Critique of: “Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men?” (2015)

• UPDATE 1: Comment on: Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men? by Gert Martin Hald, PhD
• UPDATE 2: Landripet & Stulhofer’s paper omitted two significant correlations they presented to a European conference:
  

  Reporting a preference for specific pornographic genres were significantly associated with erectile (but not ejaculatory or desire-related) male sexual dysfunction.

  Increased pornography use was slightly but significantly associated with decreased interest for partnered sex and more prevalent sexual dysfunction among women.

• UPDATE 3: Studies reporting links between porn use or porn/sex addiction and sexual dysfunctions, lower brain activation to sexual stimuli, and lower sexual satisfaction
• UPDATE 4: (August, 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.

THE ARTICLE

Study on young men: ED rates of 31%; low libido 37%, but, hey, it can’t be porn

This is an analysis of Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men? (A Brief Communication) by Landripet I, Štulhofer A.

The conclusion of this brief paper on young men in Portugal, Croatia and Norway stated that:

Pornography does not seem to be a significant risk factor for younger men’s desire, erectile, or orgasmic difficulties.

Let’s’ examine a few major problems with this overly confident conclusion.

PROBLEM 1: Study reports incredibly high rates of ED & low sexual desire

This simple cross-sectional study comparing a pair of existing databases found rates of ED as high as 31% and rates of ‘low sexual desire’ as high as 37% in men 18-40. Yet the title and abstract mention neither of these findings. Instead, the authors reassure us that “It’s not the porn”, even though the study acknowledges an ED epidemic in young men:

 “Several large-scale epidemiological studies recently pointed to a high prevalence of erectile dysfunction (ED) among younger men.”

What were the ED rates in young men in the new study, which is based on a 2011 questionnaire and another from 2014?

“In Study 1, 14.2–28.3% of participants reported ED” (2011)

“In Study 2, 30.8% of men were classified as having ED” (2014)

Note the continued rise in ED rates even between the 2011 survey and the 2014 survey. Back in 2004, Stulhofer’s research showed that ED rates in men 35-39 were only 5.8%!

This study found the same extraordinarily high rates of unexplained ED in young men found in several other studies. What were ED rates before the Internet? Kinsey (1948) reported less than 3% rate of ED for men under 40, and less than 1% for men 19 and under. The only cross-sectional study of ED rates in American men reported a 5% rate of ED in men ages 18-59. This was based on data from 1992, and one third of the men were over 40. Similarly, a 2002 meta-analysis by Dutch researchers reported that of 6 studies analyzed, 5 found ED rates for men under 40 were approximately 2%. The other one reported rates of 9%.

Also note that in the first survey, “low sexual desire” rates were an alarming 16.3% to 37.4%. How can almost 40% of young men have low libido? Such high rates were unheard of only a few short years ago. For example, in 2004, Italian urologist Carlo Foresta found low-sexual-desire rates of only 1.7% in teens. However, rates had jumped 600% to 10.3% by 2012.

Bottom line: ED rates for men under 40 have increased at least 600% in the last 20 years, and the study’s authors assert that porn is not the cause. What other variable has changed radically in the last 15-20 years?

PROBLEM 2: The only variable assessed was frequency of use in the last 12 months

The authors only assess one variable related to porn use across all subjects: self-reported frequency of use (not hours of use) over the last 12 months. There are several problems with this limited measure:

1. Frequency of use may have no relationship to hours per week, let alone various other, more relevant, variables of use
2. It tells us nothing about porn use prior to the last 12 months
3. It tells us nothing about total porn use over a lifetime

The authors conclude that in their cross-sectional study, using the questions they used, there is little evidence that frequency of porn determines which young men develop sexual dysfunctions. This result is not altogether surprising. In fact, one of the most common questions posed on recovery forums is, “Why did I develop PIED when my friends watch as much (or more) porn than I do?”

Instead of frequency of use, a combination of variables appear to be involved in porn-induced ED. These include:

1. Total hours of use
2. Years of use
3. Age started consistent porn use
4. Escalation to new genres
5. Development of porn-induced fetishes (from escalating to new genres of porn)
6. Ratio of masturbation to porn versus masturbation without porn
7. Ratio of sexual activity with a person versus masturbation to porn
8. Gaps in partnered sex (where one relies only on porn)
9. Virgin or not
10. Addiction-related brain changes or not
11. Presence of porn addiction/hypersexuality
12. Genetics

What other aspects of internet porn use might better explain porn-related sexual dysfunctions? German researchers found that intensity of arousal and number of applications opened were associated with porn-related problems, while time spent watching was not.

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. Personality facets were not significantly correlated with the IATsex score. [emphasis added]

To reiterate, the Germans found that time spent watching porn was not a factor in either porn addiction or the negative consequences of using. Instead it was the number of applications (genres), and one’s response to porn use, that made the difference. That is, a need for novelty and more stimulation. Similarly, hours of use by internet videogamers also do not predict problems. Rather, motives and obsessive passion for gaming are predictive.

In short, criteria for diagnosing problems with internet use need to be broader than hours/frequency of use. This casts doubt of the usefulness and conclusions of the “Brief Communication” under discussion here. Danish porn researcher Gert Martin Hald’s editorial comments echoed the need to assess more variables (mediators, moderators) than just frequency per week in the last 12 months:

Third, the study does not address possible moderators or mediators of the relationships studied nor is it able to determine causality. Increasingly, in research on pornography, attention is given to factors that may influence the magnitude or direction of the relationships studied (i.e., moderators) as well as the pathways through which such influence may come about (i.e., mediators). Future studies on pornography consumption and sexual difficulties may also benefit from an inclusion of such focuses.

Bottom line: All complex medical conditions involve multiple factors which must be teased apart. In any case, the authors’ statement that, “Pornography does not seem to be a significant risk factor for younger men’s desire, erectile, or orgasmic difficulties“ is unsupported, since it ignores all the other possible variables related to porn use that might be causing sexual performance problems in users. Before confidently claiming that we have nothing to worry about from internet porn, one still needs to explain away the very recent, astonishing rise in youthful ED and low sexual desire.

PROBLEM 3: Study excluded virgins and men who hadn’t had intercourse in the last 12 months

The two populations most likely to report porn-induced ED, virgins and men not having sex, were excluded from the survey. It’s not unusual for men with PIED to say they have remained virgins because they cannot achieve strong enough erections to penetrate. Many sexually experienced men say they no longer attempt sex due to PIED.

In other words, this survey wouldn’t pick up new ED in guys who had sex almost a year ago. It also wouldn’t pick up sexual dysfunctions in those who haven’t had sex in the last year, or who have exclusively been using internet porn to climax, or those who are virgins because they can’t get it up without porn. And were these men to be included (and asked if they can masturbate without internet porn), it may well be that a correlation between frequency of porn use and ED/low sexual desire would have appeared.

PROBLEM 4: The study actually found a few correlations between ED and porn use

The abstract doesn’t mention a pretty important correlation: Only 40% of the Portuguese men used porn “frequently”, while the 60% of the Norwegians used porn “frequently”. The Portuguese men had far less sexual dysfunction than the Norwegians.

Elsewhere, the authors acknowledge a statistically significant association between more frequent porn use and ED, but claim the effect size was small. However, this claim may be misleading according to an MD who is a skilled statistician and has authored many studies:

Analyzed a different way (Chi Squared), … moderate use (vs. infrequent use) increased the odds (the likelihood) of having ED by about 50% in this Croatian population. That sounds meaningful to me, although it is curious that the finding was only identified among Croats.

The authors blow this finding off and ignore it in reaching their conclusions, but in Gert Martin Hald’s formal comments about the study he says:

However, in pornography research, the interpretation of “size” may depend as much on the nature of the outcome studied as the magnitude of the relationship found. Accordingly, if the outcome is to be considered “sufficiently adverse” (e.g., sexual aggressive behaviors), even small effect sizes may carry considerable social and practical significance [2].

Landripet and Stulhofer omitted two correlations which they presented to a European conference:

However, increased pornography use was slightly but significantly associated with decreased interest for partnered sex and more prevalent sexual dysfunction among women.

Reporting a preference for specific pornographic genres were significantly associated with erectile, but not ejaculatory or desire-related male sexual dysfunction.

It’s quite telling that Landripet & Stulhofer chose to omit a very significant correlation between erectile dysfunction and preferences for specific genres of porn from their paper. It’s quite common for porn users to escalate into genres that do not match their original sexual tastes, and to experience ED when these conditioned porn preferences do not match real sexual encounters. As pointed out below, it’s very important to assess the multiple variables associated with porn use – not just hours in the last month, or frequency in the last years.

PROBLEM 5: Claiming a 1000% increase in youthful ED can be explained by other factors.

So how do the authors explain the current ED epidemic in men under 40? They suggest the epidemic must arise from he same old factors that existed before the internet.

“Epidemiological studies suggest that unhealthy lifestyles, substance abuse, stress, depression, intimacy deficit, and misinformation about sexuality are more likely factors behind male sexual dysfunctions than pornography use.”

The authors are simply quoting earlier studies that suggest smoking, lack of exercise, and drug use may be factors, because those are the historical factors, but this conclusion is difficult to swallow.

First, smoking, obesity, diabetes, and lack of exercise are not major factors for young men. It takes years for these to manifest as organic ED, in the form of cardiovascular disease or nerve dysfunction. Moreover, smoking rates have drastically declined in the last 30 years, and the use of drugs and exercise rates have held steady over recent years. Obesity rates have only increased by 4% over the last 15 years. From the 20110 study, “Erectile dysfunction and correlated factors in Brazilian men aged 18-40 years.”

“Prevalence of ED in 1,947 men was 35.0% (73.7% mild, 26.3% moderate/complete)…. Also, no association was found between ED and smoking, alcoholism, obesity, sedentary life, diabetes, hypertension, cardiovascular disease, hyperlipidemia, depression or anxiety.”

But what about the claim that “misinformation about sexuality” and “intimacy deficits” are now playing a major role in ED? Simply pulled out of the air, an exercise in creative writing.

And why have the authors ignored the research showing evidence of a link porn use and sexual dysfunction? Cambridge University, for example, reported that 60% of their porn-addicted subjects had problems with erections and desire with real partners, but not with porn. In this 2014 case study a man with low libido and anorgasmia healed his both sexual dysfunctions by eliminating porn for 8 months.

We are back to asking “What one major variable influencing sexuality has changed since 1992?” Let me guess: internet porn.