Health (2016)
  64. Nurse wants residents to talk about erectile dysfunction. Lesley Mills, a consultant nurse in sexual dysfunction (2016)
  65. How internet porn is creating a generation of men desensitised to real life sex. Dr Andrew Smiler, Dr Angela Gregory (2016)
  66. BBC: Easy access to online porn is ‘damaging’ men’s health, says NHS therapist. Psychosexual therapist Angela Gregory (2016)
  67. What to Do When You’re Dating a Guy with Problems Below the Belt. Sexologist Emily Morse, Ph.D. (2016)
  68. Non-prescription Viagra has infiltrated the bedrooms of today’s young black men. Urology professor David B. Samadi & Muhammed Mirza, MD founder of ErectileDoctor.com (2016)
  69. The Devastating Consequences of Pornography. Dr. Ursula Ofman (2016)
  70. “Porn addiction could ruin your sex life and here’s why”. Sexual function specialist Anand Patel MD, Sex therapist Janet Eccles, Neuroscientist Dr Nicola Ray (2016)
  71. Podcast: Porn-induced erectile dysfunction (PIED). By world renowned urologist Dudley Danoff & Dr. Diana Wiley (2016)
  72. The REAL reason young men suffer from erectile dysfunction, by Anand Patel, MD (2016)
  73. Turn away! Why pornography can harm your sex life. By urology professor Dr. David Samadi (2016)
  74. Urology Times asks: “What is driving younger men to seek treatment for ED?” Jason Hedges, MD, PhD (2016)
  75. Why Men are quitting Internet Porn (porn-induced ED), Andrew Doan, MD, PhD (2016)
  76. How the proliferation of porn is ruining men’s love lives. By Angela Gregory Lead for Psychosexual Therapy, Chandos Clinic, Nottingham U. Secretary British Society of Sexual Medicine (2016)
  77. A lot of cases relating to erectile dysfunction relate to pornography addiction and use. Zoe Hargreaves, NHS Psychosexual Therapist (2016)
  78. The insidious impact of internet porn. by Rose Laing MD (2016)
  79. Salvaging sex life from erectile dysfunction, Dalal Akoury MD (2016)
  80. Too much porn can lead to ED, Malaysian men warned. Clinical andrologist Dr Mohd Ismail Mohd Tambi (2016)
  81. The black and white of blue films: How porn addiction damages relationships. by Sandip Deshpande, MD (2016)
  82. Private school principals get a lesson in porn. Sexuality educator Liz Walker (2016)
  83. Six Signs that your Partner has a Pornography Addiction & What you can Do. by Diana Baldwin LCSW (2016)
  84. Is Porn Good For Us or Bad For Us? by Philip Zimbardo PhD. (2016)
  85. How Porn is Hijacking the Sex Lives of Our Young Men. by Dr. Barbara Winter (2016)
  86. A shocking new TV show aired last night and it sees young people encouraged to air their sexual problems and woes. Dr. Vena Ramphal (2016)
  87. How To Solve Common Sexual Issues, Because They May Be Mental, Physical, Or Both. Eyal Matsliah author of “Orgasm Unleashed” (2016)
  88. South African therapists and sex educators say interventions are needed to stop today’s youngsters suffering serious health effects later in life due to pornography addiction (2016)
  89. Cybersex Addiction: A Case Study. Dorothy Hayden, LCSW (2016)
  90. How Porn Wrecks Relationships, Barbara Winter, Ph.D. (2016)
  91. Porn Can Help A Relationship, But Proceed With Caution. Amanda Pasciucco LMFT, CST; Wendy Haggerty LMFT, CST (2016)
  92. How Internet Porn Is Making Young Men Impotent. Sex therapist and associate of Impotence Australia, Alinda Small (2016)
  93. Video – Can Porn Induce Erectile Dysfunction and Impotence? by Paul Kattupalli MD (2016)
  94. Video – Guyology founder Melisa Holmes MD talks about how boys develop porn-induced erectile dysfunction with many needing Viagra (2017)
  95. Video: Hormone expert Dr. Kathryn Retzler discusses porn-induced erectile dysfunction (2017)
  96. Video: Porn-Induced Erectile Dysfunction by Brad Salzman, LCSW, CSAT (2017)
  97. Irish children as young as seven are being exposed to porn. Dr Fergal Rooney (2017)
  98. Excessive Porn Consumption Can Cause Erectile Dysfunction – Myth or Truth? by Takeesha Roland-Jenkins, MS (2017)
  99. Here’s how porn is affecting Irish relationships. Sex therapist Teresa Bergin (2017)
  100. Is Technology Ruining Our Brains? (Comedy Central show). Alexandra Katehakis, MFT, CSAT-S, CST-S (2017)
  101. How to educate our youth about pornography addiction and dangers. Psychosexual therapists Nuala Deering & Dr. June Clyne (2017)
  102. Excessive Porn Consumption Can Cause Erectile Dysfunction – Myth or Truth? by Takeesha Roland-Jenkins, MS (2017)
  103. ‘Porn is a public health crisis’: experts call for government inquiry into health effects of porn. Sex therapist Mary Hodson (2017)
  104. Everything You Need To Know About Porn-Induced Erectile Dysfunction. Dr. Ralph Esposito; Elsa Orlandini Psy.D. (2017)
  105. Don’t let erectile dysfunction get you down. Psychotherapist Nuala Deering (2017)
  106. How watching porn can cause erectile dysfunction. Dr Lubda Nadvi (2017)
  107. This Is How Therapists Treat Young Men With “Porn-Induced Erectile Dysfunction”. Sex therapist Alinda Small, clinical sexologist Tanya Koens, psychotherapist Dan Auerbach (2017)
  108. TEDx Talk “Sex, Porn & Manhood” (Professor Warren Binford, 2017)
  109. Online Porn: Fastest growing addiction in the U.S. Sex addiction therapist, Chris Simon (2017)
  110. Can Watching Too Much Porn Affect Your Sex Life? Jenner Bishop, LMFT; Psychotherapist Shirani M. Pathak (2017)
  111. Young people report ‘persistent and distressing’ problems with sex lives: study (2017)
  112. ‘Tidal wave’ of porn addiction as experts warn action is needed to save the next ‘lost generation’. Psychosexual therapist Pauline Brown (2017)
  113. Young men who view more pornography experiencing erectile dysfunction, study says (Sex therapist Dr. Morgan Francis 2017)
  114. Erectile dysfunction pills are now the top party drug for British millennials. Sexual psychotherapist Raymond Francis, (2017)
  115. What You Can Do to Prevent Erectile Dysfunction. Urology professor Aaron Spitz. (2017)
  116. If you’re having problems “getting it up” you are far from alone and plenty of help is out there. Dr Joseph Alukal (2018)
  117. Ministry of Health wants more research into impact of pornography. Sex therapist Jo Robertson (2018)
  118. We need to take ownership of what porn’s doing to NZ kids. Dr Mark Thorpe (2018)
  119. Performance issues in the bedroom are not just an old man’s problem. Sex therapist Aoife Drury (2018)
  120. Porn is a ‘Mean Castration of the Male Population’ – Evgeny Kulgavchuk, a Russian sexologist, psychiatrist and therapist (2018)
  121. Erectile dysfunction: how porn, bike riding, alcohol and ill-health contribute to it, and six ways to maintain peak performance. Urologist Amin Herati (2018)
  122. Hard science: how to make your erection stronger. By Nick Knight, MD (2018)

Research Suggests the Grubbs, Perry, Wilt, Reid Review Is Disingenuous (“Pornography Problems Due to Moral Incongruence: An Integrative Model with a Systematic Review and Meta-Analysis”)

The authors of this review would have readers believe that self-identification as a porn addict is a function of religious shame/moral disapproval about porn. They only reviewed a small number of studies, which rely on the CPUI-9, an instrument developed by co-author Grubbs that produces skewed findings. The co-authors carefully omitted or misrepresented opposing research that has convincingly demonstrated that the studies they relied on in their review are misleading.

It is not “religiousness” or “moral disapproval” that predicts self-perception as a porn addict, as they imply, but rather porn use levels. Let’s look at the opposing evidence more closely.

Porn use levels are by far the strongest predictor of self-perceived porn addiction

The first study is the only study that directly correlated self-identification as a porn addict with hours of use, religiousness and moral disapproval of porn use. Its findings contradict the carefully constructed narrative about “perceived addiction” (that “porn addiction is just religious shame/moral disapproval”) – which is grounded in studies employing the flawed instrument called the CPUI-9. In this study, the strongest correlation with self-perception as an addict was with hours of porn use. Religiousness was irrelevant, and while there was predictably some correlation between self-perception as an addict and moral incongruence regarding porn use, it was roughly half the hours-of-use correlation.

In short, the porn users who thought they were addicted really were using more porn, just as one would expect of compulsive (or addicted) porn users.

To understand how this research undermines all of the CPUI-9 studies, more background is helpful. (A detailed discussion of the CPUI-9 appears at the bottom of this page.) The key insight is that the CPUI-9 includes 3 “guilt and shame/emotional distress” questions not normally found in addiction instrumentswhich skew its results, causing religious porn users to score higher and non-religious users to score lower than subjects do on standard addiction-assessment instruments. By itself this flawed instrument might have done little harm, but its creator then conflated the term “perceived addiction” with the total score on the CPUI-9. Thus, a new, very misleading meme was born, and it was immediately snapped up by anti-porn addiction advocates and plastered all over the media.

The term “perceived pornography addiction” is misleading in the extreme, because it’s just a meaningless score on an instrument that produces skewed results. But people assumed they understood what “perceived addiction” meant. They presumed it meant that the CPUI-9’s creator, Dr. Grubbs, had figured out a way to distinguish actual “addiction” from “belief in addiction.” He hadn’t. He had just given a deceptive label to his “porn use inventory,” the CPUI-9 (its 9 questions are reproduced at the bottom of the page). However, Dr. Grubbs made no effort to correct the misperceptions that rolled out into the media, pushed by anti-porn addiction sexologists and their media chums.

Misled journalists mistakenly summed up CPUI-9 findings as:

  • Believing in porn addiction is the source of your problems, not porn use itself.
  • Religious porn users are not really addicted to porn (even if they score high on the Grubbs CPUI-9) – they just have shame.

Even some sincere clinicians were duped, because some clients really do believe their porn use is more destructive and pathological than their therapists think it is. These therapists assumed the Grubbs test somehow isolated these mistaken clients when it didn’t, and they adopted (and repeated) the new meme uncritically.

As the saying goes, “The only cure for bad science is more science.” Faced with thoughtful skepticism about his assumptions, and the media’s unfounded claims that his CPUI-9 instrument could indeed distinguish “perceived pornography addiction” from genuine problematic porn use, Dr. Grubbs finally did the right thing as a scientist. He pre-registered a study to test his hypotheses/assumptions directly (not using the CPUI-9). Pre-registration is a sound scientific practice that prevents researchers from changing hypotheses after collecting data.

The results of Grubbs’s pre-registered study contradicted both his earlier conclusions and the meme (“porn addiction is just shame”) that the press helped to popularize.

Details: Dr. Grubbs set out to prove that religiosity was indeed the main predictor of “believing yourself addicted to porn.” He and his team of researchers surveyed 3 good-sized, diverse samples (male, female, etc.). He posted the results online, although his team’s paper has not yet been formally published.

As stated, this time he didn’t rely on his CPUI-9 instrument. Instead, the Grubbs team asked 2 direct ‘yes/no’ questions of porn users (“I believe that I am addicted to internet pornography.” “I would call myself an internet pornography addict.”), and compared results with variables such as hours of use, religiousness and scores on a “moral disapproval of porn” questionnaire.

Directly contradicting his earlier claims, Dr. Grubbs and his research team found that believing you are addicted to porn correlates most strongly with daily hours of porn use, not with religiousness. As noted below, some of Dr. Grubbs’s earlier studies also found that hours of use was a stronger predictor of “perceived addiction” (total CPUI-9 score) than religiosity – findings that continually did not make it into the mainstream media (or Dr. Grubbs’s own summaries).

From the new study’s abstract:

In contrast to prior literature indicating that moral incongruence and religiousness are the best predictors of perceived addiction [CPUI-9 total score], results from all three samples indicated that male gender and pornography use behaviors were the most strongly associated with self-identification as a pornography addict.

Being male is also strongly predictive of self-labeling as “addicted.” According to Dr. Grubbs, rates of male porn users who answered “yes” to one of the “addicted” questions ranged from 8-20% in the new study’s samples. These rates are consistent with other 2017 research (19% of college males addicted).

In short, there is widespread distress among some of today’s porn users. High rates of problematic use suggest that the World Health Organization’s proposed diagnosis of “Compulsive sexual behavior disorder” is genuinely needed to insure that problematic porn use is properly studied and those suffering are properly treated.

Based on their results in the new pre-registered study, Dr. Grubbs and his co-authors concluded that, “mental and sexual health professionals should take the concerns of clients identifying as pornography addicts seriously.” (emphasis supplied)

Astonishingly, Grubbs, Perry, Wilt and Reid “review” portrays the CPUI-9-based narrative as alive and well. They ignore the research described above, which totally contradicts their conclusions. The “review” also inadequately describes the significance of Fernandez, Tee & Fernandez, a study that also powerfully undermines the narrative these authors present, as explained in the next section.

A peer-reviewed non-Grubbs study also questioned the CPUI-9’s ability to assess either perceived or actual porn addiction

The above study is not the only ones to cast doubt on Dr. Grubbs’s conclusions and the press about them. In September, 2017, another study came out, which tested one of Dr. Grubbs’s hypotheses: Do Cyber Pornography Use Inventory-9 Scores Reflect Actual Compulsivity in Internet Pornography Use? Exploring the Role of Abstinence Effort.

The researchers measured actual compulsivity by asking participants to abstain from internet porn for 14 days. (Only a handful of studies have asked participants to abstain from porn use, which is one of the most unambiguous ways to reveal its effects.)

Study participants took the CPUI-9 before and after their 14-day attempt at porn abstinence. (Note: They did not abstain from masturbation or sex, only internet porn.) The researchers’ main objective was to compare ‘before’ and ‘after’ scores of the 3 sections of the CPUI-9 to several variables.

Among other findings (discussed in depth here), the inability to control use (failed abstinence attempts) correlated with the CPUI-9’s actual addiction questions 1-6, but not with the CPUI-9’s guilt and shame (emotional distress) questions 7-9. Similarly, “moral disapproval” of pornography use was only slightly related to CPUI-9 “Perceived Compulsivity” scores. These results suggest that the CPUI-9 guilt and shame questions (7-9) shouldn’t be part of a porn addiction (or even “perceived porn addiction”) assessment because they are unrelated to frequency of porn use.

To say it differently, the most addicted subjects did not score higher on religiosity. Moreover, no matter how it is measured, actual porn addiction/compulsivity is strongly correlated with higher levels of porn use, rather than with “emotional distress” questions (guilt and shame).

In summary Dr. Grubbs’s own pre-registered study and the Fernandez studies support the following:

  1. Religiousness does not “cause” porn addiction. Religiosity is not related to believing you are addicted to porn.
  2. The amount of porn viewed is the strongest predictor (by far) of actual porn addiction or belief that someone is addicted to porn.
  3. The “perceived addiction” studies (or any study that uses the CPUI-9) does not, in fact, assess “perceived porn addiction” or “belief in porn addiction” or “self-labeling as an addict,” let alone distinguish “perceived” from actual addiction.

Background about the CPUI-9 – and how it always produces badly skewed results

In the last few years Dr. Joshua Grubbs has authored a series of studies correlating porn users’ religiosity, hours of porn use, moral disapproval, and other variables with scores on his 9-item questionnaire “The Cyber Pornography Use Inventory” (CPUI-9). In an odd decision that has lead to much misunderstanding of his findings, Dr. Grubbs refers to his subjects’ total CPUI-9 score as “perceived pornography addiction.” This gives the false impression that his CPUI-9 instrument somehow indicates the degree to which a subject merely “perceives” he is addicted (rather than being actually addicted). But no instrument can do that, and certainly not this one.

To say it another way, the phrase “perceived pornography addiction” indicates nothing more than a number: the total score on the following 9-item pornography-use questionnaire with its three extraneous questions about guilt and shame. It doesn’t sort the wheat from the chaff in terms of perceived vs. genuine addiction. Nor does the CPUI-9 assess actual porn addiction.

Perceived Compulsivity Section

  1. I believe I am addicted to Internet pornography.
  2. I feel unable to stop my use of online pornography.
  3. Even when I do not want to view pornography online, I feel drawn to it

Access Efforts Section

  1. At times, I try to arrange my schedule so that I will be able to be alone in order to view pornography.
  2. I have refused to go out with friends or attend certain social functions to have the opportunity to view pornography.
  3. I have put off important priorities to view pornography.

Emotional Distress Section

  1. I feel ashamed after viewing pornography online.
  2. I feel depressed after viewing pornography online.
  3. I feel sick after viewing pornography online.

As you can see, the CPUI-9 cannot distinguish between actual porn addiction and “belief” in porn addiction. Subjects never “labeled themselves as porn addicts” in any Grubbs study. They simply answered the 9 questions above, and earned a total score.

What correlations did the Grubbs studies actually report? Total CPUI-9 scores were related to religiosity (as explained above), but also related to “hours of porn viewed per week.” In some Grubbs studies a slightly stronger correlation occurred between religiosity and total CPUI-9 scores (“perceived porn addiction”) in others a stronger correlation occurred with hours of porn use and total CPUI-9 scores (“perceived porn addiction”).

The media ignored the latter findings and grabbed onto the correlation between religiosity and total CPUI-9 scores (now misleadingly labeled “perceived addiction”), and in the process journalists morphed the finding into “religious people only believe they’re addicted to porn.” The media ignored the just-as-strong correlation between CPUI-9 scores and hours of porn use, and pumped out hundreds of inaccurate articles like this blog post by David Ley: Your Belief in Porn Addiction Makes Things Worse: The label of “porn addict” causes depression but porn watching doesn’t. Here is Ley’s inaccurate description of a Grubbs CPUI-9 study:

If someone believed they were a sex addict, this belief predicted downstream psychological suffering, no matter how much, or how little, porn they were actually using.

Removing Ley’s misrepresentations, the above sentence would accurately read: “Higher scores on the CPUI-9 correlated with scores on a psychological distress questionnaire (anxiety, depression, anger).” Which is how it tends to be for any addiction questionnaire. For example, higher scores on an alcohol use questionnaire correlate with higher levels of psychological distress. Big surprise.

The key to all the dubious claims and questionable correlations: the Emotional Distress questions (7-9) cause religious porn users to score much higher and secular porn users to score far lower, as well as creating a strong correlation between “moral disapproval” and total CPUI-9 score (“perceived porn addiction”).

To put it another way, if you use only results from CPUI-9 questions 1-6 (which assess the signs and symptoms of an actual addiction), the correlations dramatically change – and all the dubious articles claiming shame is the “real” cause porn addiction would never have been written.

To look at a few revealing correlations, let’s use data from the 2015 Grubbs paper (“Transgression as Addiction: Religiosity and Moral Disapproval as Predictors of Perceived Addiction to Pornography“). It comprises 3 separate studies and its provocative title suggests that religiosity and moral disapproval “cause” a belief in pornography addiction.

Tips for understanding the numbers in the table: zero means no correlation between two variables; 1.00 means a complete correlation between two variables. The bigger the number the stronger the correlation between the 2 variables.

In this first correlation we see how moral disapproval correlates powerfully with the 3 guilt and shame questions (Emotional Distress), yet weakly with the two other sections that assess actual addiction (questions 1-6). The Emotional Distress questions cause moral disapproval to be the strongest predictor of total CPUI-9 scores (“perceived addiction”).

But if we use only the actual porn addiction questions (1-6), the correlation is pretty weak with Moral Disapproval (in science-speak, Moral Disapproval is a weak predictor of porn addiction).

The second half of the story is how the same 3 Emotional Distress correlate very poorly with levels of porn use, while the actual porn addiction questions (1-6) correlate robustly with porn use levels.

This is how the 3 Emotional Distress questions skew results. They lead to reduced correlations between “hours of porn use” and total CPUI-9 scores (“perceived addiction”). Next, the sum total of all 3 sections of the CPUI-9 test is deceptively re-labeled as “perceived addiction” by Grubbs. Then, at the hands of determined anti-porn-addiction activists, “perceived addiction” morphs into “self identifying as a porn addict.” The activists have pounced on the strong correlation with moral disapproval, which the CPUI-9 always produces, and presto! they now claim that, “a belief in porn addiction is nothing more than shame!”

It’s a house of cards built on 3 guilt and shame question not found in any other addiction assessment, in combination with the misleading term the questionnaire’s creator uses to label his 9 questions (as a measure of “perceived porn addiction”).

The CPUI-9 house of cards came tumbling down with a 2017 study that pretty much invalidates the CPUI-9 as an instrument to assess either “perceived pornography addiction” or actual pornography addiction: Do Cyber Pornography Use Inventory-9 Scores Reflect Actual Compulsivity in Internet Pornography Use? Exploring the Role of Abstinence Effort. It also found that 1/3 of the CPUI-9 questions should be omitted to return valid results related to “moral disapproval,” “religiosity,” and “hours of porn use.” You see all the key excerpts here, but Fernandez et al., 2018 sums things up:

Second, our findings cast doubts on the suitability of the inclusion of the Emotional Distress subscale as part of the CPUI-9. As consistently found across multiple studies (e.g., Grubbs et al., 2015a,c), our findings also showed that frequency of IP use had no relationship with Emotional Distress scores. More importantly, actual compulsivity as conceptualized in the present study (failed abstinence attempts x abstinence effort) had no relationship with Emotional Distress scores.

Emotional Distress scores were significantly predicted by moral disapproval, in line with previous studies which also found a substantial overlap between the two (Grubbs et al., 2015a; Wilt et al., 2016)…. As such, the inclusion of the Emotional Distress subscale as part of the CPUI-9 might skew results in such a way that it inflates the total perceived addiction scores of IP users who morally disapprove of pornography, and deflates the total perceived addiction scores of IP users who have high Perceived Compulsivity scores, but low moral disapproval of pornography.

This may be because the Emotional Distress subscale was based on an original “Guilt” scale which was developed for use particularly with religious populations (Grubbs et al., 2010), and its utility with non-religious populations remains uncertain in light of subsequent findings related to this scale.

Here’s is the core finding: The 3 “Emotional Distress” questions have no place in the CPUI-9, or any porn addiction questionnaire. These guilt and shame questions do not assess distress surrounding addictive porn use or “perception of addiction.” These 3 questions merely artificially inflate total CPUI-9 scores for religious individuals while deflating total CPUI-9 scores for nonreligious porn addicts.

In summary, the conclusions and claims spawned by the CPUI-9 are simply invalid. Joshua Grubbs created a questionnaire that cannot, and was never validated for, sorting “perceived” from actual addiction: the CPUI-9. With zero scientific justification he re-labeled his CPUI-9 as a “perceived pornography addiction” questionnaire.

Because the CPUI-9 included 3 extraneous questions assessing guilt and shame, religious porn users’ CPUI-9 scores tend to be skewed upward. The existence of higher CPUI-9 scores for religious porn users was then fed to the media as a claim that, “religious people falsely believe they are addicted to porn.” This was followed by several studies correlating moral disapproval with CPUI-9 scores. Since religious people as a group score higher on moral disapproval, and (thus) the total CPUI-9, it was pronounced (without actual support) that religious-based moral disapproval is the true cause of pornography addiction. That’s quite a leap, and unjustified as a matter of science.

YouTube presentation exposing the CPUI-9 and the myth of “perceived addiction”: Pornography Addiction and Perceived Addiction 

Debunking “Why Are We Still So Worried About Wat­­ching Porn?” (by Marty Klein, Taylor Kohut, and Nicole Prause)

Introduction

This critique has two parts: Part 1 exposes how Nicole Prause, Marty Klein and Taylor Kohut completely misrepresent their solitary bit of “evidence” to support the article’s core falsehood – that “compulsive pornography viewing” was excluded from the new ICD-11 “Compulsive Sexual Behavior Disorder” diagnosis. Part 2 exposes the startling omissions, false claims, research misrepresentations, and cherry-picked data littering the Prause/Klein/Kohut article. (Note: Most of the article’s cherry-picked data and misrepresentations are recycled from this 2016 Prause “Letter to the editor” that YBOP thoroughly dismantled 2 years ago: Critique of: Letter to the editor “Prause et al. (2015) the latest falsification of addiction predictions”, 2016.)


PART 1: Debunking claim ICD-11 excluded “pornography viewing” from “Compulsive Sexual Behavior Disorder” diagnosis

The deniers of porn addiction are agitated because the latest version of the World Health Organization’s medical diagnostic manual, The International Classification of Diseases (ICD-11), contains a new diagnosis suitable for diagnosing what is commonly referred to as ‘porn addiction’ or ‘sex addiction’. It’s called “Compulsive Sexual Behavior Disorder” (CSBD). Nonetheless, in a bizarre “We lost, but we won” propaganda campaign, the deniers have been pulling out all the stops to spin this new diagnosis as a rejection of both “sex addiction” and “porn addiction.”

Not satisfied with the false narrative claiming a “rejection of addiction,” veteran porn-addiction deniers Nicole Prause, Marty Klein and Taylor Kohut have taken their propaganda to new levels in this July 30, 2018 Slate article: “Why Are We Still So Worried About Wat­­ching Porn?” Without supplying any evidence beyond mere opinions, the Prause/Klein/Kohut triumvirate asserts that WHO has officially excluded pornography viewing from the “Compulsive Sexual Behavior Disorder” diagnosis:

With no support, and zero logic, Prause/Klein/Kohut would have us believe that the most common compulsive sexual behavior – compulsive pornography use – has been axed from the WHO’s new diagnostic manual edition (the ICD-11). The hollowness of the authors’ campaign is apparent for many reasons, some of the most obvious of which are:

  • It is self-evident that the language itself of the CSBD diagnosis applies to those struggling with compulsive pornography use. (See below.)
  • CSBD does not describe (or exclude) any particular sexual activity.
  • Multiple studies show that at least 80% of people with compulsive sexual behaviour (hypersexuality) report compulsive internet pornography use.
  • Most of the recent 40 neuroscience-based studies (on which the WHO relied in its decision to include CSBD) have been done on internet pornography viewers­ – so it is silly to suggest that the WHO intended to exclude pornography viewing but forgot to specify it.

Before we get to a detailed evaluation of the deniers’ remarks, let’s be clear: There is neither proclamation nor vague allusion in any WHO literature that could be interpreted as excluding pornography users. Similarly, no WHO spokesperson has ever hinted that a CSBD diagnosis excludes pornography use. Here’s the CSBD diagnosis in its entirety taken directly from the ICD-11 manual:

Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.

Do you see anything about excluding pornography? What about excluding compulsively visiting prostitutes? Was any particular sexual behavior at all excluded? Of course not. The Prause/Klein/Kohut article cites no official WHO communication, and quotes no WHO spokesperson or working-group member. The article is little more than propaganda peppered with a handful of cherry-picked studies that are either misrepresented or not what they appear to be. (More below.)

If you have any doubts about the true nature of the Prause/Klein/Kohut press campaign, carefully read this responsible article about compulsive sexual behavior disorder (CSBD). Unlike their Slate article, this July 27, 2018 article in “SELF” goes straight to the source. It quotes official WHO spokesperson Christian Lindmeier. Lindmeier is one of only four officials WHO spokespersons listed on this page: Communications contacts in WHO headquarters – and the only WHO spokesperson to have formally commented about CSBD! The SELF article also interviewed Shane Kraus, who was at the center of the ICD-11’s Compulsive Sexual Behavior Disorder (CSBD) working group. Excerpt with Lindmeir quotes makes it clear that WHO did not reject “sex addiction”:

In regards to CSBD, the largest point of contention is whether or not the disorder should be categorized as an addiction. “There is ongoing scientific debate on whether or not the compulsive sexual behavior disorder constitutes the manifestation of a behavioral addiction,” WHO spokesperson Christian Lindmeier tells SELF. “WHO does not use the term sex addiction because we are not taking a position about whether it is physiologically an addiction or not.”

Who are the authors of this article?

Who are the authors of this article?

Before reviewing the details below, it would be well to consider the mouthpieces of the brazen serving of propaganda in Slate. Its authors are not impartial observers. Their pro-porn agenda is plain.

Nicole Prause is a former academic with a long history of harassing authors, researchers, therapists, reporters and others who dare to report evidence of harms from internet porn use. She appears to be quite cozy with the pornography industry, as can be seen from this image of her (far right) on the red carpet of the X-Rated Critics Organization (XRCO) awards ceremony. (According to Wikipedia the XRCO Awards are given by the American X-Rated Critics Organization annually to people working in adult entertainment and it is the only adult industry awards show reserved exclusively for industry members.[1]). It also appears that Prause may have obtained porn performers as subjects through another porn industry interest group, the Free Speech Coalition. The FSC subjects were allegedly used in her hired-gun study on the heavily tainted and very commercial “Orgasmic Meditation” scheme. Prause has also made unsupported claims about the results of her studies and her study’s methodologies. For much more documentation, see: Is Nicole Prause Influenced by the Porn Industry?

Marty Klein once boasted his very own webpage on the AVN’s Hall of Fame in recognition of his pro-porn advocacy serving the porn industry’s interests (since removed).

Taylor Kohut is a Canadian researcher who publishes biased, carefully contrived research such as: “Is Pornography Really about ‘Making Hate to Women’?” which would have gullible readers believe that porn users hold more egalitarian attitudes toward women (they don’t), and “Perceived Effects of Pornography on the Couple Relationship,” which attempts to counter the nearly 60 studies showing that porn use has negative effects on relationships. (Here’s a Vimeo presentation critiquing highly questionable Kohut and Prause studies.) Kohut’s new website and his attempt at fundraising suggest that he just may have an agenda. Kohut’s bias was clearly revealed in a brief written for the Standing Committee on Health Regarding Motion M-47 (Canada). In the brief, as in the Slate article, Kohut and his coauthors were guilty of cherry-picking a few outlying studies while misrepresenting the current state of the research on porn’s effects.

Prause/Klein/Kohut misrepresent their one and only piece of so-called “evidence”

In the following paragraph Prause/Klein/Kohut mislead the reader about “addiction” in diagnostic manuals and lie about their one and only bit of “evidence” for pornography use being excluded from the ICD-11 CSBD diagnosis:

We are also accustomed to the shock when journalists learn that “pornography addiction” is actually not recognized by any national or international diagnostic manual. With the publication of the latest International Classification of Diseases (version 11) in June, the World Health Organization once again decided not to recognize sex-film viewing as a disorder. “Pornography viewing” was considered for inclusion in the “problematic Internet use” category, but WHO decided against its inclusion because of the lack of available evidence for this disorder. (“Based on the limited current data, it would therefore seem premature to include it in the ICD-11,” the organization wrote.) The common American standard, the Diagnostic and Statistical Manual, made the same decision in their latest version as well; there is no listing for porn addiction in DSM-5.

First, neither the ICD-11 nor the APA’s DSM-5 ever uses the word “addiction” to describe an addiction – whether it be gambling addiction, heroin addiction, cigarette addiction, or you name it. Both diagnostic manuals use the word “disorder” instead of “addiction” (i.e. “gambling disorder,” “nicotine use disorder,” and so on). Thus, “sex addiction” and “porn addiction” could never have been rejected, because they were never under formal consideration in the major diagnostic manuals. Put simply, there will never be a “porn addiction” diagnosis, just as there will never be a “meth addiction” diagnosis. Yet individuals with the signs and symptoms of consistent with either a “porn addiction” or a “methamphetamine addiction” can be diagnosed using the ICD-11’s provisions.

Second, the authors’ link goes to a 2014 paper by Jon Grant, Impulse control disorders and “behavioural addictions” in the ICD-11 (2014). Before I expose Nicole Prause’s long standing misuse of the outdated Jon Grant paper, here are the indisputable facts:

(1) The Jon Grant paper is over 4 years old. In fact, 32 of the 39 neurological studies on CSB subjects listed on this page were published since the 2014 Jon Grant paper.

(2) It’s just Grant’s two cents, and not an official position paper by the World Health Organization or the CSBD work-group.

(3) Most importantly, nowhere in the paper does it say that pornography use should be excluded from CSBD. In fact, Grant says the opposite: pornography use on the internet is a form of CSB! The word “pornography” is used only once in paper and here is what Grant has to say about it:

A third key controversy in the field is whether problematic Internet use is an independent disorder. The Working Group noted that this is a heterogeneous condition, and that use of the Internet may in fact constitute a delivery system for various forms of impulse control dysfunction (e.g., pathological game playing or pornography viewing). Importantly, the descriptions of pathological gambling and of compulsive sexual behaviour disorder should note that such behaviours are increasingly seen using Internet forums, either in addition to more traditional settings, or exclusively 22, 23.

There you have it, Prause/Klein/Kohut blatantly misrepresented the only bit of “evidence” they could muster (fact-check Slate?).

However, the misrepresentation of Grant’s 2014 paper, by Prause, has been occurring for at least a year. Prause created the following image, which has been passed around pro-porn propagandists’ social media accounts. It’s a doctored screenshot of the Jon Grant paragraph I excerpted above. Counting on Twitter-induced short attention-spans, the propagandists expect you to read only what’s in the red boxes, hoping you will overlook what the paragraph actually states:

If you fell for the red-box illusion, you misread the above excerpt as:

…pornography viewing… questionable whether there is enough scientific evidence at this time to justify its inclusion as a disorder. Based on the limited current data, it would therefore seem premature to include it in the ICD-11.

Now read the entire paragraph, and you will see that Jon Grant is talking about “Internet gaming disorder,” not pornography. Grant believed it was questionable whether there was enough scientific evidence at that time to justify Internet Gaming Disorder’s inclusion as a disorder. (Incidentally, 4 years later Gaming disorder is in the ICD-11 and the scientific support for it is vast.)

A third key controversy in the field is whether problematic Internet use is an independent disorder. The Working Group noted that this is a heterogeneous condition, and that use of the Internet may in fact constitute a delivery system for various forms of impulse control dysfunction (e.g., pathological game playing or pornography viewing). Importantly, the descriptions of pathological gambling and of compulsive sexual behaviour disorder should note that such behaviours are increasingly seen using Internet forums, either in addition to more traditional settings, or exclusively 22,23. The DSM-5 has included Internet gaming disorder in the section “Conditions for further study”. Although potentially an important behaviour to understand, and one certainly with a high profile in some countries 12, it is questionable whether there is enough scientific evidence at this time to justify its inclusion as a disorder. Based on the limited current data, it would therefore seem premature to include it in the ICD-11.

Without reading only the red squares, the above excerpt reveals that Jon Grant believes that internet pornography viewing can be an impulse control disorder that would fall under the umbrella diagnosis of “Compulsive Sexual Behavior Disorder” (CSBD). This is the exact opposite of the “red square” illusion tweeted by the propagandists.

What is Jon Grant saying 4 years later? Grant was a co-author on this 2018 paper announcing (and agreeing with) the inclusion of CSBD in the upcoming ICD-11: Compulsive sexual behaviour disorder in the ICD‐11. In a second 2018 article, “Compulsive sexual behavior: A nonjudgmental approach,” Grant says that Compulsive Sexual Behavior is also called “sex addiction” or “hypersexuality” (which have always functioned in the peer-reviewed literature as synonymous terms for any compulsive sexual behavior, including compulsive porn use):

Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment.

No wonder the propagandists such as Prause are desperately reaching back 4 years to misrepresent a Jon Grant paper. Grant’s recent 2018 paper states in the very first sentence that CSB is also called sex addiction or hypersexuality!

For an accurate account of the ICD-11, see this recent article by The Society for the Advancement of Sexual Health (SASH): “Compulsive Sexual Behaviour” has been classified by World Health Organization as Mental Health Disorder. It begins with:

Despite a few misleading rumors to the contrary, it is untrue that the WHO has rejected “porn addiction” or “sex addiction”. Compulsive sexual behavior has been called by a variety of names over the years: “hypersexuality”, “porn addiction”, “sex addiction”, “out-of-control sexual behavior” and so forth. In its latest catalogue of diseases the WHO takes a step towards legitimizing the disorder by acknowledging “Compulsive Sexual Behaviour Disorder” (CSBD) as a mental illness. According to WHO expert Geoffrey Reed, the new CSBD diagnosis “lets people know they have “a genuine condition” and can seek treatment.”


PART 2: Exposing false claims, misrepresentations, cherry-picked studies, and egregious omissions

The remainder of the Prause/Klein/Kohut article is devoted to persuading the reader that porn addiction is a myth and that internet porn use causes no problems. In addition, they imply that only the “sex negative” would dare to suggest that porn use could produce negative effects. In this section we furnish relevant Prause/Klein/Kohut excerpts followed by analysis of both the claim and references supplied to support the claim. Where appropriate we provide studies that counter their assertions.

A sample of the article’s numerous omissions:

Before we address each of the article’s major assertions, it’s important to reveal what Prause/Klein/Kohut chose to omit from their magnum opus. The lists of studies contain relevant excerpts and links to the original papers.

  1. Porn addiction? This page lists 40 neuroscience-based studies (MRI, fMRI, EEG, neuropsychological, hormonal). They provide strong support for the addiction model as their findings mirror the neurological findings reported in substance addiction studies.
  2. The real experts’ opinions on porn/sex addiction? This list contains 17 recent literature reviews & commentaries by some of the top neuroscientists in the world. All support the addiction model.
  3. Porn and sexual problems? This list contains 27 studies linking porn use/porn addiction to sexual problems and lower arousal to sexual stimuli. The first 5 studies in the list demonstrate causation, as participants eliminated porn use and healed chronic sexual dysfunctions.
  4. Signs of addiction and escalation to more extreme material? Over 30 studies reporting findings consistent with escalation of porn use (tolerance), habituation to porn, and even withdrawal symptoms (all signs and symptoms associated with addiction).
  5. Porn’s effects on relationships? Almost 60 studies link porn use to less sexual and relationship satisfaction. (As far as we know all studies involving males have reported more porn use linked to poorer sexual or relationship satisfaction.)
  6. Porn use affecting emotional and mental health? Over 55 studies link porn use to poorer mental-emotional health & poorer cognitive outcomes.
  7. Porn use affecting beliefs, attitudes and behaviors? Check out individual studies – over 25 studies link porn use to “un-egalitarian attitudes” toward women and sexist views – or the summary from this 2016 meta-analysis: Media and Sexualization: State of Empirical Research, 1995–2015. Excerpt:

The goal of this review was to synthesize empirical investigations testing effects of media sexualization. The focus was on research published in peer-reviewed, English-language journals between 1995 and 2015. A total of 109 publications that contained 135 studies were reviewed. The findings provided consistent evidence that both laboratory exposure and regular, everyday exposure to this content are directly associated with a range of consequences, including higher levels of body dissatisfaction, greater self-objectification, greater support of sexist beliefs and of adversarial sexual beliefs, and greater tolerance of sexual violence toward women. Moreover, experimental exposure to this content leads both women and men to have a diminished view of women’s competence, morality, and humanity.

  1. What about sexual aggression and porn use? Another meta-analysis: A Meta‐Analysis of Pornography Consumption and Actual Acts of Sexual Aggression in General Population Studies (2015). Excerpt:

22 studies from 7 different countries were analyzed. Consumption was associated with sexual aggression in the United States and internationally, among males and females, and in cross-sectional and longitudinal studies. Associations were stronger for verbal than physical sexual aggression, although both were significant. The general pattern of results suggested that violent content may be an exacerbating factor.

  1. What about the porn use and adolescents? Check out this list of over 200 adolescent studies, or this 2012 review of the research – The Impact of Internet Pornography on Adolescents: A Review of the Research (2012). From conclusion:

Increased access to the Internet by adolescents has created unprecedented opportunities for sexual education, learning, and growth. Conversely, the risk of harm that is evident in the literature has led researchers to investigate adolescent exposure to online pornography in an effort to elucidate these relationships. Collectively, these studies suggest that youth who consume pornography may develop unrealistic sexual values and beliefs. Among the findings, higher levels of permissive sexual attitudes, sexual preoccupation, and earlier sexual experimentation have been correlated with more frequent consumption of pornography…. Nevertheless, consistent findings have emerged linking adolescent use of pornography that depicts violence with increased degrees of sexually aggressive behavior. The literature does indicate some correlation between adolescents’ use of pornography and self-concept. Girls report feeling physically inferior to the women they view in pornographic material, while boys fear they may not be as virile or able to perform as the men in these media. Adolescents also report that their use of pornography decreased as their self-confidence and social development increase. Additionally, research suggests that adolescents who use pornography, especially that found on the Internet, have lower degrees of social integration, increases in conduct problems, higher levels of delinquent behavior, higher incidence of depressive symptoms, and decreased emotional bonding with caregivers.

Prause, Ley and Klein have grossly misrepresented the current state of the research for the last few years. Now, they’ve conveniently bundled all the outlying, cherry-picked studies they regularly cite into this article. We expose the truth below. The relevant Prause/Klein/Kohut excerpts listed here are in the same sequence as in the article.

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EXCERPT #1: Repeat after me: “Neither the DSM-5 nor the ICD-11 recognizes any addiction, only disorders”

SLATE EXCERPT: “We are also accustomed to the shock when journalists learn that “pornography addiction” is actually not recognized by any national or international diagnostic manual.”

Nice try at fooling the readers, but, again, neither the ICD-11 nor the APA’s DSM-5 ever uses the word “addiction” to describe an addiction – whether it be gambling addiction, heroin addiction, cigarette addiction or you name it. Both diagnostic manuals use the word “disorder” instead of “addiction” (i.e. “gambling disorder” “nicotine use disorder”, and so on). Thus, “sex addiction” and “porn addiction” could never have been rejected, because they were never under formal consideration in the major diagnostic manuals. Put simply, there will never be a “porn addiction” diagnosis, just as there will never be a “meth addiction” diagnosis. Yet individuals with the signs and symptoms of consistent with either a “porn addiction” or a “methamphetamine addiction” can be diagnosed using the ICD-11’s provisions.

By recognizing behavioral addictions and creating the umbrella diagnosis for compulsive sexual behaviors, the World Health Organization is coming into alignment with the American Society of Addiction Medicine (ASAM). In August, 2011 America’s top addiction experts at ASAM released their sweeping definition of addiction. From the ASAM press release:

The new definition resulted from an intensive, four‐year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians and leading neuroscience researchers from across the country. … Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what’s going on in the brain.

An ASAM spokesman explained:

The new definition leaves no doubt that all addictions—whether to alcohol, heroin or sex, say—are fundamentally the same. Dr. Raju Haleja, former president of the Canadian Society for Addiction Medicine and the chair of the ASAM committee that crafted the new definition, told The Fix, “We are looking at addiction as one disease, as opposed to those who see them as separate diseases. Addiction is addiction. It