Archive for category: Uncategorized

• Link to the original full paper: “Neuroscience of Internet Pornography Addiction: A Review and Update” (2015)

Excerpt critiquing Prause et al., 2015:

Another EEG study involving three of the same authors was recently published [309]. Unfortunately, this new study suffered from many of the same methodological issues as the prior one [303]. For example, it used a heterogeneous subject pool, the researchers employed screening questionnaires that have not been validated for pathological internet pornography users, and the subjects were not screened for other manifestations of addiction or mood disorders.

In the new study, Prause et al. compared EEG activity of frequent viewers of Internet pornography with that of controls as they viewed both sexual and neutral images [309]. As expected, the LPP amplitude relative to neutral pictures increased for both groups, although the amplitude increase was smaller for the IPA subjects. Expecting a greater amplitude for frequent viewers of Internet pornography, the authors stated, “This pattern appears different from substance addiction models”.

While greater ERP amplitudes in response to addiction cues relative to neutral pictures is seen in substance addiction studies, the current finding is not unexpected, and aligns with the findings of Kühn and Gallinat [263], who found more use correlated with less brain activation in response to sexual images. In the discussion section, the authors cited Kühn and Gallinat and offered habituation as a valid explanation for the lower LPP pattern. A further explanation offered by Kühn and Gallinat, however, is that intense stimulation may have resulted in neuroplastic changes. Specifically, higher pornography use correlated with lower grey matter volume in the dorsal striatum, a region associated sexual arousal and motivation [265].

It’s important to note that the findings of Prause et al. were in the opposite direction of what they expected [309]. One might expect frequent viewers of Internet pornography and controls to have similar LPP amplitudes in response to brief exposure to sexual images if pathological consumption of Internet pornography had no effect. Instead, the unexpected finding of Prause et al. [309] suggests that frequent viewers of Internet pornography experience habituation to still images. One might logically parallel this to tolerance. In today’s world of high-speed Internet access, it is very likely that frequent consumers of Internet pornography users view sexual films and videos as opposed to still clips. Sexual films produce more physiological and subjective arousal than sexual images [310] and viewing sexual films results in less interest and sexual responsiveness to sexual images [311]. Taken together, the Prause et al., and Kühn and Gallinat studies lead to the reasonable conclusion that frequent viewers of internet pornography require greater visual stimulation to evoke brain responses comparable to healthy controls or moderate porn users.

In addition, the statement of Prause et al. [309] that, “These are the first functional physiological data of persons reporting VSS regulation problems” is problematic because it overlooks research published earlier [262,263]. Moreover, it is critical to note that one of the major challenges in assessing brain responses to cues in Internet pornography addicts is that viewing sexual stimuli is the addictive behavior. In contrast, cue-reactivity studies on cocaine addicts utilize pictures related to cocaine use (white lines on a mirror), rather than having subjects actually ingest cocaine. Since the viewing of sexual images and videos is the addictive behavior, future brain activation studies on Internet pornography users must take caution in both experimental design and interpretation of results. For example, in contrast to the one-second exposure to still images used by Prause et al. [309], Voon et al. chose explicit 9-second video clips in their cue reactivity paradigm to more closely match Internet porn stimuli [262]. Unlike the one-second exposure to still images (Prause et al. [309]), exposure to 9-second video clips evoked greater brain activation in heavy viewers of internet pornography than did one-second exposure to still images. It is further concerning that the authors referenced the Kühn and Gallinat study, released at the same time as the Voon study [262], yet they did not acknowledge the Voon et al. study anywhere in their paper despite its critical relevance.

Young men today appear to be experiencing a sharp increase in ED (and other sexual dysfunctions) since the advent of streaming internet. All studies assessing young male sexuality since 2010 report historic levels of erectile dysfunction, and startling rates of a new scourge: low libido.

Erectile dysfunction rates ranged from 14 to 37%, while rates for low libido (hypo-sexuality) ranged from 16% to 37%. One of the most dramatic examples of how younger men are suffering higher rates of ED is from a research survey of male adult film actors published in 2018: 37% of male porn stars, ages 20-29, had moderate to severe erectile dysfunction (the IIEF is the standard urology test for erectile function). Compare the younger porn actors to the older porn actors:

These high rates are a recent phenomenon, but comparing ED rates in men over time can be challenging. Traditionally, ED rates have been negligible in young men, and did not begin to rise sharply until after age 40. For example, here’s a graph from a Dutch study comparing data from prior to 2004.

The next challenge is to understand the extent to which ED rates have risen. This is thorny because ED rates have been measured using various different instruments in the last 25 years. Some researchers asked a single (yes/no) question and requested those with ED to rate its severity. Others use a 5- or 6-question version of a more recent instrument that employs Likert scales. It’s called the IIEF (The International Index of Erectile Function), and is used widely today.

Still other researchers used different questionnaires. In 2019, the BBC did its own survey of over 1000 people 18-25. Twenty percent of porn watchers 18-25 think it has affected their ability to have sex.

Historical ED rates

What about other historical rates of ED in peer-reviewed literature using various instruments? First, here are results from the 2 major cross-sectional studies on ED in sexually active American men. Both predated heavy internet penetration.

1. In the 1940s, 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.
2. A 1999 cross-sectional study (based on data gathered in 1992) published by the Journal of the American Medical Association reported erectile dysfunction rates of only 5%, and low sexual desire in 5%. In that study, the ages of the men surveyed ranged from 18 to 59, so a third of them were over 40, which means the rates for sexually active men under 40 were lower.

In 2002 Dutch researchers did a meta-analysis of 6 high-quality ED studies. All of the studies reviewed from Europe (5) reported ED rates for men under 40 of approximately 2%. The sixth was the one reported immediately above.

Note: Keep in mind that ED rates for all men in every age group are higher than rates for sexually active men. For example, in the 1992 data for sexually active men 18-59, the average ED rate was only 5%. However, the rates for men (both sexually active and not) were 7% in men 18-29, 9% in men 30-39, 11% in men 40-49, and 18% in men 50-59. In order to compare “apples to apples,” we, like most researchers, focus on rates for sexually active men. This unfortunately fails to count ED problems in young men who avoid sex due to porn-induced sexual dysfunctions.

Before we turn back to recent studies, it’s important to understand a bit more about the pathology of erectile dysfunction. ED is usually classified as either psychogenic or organic. Traditionally, psychogenic ED is associated with psychological factors (e.g., depression, stress, or anxiety) while organic ED is attributed to physical conditions (e.g., neurological, hormonal, or anatomical.) The most common diagnosis for guys under 40 is psychogenic ED.

Studies investigating ED risk factors in men under 40 typically fail to find the causes commonly associated with ED in older men, such as smoking, alcoholism, obesity, sedentary life, diabetes, hypertension, cardiovascular disease, and hyperlipidemia. Be very skeptical if you read that the preceding causes of organic ED in older men are also the cause of a sharp rise in youthful ED. It takes years for various lifestyle factors to manifest as vasculogenic or neurogenic ED. Indeed, a 2018 paper that looked at ED risk factors in young men found no differences in the usual ED risk factors between those with ED and those with no problems (average age 32). The only difference was that those with ED had low sexual desire. The researchers didn’t ask about porn use.

Recent studies on young men

Now, we turn to other recent studies on young men (~40 and under). Using the IIEF-5, a 2012 cross-sectional study of Swiss men aged 18-24 found ED rates of 30%, and a 2010 Brazilian study of men 18-40 reported ED rates of 35%. A 2013 Italian study reported one in four patients seeking help for new onset ED were younger than 40. Astonishingly, the rate of severe ED was nearly 10% higher in younger men than in men over 40. The University of Florence urology clinic reported that first time ED patients under 40 comprised about 5% of the total patient population. By 2014-2015 men under 40 seeking help for ED comprised 15% of first time patients. Also, a 2015 paper about 4,211 Italians who sought outpatient help for sexual dysfunction found that compulsive masturbators were younger than the other men and had higher rates of ED (and were likely masturbating to internet porn).

A 2014 study of new diagnoses of ED in active duty servicemen reported that rates had more than doubled between 2004 and 2013. Rates of psychogenic ED increased more than organic ED, and rates of unclassified ED remained relatively stable. A 2014 cross-sectional study of active duty, relatively healthy, male military personnel aged 21-40 found an overall ED rate of 33.2%, using the IIEF-5. About half of them also had PTSD (a known risk factor for ED). In a further military study published in 2015, the researchers found that ED was associated with sexual anxiety and genital self-image, both of which could easily be tied to heavy internet porn use.

Erectile dysfunction has implications for safe condom use. A 2015 study on problematic condom use, which sampled 479 men (mean age 20.43), reported unexplained erection difficulties during condom use in a total of 62% of the young men:13.8% during condom application, 15.7% during penetrative sex, and 32.2% during both. (This was not a cross-sectional study; researchers noted that they over-sampled those with problems.)

The next studies reveal that abnormally low sexual desire is also cropping up in young men.

• A 2014 study on Canadian adolescents reported that 53.5% of males aged 16-21 have symptoms indicative of a sexual problem. Erectile dysfunction was the most common (27%), followed by low sexual desire (24%), and problems with orgasm (11%). The authors were baffled why rates were so high, and were surprised that sexual dysfunction rates for males surpassed females, unlike in earlier published literature.
• The same Canadian researchers published a 2-year longitudinal study in 2016, in which they found that, over several checkpoints during the 2 years, the following percentages of 16-21 year old males reported:
  1. low sexual satisfaction (47.9%)
  2. low desire (46.2%)
  3. problems in erectile function (45.3%)

While females’ sexual problems improved over time the males’ sexual problems did not: “Unlike for male adolescents, we found a clearer picture of improvement over time for female adolescents, suggesting that learning and experience played a role in improving their sexual lives.” And, “The only factor that emerged as a strong predictor was relationship status: Adolescents who were not in a sexual relationship were approximately three times more likely to report a problem in sexual functioning compared to those who were in a sexual relationship.” [All subjects were sexually active, but who would be using the most porn?]

• A 2015 study on Italian high school seniors (18-19) found that 16% of those who use porn more than once per week reported abnormally low sexual desire. Non-porn users reported 0% low sexual desire.
• A 2014 survey of Croatian men under 40 and under reported ED rates of 31% and low sexual desire rates of 37%.

A 2015 study, which asked Canadian men using porn 7 or more hours per week about their sexual functioning, found that 71% had sexual dysfunctions, with 33% reporting difficulty orgasming. Average age 41.5.

This 2018 article about UK a study reported that one in two men in their 30s struggle getting and maintaining an erection!

Together, these studies suggest a recent increase in ED in men ~40 and under, as well as startling rates of anorgasmia and low sexual desire, starting quite young (as does internet porn use).

None of these studies had young men remove porn use to investigate internet porn’s effects on their sexual performance, despite the fact that its use represents a drastic change in men’s sexual environment in the digital age. However, the peer-reviewed evidence supporting internet porn as the culprit in youthful sexual dysfunction continues to accumulate. See this list of 28 studies linking porn use or porn addiction to sexual dysfunctions and lower arousal to sexual stimuli. The first 5 studies in this list demonstrate causation as participants eliminated porn use and healed chronic sexual dysfunctions.

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

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.”

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 3,000 self-reports of recovery from ED and other sexual dysfunctions after quitting internet porn can be found on these pages:

• Rebooting accounts page 1
• Rebooting accounts page 2
• Rebooting accounts page 3
• ED Recovery Stories 1
• ED Recovery Stories 2
• ED Recovery Stories 3
• ED Recovery Stories 4
• ED Recovery Stories 5
• ED Recovery Stories 6
• ED Recovery Stories 7
• ED Recovery Stories 8

Recent peer-reviewed studies assessing young male sexuality

Erectile dysfunction and correlated factors in Brazilian men aged 18-40 years (2010)

• Prevalence of ED in 1,947 men was 35.0% (73.7% mild, 26.3% moderate/complete). Used the IIEF-5.

Sexual dysfunctions among young men: prevalence and associated factors (2012)

• Ages 18-24. Swiss military (mandatory for all Swiss national males). Used the IIEF-5. ED rates of 30%

One patient out of four with newly diagnosed erectile dysfunction is a young man–worrisome picture from the everyday clinical practice (2013)

• New onset ED as the primary disorder was found in 114 (26%) men ≤ 40 years. Almost half of the young men suffered from severe ED, with comparable rates in older patients.

Erectile dysfunction among male active component service members, U.S. Armed Forces, 2004-2013 (2014).

• New diagnoses of ED in active duty servicemen reported that rates had more than doubled between 2004 and 2013.

Prevalence and characteristics of sexual functioning among sexually experienced middle to late adolescents (2014)

• Ages 16-21. Erectile Dysfunction – 27%; Low sexual desire – 24%; Problems with orgasm – 11%. Used the IIEF-5.

Sexual Functioning in Military Personnel: Preliminary Estimates and Predictors (2014)

• Ages 21-40. Used the IIEF-5. ED rates of 33%

Genital Image, Sexual Anxiety, and Erectile Dysfunction Among Young Male Military Personnel (2015)

• Age 40 and under. ED rates of 33%. Used the IIEF-5.

Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men? (2015)

• Europeans, 18–40. A yes/no question from the GSSAB (2011). ED rates ranged from 14%–28%. Low libido rates as high as 37%.

A Longitudinal Study of Problems in Sexual Functioning and Related Sexual Distress Among Middle to Late Adolescents (2016)

• 2-year longitudinal study in which they found that, over several checkpoints during the 2 years, the following percentages of 16-21 year old males: low sexual satisfaction (48%), low desire (46%), problems in erectile function (45%). Used the IIEF-5.

Erectile Dysfunction Among Male Adult Entertainers: A Survey (2018)

• 37% of male porn stars, ages 20-29, had moderate to severe erectile dysfunction. Used the IIEF-5.

Sexual Dysfunction Among Young Men: Overview of Dietary Components Associated With Erectile Dysfunction (2018)

• 24.6% of men ages 18-40 categorized as having ED. Used the IIEF-5.

Studies linking porn use/addiction to sexual problems & lower arousal

In addition to the studies below, this page contains articles and videos by over 130 experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who acknowledge and have successfully treated porn-induced ED and porn-induced loss of sexual desire. The first 6 studies demonstrate causation as participants eliminated porn use and healed chronic sexual dysfunctions:

1) Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016) – An extensive review of the literature related to porn-induced sexual problems. Involving 7 US Navy doctors, the review provides the latest data revealing a tremendous rise in youthful sexual problems. It also reviews the neurological studies related to porn addiction and sexual conditioning via Internet porn. The doctors provide 3 clinical reports of men who developed porn-induced sexual dysfunctions. Two of the three men healed their sexual dysfunctions by eliminating porn use. The third man experienced little improvement as he was unable to abstain from porn use. Excerpt:

Traditional factors that once explained men’s sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brain’s motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography’s unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use.

2) Male masturbation habits and sexual dysfunctions (2016) – It’s by a French psychiatrist who is the current president of the European Federation of Sexology. While the abstract shifts back and forth between Internet pornography use and masturbation, it’s clear that he’s mostly referring to porn-induced sexual dysfunctions (erectile dysfunction and anorgasmia). The paper revolves around his clinical experience with 35 men who developed erectile dysfunction and/or anorgasmia, and his therapeutic approaches to help them. The author states that most of his patients used porn, with several being addicted to porn. The abstract points to internet porn as the primary cause of the problems (keep in mind that masturbation does not cause chronic ED, and it is never given as a cause of ED). 19 of the 35 men saw significant improvements in sexual functioning. The other men either dropped out of treatment or are still trying to recover. Excerpts:

Intro: Harmless and even helpful in his usual form widely practiced, masturbation in its excessive and pre-eminent form, generally associated today to pornographic addiction, is too often overlooked in the clinical assessment of sexual dysfunction it can induce.

Results: Initial results for these patients, after treatment to “unlearn” their masturbatory habits and their often associated addiction to pornography, are encouraging and promising. A reduction in symptoms was obtained in 19 patients out of 35. The dysfunctions regressed and these patients were able to enjoy satisfactory sexual activity.

Conclusion: Addictive masturbation, often accompanied by a dependency on cyber-pornography, has been seen to play a role in the etiology of certain types of erectile dysfunction or coital anejaculation. It is important to systematically identify the presence of these habits rather than conduct a diagnosis by elimination, in order to include habit-breaking deconditioning techniques in managing these dysfunctions.

3) Unusual masturbatory practice as an etiological factor in the diagnosis and treatment of sexual dysfunction in young men (2014) – One of the 4 case studies in this paper reports on a man with porn-induced sexual problems (low libido, fetishes, anorgasmia). The sexual intervention called for a 6-week abstinence from porn and masturbation. After 8 months the man reported increased sexual desire, successful sex and orgasm, and enjoying “good sexual practices. This is the first peer-reviewed chronicling of a recovery from porn-induced sexual dysfunctions. Excerpts from the paper:

“When asked about masturbatory practices, he reported that in the past he had been masturbating vigorously and rapidly while watching pornography since adolescence. The pornography originally consisted mainly of zoophilia, and bondage, domination, sadism, and masochism, but he eventually got habituated to these materials and needed more hardcore pornography scenes, including transgender sex, orgies, and violent sex. He used to buy illegal pornographic movies on violent sex acts and rape and visualized those scenes in his imagination to function sexually with women. He gradually lost his desire and his ability to fantasize and decreased his masturbation frequency.”

In conjunction with weekly sessions with a sex therapist, the patient was instructed to avoid any exposure to sexually explicit material, including videos, newspapers, books, and internet pornography.

After 8 months, the patient reported experiencing successful orgasm and ejaculation. He renewed his relationship with that woman, and they gradually succeeded in enjoying good sexual practices.

4) How difficult is it to treat delayed ejaculation within a short-term psychosexual model? A case study comparison (2017) – A report on two “composite cases” illustrating the causes and treatments for delayed ejaculation (anorgasmia). “Patient B” represented several young men treated by the therapist. Interestingly, the paper states that Patient B’s “porn use had escalated into harder material”, “as is often the case”. The paper says that porn-related delayed ejaculation is not uncommon, and on the rise. The author calls for more research on porn’s effects of sexual functioning. Patient B’s delayed ejaculation was healed after 10 weeks of no porn. Excerpts:

The cases are composite cases taken from my work within the National Health Service in Croydon University Hospital, London. With the latter case (Patient B), it is important to note that the presentation reflects a number of young males who have been referred by their GPs with a similar diagnosis. Patient B is a 19-year-old who presented because he was unable to ejaculate via penetration. When he was 13, he was regularly accessing pornography sites either on his own through internet searches or via links that his friends sent him. He began masturbating every night while searching his phone for image…If he did not masturbate he was unable to sleep. The pornography he was using had escalated, as is often the case (see Hudson-Allez, 2010), into harder material (nothing illegal)…

Patient B was exposed to sexual imagery via pornography from the age of 12 and the pornography he was using had escalated to bondage and dominance by the age of 15.

We agreed that he would no longer use pornography to masturbate. This meant leaving his phone in a different room at night. We agreed that he would masturbate in a different way….

Patient B was able to achieve orgasm via penetration by the fifth session; the sessions are offered fortnightly in Croydon University Hospital so session five equates to approximately 10 weeks from consultation. He was happy and greatly relieved. In a three-month follow-up with Patient B, things were still going well.

Patient B is not an isolated case within the National Health Service (NHS) and in fact young men in general accessing psychosexual therapy, without their partners, speaks in itself to the stirrings of change.

This article therefore supports previous research that has linked masturbation style to sexual dysfunction and pornography to masturbation style. The article concludes by suggesting that the successes of psychosexual therapists in working with DE are rarely recorded in the academic literature, which has allowed the view of DE as a difficult disorder to treat remain largely unchallenged. The article calls for research into pornography usage and its effect on masturbation and genital desensitisation.

5) Situational Psychogenic Anejaculation: A Case Study (2014) – The details reveal a case of porn-induced anejaculation. The husband’s only sexual experience prior to marriage was frequent masturbation to pornography – where he was able to ejaculate. He also reported sexual intercourse as less arousing than masturbation to porn. The key piece of information is that “re-training” and psychotherapy failed to heal his anejaculation. When those interventions failed, therapists suggested a complete ban on masturbation to porn. Eventually this ban resulted in successful sexual intercourse and ejaculation with a partner for the first time in his life. A few excerpts:

A is a 33-year-old married male with heterosexual orientation, a professional from a middle socio-economic urban background. He has had no premarital sexual contacts. He watched pornography and masturbated frequently. His knowledge about sex and sexuality was adequate. Following his marriage, Mr. A described his libido as initially normal, but later reduced secondary to his ejaculatory difficulties. Despite thrusting movements for 30-45 minutes, he had never been able to ejaculate or achieve orgasm during penetrative sex with his wife.

What didn’t work:

Mr. A’s medications were rationalized; clomipramine and bupropion were discontinued, and sertraline was maintained at a dose of 150 mg per day. Therapy sessions with the couple were held weekly for the initial few months, following which they were spaced to fortnightly and later monthly. Specific suggestions including focusing on sexual sensations and concentrating on the sexual experience rather than ejaculation were used to help reduce performance anxiety and spectatoring. Since problems persisted despite these interventions, intensive sex therapy was considered.

Eventually they instituted a complete ban on masturbation (which means he continued to masturbate to porn during the above failed interventions):

A ban on any form of sexual activity was suggested. Progressive sensate focus exercises (initially non-genital and later genital) were initiated. Mr. A described an inability to experience the same degree of stimulation during penetrative sex as compared to that which he experienced during masturbation. Once the ban on masturbation was enforced, he reported an increased desire for sexual activity with his partner.

After an unspecified amount of time, the ban on masturbation to porn lead to success:

Meanwhile, Mr. A and his wife decided to go ahead with Assisted Reproductive Techniques (ART) and underwent two cycles of intrauterine insemination. During a practice session, Mr. A ejaculated for the first time, following which he has been able to ejaculate satisfactorily during a majority of the couple’s sexual interactions.

6) Pornography Induced Erectile Dysfunction Among Young Men (2019) – Abstract:

This paper explores the phenomenon of pornography induced erectile dysfunction (PIED), meaning sexual potency problems in men due to Internet pornography consumption. Empirical data from men who suffer from this condition have been collected. A combination of topical life history method (with qualitative asynchronous online narrative interviews) and personal online diaries has been employed. The data have been analyzed using theoretical interpretative analysis (according to McLuhan’s media theory), based on analytic induction. The empirical investigation indicates that there is a correlation between pornography consumption and erectile dysfunction that suggests causation. The findings are based on 11 interviews along with two video diaries and three text diaries. The men are between the ages of 16 and 52; they report that an early introduction to pornography (usually during adolescence) is followed by daily consumption until a point is reached where extreme content (involving, for example, elements of violence) is needed to maintain arousal. A critical stage is reached when sexual arousal is exclusively associated with extreme and fast-paced pornography, rendering physical intercourse bland and uninteresting. This results in an inability to maintain an erection with a real-life partner, at which point the men embark on a “re-boot” process, giving up pornography. This has helped some of the men to regain their ability to achieve and sustain an erection.

Introduction to the results section:

Having processed the data, I have noticed certain patterns and recurring themes, following a chronological narrative in all of the interviews. These are: Introduction. One is first introduced to pornography, usually before puberty. Building a habit. One begins to consume pornography regularly. Escalation. One turns to more “extreme” forms of pornography, content-wise, in order to achieve the same effects previously achieved through less “extreme” forms of pornography. Realization. One notices sexual potency problems believed to be caused by pornography use. “Re-boot” process. One tries to regulate pornography use or eliminate it completely in order to regain one’s sexual potency. The data from the interviews are presented based on the above outline.

The remaining studies are listed by date of publication:

7) The Dual Control Model – The Role Of Sexual Inhibition & Excitation In Sexual Arousal And Behavior (2007) – Newly rediscovered and very convincing. In an experiment employing video porn, 50% of the young men couldn’t become aroused or achieve erections with porn (average age was 29). The shocked researchers discovered that the men’s erectile dysfunction was,

“related to high levels of exposure to and experience with sexually explicit materials.“

The men experiencing erectile dysfunction had spent a considerable amount of time in bars and bathhouses where porn was “omnipresent,” and “continuously playing“. The researchers stated:

“Conversations with the subjects reinforced our idea that in some of them a high exposure to erotica seemed to have resulted in a lower responsivity to “vanilla sex” erotica and an increased need for novelty and variation, in some cases combined with a need for very specific types of stimuli in order to get aroused.”

8) Clinical encounters with internet pornography (2008) – Comprehensive paper, with four clinical cases, written by a psychiatrist who became aware of the negative effects internet porn was having on some of his male patients. The excerpt below describes a 31 year old man who escalated into extreme porn and developed porn-induced sexual tastes and sexual problems. This is one of the first peer-reviewed papers to depict porn use leading to tolerance, escalation, and sexual dysfunctions:

A 31-year-old male in analytic psychotherapy for mixed anxiety problems reported that he was experiencing difficulty becoming sexually aroused by his current partner. After much discussion about the woman, their relationship, possible latent conflicts or repressed emotional content (without arriving at a satisfactory explanation for his complaint), he provided the detail that he was relying on a particular fantasy to become aroused. Somewhat chagrined, he described a “scene” of an orgy involving several men and women that he had found on an Internet pornography site that had caught his fancy and become one of his favorites. Over the course of several sessions, he elaborated upon his use of Internet pornography, an activity in which he had engaged sporadically since his mid-20s. Relevant details about his use and the effects over time included clear descriptions of an increasing reliance on viewing and then recalling pornographic images in order to become sexually aroused. He also described the development of a “tolerance” to the arousing effects of any particular material after a period of time, which was followed by a search for new material with which he could achieve the prior, desired level of sexual arousal.

As we reviewed his use of pornography, it became evident that the arousal problems with his current partner coincided with use of pornography, whereas his “tolerance” to the stimulating effects of particular material occurred whether or not he was involved with a partner at the time or was simply using pornography for masturbation. His anxiety about sexual performance contributed to his reliance on viewing pornography. Unaware that the use itself had become problematic, he had interpreted his waning sexual interest in a partner to mean that she was not right for him, and had not had a relationship of greater than two months’ duration in over seven years, exchanging one partner for another just as he might change websites.

He also noted that he now could be aroused by pornographic material that he once had no interest in using. For example, he noted that five years ago he had little interest in viewing images of anal intercourse but now found such material stimulating. Similarly, material that he described as “edgier,” by which he meant “almost violent or coercive,” was something that now elicited a sexual response from him, whereas such material had been of no interest and was even off-putting. With some of these new subjects, he found himself anxious and uncomfortable even as he would become aroused.

9) Exploring the Relationship Between Erotic Disruption During the Latency Period and the Use of Sexually Explicit Material, Online Sexual Behaviors, and Sexual Dysfunctions in Young Adulthood (2009) – Study examined correlations between current porn use (sexually explicit material – SEM) and sexual dysfunctions, and porn use during “latency period” (ages 6-12) and sexual dysfunctions. The average age of participants was 22. While current porn use correlated with sexual dysfunctions, porn use during latency (ages 6-12) had an even stronger correlation with sexual dysfunctions. A few excerpts:

Findings suggested that latency erotic disruption by way of sexually explicit material (SEM) and/or child sexual abuse may be associated to adult online sexual behaviors.

Furthermore, results demonstrated that latency SEM exposure was a significant predictor of adult sexual dysfunctions.

We hypothesized that exposure to latency SEM exposure would predict adult use of SEM. Study findings supported our hypothesis, and demonstrated that latency SEM exposure was a statistically significant predictor of adult SEM use. This suggested that individuals who were exposed to SEM during latency, may continue this behavior into adulthood. Study findings also indicated that latency SEM exposure was a significant predictor of adult online sexual behaviors.

10) Use of pornography in a random sample of Norwegian heterosexual couples (2009) – Porn use was correlated with more sexual dysfunctions in the man and negative self perception in the female. The couples who did not use porn had no sexual dysfunctions. A few excerpts from the study:

In couples where only one partner used pornography, we found more problems related to arousal (male) and negative (female) self-perception.

In those couples where one partner used pornography there was a permissive erotic climate. At the same time, these couples seemed to have more dysfunctions.

The couples who did not use pornography... may be considered more traditional in relation to the theory of sexual scripts. At the same time, they did not seem to have any dysfunctions.

Couples who both reported pornography use grouped to the positive pole on the ‘‘Erotic climate’’ function and somewhat to the negative pole on the ‘‘Dysfunctions’’ function.

11) Sexual Desire, not Hypersexuality, is Related to Neurophysiological Responses Elicited by Sexual Images (2013) – This EEG study was touted in the media as evidence against the existence of porn/sex addiction. Not so. Steele et al. 2013 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).

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). That”s sensitization & desensitization, which are hallmarks of an addiction. Seven peer-reviewed papers explain the truth: 1, 2, 3, 4, 5, 6, 7. Also see this extensive YBOP critique.

12) Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014) – A Max Planck study which found 3 significant addiction-related brain changes correlating with the amount of porn consumed. It also found that the more porn consumed the less reward circuit activity in response to brief exposure (.530 second) to vanilla porn. In a 2014 article lead author Simone Kühn said:

“We assume that subjects with a high porn consumption need increasing stimulation to receive the same amount of reward. That could mean that regular consumption of pornography more or less wears out your reward system. That would fit perfectly the hypothesis that their reward systems need growing stimulation.”

A more technical description of this study from a review of the literature by Kuhn & Gallinat – Neurobiological Basis of Hypersexuality (2016).

“The more hours participants reported consuming pornography, the smaller the BOLD response in left putamen in response to sexual images. Moreover, we found that more hours spent watching pornography was associated with smaller gray matter volume in the striatum, more precisely in the right caudate reaching into the ventral putamen. We speculate that the brain structural volume deficit may reflect the results of tolerance after desensitization to sexual stimuli.”

13) Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours (2014) – This fMRI study by Cambridge University found sensitization in porn addicts which mirrored sensitization in drug addicts. It also found that porn addicts fit the accepted addiction model of wanting “it” more, but not liking “it” more. The researchers also reported that 60% of subjects (average age: 25) had difficulty achieving erections/arousal with real partners as a result of using porn, yet could achieve erections with porn. From the study (“CSB” is compulsive sexual behaviours):

“CSB subjects reported that as a result of excessive use of sexually explicit materials…..[they] experienced diminished libido or erectile function specifically in physical relationships with women (although not in relationship to the sexually explicit material)”

“Compared to healthy volunteers, CSB subjects had greater subjective sexual desire or wanting to explicit cues and had greater liking scores to erotic cues, thus demonstrating a dissociation between wanting and liking. CSB subjects also had greater impairments of sexual arousal and erectile difficulties in intimate relationships but not with sexually explicit materials highlighting that the enhanced desire scores were specific to the explicit cues and not generalized heightened sexual desire.”

14) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with “Porn Addiction” (2015) – A second EEG study from Nicole Prause’s team. This study 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 lead author claims these results “debunk porn addiction.” What legitimate scientist would claim that their lone anomalous study has debunked a well established field of study?

In reality, the findings of Prause et al. 2015 align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. Prause et al. findings also align with Banca et al. 2015. Moreover, another EEG study found that greater porn use in women correlated with less brain activation to porn. Lower EEG readings mean that subjects are paying less attention to the pictures. Put simply, frequent porn users were desensitized to static images of vanilla porn. They were bored (habituated or desensitized). See this extensive YBOP critique. Eight peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (consistent with addiction): 1, 2, 3, 4, 5, 6, 7, 8.

10) Adolescents and web porn: a new era of sexuality (2015) – This Italian study analyzed the effects of Internet porn on high school seniors, co-authored by urology professor Carlo Foresta, president of the Italian Society of Reproductive Pathophysiology. The most interesting finding is that 16% of those who consume porn more than once a week report abnormally low sexual desire compared with 0% in non-consumers (and 6% for those who consume less than once a week). From the study:

“21.9% define it as habitual, 10% report that it reduces sexual interest towards potential real-life partners, and the remaining, 9.1% report a kind of addiction. In addition, 19% of overall pornography consumers report an abnormal sexual response, while the percentage rose to 25.1% among regular consumers.”

15) Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases (2015) – A study on men (average age 41.5) with hypersexuality disorders, such as paraphilias, chronic masturbation or adultery. 27 of the men were classified as “avoidant masturbators,” meaning they masturbated (typically with porn use) one or more hours per day, or more than 7 hours per week. 71% of the men who chronically masturbated to porn reported sexual functioning problems, with 33% reporting delayed ejaculation (a precursor to porn-induced ED).

What sexual dysfunction do 38% of the remaining men have? The study doesn’t say, and the authors have ignored repeated requests for details. Two primary choices for male sexual dysfunction are erectile dysfunction and low libido. It should be noted that the men were not asked about their erectile functioning without porn. This, if all their sexual activity involved masturbating to porn, and not sex with a partner, they might never realize they had porn-induced ED. (For reasons known only to her, Prause cites this paper as debunking the existence of porn-induced sexual dysfunctions.)

16) Men’s Sexual Life and Repeated Exposure to Pornography. A New Issue? (2015) – Excerpts:

Mental health specialists should take in consideration the possible effects of pornography consumption on men sexual behaviors, men sexual difficulties and other attitudes related to sexuality. In the long term pornography seems to create sexual dysfunctions, especially the individual’s inability to reach an orgasm with his partner. Someone who spends most of his sexual life masturbating while watching porn engages his brain in rewiring its natural sexual sets (Doidge, 2007) so that it will soon need visual stimulation to achieve an orgasm.

Many different symptoms of porn consumption, such as the need to involve a partner in watching porn, the difficulty in reaching orgasm, the need for porn images in order to ejaculate turn into sexual problems. These sexual behaviors may go on for months or years and it may be mentally and bodily associated with the erectile dysfunction, although it is not an organic dysfunction. Because of this confusion, which generates embarrassment, shame and denial, lots of men refuse to encounter a specialist

Pornography offers a very simple alternative to obtain pleasure without implying other factors that were involved in human’s sexuality along the history of mankind. The brain develops an alternative path for sexuality which excludes “the other real person” from the equation. Furthermore, pornography consumption in a long term makes men more prone to difficulties in obtaining an erection in a presence of their partners.

17) Masturbation and Pornography Use Among Coupled Heterosexual Men With Decreased Sexual Desire: How Many Roles of Masturbation? (2015) – Masturbating to porn was related with decreased sexual desire and low relationship intimacy. Excerpts:

Among men who masturbated frequently, 70% used pornography at least once a week. A multivariate assessment showed that sexual boredom, frequent pornography use, and low relationship intimacy significantly increased the odds of reporting frequent masturbation among coupled men with decreased sexual desire.

Among men [with decreased sexual desire] who used pornography at least once a week [in 2011], 26.1% reported that they were unable to control their pornography use. In addition, 26.7% of men reported that their use of pornography negatively affected their partnered sex and 21.1% claimed to have attempted to stop using pornography.

18) Erectile Dysfunction, Boredom, and Hypersexuality among Coupled Men from Two European Countries (2015) – Survey reported a strong correlation between erectile dysfunction and measures of hypersexuality. The study omitted correlation data between erectile functioning and pornography use, but noted a significant correlation. An excerpt:

Among Croatian and German men, hypersexuality was significantly correlated with proneness to sexual boredom and more problems with erectile function.

19) An Online Assessment of Personality, Psychological, and Sexuality Trait Variables Associated with Self-Reported Hypersexual Behavior (2015) – Survey reported a common theme found in several other studies listed here: Porn/sex addicts report greater arousabilty (cravings related to their addiction) combined with poorer sexual function (fear of experiencing erectile dysfunction).

Hypersexual” behavior represents a perceived inability to control one’s sexual behavior. To investigate hypersexual behavior, an international sample of 510 self-identified heterosexual, bisexual, and homosexual men and women completed an anonymous online self-report questionnaire battery.

Thus, the data indicated that hypersexual behavior is more common for males, and those who report being younger in age, more easily sexually excited, more sexually inhibited due to the threat of performance failure, less sexually inhibited due to the threat of performance consequences, and more impulsive, anxious, and depressed

20) Online sexual activities: An exploratory study of problematic and non-problematic usage patterns in a sample of men (2016) – This Belgian study from a leading research university found problematic Internet porn use was associated with reduced erectile function and reduced overall sexual satisfaction. Yet problematic porn users experienced greater cravings. The study appears to report escalation, as 49% of the men viewed porn that “was not previously interesting to them or that they considered disgusting.” (See studies reporting habituation/desensitization to porn and escalation of porn use) Excerpts:

“This study is the first to directly investigate the relationships between sexual dysfunctions and problematic involvement in OSAs. Results indicated that higher sexual desire, lower overall sexual satisfaction, and lower erectile function were associated with problematic OSAs (online sexual activities). These results can be linked to those of previous studies reporting a high level of arousability in association with sexual addiction symptoms (Bancroft & Vukadinovic, 2004; Laier et al., 2013; Muise et al., 2013).”

In addition, we finally have a study that asks porn users about possible escalation to new or disturbing porn genres. Guess what it found?

“Forty-nine percent mentioned at least sometimes searching for sexual content or being involved in OSAs that were not previously interesting to them or that they considered disgusting, and 61.7% reported that at least sometimes OSAs were associated with shame or guilty feelings.”

Note – This is the first study to directly investigate the relationships between sexual dysfunctions and problematic porn use. Two other studies claiming to have investigated correlations between porn use and erectile functioning cobbled together data from earlier studies in an unsuccessful attempt to debunk porn-induced ED. Both were criticized in the peer-reviewed literature: paper #1 was not an authentic study, and has been thoroughly discredited; paper #2 actually found correlations that support porn-induced sexual dysfunction. Moreover, paper 2 was only a “brief communication” that did not report important data which the authors reported at a sexology conference.

21) The effects of sexually explicit material use on romantic relationship dynamics (2016) – As with many other studies, solitary porn users report poorer relationship and sexual satisfaction. Employing the Pornography Consumption Effect Scale (PCES), the study found that higher porn use was related to poorer sexual function, more sexual problems, and a “worse sex life”. An excerpt describing the correlation between the PCES “Negative Effects” on “Sex Life” questions and frequency of porn use:

There were no significant differences for the Negative Effect Dimension PCES across the frequency of sexually explicit material use; however, there were significant differences on the Sex Life subscale where High Frequency Porn Users reported greater negative effects than Low Frequency Porn Users.

22) Altered Appetitive Conditioning and Neural Connectivity in Subjects With Compulsive Sexual Behavior (2016) – “Compulsive Sexual Behaviors” (CSB) means the men were porn addicts, because CSB subjects averaged nearly 20 hours of porn use per week. The controls averaged 29 minutes per week. Interestingly, 3 of the 20 CSB subjects mentioned to interviewers that they suffered from “orgasmic-erection disorder,” while none of the control subjects reported sexual problems.

23) Study sees link between porn and sexual dysfunction (2017) – The findings of an upcoming study presented at the American Urological Association’s annual meeting. A few excerpts:

Young men who prefer pornography to real-world sexual encounters might find themselves caught in a trap, unable to perform sexually with other people when the opportunity presents itself, a new study reports. Porn-addicted men are more likely to suffer from erectile dysfunction and are less likely to be satisfied with sexual intercourse, according to survey findings presented Friday at the American Urological Association’s annual meeting, in Boston.

“The rates of organic causes of erectile dysfunction in this age cohort are extremely low, so the increase in erectile dysfunction that we have seen over time for this group needs to be explained,” Christman said. “We believe that pornography use may be one piece to that puzzle”.

24) Associative pathways between pornography consumption and reduced sexual satisfaction (2017) – This study is found in both lists. While it links porn use to lower sexual satisfaction, it also reported that frequency of porn use was related to a preference (or need?) for porn over people to achieve sexual arousal. An excerpt:

Finally, we found that frequency of pornography consumption was also directly related to a relative preference for pornographic rather than partnered sexual excitement. Participants in the present study primarily consumed pornography for masturbation. Thus, this finding could be indicative of a masturbatory conditioning effect (Cline, 1994; Malamuth, 1981; Wright, 2011). The more frequently pornography is used as an arousal tool for masturbation, the more an individual may become conditioned to pornographic as opposed to other sources of sexual arousal.

25) “I think it has been a negative influence in many ways but at the same time I can’t stop using it”: Self-identified problematic pornography use among a sample of young Australians (2017) – Online survey of Australians, aged 15-29. Those who had ever viewed pornography (n=856) were asked in an open-ended question: ‘How has pornography influenced your life?’.

Among participants who responded to the open-ended question (n=718), problematic usage was self-identified by 88 respondents. Male participants who reported problematic usage of pornography highlighted effects in three areas: on sexual function, arousal and relationships. Responses included “I think it has been a negative influence in many ways but at the same time I can’t stop using it” (Male, Aged 18–19). Some female participants also reported problematic usage, with many of these reporting negative feelings like guilt and shame, impact on sexual desire and compulsions relating to their use of pornography. For example as one female participant suggested; “It makes me feel guilty, and I’m trying to stop. I don’t like how I feel that I need it to get myself going, it’s not healthy.” (Female, Aged 18–19)

26) Organic and psychogenic causes of sexual dysfunction in young men (2017) – A narrative review, with a section called “Role of Pornography in Delayed Ejaculation (DE)”. An excerpt from this section:

Role of Pornography in DE

Over the last decade, a large increase in the prevalence and accessibility of Internet pornography has provided increased causes of DE associated with Althof’s second and third theory. Reports from 2008 found on average 14.4% of boys were exposed to pornography before the age of 13 and 5.2% of people viewed pornography at least daily.76 A 2016 study revealed that these values had both increased to 48.7% and 13.2%, respectively.76 An earlier age of first pornographic exposure contributes to DE through its relationship with patients exhibiting CSB. Voon et al. found that young men with CSB had viewed sexually explicit material at an earlier age than their age-controlled healthy peers.75 As previously mentioned, young men with CSB can fall victim to Althof’s third theory of DE and preferentially choose masturbation over partnered sex due to a lack of arousal in relationships. An increased number of men watching pornographic material daily also contributes to DE through Althof’s third theory. In a study of 487 male college students, Sun et al. found associations between the use of pornography and a decreased self-reported enjoyment of sexually intimate behaviors with real-life partners.76 These individuals are at an elevated risk of preferentially choosing masturbation over sexual encounters, as demonstrated in a case report by Park et al. A 20-year-old enlisted male presented with difficulty achieving orgasm with his fiancée for the previous six months. A detailed sexual history revealed that the patient relied on Internet pornography and use of a sex toy described as a “fake vagina” to masturbate while deployed. Over time, he required content of an increasingly graphic or fetish nature to orgasm. He admitted that he found his fiancée attractive but preferred the feeling of his toy because he found it more stimulating that real intercourse.77 An increase in the accessibility of Internet pornography places younger men at risk of developing DE through Althof’s second theory, as demonstrated in the following case report: Bronner et al. interviewed a 35-year-old healthy man presenting with complaints of no desire to have sex with his girlfriend despite being mentally and sexually attracted to her. A detailed sexual history revealed that this scenario had happened with the past 20 women he tried to date. He reported extensive use of pornography since adolescence that initially consisted of zoophilia, bondage, sadism, and masochism, but eventually progressed to transgender sex, orgies, and violent sex. He would visualize the pornographic scenes in his imagination to function sexually with women, but that gradually stopped working.74 The gap between the patient’s pornographic fantasies and real life became too large, causing a loss of desire. According to Althof, this will present as DE in some patients.73 This recurring theme of requiring pornographic content of an increasingly graphic or fetish nature to orgasm is defined by Park et al. as hyperactivity. As a man sensitizes his sexual arousal to pornography, sex in real life no longer activates the proper neurological pathways to ejaculate (or produce sustained erections in the case of ED).77

27) Pornography increasingly damaging health and relationships says Brno’s University Hospital study (2018) – It’s in Czech. This YBOP page contains a short press release in English and a choppy Google translation of the longer press release from the hospital website. A few excerpts from the press release:

Increased use of and exposure to pornography are increasingly damaging normal relations and even the health of young men, according to a study released Monday by Brno’s University Hospital.

It said many young men were simply not prepared for normal relationships because of the myths created by the pornography they were watching. Many men turned on by pornography could not physically get stimulated in a relationship, the study added. Psychological and even medical treatment was required, the report said.

In the Sexological department of the Faculty Hospital in Brno, we also record more and more frequent cases of young men who are not able to have a normal sex life as a result of pornography, or to establish a relationship.

The fact that pornography is not merely a “diversification” of sex life but often has a negative impact on the quality of partner sexuality is evidenced by the increasing number of patients in the Sexual Section of Brno University Hospital who, due to excessive monitoring of inappropriate sexual content, are getting into health and relationship problems.

In middle age, male partners are replacing partner sex with pornography (masturbation is available anytime, faster, without psychological, physical or material investment). At the same time, sensitivity to normal (real) sexual stimuli accompanied by the risk of having sex-related dysfunctions associated only with a partner is significantly reduced by the monitoring of pornography. This is a risk of intimacy and proximity in the relationship, ie the psychological separation of partners, the need for masturbation on the Internet is gradually increasing – the risk of addiction increases and, last but not least, sexuality can change in its intensity but also in the quality of normal pornography is not enough, and these people resort to perversion (eg, sado-masochistic or zoophilous).

As a result, excessive monitoring of pornography may result in addiction, which is manifested by sexual dysfunction, disorder of relationships leading to social isolation, disrupted concentration, or neglect of work responsibilities, where only sex plays a dominant role in life.

28) Sexual Dysfunctions in the Internet Era (2018) – Excerpts:

Low sexual desire, reduced satisfaction in sexual intercourse, and erectile dysfunction (ED) are increasingly common in young population. In an Italian study from 2013, up to 25% of subjects suffering from ED were under the age of 40 [1], and in a similar study published in 2014, more than half of Canadian sexually experienced men between the age of 16 and 21 suffered from some kind of sexual disorder [2]. At the same time, prevalence of unhealthy lifestyles associated with organic ED has not changed significantly or has decreased in the last decades, suggesting that psychogenic ED is on the rise [3]. The DSM-IV-TR defines some behaviors with hedonic qualities, such as gambling, shopping, sexual behaviors, Internet use, and video game use, as “impulse control disorders not elsewhere classified”—although these are often described as behavioral addictions [4]. Recent investigation has suggested the role of behavioral addiction in sexual dysfunctions: alterations in neurobiological pathways involved in sexual response might be a consequence of repeated, supernormal stimuli of various origins.

Among behavioral addictions, problematic Internet use and online pornography consumption are often cited as possible risk factors for sexual dysfunction, often with no definite boundary between the two phenomena. Online users are attracted to Internet pornography because of its anonymity, affordability, and accessibility, and in many cases its usage could lead users through a cybersex addiction: in these cases, users are more likely to forget the “evolutionary” role of sex, finding more excitement in self-selected sexually explicit material than in intercourse.

In literature, researchers are discordant about positive and negative function of online pornography. From the negative perspective, it represents the principal cause of compulsive masturbatory behavior, cybersex addiction, and even erectile dysfunction.

29) Is Pornography Use Related to Erectile Functioning? Results From Cross-Sectional and Latent Growth Curve Analyses” (2019) – 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. Even though this Joshua 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. See this extensive analysis for the facts.

While the Grubbs 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 it was the largest sample and averaged higher levels of porn use. Most importantly, this sample’s 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). 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).

Grubbs also correlated porn addiction scores with erectile functioning. The results reveal that even in subjects with relatively healthy erectile functioning, porn addiction was significantly related to poorer erections (–0.20 to –0.33). As before, the strongest correlation between porn addiction and poorer erections (–0.33) occurred in Grubbs’s largest sample, and the sample of an average age most likely to report porn-induced ED: sample 3, average age: 33.5 (433 subjects).

Wait a minute you ask, how dare I say significantly related? Doesn’t the Grubbs study confidently declare that the relationship was only “small to moderate,” meaning it’s no big deal? As we explored in the critique, Grubbs’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.

30) Lecture describing upcoming studies – by Urology professor Carlo Foresta, president of the Italian Society of Reproductive Pathophysiology – The lecture contains the results of longitudinal and cross-sectional studies. One study involved a survey of high school teens (pages 52-53). The study reported that sexual dysfunction doubled between 2005 and 2013, with low sexual desire increasing 600%.

• The percentage of teens that experienced alterations of their sexuality: 2004/05: 7.2%, 2012/13: 14.5%
• The percentage of teens with low sexual desire: 2004/05: 1.7%, 2012/13: 10.3% (that’s a 600% increase in 8 years)

Foresta also describes his upcoming study, “Sexuality media and new forms of sexual pathology sample 125 young males, 19-25 years” (Italian name – “Sessualità mediatica e nuove forme di patologia sessuale Campione 125 giovani maschi“). The results from the study (pages 77-78), which used the International Index of Erectile Function Questionnaire, found that regular porn users scored 50% lower on sexual desire domain and 30% lower of the erectile functioning domain.

31) (not peer-reviewed) Here’s an article about an extensive analysis of comments and questions posted on MedHelp concerning erectile dysfunction. What’s shocking is that 58% of the men asking for help were 24 or younger. Many suspected that internet porn could be involved as described in the results from the study –

The most common phrase is “erectile dysfunction” – which is mentioned more than three times as often as any other phrase – followed by “internet porn,” “performance anxiety,” and “watching porn.”

Clearly, porn is a frequently discussed subject: “I have been viewing internet pornography frequently (4 to 5 times a week) for the past 6 years,” one man writes. “I am in my mid-20s and have had a problem getting and maintaining an erection with sexual partners since my late teens when I first started looking at internet porn.”

Article about the latest spin campaign: Sexologists Deny Porn-induced ED by Claiming Masturbation Is the Problem (2016)

References (beyond those linked to above):

1. Papagiannopoulos D, Khare N, Nehra A. “Evaluation of young men with organic erectile dysfunction.” Asian journal of andrology. 2015;17(1):11-6. Epub 2014/11/06. doi: 10.4103/1008-682x.139253. PubMed PMID: 25370205; PubMed Central PMCID: PMCPmc4291852.

2. Martins FG, Abdo CH. “Erectile dysfunction and correlated factors in Brazilian men aged 18-40 years.” The journal of sexual medicine. 2010;7(6):2166-73. Epub 2009/11/06. doi: 10.1111/j.1743-6109.2009.01542.x. PubMed PMID: 19889149.

3. “Erectile dysfunction among male active component service members, U.S. Armed Forces, 2004-2013.” Msmr. 2014;21(9):13-6. Epub 2014/10/01. PubMed PMID: 25267600.

4. Wilcox SL, Redmond S, Hassan AM. “Sexual functioning in military personnel: preliminary estimates and predictors.” The journal of sexual medicine. 2014;11(10):2537-45. Epub 2014/07/22. doi: 10.1111/jsm.12643. PubMed PMID: 25042933.

5. Laumann EO, Paik A, Rosen RC. “Sexual dysfunction in the United States: prevalence and predictors.” JAMA : the journal of the American Medical Association. 1999;281(6):537-44. Epub 1999/02/18. PubMed PMID: 10022110.

6. Prins, J., M. H. Blanker, A. M. Bohnen, S. Thomas, and J. L. H. R. Bosch. “Prevalence of Erectile Dysfunction: A Systematic Review of Population-Based Studies.” International Journal of Impotence Research 14, no. 6 (December 2002): 422–32. doi:10.1038/sj.ijir.3900905.

7. de Boer, B. J., M. L. Bots, A. A. B. Lycklama a Nijeholt, J. P. C. Moors, H. M. Pieters, and Th J. M. Verheij. “Erectile Dysfunction in Primary Care: Prevalence and Patient Characteristics. The ENIGMA Study.” International Journal of Impotence Research 16, no. 4 (February 12, 2004): 358–64. doi:10.1038/sj.ijir.3901155.

8. Mialon A, Berchtold A, Michaud PA, Gmel G, Suris JC. “Sexual dysfunctions among young men: prevalence and associated factors.” The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2012;51(1):25-31. Epub 2012/06/26. doi: 10.1016/j.jadohealth.2012.01.008. PubMed PMID: 22727073.

9. Capogrosso P, Colicchia M, Ventimiglia E, Castagna G, Clementi MC, Suardi N, et al. “One patient out of four with newly diagnosed erectile dysfunction is a young man–worrisome picture from the everyday clinical practice.” The journal of sexual medicine. 2013;10(7):1833-41. Epub 2013/05/09. doi: 10.1111/jsm.12179. PubMed PMID: 23651423.

10. O’Sullivan LF, Brotto LA, Byers ES, Majerovich JA, Wuest JA. “Prevalence and characteristics of sexual functioning among sexually experienced middle to late adolescents.” The journal of sexual medicine. 2014;11(3):630-41. Epub 2014/01/15. doi: 10.1111/jsm.12419. PubMed PMID: 24418498.

11. Ivan Landripet, PhD and Aleksandar Štulhofer, PhD. “Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men?” (Brief Communication) The journal of sexual medicine, Epub 2015/03/26. doi: 10.1111/jsm.12853

12. Wilcox SL1, Redmond S, Davis TL., “Genital Image, Sexual Anxiety, and Erectile Dysfunction Among Young Male Military Personnel.” J Sex Med. 2015 Apr 30. doi: 10.1111/jsm.12880.

13. Sutton, Katherine S., Natalie Stratton, Jennifer Pytyck, Nathan J. Kolla, and James M. Cantor. “Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases.” Journal of Sex & Marital Therapy 41, no. 6 (December 2015): 563–80. doi:10.1080/0092623X.2014.935539.

14. Voon V, Mole TB, Banca P, Porter L, Morris L, Mitchell S, et al. “Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours.” PloS one. 2014;9(7):e102419. Epub 2014/07/12. doi: 10.1371/journal.pone.0102419. PubMed PMID: 25013940; PubMed Central PMCID: PMCPmc4094516.

15. Carvalheira A, Traeen B, Stulhofer A. “Masturbation and Pornography Use Among Coupled Heterosexual Men With Decreased Sexual Desire: How Many Roles of Masturbation?” Journal of sex & marital therapy. 2014:1-10. Epub 2014/09/06. doi: 10.1080/0092623x.2014.958790. PubMed PMID: 25189834.

16. Sun C, Bridges A, Johnason J, Ezzell M. “Pornography and the Male Sexual Script: An Analysis of Consumption and Sexual Relations.” Archives of sexual behavior. 2014. Epub 2014/12/04. doi: 10.1007/s10508-014-0391-2. PubMed PMID: 25466233.

17. Morgan, E. M. Associations between young adults’ use of sexually explicit materials and their sexual preferences, behaviors, and satisfaction. J. Sex Res. 2011, 48, 520–530.

18. Maddox, A. M.; Rhoades, G. K.; Markman, H. J. Viewing Sexually-Explicit Materials Alone or Together: Associations with Relationship Quality. Arch. Sex. Behav. 2011, 40, 441–448.

19. Bridges, A. J.; Morokoff, P. J. Sexual media use and relational satisfaction in heterosexual couples. Pers. Relatsh. 2011, 18, 562–585.

20. Stewart, D. N.; Szymanski, D. M. Young Adult Women’s Reports of Their Male Romantic Partner’s Pornography Use as a Correlate of Their Self-Esteem, Relationship Quality, and Sexual Satisfaction. Sex Roles 2012, 67, 257–271.

21. Sun, C.; Miezan, E.; Lee, N.-Y.; Shim, J. W. Korean Men’s Pornography use, Their Interest in Extreme Pornography, and Dyadic Sexual Relationships. Int. J. Sex. Health 2015, 27, 16–35.

22. Pornography’s Impact on Sexual Satisfaction – Zillmann – 2006 – Journal of Applied Social Psychology – Wiley Online Library http://onlinelibrary.wiley.com/doi/10.1111/j.1559-1816.1988.tb00027.x/abstract (accessed Jul 4, 2015).

23. Giovanni Castellini, Giovanni Corona, Egidia Fanni, Elisa Maseroli, Valdo Ricca and Mario Maggi, “Does compulsive sexual behavior really exist? Psychological, relational, and biological correlates of compulsive masturbation in a clinical setting.”

24. Voon V, Mole TB, Banca P, Porter L, Morris L, Mitchell S, et al. Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PloS one. 2014;9(7):e102419. Epub 2014/07/12. doi: 10.1371/journal.pone.0102419. PubMed PMID: 25013940; PubMed Central PMCID: PMCPmc4094516.

25. Kuhn S, Gallinat J. Brain structure and functional connectivity associated with pornography consumption: the brain on porn. JAMA psychiatry. 2014;71(7):827-34. Epub 2014/05/30. doi: 10.1001/jamapsychiatry.2014.93. PubMed PMID: 24871202.

Link to full paper – “Neuroscience of Internet Pornography Addiction: A Review and Update” (2015)

Excerpt critiquing “Steele et al., 2013″:

An EEG study on those complaining of problems regulating their viewing of internet pornography has reported the neural reactivity to sexual stimuli [303]. The study was designed to examine the relationship between ERP amplitudes when viewing emotional and sexual images and questionnaire measures of hypersexuality and sexual desire. The authors concluded that the absence of correlations between scores on hypersexuality questionnaires and mean P300 amplitudes when viewing sexual images “fail to provide support for models of pathological hypersexuality” [303] (p. 10). However, the lack of correlations may be better explained by arguable flaws in the methodology. For example, this study used a heterogeneous subject pool (males and females, including 7 non-heterosexuals). Cue-reactivity studies comparing the brain response of addicts to healthy controls require homogenous subjects (same sex, similar ages) to have valid results. Specific to porn addiction studies, it’s well established that males and females differ appreciably in brain and autonomic responses to the identical visual sexual stimuli [304,305,306]. Additionally, two of the screening questionnaires have not been validated for addicted IP users, and the subjects were not screened for other manifestations of addiction or mood disorders.

Moreover, the conclusion listed in the abstract, “Implications for understanding hypersexuality as high desire, rather than disordered, are discussed” [303] (p. 1) seems out of place considering the study’s finding that P300 amplitude was negatively correlated with desire for sex with a partner. As explained in Hilton (2014), this finding “directly contradicts the interpretation of P300 as high desire” [307]. The Hilton analysis further suggests that the absence of a control group and the inability of EEG technology to discriminate between “high sexual desire” and “sexual compulsion” render the Steele et al. findings uninterpretable [307].

Finally, a significant finding of the paper (higher P300 amplitude to sexual images, relative to neutral pictures) is given minimal attention in the discussion section. This is unexpected, as a common finding with substance and internet addicts is an increased P300 amplitude relative to neutral stimuli when exposed to visual cues associated with their addiction [308]. In fact, Voon, et al. [262] devoted a section of their discussion analyzing this prior study’s P300 findings. Voon et al. provided the explanation of importance of P300 not provided in the Steele paper, particularly in regards to established addiction models, concluding,

“Thus, both dACC activity in the present CSB study and P300 activity reported in a previous CSB study[303] may reflect similar underlying processes of attentional capture. Similarly, both studies show a correlation between these measures with enhanced desire. Here we suggest that dACC activity correlates with desire, which may reflect an index of craving, but does not correlate with liking suggestive of on an incentive-salience model of addictions.” [262] (p. 7)

So while these authors [303] claimed that their study refuted the application of the addiction model to CSB, Voon et al. posited that these authors actually provided evidence supporting said model.

This page contains two lists (1) neuroscience-based commentaries & reviews of the literature, and, (2) neurological studies assessing the brain structure and functioning of Internet porn users and sex/porn addicts (Compulsive Sexual Behavior Disorder).

Reviews of the literature & commentaries:

1) Neuroscience of Internet Pornography Addiction: A Review and Update (Love et al., 2015). A thorough review of the neuroscience literature related to Internet addiction sub-types, with special focus on internet porn addiction. The review also critiques two headline-grabbing EEG studies by teams headed by Nicole Prause (who claims the findings cast doubt on porn addiction). Excerpts:

Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction in at least some individuals. Regarding Internet addiction, neuroscientific research supports the assumption that underlying neural processes are similar to substance addiction… Within this review, we give a summary of the concepts proposed underlying addiction and give an overview about neuroscientific studies on Internet addiction and Internet gaming disorder. Moreover, we reviewed available neuroscientific literature on Internet pornography addiction and connect the results to the addiction model. The review leads to the conclusion that Internet pornography addiction fits into the addiction framework and shares similar basic mechanisms with substance addiction.

3.4. Neuroadaptations Related to Internet Pornography-Induced Sexual Difficulties: We hypothesize that pornography-induced sexual difficulties involve both hyperactivity and hypoactivity in the brain’s motivational system [72, 129] and neural correlates of each, or both, have been identified in recent studies on Internet pornography users [31, 48, 52, 53, 54, 86, 113, 114, 115, 120, 121, 130, 131, 132, 133, 134].

2) Sex Addiction as a Disease: Evidence for Assessment, Diagnosis, and Response to Critics (Phillips et al., 2015), which provides a chart that takes on specific criticisms of porn/sex addiction, offering citations that counter them. Excerpts:

As seen throughout this article, the common criticisms of sex as a legitimate addiction do not hold up when compared to the movement within the clinical and scientific communities over the past few decades. There is ample scientific evidence and support for sex as well as other behaviors to be accepted as addiction. This support is coming from multiple fields of practice and offers incredible hope to truly embrace change as we better understand the problem. Decades of research and developments in the field of addiction medicine and neuroscience reveal the underlying brain mechanisms involved in addiction. Scientists have identified common pathways affected by addictive behavior as well as differences between the brains of addicted and non-addicted individuals, revealing common elements of addiction, regardless of the substance or behavior. However, there remains a gap between the scientific advances and the understanding by the general public, public policy, and treatment advances.

3) Cybersex Addiction (Brand & Laier, 2015). Excerpts:

Many individuals use cybersex applications, particularly Internet pornography. Some individuals experience a loss of control over their cybersex use and report that they cannot regulate their cybersex use even if they experienced negative consequences. In recent articles, cybersex addiction is considered a specific type of Internet addiction. Some current studies investigated parallels between cybersex addiction and other behavioral addictions, such as Internet Gaming Disorder. Cue-reactivity and craving are considered to play a major role in cybersex addiction. Also, neurocognitive mechanisms of development and maintenance of cybersex addiction primarily involve impairments in decision making and executive functions. Neuroimaging studies support the assumption of meaningful commonalities between cybersex addiction and other behavioral addictions as well as substance dependency.

4) Neurobiology of Compulsive Sexual Behavior: Emerging Science (Kraus et al., 2016). Excerpts:

Although not included in DSM-5, compulsive sexual behavior (CSB) can be diagnosed in ICD-10 as an impulse control disorder. However, debate exists about CSB’s classification. Additional research is needed to understand how neurobiological features relate to clinically relevant measures like treatment outcomes for CSB. Classifying CSB as a ‘behavioral addiction’ would have significant implications for policy, prevention and treatment efforts….. Given some similarities between CSB and drug addictions, interventions effective for addictions may hold promise for CSB, thus providing insight into future research directions to investigate this possibility directly.

5) Should compulsive sexual behavior be considered an addiction? (Kraus et nal., 2016).  Excerpts:

With the release of DSM-5, gambling disorder was reclassified with substance use disorders. This change challenged beliefs that addiction occurred only by ingesting of mind-altering substances and has significant implications for policy, prevention and treatment strategies. Data suggest that excessive engagement in other behaviors (e.g. gaming, sex, compulsive shopping) may share clinical, genetic, neurobiological and phenomenological parallels with substance addictions.

Another area needing more research involves considering how technological changes may be influencing human sexual behaviors. Given that data suggest that sexual behaviors are facilitated through Internet and smartphone applications, additional research should consider how digital technologies relate to CSB (e.g. compulsive masturbation to Internet pornography or sex chatrooms) and engagement in risky sexual behaviors (e.g. condomless sex, multiple sexual partners on one occasion).

Overlapping features exist between CSB and substance use disorders. Common neurotransmitter systems may contribute to CSB and substance use disorders, and recent neuroimaging studies highlight similarities relating to craving and attentional biases. Similar pharmacological and psychotherapeutic treatments may be applicable to CSB and substance addictions.

6) Neurobiological Basis of Hypersexuality (Kuhn & Gallinat, 2016). Excerpts:

Behavioral addictions and in particular hypersexuality should remind us of the fact that addictive behavior actually relies on our natural survival system. Sex is an essential component in survival of species since it is the pathway for reproduction. Therefore it is extremely important that sex is considered pleasurable and has primal rewarding properties, and although it may turn into an addiction at which point sex may be pursued in a dangerous and counterproductive way, the neural basis for addiction might actually serve very important purposes in primal goal pursuit of individuals…. Taken together, the evidence seems to imply that alterations in the frontal lobe, amygdala, hippocampus, hypothalamus, septum, and brain regions that process reward play a prominent role in the emergence of hypersexuality. Genetic studies and neuropharmacological treatment approaches point at an involvement of the dopaminergic system.

7) Compulsive Sexual Behaviour as a Behavioural Addiction: The Impact of the Internet and Other Issues (Griffiths, 2016). Excerpts:

I have carried out empirical research into many different behavioural addictions (gambling, video-gaming, internet use, exercise, sex, work, etc.) and have argued that some types of problematic sexual behaviour can be classed as sex addiction, depending upon the definition of addiction used….

Whether problematic sexual behaviour is described as compulsive sexual behavior (CSB), sex addiction and/or hypersexual disorder, there are thousands of psychological therapists around the world who treat such disorders. Consequently, clinical evidence from those who help and treat such individuals should be given greater credence by the psychiatric community….

Arguably the most important development in the field of CSB and sex addiction is how the internet is changing and facilitating CSB. This was not mentioned until the concluding paragraph, yet research into online sex addiction (while comprising a small empirical base) has existed since the late 1990s, including sample sizes of up to almost 10 000 individuals. In fact, there have been recent reviews of empirical data concerning online sex addiction and treatment. These have outlined the many specific features of the internet that may facilitate and stimulate addictive tendencies in relation to sexual behaviour (accessibility, affordability, anonymity, convenience, escape, disinhibition, etc.).

8) Searching for Clarity in Muddy Water: Future Considerations for Classifying Compulsive Sexual Behavior as An Addiction (Kraus et al., 2016). Excerpts:

We recently considered evidence for classifying compulsive sexual behavior (CSB) as a non-substance (behavioral) addiction. Our review found that CSB shared clinical, neurobiological and phenomenological parallels with substance-use disorders….

Although the American Psychiatric Association rejected hypersexual disorder from DSM-5, a diagnosis of CSB (excessive sex drive) can be made using ICD-10. CSB is also being considered by ICD-11, although its ultimate inclusion is not certain. Future research should continue to build knowledge and strengthen a framework for better understanding CSB and translating this information into improved policy, prevention, diagnosis, and treatment efforts to minimize the negative impacts of CSB.

9) Is Internet Pornography Causing Sexual Dysfunctions? A Review With Clinical Reports (Park et al., 2016). An extensive review of the literature related to porn-induced sexual problems. Involving 7 US Navy doctors and Gary Wilson, the review provides the latest data revealing a tremendous rise in youthful sexual problems. It also reviews the neurological studies related to porn addiction and sexual conditioning via Internet porn. The doctors provide 3 clinical reports of men who developed porn-induced sexual dysfunctions. A second 2016 paper by Gary Wilson discusses the importance of studying the effects of porn by having subjects abstain from porn use: Eliminate Chronic Internet Pornography Use to Reveal Its Effects (2016).  Excerpt:

Traditional factors that once explained men’s sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brain’s motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography’s unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use.

10) Integrating Psychological and Neurobiological Considerations Regarding The Development and Maintenance of Specific Internet-Use Disorders: An Interaction of Person-Affect-Cognition-Execution model (Brand et al., 2016). A review of the mechanisms underlying the development and maintenance of specific Internet-use disorders, including “Internet-pornography-viewing disorder”. The authors suggest that pornography addiction (and cybersex addiction) be classified as internet use disorders and placed with other behavioral addictions under substance-use disorders as addictive behaviors. Excerpts:

Although the DSM-5 focuses on Internet gaming, a meaningful number of authors indicate that treatment-seeking individuals may also use other Internet applications or sites addictively….

From the current state of research, we suggest to include Internet-use disorders in the upcoming ICD-11. It is important to note that beyond Internet-gaming disorder, other types of applications are also used problematically. One approach could involve the introduction of a general term of Internet-use disorder, which could then be specified considering the first-choice application that is used (for example Internet-gaming disorder, Internet-gambling disorder, Internet-pornography-use disorder, Internet-communication disorder, and Internet-shopping disorder).

11) The Neurobiology of Sexual Addiction: Chapter from Neurobiology of Addictions, Oxford Press (Hilton et al., 2016) – Excerpts:

We review the neurobiological basis for addiction, including natural or process addiction, and then discuss how this relates to our current understanding of sexuality as a natural reward that can become functionally “unmanageable” in an individual’s life….

It is clear that the current definition and understanding of addiction has changed based with the infusion of knowledge regarding how the brain learns and desires. Whereas sexual addiction was formerly defined based solely on behavioral criteria, it is now seen also through the lens of neuromodulation. Those who will not or cannot understand these concepts may continue to cling to a more neurologically naïve perspective, but those who are able to comprehend the behavior in the context of the biology, this new paradigm provides an integrative and functional definition of sexual addiction which informs both the scientist and the clinician.

12) Neuroscientific Approaches to Online Pornography Addiction (Stark & Klucken, 2017) – Excerpts:

The availability of pornographic material has substantially increased with the development of the Internet. As a result of this, men ask for treatment more often because their pornography consumption intensity is out of control; i.e., they are not able to stop or reduce their problematic behavior although they are faced with negative consequences…. In the last two decades, several studies with neuroscientific approaches, especially functional magnetic resonance imaging (fMRI), were conducted to explore the neural correlates of watching pornography under experimental conditions and the neural correlates of excessive pornography use. Given previous results, excessive pornography consumption can be connected to already known neurobiological mechanisms underlying the development of substance-related addictions.

Finally, we summarized the studies, which investigated the correlates of excessive pornography consumption on a neural level. Despite a lack of longitudinal studies, it is plausible that the observed characteristics in men with sexual addiction are the results not the causes of excessive pornography consumption. Most of the studies report stronger cue reactivity in the reward circuit toward sexual material in excessive pornography users than in control subjects, which mirrors the findings of substance-related addictions. The results concerning a reduced prefrontal-striatal-connectivity in subjects with pornography addiction can be interpreted as a sign of an impaired cognitive control over the addictive behavior.

13) Is excessive sexual behaviour an addictive disorder? (Potenza et al., 2017) – Excerpts:

Compulsive sexual behaviour disorder (operationalised as hypersexual disorder) was considered for inclusion in DSM-5 but ultimately excluded, despite the generation of formal criteria and field trial testing. This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder.

Research into the neurobiology of compulsive sexual behaviour disorder has generated findings relating to attentional biases, incentive salience attributions, and brain-based cue reactivity that suggest substantial similarities with addictions. Compulsive sexual behaviour disorder is being proposed as an impulse-control disorder in ICD-11, consistent with a proposed view that craving, continued engagement despite adverse consequences, compulsive engagement, and diminished control represent core features of impulse-control disorders. This view might have been appropriate for some DSM-IV impulse-control disorders, specifically pathological gambling. However, these elements have long been considered central to addictions, and in the transition from DSM-IV to DSM-5, the category of Impulse Control Disorders Not Elsewhere Classified was restructured, with pathological gambling renamed and reclassified as an addictive disorder. At present, the ICD-11 beta draft site lists the impulse-control disorders, and includes compulsive sexual behaviour disorder, pyromania, kleptomania, and intermittent explosive disorder.

Compulsive sexual behaviour disorder seems to fit well with non-substance addictive disorders proposed for ICD-11, consistent with the narrower term of sex addiction currently proposed for compulsive sexual behaviour disorder on the ICD-11 draft website. We believe that classification of compulsive sexual behaviour disorder as an addictive disorder is consistent with recent data and might benefit clinicians, researchers, and individuals suffering from and personally affected by this disorder.

14) Neurobiology of Pornography Addiction – A clinical review (De Sousa & Lodha, 2017) – Excerpts:

The review first looks at the basic neurobiology of addiction with the basic reward circuit and structures involved generally in any addiction. The focus then shifts to pornography addiction and studies done on the neurobiology of the condition are reviewed. The role of dopamine in pornography addiction is reviewed along with the role of certain brain structures as seen on MRI studies. fMRI studies involving visual sexual stimuli have been used widely to study the neuroscience behind pornography usage and the findings from these studies are highlighted. The effect of pornography addiction on higher order cognitive functions and executive function is also stressed.

In total, 59 articles were identified which included reviews, mini reviews and original research papers on the issues of pornography usage, addiction and neurobiology. The research papers reviewed here were centered on those that elucidated a neurobiological basis for pornography addiction. We included studies that had decent sample size and sound methodology with appropriate statistical analysis. There were some studies with fewer participants, case series, case reports and qualitative studies that were also analyzed for this paper. Both the authors reviewed all the papers and the most relevant ones were chosen for this review. This was further supplemented with the personal clinical experience of both the authors who work regularly with patients where pornography addiction and viewing is a distressing symptom. The authors also have psychotherapeutic experience with these patients that have added value to the neurobiological understanding.

15) The Proof of the Pudding Is in the Tasting: Data Are Needed to Test Models and Hypotheses Related to Compulsive Sexual Behaviors (2018) – Excerpts:

As described elsewhere (Kraus, Voon, & Potenza, 2016a), there is an increasing number of publications on CSB, reaching over 11,400 in 2015. Nonetheless, fundamental questions on the conceptualization of CSB remain unanswered (Potenza, Gola, Voon, Kor, & Kraus, 2017). It would be relevant to consider how the DSM and the International Classification of Diseases (ICD) operate with respect to definition and classification processes. In doing so, we think it is relevant to focus on gambling disorder (also known as pathological gambling) and how it was considered in DSM-IV and DSM-5 (as well as in ICD-10 and the forthcoming ICD-11). In DSM-IV, pathological gambling was categorized as an “Impulse-Control Disorder Not Elsewhere Classified.” In DSM-5, it was reclassified as a “Substance-Related and Addictive Disorder.”…. A similar approach should be applied to CSB, which is currently being considered for inclusion as an impulse-control disorder in ICD-11 (Grant et al., 2014; Kraus et al., 2018)….

Among the domains that may suggest similarities between CSB and addictive disorders are neuroimaging studies, with several recent studies omitted by Walton et al. (2017). Initial studies often examined CSB with respect to models of addiction (reviewed in Gola, Wordecha, Marchewka, & Sescousse, 2016b; Kraus, Voon, & Potenza, 2016b). A prominent model—the incentive salience theory (Robinson & Berridge, 1993)—states that in individuals with addictions, cues associated with substances of abuse may acquire strong incentive values and evoke craving. Such reactions may relate to activations of brain regions implicated in reward processing, including the ventral striatum. Tasks assessing cue reactivity and reward processing may be modified to investigate the specificity of cues (e.g., monetary versus erotic) to specific groups (Sescousse, Barbalat, Domenech, & Dreher, 2013), and we have recently applied this task to study a clinical sample (Gola et al., 2017). We found that individuals seeking treatment for problematic pornography use and masturbation, when compared to matched (by age, gender, income, religiosity, amount of sexual contacts with partners, sexual arousability) healthy control subjects, showed increased ventral striatal reactivity for cues of erotic rewards, but not for associated rewards and not for monetary cues and rewards. This pattern of brain reactivity is in line with the incentive salience theory and suggests that a key feature of CSB may involve cue reactivity or craving induced by initially neutral cues associated with sexual activity and sexual stimuli. Additional data suggest that other brain circuits and mechanisms may be involved in CSB, and these may include anterior cingulate, hippocampus and amygdala (Banca et al., 2016; Klucken, Wehrum-Osinsky, Schweckendiek, Kruse, & Stark, 2016; Voon et al., 2014). Among these, we have hypothesized that the extended amygdala circuit that relates to high reactivity for threats and anxiety may be particularly clinically relevant (Gola, Miyakoshi, & Sescousse, 2015; Gola & Potenza, 2016) based on observation that some CSB individuals present with high levels of anxiety (Gola et al., 2017) and CSB symptoms may be reduced together with pharmacological reduction in anxiety (Gola & Potenza, 2016)…

16) Promoting educational, classification, treatment, and policy initiatives Commentary on: Compulsive sexual behaviour disorder in the ICD-11 (Kraus et al., 2018) – The world’s most widely used medical diagnostic manual, The International Classification of Diseases (ICD-11), contains a new diagnosis suitable for porn addiction: “Compulsive Sexual Behavior Disorder.” Excerpts:

For many individuals who experience persistent patterns of difficulty or failures in controlling intense, repetitive sexual impulses or urges that result in sexual behavior associated with marked distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning, it is very important to be able to name and identify their problem. It is also important that care providers (i.e., clinicians and counselors) from whom individuals may seek help are familiar with CSBs. During our studies involving over 3,000 subjects seeking treatment for CSB, we have frequently heard that individuals suffering from CSB encounter multiple barriers during their seeking of help or in contact with clinicians (Dhuffar & Griffiths, 2016). Patients report that clinicians may avoid the topic, state that such problems do not exist, or suggest that one has a high sexual drive, and should accept it instead of treating (despite that for these individuals, the CSBs may feel ego-dystonic and lead to multiple negative consequences). We believe that well-defined criteria for CSB disorder will promote educational efforts including development of training programs on how to assess and treat individuals with symptoms of CSB disorder. We hope that such programs will become a part of clinical training for psychologists, psychiatrists, and other providers of mental health care services, as well as other care providers including primary care providers, such as generalist physicians.

Basic questions on how best to conceptualize CSB disorder and provide effective treatments should be addressed. The current proposal of classifying CSB disorder as an impulse-control disorder is controversial as alternate models have been proposed (Kor, Fogel, Reid, & Potenza, 2013). There are data suggesting that CSB shares many features with addictions (Kraus et al., 2016), including recent data indicating increased reactivity of reward-related brain regions in response to cues associated with erotic stimuli (Brand, Snagowski, Laier, & Maderwald, 2016; Gola, Wordecha, Marchewka, & Sescousse, 2016; Gola et al., 2017; Klucken, Wehrum-Osinsky, Schweckendiek, Kruse, & Stark, 2016; Voon et al., 2014). Furthermore, preliminary data suggest that naltrexone, a medication with indications for alcohol- and opioid-use disorders, may be helpful for treating CSBs (Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015; Raymond, Grant, & Coleman, 2010). With respect to CSB disorder’s proposed classification as an impulse-control disorder, there are data suggesting that individuals seeking treatment for one form of CSB disorder, problematic pornography use, do not differ in terms of impulsivity from the general population. They are instead presented with increased anxiety (Gola, Miyakoshi, & Sescousse, 2015; Gola et al., 2017), and pharmacological treatment targeting anxiety symptoms may be helpful in reducing some CSB symptoms (Gola & Potenza, 2016). While it may not yet be possible to draw definitive conclusions regarding classification, more data seem to support classification as an addictive disorder when compared to an impulse-control disorder (Kraus et al., 2016), and more research is needed to examine relationships with other psychiatric conditions (Potenza et al., 2017).

17) Compulsive Sexual Behavior in Humans and Preclinical Models (2018) – Excerpts:

Compulsive sexual behavior (CSB) is widely regarded as a “behavioral addiction,” and is a major threat to quality of life and both physical and mental health. However, CSB has been slow to be recognized clinically as a diagnosable disorder. CSB is co-morbid with affective disorders as well as substance use disorders, and recent neuroimaging studies have demonstrated shared or overlapping neural pathologies disorders, especially in brain regions controlling motivational salience and inhibitory control. Clinical neuroimaging studies are reviewed that have identified structural and/or function changes in prefrontal cortex, amygdala, striatum, and thalamus in individuals suffering from CSB. A preclinical model to study the neural underpinnings of CSB in male rats is discussed consisting of a conditioned aversion procedure to examine seeking of sexual behavior despite known negative consequences.

Because CSB shares characteristics with other compulsive disorders, namely, drug addiction, comparisons of findings in CSB, and drug-addicted subjects, may be valuable to identify common neural pathologies mediating comorbidity of these disorders. Indeed, many studies have shown similar patterns of neural activity and connectivity within limbic structures that are involved in both CSB and chronic drug use [87–89].

In conclusion, this review summarized the behavioral and neuroimaging studies on human CSB and comorbidity with other disorders, including substance abuse. Together, these studies indicate that CSB is associated with functional alterations in dorsal anterior cingulate and prefrontal cortex, amygdala, striatum, and thalamus, in addition to decreased connectivity between amygdala and prefrontal cortex. Moreover, a preclinical model for CSB in male rats was described, including new evidence of neural alterations in mPFC and OFC that are correlated with loss of inhibitory control of sexual behavior. This preclinical model offers a unique opportunity to test key hypotheses to identify predispositions and underlying causes of CSB and comorbidity with other disorders.

18) Sexual Dysfunctions in the Internet Era (2018) – Excerpt:

Low sexual desire, reduced satisfaction in sexual intercourse, and erectile dysfunction (ED) are increasingly common in young population. In an Italian study from 2013, up to 25% of subjects suffering from ED were under the age of 40 [1], and in a similar study published in 2014, more than half of Canadian sexually experienced men between the age of 16 and 21 suffered from some kind of sexual disorder [2]. At the same time, prevalence of unhealthy lifestyles associated with organic ED has not changed significantly or has decreased in the last decades, suggesting that psychogenic ED is on the rise [3]. The DSM-IV-TR defines some behaviors with hedonic qualities, such as gambling, shopping, sexual behaviors, Internet use, and video game use, as “impulse control disorders not elsewhere classified”—although these are often described as behavioral addictions [4]. Recent investigation has suggested the role of behavioral addiction in sexual dysfunctions: alterations in neurobiological pathways involved in sexual response might be a consequence of repeated, supernormal stimuli of various origins.

Among behavioral addictions, problematic Internet use and online pornography consumption are often cited as possible risk factors for sexual dysfunction, often with no definite boundary between the two phenomena. Online users are attracted to Internet pornography because of its anonymity, affordability, and accessibility, and in many cases its usage could lead users through a cybersex addiction: in these cases, users are more likely to forget the “evolutionary” role of sex, finding more excitement in self-selected sexually explicit material than in intercourse.

In literature, researchers are discordant about positive and negative function of online pornography. From the negative perspective, it represents the principal cause of compulsive masturbatory behavior, cybersex addiction, and even erectile dysfunction….

19) Neurocognitive mechanisms in compulsive sexual behavior disorder (2018) – Excerpt:

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.

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].

20) A Current Understanding of the Behavioral Neuroscience of Compulsive Sexual Behavior Disorder and Problematic Pornography Use  – Excerpts:

Recent neurobiological studies have revealed that compulsive sexual behaviors are associated with altered processing of sexual material and differences in brain structure and function.

The findings summarized in our overview suggest relevant similarities with behavioral and substance-related addictions, which share many abnormalities found for CSBD (as reviewed in [127]). Although beyond the scope of the present report, substance and behavioral addictions are characterized by altered cue reactivity indexed by subjective, behavioral, and neurobiological measures (overviews and reviews: [128, 129, 130, 131, 132, 133]; alcohol: [134, 135]; cocaine: [136, 137]; tobacco: [138, 139]; gambling: [140, 141]; gaming: [142, 143]). Results concerning resting-state functional connectivity show similarities between CSBD and other addictions [144, 145].

Although few neurobiological studies of CSBD have been conducted to date, existing data suggest neurobiological abnormalities share communalities with other additions such as substance use and gambling disorders. Thus, existing data suggest that its classification may be better suited as a behavioral addiction rather than an impulse-control disorder.

21) Ventral Striatal Reactivity in Compulsive Sexual Behaviors (2018) – Excerpts:

Compulsive Sexual Behaviors (CSB) are a reason to seek treatment. Given this reality, the number of studies on CSB has increased substantially in the last decade and the World Health Organization (WHO) included CSB in its proposal for the upcoming ICD-11…… From our point of view, it is worth investigating whether CSB can be distinguished into two subtypes characterized by: (1) dominant interpersonal sexual behaviors, and (2) dominant solitary sexual behaviors and pornography watching (48, 49).

The amount of available studies on CSB (and sub-clinical populations of frequent pornography users) is constantly increasing. Among currently available studies, we were able to find nine publications (Table 1) which utilized functional magnetic resonance imaging. Only four of these (36–39) directly investigated processing of erotic cues and/or rewards and reported findings related to ventral striatum activations. Three studies indicate increased ventral striatal reactivity for erotic stimuli (36–39) or cues predicting such stimuli (36–39). These findings are consistent with Incentive Salience Theory (IST) (28), one of the most prominent frameworks describing brain functioning in addiction. The only support for another theoretical framework which predicts hypoactivation of the ventral striatum in addiction, RDS theory (29, 30), comes partially from one study (37), where individuals with CSB presented lower ventral striatal activation for exciting stimuli when compared to controls.

22) Oline Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019) – Excerpts:

In the last few years, there has been a wave of articles related to behavioral addictions; some of them have a focus on online pornography addiction. However, despite all efforts, we are still unable to profile when engaging in this behavior becomes pathological. Common problems include: sample bias, the search for diagnostic instrumentals, opposing approximations to the matter, and the fact that this entity may be encompassed inside a greater pathology (i.e., sex addiction) that may present itself with very diverse symptomatology. Behavioral addictions form a largely unexplored field of study, and usually exhibit a problematic consumption model: loss of control, impairment, and risky use. Hypersexual disorder fits this model and may be composed of several sexual behaviors, like problematic use of online pornography (POPU). Online pornography use is on the rise, with a potential for addiction considering the “triple A” influence (accessibility, affordability, anonymity). This problematic use might have adverse effects in sexual development and sexual functioning, especially among the young population.

As far as we know, a number of recent studies support this entity as an addiction with important clinical manifestations such as sexual dysfunction and psychosexual dissatisfaction. Most of the existing work is based off on similar research done on substance addicts, based on the hypothesis of online pornography as a ‘supranormal stimulus’ akin to an actual substance that, through continued consumption, can spark an addictive disorder. However, concepts like tolerance and abstinence are not yet clearly established enough to merit the labeling of addiction, and thus constitute a crucial part of future research. For the moment, a diagnostic entity encompassing out of control sexual behavior has been included in the ICD-11 due to its current clinical relevance, and it will surely be of use to address patients with these symptoms that ask clinicians for help.

23) Occurrence and development of online porn addiction: individual susceptibility factors, strengthening mechanisms and neural mechanisms (2019) – Excerpts:

Initiation and development of cybersex addiction have two stages with classical conditioning and operant conditioning. Firstly, individuals use cybersex occasionally out of entertainment and curiosity. On this stage, use of internet devices is paired with sexual arousal and The results in classical conditioning, further leads to sensitization of cybersex-related cues which trigger intense craving. Individual vulnerabilities also facilitate sensitization of cybersex-related cues. On the second stage, individuals make use of cybersex frequently to satisfy their sexual desires or During this process, cybersex-related cognitive bias like positive expectation of cybersex and coping mechanism like using it to deal with negative emotions are positively reinforced, those personal traits associated with cybersex addiction such as narcissism, sexual sensation seeking, sexual excitability, dysfunction use of sex are also positively reinforced, while common personality disorders like nervousness, low self-esteem and psychopathologies like depression, anxiety are negatively reinforced. Executive function deficits occur due to long-term cybersex use. Interaction of executive function deficits and intense craving promotes development and maintenance Of cybersex addiction. Researches using electrophysiological and brain imaging tools mainly to study cybersex addiction found that cybersex addicts may develop more and more robust craving for cybersex when facing cybersex-related cues, but they feel less and less pleasant when using it. Studies provide evidence for intense craving triggered by cybersex-related cues and impaired executive function. In conclusion, people who are vulnerable to cybersex addiction can’t stop cybersex use out of more and more intense craving for cybersex and impaired executive function, but they feel less and less satisfied when using it, and search for more and more original pornographic materials online at the cost of plenty of time and money. Once they reduce cybersex use or just quit it, they would suffer from a series of adverse effects like depression, anxiety, erection dysfunction, lack of sexual arousal.

24) Theories, prevention, and treatment of pornography-use disorder (2019)– Excerpts:

Compulsive sexual behavior disorder, including problematic pornography use, has been included in the ICD-11 as impulse control disorder. The diagnostic criteria for this disorder, however, are very similar to the criteria for disorders due to addictive behaviors, for example repetitive sexual activities becoming a central focus of the personʼs life, unsuccessful efforts to significantly reduce repetitive sexual behaviors and continued repetitive sexual behaviors despite experiencing negative consequences (WHO, 2019). Many researchers and clinicians also argue that problematic pornography use can be considered a behavioral addiction.

Cue-reactivity and craving in combination with reduced inhibitory control, implicit cognitions (e.g. approach tendencies) and experiencing gratification and compensation linked to pornography use have been demonstrated in individuals with symptoms of pornography-use disorder. Neuroscientific studies confirm the involvement of addiction-related brain circuits, including the ventral striatum and other parts of fronto-striatal loops, in the development and maintenance of problematic pornography use. Case reports and proof-of-concept studies suggest the efficacy of pharmacological interventions, for example the opioid antagonist naltrexone, for treating individuals with pornography-use disorder and compulsive sexual behavior disorder.

Theoretical considerations and empirical evidence suggest that the psychological and neurobiological mechanisms involved in addictive disorders are also valid for pornography-use disorder.

25) Self-perceived Problematic Pornography Use: An Integrative Model from a Research Domain Criteria and Ecological Perspective (2019) – Excerpts

Self-perceived problematic pornography use seems to be related to multiple units of analysis and different systems in the organism. Based on the findings within the RDoC paradigm described above, it is possible to create a cohesive model in which different units of analysis impact each other (Fig. 1). It appears that elevated levels of dopamine, present in the natural activation of the reward system related to sexual activity and orgasm, interfere with the regulation of the VTA-NAc system in people who report SPPPU. This dysregulation leads to greater activation of the reward system and increased conditioning related to the use of pornography, fostering approach behavior to pornographic material due to the increase in dopamine in the nucleus accumbens. Continued exposure to immediate and easily available pornographic material seems to create an imbalance in the mesolimbic dopaminergic system. This excess dopamine activates GABA output pathways, producing dynorphin as a byproduct, which inhibits dopamine neurons. When dopamine decreases, acetylcholine is released and can generate an aversive state (Hoebel et al. 2007), creating the negative reward system found in the second stage of addiction models. This imbalance is also correlated to the shift from approach to avoidance behavior, seen in people who report problematic pornography use…. These changes in internal and behavioral mechanisms among people with SPPPU are similar to those observed in people with substance addictions, and map into models of addiction (Love et al. 2015).

26) Cybersex addiction: an overview of the development and treatment of a newly emerging disorder (2020) – Excerpts:

Cybersex addiction is a non-substance related addiction that involves online sexual activity on the internet. Nowadays, various kinds of things related to sex or pornography are easily accessible through internet media. In Indonesia, sexuality is usually assumed taboo but most young people have been exposed to pornography. It can lead to an addiction with many negative effects on users, such as relationships, money, and psychiatric problems like major depression and anxiety disorders.

27) Which Conditions Should Be Considered as Disorders in the International Classification of Diseases (ICD-11) Designation of “Other Specified Disorders Due to Addictive Behaviors”? (2020) – A review by addiction experts concludes that pornography-use disorder is a condition that ought to be diagnosed with the ICD-11 category “other specified disorders due to addictive behaviors”. In other words, compulsive porn use looks like other recognized addictions. Excerpts:

Compulsive sexual behavior disorder, as has been included in the ICD-11 category of impulse-control disorders, may include a broad range of sexual behaviors including excessive viewing of pornography that constitutes a clinically relevant phenomenon (Brand, Blycker, & Potenza, 2019; Kraus et al., 2018). The classification of compulsive sexual behavior disorder has been debated (Derbyshire & Grant, 2015), with some authors suggesting that the addiction framework is more appropriate (Gola & Potenza, 2018), which can be particularly the case for individuals suffering specifically from problems related to pornography use and not from other compulsive or impulsive sexual behaviors (Gola, Lewczuk, & Skorko, 2016; Kraus, Martino, & Potenza, 2016).

The diagnostic guidelines for gaming disorder share several features with those for compulsive sexual behavior disorder and may potentially be adopted by changing “gaming” to “pornography use.” These three core features have been considered central to problematic pornography use (Brand, Blycker, et al., 2019) and appear to fit appropriately the basic considerations (Fig. 1). Several studies have demonstrated the clinical relevance (criterion 1) of problematic pornography use, leading to functional impairment in daily life including jeopardizing work and personal relationships, and justifying treatment (Gola & Potenza, 2016; Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015; Kraus, Voon, & Potenza, 2016). In several studies and review articles, models from the addiction research (criterion 2) have been used to derive hypotheses and to explain the results (Brand, Antons, Wegmann, & Potenza, 2019; Brand, Wegmann, et al., 2019; Brand, Young, et al., 2016; Stark et al., 2017; Wéry, Deleuze, Canale, & Billieux, 2018). Data from self-report, behavioral, electrophysiological, and neuroimaging studies demonstrate an involvement of psychological processes and underlying neural correlates that have been investigated and established to varying degrees for substance-use disorders and gambling/gaming disorders (criterion 3). Commonalities noted in prior studies include cue-reactivity and craving accompanied by increased activity in reward-related brain areas, attentional biases, disadvantageous decision-making, and (stimuli-specific) inhibitory control (e.g., Antons & Brand, 2018; Antons, Mueller, et al., 2019; Antons, Trotzke, Wegmann, & Brand, 2019; Bothe et al., 2019; Brand, Snagowski, Laier, & Maderwald, 2016; Gola et al., 2017; Klucken, Wehrum-Osinsky, Schweckendiek, Kruse, & Stark, 2016; Kowalewska et al., 2018; Mechelmans et al., 2014; Stark, Klucken, Potenza, Brand, & Strahler, 2018; Voon et al., 2014).

Based on evidence reviewed with respect to the three meta-level-criteria proposed, we suggest that pornography-use disorder is a condition that may be diagnosed with the ICD-11 category “other specified disorders due to addictive behaviors” based on the three core criteria for gaming disorder, modified with respect to pornography viewing (Brand, Blycker, et al., 2019). One conditio sine qua non for considering pornography-use disorder within this category would be that the individual suffers solely and specifically from diminished control over pornography consumption (nowadays online pornography in most cases), which is not accompanied by further compulsive sexual behaviors (Kraus et al., 2018). Further, the behavior should be considered as an addictive behavior only if it is related to functional impairment and experiencing negative consequences in daily life, as it is also the case for gaming disorder (Billieux et al., 2017; World Health Organization, 2019). However, we also note that pornography-use disorder may currently be diagnosed with the current ICD-11 diagnosis of compulsive sexual behavior disorder given that pornography viewing and the frequently accompanying sexual behaviors (most frequently masturbation but potentially other sexual activities including partnered sex) may meet the criteria for compulsive sexual behavior disorder (Kraus & Sweeney, 2019). The diagnosis of compulsive sexual behavior disorder may fit for individuals who not only use pornography addictively, but who also suffer from other non-pornography-related compulsive sexual behaviors. The diagnosis of pornography-use disorder as other specified disorder due to addictive behaviors may be more adequate for individuals who exclusively suffer from poorly controlled pornography viewing (in most cases accompanied by masturbation). Whether or not a distinction between online and offline pornography use may be useful is currently debated, which is also the case for online/offline gaming (Király & Demetrovics, 2017).

28) The Addictive Nature of Compulsive Sexual Behaviours and Problematic Online Pornography Consumption: A Review (2020) – Excerpts:

Available findings suggest that there are several features of CSBD and POPU that are consistent with characteristics of addiction, and that interventions helpful in targeting behavioural and substance addictions warrant consideration for adaptation and use in supporting individuals with CSBD and POPU. While there are no randomized trials of treatments for CSBD or POPU, opioid antagonists, cognitive behavioural therapy, and mindfulness-based intervention appear to show promise on the basis of some case reports.

The neurobiology of POPU and CSBD involves a number of shared neuroanatomical correlates with established substance use disorders, similar neuropsychological mechanisms, as well as common neurophysiological alterations in the dopamine reward system.

Several studies have cited shared patterns of neuroplasticity between sexual addiction and established addictive disorders.

Mirroring excessive substance use, the use of excessive pornography has a negative impact on several domains of functioning, impairment and distress.

29) Dysfunctional sexual behaviors: definition, clinical contexts, neurobiological profiles and treatments (2020) – Excerpts:

1. The use of pornography among young people, who use it massively online, is connected to the decrease in sexual desire and premature ejaculation, as well as in some cases to social anxiety disorders, depression, DOC, and ADHD [30-32].

2. There is a clear neurobiological difference between “sexual employees” and “porn addicts”: if the former has a ventral hypoactivity, the latter instead are characterized by greater ventral reactivity for erotic signals and rewards without hypoactivity of the reward circuits. This would suggest that employees need interpersonal physical contact, while the latter tend to solitary activity [33,34]. Also, drug addicts exhibit greater disorganization of the white matter of the prefrontal cortex [35].

3. Porn addiction, although distinct neurobiologically from sexual addiction, is still a form of behavioral addiction and this dysfunctionality favors an aggravation of the person’s psychopathological condition, directly and indirectly involving a neurobiological modification at the level of desensitization to functional sexual stimulus, hypersensitization to stimulus sexual dysfunction, a marked level of stress capable of affecting the hormonal values of the pituitary-hypothalamic-adrenal axis and hypofrontality of the prefrontal circuits [36].

4. The low tolerance of pornography consumption was confirmed by an fMRI study which found a lower presence of gray matter in the reward system (dorsal striatum) related to the quantity of pornography consumed. He also found that increased use of pornography is correlated with less activation of the reward circuit while briefly watching sexual photos. Researchers believe their results indicated desensitization and possibly tolerance, which is the need for more stimulation to achieve the same level of arousal. Furthermore, signals of lower potential have been found in Putamen in porn-dependent subjects [37].

5. Contrary to what one might think, porn addicts do not have a high sexual desire and the masturbatory practice associated with viewing pornographic material decreases the desire also favoring premature ejaculation, as the subject feels more comfortable in solo activity. Therefore individuals with greater reactivity to porn prefer to perform solitary sexual acts than shared with a real person [38,39].

6. The sudden suspension of porn addiction causes negative effects in mood, excitement, and relational and sexual satisfaction [40,41].

7. The massive use of pornography facilitates the onset of psychosocial disorders and relationship difficulties [42].

8. The neural networks involved in sexual behavior are similar to those involved in processing other rewards, including addictions.

30) What should be included in the criteria for compulsive sexual behavior disorder? (2020) – This important paper based on recent research, gently corrects some of the misleading porn research claims. Among the highlights, the authors take on the disingenuous “moral incongruence” concept so popular with pro-porn researchers. Also see the helpful chart comparing Compulsive Sexual Behaviour Disorder and the ill-fated DSM-5 Hypersexual Disorder proposal. Excerpts:

Diminished pleasure derived from sexual behavior may also reflect tolerance related to repetitive and excessive exposure to sexual stimuli, which are included in addiction models of CSBD (Kraus, Voon, & Potenza, 2016) and supported by neuroscientific findings (Gola & Draps, 2018). An important role for tolerance relating to problematic pornography use is also suggested in community and subclinical samples (Chen et al., 2021). …

The classification of CSBD as an impulse control disorder also warrants consideration. … Additional research may help refine the most appropriate classification of CSBD as happened with gambling disorder, reclassified from the category of impulse control disorders to non-substance or behavioral addictions in DSM-5 and ICD-11. … impulsivity may not contribute as strongly to problematic pornography use as some have proposed (Bőthe et al., 2019).

…Feelings of moral incongruence should not arbitrarily disqualify an individual from receiving a diagnosis of CSBD. For example, viewing of sexually explicit material that is not in alignment with one’s moral beliefs (for example, pornography that includes violence towards and objectification of women (Bridges et al., 2010), racism (Fritz, Malic, Paul, & Zhou, 2020), themes of rape and incest (Bőthe et al., 2021; Rothman, Kaczmarsky, Burke, Jansen, & Baughman, 2015) may be reported as morally incongruent, and objectively excessive viewing of such material may also result in impairment in multiple domains (e.g., legal, occupational, personal and familial). Also, one may feel moral incongruence about other behaviors (e.g., gambling in gambling disorder or substance use in substance use disorders), yet moral incongruence is not considered in the criteria for conditions related to these behaviors, even though it may warrant consideration during treatment (Lewczuk, Nowakowska, Lewandowska, Potenza, & Gola, 2020). …

31) Decision-Making in Gambling Disorder, Problematic Pornography Use, and Binge-Eating Disorder: Similarities and Differences (2021) – The review  provides an overview of the neurocognitive mechanisms of gambling disorder (GD), problematic pornography use (PPU), and binge-eating disorder (BED), focusing specifically on decision-making processes related to executive functioning (prefrontal cortex). Excerpts:

Common mechanisms underlying substance-use disorders (SUDs such as alcohol, cocaine, and opioids) and addictive or maladaptative disorders or behaviors (such as GD and PPU) have been suggested [5,6,7,8, 9••]. Shared underpinnings between addictions and EDs have also been described, mainly including top-down cognitive-control [10,11,12] and bottom-up reward-processing [13, 14] alterations. Individuals with these disorders often show impaired cognitive control and disadvantageous decision-making [12, 15,16,17]. Deficits in decision-making processes and goal-directed learning have been found across multiple disorders; thus, they could be considered clinically relevant transdiagnostic features [18,19,20]. More specifically, it has been suggested that these processes are found in individuals with behavioral addictions (e.g., in dual-process and other models of addictions) [21,22,23,24].

Similarities between CSBD and addictions have been described, and impaired control, persistent use despite adverse consequences, and tendencies to engage in risky decisions may be shared features (37••, 40).

Understanding decision-making has important implications for the assessment and treatment of individuals with GD, PPU, and BED. Similar alterations in decision-making under risk and ambiguity, as well as greater delay discounting, have been reported in GD, BED, and PPU. These findings support a transdiagnostic feature that may be amenable to interventions for the disorders.

32) Which Conditions Should Be Considered as Disorders in the International Classification of Diseases (ICD-11) Designation of “Other Specified Disorders Due to Addictive Behaviors”? (2020) – A review by addiction experts concludes that pornography-use disorder is a condition that may be diagnosed with the ICD-11 category “other specified disorders due to addictive behaviors”. In other words, compulsive porn use looks like other recognized behavioral addictions, which include gambling and gaming disorders. Excerpts –

Note that we are not suggesting the inclusion of new disorders in the ICD-11. Rather, we aim to emphasize that some specific potentially addictive behaviors are discussed in the literature, which are currently not included as specific disorders in the ICD-11, but which may fit the category of “other specified disorders due to addictive behaviors” and consequently may be coded as 6C5Y in clinical practice. (emphasis supplied)…

Based on evidence reviewed with respect to the three meta-level-criteria proposed, we suggest that pornography-use disorder is a condition that may be diagnosed with the ICD-11 category “other specified disorders due to addictive behaviors” based on the three core criteria for gaming disorder, modified with respect to pornography viewing (Brand, Blycker, et al., 2019)….

The diagnosis of pornography-use disorder as other specified disorder due to addictive behaviors may be more adequate for individuals who exclusively suffer from poorly controlled pornography viewing (in most cases accompanied by masturbation).

33) Cognitive processes related to problematic pornography use (PPU): A systematic review of experimental studies (2021) – Excerpts:

Some people experience symptoms and negative outcomes derived from their persistent, excessive, and problematic engagement in pornography viewing (i.e., Problematic Pornography Use, PPU). Recent theoretical models have turned to different cognitive processes (e.g., inhibitory control, decision making, attentional bias, etc.) to explain the development and maintenance of PPU.

In the current paper, we review and compile the evidence derived from 21 studies investigating the cognitive processes underlying PPU. In brief, PPU is related to: (a) attentional biases toward sexual stimuli, (b) deficient inhibitory control (in particular, to problems with motor response inhibition and to shift attention away from irrelevant stimuli), (c) worse performance in tasks assessing working memory, and (d) decision making impairments (in particular, to preferences for short-term small gains rather than long-term large gains, more impulsive choice patterns than non-erotica users, approach tendencies toward sexual stimuli, and inaccuracies when judging the probability and magnitude of potential outcomes under ambiguity). Some of this findings are derived from studies in clinical samples of patients with PPU or with a diagnosis of SA/HD/CSBD and PPU as their primary sexual problem (e.g., Mulhauser et al., 2014, Sklenarik et al., 2019), suggesting that these distorted cognitive processes may constitute ‘sensitive’ indicators of PPU.

At a theoretical level, the results of this review support the relevance of the main cognitive components of the I-PACE model (Brand et al., 2016, Sklenarik et al., 2019).

34) PDF of full review: Compulsive Sexual Behavior Disorder – the evolution of a new diagnosis introduced to the ICD-11, current evidence and ongoing research challenges (2021) – Abstract:

In 2019 Compulsive Sexual Behavior Disorder (CSBD) has been officially included in the forthcoming 11^th edition of the International Classification of Diseases published by the World Health Organization (WHO). The placement of CSBD as a new disease entity was preceded by a three-decade-long discussion on the conceptualization of these behaviors. Despite the potential benefits of WHO’s decisions, the controversy around this topic has not ceased. Both clinicians and scientists are still debating on gaps in the current knowledge regarding the clinical picture of people with CSBD, and the neural and psychological mechanisms underlying this problem. This article provides an overview of the most important issues related to the formation of CSBD as a separate diagnostic unit in the classifications of mental disorders (such as DSM and ICD), as well as a summary of the major controversies related to the current classification of CSBD.

See Questionable & Misleading Studies for highly publicized papers that are not what they claim to be (this outdated paper – Ley, et al., 2014 – was not a literature review and misrepresented most the papers it did cite).

Neurological Studies (fMRI, MRI, EEG, Neuro-endocrine, Neuro-pyschological):

The neurological studies below are categorized in two ways. First by the addiction-related brain changes each reported. Below that the same studies are listed by date of publication, with excerpts and clarifications.

Lists by addiction-related brain change: The four major brain changes induced by addiction are described by George F. Koob and Nora D. Volkow in their landmark review. Koob is the Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and Volkow is the director of the National Institute on Drug Abuse (NIDA). It was published in The New England Journal of Medicine: Neurobiologic Advances from the Brain Disease Model of Addiction (2016). The paper describes the major brain changes involved with both drug and behavioral addictions, while stating in its opening paragraph that sex addiction exists:

“We conclude that neuroscience continues to support the brain disease model of addiction. Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions (e.g., to food, sex, and gambling)….”

The Volkow & Koob paper outlined four fundamental addiction-caused brain changes, which are: 1) Sensitization, 2) Desensitization, 3) Dysfunctional prefrontal circuits (hypofrontality), 4) Malfunctioning stress system. All 4 of these brain changes have been identified among the many neurological studies listed on this page:

• Studies reporting sensitization (cue-reactivity & cravings) in porn users/sex addicts: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24.
• Studies reporting desensitization or habituation (resulting in tolerance) in porn users/sex addicts: 1, 2, 3, 4, 5, 6.
• Studies reporting poorer executive functioning (hypofrontality) or altered prefrontal activity in porn users/sex addicts: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17.
• Studies indicating a dysfunctional stress system in porn users/sex addicts: 1, 2, 3, 4, 5.

Lists by date of publication: The following list contains all the neurological studies published on porn users and sex addicts. Each study listed below is accompanied by a description or excerpt, and indicates which of the 4 addiction-related brain change(s) just discussed its findings endorse:

1) Preliminary Investigation of The Impulsive And Neuroanatomical Characteristics of Compulsive Sexual Behavior (Miner et al., 2009) – [dysfunctional prefrontal circuits/poorer executive function] – fMRI study involving primarily sex addicts. Study reports more impulsive behavior in a Go-NoGo task in sex addicts (hypersexuals) compared to control participants. Brain scans revealed that sex addicts had disorganized prefrontal cortex white matter compared to controls. Excerpts:

In addition to the above self-report measures, CSB patients also showed significantly more impulsivity on a behavioral task, the Go-No Go procedure.

Results also indicate that CSB patients showed significantly higher superior frontal region mean diffusivity (MD) than controls. A correlational analysis indicated significant associations between impulsivity measures and inferior frontal region fractional anisotrophy (FA) and MD, but no associations with superior frontal region measures. Similar analyses indicated a significant negative association between superior frontal lobe MD and the compulsive sexual behavior inventory.

2) Self-reported differences on measures of executive function and hypersexual behavior in a patient and community sample of men (Reid et al., 2010) – [poorer executive function] – An excerpt:

Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with sex. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. These observations led to the current investigation of differences between a group of hypersexual patients (n = 87) and a non-hypersexual community sample (n = 92) of men using the Behavior Rating Inventory of Executive Function-Adult Version  Hypersexual behavior was positively correlated with global indices of executive dysfunction and several subscales of the BRIEF-A. These findings provide preliminary evidence supporting the hypothesis that executive dysfunction may be implicated in hypersexual behavior.

3) Watching Pornographic Pictures on the Internet: Role of Sexual Arousal Ratings and Psychological-Psychiatric Symptoms for Using Internet Sex Sites Excessively (Brand et al., 2011) – [greater cravings/sensitization and poorer executive function] – An excerpt:

Results indicate that self-reported problems in daily life linked to online sexual activities were predicted by subjective sexual arousal ratings of the pornographic material, global severity of psychological symptoms, and the number of sex applications used when being on Internet sex sites in daily life, while the time spent on Internet sex sites (minutes per day) did not significantly contribute to explanation of variance in IATsex score. We see some parallels between cognitive and brain mechanisms potentially contributing to the maintenance of excessive cybersex and those described for individuals with substance dependence.

4) Pornographic Picture Processing Interferes with Working Memory Performance (Laier et al., 2013) – [greater cravings/sensitization and poorer executive function] – An excerpt:

Some individuals report problems during and after Internet sex engagement, such as missing sleep and forgetting appointments, which are associated with negative life consequences. One mechanism potentially leading to these kinds of problems is that sexual arousal during Internet sex might interfere with working memory (WM) capacity, resulting in a neglect of relevant environmental information and therefore disadvantageous decision making. Results revealed worse WM performance in the pornographic picture condition of the 4-back task compared with the three remaining picture conditions. Findings are discussed with respect to Internet addiction because WM interference by addiction-related cues is well known from substance dependencies.

5) Sexual Picture Processing Interferes with Decision-Making Under Ambiguity (Laier et al., 2013) – [greater cravings/sensitization and poorer executive function] – An excerpt:

Decision-making performance was worse when sexual pictures were associated with disadvantageous card decks compared to performance when the sexual pictures were linked to the advantageous decks. Subjective sexual arousal moderated the relationship between task condition and decision-making performance. This study emphasized that sexual arousal interfered with decision-making, which may explain why some individuals experience negative consequences in the context of cybersex use.

6) Cybersex addiction: Experienced sexual arousal when watching pornography and not real-life sexual contacts makes the difference (Laier et al., 2013) – [greater cravings/sensitization and poorer executive function] – An excerpt:

The results show that indicators of sexual arousal and craving to Internet pornographic cues predicted tendencies towards cybersex addiction in the first study. Moreover, it was shown that problematic cybersex users report greater sexual arousal and craving reactions resulting from pornographic cue presentation. In both studies, the number and the quality with real-life sexual contacts were not associated to cybersex addiction. The results support the gratification hypothesis, which assumes reinforcement, learning mechanisms, and craving to be relevant processes in the development and maintenance of cybersex addiction. Poor or unsatisfying sexual real life contacts cannot sufficiently explain cybersex addiction.

7) Sexual Desire, not Hypersexuality, is Related to Neurophysiological Responses Elicited by Sexual Images (Steele et al., 2013) – [greater cue-reactivity correlated with less sexual desire: sensitization and habituation] – This EEG study was touted in the media by spokesperson Nicole Prause as evidence against the existence of porn/sex addiction. Not so. Steele et al. 2013 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.

The often-repeated claims that subjects brains did not “respond like other addicts” is without support. This assertion is nowhere to be found in the actual study. It’s only found in Prause’s interviews.

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). Seven peer-reviewed papers explain the truth: 1, 2, 3, 4, 5, 6, 7. For more read an extensive critique.

Aside from the many unsupported claims in the press, it’s disturbing that Prause’s 2013 EGG study passed peer-review, as it suffered from serious methodological flaws: 1) subjects were heterogeneous (males, females, non-heterosexuals); 2) subjects were not screened for mental disorders or addictions; 3) study had no control group for comparison; 4) questionnaires were not validated for porn addiction.

Steele at al. is so badly flawed that only 4 of the above 20 literature reviews & commentaries bother to mention it: two critiquing it as unacceptable, while two cite it as correlating cue-reactivity with less desire for sex with a partner (signs of addiction).

8) Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (Kuhn & Gallinat, 2014) – [desensitization, habituation, and dysfunctional prefrontal circuits]. This Max Planck Institute fMRI study reported 3 neurological findings correlating with higher levels of porn use: (1) less reward system grey matter (dorsal striatum), (2) less reward circuit activation while briefly viewing sexual photos, (3) poorer functional connectivity between the dorsal striatum and dorsolateral prefrontal cortex. The researchers interpreted the 3 findings as an indication of the effects of longer-term porn exposure. Said the study,

This is in line with the hypothesis that intense exposure to pornographic stimuli results in a down-regulation of the natural neural response to sexual stimuli.

In describing the poorer functional connectivity between the PFC and the striatum the study said,

Dysfunction of this circuitry has been related to inappropriate behavioral choices, such as drug seeking, regardless of the potential negative outcome

Lead author Simone Kühn commenting in an article about the findings said:

We assume that subjects with a high porn consumption need increasing stimulation to receive the same amount of reward. That could mean that regular consumption of pornography more or less wears out your reward system. That would fit perfectly the hypothesis that their reward systems need growing stimulation.

9) Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours (Voon et al., 2014) – [sensitization/cue-reactivity and desensitization] The first in a series of Cambridge University studies found the same brain activity pattern in porn addicts (CSB subjects) as seen in drug addicts and alcoholics – greater cue-reactivity or sensitization. Lead researcher Valerie Voon said:

There are clear differences in brain activity between patients who have compulsive sexual behaviour and healthy volunteers. These differences mirror those of drug addicts.

Voon et al., 2014 also found that porn addicts fit the accepted addiction model of wanting “it” more, but not liking “it” any more. Excerpt:

Compared to healthy volunteers, CSB subjects had greater subjective sexual desire or wanting to explicit cues and had greater liking scores to erotic cues, thus demonstrating a dissociation between wanting and liking

The researchers also reported that 60% of subjects (average age: 25) had difficulty achieving erections/arousal with real partners, yet could achieve erections with porn. This indicates sensitization or habituation. Excerpts:

CSB subjects reported that as a result of excessive use of sexually explicit materials….. experienced diminished libido or erectile function specifically in physical relationships with women (although not in relationship to the sexually explicit material)…

CSB subjects compared to healthy volunteers had significantly more difficulty with sexual arousal and experienced more erectile difficulties in intimate sexual relationships but not to sexually explicit material.

10) Enhanced Attentional Bias towards Sexually Explicit Cues in Individuals with and without Compulsive Sexual Behaviours (Mechelmans et al., 2014) – [sensitization/cue-reactivity] – The second Cambridge University study. An excerpt:

Our findings of enhanced attentional bias… suggest possible overlaps with enhanced attentional bias observed in studies of drug cues in disorders of addictions. These findings converge with recent findings of neural reactivity to sexually explicit cues in [porn addicts] in a network similar to that implicated in drug-cue-reactivity studies and provide support for incentive motivation theories of addiction underlying the aberrant response to sexual cues in [porn addicts]. This finding dovetails with our recent observation that sexually explicit videos were associated with greater activity in a neural network similar to that observed in drug-cue-reactivity studies. Greater desire or wanting rather than liking was further associated with activity in this neural network. These studies together provide support for an incentive motivation theory of addiction underlying the aberrant response towards sexual cues in CSB.

11) Cybersex addiction in heterosexual female users of internet pornography can be explained by gratification hypothesis (Laier et al., 2014) – [greater cravings/sensitization] – An excerpt:

We examined 51 female IPU and 51 female non-Internet pornography users (NIPU). Using questionnaires, we assessed the severity of cybersex addiction in general, as well as propensity for sexual excitation, general problematic sexual behavior, and severity of psychological symptoms. Additionally, an experimental paradigm, including a subjective arousal rating of 100 pornographic pictures, as well as indicators of craving, was conducted. Results indicated that IPU rated pornographic pictures as more arousing and reported greater craving due to pornographic picture presentation compared with NIPU. Moreover, craving, sexual arousal rating of pictures, sensitivity to sexual excitation, problematic sexual behavior, and severity of psychological symptoms predicted tendencies toward cybersex addiction in IPU. Being in a relationship, number of sexual contacts, satisfaction with sexual contacts, and use of interactive cybersex were not associated with cybersex addiction. These results are in line with those reported for heterosexual males in previous studies. Findings regarding the reinforcing nature of sexual arousal, the mechanisms of learning, and the role of cue reactivity and craving in the development of cybersex addiction in IPU need to be discussed.

12) Empirical Evidence and Theoretical Considerations on Factors Contributing to Cybersex Addiction From a Cognitive Behavioral View (Laier et al., 2014) – [greater cravings/sensitization] – An excerpt:

The nature of a phenomenon often called cybersex addiction (CA) and its mechanisms of development are discussed. Previous work suggests that some individuals might be vulnerable to CA, while positive reinforcement and cue-reactivity are considered to be core mechanisms of CA development. In this study, 155 heterosexual males rated 100 pornographic pictures and indicated their increase of sexual arousal. Moreover, tendencies towards CA, sensitivity to sexual excitation, and dysfunctional use of sex in general were assessed. The results of the study show that there are factors of vulnerability to CA and provide evidence for the role of sexual gratification and dysfunctional coping in the development of CA.

13) Novelty, Conditioning and Attentional Bias to Sexual Rewards (Banca et al., 2015) – [greater cravings/sensitization and habituation/desensitization] – Another Cambridge University fMRI study. Compared to controls porn addicts preferred sexual novelty and conditioned cues associated porn. However, the brains of porn addicts habituated faster to sexual images. Since novelty preference wasn’t pre-existing, it is believed that porn addiction drives novelty-seeking in an attempt to overcome habituation and desensitization.

Compulsive sexual behavior (CSB) was associated with enhanced novelty preference for sexual, as compared to control images, and a generalized preference for cues conditioned to sexual and monetary versus neutral outcomes compared to healthy volunteers. CSB individuals also had greater dorsal cingulate habituation to repeated sexual versus monetary images with the degree of habituation correlating with enhanced preference for sexual novelty. Approach behaviors to sexually conditioned cues dissociable from novelty preference were associated with an early attentional bias to sexual images. This study shows that CSB individuals have a dysfunctional enhanced preference for sexual novelty possibly mediated by greater cingulate habituation along with a generalized enhancement of conditioning to rewards. An excerpt:

An excerpt from the related press release:

They found that when the sex addicts viewed the same sexual image repeatedly, compared to the healthy volunteers they experienced a greater decrease of activity in the region of the brain known as the dorsal anterior cingulate cortex, known to be involved in anticipating rewards and responding to new events. This is consistent with ‘habituation’, where the addict finds the same stimulus less and less rewarding – for example, a coffee drinker may get a caffeine ‘buzz’ from their first cup, but over time the more they drink coffee, the smaller the buzz becomes.

This same habituation effect occurs in healthy males who are repeatedly shown the same porn video. But when they then view a new video, the level of interest and arousal goes back to the original level. This implies that, to prevent habituation, the sex addict would need to seek out a constant supply of new images. In other words, habituation could drive the search for novel images.

“Our findings are particularly relevant in the context of online pornography,” adds Dr Voon. “It’s not clear what triggers sex addiction in the first place and it is likely that some people are more pre-disposed to the addiction than others, but the seemingly endless supply of novel sexual images available online helps feed their addiction, making it more and more difficult to escape.”

14) Neural Substrates of Sexual Desire in Individuals with Problematic Hypersexual Behavior (Seok & Sohn, 2015) – [greater cue reactivity/sensitization and dysfunctional prefrontal circuits] – This Korean fMRI study replicates other brain studies on porn users. Like the Cambridge University studies it found cue-induced brain activation patterns in sex addicts, which mirrored the patterns of drug addicts. In line with several German studies it found alterations in the prefrontal cortex which match the changes observed in drug addicts. What’s new is that the findings matched the prefrontal cortex activation patterns observed in drug addicts: Greater cue-reactivity to sexual images yet inhibited responses to other normally salient stimuli. An excerpt:

Our study aimed to investigate the neural correlates of sexual desire with event-related functional magnetic resonance imaging (fMRI). Twenty-three individuals with PHB and 22 age-matched healthy controls were scanned while they passively viewed sexual and nonsexual stimuli. The subjects’ levels of sexual desire were assessed in response to each sexual stimulus. Relative to controls, individuals with PHB experienced more frequent and enhanced sexual desire during exposure to sexual stimuli. Greater activation was observed in the caudate nucleus, inferior parietal lobe, dorsal anterior cingulate gyrus, thalamus, and dorsolateral prefrontal cortex in the PHB group than in the control group. In addition, the hemodynamic patterns in the activated areas differed between the groups. Consistent with the findings of brain imaging studies of substance and behavior addiction, individuals with the behavioral characteristics of PHB and enhanced desire exhibited altered activation in the prefrontal cortex and subcortical regions

15) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with “Porn Addiction” (Prause et al., 2015) – [habituation] – A second EEG study from Nicole Prause’s team. This study 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 lead author claims these results “debunk porn addiction.” What legitimate scientist would claim that their lone anomalous study has debunked a well established field of study? (one with close ties to the porn industry, perhaps?)

In reality, the findings of Prause et al. 2015 align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. Prause et al findings also align with Banca et al. 2015 which is #13 in this list. Moreover, another EEG study found that greater porn use in women correlated with less brain activation to porn. Lower EEG readings mean that subjects are paying less attention to the pictures. Put simply, frequent porn users were desensitized to static images of vanilla porn. They were bored (habituated or desensitized). Read this extensive critique. Eight peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (consistent with addiction): 1, 2, 3, 4, 5, 6, 7, 8.

16) HPA Axis Dysregulation in Men With Hypersexual Disorder (Chatzittofis, 2015) – [dysfunctional stress response] – A study with 67 male sex addicts and 39 age-matched controls. The Hypothalamus-Pituitary-Adrenal (HPA) axis is the central player in our stress response. Addictions alter the brain’s stress circuits leading to a dysfunctional HPA axis. This study on sex addicts (hypersexuals) found altered stress responses that mirror the findings with substance addictions. Excerpts from press release:

The study involved 67 men with hypersexual disorder and 39 healthy matched controls. The participants were carefully diagnosed for hypersexual disorder and any co-morbidity with depression or childhood trauma. The researchers gave them a low dose of dexamethasone on the evening before the test to inhibit their physiological stress response, and then in the morning measured their levels of stress hormones cortisol and ACTH. They found that patients with hypersexual disorder had higher levels of such hormones than the healthy controls, a difference that remained even after controlling for co-morbid depression and childhood trauma.

“Aberrant stress regulation has previously been observed in depressed and suicidal patients as well as in substance abusers,” says Professor Jokinen. “In recent years, the focus has been on whether childhood trauma can lead to a dysregulation of the body’s stress systems via so-called epigenetic mechanisms, in other words how their psychosocial environments can influence the genes that control these systems.” According to the researchers, the results suggest that the same neurobiological system involved in another type of abuse can apply to people with hypersexual disorder.

17) Prefrontal control and internet addiction: a theoretical model and review of neuropsychological and neuroimaging findings (Brand et al., 2015) – [dysfunctional prefrontal circuits/poorer executive function and sensitization] – Excerpt:

Consistent with this, results from functional neuroimaging and other neuropsychological studies demonstrate that cue-reactivity, craving, and decision making are important concepts for understanding Internet addiction. The findings on reductions in executive control are consistent with other behavioral addictions, such as pathological gambling. They also emphasize the classification of the phenomenon as an addiction, because there are also several similarities with findings in substance dependency.  Moreover, the results of the current study are comparable to findings from substance dependency research and emphasize analogies between cybersex addiction and substance dependencies or other behavioral addictions.

18) Implicit associations in cybersex addiction: Adaption of an Implicit Association Test with pornographic pictures (Snagkowski et al., 2015) – [greater cravings/sensitization] – Excerpt:

Recent studies show similarities between cybersex addiction and substance dependencies and argue to classify cybersex addiction as a behavioral addiction. In substance dependency, implicit associations are known to play a crucial role, and such implicit associations have not been studied in cybersex addiction, so far. In this experimental study, 128 heterosexual male participants completed an Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) modified with pornographic pictures. Further, problematic sexual behavior, sensitivity towards sexual excitation, tendencies towards cybersex addiction, and subjective craving due to watching pornographic pictures were assessed. Results show positive relationships between implicit associations of pornographic pictures with positive emotions and tendencies towards cybersex addiction, problematic sexual behavior, sensitivity towards sexual excitation as well as subjective craving. Moreover, a moderated regression analysis revealed that individuals who reported high subjective craving and showed positive implicit associations of pornographic pictures with positive emotions, particularly tended towards cybersex addiction. The findings suggest a potential role of positive implicit associations with pornographic pictures in the development and maintenance of cybersex addiction. Moreover, the results of the current study are comparable to findings from substance dependency research and emphasize analogies between cybersex addiction and substance dependencies or other behavioral addictions.

19) Symptoms of cybersex addiction can be linked to both approaching and avoiding pornographic stimuli: results from an analog sample of regular cybersex users (Snagkowski, et al., 2015) – [greater cravings/sensitization] – Excerpt:

Some approaches point toward similarities to substance dependencies for which approach/avoidance tendencies are crucial mechanisms. Several researchers have argued that within an addiction-related decision situation, individuals might either show tendencies to approach or avoid addiction-related stimuli. In the current study 123 heterosexual males completed an Approach-Avoidance-Task (AAT; Rinck and Becker, 2007) modified with pornographic pictures. During the AAT participants either had to push pornographic stimuli away or pull them toward themselves with a joystick. Sensitivity toward sexual excitation, problematic sexual behavior, and tendencies toward cybersex addiction were assessed with questionnaires.

Results showed that individuals with tendencies toward cybersex addiction tended to either approach or avoid pornographic stimuli. Additionally, moderated regression analyses revealed that individuals with high sexual excitation and problematic sexual behavior who showed high approach/avoidance tendencies, reported higher symptoms of cybersex addiction. Analogous to substance dependencies, results suggest that both approach and avoidance tendencies might play a role in cybersex addiction. Moreover, an interaction with sensitivity toward sexual excitation and problematic sexual behavior could have an accumulating effect on the severity of subjective complaints in everyday life due to cybersex use. The findings provide further empirical evidence for similarities between cybersex addiction and substance dependencies. Such similarities could be retraced to a comparable neural processing of cybersex- and drug-related cues.

20) Getting stuck with pornography? Overuse or neglect of cybersex cues in a multitasking situation is related to symptoms of cybersex addiction (Schiebener et al., 2015) – [greater cravings/sensitization and poorer executive control] – Excerpt:

Some individuals consume cybersex contents, such as pornographic material, in an addictive manner, which leads to severe negative consequences in private life or work. One mechanism leading to negative consequences may be reduced executive control over cognition and behavior that may be necessary to realize goal-oriented switching between cybersex use and other tasks and obligations of life. To address this aspect, we investigated 104 male participants with an executive multitasking paradigm with two sets: One set consisted of pictures of persons, the other set consisted of pornographic pictures. In both sets the pictures had to be classified according to certain criteria. The explicit goal was to work on all classification tasks to equal amounts, by switching between the sets and classification tasks in a balanced manner.

We found that less balanced performance in this multitasking paradigm was associated with a higher tendency towards cybersex addiction. Persons with this tendency often either overused or neglected working on the pornographic pictures. The results indicate that reduced executive control over multitasking performance, when being confronted with pornographic material, may contribute to dysfunctional behaviors and negative consequences resulting from cybersex addiction. However, individuals with tendencies towards cybersex addiction seem to have either an inclination to avoid or to approach the pornographic material, as discussed in motivational models of addiction.

21) Trading Later Rewards for Current Pleasure: Pornography Consumption and Delay Discounting (Negash et al., 2015) – [poorer executive control: causation experiment] – Excerpts:

Study 1: Participants completed a pornography use questionnaire and a delay discounting task at Time 1 and then again four weeks later. Participants reporting higher initial pornography use demonstrated a higher delay discounting rate at Time 2, controlling for initial delay discounting. Study 2:  Participants who abstained from pornography use demonstrated lower delay discounting than participants who abstained from their favorite food.

Internet pornography is a sexual reward that contributes to delay discounting differently than other natural rewards do, even when use is not compulsive or addictive. This research makes an important contribution, demonstrating that the effect goes beyond temporary arousal.

Pornography consumption may provide immediate sexual gratification but can have implications that transcend and affect other domains of a person’s life, especially relationships.

The finding suggests that Internet pornography is a sexual reward that contributes to delay discounting differently than other natural rewards. It is therefore important to treat pornography as a unique stimulus in reward, impulsivity, and addiction studies and to apply this accordingly in individual as well as relational treatment.

22) Sexual Excitability and Dysfunctional Coping Determine Cybersex Addiction in Homosexual Males (Laier et al., 2015) – [greater cravings/sensitization] – Excerpt:

Recent findings have demonstrated an association between CyberSex Addiction (CA) severity and indicators of sexual excitability, and that coping by sexual behaviors mediated the relationship between sexual excitability and CA symptoms. The aim of this study was to test this mediation in a sample of homosexual males. Questionnaires assessed symptoms of CA, sensitivity to sexual excitation, pornography use motivation, problematic sexual behavior, psychological symptoms, and sexual behaviors in real life and online. Moreover, participants viewed pornographic videos and indicated their sexual arousal before and after the video presentation. Results showed strong correlations between CA symptoms and indicators of sexual arousal and sexual excitability, coping by sexual behaviors, and psychological symptoms. CA was not associated with offline sexual behaviors and weekly cybersex use time. Coping by sexual behaviors partially mediated the relationship between sexual excitability and CA. The results are comparable with those reported for heterosexual males and females in previous studies and are discussed against the background of theoretical assumptions of CA, which highlight the role of positive and negative reinforcement due to cybersex use.

23) The Role of Neuroinflammation in the Pathophysiology of Hypersexual Disorder (Jokinen et al., 2016) – [dysfunctional stress response and neuro-inflammation] – This study reported higher levels of circulating Tumor Necrosis Factor (TNF) in sex addicts when compared to healthy controls. Elevated levels of TNF (a marker of inflammation) have also been found in substance abusers and drug-addicted animals (alcohol, heroin, meth). There were strong correlations between TNF levels and rating scales measuring hypersexuality.

24) Compulsive Sexual Behavior: Prefrontal And Limbic Volume and Interactions (Schmidt et al., 2016) – [dysfunctional prefrontal circuits and sensitization] – This is an fMRI study. Compared to healthy controls CSB subjects (porn addicts) had increased left amygdala volume and reduced functional connectivity between the amygdala and dorsolateral prefrontal cortex DLPFC. Reduced functional connectivity between the amygdala and the prefrontal cortex aligns with substance addictions. It is thought that poorer connectivity diminishes the prefrontal cortex’s control over a user’s impulse to engage in the addictive behavior. This study suggests that drug toxicity may lead to less grey matter and thus reduced amygdala volume in drug addicts. The amygdala is consistently active during porn viewing, especially during initial exposure to a sexual cue. Perhaps the constant sexual novelty and searching and seeking leads to a unique effect on the amygdala in compulsive porn users. Alternatively, years of porn addiction and severe negative consequences are very stressful – and chronic social stress is related to increased amygdala volume. Study #16 above found that “sex addicts” have an overactive stress system. Could the chronic stress related to porn/sex addiction, along with factors that make sex unique, lead to greater amygdala volume? An excerpt:

Our current findings highlight elevated volumes in a region implicated in motivational salience and lower resting state connectivity of prefrontal top-down regulatory control networks. Disruption of such networks may explain the aberrant behavioral patterns toward environmentally salient reward or enhanced reactivity to salient incentive cues. Although our volumetric findings contrast with those in SUD, these findings may reflect differences as a function of the neurotoxic effects of chronic drug exposure. Emerging evidence suggests potential overlaps with an addiction process particularly supporting incentive motivation theories. We have shown that activity in this salience network is then enhanced following exposure to highly salient or preferred sexually explicit cues [Brand et al., 2016; Seok and Sohn, 2015; Voon et al., 2014] along with enhanced attentional bias [Mechelmans et al., 2014] and desire specific to the sexual cue but not generalized sexual desire [Brand et al., 2016; Voon et al., 2014]. Enhanced attention to sexually explicit cues is further associated with preference for sexually conditioned cues thus confirming the relationship between sexual cue conditioning and attentional bias [Banca et al., 2016]. These findings of enhanced activity related to sexually conditioned cues differ from that of the outcome (or the unconditioned stimulus) in which enhanced habituation, possibly consistent with the concept of tolerance, increases the preference for novel sexual stimuli [Banca et al., 2016]. Together these findings help elucidate the underlying neurobiology of CSB leading toward a greater understanding of the disorder and identification of possible therapeutic markers.

25) Ventral Striatum Activity When Watching Preferred Pornographic Pictures is Correlated With Symptoms of Internet Pornography Addiction (Brand et al., 2016) – [greater cue reactivity/sensitization] – A German fMRI study. Finding #1: Reward center activity (ventral striatum) was higher for preferred pornographic pictures. Finding #2: Ventral striatum reactivity correlated with the internet sex addiction score. Both findings indicate sensitization and align with the addiction model. The authors state that the “Neural basis of Internet pornography addiction is comparable to other addictions.” An excerpt:

One type of Internet addiction is excessive pornography consumption, also referred to as cybersex or Internet pornography addiction. Neuroimaging studies found ventral striatum activity when participants watched explicit sexual stimuli compared to non-explicit sexual/erotic material. We now hypothesized that the ventral striatum should respond to preferred pornographic compared to non-preferred pornographic pictures and that the ventral striatum activity in this contrast should be correlated with subjective symptoms of Internet pornography addiction. We studied 19 heterosexual male participants with a picture paradigm including preferred and non-preferred pornographic material.

Pictures from the preferred category were rated as more arousing, less unpleasant, and closer to ideal. Ventral striatum response was stronger for the preferred condition compared to non-preferred pictures. Ventral striatum activity in this contrast was correlated with the self-reported symptoms of Internet pornography addiction. The subjective symptom severity was also the only significant predictor in a regression analysis with ventral striatum response as dependent variable and subjective symptoms of Internet pornography addiction, general sexual excitability, hypersexual behavior, depression, interpersonal sensitivity, and sexual behavior in the last days as predictors. The results support the role for the ventral striatum in processing reward anticipation and gratification linked to subjectively preferred pornographic material. Mechanisms for reward anticipation in ventral striatum may contribute to a neural explanation of why individuals with certain preferences and sexual fantasies are at-risk for losing their control over Internet pornography consumption.

26) Altered Appetitive Conditioning and Neural Connectivity in Subjects With Compulsive Sexual Behavior (Klucken et al., 2016) – [greater cue reactivity/sensitization and dysfunctional prefrontal circuits] – This German fMRI study replicated two major findings from Voon et al., 2014 and Kuhn & Gallinat 2014. Main Findings: The neural correlates of appetitive conditioning and neural connectivity were altered in the CSB group. According to the researchers, the first alteration – heightened amygdala activation – might reflect facilitated conditioning (greater “wiring” to previously neutral cues predicting porn images). The second alteration – decreased connectivity between the ventral striatum and the prefrontal cortex – could be a marker for impaired ability to control impulses. Said the researchers, “These [alterations] are in line with other studies investigating the neural correlates of addiction disorders and impulse control deficits.” The findings of greater amygdalar activation to cues (sensitization) and decreased connectivity between the reward center and the prefrontal cortex (hypofrontality) are two of the major brain changes seen in substance addiction. In addition, 3 of the 20 compulsive porn users suffered from “orgasmic-erection disorder.” An excerpt:

In general, the observed increased amygdala activity and the concurrently decreased ventral striatal-PFC coupling allows speculations about the etiology and treatment of CSB. Subjects with CSB seemed more prone to establish associations between formally neutral cues and sexually relevant environmental stimuli. Thus, these subjects are more likely to encounter cues that elicit approaching behavior. Whether this leads to CSB or is a result of CSB must be answered by future research. In addition, impaired regulation processes, which are reflected in the decreased ventral striatal-prefrontal coupling, might further support the maintenance of the problematic behavior.

27) Compulsivity Across the Pathological Misuse of Drug and Non-Drug Rewards (Banca et al., 2016) – [greater cue reactivity/sensitization, enhanced conditioned responses] – This Cambridge University fMRI study compares aspects of compulsivity in alcoholics, binge-eaters, video game addicts and porn addicts (CSB). Excerpts:

In contrast to other disorders, CSB compared to HV showed faster acquisition to reward outcomes along with a greater perseveration in the reward condition irrespective of outcome. The CSB subjects did not show any specific impairments in set shifting or reversal learning. These findings converge with our previous findings of enhanced preference for stimuli conditioned to either sexual or monetary outcomes, overall suggesting enhanced sensitivity to rewards (Banca et al., 2016). Further studies using salient rewards are indicated.

28) Subjective Craving for Pornography and Associative Learning Predict Tendencies Towards Cybersex Addiction in a Sample of Regular Cybersex Users (Snagkowski et al., 2016) – [greater cue reactivity/sensitization, enhanced conditioned responses] – This unique study conditioned subjects to formerly neutral shapes, which predicted the appearance of a pornographic image. Excerpts:

There is no consensus regarding the diagnostic criteria of cybersex addiction. Some approaches postulate similarities to substance dependencies, for which associative learning is a crucial mechanism. In this study, 86 heterosexual males completed a Standard Pavlovian to Instrumental Transfer Task modified with pornographic pictures to investigate associative learning in cybersex addiction. Additionally, subjective craving due to watching pornographic pictures and tendencies towards cybersex addiction were assessed. Results showed an effect of subjective craving on tendencies towards cybersex addiction, moderated by associative learning. Overall, these findings point towards a crucial role of associative learning for the development of cybersex addiction, while providing further empirical evidence for similarities between substance dependencies and cybersex addiction. In summary, the results of the current study suggest that associative learning might play a crucial role regarding the development of cybersex addiction. Our findings provide further evidence for similarities between cybersex addiction and substance dependencies since influences of subjective craving and associative learning were shown.

29) Mood changes after watching pornography on the Internet are linked to symptoms of Internet-pornography-viewing disorder (Laier & Brand, 2016) – [greater cravings/sensitization, less liking] – Excerpts:

The main results of the study are that tendencies towards Internet Pornography Disorder (IPD) were associated negatively with feeling generally good, awake, and calm as well as positively with perceived stress in daily life and the motivation to use Internet pornography in terms of excitation seeking and emotional avoidance.  Furthermore, tendencies towards IPD were negatively related to mood before and after watching Internet pornography as well as an actual increase of good and calm mood. The relationship between tendencies towards IPD and excitement seeking due to Internet-pornography use was moderated by the evaluation of the experienced orgasm’s satisfaction. Generally, the results of the study are in line with the hypothesis that IPD is linked to the motivation to find sexual gratification and to avoid or to cope with aversive emotions as well as with the assumption that mood changes following pornography consumption are linked to IPD (Cooper et al., 1999 and Laier and Brand, 2014).

30) Problematic sexual behavior in young adults: Associations across clinical, behavioral, and neurocognitive variables (2016) – [poorer executive functioning] – Individuals with Problematic Sexual Behaviors (PSB) exhibited several neuro-cognitive deficits. These findings indicate poorer executive functioning (hypofrontality) which is a key brain feature occurring in drug addicts. A few excerpts:

One notable result from this analysis is that PSB shows significant associations with a number of deleterious clinical factors, including lower self-esteem, decreased quality of life, elevated BMI, and higher comorbidity rates for several disorders…

…it is also possible that the clinical features identified in the PSB group are actually the result of a tertiary variable which gives rise to both PSB and the other clinical features. One potential factor filling this role could be the neurocognitive deficits identified in the PSB group, particularly those relating to working memory, impulsivity/impulse control, and decision making. From this characterization, it is be possible to trace the problems evident in PSB and additional clinical features, such as emotional dysregulation, to particular cognitive deficits…

If the cognitive problems identified in this analysis are actually the core feature of PSB, this may have notable clinical implications.

31) Methylation of HPA Axis Related Genes in Men With Hypersexual Disorder (Jokinen et al., 2017) – [dysfunctional stress response, epigenetic changes] – This is a follow-up of #16 above which found that sex addicts have dysfunctional stress systems – a key neuro-endocrine change caused by addiction. The current study found epigenetic changes on genes central to the human stress response and closely associated with addiction. With epigenetic changes, the DNA sequence isn’t altered (as happens with a mutation). Instead, the gene is tagged and its expression is turned up or down (short video explaining epigenetics). The epigenetic changes reported in this study resulted in altered CRF gene activity. CRF is a neurotransmitter and hormone that drives addictive behaviors such as cravings, and is a major player in many of the withdrawal symptoms experienced in connection with substance and behavioral addictions, including porn addiction.

32) Exploring the Relationship between Sexual Compulsivity and Attentional Bias to Sex-Related Words in a Cohort of Sexually Active Individuals (Albery et al., 2017) – [greater cue reactivity/sensitization, desensitization] – This study replicates the findings of this 2014 Cambridge University study, which compared the attentional bias of porn addicts to healthy controls. Here’s what’s new: The study correlated the “years of sexual activity” with 1) the sex addiction scores and also 2) the results of the attentional bias task. Among those scoring high on sexual addiction, fewer years of sexual experience were related to greater attentional bias (explanation of attentional bias). So higher sexual compulsivity scores + fewer years of sexual experience = greater signs of addiction (greater attentional bias, or interference). But attentional bias declines sharply in the compulsive users, and disappears at the highest number of years of sexual experience. The authors concluded that this result could indicate that more years of “compulsive sexual activity” lead to greater habituation or a general numbing of the pleasure response (desensitization). An excerpt from the conclusion:

One possible explanation for these results is that as a sexually compulsive individual engages in more compulsive behaviour, an associated arousal template develops [36–38] and that over time, more extreme behaviour is required for the same level of arousal to be realised. It is further argued that as an individual engages in more compulsive behaviour, neuropathways become desensitized to more ‘normalised’ sexual stimuli or images and individuals turn to more ‘extreme’ stimuli to realise the arousal desired. This is in accordance with work showing that ‘healthy’ males become habituated to explicit stimuli over time and that this habituation is characterised by decreased arousal and appetitive responses [39]. This suggests that more compulsive, sexually active participants have become ‘numb’ or more indifferent to the ‘normalised’ sex-related words used in the present study and as such display decreased attentional bias, while those with increased compulsivity and less experience still showed interference because the stimuli reflect more sensitised cognition.

33) Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video (Messina et al., 2017) – [poorer executive functioning, greater cravings/sensitization] – Exposure to porn affected executive functioning in men with “compulsive sexual behaviors,” but not healthy controls. Poorer executive functioning when exposed to addiction-related cues is a hallmark of substance disorders (indicating both altered prefrontal circuits and sensitization). Excerpts:

This finding indicates better cognitive flexibility after sexual stimulation by controls compared with sexually compulsive participants. These data support the idea that sexually compulsive men do not to take advantage of the possible learning effect from experience, which could result in better behavior modification. This also could be understood as a lack of a learning effect by the sexually compulsive group when they were sexually stimulated, similar to what happens in the cycle of sexual addiction, which starts with an increasing amount of sexual cognition, followed by the activation of sexual scripts and then orgasm, very often involving exposure to risky situations.

34) Can Pornography be Addictive? An fMRI Study of Men Seeking Treatment for Problematic Pornography Use (Gola et al., 2017) – [greater cue reactivity/sensitization, enhanced conditioned responses] – An fMRI study involving a unique cue-reactivity paradigm where formerly neutral shapes predicted the appearance of pornographic images. Excerpts:

Men with and without problematic porn use (PPU) differed in brain reactions to cues predicting erotic pictures, but not in reactions to erotic pictures themselves, consistent with the incentive salience theory of addictions. This brain activation was accompanied by increased behavioral motivation to view erotic images (higher ‘wanting’). Ventral striatal reactivity for cues predicting erotic pictures was significantly related to the severity of PPU, amount of pornography use per week and number of weekly masturbations. Our findings suggest that like in substance-use and gambling disorders the neural and behavioral mechanisms linked to anticipatory processing of cues relate importantly to clinically relevant features of PPU. These findings suggest that PPU may represent a behavioral addiction and that interventions helpful in targeting behavioral and substance addictions warrant consideration for adaptation and use in helping men with PPU.

35) Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (Kunaharan et al., 2017) – [habituation or desensitization] – Study assessed porn users’ responses (EEG readings & Startle Response) to various emotion-inducing images – including erotica. The study found several neurological differences between low frequency porn users and high frequency porn users. Excerpts:

Findings suggest that increased pornography use appears to have an influence on the brain’s non-conscious responses to emotion-inducing stimuli which was not shown by explicit self-report.

4.1. Explicit Ratings: Interestingly, the high porn use group rated the erotic images as more unpleasant than the medium use group. The authors suggest this may be due to the relatively “soft-core” nature of the “erotic” images contained in the IAPS database not providing the level of stimulation that they may usually seek out, as it has been shown by Harper and Hodgins [58] that with frequent viewing of pornographic material, many individuals often escalate into viewing more intense material to maintain the same level of physiological arousal. The “pleasant” emotion category saw valence ratings by all three groups to be relatively similar with the high use group rating the images as slightly more unpleasant on average than the other groups. This may again be due to the “pleasant” images presented not being stimulating enough for the individuals in the high use group. Studies have consistently shown a physiological downregulation in processing of appetitive content due to habituation effects in individuals who frequently seek out pornographic material [3, 7, 8]. It is the authors’ contention that this effect may account for the results observed.

4.3. Startle Reflex Modulation (SRM): The relative higher amplitude startle effect seen in the low and medium porn use groups may be explained by those in the group intentionally avoiding the use of pornography, as they may find it to be relatively more unpleasant. Alternatively, the results obtained also may be due to a habituation effect, whereby individuals in these groups do watch more pornography than they explicitly stated—possibly due to reasons of embarrassment among others, as habituation effects have been shown to increase startle eye blink responses [41, 42].

36) Exposure to Sexual Stimuli Induces Greater Discounting Leading to Increased Involvement in Cyber Delinquency Among Men (Cheng & Chiou, 2017) – [poorer executive functioning, greater impulsivity – causation experiment] – In two studies exposure to visual sexual stimuli resulted in: 1) greater delayed discounting (inability to delay gratification), 2) greater inclination to engage in cyber-delinquency, 3) greater inclination to purchase counterfeit goods and hack someone’s Facebook account. Taken together this indicates that porn use increases impulsivity and may reduce certain executive functions (self-control, judgment, foreseeing consequences, impulse control). Excerpt:

People frequently encounter sexual stimuli during Internet use. Research has shown that stimuli inducing sexual motivation can lead to greater impulsivity in men, as manifested in greater temporal discounting (i.e., a tendency to prefer smaller, immediate gains to larger, future ones).

In conclusion, the current results demonstrate an association between sexual stimuli (e.g., exposure to pictures of sexy women or sexually arousing clothing) and men’s involvement in cyber delinquency. Our findings suggest that men’s impulsivity and self-control, as manifested by temporal discounting, are susceptible to failure in the face of ubiquitous sexual stimuli. Men may benefit from monitoring whether exposure to sexual stimuli is associated with their subsequent delinquent choices and behavior. Our findings suggest that encountering sexual stimuli can tempt men down the road of cyber delinquency

The current results suggest that the high availability of sexual stimuli in cyberspace may be more closely associated with men’s cyber-delinquent behavior than previously thought.

37) Predictors for (Problematic) Use of Internet Sexually Explicit Material: Role of Trait Sexual Motivation and Implicit Approach Tendencies Towards Sexually Explicit Material (Stark et al., 2017) – [greater cue reactivity/sensitization/cravings] – Excerpts:

The present study investigated whether trait sexual motivation and implicit approach tendencies toward sexual material are predictors of problematic SEM use and of the daily time spent watching SEM. In a behavioral experiment, we used the Approach-Avoidance Task (AAT) for measuring implicit approach tendencies towards sexual material. A positive correlation between implicit approach tendency towards SEM and the daily time spent on watching SEM might be explained by attentional effects: A high implicit approach tendency can be interpreted as an attentional bias towards SEM. A subject with this attentional bias might be more attracted to sexual cues on the Internet resulting in higher amounts of time spent on SEM sites.

38) Pornography Addiction Detection based on Neurophysiological Computational Approach (Kamaruddin et al., 2018) – Excerpt:

In this paper, a method of using brain signal from frontal area captured using EEG is proposed to detect whether the participant may have porn addiction or otherwise. It acts as a complementary approach to common psychological questionnaire. Experimental results show that the addicted participants had low alpha waves activity in the frontal brain region compared to non-addicted participants. It can be observed using power spectra computed using Low Resolution Electromagnetic Tomography (LORETA). The theta band also show there is disparity between addicted and non-addicted. However, the distinction is not as obvious as alpha band.

39) Gray matter deficits and altered resting-state connectivity in the superior temporal gyrus among individuals with problematic hypersexual behavior (Seok & Sohn, 2018) – [gray matter deficits in temporal cortex, poorer functional connectivity between temporal cortex and precuneus & caudate] – An fMRI study comparing carefully screened sex addicts (“problematic hypersexual behavior”) to healthy control subjects. Compared to controls sex addicts had: 1) reduced gray matter in the temporal lobes (regions associated with inhibiting sexual impulses); 2) reduced precuneus to temporal cortex functional connectivity (may indicate abnormality in ability to shift attention); 3) reduced caudate to temporal cortex functional connectivity (may inhibit the top-down control of impulses). Excerpts:

These findings suggest that the structural deficits in the temporal gyrus and the altered functional connectivity between the temporal gyrus and specific areas (i.e., the precuneus and caudate) might contribute to the disturbances in tonic inhibition of sexual arousal in individuals with PHB. Thus, these results suggest that changes in structure and functional connectivity in the temporal gyrus might be PHB specific features and may be biomarker candidates for the diagnosis of PHB.

Gray matter enlargement in the right cerebellar tonsil and increased connectivity of the left cerebellar tonsil with the left STG were also observed…. Therefore, it is possible that the increased gray matter volume and functional connectivity in the cerebellum is associated with compulsive behavior in individuals with PHB.

In summary, the present VBM and functional connectivity study showed gray matter deficits and altered functional connectivity in the temporal gyrus among individuals with PHB. More importantly, the diminished structure and functional connectivity were negatively correlated with the severity of PHB. These findings provide new insights into the underlying neural mechanisms of PHB.

40) Tendencies toward Internet-pornography-use disorder: Differences in men and women regarding attentional biases to pornographic stimuli (Pekal et al., 2018) – [greater cue reactivity/sensitization, enhanced cravings]. Excerpts

 Several authors consider Internet-pornography-use disorder (IPD) as addictive disorder. One of the mechanisms that has been intensively studied in substance- and non-substance-use disorders is an enhanced attentional bias toward addiction-related cues. Attentional biases are described as cognitive processes of individual’s perception affected by the addiction-related cues caused by the conditioned incentive salience of the cue itself. It is assumed in the I-PACE model that in individuals prone to develop IPD symptoms implicit cognitions as well as cue-reactivity and craving arise and increase within the addiction process. To investigate the role of attentional biases in the development of IPD, we investigated a sample of 174 male and female participants. Attentional bias was measured with the Visual Probe Task, in which participants had to react on arrows appearing after pornographic or neutral pictures. In addition, participants had to indicate their sexual arousal induced by pornographic pictures. Furthermore, tendencies toward IPD were measured using the short-Internetsex Addiction Test. The results of this study showed a relationship between attentional bias and symptom severity of IPD partially mediated by indicators for cue-reactivity and craving. While men and women generally differ in reaction times due to pornographic pictures, a moderated regression analysis revealed that attentional biases occur independently of sex in the context of IPD symptoms. The results support theoretical assumptions of the I-PACE model regarding the incentive salience of addiction-related cues and are consistent with studies addressing cue-reactivity and craving in substance-use disorders.

41) Altered Prefrontal and Inferior Parietal Activity During a Stroop Task in Individuals With Problematic Hypersexual Behavior (Seok & Sohn, 2018) – [poorer executive control- impaired PFC functionality. Excerpts:

Accumulating evidence suggests a relationship between problematic hypersexual behavior (PHB) and diminished executive control. Clinical studies have demonstrated that individuals with PHB exhibit high levels of impulsivity; however, relatively little is known regarding the neural mechanisms underlying impaired executive control in PHB. This study investigated the neural correlates of executive control in individuals with PHB and healthy controls using event-related functional magnetic resonance imaging (fMRI). Twenty-three individuals with PHB and 22 healthy control participants underwent fMRI while performing a Stroop task. Response time and error rates were measured as surrogate indicators of executive control. Individuals with PHB exhibited impaired task performance and lower activation in the right dorsolateral prefrontal cortex (DLPFC) and inferior parietal cortex relative to healthy controls during the Stroop task. In addition, blood oxygen level-dependent responses in these areas were negatively associated with PHB severity. The right DLPFC and inferior parietal cortex are associated with higher-order cognitive control and visual attention, respectively. Our findings suggest that individuals with PHB have diminished executive control and impaired functionality in the right DLPFC and inferior parietal cortex, providing a neural basis for PHB.

42) Trait and state impulsivity in males with tendency towards Internet-pornography-use disorder (Antons & Brand, 2018) – [enhanced cravings, greater state & trait impulsivity]. Excerpts:

Results indicate that trait impulsivity was associated with higher symptom severity of Internet-pornography-use disorder (IPD). Especially those males with higher trait impulsivity and state impulsivity in the pornographic condition of the stop-signal task as well as those with high craving reactions showed severe symptoms of IPD.

The results indicate that both trait and state impulsivity play a crucial role in the development of IPD. In accordance with dual-process models of addiction, the results may be indicative of an imbalance between the impulsive and reflective systems which might be triggered by pornographic material. This may result in loss of control over the Internet-pornography use albeit experiencing negative consequences.

43) Facets of impulsivity and related aspects differentiate among recreational and unregulated use of Internet pornography (Stephanie et al., 2019) – [enhanced cravings, greater delayed discounting (hypofrontality), habituation]. Excerpts:

Because of its primarily rewarding nature, Internet pornography (IP) is a predestinated target for addictive behaviors. Impulsivity-related constructs have been identified as promoters of addictive behaviors. In this study, we investigated impulsive tendencies (trait impulsivity, delay discounting, and cognitive style), craving toward IP, attitude regarding IP, and coping styles in individuals with recreational–occasional, recreational–frequent, and unregulated IP use. Groups of individuals with recreational–occasional use (n = 333), recreational–frequent use (n = 394), and unregulated use (n = 225) of IP were identified by screening instruments.

Individuals with unregulated use showed the highest scores for craving, attentional impulsivity, delay discounting, and dysfunctional coping, and lowest scores for functional coping and need for cognition. The results indicate that some facets of impulsivity and related factors such as craving and a more negative attitude are specific for unregulated IP users. The results are also consistent with models on specific Internet use disorders and addictive behaviors…. Furthermore, individuals with unregulated IP use had a more negative attitude toward IP compared to the recreational–frequent users. This result might suggest that individuals with unregulated IP use have a high motivation or urge to use IP, although they may have developed a negative attitude toward IP use, perhaps because they have already experienced negative consequences linked to their IP use pattern. This is consistent with the incentive-sensitization theory of addiction (Berridge & Robinson, 2016), which proposes a shift from liking to wanting during addiction.

A further interesting result is that the effect size for post-hoc tests duration in minutes per session, when comparing unregulated users with recreational–frequent users, was higher in comparison to the frequency per week. This might indicate that individuals with unregulated IP use especially have difficulties to stop watching IP during a session or need longer time to achieve the desired reward, which might be comparable with a form of tolerance in substance use disorders. This is consistent with the results from a diary assessment, which revealed that pornographic binges are one of the most characteristic behaviors in treatment-seeking males with compulsive sexual behaviors (Wordecha et al., 2018).

44) Approach bias for erotic stimuli in heterosexual male college students who use pornography (2019) – [enhanced approach bias (sensitization)]. Excerpts:

The results support the hypothesis that heterosexual male college students who use pornography are faster to approach than to avoid erotic stimuli during an AAT task….. These findings are also in line with several SRC tasks suggesting that addicted individuals display an action tendency to approach rather than avoid addictive stimuli (Bradley et al., 2004; Field et al., 2006, 2008).

Overall, the findings suggest that approach for addictive stimuli may be a more rapid or prepared response than avoidance, which may be explained by the interplay of other cognitive biases in addictive behaviors….. Moreover, total scores on the BPS were positively correlated with approach bias scores, indicating that the greater the severity of problematic pornography use, the stronger the degree of approach for erotic stimuli. This association was further supported by results suggesting that individuals with problematic pornography use, as classified by the PPUS, showed more than a 200% stronger approach bias for erotic stimuli compared to individuals without problematic pornography use.

Taken together, the results suggest parallels between substance and behavioral addictions (Grant et al., 2010). Pornography use (particularly problematic use) was linked to faster approaches to erotic stimuli than neutral stimuli, an approach bias similar to that observed in alcohol-use disorders (Field et al., 2008; Wiers et al., 2011), cannabis use (Cousijn et al., 2011; Field et al., 2006), and tobacco-use disorders (Bradley et al., 2004). An overlap between cognitive features and neurobiological mechanisms involved in both substance addictions and problematic pornography use seems likely, which is consistent with prior studies (Kowalewska et al., 2018; Stark et al., 2018).

45) Hypermethylation-associated downregulation of microRNA-4456 in hypersexual disorder with putative influence on oxytocin signalling: A DNA methylation analysis of miRNA genes (2019) – [likely dysfunctional stress system]. Study on subjects with hypersexuality (porn/sex addiction) reports epigenetic changes mirroring those occurring in alcoholics. The epigenetic changes occurred in genes associated with the oxytocin system (which is important in love, bonding, addiction, stress, sexual functioning, etc.). Excerpts:

In a DNA methylation association analysis in peripheral blood, we identify distinct CpG-sites associated with MIR708 and MIR4456 that are significantly differentially methylated in hypersexuality disorder (HD) patients. Additionally, we demonstrate that hsamiR- 4456 associated methylation locus cg01299774 is differentially methylated in alcohol dependence, suggesting that it may be primarily associated with the addictive component observed in HD.

The involvement of the oxytocin signaling pathway identified in this study appears to be significantly implicated in many of the characteristics defining HD as proposed by Kafka et al. [1], such as sexual desire dysregulation, compulsivity, impulsivity and (sexual) addiction.

In conclusion, MIR4456 has significantly lower expression in HD. Our study provides evidence that DNA methylation at the cg01299774 locus is associated with the expression of MIR4456. This miRNA putatively targets genes preferentially expressed in brain tissue and involved in major neuronal molecular mechanisms thought to be relevant to the pathogenesis of HD. Our findings from the investigation of shifts in the epigenome contributes to further elucidating the biological mechanisms behind the pathophysiology of HD with special emphasis onMIR4456 and its role in oxytocin regulation.

46) Gray matter volume differences in impulse control and addictive disorders (Draps et al., 2020) –  [hypofrontaility: descreased prefrontal cortex & anterior cingulate cortex  gray matter]. Excerpts:

Here we contrast gray matter volumes (GMVs) across groups of individuals with compulsive sexual behavior disorder (CSBD), gambling disorder (GD), and alcohol use disorder (AUD) with those with none of these disorders (healthy controls participants; HCs).

Affected individuals (CSBD, GD, AUD) compared to HC participants showed smaller GMVs in the left frontal pole, specifically in the orbitofrontal cortex. The most pronounced differences were observed in the GD and AUD groups, and the least in the CSBD group. There was a negative correlation between GMVs and disorder severity in the CSBD group. Higher severity of CSBD symptoms was correlated with decreased GMV in the right anterior cingulate gyrus.

This study is the first showing smaller GMVs in 3 clinical groups of CSBD, GD and AUD. Our findings suggest similarities between specific impulse control disorders and addictions.

The anterior cingulate cortex (ACC) has been implicated functionally in cognitive control, processing negative stimuli [56],[57], error prediction processing, reward learning [58], [59] and cue-reactivity [60],[34]. With respect to CSBD, ACC activity in response to sexually explicit cues was linked to sexual desire in men with CSBD [61]. Men with CSBD also displayed an enhanced preference for sexual novelty, which was related to ACC habituation [62]. As such, the current findings extend prior functional studies by suggesting that ACC volume relates importantly to CSBD symptomatology in men.

47) High Plasma Oxytocin Levels in Men With Hypersexual Disorder (2020) – From the researche group that published 4 previous neuro-endocrine studies on male “hypersexuals” (sex/porn addicts). Because oxytocin is involved in our stress response, higher blood levels were interpreted as an indicator of an overactive stress system in the sex addicts. This finding aligns with the researcher’s previous studies and neurological studies reporting a dysfunctional stress response in substance abusers. Interestingly, therapy (CBT) reduced oxytocin levels in hypersexual patients. Excerpts:

Hypersexual disorder (HD) integrating pathophysiological aspects such as sexual desire deregulation, sexual addiction, impulsivity and compulsivity was suggested as a diagnosis for the DSM-5. “Compulsive Sexual Behavior Disorder” is now presented as an impulse-control disorder in ICD-11. Recent studies showed dysregulated HPA axis in men with HD. Oxytocin (OXT) affects the function of the HPA axis; no studies have assessed OXT levels in patients with HD. Whether a CBT treatment for HD symptoms has an effect on OXT levels has not been investigated.

We examined plasma OXT levels in 64 male patients with HD and 38 male age-matched healthy volunteers. Further, we examined correlations between plasma OXT levels and dimensional symptoms of HD using the rating scales measuring hypersexual behaviour.

Patients with HD had significantly higher OXT  levels compared to healthy volunteers. There were significant positive correlations between OXT levels and the rating scales measuring hypersexual behaviour. Patients who completed CBT treatment had significant reduction of OXT levels from pre-treatment.The results suggest hyperactive oxytonergic system in male patients with hypersexual disorder which may be a compensatory mechanism to attenuate hyperactive stress system. A successful CBT group therapy may have effect on hyperactive oxytonergic system.

48) Inhibitory control and problematic Internet-pornography use – The important balancing role of the insula (Anton & Brand, 2020) – The authors state their results indicate tolerance, a hallmark of an addiction process. Excerpts:

Our current study should be seen as a first approach inspiring future investigations regarding the associations between psychological and neural mechanisms of craving, problematic IP use, motivation to change behavior, and inhibitory control.

Consistent with previous studies (e.g., Antons & Brand, 2018; Brand, Snagowski, Laier, & Maderwald, 2016; Gola et al., 2017; Laier et al., 2013), we found a high correlation between subjective craving and symptom severity of problematic IP use in both conditions. However, the increase in craving as measure for cue-reactivity was not associated with symptom severity of problematic IP use, this may relate to tolerance (cf. Wéry & Billieux, 2017) given that the pornographic images used in this study were not individualized in terms of subjective preferences. Therefore, the standardized pornographic material used may not be strong enough for inducing cue-reactivity in individuals with high symptom severity associated with low effects on the impulsive, reflective, and interoceptive systems as well as inhibitory control ability.

Effects of tolerance and motivational aspects may explain the better inhibitory control performance in individuals with higher symptom severity which was associated with differential activity of the interoceptive and reflective system. Diminished control over IP use presumably results from the interaction between the impulsive, reflective, and interoceptive systems.

Taken together, the insula as the key structure representing the interoceptive system plays a pivotal role in inhibitory control when pornographic images are present. Data suggest that individuals with higher symptom severity of problematic IP use performed better in the task due to decreased insula activity during image processing and increased activity during inhibitory control processing. This pattern of activity might be based on effects of tolerance, that is, less hyperactivity of the impulsive system causes less controlling resources of the interoceptive and reflective system. Hence, a shift from impulsive to compulsive behaviors as a consequence of developing problematic IP use or a motivational (avoidance-related) aspect might be relevant, so that all resources were focused on the task and away from pornographic images. The study contributes to a better understanding of diminished control over IP use which is presumably not only a result of an imbalance between dual systems but of the interaction between impulsive, reflective, and interoceptive systems.

49) Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder (2020) – From the research group that published 5 previous neuro-endocrine studies on male “hypersexuals” (sex/porn addicts), revealing altered stress systems, a major marker for addiction (1, 2, 3, 4, 5.). Excerpts:

In this study, we found that male patients with HD had no significant difference in plasma testosterone levels compared with healthy volunteers. On the contrary, they had significantly higher plasma levels of LH.

HD includes in its definition that the behavior can be a result of dysphoric states and stress,¹ and we have previously reported a dysregulation with hyperactivity of the HPA axis¹³ as well as related epigenetic changes in men with HD.

There are complex interactions between HPA and HPG axis, both excitatory as well as inhibitory with differences depending on the developmental stage of the brain.²⁷ Stressful events through effects of the HPA axis may cause an inhibition of LH suppression and consequently of reproduction.²⁷ The 2 systems have reciprocal interactions, and early stressors may alter neuroendocrine responses through epigenetic modifications.

The proposed mechanisms might include the HPA and HPG interaction, the reward neural network, or the inhibition of regulation impulse control of prefrontal cortex regions.³² In conclusion, we report for the first time increased LH plasma levels in hypersexual men compared with healthy volunteers. These preliminary findings contribute to growing literature on the involvement of neuroendocrine systems and dysregulation in HD.

50) Approach bias for erotic stimuli among heterosexual female college students who use pornography (2020) – Neuro-psychological study on female porn users reports findings that mirror those seen in substance addiction studies. Approach bias to porn (sensitization) and anhedonia (desensitization) were positively correlated with pornography use. Study also reported: “we also found a significant positive association between erotic approach bias scores and scores on the SHAPS, which quantifies anhedonia. This indicates that the stronger the approach bias for erotic stimuli, the less pleasure the individual reported experiencing“. Put simply, the neuropsychological sign of an addiction process correlated with lack of pleasure (anhedonia). Excerpts:

Approach bias, or the relatively automatic action tendency to move certain stimuli toward the body rather than away from it, is a key cognitive process involved in key cognitive process involved in addictive behaviors. Dual processing models of addiction posit that addictive behaviors develop as a result of an imbalance between appetitive, “impulsive” motivational
drives and regulatory executive systems. Repeated engagement in addictive behaviors may lead to relatively automatic action tendencies whereby individuals approach rather than avoid addictive stimuli. This study assessed whether an approach bias for erotic stimuli exists among heterosexual college-aged females who report using pornography.

Participants demonstrated a significant approach bias of 24.81 ms for erotic stimuli as compared to neutral stimuli, and this approach bias significantly positively correlated with Problematic Pornography Use Scale scores. These findings are in line with and extend previous findings reporting an approach bias for erotic stimuli among men who regularly use pornography (Sklenarik et al., 2019; Stark et al., 2017).

Moreover, approach bias scores were significantly positively correlated with anhedonia  indicating that the stronger the degree of approach for erotic stimuli, the more anhedonia that was observed.….. This indicates that the stronger the approach bias for erotic stimuli, the less pleasure the individual reported experiencing.

51) Sexual cues alter working memory performance and brain processing in men with compulsive sexual behavior (2020) – [sensitization and poorer executive functioning]

On the behavioural level, patients were slowed down by pornographic material depending on their pornography consumption in the last week, which was reflected by a higher activation in the lingual gyrus. In addition, the lingual gyrus showed a higher functional connectivity to the insula during processing of pornographic stimuli in the patient group. In contrast, healthy subjects showed faster responses when confronted with pornographic pictures only with high cognitive load. Also, patients showed a better memory for pornographic pictures in a surprise recognition task compared to controls, speaking for a higher relevance of pornographic material in the patient group. These findings are in line with the incentive salience theory of addiction, especially the higher functional connectivity to the salience network with the insula as a key hub and the higher lingual activity during processing of pornographic pictures depending on recent pornography consumption.

This could be interpreted in a way that pornographic material has (probably due to learning processes) a high relevance for patients and thus activates the salience (insula) and attention network (inferior parietal), which then leads to a slower reaction time as the salient information is not relevant for the task. Based on these findings, one may conclude that, for subjects displaying CSB, pornographic material has a higher distracting effect and thus a higher salience. Subsequently, the data supports the IST of addiction in CSB.

52) Subjective reward value of visual sexual stimuli is coded in human striatum and orbitofrontal cortex (2020) – [sensitization] – Excerpts:

The higher a subject rated a VSS clip on sexual arousal or valence, the higher activity we found in NAcc, caudate nucleus and OFC during VSS viewing. Additionally, the association between individual sexual arousal ratings and NAcc as well as caudate nucleus activity was stronger when subjects reported more symptoms of problematic pornography use (PPU) measured by the s-IATsex

These individual differences in preference coding might represent a mechanism that mediates addictive VSS use experienced by some individuals. We not only found an association of NAcc and caudate activity with sexual arousal ratings during VSS viewing but the strength of this association was greater when the subject reported more problematic pornography use (PPU). The result supports the hypothesis, that incentive value responses in NAcc and caudate differentiate more strongly between differently preferred stimuli, the more a subject experiences PPU. This extends past studies, where PPU has been linked to a higher striatal response to VSS as compared to a control or non-preferred condition [29,38]. One study, also using an SID task, found increased NAcc activity associated with increased PPU during the anticipation phase only [41]. Our results indicate that a similar effect, i.e. altered incentive salience processing associated with PPU, can also be found in the delivery phase, but only if individual preference is taken into account. The increasing differentiation of incentive value signals in the NAcc could reflect an increased need for seeking and identifying preferred VSS during addiction development.

Given these results can be replicated, they may have important clinical implications. Increased differentiation of incentive value signals might be connected to an increase in time spent searching for highly stimulating material, which later leads to issues in personal or professional life and suffering because of this behavior.

53) The Neurosciences of Health Communication: An fNIRS Analysis of Prefrontal Cortex and Porn Consumption in Young Women for the Development of Prevention Health Programs (2020) – Excerpts:

The results indicate that the viewing of the pornographic clip (vs. control clip) causes an activation of Brodmann’s area 45 of the right hemisphere. An effect also appears between the level of self-reported consumption and the activation of right BA 45: the higher the level of self-reported consumption, the greater the activation. On the other hand, those participants who have never consumed pornographic material do not show activity of the right BA 45 compared to the control clip (indicating a qualitative difference between non-consumers and consumers). These results are consistent with other research made in the field of addictions. It is hypothesized that the mirror neuron system may be involved, through the mechanism of empathy, which could provoke vicarious eroticism.

54) Event-related potentials in a two-choice oddball task of impaired behavioral inhibitory control among males with tendencies towards cybersex addiction (2020) – Excerpts:

Impaired behavioral inhibitory control (BIC) is known to play a crucial role in addictive behavior. However, research has been inconclusive as to whether this is also the case for cybersex addiction. This study aimed to investigate the time course of BIC in male individuals with tendencies towards cybersex addiction (TCA) using event-related potentials (ERPs) and to provide neurophysiological evidence of their deficient BIC.

Individuals with TCA were more impulsive than HC participants and shared neuropsychological and ERP characteristics of substance use disorder or behavioral addictions, which supports the view that cybersex addiction can be conceptualized as a behavioral addiction.

Theoretically, our results indicate that cybersex addiction resembles substance use disorder and impulse control disorder in terms of impulsivity at electrophysiological and behavioral levels. Our findings may fuel the persistent controversy about the possibility of cybersex addiction as a novel type of psychiatric disorder.

55) White matter microstructural and Compulsive Sexual Behaviors Disorder – Diffusion Tensor Imaging study – Brain scan study comparing the white matter structure of porn/sex addicts (CSBD) to controls. Significant differences between controls and CSB subjects. Excerpts:

This is one of the first DTI studies assessing differences between patients with the Compulsive Sexual Behaviors Disorder and healthy controls. Our analysis has uncovered FA reductions in six regions of the brain in CSBD subjects, compared to controls. The differentiating tracts were found in the cerebellum (there were probably parts of the same tract in the cerebellum), the retrolenticular part of the internal capsule, the superior corona radiata and the middle or lateral occipital gyrus white matter.

Our DTI data shows that the neural correlates of CSBD overlap with regions previously reported in the literature as related both, to addiction and OCD (see the red area in Fig. 3). Thus, the present study demonstrated an important similarity in shared FA reductions between CSBD and both OCD and addictions.

Together these neurological studies reported:

1. The 3 major addiction-related brain changes: sensitization, desensitization, and hypofrontality.
2. More porn use correlated with less grey matter in the reward circuit (dorsal striatum).
3. More porn use correlated with less reward circuit activation when briefly viewing sexual images.
4. More porn use correlated with disrupted neural connections between the reward circuit and prefrontal cortex.
5. Addicts had greater prefrontal activity to sexual cues, but less brain activity to normal stimuli (matches drug addiction).
6. Porn use/exposure to porn related to greater delayed discounting (inability to delay gratification). This is a sign of poorer executive functioning.
7. 60% of compulsive porn addicted subjects in one study experienced ED or low libido with partners, but not with porn: all stated that internet porn use caused their ED/low libido.
8. Enhanced attentional bias comparable to drug users. Indicates sensitization (a product of DeltaFosb).
9. Greater wanting & craving for porn, but not greater liking. This aligns with the accepted model of addiction – incentive sensitization.
10. Porn addicts have greater preference for sexual novelty yet their brains habituated faster to sexual images. Not pre-existing.
11. The younger the porn users the greater the cue-induced reactivity in the reward center.
12. Higher EEG (P300) readings when porn users were exposed to porn cues (which occurs in other addictions).
13. Less desire for sex with a person correlating with greater cue-reactivity to porn images.
14. More porn use correlated with lower LPP amplitude when briefly viewing sexual photos: indicates habituation or desensitization.
15. Dysfunctional HPA axis and altered brain stress circuits, which occurs in drug addictions (and greater amygdala volume, which is associated with chronic social stress).
16. Epigenetic changes on genes central to the human stress response and closely associated with addiction.
17. Higher levels of Tumor Necrosis Factor (TNF) – which also occurs in drug abuse and addiction.
18. A deficit in temporal cortex gray matter; poorer connectivity between temporal corporate and several other regions.
19. Greater state impulsivity.
20. Decreased prefrontal cortex and anterior cingulate gyrus gray matter compared to healthy controls.
21. Reductions in white matter compared to healthy controls.

Published: 3/12/2015 (link to original article)

• UPDATE: June 11, 2015: A peer-reviewed critique by Richard A. Isenberg MD
• UPDATE: List of 0f over 100 studies linking porn use/porn addiction to sexual problems, low libido, less brain activation to sexual stimuli, and less sexual  & relationship satisfaction.
• UPDATE: August 5, 2016: Peer-reviewed paper by US Navy doctors – Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016) – It’s an extensive review of the literature on porn-induced sexual problems. The review provides the latest data revealing a tremendous rise in youthful sexual problems. The paper also examines the neurological studies related to porn addiction and sexual conditioning. The doctors provide 3 clinical reports of men who developed porn-induced sexual dysfunctions.

MAIN ARTICLE

The following study by Nicole Prause & Jim Pfaus claims to have investigated porn-induced erectile dysfunction: “Viewing Sexual Stimuli Associated with Greater Sexual Responsiveness, Not Erectile Dysfunction.” This would be exciting news, if, in fact, the researchers actually gathered data that is essential to investigate porn-induced ED (PIED). Let me start off by making something clear, that I will explain in further detail below; this study doesn’t, and due to its poor design can’t, tell us anything about whether or not today’s high-speed internet porn leads to erectile dysfunction with a partner.

Why can’t this study tell us anything important about the possibility of PIED? Because of what it doesn’t do, and the many, many flaws in what it claims to have done.

What the study doesn’t do:

1) The study doesn’t investigate men complaining of erectile dysfunction. The study doesn’t examine young men with years of porn use and unexplained ED (that is, men for whom organic, below-the-belt problems have been ruled out). Nor does the study investigate porn-induced ED in such men by having them remove porn use and monitor possible changes. In fact, the researchers didn’t even furnish details for their subjects who revealed they had erectile function problems on the IIEF [erectile-function] questionnaire (later). Yet the authors draw far reaching conclusions about the non-existence of porn-induced ED.

2) The study doesn’t study men with porn addiction, or even “heavy” porn users. Just non-compulsive users. From the study’s conclusion:

“These data did not include hypersexual patients. Results are probably best interpreted as limited to men with normal, regular VSS use.”

Translation: The study did not include “hypersexuals”, which is the authors’ term for “porn addicts”. Excluding hypersexuals is a huge weakness, considering that most men with chronic porn-induced ED self-identify as porn addicts. A small minority of men with porn-induced ED do not appear to be addicted, but they usually have a history of years of porn use.

Not only does this study not examine men with chronic ED, it excludes heavy porn users and porn addicts. Nothing like not looking at something if you don’t want to find evidence of it!

3) The college age subjects were not asked about years of porn use! The subjects, as far as I know, could have started using porn merely weeks before the study, or they could have given up their porn watching ways just before the study was conducted after watching for years. Some could have started at age 10, or started in their sophomore year of college, or they could have just broken up with their girlfriend last month, and are now heavy users.

4) The study doesn’t assess actual erections in relation to hours of use, contrary to what its title implies.

The study claims (more below) that men were asked a single question about how aroused they were after they were shown some porn. As the study said,

“No physiological genital response data were included to support men’s self-reported experience.”

To summarize, this study:

1. Did not assess individuals complaining of erectile dysfunction
2. Did not include heavy porn users or porn addicts
3. Did not assess “sexual response” (contrary to the misleading title)
4. Did not ask men to attempt masturbation without porn (the way to test for porn-induced ED)
5. Did not have men remove porn to see if erectile functioning eventually improved (the only way to know it’s porn-induced)
6. Did not ask about years or porn use, age guys started using porn, type of porn, or escalation of use.
7. Did not ask about delayed ejaculation or anorgasmia (precursors to PIED)

What the study claims to do (link to study):

The claims are almost irrelevant as this jumbled data-salad is not even a true study with subjects chosen for this investigation. Instead, lead author Prause claims to have cannibalized bits and pieces of four of her older studies to construct this ED “study.” However, those four studies were not about erectile dysfunction, nor did any of them report correlations between porn use and erectile function. Far more egregious is that the collective data from those four studies in no way line up with the data claimed for this ED study. The forthcoming details will have you asking, “How in the world did this mess pass peer-review?”

Before I explore the discrepancies, omissions, and sleights of hand the authors employed, you will need a few basics on the study. Using primarily university psychology students (average age 23), the study claimed to examine the relationship between:

1. Some subjects’ weekly hours of porn use and self-reported arousal after viewing porn in the lab (based on a single question that did not ask about erections), and
2. Some subjects’ weekly hours of porn use and some subjects’ scores on the International Index of Erectile Function (IIEF).

The authors’ claims for 1 & 2 above are as follows:

1. Those who used 2+ hours of porn per week reported a somewhat higher sexual arousal score (6/9) than the two lower categories of porn use (5/9).
2. No significant correlation was found between moderate porn use and erectile function scores on the IIEF.

I dissect the claims under number 1 and number 2 below. With each claim I hark back to the discrepancies and omissions that I will now detail.

A closer look at the study: Missing subjects, omissions, discrepancies & unsupported claims

1) The starting point: We are told that the subjects and data for this ED study were culled from four other studies, which have already been published:

“Two hundred eighty men participated over four different studies conducted by the first author. These data have been published or are under review [33–36],”

As noted, none of the four studies (study 1, study 2, study 3, study 4) assessed the relationship between porn use and erectile dysfunction. Only one study reported erectile functioning scores, for only 47 men.

2) Number of total subjects: Lead author Prause tweeted several times about the study, letting the world know that 280 subjects were involved, and that they had “no problems at home”. However, the four underlying studies contained only 234 male subjects. While 280 appears once in this study’s Table 1 as the number of subjects reporting “intercourse partners last year”, so do the numbers 262, 257, 212 and 127. Yet, none of these numbers match anything reported in the 4 underlying studies, and only 47 men took the erection questionnaire. Contrary to her tweet, the average score (21.4) for erectile function placed these 47 young men, on average, squarely in the mild ED category. Oops.

• Discrepancy 1: 46 subjects appear out of nowhere in the claim of 280 subjects, while the actual number of subjects (234) is found nowhere in the ED study.
• Discrepancy 2: Subject numbers in Table 1: 280, 262, 257, 212 and 127 – match nothing from the 4 underlying studies.
• Unsupported claim: Prause tweets that the study involved 280 subjects.
• Missing: Any explanation of how Prause conjured the number “280” for her subjects.
• Unsupported claim 2: Prause tweeted they had no problems, but their erection scores indicate ED on average.

3) Number of subjects who took the IIEF (erectile-function test): The ED study claims that 127 men took the IIEF (pg 11 also says 133). However, only one of the four studies reported IIEF scores, and the number of subjects who took it was 47. Where did Prause get the extra 80 men? She doesn’t explain. This study did not assess the erectile functioning of 280 subjects, nor 234, and not even 127. Again, only 47 subjects took the IIEF.

• Discrepancy: Study claims that 127 subjects took the IIEF, but it’s really 47.
• Unsupported claim: Prause tweets that 280 subjects were involved.
• Missing: Any raw data on the mysterious 127

4) Average IIEF score for 47 subjects same as for the missing 80: As described above, only one study, with 47 men, reported an IIEF score. That study only reported a score for the full 15-question IIEF, not the 6-question “erection subscale” reported in the current study. Wherever it came from, the average score for the 6-question erection subscale was 21.4, and indicates “mild erectile dysfunction”. In addition, the current ED study also claims an average IIEF score of 21.4 for the entire 127. Say what? We know the “accounted for” 47 men averaged 21.4, and the 127 averaged 21.4. This means that the 80 missing men had to also average 21.4. What is the probability that happening?

• Unbelievable coincidence: The average IIEF scores for the 47 men must be the same as the unaccounted for 80 men.
• Misleading: The average score (21.4) indicates “mild erectile dysfunction”, while the study claims the men had “relatively good erectile function” (maybe relative to a 70-year old man?).
• Missing: IIEF scores for erection sub-scale on original study.
• Missing: The IIEF scores for any subject. No raw data, no scatter plot, no graph.

5) Number of subjects for hours/week porn viewing: The ED study claims to have porn viewing data on 136 men. Instead, only 90 subjects, from 2 studies, report hours viewing per week. Where did the authors conjure up 46 extra subjects? In addition, this study claims to correlate hours of porn viewing per week with the IIEF scores, but 90 men (hrs/week) doesn’t match 47 men (IIEF scores).

• Discrepancy 1: Study claims hrs/week viewing porn data for 136 subjects, but it’s really 90.
• Discrepancy 2: Study claims to correlate hrs/week porn viewing with IIEF scores, but 90 doesn’t equal 47
• Unsupported claim: Prause tweets N=280, but the true N=47.
• Missing: Hours viewed for the subjects. No raw data, no scatter plot, no graph, no mean or standard deviation.
• Missing: No legitimate data on the correlation between porn use and hours viewed per week.

6) Sexual arousal ratings: On page 8 the authors state that men rated their sexual arousal after viewing porn on a scale from 1 to 9.

“men were asked to indicate their level of “sexual arousal” ranging from 1 “not at all” to 9 “extremely.”

In reality, only 1 of the 4 underlying studies used a 1 to 9 scale. One used a 0 to 7 scale, one used a 1 to 7 scale, and one study did not report sexual arousal ratings. By the way, the study misleads the press, and readers, by implying in its title that erections were measured in the lab and found to be more “responsive” in association with more porn viewing. This did not happen. At best, the scores imply craving or horniness.

• Discrepancy: Arousal scales in ED paper don’t match arousal scales in 3 underlying studies.
• Unsupported claim: This study did not assess “sexual responsiveness” or erectile response.
• Missing: No raw data or scatter plot for the subjects.

7) Stimulus used for sexual arousal ratings: The authors make a big deal about the sexual arousal ratings being slightly higher for the 2 plus hour/ per week group. Wouldn’t a good study use the same stimulus for all subjects? Of course. But not this study. Three different types of sexual stimuli were used in the 4 underlying studies: Two studies used a 3-minute film, one study used a 20-second film, and one study used still images. It’s well established that films are far more arousing than photos. What’s shocking is that in this study Prause claims all 4 studies used sexual films:

“The VSS presented in the studies were all films.”

Absolutely false! Only 2 studies with 90 men reported scores, and 47 of those men viewed only pictures of naked women, not films.

• Discrepancy 1: Four different studies, and 3 different types of sexual stimuli...but one graph.
• Discrepancy 2: In the graph below are 136 subjects, yet only 90 subjects actually reported hours of porn/week in any of the underlying studies.
• Discrepancy 3: The sexual arousal scale is 1 – 7 in the graph below, yet the study said the scale was 1 – 9 (which was claimed to have been used in 1 of the 4 studies)
• Unsupported claim: Prause claims all 4 studies used films.

Keep in mind that these porn viewing subjects are the same group as in number 5 above, and in the graph under number 1. Both claim 136 men, but the data says otherwise.

8) No data correlating porn use with IIEF scores: What’s the headline news from this study? The authors claim there was no relationship between erectile functioning scores and hours of porn viewed per week. Big news, but no data. All they offer are a few sentences (pg 11-12) reassuring us that no correlation was found. No data, no graph, no scores, nothing. Only an allusion to the mysterious 127 men, 80 of whom are unaccounted for, discussed in 3 and 4 above. From the study:

“Men (N = 127) reported relatively good erectile functioning (see Table 1). Neither the total scale score, nor the erectile subscale score, on the International Index of Erectile Functioning was related to the hours of VSS viewed in the average week.”

• Missing 1: Any graph or table showing us a correlation between hours of porn viewed/week and IIEF scores.
• Missing 2: Raw data. Any data.
• Discrepancy: They appear to claim 127 subjects, yet only 47 men took the IIEF.
• Misleading: Claiming the men “reported relatively good erectile functioning”, while the average score (21.4) indicates mild ED.

With absolutely nothing in the 4 underlying studies matching the ED study, and with 80 subjects nowhere to be found, excuse me if I don’t take the authors’ word on the lack of correlation with hours of use. To illustrate this point, the study’s conclusion opens with a string of inaccuracies:

“Data from a large sample of men (N = 280) across similar studies were aggregated to test the hypothesis that consuming more VSS was related to erectile problems.”

In just this one sentence, I can identify a host of unsupported claims:

• “N = 280”: Nope, only 47 men took the IIEF
• “across similar studies“: Nope, the studies were not similar.
• “were aggregated“: Nothing matches the underlying 4 studies
• “to test the hypothesis“: No data were presented for the authors’ hypothesis.

The entire study is like this, with subjects, numbers, methodologies, and claims appearing from nowhere, and unsupported by the underlying studies.

Let’s look more closely at what the researchers claim to have investigated

NUMBER 1: Weekly hours of porn use and self-reported arousal after viewing porn in the lab

The researchers claim to have placed 136 participants in three groups based on weekly porn use (graph below). Discrepancy: Weekly porn use is only reported for 90 subjects in 2 studies.

Men were shown porn in the lab, and the study claimed they rated their arousal using a scale of 1 to 9.

• Discrepancy 1: Only 1 of the 4 underlying studies used a 1 to 9 scale. One used a 0 to 7 scale, one used a 1 to 7 scale, and one study did not report sexual arousal ratings.
• Discrepancy 2: Apples and oranges: One study used still images, one a 20 second film, two used a 3 minute video.

The bar graph allowed the authors to avoid plotting arousal scores clearly. Thus, readers cannot contemplate variations in self-reported arousal relative to hours of porn use for themselves. The researchers imply that answering a question about “sexual arousal” is solid evidence of erectile function. In fact, there’s a footnote in one study saying that the researchers ignored questionnaire results on “penile erection” because they presumed that “sexual arousal” would gather the same information. However, that is most definitely not a reasonable assumption for guys with porn-induced erectile dysfunction (who are very aroused by porn but can’t get erections with partners), and it may not be true of participants here either.

Another, more legitimate, way to interpret this arousal difference between the two porn-use groups is probably that men in ‘2+ hours per week’ category experienced slightly greater cravings to use porn. Interestingly, they had less desire for sex with a partner and more desire to masturbate than those who logged .01-2 hours watching porn. (Figure 2 in study). This is quite possibly evidence of sensitization, which is greater reward circuit (brain) activation and craving when exposed to (porn) cues. Sensitization can be a precursor to addiction.

Recently, two Cambridge University studies demonstrated sensitization in compulsive porn users. Participants’ brains were hyper-aroused in response to porn video clips, even though they didn’t “like” some of the sexual stimuli more than control participants. In a dramatic example of how sensitization can affect sexual performance, 60% of the Cambridge subjects reported arousal/erectile problems with partners, but not with porn. From the Cambridge study:

“CSB subjects reported that as a result of excessive use of sexually explicit materials…..they experienced diminished libido or erectile function specifically in physical relationships with women (although not in relationship to the sexually explicit material)”

Put simply, a heavy porn user can experience higher subjective arousal (cravings) yet also experience erection problems with a partner. In short, his arousal in response to porn is not evidence of his “sexual responsiveness”/erectile function.

• Watching more porn will improve erections??

Astoundingly, the authors of the current study suggest that “VSS viewing might even improve erectile functioning.” Their advice is based on arousal and desire scores (not erectile-function scores). This is the worst advice possible if these “aroused” young men are, in fact, becoming sensitized (addicted) to porn. Their porn viewing arousal would not translate to their erectile function during real sex, which tends to decline in those who develop porn-induced ED as their sensitization to porn grows. Such a decline is precisely what the Cambridge subjects reported.

Certainly, viewing porn might improve erections while viewers watch, but the problem for those reporting porn-induced ED is overwhelmingly erectile function with partners. Moreover, there is no evidence in this study that viewing porn, or, as the authors obligingly suggest, a variety of porn, improves erectile function with partners. If this were correct, I would think the 47 young men tested for erectile function would have reported better boners the more porn they watched. Instead, they reported “mild erectile dysfunction” as a group.

It’s worth noting that the Cambridge researchers addressed both compulsive porn users (CSB) and young men with ED while investigating porn addicts’ brains. The current study missed both aspects, while purporting to investigate ED in young porn users.

NUMBER 2: Weekly hours of porn use and scores on a questionnaire entitled the International Index of Erectile Function (IIEF)

Here’s where things get really ugly. The authors claimed that 127 young men completed a questionnaire called the IIEF, a 15-item survey (not a “19-item survey” as the authors state), in which men score their erectile health, desire and sexual satisfaction during masturbation and, primarily, sexual intercourse. Again, no actual penis responses were measured to confirm these self-reported scores. Discrepancy: only 47 men took the IIEF. Note: they also say on page 11 that 133 men took the IIEF. Does it ever end?

• The Unknown 59 (sic)

For a moment let’s imagine we are in a parallel universe, and 127 men actually took the IIEF. The authors stated that only 59 had partners with whom they could observe their current erectile health. This makes the number of partnered subjects whose erectile health was actually investigated quite small. Yet these are the only participants who can help researchers understand current erectile function in relation to porn use. Why? Because, as the authors acknowledge, assessing current erectile function is dependent on the availability of a partner.

• First, many young guys report a rapid decline in erectile health when they try to have sex with a partner after being on their own (with porn use) for a time. So “erectile function” tests based on remembered erectile function with partners would be of little value.
• Second, men on recovery forums report that porn-induced ED is overwhelmingly likely to occur during partnered sex (or during masturbation without porn, a statistic the researchers didn’t collect) – not with porn. In fact, some guys have dubbed this phenomenon “copulatory impotence.”

So, why aren’t the partnered men who took the IIEF the only subjects included in this study? And why aren’t their data broken out clearly for readers? The researchers tell us that there was no association between viewing hours and erectile function when the partnered participants “were included in analyses.” However, we learn nothing about those claimed analyses, or how they compare with the others. They’re always lumped into larger, un-sourceable numbers, like 280 or 127. Exit the parallel universe and back to more shenanigans.

• “Mild erectile dysfunction”

Let’s take another look at the IIEF’s “erectile function” subscale. The chart below shows the questions and scoring. (View entire test and subscale.) Possible scores for this subscale range from 1 to 30. For the men who are claimed to have completed this subscale, the mean (average) score was only 21.4 out of a possible 30. On average, they fell well within the “mild erectile dysfunction” category.

Keep in mind that these sorry erectile function scores were self-reported by 23-year old men, none of whom watched porn compulsively. This suggests internet porn, even consumed in a non-compulsive manner, may be having detrimental effects on youthful erections irrespective of (no) correlation with hours used.

In fact, these young men were well below previously established control group scores for much older men. In 1997, the studies conducted to validate the IIEF reported that erectile-function scores averaged 26.9 (average age 58), and 25.8 (average age 55). In short, older men in 1997 – before internet porn – had healthier erections even in middle age than these 23-year olds.

Unlikely coincidence? How could the 47 subjects who took the IIEF have exactly the same average (21.4) as the 80 ghostly subjects no one can find (21.4)?

Moreover, as 21.4 is the average score (for some, indeterminate N), it means that the scores for some participants were lower than 21.4. In fact, the SD (standard deviation) was large (9.8), so there was a wide range of erectile function scores. It’s likely some fell into the “moderate” and “severe” erectile dysfunction categories. However, we don’t know, because data are not provided – which brings me to…

• Study graphics

Why didn’t the authors in the current study do what conscientious researchers did in a recent study on porn users’ brains, “Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn,” and plot all their data on a graph like that reproduced below? This allows the reader to see clearly that as pornography consumption rises, grey matter in the brain decreases. Why did the authors of this ED study hide individual data in mean scores and simplistic bar graphs?

• Weekly Use?

The authors offer no support for their assumption that a correlation with weekly porn use is vital to establishing the existence of porn-induced erectile dysfunction, even though all their claims rest on the lack of correlation with weekly use scores. In 2011, German researchers found that porn-related problems correlate not with time spent, but rather with number of sex applications opened during porn sessions. Thus, the absence of a correlation between weekly hours of porn use and ED issues (let alone correlations with their other questionnaire results) isn’t surprising, as novelty (number of clips, tabs open, etc.) appears to be more important than hours.

Moreover, precisely how were “weekly porn use” scores determined? The researchers do not say. Was it simply, “How much porn did you use last week?” If so, there could be new porn users who haven’t had time to develop erectile problems in the “2+ hours” bin. And long-time users with porn-related problems, who had recently decided to cut out porn, perhaps due to sexual dysfunction symptoms, in the “0 hours” bin, making correlations even more unlikely.

Regardless of how the lead author calculated “weekly use,” the most important data are still missing: total porn use and characteristics of use. Participants weren’t asked about years of porn use or age (developmental stage) they began using. Moreover, the researchers didn’t control for other factors that men on recovery forums often find are related to their performance issues: escalation to more extreme material, lengthy periods without partnered sex, need for novel porn, and masturbation only with internet porn.

Under the circumstances, and given the appalling numerical inconsistencies, a lack of correlations is of dubious significance, and the authors’ dismissal of the phenomenon of porn-induced ED unwarranted.

Sexual conditioning: An idea worth exploring

The researchers correctly point out that:

Erections may become conditioned to aspects of VSS [porn] that do not transition easily to real-life partner situations. Sexual arousal may be conditioned to novel stimuli, including particular sexual images, specific sexual films or even non-sexual images. It is conceivable that experiencing the majority of sexual arousal within the context of VSS may result in a diminished erectile response during partnered sexual interactions. Similarly, young men who view VSS expect that partnered sex will occur with themes similar to what they view in VSS. Accordingly, when high stimulation expectations are not met, partnered sexual stimulation may not produce an erection.

Recognizing this possibility, one wonders why the researchers asked only about weekly hours and didn’t ask their participants questions that would have helped reveal a possible link between their porn viewing and sexual conditioning, such as

• at what age they began viewing porn videos
• how many years they had viewed it
• whether their tastes escalated over time to more extreme fetish porn
• what percentages of their masturbations took place with and without porn.

If they wanted to find important data on porn-induced ED, they might also have asked the young men with low erectile function scores to masturbate both without porn and with it, and compare their experiences. Men with porn-induced ED generally have great difficulty masturbating without porn because they have conditioned their sexual arousal to screens, voyeurism, fetish content and/or constant novelty. Of course the researchers did not do that, because this wasn’t a study specifically looking at the possibility of porn-induced ED.

Growing cause for concern

Highly regarded urologists have already spoken up about the issue of porn-induced ED, including academic urologists, such as Abraham Morgentaler, MD, Harvard urology professor and author, and Cornell urology professor and author Harry Fisch, MD. Said Morgentaler, “It’s hard to know exactly how many young men are suffering from porn-induced ED. But it’s clear that this is a new phenomenon, and it’s not rare.” Fisch writes bluntly that porn is killing sex. In his book The New Naked, he zeroes in on the decisive element: the internet. It “provided ultra-easy access to something that is fine as an occasional treat but hell for your [sexual] health on a daily basis.”

Interestingly, in the last few years a number of studies have reported unprecedented ED in young males, although none have inquired about internet porn use:

1. Sexual functioning in military personnel: preliminary estimates and predictors. (2014) ED – 33%
2. Sexual dysfunctions among young men: prevalence and associated factors. (2012) ED – 30%
3. Erectile dysfunction among male active component service members, U.S. Armed Forces, 2004-2013. (2014) Annual incidence rates more than doubled between 2004 and 2013
4. Prevalence and characteristics of sexual functioning among sexually experienced middle to late adolescents. (2014) 16-21 year olds:

• Erectile Dysfunction – 27%
• Low sexual desire – 24%
• Problems with orgasm – 11%

Given that internet porn use is now nearly universal in young men, we should be slow to dismiss internet porn use as a potential cause of today’s widespread youthful erectile dysfunction without a very thorough scientific investigation of subjects complaining of it. And slow as well to assume the authors are correct in their surmise that widespread youthful ED is due to “concerns about the partner’s STD status, relationship expectations, and concerns about one’s own attractiveness or penis size.” Those factors have presumably been around for a much longer time than internet porn, and the spike in youthful ED problems is quite recent.

Most importantly, those concerns do not apply to guys who are unable to masturbate without porn, as they aren’t worried about any of those concerns with their own hand.

While it is vital to publish all analyses about the subject of porn-induced sexual dysfunction that are based on solid research, this particular analysis raises a thicket of red flags. Today’s youthful porn users deserve better.

Does Internet porn reveal our sexual desires—or alter them?
 
Fellow “Psychology Today” blogger Leon F. Seltzer recently completed a herculean 12-part blog series on the subject of the Internet and human sexual desire (based on Ogi Ogas and Sai Gaddam’s A Billion Wicked Thoughts, 2011). In his final segment, he did an excellent job of outlining the risks associated with Internet porn use.

However, I hope he will take another look at Ogas and Gaddam’s assumptions and analysis in light of the perils of today’s Internet porn. Specifically, I hope he will reconsider whether A Billion Wicked Thoughts actually delivers what he suggests it does, namely, the “unvarnished truth of [our] sexual preferences and desires.”

It’s quite possible that A Billion Wicked Thoughts delivers something quite different: a snapshot of a moving target of millions of users’ random sexual tastes, many of whom are heavily under the influence of a neurobiological process that Ogas and Gaddam have not considered. That process is tolerance, a physiological process common to brains as they slip into addiction—whereby the user becomes increasingly numb to pleasure (desensitized) and therefore seeks more and more stimulation.

For example, some users search for one video for a few minutes a few times a week. Analyzing their results might yield some meaningful data about porn tastes across the population. Other users open 10+ tabs on a couple of screens and edge to video after video, primarily in search of novelty because the dopamine squirts from novelty produce a drug-like effect in the brain. Obviously, this group will be contributing disproportionately to the search statistics. Moreover, as we’ll see in a moment, their tastes often quickly morph as they pursue novelty any way they can. This limits the value of their data when analyzing fundamental sexual desires across all users.

In other words, the lion’s share of searches could well be coming from a disproportionately small number of users, and yet neither Ogas and Gaddam nor their readers seem to recognize this. The authors’ attempt to draw far-reaching conclusions from the content of such searches is like analyzing a client’s psychological make-up based on whether he became addicted to drugs via sniffing or shooting up. Incidentally, it’s the novelty seekers who have the most serious problems from their porn use according to German researchers. This is consistent with the suggestion that addiction-related brain changes are at work in their brains.

No one knows how many of today’s users are driven by tolerance, but it’s likely the percentage is large enough that Ogas and Gaddam’s data do not, in fact, reveal deep, meaningful patterns about human sexual desire.

I’m grateful to Seltzer for initiating this dialog. Ever since Wicked Thoughts came out, I’ve had reservations about its assumptions. My reply will be divided into two parts. This part addresses the tolerance issue. A subsequent post addresses the Wicked Thoughts’ underlying assumption; namely, that sexual tastes are immutable.

Desensitization and morphing porn tastes

In his book on brain plasticity, The Brain That Changes Itself, psychiatrist Norman Doidge pointed out that,

“Pornography seems, at first glance, to be a purely instinctual matter: sexually explicit pictures trigger instinctual responses, which are the product of millions of years of evolution. But if that were true, pornography would be unchanging. The same triggers, bodily parts and their proportions, that appealed to our ancestors would excite us. This is what pornographers would have us believe, for they claim they are battling sexual repression, taboo, and fear and that their goal is to liberate the natural, pent-up sexual instincts.

But in fact the content of pornography is a dynamic phenomenon that perfectly illustrates the progress of an acquired taste. … The plastic influence of pornography on adults can … be profound, and those who use it have no sense of the extent to which their brains are reshaped by it.

[I have] treated or assessed a number of men who all had essentially the same story. Each had acquired a taste for a kind of pornography that, to a greater or lesser degree, troubled or even disgusted him, had a disturbing effect on the pattern of his sexual excitement, and ultimately affected his relationships and sexual potency. …

When pornographers boast that they are pushing the envelope by introducing new, harder themes, what they don’t say is that they must, because their customers are building up a tolerance to the content. (emphasis added)”

Thus, a heterosexual male might start with nude stills of a favorite movie star. Then, as his brain stops responding to those, he “progresses” to videos of solo sex, vanilla sex, lesbian action, insertions, gang bangs, transexual porn, gay porn, gross porn (however he defines that) and even minor porn. Gay porn users and female porn users report the same phenomenon, with progressions that are equally unsettling to them. A gay man shared this experience under an earlier post:

“I believe I was born gay, my first fantasies were about men and men have always aroused me, whereas women have aroused me very little. I became addicted to internet porn in my late teens. Gay sex to me is very normal and natural. Yet I lost interest in it over time. I became interested in straight porn and found myself increasingly losing interest in the male anatomy and developing a fetish for female genitalia. I had no attraction to it before my porn viewing became excessive. New genres gradually replaced old ones in sexual appeal. To my shock, I started to think that I could potentially be bisexual, so I arranged a meeting with a female escort to test out this possibility.
However, I did not experience much arousal and the situation felt wrong to me. It was completely different to porn.

I decided to stop watching pornography, and after being porn-free for quite some time I can happily say my fetish for women has gone. Gay sex has returned to the norm for me. I can also add that during my porn escalation, transexual porn never became arousing to me in the slightest, despite the fact pre-operative transwomen have a penis. It would be like asking a straight man if he would have sex with a man that had a vagina, which I have to add is something that did appeal to me at one time.”

It’s evident that this type of porn-related progression has little to do with users uncovering their “deepest urges and most uninhibited thoughts” (Ogas and Gaddam’s words). The targets are moving too fast. Rare users even recognize the process while it’s unfolding:

“Porn binges for 4-6 hours the last couple days. On the plus side, it did become more obvious that the transsexual porn is unrelated to my sexuality. After spending 30+ hours over the past 5 days watching porn, transsexual porn started to become boring! I began searching for other more disgusting and shocking stuff.”

So what’s actually going on? Let’s start by distinguishing desensitization from habituation. Satiety (habituation) and a desire for novelty are built right into the mammalian brain and are not pathological. You can’t eat another bite of turkey (satiety), but you feel palpable enthusiasm for pumpkin pie (dopamine released for novel, high-calorie food). The process repeats itself the next day. Obviously, this natural process can leave porn users somewhat vulnerable to overconsuming novel erotica simply because novelty registers as “yes!”

Desensitization, in contrast, is a pathology arising from continued overconsumption. Measurable, physical brain changes (declines in D2 nerve cell receptors) indicate an addiction is in process. Unlike the transitory effects of habituation, desensitization takes time to reverse, in part because it is tied to other stubborn addiction-related brain changes.

Novelty = dopamine

In the case of Internet porn users, the appeal of overconsumption is that it allows the user to override his innate satiety-recovery window. Instead of waiting for his sexual appetite to return naturally he can click to enough stimulation to produce a rush of excitory neurochemicals (such as dopamine and norepinephrine). He achieves arousal that would otherwise be impossible, or more difficult.

Now, his brain perceives all porn that gets him aroused, regardless of content, as valuable because it releases “go get it” neurochemicals. Again, all he needs is novel, shocking material, whether or not it matches his fundamental sexual inclinations. The fallacy in Wicked Thoughts is that only our fundamental tastes can release enough dopamine in our brains to motivate porn use. Nothing could be farther from the truth. Dopamine is dopamine, however you trigger it.

Thus, escalation to bizarre porn is meaningful primarily because it is a major warning sign of addiction, not because it tells porn addicts (or anyone else) useful information about their innate sexual desires. The deeper one’s addiction, the more desperate the need for this neurochemical relief, in part because normal pleasures are growing less satisfying and cravings more intense.

Worse yet, if a porn user climaxes to something that is not consistent with his underlying sexual orientation and fundamental inclinations, but it releases enough dopamine and norepinephrine in his brain (because it is exciting or even anxiety-producing), his brain will also wire the new stimulus up to his reward circuitry. The next time he encounters any cues related to it, he will find it mysteriously arousing—and today’s therapists will often swiftly assure him he has discovered valuable information about his “deepest urges.” Not so.

Of course, some porn users get their novelty fix by viewing new porn within their preferred genre (i.e., the genre that reflects their fundamental sexual desires). However, many of today’s porn users report that their sexual tastes morph all over the place as their brains grow desensitized. That said, porn addiction dynamics may be somewhat different in men and women.

One-way street?

Those on the escalation treadmill are often horrified to discover that they can no longer climax to their former tastes. Sadly, the more distressing (to them) their new porn choices, the more compelling those choices can become, due to the excitory neurochemicals released by their anxiety about what they’re watching.

Seldom do they figure out that their brain’s desensitization would naturally reverse itself—thereby restoring their dopamine receptors and their responsiveness to their earlier tastes. Why? They dare not cease masturbating even for a few weeks, in part because when they try to stop their libido may drop off alarmingly and they don’t realize it’s a temporary effect of restoring their brains to balance. The word on the street is, “use it or lose it,” and since many are already losing their mojo due to overconsumption, they’re terrified to stop.

In short, the issue for these users is not freedom to pursue their deep desires, but rather alien tastes, which are primarily the product of avoidable neurochemical changes inadvertently brought on by the users themselves. 

It’s happening in part because of superficial analysis that is, frankly, dangerously misleading, not to mention potentially distressing, for porn users caught on this slippery slope:

1. It wrongly implies that they have no control over their changing tastes.
2. It misdirects their attention away from the scientific information about the neuroscience of addiction, which they need to understand their circumstances and steer for the results they want.
3. It encourages them to ignore, or accept and pursue, their escalating tastes as healthy, when they are, for many of today’s users, symptoms of a well established disease process: behavioral addiction.

“Normalizing” addiction

Seltzer writes:

“One of the most helpful things that A Billion Wicked Thoughts accomplishes is normalizing many sexual preferences that to this point may have struck you (and maybe most people) as deviant. Obviously, the more widespread a predilection, the more difficult it is to simply dismiss it as “sick”—especially if there are psychological and biological causes that convincingly explain it.”

What if some of these so-called ‘deviant’ tastes are solely due to addiction and tolerance (the need for stronger stimulation)? If enough people experience evidence of a pathology it may become the norm, but it doesn’t mean their behavior isn’t “sick.”

Addiction epidemics have occurred before in humanity’s history and they did not make the symptoms the addicts suffered “normal” in the sense of “free of pathology.” For example, in the mid-18th century, parts of inner London suffered the world’s first mass epidemic of alcoholism. And in The Compass of Pleasure David Linden recounts a mass addiction to inhaling cheap ether in Ireland in the 1880s.

In the case of Internet porn, is it wise to assume that all we need to know is whether tastes are “normal” or “deviant”—basing our answer on statistics rather than physiology? Are we even framing the right question if we ignore the possibility that morphing porn tastes could be driven by a numbed reward circuitry in pursuit of a neurochemical buzz regardless of content?

Reversing engines: evidence that porn tastes are not innate

Most tellingly, users who stop all Internet porn and allow their brains to return to normal sensitivity generally discover that they weren’t on a one-way street after all. Their porn tastes slowly begin to reverse themselves—curiously, in reverse order—all the way back to their earliest tastes. For example, real sex with their partners often becomes arousing (again).

The process is not easy. It generally entails nasty withdrawal symptoms, annoying flashbacks, and often a long period of “libido flatline.” But, for many, it completely restores their true sexual desires, which their porn use no longer reflected. Said one man:

“I used to get turned on by anything remotely feminine when I was 13, but that steadily changed as I watched more and more porn. I started to get anxious about my sexuality because I knew I was straight based on history, but at the same time I could not physically respond to the old cues. Sometimes when I was especially relaxed or drunk, I would respond as I did when younger. It was very confusing because I never had any homosexual fantasies or desires. Giving up masturbation to porn has completely eliminated any doubt, because now my libido is almost too much to handle. I’m more responsive to women, and responded to more by women.”

Superficial analysis harms

The assumptions of Ogas and Gaddam rest on the mistaken conviction that all sexual tastes are unchanging and that no matter how porn is delivered to our brains, our tastes will conform to our innate, unchanging proclivities.

Given that chronic overstimulation via Internet porn is transforming viewers’ sexual tastes, the Ogas and Gaddam snapshot offers little genuine insight into human desire. The most useful application of their data might be to serve as a comparison with similar data from another era, so that the dynamic process of escalation can be measured across the population over time, and the data’s true significance better understood.

The study of human desire will remain superficial and of little use to humans until experts integrate and teach the public how the brain works, how it learns, and how addictions can distort sexual tastes due to desensitization/tolerance.

In my next post I’ll address the key assumption that underlies Ogas and Gaddam’s work, namely, the claim that our sexual tastes are immutable.