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


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

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

However, the next paragraph gives us this garbage:

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

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

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

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

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

The two main findings:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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



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


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


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


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


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

Clinical Implications

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

Strengths & Limitations

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


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

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


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

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

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

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