Porn Use & Sex Addiction Studies

Research is needed on sex and porn addicts' brainsThe list of studies can be found below this introduction. An (L) in front of the link indicates a lay article, usually about a study.

Although this section is named "Porn Use & Sex  Addiction," Internet porn addiction is not sex addiction (see Porn Addiction Is Not Sex Addiction--And Why It Matters). Internet porn addiction is considered by many experts to a subset of internet addiction.YBOP has created several lists of porn studies:

Several recent reviews of the literature lend support to the addiction model:

  1. See this 2015 paper by two medical doctors: Sex Addiction as a Disease: Evidence for Assessment, Diagnosis, and Response to Critics, which provides a chart from that takes on specific criticisms and offers citations that counter them.
  2. For a thorough review of the neuroscience literature related to Internet addiction subtypes, with special focus on internet porn addiction, see - Neuroscience of Internet Pornography Addiction: A Review and Update (2015). The review also critiques two recent headline-grabbing EEG studies which purport to have "debunked" porn addiction.
  3. Cybersex Addiction (2015). Excerpts: "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. Neuroimaging studies support the assumption of meaningful commonalities between cybersex addiction and other behavioral addictions as well as substance dependency."
  4. Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016) - An extensive review of the literature on porn-induced sexual problems by 7 US Navy doctors and Gary Wilson. The review provides the latest data revealing a tremendous rise in youthful sexual problems..The paper also reviews the neurological studies related to porn addiction and sexual conditioning. 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).
  5. This short review - Neurobiology of Compulsive Sexual Behavior: Emerging Science (2016) - concluded "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."
  6. A 2016 review of compulsive sexual behaviors (CSB) - Should compulsive sexual behavior be considered an addiction? (2016) - concluded that: "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." Most of the neuroscience supporting the existence of "sex addiction" actually comes from studies on porn users, not sex addicts. Conflating internet porn addiction with sex addiction weakens the paper.
  7. Compulsive Sexual Behaviour as a Behavioural Addiction: The Impact of the Internet and Other Issues (2016). Excerpts: "more emphasis is needed on the characteristics of the internet as these may facilitate problematic sexual behaviour." and "clinical evidence from those who help and treat such individuals should be given greater credence by the psychiatric community."
  8. While the term "hypersexuality" should be discarded, this is a good review by Max Planck neuroscientists Neurobiological Basis of Hypersexuality (2016). Excerpt: "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."
  9. Searching for clarity in muddy water: future considerations for classifying compulsive sexual behavior as an addiction (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.
  10. Integrating psychological and neurobiological considerations regarding the development and maintenance of specific Internet-use disorders: An Interaction of Person-Affect-Cognition-Execution model (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.
  11. Neuroscientific Approaches to Online Pornography Addiction (2017) - Excerpt: 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.
  12. Is excessive sexual behaviour an addictive disorder? (2017) - Excerpts: 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. 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.
  13. Is excessive sexual behaviour an addictive disorder? (2017) - Excerpts: 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. 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. The Proof of the Pudding Is in the Tasting: Data Are Needed to Test Models and Hypotheses Related to Compulsive Sexual Behaviors (2018) - Excerpts: 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).

At this time multiple studies have directly examined the brains of porn users & sex addicts (See this page for critiques and analysis of highly questionable and misleading studies):

  1. Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014) - A German study which found 3 significant addiction-related brain changes that correlated with the amount of porn consumed. It also found that the more porn consumed the less activity in the reward circuit, indicating desensitization, and increasing the need for greater stimulation (tolerance).
  2. Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours (2014) - The first in a series of studies. It found the same brain activity as seen in drug addicts and alcoholics. It also found that porn addicts fit the accepted addiction model of wanting "it" more, but not liking "it" more. One other major finding (not reported in the media), was that over 50% of subjects (average age: 25) had difficulty achieving erections/arousal with real partners, yet could achieve erections with porn.
  3. Enhanced Attentional Bias towards Sexually Explicit Cues in Individuals with and without Compulsive Sexual Behaviours (2014) - Findings match those seen in drug addiction.
  4. Novelty, Conditioning and Attentional Bias to Sexual Rewards (2015) - 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, porn addiction drives novelty-seeking in an attempt to overcome habituation and desensitization.
  5. Neural Substrates of Sexual Desire in Individuals with Problematic Hypersexual Behavior (2015) - 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.
  6. 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 addiction. Not so. This SPAN Lab study, like #5 below, actually supports the existence of porn addiction. Why? The study reported higher EEG readings (P300) when subjects were exposed to porn photos. Studies consistently show that an elevated P300 occurs when addicts are exposed to cues (such as images) related to their addiction. However, the study had no control group for comparison, which made the findings uninterpretable. In line with the Cambridge studies, this EEG study reported greater cue-reactivity to porn correlated with less desire for partnered sex. Neither finding matched the headlines. Read more.
  7. Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another SPAN Lab EEG study comparing the 2013 subjects from the above study to an actual control group. The results: compared to controls porn addicts had less response to photos of vanilla porn. The lead author, Nicole Prause, claims these results debunk porn addiction, yet these findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. In other words, "porn addicts" were desensitized and needed greater stimulation than non-addicts. Read more.
  8. HPA axis dysregulation in men with hypersexual disorder (2015) - 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 drug addiction.
  9. The Role of Neuroinflammation in the Pathophysiology of Hypersexual Disorder (2016) - 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).
  10. Methylation of HPA Axis Related Genes in Men With Hypersexual Disorder (2017) - This is a follow-up of #8 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.
  11. Compulsive sexual behavior: Prefrontal and limbic volume and interactions (2016) - 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.
  12. Ventral striatum activity when watching preferred pornographic pictures is correlated with symptoms of Internet pornography addiction (2016) - 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."
  13. Altered Appetitive Conditioning and Neural Connectivity in Subjects With Compulsive Sexual Behavior (2016) - A German fMRI study replicating two major findings from Voon et al., 2014 and Kuhn & Gallinat 2014. Compared to controls compulsive porn users had 1) greater conditioned cue-induced activity in the amygdala, while having 2) decreased coupling between the ventral striatum and the prefrontal cortex. Number 1 indicates sensitization, while number 2 indicates hypofronatlity. In addition, 3 of the 20 compulsive porn users suffered from "orgasmic-erection disorder".
  14. Preliminary investigation of the impulsive and neuroanatomical characteristics of compulsive sexual behavior (2009) - 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 greater disorganized prefrontal cortex white matter. This finding is consistent with hypofrontality, a hallmark of addiction.
  15. Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017) – An excerpt: 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.
  16. Can Pornography be Addictive? An fMRI Study of Men Seeking Treatment for Problematic Pornography Use (2017) - Excerpts: Our findings suggest that, similar to what is observed in substance and gambling addictions, the neural and behavioral mechanisms associated with the anticipatory processing of cues specifically predicting erotic rewards relate importantly to clinically relevant features of problematic pornography use (PPU)
  17. Compulsivity across the pathological misuse of drug and non-drug rewards (2016) - A Cambridge University study comparing aspects of compulsivity in alcoholics, binge-eaters, video game addicts and porn addicts (CSB). Excerpts: CSB subjects were faster to learning from rewards in the acquisition phase compared to healthy volunteers and were more likely to perseverate or stay after either a loss or a win in the Reward condition.
  18. Pornography Addiction Detection based on Neurophysiological Computational Approach (2018) - An EEG study reporting several neurological differences between porn addicts and non-addicts. Unique in that the subjects average age was 14.
  19. Gray matter deficits and altered resting-state connectivity in the superior temporal gyrus among individuals with problematic hypersexual behavior (2018) - fMRI study. Summary: …study showed gray matter deficits and altered functional connectivity in the temporal gyrus among individuals with PHB (sex addicts). 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.

Together these brain studies found:

  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 addicts have greater preference for sexual novelty yet their brains habituated faster to sexual images. Not pre-existing.
  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 accumulation).
  9. Greater wanting & craving for porn, but not greater liking. This aligns with the accepted model of addiction - incentive sensitization.
  10. The younger the porn users the greater the cue-induced reactivity in the reward center.
  11. Higher EEG (P300) readings when porn users were exposed to porn cues (which occurs in other addictions).
  12. Less desire for sex with a person correlating with greater cue-reactivity to porn images.
  13. More porn use correlated with lower LPP amplitude when briefly viewing sexual photos: indicates habituation or desensitization.
  14. Dysfunctional HPA axis which reflects altered brain stress circuits, which occurs in drug addictions (and greater amygdala volume, which is associated with chronic social stress).
  15. Epigenetic changes on genes central to the human stress response and closely associated with addiction.
  16. Higher circulating levels of Tumor Necrosis Factor (TNF) which also occurs in drug abuse and addiction.

The following neuropsychology studies add support to the above neurological studies:

  1. Self-reported differences on measures of executive function and hypersexual behavior in a patient and community sample of men (2010)
  2. Watching Pornographic Pictures on the Internet: Role of Sexual Arousal Ratings and Psychological-Psychiatric Symptoms for Using Internet Sex Sites Excessively (2011)
  3. Enhanced Attentional Bias towards Sexually Explicit Cues in Individuals with and without Compulsive Sexual Behaviours (2014)
  4. Pornographic picture processing interferes with working memory performance (2013)
  5. Sexual Picture Processing Interferes with Decision-Making Under Ambiguity (2013)
  6. Cybersex addiction: Experienced sexual arousal when watching pornography and not real-life sexual contacts makes the difference (2013)
  7. Cybersex addiction in heterosexual female users of internet pornography can be explained by gratification hypothesis (2014)
  8. Empirical Evidence and Theoretical Considerations on Factors Contributing to Cybersex Addiction From a Cognitive Behavioral View (2014)
  9. Implicit associations in cybersex addiction: Adaption of an Implicit Association Test with pornographic pictures. (2015)
  10. Symptoms of cybersex addiction can be linked to both approaching and avoiding pornographic stimuli: results from an analog sample of regular cybersex users (2015)
  11. Getting stuck with pornography? Overuse or neglect of cybersex cues in a multitasking situation is related to symptoms of cybersex addiction (2015)
  12. Sexual Excitability and Dysfunctional Coping Determine Cybersex Addiction in Homosexual Males (2015)
  13. Trading Later Rewards for Current Pleasure: Pornography Consumption and Delay Discounting (2015)
  14. Subjective Craving for Pornography and Associative Learning Predict Tendencies Towards Cybersex Addiction in a Sample of Regular Cybersex Users (2016)
  15. Exploring the Relationship between Sexual Compulsivity and Attentional Bias to Sex-Related Words in a Cohort of Sexually Active Individuals (2016)
  16. Mood changes after watching pornography on the Internet are linked to symptoms of Internet-pornography-viewing disorder (2016)
  17. Problematic sexual behavior in young adults: Associations across clinical, behavioral, and neurocognitive variables (2016)
  18. Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video (2017)
  19. Exposure to Sexual Stimuli Induces Greater Discounting Leading to Increased Involvement in Cyber Delinquency Among Men (2017)
  20. Predictors for (Problematic) Use of Internet Sexually Explicit Material: Role of Trait Sexual Motivation and Implicit Approach Tendencies Towards Sexually Explicit Material (2017)

Prior to the above studies YBOP claimed that internet porn addiction was real and caused the same fundamental brain changes as seen in other addictions. We were confident in this claim because basic physiology rests on the fact that drugs do not create anything new or different; they simply increase or decrease normal brain functions. We already possess the machinery for addiction (mammalian mating/bonding/love circuitry), and for binging (storing calories, mating season). Moreover, years of addiction research have clearly demonstrated that addiction is a single condition, reflected in a typical constellation of signs, symptoms and behaviors (Natural Rewards, Neuroplasticity, and Non-Drug Addictions (2011).

These studies on Internet porn users should come as no surprise because some 230 brain studies had already confirmed that "Internet addicts" develop the same major addiction-related brain changes that occur in all addictions. Many more assessment-based Internet addiction studies back up what the brain studies found. Internet porn, internet gaming, and social media are now being viewed as separate applications or subcategories of Internet use. An individual can be addicted to Facebook or Internet porn, while not having a "generalized Internet addiction". A 2006 Dutch study found that erotica had the highest addictive potential of all Internet applications.

No wonder. Internet erotica is an extreme version of natural rewards that we're all wired to pursue: sexual arousal and apparent mating opportunities. Today's extreme porn is as unnatural a "natural reinforcer" as today's junk food is. See our article Porn Then and Now: Welcome to Brain Training, and this excellent peer-reviewed article, with a current review of where neuroscience is with respect to Internet porn addiction: Pornography addiction – a supranormal stimulus considered in the context of neuroplasticity (2013).

Recent research on brain changes in response to "highly palatable foods" is revealing evidence of an addiction process. If gambling, gaming, Internet use and food can alter the brain in this way, it would have been amazing to believe that Internet porn alone could not. This is why In 2011, 3000 doctors of the American Society for Addiction Medicine (ASAM) came out with a public statement clarifying that behavioral addictions (sexual, food, gambling) are fundamentally like substance addictions in terms of brain changes. Said ASAM:

"We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors."

In its faq's ASAM specifically addressed sexual behavior addictions:

QUESTION: This new definition of addiction refers to addiction involving gambling, food, and sexual behaviours. Does ASAM really believe that food and sex are addicting?

ANSWER: The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviours that are rewarding. ... This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. ... Food and sexual behaviours and gambling behaviours can be associated with the "pathological pursuit of rewards" described in this new definition of addiction.

In light of the latest scientific advances, the criticisms of the sexual-behavior addiction model are unfounded and outdated.

Brain Studies on Porn Users

This page lists the studies assessing the brain structure and functioning of Internet porn users. To date every study offers support for the porn addiction model (no studies falsify the porn addiction model). The results of these 39 neurological studies (and upcoming studies) are consistent with 260+ Internet addiction "brain studies", many of which also include internet porn use. All support the premise that internet porn use can cause addiction-related brain changes, as do studies reporting escalation or tolerance, and these 14 recent neuroscience-based reviews of the literature & commentaries:

Reviews of the literature:

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 recent headline-grabbing EEG studies by teams headed by Nicole Prause (who falsely 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.

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 al., 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). Excerpts:

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.

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].

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) 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)...

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.
  • 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.
  • Studies indicating a dysfunctional stress system in porn users/sex addicts: 1, 2, 3.

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 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). Five peer-reviewed papers explain the truth: 1, 2, 3, 4, 5. Also see an extensive YBOP 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.

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 the Max Planck press release 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?

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). See this extensive YBOP critique. Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (consistent with addiction): 1, 2, 3, 4, 5, 6.

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 (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 (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.

Together these neurological studies found:

  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. 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.
  7. Enhanced attentional bias comparable to drug users. Indicates sensitization (a product of DeltaFosb).
  8. Greater wanting & craving for porn, but not greater liking. This aligns with the accepted model of addiction - incentive sensitization.
  9. Porn addicts have greater preference for sexual novelty yet their brains habituated faster to sexual images. Not pre-existing.
  10. The younger the porn users the greater the cue-induced reactivity in the reward center.
  11. Higher EEG (P300) readings when porn users were exposed to porn cues (which occurs in other addictions).
  12. Less desire for sex with a person correlating with greater cue-reactivity to porn images.
  13. More porn use correlated with lower LPP amplitude when briefly viewing sexual photos: indicates habituation or desensitization.
  14. Dysfunctional HPA axis and altered brain stress circuits, which occurs in drug addictions (and greater amygdala volume, which is associated with chronic social stress).
  15. Epigenetic changes on genes central to the human stress response and closely associated with addiction.
  16. Higher levels of Tumor Necrosis Factor (TNF) - which also occurs in drug abuse and addiction.
  17. A deficit in temporal cortex gray matter; poorer connectivity between temporal corporate and several other regions

Articles listing relevant studies and debunking misinformation:


 

David Ley Attacks the NoFap Movement (May, 2015)

Comments: This was written in response to David Ley's blog post attacking nofap. It serves a bigger purpose: 1) to expose that the so-called science contradicting porn addiction is smoke and mirrors, and 2) the papers claiming to refute porn addiction come from two individuals who often team up - Nicole Prause & David Ley.


David Ley's blog post The NoFap Phenomenon is packed full of straw men, mischaracterizations and lies. Note that Ley's post contains no references to back his claims. Also note that Ley closed comments, which is very unusual for Psychology Today blog posts. In essence, Ley's post borders on libel with no support for his allegations or claims.

Ley is the author of The Myth of Sex Addiction. He has written 20 or so blog posts attacking and dismissing NoFap, porn addiction and porn-induced ED. He states that porn use is harmless and if someone develops problems it's because they had "other issues". TV shows, magazines, websites too often turn to Ley as an "authority" on porn addiction and porn's effects because the medical researchers - who would give an accurate picture of the state of internet addiction research - generally aren't focused on internet porn specifically. Nor are they as readily available as eager Dr. Ley. He therefore gets to shape the debate in the media despite his utter lack of education in the neuroscience of addiction and sexual conditioning.

As stated, David Ley has a history of attacking Nofap, Pornfree, RebootNation, etc. in blog posts and on Twitter. While the vitriol of his rhetoric has increased, he no longer allows rebuttal. Ley closes comments on all porn-related blog posts. He has done so because comments on his post calling porn-induced ED a myth didn't go his way. Specifically, the following comments under that post, by two experts who took him to task, led to his eventual ban on commenting.

Ask yourself: How ethical is it for a psychologist to attack self-help groups such as Nofap? If he has a problem with the concept of internet porn addiction, shouldn't he attack the scientists who are doing the research rather than people who are struggling to recover? What would you think of a "scientist" who didn't believe in cancer, but instead of going after oncologists, went after cancer patients struggling to regain their health?

And how ethical is it to mischaracterize and libel these groups quitting porn and sharing their experiences - yet allow them no recourse because you closed comments? I could go line-by-line through Ley's post, but here are a few examples of unsupported claims from his post attacking Nofap:

"An interesting note is that no one in the r/NoFap movement is actually a scientist who does research on neurophysiology and function."

Ley is claiming to know the occupations of all 170,000+ members of Nofap. Really? Actually, Nofap includes neuroscientists, psychologists, and several MD's who identify as such. Here are a few MD's who recovered (PIED). Here's a young psychiatrist, who had PIED, whom I interviewed on my radio show. Ley thinks nothing of making up crap that fits his prejudices on this subject:

"Instead, they are enthusiastic amateurs, who've learned enough about brain science to be dangerous, as they see what they expect to see, and interpret brain science to support their assumptions."

Of course he gives no examples, no citations, just vague accusations. It must be noted that Ley has absolutely no background in neurobiology. This is the same claim made in many of Ley's other porn-related posts. But what is the reality?

Reality

First, there are 17 "brain studies", 17 neuropsychology studies, and 12 reviews of the literature published on porn users: Without exception every study and review lends support for the porn addiction model. See this page Brain Studies on Porn Users - for an up to date list. These are not "enthusiastic amateurs" or "just YBOP" saying porn causes addiction-related brain changes. (That is what Ley tells journalists who contact him.) Top neuroscientists at Cambridge University, Yale University, and Germany's Max Planck Institute are saying porn use alters the brain.

Again, that's 100%. These brain studies must be considered in a larger context as well. In the last few years over 260 internet addiction brain studies have arrived, all showing the same fundamental brain changes as seen in drug addiction. Many include porn users, and all point to the ability of internet-based stimuli to cause pathological learning (in this case, addiction).

The internet addiction studies must be considered in the context of decades of addiction neuroscience, which informs us that all addictions share the same fundamental brain changes and mechanisms. In line with the preponderance of evidence, The American Society of Addiction Medicine published a "new definition of addiction" in 2011. ASAM stated that behavioral addictions exist, including sexual behavior addictions, and they are as real as drug addictions.

ASAM's 3000 medical doctors are the real addiction experts, not Ley or other vocal sexologists who claim that internet porn has no more impact on the human brain than stick figures on cave walls. ASAM's members include many of the world's top addiction neuroscientists. Read Ley's blog posts carefully. He does not cite a single addiction neuroscientist. What "science" does Ley use to back his claims? Mainly the research papers he and his sidekick Nicole Prause produce, rubber-stamped by their sexology cronies. These papers would simply not pass peer-review by addiction neuroscience experts.

Where's Ley's evidence?

Surprisingly, most of Ley's "science" relies on only two people, himself & Nicole Prause, and these two papers:

  • First paper: "Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images" (2013). Nicole Prause was the main author
  • Second paper: "The Emperor Has No Clothes: A review of the 'Pornography Addiction' model" (2014). David Ley & Nicole Prause were the main authors.

Ley & Prause not only teamed up to write paper #2, but they also teamed up to write a Psychology Today blog post about paper #1. The blog post showed up 5 months before Prause's paper was formally published (so no one could refute it). You may have seen Ley's blog post with the oh-so-catchy title: Your Brain on Porn - It's NOT Addictive. Put simply, most of the noise emanates from two people who teamed up to write and publicize two papers. Neither paper is what it claims to be, nor what the headlines imply.

First paper - The Prause EEG study (Steele et al., 2013)

This Nicole Prause EEG study study is listed on Brain Studies on Porn Users because it actually supports porn addiction (the first of the two papers just discussed). While Prause made several unfounded, contrary claims in her press interviews about it, her study actually reported higher EEG readings when porn users were exposed to cues. This is exactly what occurs when addicts are exposed to cues related to their addiction. Thus, Prause's results found evidence consistent with porn addiction - even as she claimed the opposite. In addition, the study reported greater cue-reactivity for porn correlating to less desire for partnered sex. Put simply: The study found greater brain activation for porn and less desire for sex (but not less desire for masturbation). Not exactly what the headlines claimed.

Please read this Psychology Today Prause interview about her EEG study. Then read the 2 comments under the interview of Prause by Psychology professor John A. Johnson:

"My mind still boggles at the Prause claim that her subjects' brains did not respond to sexual images like drug addicts' brains respond to their drug, given that she reports higher P300 readings for the sexual images. Just like addicts who show P300 spikes when presented with their drug of choice. How could she draw a conclusion that is the opposite of the actual results? I think it could be due to her preconceptions--what she expected to find."

Then read this comment - John Johnson continues.

You can also read these 5 peer-reviewed analyses Prause's EEG study. All support Johnson's claims that Prause's study actually aligns with the "addiction model" (that she and Ley irresponsibly disparage).

  1. ‘High Desire’, or ‘Merely’ An Addiction? A Response to Steele et al. (2014), by Donald L. Hilton, Jr., MD
  2. The first Cambridge study - Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours (2014), by Valerie Voon, Thomas B. Mole, Paula Banca, Laura Porter, Laurel Morris, Simon Mitchell, Tatyana R. Lapa, Judy Karr, Neil A. Harrison, Marc N. Potenza, and Michael Irvine. Note that 11 addiction neuroscientists discuss Prause's EEG study starting with this sentence:  "Our findings suggest dACC activity reflects the role of sexual desire, which may have similarities to a study on the P300 in CSB subjects correlating with desire [25]." In other words, they were politely telling Prause that she didn't understand her own results, which were consistent with an addiction finding.
  3. Neuroscience of Internet Pornography Addiction: A Review and Update (2015), by Todd Love, Christian Laier, Matthias Brand, Linda Hatch & Raju Hajela
  4. Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016), by Brian Y. Park, Gary Wilson , Jonathan Berger, Matthew Christman, Bryn Reina, Frank Bishop, Warren P. Klam and Andrew P. Doan
  5. Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017) by Sajeev Kunaharan, Sean Halpin, Thiagarajan Sitharthan, Shannon Bosshard, and Peter Walla

You can also read this full critique, documenting what the Prause EEG study really found, and how the claims in the press do not align with the actual findings. I suggest reading the short version. 

Second paper - The Ley & Prause "review"

The second paper is not a study at all. Instead, it claims to be a "review of the literature" on porn addiction and porn's effects. Nothing could be farther from the truth. The following is a very long analysis, which goes line-by-line, showing all the shenanigans Ley & Prause pulled - The Emperor Has No Clothes: A Fractured Fairytale Posing As A Review  It completely dismantles the so-called review, and documents dozens of misrepresentations of the research they cited.

The most shocking aspect of the Ley review is that it omitted ALL the studies that found negative effects/evidence of porn use. Yes, you read that right. While purporting to write an "objective" review, these two sexologists justified omitting these studies on the grounds that these were correlational studies. Guess what? All studies on porn are correlational. There are, and pretty much will be, only correlational studies, because researchers have no way to find "porn virgins" or keep subjects off of porn for extended periods in order compare effects. (Thousands of guys are quitting porn voluntarily on various forums, however, and their results suggest that internet porn is the key variable in their symptoms and recoveries.)

A few examples of what Ley & Prause pulled:

  1. As stated, they did not allow any studies showing ill effects from porn use on the grounds that they are "merely" correlational, and then proceeded to cite as support for their pet theories various correlational studies.
  2. They cherry-picked random, misleading lines from within studies, failing to report the researchers' actual opposing conclusions.
  3. They cited as support numerous studies that are entirely irrelevant to the text and the claims made.
  4. They defended their dismissal of behavioral addiction on the basis of studies that are as much as 25 years old, ignoring recent, far more numerous, contradictory studies/reviews that reflect the current consensus of addiction experts.
  5. They did not acknowledge (or analyze) dozens of brain studies on internet addicts.
  6. They ignored the two publicized brain-scan studies performed on porn users at Cambridge University and Max Planck, which dismantle the Ley/Prause conclusions.

Incidentally, their pro-porn editors Michael Perelman, Charles Moser and Peggy Kleinplatz resuscitated a defunct sexology journal called Current Sexual Health Reports (which hadn't published in many years) in order to foist this "review" on the unsuspecting public! I suspect Ley made history: this may be the first time ever that a literature review was authored by someone who 1) has never published before 2) has no expertise in the field (addiction).

Bottom line: When you see a link to an article that says porn addiction has been dismantled, follow the source. I can almost guarantee you will discover one of these 2 easily refutable, and irresponsible papers behind the claims.

What about Porn-Induced ED?

Ley & Prause claim PIED is a myth. More propaganda. First, this page links to about 70 experts, including several urology professors, who recognize and treat PIED - Porn-Induced ED in the Media: Experts who recognize PIED.

(Update - Porn-induced ED presented at the American Urologic Association Conference, May 6-10, 2016: Part 1, Part 2, Part 3

Second, all the recent studies on sexual function in young men have found unbelievably high rates of ED and low sexual desire: ED rates from 27% - 33%; low sexual desire from 24 -37% (so far). See: Research confirms enormous rise in youthful ED.

The only major ED study on American men was done just before the internet became widely available. It reported a 5% rate of ED in men ages 18-59. This was based on data from 1992, and note that one third of the men were over 40. (Historically older men reported the highest rates of ED.)

Until one can explain an 1000% jump in sexual problems in the last 15 years in young men, it's wise to assume that the above experts may be right about PIED, and that sexologists with an agenda are likely untrustworthy.

Finally, we have over a dozen studies that link porn use or porn addiction to sexual dysfunctions and lower brain activation to sexual stimuli. Many more studies link porn to lower sexual satisfaction. Link to the list of studies. Here are just a few examples:

1) Cambridge University study, which reported Porn-Induced ED in 60% of the porn addicts they scanned. From the study:

"[porn addicts] 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.”

2) The Max Planck study on porn users which found that the more porn consumed the less activity in their brains' reward centers when exposed to sexual images. From the study:

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

Lead author Simone Kühn told journalists – “That could mean that regular consumption of pornography more or less wears out your reward system.” And  That would fit perfectly the hypothesis that their reward systems need growing stimulation.

3) 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." 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).


Update: It should be noted that both David Ley and Nicole Prause profit from denying sex and porn addiction. For example, both now offer "expert" testimony against sex addiction fee.  At the end of this Psychology Today blog post Ley states:

"Disclosure: David Ley has provided testimony in legal cases involving claims of sex addiction."

Ley also makes money selling two books which deny sex and porn addiction ("The Myth of Sex Addiction", 2012 and "Ethical Porn for Dicks", 2016). Pornhub is one of the four Amazon.com endorsements listed for Ley's 2016 book. Finally, David Ley makes money via CEU seminars, where he promotes the ideas presented in his two books.

From her Liberos website (page since removed, and Prause had it removed from the Internet WayBack Machine):

“Sex addiction” is increasingly being used as a defense in legal proceedings, but its scientific status is poor. We have provided expert testimony to describe the current state of the science and acted as legal consultants to help teams understand the current state of the science in this area to successfully represent their client.

Legal consultations and testimony are generally are [sic] billed on an hourly rate.

Most shockingly, Prause (and occasionally Ley) engage in targeted harassment, defamation and cyber-stalking. See this page that was created to counter the ongoing harassment and false claims made by former UCLA researcher Nicole Prause as part of an ongoing "astroturf" campaign to persuade people that anyone who disagrees with her conclusions deserves to be reviled.

Dismantling David Ley's Response to Philip Zimbardo: "We Must Rely on Good Science in Porn Debate"

The following is YBOP's response to David Ley's Psychology Today blog post "We Must Rely on Good Science in Porn Debate (2016)." Ley's post is his response to Philip Zimbardo's Psychology Today blog post "Is Porn Good For Us or Bad For Us?" (2016).

While Ley's title says we must rely on "good science," it is Ley who links to only a single paper (which actually supports the concept of porn addiction). In contrast, Zimbardo provides 14 references (13 studies, one article) and a link to his new book "Man, Interrupted: Why Young Men are Struggling & What We Can Do About It". Zimbardo could have cited many more studies, as you will see.

Ley Links to Only a Single Citation, and It Supports Porn Addiction

Ley provides plenty of bluster, but there's not a single citation in Ley's post that refutes anything in Zimbardo's post. In fact, Ley's article links to only one citation - which is a recent review of the literature on compulsive sexual behaviors, by Shane Kraus, Valerie Voon & Marc Potenza. Contrary to Ley's claim, the "Voon review" actually supports the existence of porn addiction. An excerpt from the review: 

"Overlapping features exist between CSB [compulsive sexual behavior] 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."

In other words, the research on CSBs has much in common with substance abuse disorders, even if cautious scientists want to see further evidence. Two of the authors of this review (Valerie Voon & Marc Potenza) are top addiction neuroscientists. Together they have published three studies on "porn addicts." Two of the studies were fMRIs (brain scans), while one was neuropsychological (attentional bias). While Voon and Potenza tend to be very guarded, they stated that their three brain studies align perfectly with the addiction model (1, 2, 3). Ley ignores all of this and excerpts the cautious portion of the paper, which is a normal feature of serious scientific papers. Then he interprets it for us, claiming it means the data is conflicted (rather than merely still limited):

“Insufficient data are available regarding what clusters of symptoms may best constitute CSB (Compulsive Sexual Behavior) or what threshold may be most appropriate for defining CSB. Such insufficient data complicate classification, prevention and treatment efforts. While neuroimaging data suggest similarities between substance addictions and CSB, data are limited by small sample sizes, solely male heterosexual samples, and cross-sectional design.”

Read the above carefully. Yes, the researchers want more data. (They always do.) However, Kraus, Voon and Potenza clearly state that the existing data points for substance addictions and CSBs are neurobiologically similar. Simply put, drug addictions and compulsive sexual behaviors share similar neurobiological features and brain changes. By the way, nearly all the brain studies cited in this review to demonstrate that CSBs are very similar to substance abuse disorders involved compulsive internet porn users. It's not surprising as a separate review (Neurobiology of Compulsive Sexual Behavior: Emerging Science. 2016) published a month earlier by Kraus, Voon and Potenza concluded:

"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."

In other words, the conflict does not lie in the neuroscience on porn addicts, which is clear, and very similar to that on substance abusers. Instead, the conflict surrounds what "cluster of symptoms" best defines compulsive sexual behaviors (CSB). The difficulty agreeing on a cluster of symptoms arises from the fact that the researchers fail to tease apart sex addiction from Internet porn addiction, lumping them together as "CSBs."

Update: Valerie Voon and other addiction researchers teamed up to write this commentary on the inclusion of the diagnosis of "compulsive sexual behaviour disorder” in the upcoming  ICD-11: Is excessive sexual behaviour an addictive disorder? (Potenza et al., 2017) - You can see from the Excerpts that Valerie Voon fully supports the addiction model:

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.

All 39 Neuroscience-Based Studies on Porn Users Support Zimbardo's Claim; None support Ley's

There's a reason that Ley provided zero studies while Zimbardo tucked in 13. Truth be told, Zimabardo could have cited 20 more neuroscience-based studies on CSB subjects. Put simply, Ley's post omitted all 39 neuroscience-based studies on porn users that have been published in the last few years (up-to-date list). So far, the results of every "brain study" (MRI, fMRI, EEG, neuropsychological, neuro-endocrine) offer support for the concept of porn addiction. In addition to reporting the same fundamental brain changes as seen in substance addicts, a few studies also reported that greater porn use is associated with erectile dysfunction, decreased libido, anorgasmia, delayed ejaculation, and reduced neural response to images of vanilla porn.

The 37 studies on porn users also align with over 250 internet addiction "brain studies" (PET, MRI, fMRI, EEG) published in the last few years. Without exception, these studies report the same addiction-related brain changes as seen in substance addicts. Internet porn addiction is, according to various experts, a subtype of internet addiction as well as a CSB, as this recent review of the neuroscience literature pointed out: "Neuroscience of Internet Pornography Addiction: A Review and Update (2015)." Also see Sex Addiction as a Disease: Evidence for Assessment, Diagnosis, and Response to Critics (2015), which provides a chart that takes on specific criticisms and offers citations that counter them.

Addressing Specific Claims in Ley's Blog Post

LEY: "Dr. Zimbardo goes on to cite several studies and articles which have alleged that pornography has a neurological effect. Unfortunately, there’s the problem of causation versus correlation, again, something I learned about in basic research classes."

RESPONSE: This single sentence demonstrates a profound lack of knowledge as to how research works.

When someone uses "no causation has been demonstrated" it makes listening scientists doubt that person's basic understanding of science or research. When it comes to psychological and medical studies little research reveals causation directly. For example, all studies on the relationship between lung cancer and cigarette smoking are correlative - but cause and effect are settled.

In light of ethical requirements researchers are usually precluded from constructing experimental research designs which would prove pornography causes certain harms. Therefore, they must instead use correlational models. Over time, when a significant body of correlational studies are amassed in any given research area, there comes a point where the body of evidence can be said to prove a point of theory, even though there were no experimental studies. Put another way, no single correlation study could ever provide a “smoking gun” in an area of study, but the converging evidence of multiple correlational studies is used to establish evidence. When it comes to porn use, nearly every study published is correlative. To "prove" porn use is causing erectile dysfunction or addiction-related brain changes you would have to do one of two things:

  1. Have two large groups of identical twins separated at birth. Make sure one group never watches porn. Make sure that every individual in the other group watches the exact same type of porn, for exact same hours, and the exact same age. Continue the experiment for 30 years or so, followed by assessment of the differences.
  2. Eliminate the variable whose effects you wish to measure. Specifically, have porn users stop, and assess the changes months (years?) later. This is exactly what is occurring informally online as thousands of young men stop internet porn use to alleviate chronic non-organic sexual dysfunctions (that turn out to have been caused by porn use).

To this date only 8 studies have removed porn and observed the results. All 8 found significant changes. Five of those studies had compulsive porn users with severe sexual dysfunctions abstain from porn. Those 5 studies demonstrate causation as patients healed chronic sexual dysfunctions by removing a single variable: porn. The 8 studies:

1) Trading Later Rewards for Current Pleasure: Pornography Consumption and Delay Discounting (2015) – This study reported that greater porn use was correlated with less ability to delay gratification. The researchers assessed porn users a month later and found that continued porn use correlated with less ability to delay gratification. Finally, researchers divided subjects into 2 groups: Half tried to abstain from their favorite food; half tried to abstain from internet porn. The subjects who tried to abstain from porn experienced significant changes: they scored better on their ability to delay gratification. The researchers said:

"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.”

2) A Love That Doesn’t Last: Pornography Consumption and Weakened Commitment to One’s Romantic Partner (2012) – The study had subjects try to abstain from porn use for 3 weeks. Upon comparing the two groups, those who continued using pornography reported lower levels of commitment than those who tried to abstain.

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 article 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. 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) 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 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.

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.

5) 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). 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.

6) 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)…

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.

7) 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.

8) How Abstinence Affects Preferences (2016) [preliminary results] – Excerpts from the article:

Results of the First Wave - Main Findings

  1. The length of the longest streak participants performed before taking part in the survey correlates with time preferences. The second survey will answer the question if longer periods of abstinence render participants more able to delay rewards, or if more patient participants are more likely to perform longer streaks.
  2. Longer periods of abstinence most likely cause less risk aversion (which is good). The second survey will provide the final proof.
  3. Personality correlates with length of streaks. The second wave will reveal if abstinence influences personality or if personality can explain variation in the length of streaks.

Results of the Second Wave - Main Findings

  1. Abstaining from pornography and masturbation increases the ability to delay rewards
  2. Participating in a period of abstinence renders people more willing to take risks
  3. Abstinence renders people more altruistic
  4. Abstinence renders people more extroverted, more conscientious, and less neurotic

LEY: "Numerous studies have now demonstrated that high porn-users tend to be people with higher libido"

RESPONSE: There's a reason Ley provides no citation. Study after study refutes this often repeated Ley meme. 

Ley's "higher libido" claim appears to based on his blog post with the catchy title: "Your Brain on Porn - It's NOT Addictive". The Ley blog post is not about the science behind YBOP. Instead, it's about a single EEG study, whose lead author is his colleague Nicole Prause: (Steele et al. 2013). Both Ley and Prause claimed that the study's findings support the premise that porn/sex addiction is nothing more than "high sexual desire."

Contrary to claims by Ley and Prause, Steele et al. reported greater cue-reactivity to porn correlating with LESS desire for sex with a partner (but not lower desire to masturbate to porn). To put it another way - individuals with more brain activation and cravings for porn would rather masturbate to porn than have sex with a real person. This is not an indication of "high sexual desire."

Greater cue reactivity to porn coupled with lower desire for sex with real partners aligns the 2014 Cambridge University brain study on porn addicts. The actual findings of Steele et al., 2013 do not support its conclusion, or Ley's blog post assertions. Five subsequent peer-reviewed papers say that the Steele et al. findings actually lend support to the porn addiction model (as opposed to the "high sexual desire" hypothesis) 1, 2, 3, 4, 5.

In 2015, Nicole Prause published a second EEG study, which found LESS neural response (with brief exposure to still images) in “porn addicts” when compared to controls (Steele et al., 2013 had no control subjects) This is evidence of abnormally reduced desire in porn addicts. These findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. In other words, "porn addicts" were desensitized and - far from having high sexual desire - needed greater stimulation than non-addicts to be turned on. Put simply, the results of Prause's second EEG study indicate LESS sexual arousal - not higher sexual desire. Six peer-reviewed papers all agree that Prause et al., 2015 actually found desensitization/habituation in frequent porn users: 1, 2, 3, 4. 5, 6.

In fact, Prause stated in this recent Quora post that she no longer believes that "sex addicts" have high libidos:

"I was partial to the high sex drive explanation, but this LPP study we just published is persuading me to be more open to sexual compulsivity."

Since Prause has flip-flopped, where is Ley's support for the "porn/sex addiction = high libido" claim? Below are multiple studies that tested, and falsified, David Ley's "high libido = sex/porn addiction" claim entirely:

1) "Is High Sexual Desire a Facet of Male Hypersexuality? Results from an Online Study." (2015) - Researchers found virtually no overlap between the men with hypersexuality and the men with "High Sexual Desire". Excerpt from the paper:

"The study findings point to a distinct phenomenology of High Sexual Desire and Hypersexuality in men."

2) "Hypersexuality and High Sexual Desire: Exploring the Structure of Problematic Sexuality" (2015) - The study found little overlap between high sexual desire and hypersexuality. Excerpt from the paper:

"Our study supports the distinctiveness of hypersexuality and high sexual desire/activity."

3) "Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours" (2014) - A Cambridge University fMRI study comparing porn addicts to healthy controls. The study found that porn addicts had lower sexual desire and greater difficulty achieving erections, yet had greater cue-reactivity to porn (similar to Steele et al. above). Excerpts from the paper:

"On an adapted version of the Arizona Sexual Experiences Scale [43], 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 (Table S3 in File S1)."

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)...

4) “Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases" (2015) – Study on men with hypersexuality disorders. 27 were classified as “avoidant masturbators,” meaning they masturbated to porn one or more hours per day or more than 7 hours per week. 71% of the compulsive porn users reported sexual functioning problems, with 33% reporting delayed ejaculation.

5) "Erectile Dysfunction, Boredom, and Hypersexuality among Coupled Men from Two European Countries" (2015) - This survey reported a strong correlation between erectile dysfunction and measures of hypersexuality. Excerpt:

"Hypersexuality was significantly correlated with proneness to sexual boredom and more problems with erectile function."

6) “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."

7) "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."

8) "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."

9) "Pornography use: who uses it and how it is associated with couple outcomes" (2012) - While not a study on "hypersexuals", it reported that 1) porn use was consistently correlated with low scores on sexual satisfaction, and 2) that there was no differences in sexual desire between the porn users and the non-users.

10) 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. This SPAN Lab study, like #11 below, 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. However, due to methodological flaws the findings are uninterpretable: 1) the study had no control group for comparison; 2) subjects were heterogeneous (males, females, non-heterosexuals); 3) subjects were not screened for mental disorders or addictions; 4) the questionnaires were not validated for porn 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 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 (their desire for partnered sex was dropping in relation to their porn use). Five peer-reviewed papers expose the truth: 1, 2, 3, 4, 5. Also see the extensive YBOP critique.

11) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another SPAN Lab EEG (brain-wave) study comparing the 2013 subjects from the above study 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, Nicole Prause, claims these results "debunk porn addiction". What legitimate scientist would claim that their lone anomalous study has debunked an entire 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's findings also align with Banca et al. 2015 which is #4 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). See this extensive YBOP critique. Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (a sign of addiction): 1, 2, 3, 4, 5, 6.

12) 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.

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.

13) 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."

14) 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 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.

15) Understanding the Personality and Behavioral Mechanisms Defining Hypersexuality in Men Who Have Sex With Men (2016)

Further, we found no associations between the CSBI Control scale and the BIS-BAS. This would indicate that lack of sexual behavior control is related to specific sexual excitation and inhibitory mechanisms and not to more general behavioral activation and inhibitory mechanisms. This would seem to support conceptualizing hypersexuality as a dysfunction of sexuality as proposed by Kafka. Further, it does not appear that hypersexuality is a manifestation of high sex drive, but that it involves high excitation and a lack of inhibitory control, at least with respect to inhibition owing to expected negative outcomes.

16) Hypersexual, Sexually Compulsive, or Just Highly Sexually Active? Investigating Three Distinct Groups of Gay and Bisexual Men and Their Profiles of HIV-Related Sexual Risk (2016) - If high sexual desire and sex addiction were the same, there would only be one group of individuals per population. This study, like the ones above, reported several distinct sub-groups, yet all groups reported similar rates of sexual activity.  

Emerging research supports the notion that sexual compulsivity (SC) and hypersexual disorder (HD) among gay and bisexual men (GBM) might be conceptualized as comprising three groups—Neither SC nor HD; SC only, and Both SC and HD—that capture distinct levels of severity across the SC/HD continuum.

Nearly half (48.9 %) of this highly sexually active sample was classified as Neither SC nor HD, 30 % as SC Only, and 21.1 % as Both SC and HD. While we found no significant differences between the three groups on reported number of male partners, anal sex acts, or anal sex acts

17) 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.

18) 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). 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.

19) 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."

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 ED. Moreover, paper 2 was only a "brief communication" that did not report important data.

21) 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.

22) 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.

23) “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).

24) 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.

In short, the evidence is piling up that internet porn erodes normal sexual desire, leaving users less responsive to pleasure. They may crave porn, but that is more likely evidence of an addiction-related brain change known as "sensitization" (hyper-reactivity to addiction-related cues). Cravings certainly cannot be assumed to be evidence of greater libido.


LEY: "It is most likely that these dispositions correlate with neurological characteristics, which these studies are finding. In other words, these neurological characteristics are in fact the cause, not the effect."

RESPONSE: Without a shred of evidence or a single example, Ley is claiming that the brain changes found the 39 studies addiction must have existed before porn use. In reality, the two main addiction-related brain changes reported by the studies can only develop from chronic use:

  1. Sensitization: Chronic use leads to altered nerve connections which cause the reward circuitry to buzz in response to addiction-related cues or thoughts. This Pavlovian memory is what induces severe cravings that make the addiction far more compelling than other activities in the addict's life. (Studies reporting sensitization in internet porn users: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20.)
  2. Desensitization: Chronic use leads to the individual becoming less sensitive to pleasure, which often manifests as the need for greater and greater stimulation to achieve the same buzz. This is referred to as tolerance and only occurs with chronic use. (Studies reporting desensitization in porn users: : 1, 2, 3, 4, 5, 6.)

It's quite telling that Ley is incapable of naming these "neurological characteristics." Reality: The mechanisms of addiction have been studied for nearly 60 years. The very specific brain changes caused by addiction have been elucidated down to the cellular, protein, and epigenetic levels. These brain changes have been correlated over and over with the behaviors collectively known as the "addiction phenotype." Addiction-like behaviors can be induced in animals simply by increasing a single protein within the reward center (Deltafosb). In short, a lot is known about the biology of addiction - more than any other mental disorder - even if it remains unknown to Dr. Ley.

Four major brain changes are involved with both drug and behavioral addictions, as outlined in this paper published this year in The New England Journal of Medicine: "Neurobiologic Advances from the Brain Disease Model of Addiction (2016)". This landmark review by the Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) George F. Koob, and the director of the National Institute on Drug Abuse (NIDA) Nora D. Volkow, not only outlines the brain changes involved in addiction, it also states 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)...."

In simple, and very broad, terms the major fundamental brain changes are: 1) Sensitization, 2) Desensitization, 3) Hypofrontality/Dysfunctional prefrontal circuits 4) Dysfunctional stress circuits. All 4 of these brain changes have been identified among the 23 neuroscience studies on porn users:

  1. Studies reporting sensitization in porn users: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20.
  2. Studies reporting desensitization in porn users: 1, 2, 3, 4, 5, 6.
  3. Studies reporting "hypofrontality" in porn users: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13.
  4. Studies reporting dysfunctional stress responses in porn users: 1, 2, 3.

I find it interesting that Dr. Ley seems to always claim that there's no scientific support for porn addiction, yet not only do 37 studies provide support for porn/sex addiction, the world's top addiction experts do also. The little bubble he has constructed, where porn addiction cannot possibly exist, is seriously out of step with science.


LEY: "Grubbs also found recently that the identity of “porn addict” is an iatrogenic concept, which creates harm and distress, by telling an individual to hate and fear their own sexuality"

RESPONSE: Nothing could farther from the truth. Here is an extensive analysis of Grubbs's study - Critique of "Perceived Addiction to Internet Pornography and Psychological Distress: Examining Relationships Concurrently and Over Time" (2015).

Both Ley's and the Grubbs study's claims depend upon two false premises:

  1. That Grubbs's porn addiction test (CPUI) assesses "perceived porn addiction" rather than actual addiction. It does not. Grubbs et al. re-labeled Grubbs's self-created porn addiction test as a "perceived porn addiction" test. However, this Cyber Pornography Use Inventory (CPUI) questionnaire is in fact similar to many other drug and behavioral addiction questionnaires. Like other addiction tests, the CPUI assesses behaviors and symptoms common to all addictions, such as: the inability to control use; compulsion to use, cravings to use, negative psychological, social and emotional effects; and preoccupation with using. In fact, only 1 of its 9 questions even hints at "perceived addiction." Yet we are told that a person's total score for all 9 questions is synonymous with "perceived addiction" rather than addiction itself. Very misleading, very clever, and without any scientific basis.
  2. That Grubbs found little correlation between CPUI scores and hours of porn use. Contrary to Ley's claim, Grubbs found a pretty strong correlation between hours of use and the CPUI! From p. 6 of the study:

"Additionally, average daily pornography use in hours was significantly and positively associated with depression, anxiety, and anger, as well as with perceived addiction."

Stop the presses! This excerpt directly contradicts all the headlines, which claim that pornography use was NOT strongly correlated with psychological distress or "perceived addiction." Again, whenever you see the phrase "perceived addiction" it actually denotes the subjects' total score on the CPUI (which is a porn addiction test). Really get this: The Grubbs study did NOT assess "perceived addiction." There are many more details in this critique that debunks assertions put forth in lay articles and the claims made within the Grubbs's studies: Is Joshua Grubbs pulling the wool over our eyes with his "perceived porn addiction" research? (2016).

Update: Joshua Grubbs published a study testing the talking point that religious people are more likely to believe they are addicted to porn (even though the Grubbs studies never assessed “belief in being addicted porn”). Faced with thoughtful skepticism about his assumptions, and reservations about the unfounded claims that his CPUI-9 instrument could indeed distinguish “perceived pornography addiction” from genuine problematic porn use, Dr. Grubbs did the right thing as a scientist. He pre-registered a study to test his hypotheses/assumptions directly. Pre-registration is a sound scientific practice that prevents researchers from changing hypotheses after collecting data.

The results contradicted both his earlier conclusions and the meme (“porn addiction is just shame”) that the press helped to popularize.

Dr. Grubbs set out to prove that religiosity was the main predictor of "believing yourself addicted to porn." He and his team of researchers surveyed 3 rather large, diverse samples (male, female, etc.): Who’s a Porn Addict? Examining the Roles of Pornography Use, Religiousness, and Moral Incongruence. (He posted the results online, although his team’s paper has not yet been formally published).

This time, however, he didn’t rely on his CPUI-9 instrument. (The CPUI-9 includes 3 “guilt and shame/emotional distress” questions not normally found in addiction instruments – and which skew its results, causing religious porn users to score higher and non-religious users to score lower than subjects do on standard addiction-assessment instruments.) Instead, the Grubbs team asked 2 direct yes/no questions of porn users (“I believe that I am addicted to internet pornography.” “I would call myself an internet pornography addict.”), and compared results with scores on a “moral disapproval” questionnaire.

Directly contradicting his earlier claims, Dr. Grubbs and his research team found that believing you are addicted to porn correlates most strongly with daily hours of porn use, not with religiousness. As noted above, some of Grubbs studies also found that hours of use was a stronger predictor of "perceived addiction" than religiosity. From the new study's abstract:

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

Based on their results, Dr. Grubbs and his co-authors advise that,

"mental and sexual health professionals should take the concerns of clients identifying as pornography addicts seriously."


LEY: "There has not been a single peer-reviewed paper published which demonstrate any evidence that ED related to porn use is a real phenomenon."

RESPONSE: Absoluely false. And it's not just erectile dysfunction. Several studies have found relationships between porn use in young men and ED, anorgamsia, low sexual desire, delayed ejaculation and lower brain activation to sexual images. In addition this page contains articles and videos by over 100 experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who acknowledge and have successfully treated porn-induced ED and porn-induced loss of sexual desire.

Studies reporting links between porn use/sex addiction and ED, anorgamsia, low sexual desire, delayed ejaculation, and lower brain activation to sexual images.

The first 5 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 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). 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) 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."

7) 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."

8) 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."

9) 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."

10) Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases (2015) - Study on men (average age 41.5) with hypersexuality disorders, such as paraphilias and chronic masturbation or adultery. 27 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% 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 requests for details. Two primary choices for male sexual dysfunction are ED and low libido. The men were not asked about their erectile functioning without porn. If all their sexual activity involved masturbating to porn, and not sex with a partner, they might never realize they had porn-induced ED.

11) 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.

12) 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.

13) 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.

14) 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."

15) 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 addiction. Not so. In line with the Cambridge University brain scan studies, this EEG study reported greater cue-reactivity to porn correlated with less desire for partnered sex. To put another way - individuals with more brain activation and cravings for porn would rather masturbate to porn than have sex with a real person. Study spokesperson Nicole Prause claimed that porn users merely had "high libido", yet the results of the study say something quite different.Four peer-reviewed papers expose the truth: 1, 2, 3, 4, 5. Also see the extensive YBOP critique.

16) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another Nicole Prause EEG study. This time comparing the 2013 subjects from the above study to an actual control group. The results: compared to controls, "porn addicts" had less response to one-second exposure to photos of vanilla porn. The lead author, Nicole Prause, claimed these results debunk porn addiction (contrary to caims no studies falsify the porn addiction model). However, these findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. Put simply, frequent porn users were desensitized to static images of vanilla porn. They were bored (habituated or desensitized). Five peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users: 1, 2, 3, 4. 5, 6. (also see this extensive YBOP critique). By the way, another EEG study found that greater porn use in women correlated with less brain activation to porn.

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) 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.

19) 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.

20) 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

21) 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".

22) 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.

23) “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)

24) 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.

23) 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.

24) (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)


LEY: However, Dr. Zimbardo fails to acknowledge or consider the tremendous social changes which occurred with the invention of erectile performance medications, and which dramatically increased willingness to disclose erectile dysfunction, by reducing the shame associated with it.

RESPONSE: Studies assessing young male sexuality since 2010 report historic levels of sexual dysfunctions, and startling rates of a new scourge: low libido. Documented in this lay article and in this peer-reviewed paper involving 7 US Navy doctors - Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016)

Ley cited nothing as, once again, there is no empirical support for his claim that the introduction of Viagra (1997) led to men finally tell the truth in studies on sexual dysfunction (13 years later). These are not the rates of men visiting their doctors to request ED medication. The ED rates cited refer only to peer-reviewed studies (usually anonymous) on population wide rates of sexual dysfunction. To put it another way, the ‘Viagra hypothesis’ is claiming that in every single study published between 1948 and 2010, in countries all over the world, the young male participants consistently lied about their erectile functioning. Then, all of a sudden, in 2010 all the young men (and only the young men) began to tell the truth about their ED problems. This is absurd. Ley's claim is like saying that the introduction of aspirin led to anonymous studies reporting a 1000% increase in headaches among only one age group. A few more points that refute the "Viagra causes ED" claim:

1) The claim about "willingness to disclose" doesn't apply here. The ED and low libido rates are not rates for men visiting their doctor for erectile dysfunction. Instead, the ED and low libido rates come from studies mostly employing anonymous standardized questionnaires where men rate the quality of their erections and arousal during sex. That has not changed because Viagra was introduced.

2) The exponential rise in ED and low libido rates occurred only in men under 40. This alone refutes Ley's claim.

3) In this same time period there was a concomitant increase in low sexual desire (and evidence of increases in difficulty orgasming too). The largest US study from 1992 reported 5% of men under 40 had low sexual desire.

  • A 2014 Canadian study reported low sexual desire in 24% of 16-21 year olds!
  • A 2014 survey of Croatian men 40 and under reported low sexual desire rates of 37%.
  • Again, this aligns with a 2015 study on Italian high school seniors (18-19), which 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 (as one would expect in 18-year olds).

4) These days, ED rates are often higher for young men than for old men (who obviously used less internet porn growing up). The 2014 Canadian study 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%).

  • Reality check: these rates are higher than those reported for 50-60 year olds in the large 1992 study on men 18-60!

5) Two studies published AFTER Viagra was introduced report higher ED rates in young men. If Viagra ads caused ED in men, wouldn't we see far higher rates in older men? These were studies of the same European countries using the same questionnaires (GSSAB). Instead rates in young men are abnormally high now.

  • The 2001-2002 ED rates for men 40-80 were about 13% in Europe.
  • By 2011, ED rates in young Europeans, 18-40, ranged from 14-28%.

6) Common sense: There's absolutely no evidence to suggest that a young man today would be any less embarrassed or ashamed when experiencing erectile dysfunction than a young man was in 1995 (once again, shame is irrelevant as all data came from studies using anonymous questionnaires). 


LEY: Indeed, multiple peer-reviewed articles have now been published which found no evidence for PIED, but instead, found the opposite effect, that porn use and concomitant masturbation, is likely to result in delayed orgasm.

RESPONSE TO FIRST PART: "multiple peer-reviewed articles have now been published which found no evidence for PIED"

First, there's only one way to confirm whether erectile dysfunction is porn-induced (PIED) or not: Eliminate porn use for a extended period of time and see if the sufferer regains normal erectile functioning. Three studies have done this, thus proving the existence of porn-induced sexual dysfunctions. See this list of 24 studies linking porn use/sex addiction to sexual problems (the first 5 demonstrate causation as participants eliminated porn use and healed chronic sexual dysfunctions).

The "multiple articles" that Ley could be referring to are really only two papers that claimed to have found little relationship between the amount of porn use and erectile dysfunction. The first paper, Prause & Pfaus 2015, has been so roundly criticized for missing data, unsupported claims, poor methodology, and statements that are in direct opposition of its data, that it is, in effect, discredited. It was formally critiqued in an academic journal by a researcher and reproductive medicine doctor. This lay critique exposes even more holes in the paper.

A second paper (Landripet & Stulhofer) found extraordinarily high rates of low libido and ED in men under 40 (it wasn't a full study, but a "brief communication"). Contrary to Ley's claims, 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.

Here’s the sneaky part that says a lot about the two authors: Landripet & Stulhofer's “brief communication” omitted three significant correlations they presented to a European conference (excerpts from their abstract):

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

The authors blow this finding off and ignore it in reaching their conclusions, as they also ignore Danish porn researcher Gert Martin Hald's formal commentary about the study, in which 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].

Gert Martin Hald's editorial comments emphasize 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.

In other words, using only a single limited variable such as "hours of use in the last month" may not reveal anything. It's already established in studies on both internet porn addiction (1, 2, 3) and internet video-gaming addiction, that symptoms do not correlate with "hours of use." Instead of just current hours of use, a combination of variables appears to correlate best with porn-induced ED. These may include:

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

The better way to research the phenomenon of porn-induced sexual dysfunctions, is to remove the variable of internet porn use and observe the outcome. Such research reveals causation instead of correlations open to interpretation. My site has documented a few thousand men who removed internet porn and recovered from chronic sexual dysfunctions.

SUMMARY: Only one valid study has attempted to correlate the amount of porn use with ED. Contrary to Ley's claim, this study reports at least one meaningful correlation between ED and porn use. Offsetting this single "brief communication," we have 25 studies reporting relationships between porn use in young men and ED, anorgasmia, low sexual desire, delayed ejaculation and lower brain activation to sexual images. 


LEY: "Indeed, multiple peer-reviewed articles have now been published which found no evidence for PIED, but instead, found the opposite effect, that porn use and concomitant masturbation, is likely to result in delayed orgasm."

RESPONSE TO SECOND PART: "but instead, found the opposite effect, that porn use and concomitant masturbation, is likely to result in delayed orgasm."

How bizarre. Ley appears to be claiming that delayed orgasm is "the opposite" of erectile dysfunction. Hats off to Ley. This has to be the most over-the-top bits of spin he's ever written. Ley appears to be spinning the results of this 2015 study on men with hypersexuality disorders - “Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases”.

The study classified 27 men as “avoidant masturbators,” meaning they masturbated to porn one or more hours per day or more than 7 hours per week. 71% of the compulsive porn users reported sexual functioning problems, with 33% reporting delayed ejaculation.

What sexual dysfunction do 38% of the remaining men have? The study doesn't say, and the authors have publicly refused to give details. The two other primary choices for male sexual dysfunction are ED and low libido. You do the math. 

In reality, porn-induced delayed ejaculation is often a precursor to porn-induced erectile dysfunction. Like ED, delayed ejaculation is one of the primary reasons men choose to abstain from porn in search of recovery. This page contains many stories by men who recovered from porn-induced delayed ejaculation. Delayed ejaculation arises from the same brain changes that eventually lead to full blown PIED (i.e. desensitization/habituation and conditioning one's sexual arousal to everything associated with internet porn use instead of to real partners). 

SUMMARY: Ley is trying to spin a 71% rate of sexual dysfunction in compulsive porn users into evidence that porn use is really beneficial! That's Ley as his best.


LEY: Numerous research studies in the past year from authors such as Joshua Grubbs of Case Western  and Alexander Stulhofer of Croatia, have consistently confirmed the role of morality and religiosity in the backgrounds of those who identify as sex or porn addicts. In other words, both of these researchers have demonstrated that sex/porn addicts are not in fact watching more porn or having more sex than anyone else - they just feel worse and more conflicted about the sex they are having.

RESPONSE: Numerous? Since there are no citations let's consider the two studies mentioned: In the case of Grubbs and Stulhofer how have the researchers distinguished between shame related to sex/porn and shame from the inability to control use despite negative consequences? This is left unexplained. (In other words, they haven't.)

As for Stulhofer paper (Is High Sexual Desire a Facet of Male Hypersexuality? Results from an Online Study) It's conclusion says:

Compared to the rest of the sample, men in the hypersexuality group had significantly higher odds of being single, not exclusively heterosexual, religious, depressed, prone to sexual boredom, experiencing substance abuse consequences, holding negative attitudes toward pornography use, and evaluating one's sexual morality more negatively. In contrast, the high sexual desire group differed from controls only in reporting more positive attitudes toward pornography use.

First, Stulhofer reported very little overlap between the hypersexuality group (sex/porn addicts) and the high libido group. As explained above, this refutes Ley's claim that "hypersexuals" simply have high sexual desire. 

Second, the addicts held negative attitudes towards pornography use. Is it really so odd for an addict to feel bad about being unable to control use despite the negative consequences? Wouldn't we expect an out-of-control alcoholic to have negative feelings towards drinking alcohol? What does the phrase "evaluating one's sexual morality" mean when it is applied to out-of-control porn use that is impacting one's life negatively? It could be as simple as, "Addicts experience negative feelings towards their addiction."

As for Grubbs et al's results, might they be explained, in part, by the fact that religious people are generally better informed (or, in some cases overly informed) about the risks of internet porn use, so they "connect the dots" more quickly and in higher percentages when asked about their addiction? Religious people are probably also more inclined to try stopping, and therefore more likely to experience distressing withdrawal symptoms or recognize their inability to control their (perhaps) infrequent use. Withdrawal symptoms are anxiety-producing in themselves. In contrast, the non-religious simply don't think to experiment with stopping porn so they may not experience severe cravings and withdrawal symptoms unless they slam into a wall o' hurt and try quitting.

If religion were the key factor in a "belief in porn addiction," one would expect the majority of those on the recovery forums to be religious. That is not what we see. The most popular English-speaking porn-recovery forum we know of, r/nofap, polled their members (back in 2012). 60+% of their members were non-religious (23% Christian). Shortly after that poll, a "Christian nofap" was founded, which means that the percentage of religious on r/nofap is even lower now. In a later member survey, only 11% were quitting for religious reasons. Since that first poll, the number of members on r/nofap has exploded. It's 170K+ members now, and overwhelming non-religious.

Grubbs needs better methodology - methodology that does not conflate shame arising from "being unable to quit an addiction that is producing negative effects" with shame arising from porn's content. Two quite different phenomena.


Is it Ethical for a Psychologist to Consistently Attack a Self-Help Group?

Ley suggests that NoFap, a porn-recovery forum, is somehow dangerous. In this piece he continues his ongoing defamatory attacks on the NoFap community. If he disagrees with the scientific findings on internet porn users' brains (which support the efforts on NoFap), he should take it up with the researchers themselves, not take it out on a self-help community. This is like attacking cancer patients because one disagrees with oncology protocols. (Nofap moderator dismantles Ley's article)

Not only is it disturbing that Ley attacks people endeavoring to recover from the effects of overconsuming internet porn, it may be a violation of various principles of the American Psychological Association. The APA has 5 guiding principles for all psychologists and Ley's chronic disparaging of NoFap appears to violate all 5:

Principle A: Beneficence 4.05 and Nonmaleficence (in part)

... In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons… .... Because psychologists' scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational or political factors that might lead to misuse of their influence...

Principle B:  Fidelity and Responsibility (in part)

Psychologists … are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior and seek to manage conflicts of interest that could lead to exploitation or harm. ...

Principle C: Integrity (in part)

Psychologists seek to promote accuracy, honesty and truthfulness in the science, teaching and practice of psychology. In these activities psychologists do not steal, cheat or engage in fraud, subterfuge or intentional misrepresentation of fact.

Principle D: Respect for People’s Rights (in part)

Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence and the limitations of their expertise do not lead to or condone unjust practices.

Principle E: Dignity (in part)

Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination.


Update: It should be noted that both David Ley profits from denying sex and porn addiction. At the end of this Psychology Today blog post Ley states:

"Disclosure: David Ley has provided testimony in legal cases involving claims of sex addiction."

Ley also makes money selling two books which deny sex and porn addiction ("The Myth of Sex Addiction", 2012 and "Ethical Porn for Dicks", 2016). Pornhub (which is owned by porn ginat mindgeek) is one of the five Amazon.com endorsements listed for Ley's 2016 book about porn. Finally, David Ley makes money via CEU seminars, where he promotes the ideas presented in his two books.

David Ley's Blog Post "We Must Rely on Good Science in Porn Debate" (March 2, 2016)

Disagreeing with one’s heroes is always an interesting growth experience. As young psychologists, we learn about the revolutionary work of Dr. Philip Zimbardo, and the way in which his research and insights have changed our understandings of human behavior and morality. As a psychologist, and a person, I owe Dr. Zimbardo a debt of gratitude. That’s why I find it so difficult now, to say that he is simply, flatly, dangerously wrong in his recent post about pornography.

Dr. Zimbardo cites the Your Brain on Porn and Reddit NoFap websites as evidence for the addictive, dangerous nature of pornography use. It’s unfortunate that he does so, with no recognition or caveats regarding the danger of using self-selected anecdotes, subject to peer pressure and conformity theory, as evidence. I learned about those tenets of psychological theories in the same undergraduate psychology classes where I also learned about Dr. Zimbardo’s research. Unfortunately, the plural of anecdote, is not data, and the many stories on these sites reveal much more about the social psychology at work, as opposed to the dangers of porn which Dr. Zimbardo cites.

Dr. Zimbardo goes on to cite several studies and articles which have alleged that pornography has a neurological effect. Unfortunately, there’s the problem of causation versus correlation, again, something I learned about in basic research classes. These correlative studies which suggest a link between porn consumption and neurological effects, unfortunately cannot identify the impact and role of predisposing variables such as libido, and sensation seeking. Numerous studies have now demonstrated that high porn-users tend to be people with higher libido, and a greater tendency towards sensation-seeking. It is most likely that these dispositions correlate with neurological characteristics, which these studies are finding. In other words, these neurological characteristics are in fact the cause, not the effect.

Dr. Valerie Voon, who conducted the Cambridge brain porn study cited by Dr. Zimbardo, as well as many others, has recently published a paper where she and her co-authors actually state that at this point, there is not a scientific consensus that porn or sex actually is an addiction, nor that this language is appropriate. Her paper indicates that literature on such issues is overly biased towards heterosexual males, and that the absence of data on other populations greatly hinders the applicability or generalizability of their findings.  In her words (link is external), “Insufficient data are available regarding what clusters of symptoms may best constitute CSB (Compulsive Sexual Behavior) or what threshold may be most appropriate for defining CSB. Such insufficient data complicate classification, prevention and treatment efforts. While neuroimaging data suggest similarities between substance addictions and CSB, data are limited by small sample sizes, solely male heterosexual samples, and cross-sectional design.” It's unfortunate that Dr. Zimbardo has not exercised the same caution in interpreting this insufficient evidence.

Numerous research studies in the past year from authors such as Joshua Grubbs of Case Western  and Alexander Stulhofer of Croatia, have consistently confirmed the role of morality and religiosity in the backgrounds of those who identify as sex or porn addicts. Further, those researchers have empirically demonstrated in multiple, replicated studies, that the identity of sex/porn addict is not predicted by sexual frequency. In other words, both of these researchers have demonstrated that sex/porn addicts are not in fact watching more porn or having more sex than anyone else - they just feel worse and more conflicted about the sex they are having.

Grubbs also found recently that the identity of “porn addict” is an iatrogenic concept, which creates harm and distress, by telling an individual to hate and fear their own sexuality. Sadly, and surprisingly, Dr. Zimbardo is perpetuating this harm, by encouraging men to hate and fear their own sexual response to pornography, and to embrace the identity of porn addict. Given Dr. Zimbardo's own body of research, about the impact of identity and expectation on behavior and feelings, I'm surprised that he does not see the impact that his views may have upon those who are struggling with porn-related behaviors, driving them into these identities Dr. Zimbardo endorses.

Finally, Dr. Zimbardo cites recent claims of Porn Induced Erectile Dysfunction as evidence of the indisputable effects of pornography. Dr. Zimbardo points to the changes in rates of erectile dusfunction reported by males, between Kinsey’s studies in 1948 and recent studies showing higher rates of ED reported by young men. However, Dr. Zimbardo fails to acknowledge or consider the tremendous social changes which occurred with the invention of erectile performance medications, and which dramatically increased willingness to disclose erectile dysfunction, by reducing the shame associated with it. Further, Dr. Zimbardo fails to mention that in every study exploring ED in young men, these effects are linked to issues of anxiety, drug use, obesity, medication and sexual experience. There has not been a single peer-reviewed paper published which demonstrate any evidence that ED related to porn use is a real phenomenon. Indeed, multiple peer-reviewed articles have now been published which found no evidence for PIED, but instead, found the opposite effect, that porn use and concomitant masturbation, is likely to result in delayed orgasm.

I agree with Dr. Zimbardo’s conclusions – we DO need to be having more open dialogue about the role that porn plays in our sexuality, and in the sexual education of our youth. Sadly, Dr. Zimbardo and I disagree strongly about what qualifies as scientific evidence in that discussion. I believe that such a social dialogue must be guided by clear, empirically-based thinking. Elsewise, morality-based fears can easily lead us to replicate the mistakes of the past, when the American Psychological Association condoned torture, when the American mental health industry supported the false ideas of recovered memory syndrome of Satanic child abuse, or when women who liked sex as much as men were called nymphomaniacs and subjected to horrific treatments on the basis of gender bias. In each of these cases, anecdotes and clinician confidence such as Dr. Zimbardo musters in support of his theories, were used to support unethical, and scientifically invalid clinical approaches. Science today is better than that, in part because of the contributions of Dr. Zimbardo, in helping us to understand how context and social biases can affect our thoughts and feelings regarding complex social behaviors. Our job at this point is to help people struggling with issues of porn, to deal with these issues in effective ways which do not mistake effects for causes.

How to recognize biased articles: They cite Prause et al., 2015 (falsely claiming it debunks porn addiction), while omitting over 3 dozen neurological studies supporting porn addiction

A number of articles and interviews have attempted to pushback at the TIME article ("Porn and the Threat to Virility") and the Utah resolution declaring internet porn a public health problem (one example). What might be a few "dead giveaways" that such an article is nothing more than a propaganda piece?

  1. Psychologists David Ley and/or Nicole Prause are cited as "the experts," while actual top addiction neuroscientists, who have published highly respected studies on porn users (Voon, Kraus, Potenza, Brand, Laier, Hajela, Kuhn, Gallinat, Klucken, Seok, Sohn, Gola, Banca, etc.), are omitted. Neither Ley nor Prause are affiliated with any university, yet some journalists, perhaps influenced by Prause's potent media services, mysteriously prefer both over the top neuroscientists at Yale University, Cambridge University, University of Duisburg-Essen, and the Max Planck Institute. Go figure.
  2. The articles tend to cite Prause's lone, anomalous 2015 brainwave (EEG) study as proof that porn addiction doesn't exist, while simultaneously omitting 38 neurological studies and 14 recent reviews of the literature: Current list of brain studies on porn users/sex addicts. (a few articles cite Prause's 2013 EEG study, which, in fact, lends support to the porn addiction model and porn-induced sexual conditioning)
  3. The articles omit over 20 studies pointing to escalation & habituation in porn users (and even withdrawal symptoms).
  4. The articles omit 25 studies linking porn use to sexual problems and lower arousal to sexual stimuli (the first 5 studies in the list demonstrate causation, as participants eliminated porn use and healed chronic sexual dysfunctions).
  5. The articles omit over 55 studies linking porn use to less sexual satisfaction and poorer intimate relationships.
  6. The articles omit 50 studies linking porn use to poorer mental-emotional health & poorer cognitive outcomes.
  7. The articles omit over 25 studies linking porn use to "un-egalitarian attitudes" toward women
  8. The articles omit the many studies on adolescents, which report that porn use is related to such factors as poorer academics, more sexist attitudes, more aggression, poorer health, poorer relationships, lower life satisfaction, viewing people as objects, increased sexual risk taking, less condom use, greater sexual violence, unexplained anxiety, greater sexual coercion, less sexual satisfaction, lower libido, greater permissive attitudes, and a whole lot more.
  9. The articles falsely claim that porn addicts simply have a high libido, even though 24 studies have falsified this often repeated meme.
  10. In classic "astroturfing-style," the articles engage in ad hominem attacks on those with opposing views (such as libelous claims of nonexistent "restraining-orders," "stalking," and religious and profit motives), without supplying objective proof of such claims.

Reality Check Concerning Prause's 2015 EEG Study (Prause et al., 2015)

Prause's 2015 EEG study (claiming to debunk porn addiction) actually supports the existence of porn addiction because her team found desensitization in the heavy porn users.

Compared to controls, more frequent porn users had lower brain activation to one-second exposure to photos of vanilla porn. The lead author, Nicole Prause claims these results debunk porn addiction. However, these findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with lower brain activation in response to pictures of vanilla porn (and less gray matter in the dorsal striatum). In other words, the frequent porn users were desensitized to still images and needed greater stimulation than occasional porn users. These findings are consistent with tolerance, a sign of addiction. Tolerance is defined as a person’s diminished response to a drug or stimulus that is the result of repeated use. Six peer-reviewed papers agree with the YBOP analysis, namely that what Prause actually found is consistent with the effects of addiction in her study's subjects:

  1. Neuroscience of Internet Pornography Addiction: A Review and Update (2015)
  2. Decreased LPP for sexual images in problematic pornography users may be consistent with addiction models. Everything depends on the model (2016)
  3. Neurobiology of Compulsive Sexual Behavior: Emerging Science (2016)
  4. Should compulsive sexual behavior be considered an addiction? (2016)
  5. Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016)
  6. Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017)

Author of the second critique, neuroscientist Mateusz Gola, summed up it up nicely:

"Unfortunately the bold title of Prause et al. (2015) article has already had an impact on mass media, thus popularizing a scientifically unjustified conclusion."

What legitimate researcher would ever claim to have debunked an entire field of research and to refute all previous studies with a single EEG study? (Close ties to the industry in question might cloud a researcher's perceptions).

Not only was the title scientifically unjustified, Nicole Prause claimed her study contained 122 subjects (N). In reality, the study had only 55 subjects who were "experiencing problems regulating their viewing of sexual images”. The subjects were recruited from Pocatello Idaho, which is over 50% Mormon. The other 67 participants were controls.

In a second dubious claim, Prause et al., 2015 stated in both the abstract and in the body of the study:

"These are the first functional physiological data of persons reporting VSS regulation problems".

This is clearly not the case, as the Cambridge fMRI study was published nearly a year earlier.

In a third claim Nicole Prause has consistently asserted that Prause et al., 2015 is "the largest neuroscience investigation of porn addiction ever conducted". It should be noted that compared to brain scan studies, EEG studies are far less expensive per subject. It's easy to gather a large group of "porn addicted" subjects if you don't screen the subjects for porn addiction or any exclusionary condition (mental problems, addictions, psychotropic drug use, etc.). A few problems with Prause's claim:

  1. It's not a study on porn addiction if it has no porn addicts. This study, and 2 earlier Prause studies (Prause et al., 2013 & Steele et al., 2013), did not assess whether any of the subjects were porn addicts or not. Prause admitted in an interview that many of the subjects had little difficulty controlling use: they were not addicts. All of the subjects would have to have been confirmed porn addicts to permit a legitimate comparison with a group of non-porn addicts. In addition the Prause Studies did not screen subjects for mental disorders, compulsive behaviors, or other addictions. Three of the five peer-reviewed critiques point out these fatal flaws: 2, 3, 4.
  2. "HPA axis dysregulation in men with hypersexual disorder" (2015) could be considered the largest neuroscience-based study to date on "hypersexuals" (with 67 subjects in treatment for sex addiction, as compared to Prause's 55 subjects who were upset about their porn use). The study assessed the brain's response to stress by assessing a hormone release by the brain (ACTH), and a hormone controlled by the brain (cortisol). While this study was a published a few months after Prause et al., 2015, Nicole Prause continues to claim her EEG study as the largest.
  3. Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014) - Could be considered larger than Prause et al., 2015, because it had 64 subjects, and all were carefully screened for exclusionary items such as addictions, substance use, mental disorders, and medical & neurological disorders. The 3 Prause Studies did not do this.

You Can't "Debunk Porn Addiction" if Your Subjects Are Not Porn Addicts

The 3 Prause Studies (Prause et al., 2013, Prause et al., 2015, Steele et al., 2013.) all involved the same subjects. Here's what we know about the "porn addicted users" in Prause's 3 studies (the "Prause Studies"): They were not necessarily addicts, as they were never assessed for porn addiction. Thus, they can't legitimately be used to "falsify" anything to do with the addiction model. As a group they were desensitized or habituated to vanilla porn, which is consistent with predictions of the addiction model. Here's what each study actually reported about the "porn addicted" subjects:

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

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

Make no mistake, neither Steele et al., 2013 nor Prause et al., 2015 described these 55 subjects as porn addicts or compulsive porn users. The subjects only admitted to feeling "distressed" by their porn use. Confirming the mixed nature of her subjects, Prause admitted in 2013 interview that some of the 55 subjects experienced only minor problems (which means they were not porn addicts):

"This study only included people who reported problems, ranging from relatively minor to overwhelming problems, controlling their viewing of visual sexual stimuli."

Besides not establishing which of the subjects were porn addicted, the Prause Studies did not screen subjects for mental disorders, compulsive behaviors, current drug use, or other addictions. This is critically important for any "brain study" on addiction, lest confounds render results meaningless.

In summary, the 3 Prause Studies did not assess whether the subjects were porn addicts or not. The authors admitted that many of the subjects had little difficulty controlling use. All of the subjects would have to have been confirmed porn addicts to permit a legitimate comparison with a group of non-porn addicts.

In 2013 Prause Said That Less Brain Activation Would Indicate Habituation or Addiction

You read that correctly. Prause's 2015 claim of "debunking porn addiction" represents a flip-flop from her 2013 study's claim of "debunking porn addiction."

In her 2013 EEG study and related blog post, Prause admits that reduced brain activation would indicate habituation or addiction, but claimed her subjects didn't show reduced activation. This claim, however, was groundless as explained here. She had no control group, so she could not compare "porn addicts'" EEG readings to "non-addicts'" readings. As a result, her 2013 study told us nothing about the EEG readings for either healthy individuals or "hypersexuals."

Finally, in 2015 she added control subjects and published a second study. Sure enough, her "porn addicted" subjects displayed reduced brain activation in comparison to controls - just as would be expected in porn users suffering from habituation or addiction. Undaunted by findings that undermined her 2013 conclusion, she boldly, and without any basis in science, claimed that her corrected findings - which were consistent with the presence of addiction - "dismantled porn addiction." And this is the talking point these propaganda pieces latch onto, with no support other than Prause's unfounded claims.

Let's back up and look more closely at Prause's views from her 2013 study (Steele et al.):

"Therefore, individuals with high sexual desire could exhibit large P300 amplitude difference between sexual stimuli and neutral stimuli due to salience and emotional content of the stimuli. Alternatively, little or no P300 amplitude difference could be measured due to habituation to VSS."

In 2013, Prause said that porn addicts, when compared to controls, could either exhibit:

  1. higher EEG readings due to cue-reactivity to images, or
  2. lower EEG readings due to habituation to porn (VSS).

Five months before her 2013 EEG study was published, Prause and David Ley teamed up to write this Psychology Today blog post about her upcoming 2013 study (and its unsupported claims). In it they admit that "diminished electrical response" would indicate habituation or desensitization:

"But, when EEG’s were administered to these individuals, as they viewed erotic stimuli, results were surprising, and not at all consistent with sex addiction theory. If viewing pornography actually was habituating (or desensitizing), like drugs are, then viewing pornography would have a diminished electrical response in the brain. In fact, in these results, there was no such response. Instead, the participants’ overall demonstrated increased electrical brain responses to the erotic imagery they were shown, just like the brains of “normal people”...

So, we have 2013 Prause saying "diminished electrical response" would indicate habituation or desensitization. Later, however, in 2015, when Prause added controls for comparison and found evidence of desensitization (common in addicts), she tells us "diminished electrical response" debunks porn addiction. Huh?

In the intervening two years it took Prause to compare her same tired subject data with an actual control group, she executed a complete flip-flop. In 2015, she claimed the evidence of desensitization that she found when she added the control group isn't evidence of addiction (which she claimed in 2013 it would have been). Instead, evidence of desensitization now (magically) "disproves addiction" (even though it aligns with addiction perfectly). This is inconsistent and unscientific, and suggests that regardless of opposing findings, she will always claim to have "disproven addiction."

What About Brain Studies That Debunk Porn Addiction?

There are none. Unbelievably, the Prause et al. team boldly claimed to have falsified the porn addiction model with a single paragraph taken from this 2016 "letter to the editor." In reality the Prause letter falsified nothing, as this extensive critique reveals: Letter to the editor “Prause et al. (2015) the latest falsification of addiction predictions" (2016). In short, there are no studies that “falsify porn addiction.” This page lists all the studies assessing the brain structure and functioning of internet porn users. To date, every study offers support for the porn addiction model (including Prause's two studies just discussed). However, whenever an article claiming to debunk porn addiction cites a study, I expect you will find one of her two EEG studies, or an irresponsible "review" by Prause, Ley and Finn. Here they are for easy reference:

  1. Sexual Desire, not Hypersexuality, is Related to Neurophysiological Responses Elicited by Sexual Images (Steele et al., 2013)
  2. Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (Prause et al., 2015)
  3. The Emperor Has No Clothes: A Review of the 'Pornography Addiction' Model, by David Ley, Nicole Prause & Peter Finn (Ley et al., 2014)

Kinsey Institute grad Nicole Prause is the lead author on studies 1 and 2, and is the second author on paper #3. We already saw above that study #2 (Prause et al., 2015) lends support to the porn addiction model. But how does Prause's 2013 EEG study (Steele et al., 2013), touted in the media as evidence against the existence of porn addiction, actually support the porn addiction model?

This study's only significant finding was that individuals with greater cue-reactivity to porn had less desire for sex with a partner (but not lower desire to masturbate to porn). Put another way, individuals with more brain activation and cravings for porn would rather masturbate to porn than have sex with a real person. This is typical of addicts, not healthy subjects.

Study spokesman Nicole Prause claimed that frequent porn users merely had high libido, yet the results of the study say something quite different. As Valerie Voon (and 10 other neuroscientists) explained, Prause's 2013 findings of greater cue-reactivity to porn coupled with lower desire for sex with real partners aligned with their 2014 brain scan study on porn addicts. Put simply, the actual findings of the 2013 EEG study in no way match the unsupported "debunking" headlines. Five peer-reviewed papers expose the truth about this earlier study by Prause's team: 1, 2, 3, 4, 5. (Also see this extensive YBOP critique.)

As a side note, this same 2013 study reported higher EEG readings (P300) when subjects were exposed to porn photos. Studies consistently show that an elevated P300 occurs when addicts are exposed to cues (such as images) related to their addiction. This finding supports the porn addiction model, as the above peer-reviewed papers explained and psychology professor emeritus John A. Johnson pointed out in a comment under a 2013 Psychology Today Prause interview:

"My mind still boggles at the Prause claim that her subjects' brains did not respond to sexual images like drug addicts' brains respond to their drug, given that she reports higher P300 readings for the sexual images. Just like addicts who show P300 spikes when presented with their drug of choice. How could she draw a conclusion that is the opposite of the actual results?"

Dr. Johnson, who has no opinion on sex or porn addiction, commented a second time under the Prause interview:

Mustanski asks, "What was the purpose of the study?" And Prause replies, "Our study tested whether people who report such problems [problems with regulating their viewing of online erotica] look like other addicts from their brain responses to sexual images."

But the study did not compare brain recordings from persons having problems regulating their viewing of online erotica to brain recordings from drug addicts and brain recordings from a non-addict control group, which would have been the obvious way to see if brain responses from the troubled group look more like the brain responses of addicts or non-addicts.....

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.

The third paper listed above is not a study at all. Instead, it poses as an impartial "review of the literature" on porn addiction and porn's effects. Nothing could be farther from the truth. The lead author, David Ley, is the author of The Myth of Sex Addiction and Nicole Prause is its second author. Ley & Prause not only teamed up to write paper #3, they also teamed up to write a Psychology Today blog post about paper #1. The blog post appeared 5 months before Prause's paper was formally published (so no one could refute it). You may have seen Ley's blog post with the oh-so-catchy title: "Your Brain on Porn - It's NOT Addictive". Ley zealously denies both sex and porn addiction. He has written 20 or so blog posts attacking porn-recovery forums, and dismissing porn addiction and porn-induced ED. He is not an addiction scientist, but rather a clinical psychologist, and like Prause is not associated with any university or research institute. Read more about Ley & Prause and their collaborations here.

The following is a very long analysis of paper #3, which goes line-by-line, showing all the shenanigans Ley & Prause incorporated in their "review": The Emperor Has No Clothes: A Fractured Fairytale Posing As A Review. It completely dismantles the so-called review, and documents dozens of misrepresentations of the research they cited. The most shocking aspect of the Ley review is that it omitted ALL the many studies that reported negative effects related to porn use or found porn addiction!

Yes, you read that right. While purporting to write an "objective" review, Ley & Prause justified omitting hundreds of studies on the grounds that these were correlational studies. Guess what? Virtually all studies on porn are correlational, even those they cited, or misused. There are, and pretty much will be, only correlational studies, because researchers have no way to prove causation by comparing users with "porn virgins" or by keeping subjects off of porn for extended periods in order compare effects. (Thousands of guys are quitting porn voluntarily on various forums, however, and their results suggest that removing internet porn is the key variable in their symptoms and recoveries.)

Inherent Bias?

It's unprecedented for a legitimate researcher to claim that their lone anomalous study has debunked a hypothesis supported by multiple neurological studies and decades of relevant research. Moreover, what legitimate researcher would be constantly tweeting that has debunked porn addiction? What legitimate researcher would personally attack young men who run porn-recovery forums? What legitimate sex researcher would vociferously (and viciously) campaign against proposition 60 (condoms in porn)? What legitimate sex researcher would have her photo taken on the red carpet of the "Adult Video Awards", standing arm in arm with porn producers?

What's going on here? Quite a bit as this page documents the tip of the iceberg concerning Prause's harassment and cyberstalking of anyone who suggests porn might cause a problem. By her own admission, rejects the concept of porn addiction. For example, a quote from this recent Martin Daubney article about sex/porn addictions:

Dr Nicole Prause, principal investigator at the Sexual Psychophysiology and Affective Neuroscience (Span) Laboratory in Los Angeles, calls herself a “professional debunker” of sex addiction.

In addition, Nicole Prause's former Twitter slogan suggests she may lack the impartiality required for scientific research:

"Studying why people choose to engage in sexual behaviors without invoking addiction nonsense"

Updates on Nicole Prause's twitter slogan: 

  1. UCLA did not renew Prause's contract. She hasn't been employed by any university since early 2015.
  2. In October, 2015 Prause's original Twitter account is permanently suspended for harassment.

While many articles continue to describe Prause as a UCLA researcher, she hasn't been employed by any university since the beginning of 2015. Finally, it's important to know that the enterprising Prause offered (for a fee) her "expert" testimony against sex addiction and porn addiction. It seems as though Prause is attempting to sell her services to profit from the unsupportable anti-porn addiction conclusions of her two EEG studies (1, 2), even though 11 peer-reviewed analyses say both studies support the addiction model!

 

 

 

 

 

 

 

 

 

 

 

 

 

Interestingly, David Ley also profits from denying sex and porn addiction. At the end of this Psychology Today blog post Ley states:

"Disclosure: David Ley has provided testimony in legal cases involving claims of sex addiction."

Ley also makes money selling two books which deny sex and porn addiction ("The Myth of Sex Addiction", 2012 and "Ethical Porn for Dicks", 2016). Pornhub is one of the four Amazon.com endorsements listed for Ley's 2016 book about pornography: 

"David Ley's voice brings much-needed nuance to some of the most important conversations occurring about pornography today.”―pornhub

Finally, David Ley makes money via CEU seminars, where he promotes the ideas presented in his two books.

Dismantling The Naysayers' Talking Points

If you want a quick refutation of the naysayers' pseudoscientific claims that they have "dismantled porn addiction," watch Gabe Deem's video: PORN MYTHS - The Truth Behind Addiction And Sexual Dysfunctions.

The following articles cite numerous studies, furnish illustrative examples, and elaborate logical arguments to dismantle many common anti-porn addiction propaganda talking points:

This section collects studies about which YBOP and others have reservations - Questionable & Misleading Studies. In some, the methodology raises concerns. In others, the conclusions appear inadequately supported. In others, the title or terminology used is misleading given the actual study results. Some grossly misrepresent the actual findings.

All the Neuroscience Supports the Porn Addiction Model

Listed below are all the studies assessing the brain structure and functioning of Internet porn users (even the one claiming to have debunked porn addiction). To date every study offers support for the porn addiction model. The results of these 37 studies (and upcoming studies) are consistent with 230+ Internet addiction brain studies, many of which also include internet porn use. To date every study offers support for the porn addiction model (no studies falsify the porn addiction model), as do 13 recent neuroscience-based reviews of the literature:

  1. Neuroscience of Internet Pornography Addiction: A Review and Update (2015). The review also critiques two recent headline-grabbing EEG studies which purport to have "debunked" porn addiction.
  2. Sex Addiction as a Disease: Evidence for Assessment, Diagnosis, and Response to Critics (2015), which provides a chart that takes on specific criticisms and offers citations that counter them.
  3. Neurobiology of Compulsive Sexual Behavior: Emerging Science (2016) Excerpt: "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."
  4. Should Compulsive Sexual Behavior be Considered an Addiction? (2016) Excerpt: "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"
  5. Neurobiological Basis of Hypersexuality (2016). Excerpt: "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."
  6. Compulsive Sexual Behaviour as a Behavioural Addiction: The Impact of the Internet and Other Issues (2016)  Excerpts: "more emphasis is needed on the characteristics of the internet as these may facilitate problematic sexual behaviour." and "clinical evidence from those who help and treat such individuals should be given greater credence by the psychiatric community."
  7. Cybersex Addiction (2015) Excerpts: 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. Neuroimaging studies support the assumption of meaningful commonalities between cybersex addiction and other behavioral addictions as well as substance dependency.
  8. Searching for clarity in muddy water: future considerations for classifying compulsive sexual behavior as an addiction (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.
  9. 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 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.
  10. Integrating psychological and neurobiological considerations regarding the development and maintenance of specific Internet-use disorders: An Interaction of Person-Affect-Cognition-Execution model (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.
  11. Sexual Addiction chapter from Neurobiology of Addictions, Oxford Press (2016) - Excerpt: 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.
  12. Neuroscientific Approaches to Online Pornography Addiction (2017) - Excerpt: 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.
  13. Is excessive sexual behaviour an addictive disorder? (2017) - Excerpts: 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. 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. The Proof of the Pudding Is in the Tasting: Data Are Needed to Test Models and Hypotheses Related to Compulsive Sexual Behaviors (2018) - Excerpts: 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).

 

See Questionable & Misleading Studies for highly publicized papers that are not what they claim to be.

See this page for the many studies linking porn use to sexual problems and decreased sexual & relationship satisfaction

"Brain Studies" (fMRI, MRI, EEG, Neuro-endocrine):

  1. Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014) - This Max Planck Institute fMRI study found less gray matter in the reward system (dorsal striatum) correlating with the amount of porn consumed. It also found that more porn use correlated with less reward circuit activation while briefly viewing sexual photos. Researchers believed their findings indicated desensitization, and possibly tolerance, which is the need for greater stimulation to achieve the same high. The study also reported that more porn viewing was linked to poorer connections between the reward circuit and prefrontal cortex.
  2. Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours (2014) - The first in a series of Cambridge University studies found the same brain activity pattern as seen in drug addicts and alcoholics. 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, yet could achieve erections with porn.
  3. Enhanced Attentional Bias towards Sexually Explicit Cues in Individuals with and without Compulsive Sexual Behaviours (2014) - 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]."
  4. Novelty, Conditioning and Attentional Bias to Sexual Rewards (2015) - 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, porn addiction drives novelty-seeking in an attempt to overcome habituation and desensitization.
  5. Neural Substrates of Sexual Desire in Individuals with Problematic Hypersexual Behavior (2015) - 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 perfectly matched the prefrontal cortex activation patterns observed in drug addicts: Greater cue-reactivity to sexual images, yet inhibited response to other normal stimuli.
  6. 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. This SPAN Lab study, like #7 below, 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. However, due to methodological flaws the findings are uninterpretable: 1) the study had no control group for comparison; 2) subjects were heterogeneous (males, females, non-heterosexuals); 3) subjects were not screened for mental disorders or addictions; 4) the questionnaires were not validated for porn 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 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 (their desire for partnered sex was dropping in relation to their porn use). Five peer-reviewed papers expose the truth: 1, 2, 3, 4, 5. Also see the extensive YBOP critique.
  7. Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another SPAN Lab EEG (brain-wave) study comparing the 2013 subjects from the above study 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, Nicole Prause, claims these results "debunk porn addiction". What legitimate scientist would claim that their lone anomalous study has debunked an entire 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's findings also align with Banca et al. 2015 which is #4 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). See this extensive YBOP critique. Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (a sign of addiction): 1, 2, 3, 4, 5, 6.
  8. HPA axis dysregulation in men with hypersexual disorder (2015) - 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 drug addiction.
  9. The Role of Neuroinflammation in the Pathophysiology of Hypersexual Disorder (2016) - 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.
  10. Methylation of HPA Axis Related Genes in Men With Hypersexual Disorder (2017) - This is a follow-up of #8 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.
  11. Compulsive sexual behavior: Prefrontal and limbic volume and interactions (2016) - 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 gray 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 is very stressful - and chronic social stress is related to increased amygdala volume. Study #8 above found that "sex addicts" have a overactive stress system. Could the chronic stress related to porn/sex addiction, along with factors that make sex unique, lead to greater amygdala volume?
  12. Can Pornography be Addictive? An fMRI Study of Men Seeking Treatment for Problematic Pornography Use (2017) - 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.
  13. Altered Appetitive Conditioning and Neural Connectivity in Subjects With Compulsive Sexual Behavior (2016) - A German fMRI study replicating 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".
  14. Compulsivity across the pathological misuse of drug and non-drug rewards (2016) - A Cambridge University study comparing aspects of compulsivity in alcoholics, binge-eaters, video game addicts and porn addicts (CSB). Excerpts: CSB subjects were faster to learning from rewards in the acquisition phase compared to healthy volunteers and were more likely to perseverate or stay after either a loss or a win in the Reward condition. 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).
  15. Can pornography be addictive? An fMRI study of men seeking treatment for problematic pornography use (2017) - Excerpts: Men with and without problematic porn sue (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.
  16. Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017) - Study assessed porn user's 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. An excerpt: 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.
  17. Preliminary investigation of the impulsive and neuroanatomical characteristics of compulsive sexual behavior (2009) - 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 greater disorganized prefrontal cortex white matter. This finding is consistent with hypofrontality, a hallmark of addiction.
  18. Pornography Addiction Detection based on Neurophysiological Computational Approach (2018) - An EEG study reporting several neurological differences between porn addicts and non-addicts. Unique in that the subjects average age was 14.
  19. Gray matter deficits and altered resting-state connectivity in the superior temporal gyrus among individuals with problematic hypersexual behavior (2018) - fMRI study. Summary: …study showed gray matter deficits and altered functional connectivity in the temporal gyrus among individuals with PHB (sex addicts). 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.

The above studies are all the "brain studies" published (or in the press) on internet porn users.

Together these brain studies found:

  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. 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.
  7. Enhanced attentional bias comparable to drug users. Indicates sensitization (a product of DeltaFosb).
  8. Greater wanting & craving for porn, but not greater liking. This aligns with the accepted model of addiction - incentive sensitization.
  9. Porn addicts have greater preference for sexual novelty yet their brains habituated faster to sexual images. Not pre-existing.
  10. The younger the porn users the greater the cue-induced reactivity in the reward center.
  11. Higher EEG (P300) readings when porn users were exposed to porn cues (which occurs in other addictions).
  12. Less desire for sex with a person correlating with greater cue-reactivity to porn images.
  13. More porn use correlated with lower LPP amplitude when briefly viewing sexual photos: indicates habituation or desensitization.
  14. Dysfunctional HPA axis which reflects altered brain stress circuits, which occurs in drug addictions (and greater amygdala volume, which is associated with chronic social stress).
  15. Epigenetic changes on genes central to the human stress response and closely associated with addiction.
  16. Higher levels of Tumor Necrosis Factor (TNF) - which also occurs in drug abuse and addiction.
  17. A deficit in temporal cortex gray matter; poorer connectivity between temporal corporate and several other regions

Neuro-Psychological Studies on Porn Users (with excerpts):

  1. Self-reported differences on measures of executive function and hypersexual behavior in a patient and community sample of men (2010) - 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.
  2. Watching Pornographic Pictures on the Internet: Role of Sexual Arousal Ratings and Psychological-Psychiatric Symptoms for Using Internet Sex Sites Excessively (2011) - 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
  3. Pornographic picture processing interferes with working memory performance (2013) - 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.
  4. Sexual Picture Processing Interferes with Decision-Making Under Ambiguity (2013) - 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.
  5. Cybersex addiction: Experienced sexual arousal when watching pornography and not real-life sexual contacts makes the difference (2013) - 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.
  6. Cybersex addiction in heterosexual female users of internet pornography can be explained by gratification hypothesis (2014) - Results indicated that Internet porn users rated pornographic pictures as more arousing and reported greater craving due to pornographic picture presentation compared with non-users. 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 porn users. Being in a relationship, number of sexual contacts, satisfaction with sexual contacts, and use of interactive cybersex were not associated with cybersex addiction.
  7. Empirical Evidence and Theoretical Considerations on Factors Contributing to Cybersex Addiction From a Cognitive Behavioral View (2014) - 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.
  8. Prefrontal control and internet addiction: a theoretical model and review of neuropsychological and neuroimaging findings (2015) - 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.
  9. Implicit associations in cybersex addiction: Adaption of an Implicit Association Test with pornographic pictures. (2015) - 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. 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.
  10. Symptoms of cybersex addiction can be linked to both approaching and avoiding pornographic stimuli: results from an analog sample of regular cybersex users (2015) - 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.
  11. Getting stuck with pornography? Overuse or neglect of cybersex cues in a multitasking situation is related to symptoms of cybersex addiction (2015) - 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. The results of the current study point towards a role of executive control functions, i.e. functions mediated by the prefrontal cortex, for the development and maintenance of problematic cybersex use (as suggested by Brand et al., 2014). Particularly a reduced ability to monitor consumption and to switch between pornographic material and other contents in a goal adequate manner may be one mechanism in the development and maintenance of cybersex addiction.
  12. Trading Later Rewards for Current Pleasure: Pornography Consumption and Delay Discounting (2015) - 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. 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.
  13. Sexual Excitability and Dysfunctional Coping Determine Cybersex Addiction in Homosexual Males (2015) - 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.
  14. Subjective Craving for Pornography and Associative Learning Predict Tendencies Towards Cybersex Addiction in a Sample of Regular Cybersex Users (2016) - 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
  15. Exploring the Relationship between Sexual Compulsivity and Attentional Bias to Sex-Related Words in a Cohort of Sexually Active Individuals (2016) - This study replicates the findings of this 2014 Cambridge University study that compared the attentional bias of porn addicts to healthy controls. The new study differs: rather than comparing porn addicts to controls, the new study correlated scores on a sex addiction questionnaire to the results of a task assessing attentional bias (explanation of attentional bias). The study described two key results: 1) Higher sexual compulsivity scores correlated with greater interference (increased distraction) during the attentional bias task. This aligns with substance abuse studies. 2) Among those scoring high on sexual addiction, fewer years of sexual experience were related to greater attentional bias. 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 section: "One possible explanation for these results is that as a sexually compulsive individual engages in more compulsive behaviour, an associated arousal template develops 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."
  16. Mood changes after watching pornography on the Internet are linked to symptoms of Internet-pornography-viewing disorder (2016) - 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).
  17. Problematic sexual behavior in young adults: Associations across clinical, behavioral, and neurocognitive variables (2016) - Individuals with Problematic Sexual Behaviors (PSB) exhibited several neuro-cognitive deficits. These findings indicate poorer executive functioning (hypofrontality) which is a key brain feature occuring in drug addicts. A few excerpts: 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.
  18. Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video (2017) - 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.
  19. Exposure to Sexual Stimuli Induces Greater Discounting Leading to Increased Involvement in Cyber Delinquency Among Men (2017) - 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-deliquency, 3) greater inclination to purchase counterfeit goods & 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: These findings provide insight into a strategy for reducing men's involvement in cyber delinquency; that is, through less exposure to sexual stimuli and promotion of delayed gratification. 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.
  20. Predictors for (Problematic) Use of Internet Sexually Explicit Material: Role of Trait Sexual Motivation and Implicit Approach Tendencies Towards Sexually Explicit Material (2017) - Excerpts: The present study investigated whether trait sexual motivation and implicit approach tendencies towards 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.

 

Upcoming Studies From 3rd & 4th International Conference on Behavioral Addictions

The following abstracts related to porn use and sex addiction were taken from the 3rd International Conference on Behavioral Addictions March 14–16, 2016, and 4th International Conference on Behavioral Addictions February 20-22, 2017. Most abstracts presented are eventually published in peer-reviewed journals.


 

Internet pornography addiction: Theoretical models, behavioral data, and neuroimaging findings

MATTHIAS BRAND

University of Duisburg-Essen, Duisburg, Germany

Background and aims: Internet pornography addiction (IPA) is considered one specific type of Internet addiction. From substance dependence research, it is well known that addiction can be viewed as a transition from voluntary, recreational drug use to compulsive drug-seeking habits, neurally underpinned by a transition from prefrontal cortical to striatal control over drug seeking and taking (Everitt & Robbins, 2015).

Methods: These concepts have been recently transferred to Internet addiction in general, and IPA in specific. For example, in two recently published theoretical models on Internet addiction (Brand et al., 2014) and specifically on Internet Gaming Disorder (Dong & Potenza, 2014), cognitive processes and emotional responses to specific Internet-related cues are considered crucial in the development and maintenance of the addictive behavior. These models are investigated in the context of PA.

Results: Behavioral data support the theoretical assumption showing that cue-reactivity and craving can be demonstrated in individuals with IPA. Also, executive reductions and reduced inhibitory control when being confronted with pornographic material increase the probability of experiencing a loss of control over the consumption of pornography. Functional neuroimaging findings suggest specific brain correlates of IPA, which are comparable with those reported in individuals with Internet Gaming Disorder and other behavioral addictions as well as substance dependence. Particularly the ventral striatum, a region associated with reward anticipation, responds to the confrontation with explicit pornographic material in subjects with IPA.

Conclusions: Existing findings suggest that IPA is a specific type of Internet addiction, which is comparable with Internet Gaming Disorder and other types of behavioral addictions.


 

Incentive salience and novelty in compulsive sexual behaviors

VALERIE VOON

University of Cambridge, Cambridge, United Kingdom

Compulsive sexual behaviors (CSB) or sexual addiction are commonly hidden and can be associated with marked distress. The behaviors occur commonly in the general population at 2–4% and can be associated with dopaminergic medications used in the treatment of Parkinson’s disease at a similar frequency of 3.5%. In preclinical studies, sexual motivation is associated with dopaminergic mechanisms. This talk will focus on evidence supporting a role for incentive motivation theories. CSB is associated with enhanced reactivity to sexual cues of a neural network implicated in drug cue reactivity studies with greater subjective ‘wanting’ associated with enhanced connectivity of this network. The sexual cues are associated with enhanced early attentional bias which link with a greater preference for cues conditioned to sexual rewards. Functional connectivity of this saliency network is decreased at rest and influenced by depression scores. CSB is also associated with greater preference for novel sexual imagery linked to enhanced dorsal cingulate habituation to sexual outcomes. These findings highlight a relationship with incentive motivation and negative emotionality theories of addiction and emphasize a role for habituation and preference for sexual novelty that might be unique to online sexual materials


 

Gender differences between males and females in sex addiction – Psychological and social Characteristics and implications in treatment

RONIT ARGAMAN

MSW Argaman Institute Tel Aviv, Israel

Background and aims: According to researchers and therapists around the world, the prevalence of sex addiction in the United States ranges from 3–8%. Social awareness to the problem in the 70s and 80s, focused primarily on men sex addicts and myths in relation to sex addiction present it as a masculine phenomenon. In recent years, there is a growing recognition that women also suffer from sex and love addiction, and there is a growing need for treatment adjustments. However, social perceptions related to the sexual behavior of men and women in general and hyper-sexuality in particular (double standard) stops many women from turning to help. Although we can find similarities in sex addiction among men and women there are also significant differences that may affect the unique therapeutic needs of women. Differences in the perception of the romantic and sexual relationship between men and women. Difficulty in defining the problem by the woman herself or by therapists. Different types of sexual behaviors and their etiology – with men sexual behavior focuses mainly on objectifying and emotional detachment (sexual stimulation), while in women the focus is on attachment and self-objectification (sexually stimulating relationship). Severe consequences of sexual behavior on women, medical (STI / STD, unwanted pregnancy), psychological (humiliation, shame), rape and sexual abuse. The presentation will focus on gender differences both in personal and social perspectives and therapeutic perspective.


 

Exploring the Pathways Model for Problem Gamblers in Hypersexual Patients

ERIN B. COOPER, RORY C. REID

University of California Los Angeles, Los Angeles, CA, US

Background and aims: While there has been an increase in the amount of research linked to hypersexual behavior over the past decade, there is a paucity of work highlighting the etiology, risk factors, or possible pathways through which hypersexuality may arise.

Methods: We examined NEO-Personality Inventory data from the DSM-5 Field Trial for Hypersexual Disorder among men (N = 254) who were classified as meeting the threshold.

Results: We hypothesized 3 latent classes of hypersexual patients based on the pathways model commonly applied to those with gambling disorder. The data was explored using Latent Class Analysis (LCA) with alternative models compared to the hypothesized latent classes. The 3 classes model was supported with facets of personality paralleling the pathways model among problem gamblers.

Conclusion: This is the first study to compare the pathways model common to gamblers with hypersexual patients. The parallel in data between hypersexual behavior and gambling disorder suggests these two patterns of de-regulated behaviors may share common pathways in their development.


 

One or Multiple Neural Mechanisms of Problematic Pornography Use?

MATEUSZ GOLA

University of California San Diego, San Diego, USA Polish Academy of Science, Warsaw, Poland

Background and aims: Clinicians and researchers often hesitate how to conceptualize problematic pornography use (PPU). The two most discussed frameworks are behavioral addiction and compulsion. Neuroscientific studies on pornography use and compulsive sexual behaviors (CSB) indicate a significant involvement of brain reward circuits in such conditions and the similarities with other addiction-related behaviors. However, clinical observations and recent studies on risky sexual behaviors and problematic alcohol use show that reward circuitry disruption is not the only possible neural mechanism of problematic behaviors. Due to recent findings, addictive behaviors may be underlined either by increased reward system reactivity for appetitive cues or increased amygdala threat-reactivity.

Methods: Here we present our studies on paroxetine treatment of PPU and role of amygdale threat-reactivity in this condition.

Results and Conclusions: We will discuss the meaning of these findings for PPU and CSB treatment as well as for directions of future neuroscience research.


 

A Review on Pharmacotherapy and Management of Hypersexual Behavior

FARSHAD HASHEMIAN, ELNAZ ROOHI

Islamic Azad University, Tehran, Tehran, Iran

Background and aims: There has been a growing interest in the area of pharmacotherapy of sexual disorders in the recent years. Different hormonal levels, neurotransmitters, receptors, and brain areas involved in sexual desire have been yet identified. However, there is still incomplete understanding of neurobiology of hypersexual behavior. Various pharmacological agents have been reported to decrease sexual behavior. The aim of the present article was to review pharmacological treatments available for patients with hypersexual behavior. Moreover, mechanism of action, dosages and algorithm of use of the available treatments were discussed. Optional new treatments undergoing clinical trials were also mentioned.

Methods: Studies were identified by searching electronic databases of Medline, PsycINFO, Cochrane Library, and Clinical Trial Registers. All eligible studies investigating efficacy and safety of the pharmacological treatments for patients with hypersexual disorder conducted between 2000 and 2015 were included in the present article.

Results: Current pharmacotherapies include Selective Serotonin Reuptake Inhibitors (SSRIs), Antiandrogens, and Gonadotropin-releasing hormone agonists. The most commonly used pharmacotherapy is reported to be SSRIs. However, Anti-androgen therapy has been reported to decrease sexual desire and have an effect size comparable to cognitive behavioral therapy. Gonadotropin-releasing hormone agonists were reported to be treatment options for patients with severe hypersexual disorder.

Conclusions: The use of pharmacotherapy integrated with behavioral and cognitive therapies is recommended. There are still gaps in the knowledge regarding pharmacotherapy of hypersexual disorder. Development of agents with more efficacy and better safety profiles are needed


 

Overactive Stress System Linked to Hypersexual Disorder in Men

JUSSI JOKINEN, ANDREAS CHATZITTOFIS, JONAS HALLBERG, PETER NORDSTRÖM,

KATARINA ÖBERG, STEFAN ARVER

Karolinska Institute, Stockholm, Sweden

Background and aims: Hypersexual disorder integrates pathophysiological aspects such as sexual desire deregulation, sexual addiction, impulsivity and compulsivity. However, little is known about the neurobiology behind this disorder. A dysregulation of the hypothalamic pituitary adrenal (HPA) axis has been shown in psychiatric disorders but has not been investigated in hypersexual disorder. The aim of this study was to investigate the function of the HPA axis in men with hypersexual disorder.

Methods: The study includes 67 male patients with hypersexual disorder and 39 healthy male volunteers. The Sexual Compulsive scale (SCS), Hypersexual Disorder Current Assessment Scale (HD:CAS), Montgomery-Åsberg Depression Scale-Self Rating (MADRS-S) and Childhood Trauma Questionnaire (CTQ), were used in assessing hypersexual behavior, depression severity, and early life adversity. Basal morning plasma levels of cortisol and ACTH were assessed and low dose (0.5mg) dexamethasone suppression test was performed with cortisol and ACTH measured post dexamethasone administration. Non-suppression status was defined with DST-cortisol levels _138nmol/l.

Results: Patients with hypersexual disorder were significantly more often DST non-suppressors and had significantly higher DST-ACTH levels compared to healthy volunteers. The patients reported significantly more childhood trauma and depression symptoms compared to healthy volunteers. CTQ scores showed a significant negative correlation with DST-ACTH whereas SCS and HD: CAS scores showed a negative correlation with baseline cortisol in patients. The diagnosis of hypersexual disorder was significantly associated DST non-suppression and higher plasma DST-ACTH even when adjusted for childhood trauma. Sensitivity analysis omitting patients with comorbid depression diagnosis did not change the results.

Conclusions: The results suggest HPA axis dysregulation in male patients with hypersexual disorder. We will discuss these findings and future research on neurobiological markers of hypersexual disorder.


 

Losing Control: Clinical characteristics of men interested in treatment for use of pornography

SHANE W. KRAUS, STEVE MARTINO, MARC POTENZA

VA Connecticut Healthcare System, West Haven, Connecticut, USA

Background and aims: The current study investigated the prevalence of, and factors associated with, men’s interest in seeking treatment for use of pornography.

Methods: Using the Internet, we recruited 1298 male pornography users to complete questionnaires assessing demographic and sexual behaviors, hypersexuality, pornography-use characteristics, and current interest in seeking treatment for use of pornography.

Results: Approximately 14% of men expressed an interest in seeking treatment for use of pornography. Treatment-interested men had 9.5 higher odds of reporting clinically significant levels of hypersexuality compared to treatment-disinterested men. Bivariate analyses also found that treatment-interested men were less likely to be married/partnered, but consumed more pornography weekly, masturbated more often, and had more past attempts to cut back or quit using pornography compared to treatment-disinterested men. Regression analysis found that daily pornography use, frequent past attempts to cut back or quit using pornography and scores on the Hypersexual Behavior Inventory Control subscale were predictors of interest-in-seeking-treatment status.

Conclusions: Current study findings could help develop screening practices aimed at identifying specific aspects of sexual self-control (i.e., “loss of control”), impulsivity, and/or compulsivity associated with excessive/problematic use of pornography among treatment-seeking individuals.


 

Specific Forms of Passionate Attachment Differentially Mediate Relationships between Pornography Use and Sexual Compulsivity

SHANE W. KRAUS, STEVE MARTINO, JOHN ANDREW STURGEON, ARIEL KOR, MARC N. POTENZA

Connecticut Healthcare System, West Haven, Connecticut USA

Background and aims: The current study examined the mediational role of two types of “passionate attachment” in the relationship of pornography use and sexual compulsivity. Harmonious passion refers to when a person’s sexual behavior is in harmony with other areas of his or her life. Obsessive passion refers to an “uncontrollable urge” to engage in sexual activity that creates conflict with other areas of a person’s life and contributes to personal distress.

Methods: Using the Internet, we recruited 265 university men to complete questionnaires assessing demographics, pornography-use characteristics, passionate attachment for pornography and sexual compulsivity (non-specific to pornography). Relationships between study variables were examined using structural path modeling analysis.

Results: Harmonious passion ratings were found to significantly, though partially, mediate the relationship between weekly pornography use and sexual compulsivity ratings. Obsessive passion ratings were found to fully mediate the relationship between weekly pornography use and sexual compulsivity ratings. When a fully specified two-mediator model was employed, only obsessive passion remained a significant predictor of sexual compulsivity. The relationship between weekly pornography use and sexual compulsivity was fully explained by obsessive passion ratings, while harmonious passion was not found to contribute to sexual compulsivity scores, above and beyond the effect of obsessive passion.

Conclusions: The findings that obsessive passion, but not harmonious passion, links pornography use and sexual compulsivity suggests that obsessive forms of passionate attachment may represent a target for treatment development for reducing and eliminating problematic pornography use or other compulsive sexual behaviors.


 

In the mood to watch pornography? The role of general versus situational mood for Internet pornography addiction

CHRISTIAN LAIER, MARCO BÄUMER, MATTHIAS BRAND

University of Duisburg-Essen, Duisburg, Germany

Background and aims: Pathological Internet pornography use is considered a specific Internet addiction (Young, 2008). In a recent cognitive-behavioral model of Internet pornography addiction (IPA), positive and negative reinforcement resulting from Internet pornography use were hypothesized to be important mechanisms in the development of IPA (Laier & Brand, 2014). This study investigates mood changes due to Internet pornography use in relationship with tendencies toward IPA.

Methods: Male participants (N = 39) were investigated using an online survey with two parts: In the first assessment, demographic information, tendencies towards IPA, Internet pornography use motivation, and general mood were assessed. In the second assessment, participants were asked to indicate their sexual arousal and their actual mood before and after a voluntarily, self-determined use of Internet pornography at home.

Results: The results showed that tendencies toward IPA correlated with emotional avoidance and excitement seeking due to Internet pornography use, but not with general mood. Furthermore, tendencies toward IPA correlated with nervousness before Internet pornography use. Internet pornography consumption led to a decrease of sexual arousal, better mood, and less nervousness.

Conclusions: The findings demonstrated that tendencies toward IPA were related to the Internet pornography use motivation to find gratification and to cope with aversive emotional states. Moreover, IPA was associated with aversive mood prior to voluntary Internet pornography use. Together with the observation that Internet pornography use changed mood, the results support theoretical assumptions that besides gratification also negative reinforcement plays an important role in the development of IPA.


 

What is Hypersexuality? An Investigation of Psychological Mechanisms in Men who have Sex with Men

MICHAEL H. MINER1, ANGUS MACDONALD, III2, ERICK JANSSEN3, REBECCA SWINBURNE ROMINE4,

ELI COLEMAN AND NANCY RAYMOND5

1University of Minnesota Medical School, Duluth, MN, USA

2University of Minnesota, Minneapolis, MN, USA

3KU Leuven, Leuven, Flanders, Belgium

4University of Kansas, Lawrence, KS, USA

5University of Minnesota Medical School, Minneapolis, MN, USA

Background and Aims: The major criticism of hypersexuality has been the lack of empirical support for any of the conceptualizations put forward to explain it. This study is designed to investigate personality, cognitive, and psychophysiological factors that have been hypothesized to characterize hypersexuality by numerous authors.

Methods: Participants were 243 men who have sex with men recruited using both on-line and community-based venues, programs, and word of mouth. Participants must have had sex with a man in the last 90-days, have no indications of major thought disorder or cognitive dysfunction, and be at least 18 years of age. Participants were assigned to a hypersexual disorder or comparison group based on a SCID-type interview. Data included three cognitive tasks, a self-report computer administered questionnaire, and a psychophysiological assessment of sexual arousal following mood induction.

Results: Results showed group differences in personality factors, sexual behavioral control, and experiences of sexual urges and fantasies. Sexual behavior control was related to sexual excitation and sexual inhibition, but not to more general behavioral arousal or behavior inhibition. Hypersexual participants showed lower levels of physiological arousal during the laboratory procedure, but did not show differences in inhibition of arousal by negative affect.

Conclusions: We found that while hypersexuality is related to broad personality factors, the lack of sexual behavioral control appears to be related to arousal and inhibitory factors specific to sexual behavior and not general behavioral arousal and inhibitory systems. Further, our data is contradictory with respect to whether hypersexuality can be explained by higher levels of sexual arousal/excitation.


 

Differences between problematic and non-problematic Internet pornography users: The role of sexual excitability and hypersexual behaviors

JARO PEKAL, CHRISTIAN LAIER, MATTHIAS BRAND

University of Duisburg-Essen, Duisburg, Germany

Background and aims: The classification of Internet pornography addiction (IPA) is still discussed controversially. Some authors consider IPA as one specific type of Internet addiction (Brand et al., 2014). Theoretically, habitual sexual excitability and hypersexual behavior are specific predispositions for the development and maintenance of IPA. In the current study, problematic and healthy Internet pornography users were compared regarding sexual excitability and hypersexuality.

Methods: Out of a sample of overall N = 274 male participants, two groups (both n = 25) consisting of healthy and problematic IP users were extracted ex post facto by using the short Internet Addiction Test modified for cybersex that measures tendencies towards IPA. These groups were compared regarding their self-reports on general sexual excitability (Sexual Excitation Scale) and hypersexual behavior (Hypersexual Behavior Inventory).

Results: The results showed significant differences between problematic and non-problematic IP users regarding sexual excitability and hypersexual behavior. Further, problematic IP users reported significantly higher scores on both scales. No differences were found for sexual inhibition.

Discussion and Conclusions: Overall, the results underline the importance of specific predispositions for the development and maintenance of IPA and strengthen the theoretical model developed for specific Internet addiction. Moreover, results support the gratification hypothesis (Young, 2004), whereby the anticipation and the reception of sexual arousal can be seen as a major factor in developing IPA. To further evaluate the theoretical model by Brand and colleagues, other crucial factors like dysfunctional coping strategies and psychological symptom severity need to be tested for problematic and non-problematic IP users.


 

Advancing Understanding of DSM-5 Non-Substance-Related Disorders: Comparing Hypersexuality and Gambling Disorder

RORY C. REID, JON GRANT, MARC POTENZA

University of California Los Angeles, Los Angeles, CA, USA

Background and Aims: The past decade has seen an increase in research investigating de-regulated hypersexual behavior and gambling disorder. Collectively classified as behavioral addictions, little has been done to explore commonalities between different manifestations of de-regulated behavior. The current study reports findings comparing characteristics of gambling disorder with the proposed classification criteria for hypersexual disorder for the DSM-5.

Methods: Self-report questionnaires measuring common indices reflecting stress proneness, emotional dysregulation, and impulsivity were administered to separate groups of treatment seeking patients with gambling disorder (n = 77) or individuals meeting criteria for the DSM-5 hypersexual disorder (n = 74).

Results: Multivariate statistics were used to explore group differences across study variables. Both groups showed comparable scores across measures and both groups had scores significantly higher than those observed in norming groups for the psychometric properties of each scale. Examination of effect sizes also supported the lack of significant differences between groups.

Conclusions: While understanding about the etiology of these disorders continues to evolve, the underlying issues that precipitate and perpetuate these patterns of de-regulated behavior may be similar. These results suggest that problem gamblers and hypersexual patients may engage in dysfunctional behavior for similar reasons and that interventions targeting stress coping, impulsivity, and emotional regulation may generalize to both populations.


 

Internet pornography addiction and attentional bias towards pornographic pictures in a sample of regular male and female cybersex users

JAN SNAGOWSKI, JARO PEKAL, LYDIA HARBARTH, CHRISTIAN LAIER, MATTHIAS BRAND

University of Duisburg-Essen, Duisburg, Germany

Background and aims: Research on Internet pornography addiction (IPA) as a form of specific Internet addiction has received growing attention in the past years. Recent studies indicated analogies to substance dependencies, for which attentional bias is considered a crucial mechanism in the addiction process. The underlying study investigated relationships between attentional bias and tendencies toward IPA in a sample of regular male and female cybersex users.

Methods: In this study male (n = 60) and female (n = 60) regular cybersex users completed an Addiction Stroop (Bruce & Jones, 2004) and a Visual Probe Task (Mogg et al., 2003), which were modified with pornographic pictures. Sexual sensation seeking and tendencies toward IPA were assessed with questionnaires.

Results: The results show that male participants had significantly higher scores regarding attentional bias, sexual sensation seeking, and tendencies toward IPA. However, moderated regression analyses did not reveal any significant interactions of sex and attentional bias on tendencies toward IPA.

Conclusions: Overall, results suggest differences in male and female cybersex users regarding the relative strength of attentional bias towards pornographic pictures as well as tendencies towards IPA. This strengthens the assumption that IPA might be more prevalent in men, while higher attentional bias scores could be referred to a higher pornography consumption of men. However, our findings suggest that an attentional bias towards pornographic pictures might be a crucial mechanism in both men and women for developing and maintaining an IPA.


 

Approach bias towards explicit sexual stimuli and sexual motivation

RUDOLF STARK, TIM KLUCKEN, JAN SNAGOWSKI, SINA WEHRUM-OSINSKY

Justus Liebig University, Gießen, Germany

Background and aims: Explicit sexual material attracts attention. However, the question whether trait sexual motivation modulates this attentional bias is still under debate.

Methods: In the present study we use a joystick taskto measure biases in approach and avoidance behavior in females and males. The subjects had to pull or push a joystick to shrink or enlarge positive, negative or explicit sexual pictures. It was assumed that the reaction times differ with regard to the direction of movement (approach or withdrawal) and the emotional value of the pictures, resulting in specific biases. Further we measured trait sexual motivation, a psychological construct related to sexual drive, using a questionnaire.

Results: The first analyses revealed that the biases towards sexual stimuli measured by the applied experimental approach were minimal and the relation to trait sexual motivation was not statistically significant.

Discussion: The results will be presented in detail at the conference and the implications will be discussed


 

Gender differences in sex addiction

AVIV WEINSTEIN, RINAT ZOLEK, ANA BABKIN, MICHEL LEJOYEUX

Ariel University, Ari’el, Israel

Background and aims: sexual addiction – otherwise known as compulsive sexual behavior – is associated with serious psycho-social problems and risk-taking behavior. The aim of this study was to investigate sex differences among men and women who use sites on the Internet dedicated to pornography and cybersex.

Methods: the study used the Cybersex addiction test, Craving for pornography questionnaire, and a Questionnaire on intimacy among 267 participants (192 males and 75 females). Participants’ mean age for males was 28.16 (SD = 6.8) and for females 25.5 (SD = 5.13). They used sites that are dedicated to pornography and cybersex on the Internet.

Results of regression analysis indicated that pornography, gender, and cybersex significantly predicted difficulties in intimacy and it accounted for 66.1% of the variance of rating on the intimacy questionnaire. Second, regression analysis also indicated that craving for pornography, gender, and difficulties in forming intimate relationships significantly predicted frequency of cybersex use and it accounted for 83.7% of the variance in ratings of cybersex use. Third, men had higher scores of frequency of using cybersex than women [t(2,224) = 1.97, p < 0.05] and higher scores of craving for pornography than women [t(2,265) = 3.26, p < 0.01] and no higher scores on the questionnaire measuring difficulties in forming intimate relationship than women [t(2,224) = 1, p = 0.32].

Conclusions: These findings support previous evidence for sex differences in compulsive sexual behavior. We will also describe the psycho-biological evidence for gender differences in sex addiction


 

Social anxiety contributes to sex addiction among individuals who use a dating application on the Internet

AVIV WEINSTEIN, YONI ZLOT, MAYA GOLDSTEIN

Ariel University, Ari’el, Israel

Background and Aims: there is an increasing trend in the use of the Internet for dating and sexual purposes (“Tinder”). The aim of this study was to investigate the effects of social anxiety, sensation seeking and gender on sex addiction among those who use Internet sites for dating.

Methods: 279 participants (128 males and 151 females) age range: 18–38 years answered questionnaires on the Internet (Google drive). Questionnaires included demographic information, the Leibowitz social anxiety scale, Sensation seeking scale, and Sexual addiction screening test (SAST).

Results: users of Internet dating applications showed higher scores on the SAST than non-users [(t(2,277) = 2.09; p < 0.05)]. Secondly, regression analysis showed that social anxiety accounted significantly to the variance of sexual addiction (Beta = .245; p < .001). Gender or scores on the sensation seeking questionnaire did not contribute significantly to the variance of sexual addiction scores.

Discussion and conclusions: results of this study indicate that users of dating applications on the internet have higher levels of sex addiction. Sex addiction can also predict levels of social anxiety. The study improves our understanding on the factors that influence sex addiction. The results indicate that social anxiety rather than sensation seeking is a major factor affecting the use of Internet dating applications for sexual purposes


 

Characteristics of self-identified patients with sexual addiction in an outpatient clinic

ALINE WÉRY, KIM VOGELAERE, GAËLLE CHALLET-BOUJU, FRANÇOIS-XAVIER POUDAT, MARTHYLLE

LAGADEC, CHARLOTTE BRÉGEAU, JOËL BILLIEUX, MARIE GRALL-BRONNEC

Catholic University of Louvain, Louvain-la-Neuve, Belgium

Background and aims: Research on sexual addiction (SA) has flourished during the last decade, supported by the development of Internet and online sexual activities (e.g., sex chat and webcam, free access pornography). However, despite the increasing number of SA researches, few empirical data are available on the characteristics of treatment seeking self-defined “sex addicts”. The purpose of this study is to describe the characteristics, habits, and comorbidities in a sample of people seeking-treatment in a specialized outpatient program.

Methods: This study included 72 patients who consulted the Department of Addictology and Psychiatry in the University Hospital of Nantes (France) from April 2010 to December 2014. Measures included self-reports and hetero-questionnaires completed by a psychologist of the outpatient program.

Results: The majority of the 72 patients were middle-aged (M: 40.33; SD: 10.93) men consulting mainly for hypersexuality, risky sexual behaviors, and overuse of cybersex. Some patients presented paraphilia and sexual dysfunctions. The majority of the sample presented comorbid psychiatric or addictive diagnosis, low self-esteem, and a history of trauma.

Conclusions: The current study highlighted that SA is related to heterogeneous risk factors (e.g., traumatic events, comorbid states, psychosocial variables) often characterized by multiple SA-related behaviors, whose interrelations are complex. Treatment programs should take into account this heterogeneity and favor tailored rather than standardized.


BELOW ARE THE ABSTRACTS FROM THE 2017 CONFERENCE


Internet addiction: Current theoretical considerations and future directions

MATTHIAS BRAND

1General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, Germany 2Erwin L. Hahn Institute for Magnetic Resonance Imaging, University of Duisburg, Germany; E-mail: matthias.brand@uni-due.de

Background and aims: Internet-gaming disorder has been included in the appendix of the DSM-5 indicating that it is likely a relevant clinical phenomenon, which deserves fur­ther attention. Beyond the addictive use of Internet games, other types of Internet applications are also discussed as being used addictively, for example communication appli­cations, pornography, gambling, and shopping applications. Based on previous research from both the substance and the behavioral addiction area, theoretical considerations of the development and maintenance of specific types of Inter­net-use disorders are suggested.

Methods: The theoretical model of Internet addiction by Brand et al. (2014) and that by Dong and Potenza (2014) have been integrated into a new theoretical framework. In addition, very recent articles on Internet-gaming disorder and other types of an addictive use of specific Internet applications have been considered.

Results: The Interaction of Person˗Affect˗Cognition˗Execution (I-PACE) model of specific Internet-use disorders has been suggested (Brand et al., 2016). The I-PACE model is considered a process model, which specifies several predis­posing factors (e.g., neurobiological and psychological constitutions), moderating variables (e.g., coping style, In­ternet-use expectancies, and implicit associations), and me­diating variables (e.g., affective and cognitive responses to internal and external triggers), which act in concert with reduced inhibitory control and executive functioning. On the brain level, a dysfunctional interaction of limbic and para-limbic structures, e.g. the ventral striatum, and pre­frontal areas, particularly the dorsolateral prefrontal cortex, is considered a main neural correlate of specific Internet-use disorders. These neural correlates of Internet-use disor­ders are consistent with what is known about other types of behavioral addictions.

Conclusions: The I-PACE model summarizes the mechanisms potentially underlying the de­velopment and maintenance of specific Internet-use disor­ders and also reflects the temporal dynamics of the addic­tion process. The hypotheses summarized in this model should be specified for the specific types of Internet-use disorders, such as Internet-gaming, gambling, pornogra­phy-viewing, shopping, and communication.


Attentional bias and inhibition in males with tendency to Internet-pornography-viewing disorder

STEPHANIE ANTONS1*, JAN SNAGOWSKI1 and MATTHIAS BRAND1, 2

1General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, Germany 2Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany *E-mail: stephanie.antons@uni-due.de

Background and aims: Recent studies investigated the in­terference of addiction-related cues with cognitive process­es in Internet-pornography-viewing disorder (IPD) and found comparable results to those reported for substance-use disorders (SUD). In the I-PACE (Interaction of Person˗ Affect˗Cognition˗Execution) model of specific Internet-use disorders, it has been suggested that craving, attentional bias, and dysfunctional inhibitory control are main process­es underlying the development and maintenance of Inter­net-use disorders (Brand et al., 2016). In the current study, we investigated particularly the association of attentional bias, inhibitory control, and symptoms of IPD.

Methods: To investigate these relationships, two experimental studies comparing male participants with high and low tendencies towards IPD were conducted. Tendencies towards IPD were assessed with the short version of the Internet Addic­tion Test modified for Internet sex sites (Laier et al., 2013). In the first study, 61 participants completed a Visual Probe Task (Mogg et al., 2003) which was modified with porno­graphic stimuli. In the second study, 12 participants were investigated so far with two modified Stop-Signal Tasks (Logan et al., 1984) which included task-irrelevant neutral and pornographic stimuli.

Results: Participants with high tendencies towards IPD showed higher attentional bias to pornographic stimuli in comparison to participants with low tendencies towards IPD. The first analyses from the second study revealed that males with high tendencies to­wards IPD had longer inhibition times and more errors in stop trials especially when confronted with pornographic pictures.

Conclusions: Results provide further evidence for similarities between IPD and SUD. Clinical implications are discussed.


Mindfulness-based interventions in the assessment, treatment and relapse prevention of compulsive sexual behaviors: Experiences from clinical practice

GRETCHEN R. BLYCKER1 and MARC N. POTENZA2

1Halsosam Therapy, Jamestown, RI and University of Rhode Island, Kingston, RI, USA 2Connecticut Mental Health Center and Yale University School of Medicine, New Haven, CT, USA *E-mail: Gretchen.blycker@gmail.com

Background and aims: Compulsive sexual behaviors in­clude a range of sexual activities including excessive and problematic pornography use, disordered hypersexuality and sexual infidelity. Although many individuals and cou­ples suffer from compulsive sexual behaviors, relatively few seek treatment and empirically validated treatments are largely lacking. Tenets of Eastern philosophy have been incorporated into empirically validated treatments for stress reduction and other psychiatric and psychologi­cal concerns. However, their application to sexual health is less well investigated.

Methods: Through an Eastern-influenced Hakomi clinical training, a mindfulness-based approach to therapeutic interventions aimed at improving sexual, intimacy-oriented and relationship health has been developed and explored in clinical practice. Cases from clinical practice will be presented as a means to provide a basis for future direct clinical investigation into therapeu­tic approaches to help people suffering from the impact of compulsive sexual behaviors.

Results: Cases from men, women and couples will be presented. Examples of how mindfulness-based interventions have helped individuals reduce compulsive and addictive sexual behaviors and move towards and attain healthy sexual relationship func­tioning will be discussed. Conclusions: In clinical prac­tice, mindfulness-based approaches resonate with a broad range of individuals and help people develop skills that assist in creating more connected and healthy patterns of sexual functioning. Future studies should examine direct­ly in randomized clinical trials the efficacy and tolerabili­ty of mindfulness-based approaches for individuals and couples suffering from the impact of compulsive sexual behaviors.


Cue-reactivity and craving in Internet-pornography-viewing disorder: Behavioral and neuroimaging findings

MATTHIAS BRAND1,2*

1General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, Germany2Erwin L. Hahn Institute for Magnetic Resonance Imaging, University of Duisburg-Essen, Germany*E-mail: matthias.brand@uni-due.de

Background and aims: Internet-pornography-viewing dis­order (IPD) is considered one type of specific Internet-use disorders, but potentially shares some mechanisms with general hypersexual behavior. Cue-reactivity and craving are crucial concepts in both substance and behavioral ad­diction research.

Methods: These concepts have been re­cently investigated in subjects with hypersexual behavior and in individuals with IPD. Studies addressing behavioral correlates of cue-reactivity and craving as well as results from neuroimaging investigations are summarized.

Results: Behavioral data support the theoretical hypothesis that cue-reactivity and craving are mechanisms underlying IPD. Be­havioral data are complemented by functional neuroimag­ing findings, which suggest a contribution of the ventral striatum to the subjective feeling of craving. Cue-induced hypersensitivity of the ventral striatum and further brain areas, which are involved in reward anticipation and re­ward processing, can be considered an important brain cor­relate of IPD.

Conclusions: The findings on cue-reactivity and craving in IPD are consistent with the recently suggest­ed Interaction of Person–Affect–Cognition–Execution (I-PACE) model of specific Internet-use disorders. This model suggests that gratification and reinforcement learn­ing contribute to the development of cue-reactivity and craving when being confronted with specific stimuli, which makes it more likely that individuals develop a diminished control over their behavior. Specifications of the I-PACE model for IPD and hypersexual behavior are discussed.


Adolescent hypersexuality: Is it a distinct disorder?

YANIV EFRATI1 and MARIO MIKULINCER1

1Baruch Ivcher School of Psychology, Interdisciplinary Center (IDC) Herzliya, Herzliya, Israel E-mail: ypefrati@gmail.com

Background and aims: Adolescent hypersexuality, and its position within personality dispositions, is the subject of this presentation. The personality dispositions examined were attachment style, temperament, gender, religiosity, and psychopathology.

Methods: To do so, 311 high-school adolescents (184 boys, 127 girls) between the ages 16–18 (M = 16.94, SD = .65), enrolled in the eleventh (n = 135, 43.4%) and twelfth (n = 176, 56.6%) grades, most of whom (95.8%) were native Israelis. By religiosity, 22.2% defined themselves as secular, 77.8% reported various degrees of religiosity. Five possible empirical models were examined, all based on current theory and research on hypersexuality.

Results and Conclusions: The fourth model was found to be compatible with the data, indicating that psychopatholo­gy and hypersexuality are independent disorders and are not related by a mediating process. In addition, religiosity and gender are predictors, but the relationship between temperament and attachment is independent of them – the process is identical in religious and non-religious adoles­cents, both boy and girl. Additionally, the hormone oxy­tocin may be related to hypersexuality, with implications that could affect the therapeutic meaning of understanding the location of adolescent hypersexuality as a disorder in and of itself.


Altered orbitofrontal reactivity during reward processing among problematic pornography users and pathological gamblers

MATEUSZ GOLA1,2 *PHD, MAŁGORZATA WORDECHA3, MICHAŁ LEW-STAROWICZ5 MD, PHD, MARC N. POTENZA6,7 MD, PHD, ARTUR MARCHEWKA3 PHD and GUILLAUME SESCOUSSE4 PHD

1 Swartz Center for Computational Neuroscience, Institute for Neural Computations, University of California San Diego, San Diego, USA 2 Institute of Psychology, Polish Academy of Science, Warsaw, Poland 3 Laboratory of Brain Imaging, Neurobiology Center, Nencki Institute of Experimental Biology of Polish Academy of Science, Warsaw, Poland 4 Radboud University, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands 5 III Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland 6 Departments of Psychiatry and Neurobiology, Child Study Center and CASAColumbia, Yale School of Medicine, New Haven, CT, USA 7 Connecticut Mental Health Center, New Haven, CT, USA *E-mail: Mateusz.gola@gmail.com

Background and aims: Frequent pornography use is highly relevant among young males (Hald, 2006). For majority, pornography viewing is a form of entertainment, but for some individuals problematic pornography use (PPU) ac­companied by excessive masturbation is a reason for treat­ment seeking (Gola et al., 2016). What differentiate prob­lematic and regular pornography users? And how does it mimic other problematic behaviors, such as e.g. pathologi­cal gambling?

Methods: Using fMRI methodology we examined brain reactivity towards erotic and monetary stimuli, disentangling cue-related ‘wanting’ from reward-related ‘liking’ among 28 heterosexual males seeking treat­ment for PPU and 24 matched controls (Gola et al., 2016). The same procedure had been used previously in studies on pathological gambling (Sescousse et al., 2013).

Results: As we showed before (Gola et al., 2016) compared with control subjects, PPU subjects showed increased activation of brain reward circuits (ventral striatum) specifically for cues predicting erotic pictures but not for cues predicting monetary gains, which exactly mimics results of previous study with the same method on individuals with gambling disorder (Sescousse, et al., 2013). Here we focused on oth­er brain region involved in reward processing – orbitofron­tal cortex (OFC). As it had been shown, evolutionally old­er posterior OFC in healthy subjects is involved in processing of primary rewards (food and sex), while ante­rior OFC process secondary rewards (such as money or so­cial reinforces). According to this state of art aOFC is in our study it was the only ROI expressing higher activa­tions for monetary gains than erotic rewards in control subjects. But interestingly, for PPU subjects the aOFC was more active for erotic pictures than monetary rewards, while pOFC remained unchanged. The amount of this shift in aOFC was related to PPU severity measures. Among subjects with pathological gambling opposite pattern of changes was observed: pOFC was activated more for mon­etary rewards, while aOFC activations remained un­changed when compared to controls (Sescousse et al., 2013).

Conclusions: Our results suggest that PPU subjects may experience difficulties in differentiating between val­ue of erotic and non-erotic rewards similarly to pathologi­cal gamblers in case of monetary and non-monetary re­wards. Our results show also that PPU resembles neural and behavioral patterns well-described in gambling disor­der although functional changes.


Interpersonal violence, early life adversity and suicidal behavior in men with hypersexual disorder

JUSSI JOKINENa, b*, ANDREAS CHATZITTOFISa, JOSEPHINE SAVARDa, PETER NORDSTRÖMa, JONAS HALLBERGc, KATARINA ÖBERGc and STEFAN ARVERc

a Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet, Karolinska University Hospital, Solna, SE-171 76 Stockholm, Swedenb Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Swedenc Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Sweden*E-mail: jussi.jokinen@ki.se

Background and aims: Few studies have investigated childhood adversity, interpersonal violence and suicidal behavior in hypersexual disorder. The aim of this study was to assess self-reported interpersonal violence in men with hypersexuality compared to healthy volunteers and to study association between the experience of interpersonal violence and suicidal behavior.

Methods: The study in­cludes 67 male patients with hypersexual disorder (HD) and 40 male healthy volunteers. The Childhood trauma questionnaire-Short Form (CTQ-SF) and the Karolinska Interpersonal Violence Scales (KIVS) were used for as­sessing early life adversity and interpersonal violence as a child and in adult life. Suicidal behavior (attempts and ide­ation) was assessed with the Mini-International Neuropsy­chiatric Interview (MINI 6.0) and the Montgomery-Åsberg Depression Rating Scale-Self rating (MADRS-S).

Results: Men with HD reported more exposure to violence in child­hood and more violent behavior as adults compared to healthy volunteers. Suicide attempters (n = 8, 12%) report­ed higher KIVS total score, more used violence as a child, more exposure to violence as an adult as well as higher score on CTQ-SF subscale measuring sexual abuse com­pared to hypersexual men without suicide attempt.

Conclu­sions: Hypersexuality was associated with interpersonal violence with highest total scores in patients with suicide attempt.


Methylation of the HPA axis related genes in men with hypersexual disorder

JUSSI JOKINENa, b*, ADRIAN BOSTRÖMc, ANDREAS CHATZITTOFISa, KATARINA GÖRTS ÖBERGd, JOHN N. FLANAGANd, STEFAN ARVERd and HELGI SCHIÖTHc

a Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet, Stockholm, Swedenb Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Swedenc Department of Neuroscience, Uppsala University , Uppsala, Swedend Department of Medicine, Karolinska Institutet, Stockholm, Sweden*E-mail: jussi.jokinen@ki.se; jussi.jokinen@umu.se

Background and aims: Hypersexual Disorder (HD) defined as non-paraphilic sexual desire disorder with components of compulsivity, impulsivity and behavioral addiction, was proposed as a diagnosis in the DSM 5. Some overlapping features between HD and substance use disorder including common neurotransmitter systems and dysregulated hypo­thalamic-pituitary-adrenal (HPA) axis function have been reported. In this study, comprising 67 male patients diag­nosed with HD and 39 healthy male volunteers, we aimed to identify HPA-axis coupled CpG-sites, in which modifi­cations of the epigenetic profile are associated with hyper­sexuality.

Methods: The genome-wide methylation pattern was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip, measuring the methylation state of over 850 K CpG sites. Prior to analysis, the global DNA methylation pattern was pre-processed according to standard protocols and adjusted for white blood cell type heterogeneity. We included CpG sites located within 2000 bp of the transcriptional start site of the following HPA-axis coupled genes: Corticotropin releasing hormone (CRH), corticotropin releasing hormone binding protein (CRHBP), corticotropin releasing hormone receptor 1 (CRHR1), corticotropin releasing hormone receptor 2 (CRHR2), FKBP5 and the glucocorticoid receptor (NR3C1). We performed multiple linear regression models of methylation M-values to a categorical variable of hyper­sexuality, adjusting for depression, DST non-suppression status, Childhood Trauma Questionnaire total score and plasma levels of TNF-alpha and IL-6.

Results: 76 individ­ual CpG sites were tested, and four of these were nomi­nally significant (p < 0.05), associated with the genes CRH, CRHR2 and NR3C1. Cg23409074 – located 48 bp upstream of the TSS of the CRH gene – was significantly hypomethylated in hypersexual patients after corrections for multiple testing using the FDR-method. Methylation levels of cg23409074 were positively correlated with gene expression of the CRH gene in an independent cohort of 11 healthy male subjects.

Conclusions: CRH is an impor­tant integrator of neuroendocrine stress responses in the brain, modulating behavior and the autonomic nervous system. Our results show epigenetic changes in CRH gene related to hypersexual disorder in men.


Psychometrics properties of a problematic pornography use scale and associations with psychological and clinical characteristics in US military veterans

ARIEL KOR1, MARC. N. POTENZA, M.D., PhD.2,3, RANI A. HOFF, PhD.2, 4, ELIZABETH PORTER, MBA4 and SHANE W. KRAUS, PhD.,5

1Teachers College, Columbia University, Department of Counseling & Clinical Psychology, Teachers College, Columbia University, USA2Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA3Department of Neuroscience, Child Study Center and the National Center on Addiction and Substance Abuse, Yale School of Medicine, New Haven, CT, USA4VISN 1 MIRECC, VA CT Healthcare System, West Haven, CT, USA5VISN 1 New England MIRECC, Edith Nourse Rogers Memorial Veterans Hospital, Bedford MA, USA*E-mail: shane.kraus@va.gov

Background and aims: Although most individuals viewing pornography experience few problems with pornography, a subset of individuals report significant problems managing their use. The Problematic Pornography Use Scale (PPUS) was developed to assess for problematic use of pornogra­phy among adults living in Israel. Despite its initial prom­ising psychometric properties, the PPUS has not been vali­dated among US adult pornography users. To investigate further, the current study evaluated the psychometric prop­erties of the PPUS in a sample of males and females re­porting pornography use.

Methods: A sample of 223 US military veterans completed measures assessing demo­graphics, psychopathology, frequency of pornography use, craving for pornography, problematic use of pornography, hypersexuality, and impulsivity.

Results: Findings found that the PPUS demonstrated high internal consistency, convergent, discriminant, and construct validity. Higher PPUS scores were associated with higher frequency of weekly pornography use, male gender, craving for pornog­raphy, and affective disorders.

Conclusions: The PPUS showed promising psychometric properties among a sam­ple of US veterans reporting pornography use, although additional research is needed to examine its factor struc­ture and determine the appropriate threshold to accurately detect problematic use.


How impulsivity is related to problematic pornography use? Longitudinal study among participants of 12-steps sexual addiction treatment program

EWELINA KOWALEWSKA1*, JAROSLAW SADOWSKI2, MALGORZATA WORDECHA3, KAROLINA GOLEC4, MIKOLAJ CZAJKOWSKI, PhD2 and MATEUSZ GOLA, PhD3, 5

1Department of Psychology, University of Social Sciences and Humanities, Warsaw, Poland 2 Department of Economy, University of Warsaw, Warsaw, Poland 3 Institute of Psychology, Polish Academy of Sciences, Warsaw, Poland 4 Department of Psychology, University of Warsaw, Warsaw, Poland 5 Swartz Center for Computational Neuroscience, Institute for Neural Computations, University of California San Diego, San Diego, USA *E-mail: ekowalewska@swps.edu.pl

Background and aims: Some research show relation be­tween impulsivity and pornography use (Mainer et al., 2009; Mick & Hollander, 2006; Davis et al., 2002; Shapira et al., 2000). One aspect of impulsivity is the ability of de­laying gratification and discounting. It remains unknown whether deferment of gratification is the cause or the result of frequent pornography use.

Methods: We measured dis­counting by MCQ questionnaire (Monetary Choice Ques­tionnaire; Kirby & Marakovic, 1996) in two studies. In Study 1, data were collected from surveys conducted on a members of 12-steps groups for sexual addiction (N = 77, mean age 34.4, SD = 8.3) and control individuals (N = 171, mean age 25.6, SD = 6.4). In Study 2, we conducted re­peated measurement after 3 months on a 17 members of 12-steps group for sexual addiction from Study 1 (N = 17, mean age 34.8, SD = 2.2). The average time of sexual ab­stinence in clinical group was 243.4 days (SD = 347.4, Min. = 2, Max. = 1216; Study 1) and 308.5 days (SD = 372.9, Min. = 1, Max. = 1281; Study 2). Both studies were performed via the Internet.

Results: In Study 1 time spent on pornography and masturbation was correlated pos­itively with the discounting parameter. Correlations be­tween these variables were stronger in among sex addicts (masturbation frequency, r = 0.30, p < 0.05; pornography use, r = 0.28, p < 0.05) than the control group (masturba­tion frequency, r = 0.23, p < 0.05; pornography use, r = 0.19, p < 0.05) The strongest correlation (r = −0.39) occurs between the discounting parameter and sobriety among sex addicts. Contrary to our hypothesis average discounting function parameters were higher in control group than in group of sex addicts. In Study 2, results didn’t show signifi­cant relation between discounting and time of sexual absti­nence. However, groups did not significantly differ in dis­counting between measurements and gain in sobriety during 3 months was not accompanied by decrease of dis­counting. Changes in sobriety could be better explained by number of mentee on 12-step program (r = 0.92, p < 0.05) or current step in 12-steps therapy (r = 0,68; p < 0,001) than by discounting.

Conclusions: The ability of delaying gratification is rather not modified by the pornography use. Probably it is a constant feature that can determine the fre­quency of pornography use in the general population. Among the members of the 12-steps groups for sex addicts the ability of delaying gratification, paradoxically, is higher than in the general population and is not modified during 3 months of working on a 12-steps program. Moreover, dis­counting does not change with the time of abstinence. This result may suggest that individuals with low discounting may be more prone to benefit form 12-step program, than those with high discounting.


Pornography avoidance self-efficacy scale: Psychometric properties

SHANE W. KRAUSa, b, *, HAROLD ROSENBERGb, CHARLA NICHc STEVE MARTINOc, d and MARC N. POTENZAc

a Department of Psychology, Bowling Green State University, Bowling Green, OH, 43403, USA b VISN 1 New England MIRECC, Edith Nourse Rogers Memorial Veterans Hospital, 200 Spring Road, Bedford MA, USA c Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA d VISN 1 New England MIRECC, VA Connecticut Healthcare System, West Haven, CT USA *E-mail: shane.kraus@va.gov

Background and aims: The presented study examined whether participants’ self-efficacy to avoid using pornog­raphy in each of 18 emotional, social, and sexually arous­ing contexts was associated with their typical frequency of pornography use.

Methods: Using a web-based data collection procedure, 229 male pornography users who had sought or had considered seeking professional help for their use of pornography completed questionnaires as­sessing their context-specific self-efficacy, history of por­nography use, self-efficacy to employ specific pornogra­phy-reduction strategies, clinical hypersexuality, and demographic characteristics.

Results: A series of ANO­VAs showed that frequency of pornography use was sig­nificantly and negatively associated with level of confi­dence in 12 of the 18 contexts. Similarly, we found that lower hypersexuality and higher confidence to employ pornography-use-reduction strategies were associated with higher confidence to avoid using pornography in each of the 18 situations. An exploratory factor analysis also revealed three clusters of situations: (a) Sexual arous­al/Boredom/Opportunity, (b) Intoxication/Locations/Easy access, and (c) Negative Emotions; the two remaining sit­uations did not load on any of three clusters. Because only one of the three clusters reflected a consistent theme, we do not recommend averaging self-efficacy within clusters comprised of different types of situations.

Conclusions: Mental health clinicians could use the questionnaire to identify specific higher risk situations for relapse in indi­viduals seeking to reduce or stop using pornography prob­lematically.


Brief Pornography Screener: A comparison of US and Polish pornography users

SHANE W. KRAUS, PhD.,1 MATEUSZ GOLA, PhD.,2 EWELINA KOWALEWSKA,3 MICHAL LEW-STAROWICZ , M.D., PhD.4 RANI A. HOFF, PhD.,5, 6 ELIZABETH PORTER, MBA,6 and MARC. N. POTENZA, M.D., PhD.5,7

1VISN 1 New England MIRECC, Edith Nourse Rogers Memorial Veterans Hospital, Bedford MA, USA2Swartz Center for Computational Neuroscience, Institute for Neural Computations, University of California San Diego, San Diego, USA3Department of Psychology, University of Social Sciences and Humanities, Warsaw, Poland4Institute of Psychiatry and Neurology, 3rd Psychiatric Clinic, Warsaw, Poland5Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA6VISN 1 MIRECC, VA CT Healthcare System, West Haven CT, USA7Department of Neuroscience, Child Study Center and the National Center on Addiction and Substance Abuse, Yale School of Medicine, New Haven, CT, USA*E-mail: shane.kraus@va.gov

Background and aims: The current study evaluated the psychometric properties of a newly developed six-item questionnaire designed to identify behaviors, thoughts, and experiences associated with problematic use of pornogra­phy. Methods: In Studies 1 and 2, 223 US military veter­ans and 703 Polish community members were adminis­tered the Brief Pornography Screener (BPS) and measures assessing frequency of pornography use, craving for por­nography, problematic use of pornography, clinical hyper­sexuality, and impulsivity. In Study 3, 26 Polish male clin­ical patients were administered the BPS and measures of psychopathology.

Results: In Study 1, findings supported dropping one item from the questionnaire; the five remain­ing items were subjected to an exploratory factor analysis which yielded a one-factor solution with an eigenvalue of 3.75 that accounted for 62.5% of the total variance. The BPS also demonstrated high internal reliability (α = 0.89). Next, we found that BPS scores were significantly and positively associated with craving for pornography, prob­lematic use of pornography, and hypersexuality, but weak­ly related to impulsivity. In Study 2, findings were similar in that BPS scores were positively associated with a meas­ure of hypersexuality but weakly associated with scores on measures assessing obsessive-compulsive symptoms and impulsivity. Results also indicated that the one-factor solu­tion yielded an excellent fit: χ2/df = 5.86, p = 0.00, RM­SEA = 0.08, SRMR = 0.02, CFI = 0.99, and TLI = 0.97. In Study 3, we assessed the classification quality of BPS us­ing an a priori selected group of patients against a control group. The ROC analysis indicated that the AUC value was 0.863 (SE = 0.024; p < 0.001; 95% CI: 81.5−91.1).

Conclusions: The BPS demonstrated promising psycho­metric properties across both US and Polish samples and could be used by clinicians in mental health settings to identify individuals.


Sexual arousal reaction to pornographic stimuli mediates the relationship between predisposing personal characteristics and symptoms of Internet-pornography-viewing disorder

CHRISTIAN LAIER1 and MATTHIAS BRAND1,2

1 General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, Duisburg-Essen, Germany2 Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany*E-mail: Christian.laier@uni-due.de

Background and aims: Main factors underlying Internet-pornography-viewing in general are seeking sexual excita­tion and sexual pleasure, satisfying sexual curiosity, or avoiding aversive emotions (Reid et al., 2011). The I-PACE (Interaction of Person−Affect−Cognition−Execution) model of specific Internet-use disorders (Brand et al., 2016) postu­lates an interaction of user’s personal characteristics, affec­tive responses, cognitive processes, and executive functions with the gratification gained by viewing Internet-pornogra­phy. The aim of the study was to investigate the relationship between the personal characteristics such as pornography-viewing motivation, psychological symptoms, and per­ceived stress with sexual arousal as reaction to pornographic material and tendencies towards Internet-pornography-viewing disorder (IPD).

Methods: Male participants (N = 88) were investigated in a laboratory setting. Questionnaires assessed tendencies towards IPD, pornography-viewing mo­tivation, psychological symptoms, and perceived stress. Moreover, participants viewed pornographic pictures and indicated their sexual arousal and their need to masturbate before and after cue presentation.

Results: The results showed that tendencies towards IPD were strongly associat­ed to all factors of pornography-viewing motivation, psy­chological symptoms, perceived stress, and indicators of sexual arousal reactions. Moreover, the need to masturbate partially mediated the relationship between the motivation to view pornography and the relationship between psycho­logical symptoms and stress with symptoms of IPD.

Con­clusions: The findings showed that tendencies towards IPD were associated to the postulated personal characteristics and that this relation was partially mediated by an indicator of sexual arousal. Thus, the results are in line with the I-PACE model and strengthen the assumption that future re­search should focus on the interaction of specific variables beyond bivariate correlations to give further insights into the psychological mechanisms underlying IPD.


Compulsivity and impulsivity in sexual addiction

ERIC LEPPINK

University of Chicago, Chicago, USA E-mail: eleppink@yoda.bsd.uchicago.edu

Sexual addiction has frequently been characterized as a dis­order of impulsivity, suggesting that the initiation and/or persistence of the problematic behavior may be due to an inability to suppress impulses to engage in the rewarding behavior. Current findings related to this disorder, however, have suggested that in addition to impulsivity, compulsivity may play a notable role in the presentation and perpetua­tion of sexual addiction. This presentation will present new neurocognitive and neuroimaging data regarding the broad­er clinical domains of compulsivity and impulsivity in sex­ual addiction. Particular emphasis will be placed on current understanding of neurobiology and neurocognition in pa­tients with sexual addiction and how these data may im­prove treatment approaches.


Treatment seeking for problematic pornography use among women

KAROL LEWCZUK1, JOANNA SZMYD2 and MATEUSZ GOLA3,4*

1 Department of Psychology, University of Warsaw, Warsaw, Poland2Department of Cognitive Psychology, University of Finance and Management, Warsaw, Poland3 Institute of Psychology, Polish Academy of Sciences, Warsaw , Poland4 Swartz Center for Computational Neuroscience, Institute for Neural Computations, University of California San Diego, San Diego, USA*E-mail: mgola@ucsd.edu

Backgrounds and aims: Previous studies examined psycho­logical factors related to treatment-seeking for problematic pornography use (PU) among males. In this study we fo­cused on females who seek treatment for problematic PU and examined the differences with regards to variables re­lated to problematic PU between this group and the group of women that did not seek such treatment. Secondly, we in­vestigated the relationships between critical constructs re­lated to problematic PU with path analysis method, empha­sizing the predictors for treatment-seeking among women. We also compared our results to previous studies on males.

Methods: A survey study was conducted on 719 Caucasian females 14 to 63 years old, including 39 treatment-seekers for problematic PU (referred by psychotherapists after their initial visit)

Results: Treatment-seeking among females is related to negative symptoms associated with PU, but also to the mere amount of PU. This stands in opposition to pre­viously published analyses on males. Additionally, in the case of females, religiosity is a strong, significant predictor of treatment seeking.

Discussion: Differently from previous studies that focused on male samples, our analysis showed that in case of women mere amount of PU may be related with treatment-seeking behavior even after accounting for negative symptoms associated with PU. Moreover, reli­giousness is a significant predictor of treatment seeking among women, what may indicate that in case of women, treatment seeking for problematic PU is motivated not only by experienced negative symptoms of PU, but also personal beliefs about PU and social norms. Those factors should be taken into account in treatment.

Conclusions: Negative symptoms associated with pornography use, frequency of pornography use and religiousness are associated with treat­ment-seeking among women – this pattern is different than the results obtained in previous studies on males.


Behavioral Indications of Cognitive Disruption in Hypersexuality

MICHAEL H. MINER1*, ANGUS MACDONALD, III2 and EDWARD PATZALT3

1Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN. USA2Department of Psychology, University of Minnesota, Minneapolis, MN. USA3Department of Psychology, Harvard University, Cambridge, MA. USA*E-mail: miner001@umn.edu

Background and aims: Addictive processes are thought to be the result of a number of underlying cognitive disrup­tions that influence decision-making. Specifically, it has been suggested that addiction accesses the same neuro­physiological mechanisms used by normal reinforcement learning systems. Our aim is to examine the involvement of disruptions in three areas of cognitive control, (1) Shift­ing reinforcement contingencies, (2) delaying gratification and risk-taking, and (3) stimulus interference.

Methods: We examined a sample of 242 adult men who had a sexual in­terest or had engaged in sexual behavior with men. Ninety-three met criteria for hypersexuality. Participants complet­ed three cognitive tasks: a reversal learning task, a delayed discounting task, and a single-trial Stroop.

Results: We ex­plored both group differences and correlations with the Compulsive Sexual Behavior Inventory obtained by vari­ous computational models characterizing responses to these three measures of cognitive control. We found few indica­tions that hypersexuality, either defined by group assign­ment or by score on the CSBI, was associated with meas­ures of cognitive disruptions that have characterized other forms of addiction. We did find a significant interaction be­tween a Grattan effect on the Stroop and CSBI score in pre­dicting number of sexual encounters over a 90-day period.

Conclusions: Hypersexuality, at least in MSM, does not ap­pear to be related to the cognitive disruptions found in oth­er addictions, such as cocaine abuse. However, in the pres­ence of high levels of hypersexuality, at least as measured by the CSBI, a failure to moderate behavior due to immedi­ate previous experience does appear related to increased sexual behavior. Thus, the mechanism by which hypersexu­ality leads to high levels of partnered sex may be through this disruption in moment to moment modification of be­havior. Our findings are influenced by sampling in that hy­persexuality manifests itself differently in MSM. Addition­ally, hypersexuality is multi-dimensional, and it may be that different behaviors result from multiple sources of dis­ruption,


Craving responses to watching pornographic clips are related to symptoms of Internet-pornography-viewing disorder

JARO PEKAL1* and MATTHIAS BRAND1,2

1General Psychology: Cognition, University of Duisburg-Essen and Center for Behavioral Addiction Research (CeBAR), Germany 2Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany *E-mail: jaroslaw.pekal@uni-due.de

Background and aims: Cue-Reactivity and craving reac­tions are important aspects in the development of sub­stance-use disorders. Since it has been suggested that both processes are also involved in Internet-pornography-view­ing disorder (IPD), it is important to investigate them in more detail. Some authors consider the anticipation of grat­ification as key factor in the development and maintenance of an IPD. In the I-PACE (Interaction of Person-Affect- Cognition-Execution) model for specific Internet-use disor­ders (Brand et al., 2016), cue reactivity and craving as well as reward-learning mechanisms are assumed to be crucial mechanisms of an IPD. In former cue-reactivity studies mostly pornographic pictures were used for induction of sexual arousal and craving. The aim of the current study was to investigate the effects of pornographic clips on sub­jective craving and relationships with specific cognitions about Internet-pornography-viewing and tendencies to­wards IPD.

Methods: An experimental study with a sample of 51 male participants was conducted. All participants viewed 60 pornographic clips, rated them with respect to sexual arousal and indicated their current sexual arousal and their need to masturbate before and after the cue pres­entation. Furthermore, questionnaires were used to assess motives for viewing pornography, Internet-pornography-use expectancies and tendencies towards IPD.

Results: The pornographic clips were rated as sexually arousing and lead to an increase of sexual arousal and the need to masturbate. Moreover, sexual arousal reactions were moderately to strongly associated with expectancies and motives to view Internet-pornography as well as with symptoms of IPD.

Conclusions: The results are consistent with former studies on IPD and emphasize the involvement of cue-reactivity and craving in IPD as suggested in the I-PACE model for specific Internet-use disorders. From a methodically view, the observed effects of the cue-reactivity paradigm with pornographic clips are comparable to those reported when pictures were used as cues.


How might compulsive sexual behaviors be considered in ICD-11 and what are the clinical implications?

MARC N. POTENZA1

1Connecticut Mental Health Center and Yale University School of Medicine, USA *E-mail: marc.potenza@yale.edu

Background and aims: Although prevalence estimates are largely lacking, a considerable number of individuals may encounter problems with various forms of problematic sexual behaviors related to hypersexuality, problematic pornography viewing or compulsive sexual behaviors. In preparation for the fifth edition of the Diagnostic and Sta­tistical Manual (DSM-5), hypersexual disorder was field-tested and considered for inclusion but was ultimately ex­cluded from the manual. In preparation for the eleventh edition of the International Classification of Diseases (ICD-11), non-substance or behavioral addictions are be­ing considered for inclusion, with questions regarding defi­nitions and classifications being discussed.

Methods: The obsessive-compulsive and related disorders group and the substance use disorders group have considered behavioral addictions including those relating to sex. Three work­group meetings organized by the World Health Organiza­tion have considered Internet-related behaviors and disor­ders, with consideration of both online and offline behaviors with addictive potential. In these meetings, in­ternational participation from the majority of the World Health Organization’s global zones participated to help en­sure that global jurisdictions were well represented and involved in the process of considering how best to concep­tualize and define behavioral addictions and related sub­syndromal behaviors.

Results: The obsessive-compulsive and related disorders group has reported an opinion that compulsive sexual behaviors be recognized as a specific diagnostic entity in the impulse control disorder section. The addictive disorders group in ICD-11 has proposed cri­teria for gambling disorder and gaming disorder, with both online and offline specifiers. Related definitions for haz­ardous gambling and gaming have been proposed, with these definitions being mutually exclusive from the corre­sponding disorder conditions. While no specific behavioral addiction related to sexual behaviors has been proposed, a category for “Disorders Due to Addictive Behaviors” has been proposed, and this designation may be used to diag­nose behavioral addictions related to sex.

Conclusions: Al­though the ICD-11 process is not yet finalized, problemat­ic, compulsive, excessive and/or hypersexual behaviors relating to sex are being discussed with respect to inclu­sion in ICD-11. A currently proposed diagnostic category by the addictive disorders group would permit clinicians to have a diagnosis for a broad range of addictive behaviors relating to sex. Given the use of the ICD by a large num­ber of groups including many clinicians and insurance companies, the existence of a diagnostic entity capturing addictive behaviors relating to sex may have significant clinical and public health impacts.


Out-of-control use of the internet for sexual purposes as behavioural addiction?

ANNA ŠEVČÍKOVÁ1*, LUKAS BLINKA1 and VERONIKA SOUKALOVÁ1

1Masaryk University, Brno, Czech Republic*E-mail: asevciko@fss.muni.cz

Background and aims: There is an ongoing debate wheth­er excessive sexual behaviour should be understood as a form of behavioural addiction (Karila, Wéry, Weistein et al., 2014). The present qualitative study aimed at analys­ing the extent to which out-of-control use of the internet for sexual purposes (OUISP) may be framed by the con­cept of behavioural addiction among those individuals who were in treatment due to their OUISP.

Methods: We conducted in-depth interviews with 21 participants aged 22–54 years (Mage = 34.24 years). Using a thematic anal­ysis, the clinical symptoms of OUISP were analysed with the criteria of behavioural addiction, with the special fo­cus on tolerance and withdrawal symptoms (Griffiths, 2001).

Results: The dominant problematic behaviour was out-of-control online pornography use (OOPU). Building up tolerance to OOPU manifested itself as an increasing amount of time spent on pornographic websites as well as searching for new and more sexually explicit stimuli with­in the non-deviant spectrum. Withdrawal symptoms mani­fested themselves on a psychosomatic level and took the form of searching for alternative sexual objects. Fifteen participants fulfilled all of the addiction criteria.

Conclu­sions: The study indicates a usefulness for the behavioural addiction framework.


The contribution of personality factors and gender to ratings of sex addiction among men and women who use the internet for sex purposes

LI SHIMONI L.1, MORIAH DAYAN1 and AVIV WEINSTEIN*1

1Department of Behavioral Science, Ariel University, Science Park, Ariel, Israel. *E-mail: avivweinstein@yahoo.com

Background and aims: Sex addiction otherwise known as hypersexual disorder is characterized by excessive sexual activity which includes watching pornography, using chat rooms and cybersex on the internet. In this study we have investigated the contribution of the big five personality fac­tors and sex to sex addiction.

Methods: 267 participants (186 males and 81 females) were recruited from internet sites that are used for finding sexual partners. Participants filled in the Sexual Addiction Screening Test (SAST) the Big Five Index and a demographic questionnaire.

Results: Men have shown higher scores on the SAST than women [t (1,265) = 4.1; p < 0.001]. Regression analysis showed that conscientiousness contributed negatively (F(5,261) = 8.12; R = 0.36, p < 0.01, β = –0.24) and openness contrib­uted positively (F(5,261) = 8.12, R = 0.36, p < 0.01, β = 0.1) to the variance of sex addiction scores. Neuroticism only marginally contributed to sex addiction scores (F(5,261) = 8.12, R = 0.36, p = 0.085, β = 0.12) . Finally, there was an interaction between sex and openness (R2change = 0.013, F2(1,263) = 3.782, p = 0.05) which indicated that openness contributed to sex addiction among women (β = 0.283, p = 0.01).

Discussion and conclusions: this study showed that personality factors such as (lack of) conscientiousness and openness contributed to sex addiction. The study also con­firmed previous evidence for higher scores of sex addiction among males compared with females. Among women, openness was associated with greater propensity for sex ad­diction. These personality factors predict who has the pro­pensity to develop sex addiction.


Distractibility by sexual stimuli – a biological marker of hypersexuality?

RUDOLF STARK1*, ONNO KRUSE1, TIM KLUCKEN2, JANA STRAHLER1 and SINA WEHRUM-OSINSKY1

1 Justus Liebig University Giessen, Germany 2 University of Siegen, Germany *E-mail: rudolf.stark@psychol.uni-giessen.de

Background and aims: A high distractibility by sexual stim­uli could be a possible vulnerability factor for the develop­ment of sexual addiction. The first hypothesis of the present study was that subjects with high trait sexual motivation are more attracted by sexual cues than subjects with low trait sexual motivation. The second hypothesis was that this distractibility by sexual stimuli can result in addictive sexu­al behaviour, e.g. problematic use of pornography. Assum­ing this to be true then the distractibility should be greater in sexual addicts than in healthy control subjects.

Methods: We conducted two experiments with the same experimental functional magnetic resonance imaging (fMRI) paradigm. In the first experiment we examined 100 healthy subjects (50 females). In the second experiment we compared the responses of 20 male sexual addicts to those of 20 control subjects. The experimental task required the decision whether two lines, which were located left and right from a picture with either neutral or sexual content, were equally aligned or not.

Results: First results show that the reaction times in the line alignment task were indeed greater in case of a sexual distractor than in case of a neutral distractor. However, the trait sexual motivation and the presence of sexual addiction had only small if any effects on reaction times and the neural activation pattern.

Conclusions: Against our hypothesis, the distractibility by sexual stimuli is obviously not a prominent vulnerability factor for the de­velopment of a sexual addiction. Maybe this result can be traced back to a ceiling effect: Sexual cues strongly attract attention independent of trait sexual motivation or sexual compulsive behaviour.


Clinical characteristics associated with digital hookups, psychopathology, and clinical hypersexuality among US military veterans

JACK L. TURBAN B.A.a, MARC N. POTENZA M.D., PhD.a, b, c, RANI A. HOFF PhD., MPHa, d, STEVE MARTINO PhD.a, d, and SHANE W. KRAUS, PhD.d

a Department of Psychiatry, Yale School of Medicine, New Haven, CT, USAb Department of Neuroscience, Child Study Center and the National Center on Addiction and Substance Abuse, Yale School of Medicine, New Haven, CT, USAc Connecticut Mental Health Center, New Haven, CT, USAd VISN1 New England MIRECC, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA*E-mail: shane.kraus@va.gov

Background and aims: Digital social media platforms (e.g., Match, Manhunt, Grindr, Tinder) provide outlets through which individuals can find partners for consensual sexual encounters.

Methods: Using a sample of US post-deploy­ment military returning war veterans, we evaluated the prevalence of digital sex seeking with clinical correlates of psychopathology, suicidal ideation, and sexually transmit­ted infections (STIs). Specifically, using data from a base­line telephone interview and follow-up internet-based sur­vey, we assessed the prevalence of sexual partnering via digital social-media platforms in a national sample of 283 US combat veterans.

Results: Among veterans, 35.5% of men and 8.5% of women reported having used digital so­cial media to meet someone for sex in their lifetime. Veter­ans who reported having used digital social media to find sexual partners (DSMSP+) as compared to those who did not (DSMSP-) were more likely to be young, male, and in the Marine Corps. After adjusting for sociodemographic variables, DSMSP+ status was significantly associated with post-traumatic stress disorder (OR = 2.26, p = 0.01), in­somnia (OR = 1.99, p = 0.02), depression (OR = 1.95, p = 0.03), clinical hypersexuality (OR = 6.16, p < 0.001), sui­cidal ideation (OR = 3.24, p = 0.04), and treatment for an STI (OR = 1.98, p = 0.04).

Conclusions: Among a national sample of US post-deployment military veterans, DSMSP+ behaviors were prevalent, particularly among male veter­ans. Findings also suggest that in particular veterans who engage in DSMSP+ behaviors should be thoroughly screened during routine mental health appointments and counseled on the benefits of safe sexual practices.


Compulsive sexual behaviour: prefrontal and limbic volume and interactions

VALERIE VOON1, CASPER SCHMIDT1, LAUREL MORRIS1, TIMO KVAMME1, PAULA HALL2 and THADDEUS BIRCHARD1

1 Department of Psychiatry, University of Cambridge, Cambridge, UK2 United Kingdom Council for PsychotherapyE-mail: voonval@gmail.com

Background and aims: Compulsive sexual behaviors (CSB) are relatively common and associated with signifi­cant personal and social dysfunction. The underlying neu­robiology is still poorly understood. The present study ex­amines brain volumes and resting state functional connectivity in CSB compared with matched healthy vol­unteers (HV).

Methods: Structural MRI (MPRAGE) data were collected in 92 subjects (23 CSB males and 69 age-matched male HV) and analyzed using voxel-based mor­phometry. Resting state functional MRI data using multi-echo planar sequence and independent components analysis (ME-ICA) were collected in 68 subjects (23 CSB subjects and 45 age-matched HV).

Results: CSB subjects showed greater left amygdala gray matter volumes (small volume corrected, Bonferroni adjusted P < 0.01) and re­duced resting state functional connectivity between the left amygdala seed and bilateral dorsolateral prefrontal cortex (whole brain, cluster corrected FWE P < 0.05) compared with HV.

Conclusions: CSB is associated with elevated volumes in limbic regions relevant to motivational sali­ence and emotion processing, and impaired functional con­nectivity between prefrontal control regulatory and limbic regions. Future studies should aim to assess longitudinal measures to investigate whether these findings are risk fac­tors that predate the onset of the behaviors or are conse­quences of the behaviors.


Clinical diversity among males seeking treatment for compulsive sexual behaviors. Qualitative study followed by 10-week diary assessment

MAŁGORZATA WORDECHA*1, MATEUSZ WILK1, EWELINA KOWALEWSKA2, MACIEJ SKORKO1 and MATEUSZ GOLA1,3

1Institute of Psychology, Polish Academy of Sciences, Warsaw, Poland 2University of Social Sciences and Humanities, Warsaw, Poland 3Swartz Center for Computational Neuroscience, Institute for Neural Computations, University of California San Diego, San Diego, CA, USA *E-mail: mwordecha@psych.pan.pl

Background and aims: We wanted to assess similarities and diversity among males seeking treatment for compulsive sexual behaviors and verify a correspondence of perceived reasons of pornography use with real-life data.

Methods: We conducted semi-structuralized interviews with 9 males in age of 22–37 years (M= 31.7; SD = 4.85) followed by 10-week long diary assessment. During interviews we cov­ered characteristic of CSB symptoms, underlying psycho­logical mechanisms, and role of social relations. Using questioners’ methods, we verified qualitative data and in addition we conducted10-week long diary assessment to examine real-life patterns of CSB.

Results: All subjects ex­pressed high level of severity of pornography use and mas­turbation. They also presented increased level of anxiety and declared that pornography use and masturbation serves for mood and stress regulation. There was high diversity in terms of impulsivity, social competence and other psycho­logical mechanism underlying CSB. Data collected in diary assessment uncovered high diversity in patterns of sexual behaviors (such as frequency or binge pornography use, dyadic sexual activity) and triggers. It was impossible to fit one regression model for all subjects. Instead each subject had his own model of predictors of CSB mostly not related to decelerated triggers.

Discussion and conclusions: De­spite similar scheme of problematic sexual behavior and accompanied emotions and thoughts CSB seems to have homogeneous psychological mechanisms. Individual analy­sis of longitudinal diary assessment uncovered high varia­bility in individual predictors of pornography use and mas­turbation. Therefore, those individual patters have to be carefully studied in clinical settings to provide effective treatment.


The six-component problematic pornography consumption scale

BEÁTA BŐTHE1,2*, ISTVÁN TÓTH-KIRÁLY1,2, ÁGNES ZSILA1,2, MARK D. GRIFFITHS3, ZSOLT DEMETROVICS2 AND GÁBOR OROSZ2,4

1Doctoral School of Psychology, Eötvös Loránd University, Budapest, Hungary 2Institute of Psychology, Eötvös Loránd University, Budapest, Hungary 3Psychology Department, Nottingham Trent University, Nottingham, United Kingdom 4Institute of Cognitive Neuroscience and Psychology, Hungarian Research Centre for Natural Sciences, Budapest, Hungary *E-mail: bothe.beata@ppk.elte.hu

Background and aims: To our best knowledge, no scale ex­ists with strong psychometric properties assessing problem­atic pornography consumption which is based on an over­arching theoretical background. The goal of the present study was to develop a short scale (Problematic Pornogra­phy Consumption Scale; PPCS) on the basis of Griffiths` (2005) six-component addiction model that can assess problematic pornography consumption.

Methods: The sam­ple comprised 772 respondents (390 females; Mage = 22.56, SD = 4.98 years). Items creation was based on the definitions of the components of Griffiths’ model.

Results: A confirmatory factor analysis was carried out leading to an 18-item second-order factor structure. The reliability of the PPCS was good and measurement invariance was estab­lished. Considering the sensitivity and specificity values, we identified an optimal cut-off to distinguish between problematic and non-problematic pornography users. In the present sample, 3.6% of the pornography consumers be­longed to the at-risk group.

Discussion and Conclusion: The PPCS is a multidimensional scale of problematic por­nography consumption with strong theoretical background that also has strong psychometric properties.


Sex mindset beliefs can diminish the negative association between relationship satisfaction and problematic pornography consumption

BEÁTA BŐTHE1,2†*, ISTVÁN TÓTH-KIRÁLY1,2, ZSOLT DEMETROVICS2 AND GÁBOR OROSZ2,3†

1Doctoral School of Psychology, Eötvös Loránd University, Budapest, Hungary 2Institute of Psychology, Eötvös Loránd University, Budapest, Hungary 3Institute of Cognitive Neuroscience and Psychology, Hungarian Research Centre for Natural Sciences, Budapest, Hungary † Authors contributed equally to this research. *E-mail: bothe.beata@ppk.elte.hu

Background and aims: The present research investigated the associations between relationship satisfaction and prob­lematic pornography consumption considering beliefs about the changeability of sexual life.

Methods: In Study 1 (N1 = 769), the Sex Mindset Scale was created which measures beliefs about the malleability of sexual life. In Study 2 and Study 3 (N2 = 315, N3 = 378), structural equa­tion modeling (SEM) was used to identify the relationship patterns between problematic pornography consumption, relationship satisfaction and sex mindset beliefs.

Results: Confirmatory factor analyses (Study 1) demonstrated strong psychometric properties. Each examined model (Study 2 and Study 3) showed that sex mindset beliefs are positively and directly related to relationship satisfaction, while negatively and directly related to problematic pornography consumption. Additionally, Problematic pornography con­sumption and relationship satisfaction were not related. Thus, problematic pornography use did not mediate the re­lationship between sex mindset beliefs and relationship sat­isfaction.

Discussion and Conclusions: In the light of our results, the negative relationship between problematic por­nography consumption and relationship satisfaction disap­pears by considering sex mindset as a common denominator.


Hypersexuality and its association with pedophilic sexual interests and criminal behaviors in a German male community sample

DR. DANIEL TURNER1, 2 *, DR. VERENA KLEIN2, PROF. DR. ALEXANDER SCHMIDT3 and PROF. DR.PEER BRIKEN2

1Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Germany 2Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Germany 3Department of Psychology, Legal Psychology, Medical School Hamburg, Germany *E-mail: daniel.turner@unimedizin-mainz.de

Background and aims: Hypersexuality, sexual addiction or hypersexual disorder describes recurrent and intense sexual fantasies, sexual urges, or sexual behaviors that in­terfere with other important (non-sexual) goals or obliga­tions (Kafka, 2010). Although hypersexuality has recently received much consideration in the sexual offender litera­ture and is seen as one important risk factor for sexual of­fending, still not much is known about the prevalence of hypersexuality and its relationship to pedophilic sexual interests and criminal behaviors in the general population.

Methods: In a large community sample consisting of 8,718 German men who participated in an online study, we assessed self-reported hypersexual behaviors using the total sexual outlets (TSO) questionnaire and evaluated its association with self-reported pedophilic sexual interests and antisocial behaviors.

Results: Overall, the mean TSO per week was 3.46 (SD = 2.29) and participants spent on average 45.2 minutes per day (SD = 38.1) with sexual fantasies and urges. Altogether, 12.1% of the participants (n = 1,011) could be classified as hypersexual according to the classical cut-off value of TSO ≥ 7 (Kafka, 1991). Hypersexuality (TSO ≥ 7) as well as the TSO absolute values were positively correlated with sexual fantasies in­volving children, the consumption of child pornography, self-reported previous property and violent offences but not with contact sexual offending.

Conclusions: Although hypersexuality is seen as an important risk factor for sex­ual offending in sexual offender samples, this relationship could not be replicated in a community sample at least for contact sexual offending. Nevertheless, in clinical practice an assessment of criminal behaviors and pedophilic fanta­sies in hypersexual individuals and vice versa hypersexu­ality in men showing antisocial or pedophilic behaviors should be considered.

YBOP response to Jim Pfaus's "Trust a Scientist: Sex Addiction Is a Myth" (January, 2016)

How about trusting addiction neuroscientists and peer-reviewed papers?

Before I address many of the claims within the Pfaus article (link to the Pfaus article), it must be noted that Jim Pfaus omitted the 37 neuroscience-based studies (and 13 reviews of the literature) on porn users published in the last few years. So far, the results of every "brain study" (MRI, fMRI, EEG, neuropsychological, neuro-hormonal) offer support for the concept of porn addiction. In addition to reporting the same fundamental brain changes as seen in substance addicts, a few studies also reported greater porn use is associated with erectile dysfunction, delayed ejaculation, decreased libido, and reduced neural response to images of vanilla porn. The up-to-date list of current "brain studies" is here.

Clicking on the name of the study leads to the original paper. A 2016 review of "compulsive sexual behaviors" (CSB) by neuroscientists at Yale and Cambridge universities contains a section on the "Neurobiological Basis of CSB". This section alone exposes the Pfaus article for what it is: a propaganda piece.

The 37 studies on porn users also align with over 260 internet addiction "brain studies" (PET, MRI, fMRI, EEG) published in the last few years. Without exception, these studies reported the same addiction-related brain changes as seen in substance addicts. Internet porn addiction is, in fact, a subtype of internet addiction, as this recent review of the neuroscience literature pointed out - "Neuroscience of Internet Pornography Addiction: A Review and Update (2015)"

Let's examine the claims and distortions in this piece by Jim Pfaus:

PFAUS: "They’re not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and by definition, they don’t constitute what most researchers understand to be addiction."

RESPONSE: The claim about "most researchers" is unsupported. Some of the top addiction researchers in the world recognize Internet porn addiction. Valerie Voon of Cambridge University, Marc Potenza of Yale University, Simone Kuhn of the Max Planck Institute, and many others have published studies the results of which support the porn addiction model. See this list.

Moreover, it appears that DSM sexuality work group member Richard Krueger MD told a Canadian journalist that he had no doubt internet porn addiction is real, and that he expected that the DSM would eventually include internet porn addiction when adequate research became available.

As for addiction experts, the American Society of Addiction Medicine (ASAM) published its new definition of addiction and stated that all addiction is one condition and that "sexual behavior addictions" not only exist but involve the same fundamental mechanisms and brain changes as do drug addictions. ASAM's 3000 medical doctors are many of the addiction researchers that provide the hard data, such head of NIDA, Nora Volkow, MD. PhD, and Eric Nestler MD, PhD.

QUOTE FROM ASAM FAQS -

5. QUESTION: "This new definition of addiction refers to addiction involving gambling, food, and sexual behaviors. Does ASAM really believe that food and sex are addicting?

ANSWER: "Addiction to gambling has been well described in the scientific literature for several decades. In fact, the latest edition of the DSM (DSM-V) will list gambling disorder in the same section with substance use disorders. The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This is the first time that ASAM has taken an official position that addiction is not solely “substance dependence.” This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the pathological pursuit of rewards described in this new definition of addiction."

As for the highly controversial and politicized DSM, it must be remembered that this same organization classified homosexuality as a mental disorder. The DSM doesn't determine reality, nor is reality up for a vote. It's quite telling that the head of The National Institute of Mental Health (NIMH), Tom Insel stated that the newly published DSM-5 "lacked validity". Insel stated that "patients deserve better" and that the NIMH would no longer fund research based on the DSM diagnostic categories. Insel was very clear we he stated,

"it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.”

But the big news is that The World Health Organization appears poised to set right the APA’s excessive caution. The next edition of the ICD is due out in 2018. The beta draft of the new ICD-11 includes a diagnosis for “Compulsive sexual behavior disorder” - which is an umbrella term for “sex addiction”, “porn addiction”, “cybersex addiction”, hypersexuality, “out of control sexual behaviors”, and the like. The debate about porn addiction is over.


PFAUS: "Here’s why: addicts withdraw......The same goes for a guy obsessed with watching porn. He might prefer to endlessly watch porn, but when he’s unable to, no withdrawal indicative of addiction occurs. He’ll never be physically addicted."

RESPONSE: Pfaus spends considerable text suggesting that "withdrawal symptoms" equal "addiction". First, it is well established in the addiction field that neither the presence nor absence of withdrawal symptoms determines the existence of an addiction. That said, porn addicts consistently report withdrawal symptoms that mirror drug withdrawal. Please see multiple reports on these pages:

Pfaus may claim these are only anecdotes, yet it wasn’t until 2017 that two research teams asked internet-porn users directly about withdrawal symptoms. Both reported withdrawal symptoms in “problematic porn users” (1, 2).  Also, Swansea and Milan universities reported that internet addicts, most of whom had been accessing porn or gambling, suffered a form of cold turkey when they stopped using the web, just like people coming off drugs.

In saying that "physical symptoms" must be present for an addiction to exist, Pfaus is confusing addiction with physical dependence. For example, millions of individuals take chronically high levels of pharmaceuticals such as opioids for chronic pain, or prednisone for autoimmune conditions. Their brains and tissues have become dependent on them, and immediate cessation of use could cause severe withdrawals symptoms. However they are not necessarily addicted. Addiction involves multiple well-indentified brain changes that lead to what we know as the "addiction phenotype". If the distinction is unclear, I recommend this simple explanation by NIDA.

Pfaus's "withdrawal = addiction" argument falls apart when we consider that nicotine is often listed as the most addictive substance, and yet causes relatively mild withdrawal symptoms. Finally, the DSM-5 has added pathological gambling into the newly created behavioral addiction category, ending the argument that only drugs can cause and addiction, and with it the claim that "dependence" equals addiction. See this DSM-5 publication.


PFAUS: "As such, the anti-fapper narrative is usually the only point discussed: Guys stop masturbating after they stop downloading porn, and after a few days, they say they’re able to get normal erections again."

RESPONSE: Pfaus falsely claims it takes a "few days" for men with porn-induced ED to regain normal erectile functioning. Instead, it generally takes months, and up to two years, in some cases, for young men to achieve normal erections again. Pfaus has often spun the nonsensical story that porn-induced ED is cause by a refractory period. I've never heard of a 9-month refractory period for a 23-year old. Readers might find interesting this peer-reviewed paper describing porn-induced anorgasmia/loss of libido in a 35-year-old healthy man. It took 8-months of no porn for him to regain normal sexual functioning.


PFAUS: "This coincides with the somewhat popular idea that watching porn leads to erectile dysfunction, a position that porn-addiction advocates such as Marnia Robinson and Gary Wilson state emphatically."

RESPONSE: First, my book Your Brain on Porn: Internet Pornography and the Emerging Science of Addiction, which came out last year, addresses porn related sexual dysfunctions such as difficulty orgasming and sustaining erections. It has been endorsed by various experts. And I recommend it to anyone who wants to understand what is going on on recovery forums, as well as the relevant science (more of which has come out since, and all of which aligns with what I wrote).

Second, it's not just Gary Wilson. On this page readers can see articles and video by over 100 experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who have successfully treated porn-induced ED and porn-induced loss of sexual desire

Several studies support what these experts have observed (the first 5 studies listed 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 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). 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) 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."

7) 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."

8) 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 ED. Moreover, paper 2 was only a "brief communication" that did not report important data.

9) 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."

10) Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases (2015) - Study on men (average age 41.5) with hypersexuality disorders, such as paraphilias and chronic masturbation or adultery. 27 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% 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 requests for details. Two primary choices for male sexual dysfunction are ED and low libido. The men were not asked about their erectile functioning without porn. If all their sexual activity involved masturbating to porn, and not sex with a partner, they might never realize they had porn-induced ED.

11) 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.

12) 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.

13) 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.

14) 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."

15) 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 addiction. Not so. In line with the Cambridge University brain scan studies, this EEG study reported greater cue-reactivity to porn correlated with less desire for partnered sex. To put another way - individuals with more brain activation and cravings for 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 (their desire for partnered sex was dropping in relation to signs of addiction). Five peer-reviewed papers expose the truth: 1, 2, 3, 4, 5. Also see the extensive YBOP critique.

16) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another Nicole Prause EEG study. This time comparing the 2013 subjects from the above study to an actual control group. The results: compared to controls, "porn addicts" had less response to one-second exposure to photos of vanilla porn. The lead author, Nicole Prause, claimed these results debunk porn addiction (contrary to caims no studies falsify the porn addiction model). However, these findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. Put simply, frequent porn users were desensitized to static images of vanilla porn. They were bored (habituated or desensitized). See this extensive YBOP critique. Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (a sign of addiction): 1, 2, 3, 4, 5, 6. By the way, another EEG study found that greater porn use in women correlated with less brain activation to porn.

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) 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.

19) 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

21) 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".

22) - 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.

23) “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)

24) 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.

24) 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.

25) (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)

Dubious studies find no such correlations between ED rates and recent hours/frequency of porn use, and make exaggerated claims that their authors have thus "disproven" the existence of porn-induced sexual dysfunctions. It remains to be seen which aspects of porn use are most predictive of sexual dysfunctions. Frequency of use may not be as predictive as some constellation of years of use, age use started, weekly hours of use over time, percentage of climaxes to internet porn, escalation to novel porn genres, development of porn-induced fetishes, gaps in partnered sex, genetics, etc.

Reality check. All studies assessing young male sexuality since 2010 report historic levels of sexual dysfunctions, and startling rates of a new scourge: low libido. All documented in this article.

Erectile dysfunction rates ranged from 27 to 33%, while rates for low libido (hypo-sexuality) ranged from 16% to 37%. The lower ranges are taken from studies involving teens and men 25 and under, while the higher ranges are from studies involving men 40 and under.

Prior to the advent of free streaming porn, cross-sectional studies and meta-analysis consistently reported erectile dysfunction rates of 2-5% in men under 40. That's nearly a 1000% increase in youthful ED rates in the last 20 years. What variable has changed in the last 15 years that could account for this astronomical rise? Article about the latest spin campaign: Sexologists Deny Porn-induced ED by Claiming Masturbation Is the Problem (2016)


PFAUS: "These types of advocates are wedded to the idea that porn is an uncontrolled stimulus the brain gets addicted to because of the dopamine release it causes. According to their thinking, anything that causes dopamine release is addictive"

RESPONSE: A false statement by Pfaus. Of course, I never said that "anything that causes dopamine release is addictive". I'm guessing that Pfaus, of all researchers, realizes that sexual activity is a unique natural reward. Sexual activity induces the highest levels of nucleus accumbens dopamine naturally available. The same goes for endogenous opioids. In fact, Pfaus has published studies showing that sexual activity leads to conditioned place preference (CPP). CPP is used to assess the addictiveness of substances. Studies on rats have demonstrated that sex is a unique stimulus in that it activates the same reward system neurons as addictive drugs such as meth. By comparison, other natural rewards (food, water) may only overlap 10-20% with the sex/addictive drug neurons.

I suggest the following study, which compared the neurobiology of sexual activity with the neurobiology of sensitization to addictive drugs. (By the way sensitization is the core brain change involved in addiction, as proposed by the incentive motivation theory of addiction.) "Natural and Drug Rewards Act on Common Neural Plasticity Mechanisms with ΔFosB as a Key Mediator (2013)". An excerpt from conclusion:

"Thus, natural and drug rewards not only converge on the same neural pathway, they converge on tphe same molecular mediators, and likely in the same neurons in the nucleus to influence the incentive salience and the “wanting” of both types of rewards."

This means that addictive drugs and sex activity induce the same brain changes on the same neurons that lead to craving and wanting for IT, whether that IT is drugs or sex.


PFAUS: "For instance, according to proponents of the sex addiction industry, the more porn someone watches, the more they’ll experience erectile dysfunction."

RESPONSE: No so. It's already established in studies on both internet porn addiction (1, 2, 3) and internet video-gaming addiction, that symptoms do not correlate with "hours of use." Instead of just current hours of use, a combination of variables appear to correlate best with porn-induced ED. These may include:

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

The better way to research this phenomenon, is to remove the variable of internet porn use and observe the outcome. Such research reveals causation instead of correlations open to interpretation. My site has documented a few thousand men who removed porn and recovered from chronic sexual dysfunctions.


PFAUS: "However, my recent study with Nicole Prause, a psychophysiologist and neuroscientist at UCLA, showed that’s absurd. While advocates of sex and porn addiction are quick to correlate the amount of porn a guy looks at to how desensitized his penis is, our study showed that watching immense amounts of porn made men more sensitive to less explicit stimuli. Simply put, men who regularly watched porn at home were more aroused while watching porn in the lab than the men in the control group. They were able to get erections quicker and had no trouble maintaining them, even when the porn being watched was “vanilla” (i.e., free of hardcore sex acts like bondage)."

RESPONSE: Many of the above claims remain unsupported despite requests for evidence that they are true.

1) First, the paper wasn't a study at all. Instead Jim's co-author Prause claimed to have gathered data from four of her earlier studies, none of which had anything to do with erectile dysfunction. Jim Pfaus was not involved in those 4 earlier studies. The four underlying papers claimed to have assessed hours of porn use in the last month. No other variables related to porn use were examined.

2) None of the data from the Prause & Pfaus (2015) paper matched the four earlier studies. The discrepancies were not small and have not been explained. A comment by researcher Richard A. Isenberg MD, published in Sexual Medicine Open Access, points out several (but not all) of the discrepancies, errors, and unsupported claims.

3) Contrary to Pfaus's claims, the Prause & Pfaus paper did not assess erection quality in the lab or "speed of erections". Remember this was data from 4 earlier papers - none of which reported physiological assessment of erections in lab. The papers only asked guys to rate their "arousal," after briefly viewing porn (not to rate their erectile function). An excerpt from Prause & Pfaus (2015) clearly states that no genital responses were included:

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

Really get this: The men who watched more porn did NOT have better or stronger erections. There were no assessments of erections in the lab.

4) As Dr. Isenberg wondered, how is it possible for Prause & Pfaus to have compared different subject's arousal levels when 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 paper Prause & Pfaus claim that all 4 studies used sexual films:

"The VSS presented in the studies were all films."

Yet this was not the case.

5) Dr. Isenberg also asked how Prause & Pfaus compared different subject's arousal levels when 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. Once again Prause & Pfaus inaccurately claim that:

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

Yet this was not the case.

For argument sake let's say that men who watched more had slightly higher self reported arousal to porn. Another, more science-based, way to interpret this arousal difference is the men who used more porn experienced greater cravings to use porn. Interestingly, they had less desire for sex with a partner and more desire to masturbate than those who logged fewer hours watching porn. (Figure 2 in study). Increased cravings to watch could be evidence of sensitization, which is greater reward circuit (brain) activation and desire to use when exposed to (porn) cues. Sensitization can be a precursor to addiction.

Three Cambridge University fMRI studies have 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. Simply put, craving to use porn tells us nothing about quality of erections when having sex with real persons.

Again, to understand the effects of internet pornography, trust addiction neuroscientists and their peer-reviewed papers.

It must be noted that Prause (and occasionally Pfaus) engage in targeted harassment, defamation and cyber-stalking. See this page that was created to counter the ongoing harassment and false claims made by former UCLA researcher Nicole Prause as part of an ongoing "astroturf" campaign to persuade people that anyone who disagrees with her conclusions deserves to be reviled.


Comments under the Pfaus article:

by Charles Samenow, MD, MPH, editor of Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention:

It’s a shame that you destroy any credibility by citing things that are factually inaccurate. As the editor of Sexual Addiction and Compulsivity (note the title includes a broad approach to this disorder… and we continue to publish articles based on differing models including hypersexuality, problematic sexual behaviors, etc…) I can safely say that #1) we use external reviewers all the time and 2) our low impact factor has largely been due to the fact that for years we received almost no submissions due to the dearth of research in the area leading us to a very low rejection and circulation rate. Impact factor is not just related to number of citations. Finally, David Delmonico who was instrumental in the journal previously, actually has stepped down from the associate editor position due to inactivity over several years. So your insinuations that he is self-promoting are not only incorrect but quite frankly unprofessional. Quite ironic that you as an author who bases his whole critique on following research/science (or lack thereof) did not do his due diligence in reaching out to me or others to check his facts first. Any one of us on the editorial board or in SASH are always willing to dialogue, share, and keep an open mind. Are you?


Written by Frederick Toates:

The following comments were written by a retired UK professor (Frederick Toates) who is the author of the recent book “How Sexual Desire Works: The Enigmatic Urge.” It is a comprehensive review of the relevant research in this field. These comments are posted with his permission:

Right at the outset, the author switches vocabulary from addiction, writing “…in fact, hypersexuality and porn obsessions are not addictions at all”. Of course, hypersexuality is not synonymous with addiction unless other criteria are also met but rephrasing addiction as obsession seems to me to be confusing. In a clinical context, obsession is a very different phenomenon from addiction, though sharing some features. I would invite anyone who feels that using ‘obsession’ in some way mitigates the impact to observe the bleeding hands of an OCD hand-washer and compare this with a kid told to put his smartphone away. 

 We are told that the guy denied his porn shows no sign of physical addiction. But what other kind of addiction is there that he might or might not show? This suggests a Cartesian split between body and mind, which modern neuroscience rejects. If Jim Pfaus means signs outside the brain/mind, then neither do many cocaine addicts show this.
 
 My reading of their books does not suggest to me that Wilson/Robinson do claim that “anything that causes dopamine release is addictive”. Dopamine is released all the time in all of us and I can’t believe that they are unaware of this. Surely their point is that under certain conditions dopamine release can be such as to increase incentive salience to the point of addiction.
 
 Jim Pfaus writes: “But there’s a difference between compulsion and addiction. Addiction can’t be stopped without major consequence, including new brain activity. Compulsive behavior can be stopped; it’s just difficult to do so”. The experience of US soldiers being offered discharge from Vietnam was that a change of circumstances could quickly undermine even heroin addiction (Robins). Doubtless there was new brain activity accompanying their discharge but so is there in a compulsive checker or hand-washer who heals (see Jeff Schwartz, UCLA). It is true that withdrawal from alcohol can be extremely dangerous without medical supervision but that does not mean that from a psychological perspective alcohol addiction should be put in a class all of its own. The idea that compulsive behaviour is simply “difficult” to stop is something of an understatement to put it mildly.
 
 Jim writes “Plenty of compulsive and ritualistic sexual behaviors aren’t addictions; they’re symptomatic of other issues”. But most if not all addictions can be symptomatic of other issues. See the brilliant work of Bruce Alexander and Gabor Mate on the triggering role of alienation and despair in drug addicts.
 
 Take the extreme case of a young man who masturbates until he has damaged his penis and who seeks help. I find it hard to see how it would enlighten him to be told that he is compelled but not addicted.
 
 Let me hasten to add that I am not writing from a religious perspective and neither do I stand to make a single cent from sexual addiction. I wrote what I thought was a balanced account of sexual addiction in a recent book and indeed it earned a very high praise from no less a dignitary than Jim Pfaus! (Please see link — http://www.amazon.com/How-Sexual-Desire-Works-Enigmatic/dp/1107688043/ref=sr_1_1?s=books&ie=UTF8&qid=1453918582&sr=1-1

 

YBOP response to claims in a David Ley comment (January, 2016)

I was altered to Ley's comment and asked to respond directly on the above thread. Since my response was blocked, I decided to post an easier to read version on YBOP.

Before I address David Ley's claims it must be noted that he consistently fails to mention the 35 neuroscience-based studies on porn users published in the last few years (and 12 reviews of the literature by some of the top neuroscientists in the world). So far, the results of every "brain study" (MRI, fMRI, EEG, neuropsychological, hormonal) offer support for the concept of porn addiction. In addition to reporting the same fundamental brain changes as seen in substance addicts, a few studies also reported greater porn use is associated with erectile dysfunction, decreased libido, and reduced neural response to images of vanilla porn. The up-to-date list of current "brain studies" is here. Clicking on the name of the study leads to the original paper.

These 35 studies also align with over 230 internet addiction "brain studies" (PET, MRI, fMRI, EEG) published in the last few years. Without exception, these studies reported the same addiction-related brain changes as seen in substance addicts. Internet porn addiction is, in fact, a subtype of internet addiction, as this recent review of the neuroscience literature pointed out: "Neuroscience of Internet Pornography Addiction: A Review and Update (2015)"


LEY: "That the introduction of Viagra is the cause of the 1000% increase in ED rates in ONLY young men over the last 20 years."

YBOP RESPONSE: The tremendous rise in youthful ED and low sexual desire is documented in this peer-reviewed paper by 7 US Navy doctors: Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016).

Ley cited nothing as, once again, there is no empirical support for his claim that the introduction of Viagra led to men finally tell the truth in studies on sexual dysfunction. We are not talking about an increase in men visiting their doctors for ED medication. The ED rates refer only to peer-reviewed studies (usually anonymous surveys) on population wide rates of sexual dysfunction. To put it another way, Ley is claiming that in every single study published between 1948 and 2010, in countries all over the world, the male participants consistently lied about their erectile functioning. Then in 2010 all young men, and only young men, started to tell the truth in anonymous questionnaires about erectile functioning. That is absurd. Ley's claim is like saying that the introduction of aspirin caused studies to report a 1000% increase in headaches among one age group. A few points that refute the "Viagra causes ED" claim:

1) The claim about "willingness to disclose" doesn't apply here. The ED and low libido rates are not rates for men visiting their doctor for erectile dysfunction. Instead, the ED and low libido rates come from studies mostly employing anonymous standardized questionnaires where men rate the quality of their erections and arousal during sex. That has not changed because Viagra was introduced.

2) The exponential rise in ED and low libido rates occurred only in men under 40. This alone refutes Ley's claim.

3) In this same time period there was a concomitant increase in low sexual desire. The largest US study from 1992 reported 5% of men under 40 had low sexual desire.

  • A 2014 Canadian study reported low sexual desire in 24% of 16-21 year olds!
  • A 2014 survey of Croatian men 40 and under reported low sexual desire rates of 37%.
  • Again, this aligns with a 2015 study on Italian high school seniors (18-19), which 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 (as one would expect in 18-year olds).

4) These days, ED rates are often higher for young men than for old men (who obviously used less internet porn growing up). The 2014 Canadian study 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%).

  • Reality check: these rates are higher than those reported for 50-60 year olds in the large 1992 study on men 18-60!

5) Two studies published AFTER Viagra was introduced report higher ED rates in young men. If Viagra ads caused ED in men, wouldn't we see far higher rates in older men? These were studies of the same European countries using the same questionnaires (GSSAB). Instead rates in young men are abnormally high now.

  • The 2001-2002 ED rates for men 40-80 were about 13% in Europe.
  • By 2011, ED rates in young Europeans, 18-40, ranged from 14-28%.

6) Common sense: There's absolutely no evidence to suggest that a young man today would be any less embarrassed or ashamed when experiencing erectile dysfunction than a young man was in 1995 (once again, shame is irrelevant as all data came from studies using anonymous questionaires). 


LEY: "The attempt to distinguish porn addiction from sex addiction is a common trope in believers of porn addiction."

RESPONSE: The attempt to conflate porn addiction with sex addiction is the common tactic of Dr. Ley. He does this so he can trot out Tiger Woods and Bill Clinton, while ignoring that many young men today spend their adolescence watching hard-core streaming videos, and do so for years prior to attempting sex. Sitting alone surfing through tube sites is not sex. Many are still virgins due to their overuse of streaming porn (ED rates are 27-33% for men under 40). I suggest our article - Porn Addiction Is Not Sex Addiction--And Why It Matters.


LEY: "Unfortunately, their real argument is that it is masturbation to porn which is addictive – the overwhelming majority of porn consumption involves masturbation."

RESPONSE: Nice try. Every study cited was about porn use. This is another common tactic of Dr. Ley. He cleverly attempts to move the conversation away from Internet porn and onto masturbation. He does this so he can employ the same tired talking points of Kellogg, shame, religion, fear of sex... Everyone knows masturbation doesn't cause ED. None of the studies cited were about masturbation. Please Dr. Ley, stay on topic. This isn't about shame, as the primary reason men abstain from porn is to heal porn-induced sexual dysfunctions. These men want to have sex, enjoyable sex, and most are unmarried.


LEY: "The brain studies on porn effect are interesting."

RESPONSE: Dr. Ley, why is it that you always claim there is no scientific support for porn/sex addiction - even though there are now 37 neuroscience-based studies (MRI, fMRI, EEG, Neurospych, Hormonal) providing strong support for the addiction model? How can we take you seriously when you are either ignorant of the current state of the neuroscience, or willfully ignoring it?


LEY: "What they really seem to demonstrate is that people with higher libido and higher sensation-seeking gravitate towards greater porn use, as a result of pre-existing neurological characteristics."

RESPONSE: This same tired claim about porn addiction or sex addiction being nothing more than high libido doesn't fly. It has been thoroughly falsified in the peer-reviewed literature.

You may have seen the "high libido" claim in Ley's Psychology Today blog post with the catchy title: "Your Brain on Porn - It's NOT Addictive". Ley's 3-year old blog post is not about the science behind YBOP. Instead, it's about a single EEG study, whose lead author is Nicole Prause. Both Ley and Prause claimed that the study's (Steele et al. 2013) findings support the premise that porn/sex addiction is nothing more than "high sexual desire."

Contrary to claims by Ley and Nicole Prause, Steele et al., 2013 reported greater cue-reactivity (higher EEG) to porn correlating with LESS desire for sex with a partner (but not lower desire to masturbate to porn). To put it another way - individuals with more brain activation and cravings for porn preferred masturbating to porn over having sex with a real person.

Greater cue-reactivity to porn coupled with lower desire for sex with real partners aligns the 2014 Cambridge University brain study on porn addicts. The actual findings of Steele et al., 2013 in no way match the concocted headlines or Ley's blog post assertions. Five subsequent peer-reviewed papers say that the Steele et al. findings actually lend support to the porn addiction model (as opposed to the "high sexual desire" hypothesis): 1, 2, 3, 4, 5.

In 2015, Nicole Prause published a second EEG study, which found LESS neural response (with brief exposure to still images) for “porn addicts” when compared to controls. This is evidence of abnormally reduced desire in porn addicts. These findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. In other words, "porn addicts" were desensitized and - far from having high sexual desire - needed greater stimulation than non-addicts to be turned on (six peer-reviewed papers agree with YBOP: 1, 2, 3, 4. 5, 6.)

Put simply, the results of Prause's second EEG study indicate LESS sexual arousal - not higher desire. In fact, Nicole Prause stated in this Quora post that she no longer believes that "sex addicts" have high libidos - 

"I was partial to the high sex drive explanation, but this LPP study we just published is persuading me to be more open to sexual compulsivity."

Since Prause has flip-flopped, where is Ley's support for the "porn/sex addiction = high libido" claim? Below are multiple studies that tested, and falsified, David Ley's "high libido = sex/porn addiction" claim entirely:

1) "Is High Sexual Desire a Facet of Male Hypersexuality? Results from an Online Study." (2015) - Researchers found virtually no overlap between the men with hypersexuality and the men with "High Sexual Desire". Excerpt from the paper:

"The study findings point to a distinct phenomenology of High Sexual Desire and Hypersexuality in men."

2) "Hypersexuality and High Sexual Desire: Exploring the Structure of Problematic Sexuality" (2015) - The study found little overlap between high sexual desire and hypersexuality. Excerpt from the paper:

"Our study supports the distinctiveness of hypersexuality and high sexual desire/activity."

3) "Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours" (2014) - A Cambridge University fMRI study comparing porn addicts to healthy controls. The study found that porn addicts had lower sexual desire and greater difficulty achieving erections, yet had greater cue-reactivity to porn (similar to Steele et al. above). Excerpts from the paper:

"On an adapted version of the Arizona Sexual Experiences Scale [43], 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 (Table S3 in File S1)."

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)...

4) “Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases" (2015) – Study on men with hypersexuality disorders. 27 were classified as “avoidant masturbators,” meaning they masturbated to porn one or more hours per day or more than 7 hours per week. 71% of the compulsive porn users reported sexual functioning problems, with 33% reporting delayed ejaculation.

5) "Erectile Dysfunction, Boredom, and Hypersexuality among Coupled Men from Two European Countries" (2015) - This survey reported a strong correlation between erectile dysfunction and measures of hypersexuality. Excerpt:

"Hypersexuality was significantly correlated with proneness to sexual boredom and more problems with erectile function."

6) “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."

7) "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."

8) "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."

9) "Pornography use: who uses it and how it is associated with couple outcomes" (2012) - While not a study on "hypersexuals", it reported that 1) porn use was consistently correlated with low scores on sexual satisfaction, and 2) that there was no differences in sexual desire between the porn users and the non-users.

10) 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. This SPAN Lab study, like #11 below, 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. However, due to methodological flaws the findings are uninterpretable: 1) the study had no control group for comparison; 2) subjects were heterogeneous (males, females, non-heterosexuals); 3) subjects were not screened for mental disorders or addictions; 4) the questionnaires were not validated for porn 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 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 (their desire for partnered sex was dropping in relation to their porn use). Five peer-reviewed papers expose the truth: 1, 2, 3, 4, 5. Also see the extensive YBOP critique.

11) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another SPAN Lab EEG (brain-wave) study comparing the 2013 subjects from the above study 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, Nicole Prause, claims these results "debunk porn addiction". What legitimate scientist would claim that their lone anomalous study has debunked an entire 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's findings also align with Banca et al. 2015 which is #4 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). See this extensive YBOP critique. Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (a sign of addiction): 1, 2, 3, 4, 5, 6.

12) 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.

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.

13) 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."

14) 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 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.

15) Understanding the Personality and Behavioral Mechanisms Defining Hypersexuality in Men Who Have Sex With Men (2016)

Further, we found no associations between the CSBI Control scale and the BIS-BAS. This would indicate that lack of sexual behavior control is related to specific sexual excitation and inhibitory mechanisms and not to more general behavioral activation and inhibitory mechanisms. This would seem to support conceptualizing hypersexuality as a dysfunction of sexuality as proposed by Kafka. Further, it does not appear that hypersexuality is a manifestation of high sex drive, but that it involves high excitation and a lack of inhibitory control, at least with respect to inhibition owing to expected negative outcomes.

16) Hypersexual, Sexually Compulsive, or Just Highly Sexually Active? Investigating Three Distinct Groups of Gay and Bisexual Men and Their Profiles of HIV-Related Sexual Risk (2016) - If high sexual desire and sex addiction were the same, there would only be one group of individuals per population. This study, like the ones above, reported several distinct sub-groups, yet all groups reported similar rates of sexual activity.  

Emerging research supports the notion that sexual compulsivity (SC) and hypersexual disorder (HD) among gay and bisexual men (GBM) might be conceptualized as comprising three groups—Neither SC nor HD; SC only, and Both SC and HD—that capture distinct levels of severity across the SC/HD continuum.

Nearly half (48.9 %) of this highly sexually active sample was classified as Neither SC nor HD, 30 % as SC Only, and 21.1 % as Both SC and HD. While we found no significant differences between the three groups on reported number of male partners, anal sex acts, or anal sex acts

17) 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.

18) 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). 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.

19) 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."

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 ED. Moreover, paper 2 was only a "brief communication" that did not report important data.

21) 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.

22) 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.

23) “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).

24) 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.

In short, the evidence is piling up that internet porn erodes normal sexual desire, leaving users less responsive to pleasure. They may crave porn, but that is more likely evidence of an addiction-related brain change known as "sensitization" (hyper-reactivity to addiction-related cues). Cravings certainly cannot be assumed to be evidence of greater libido.


LEY: "No causality has been demonstrated, indicating that porn causes any brain changes, certainly none which are distinct from other forms of entertainment such as television or pro-sports."

RESPONSE: This one sentence demonstrates a profound lack of knowledge related to how research works, and ignorance of the brain changes involved in addiction (more in my next answer). 

When someone uses "no causation has been demonstrated" it makes listening scientists doubt that someone' s basic understanding of science or research. When it comes to psychological and medical studies little research reveals causation. For example, all studies on the relationship between lung cancer and cigarette smoking are correlative - but cause and effect are clear.

In light of ethical requirements researchers are usually precluded from constructing experimental research designs which would prove pornography causes certain harms. Therefore, they must instead use correlational models. Over time, when a significant body of correlational studies are amassed in any given research area, there comes a point where the body of evidence can be said to prove a point of theory, even though there were no experimental studies. Put another way, no single correlation study could ever provide a “smoking gun” in an area of study, but the converging evidence of multiple correlational studies is used to establish evidence. When it comes to porn use, nearly every study published is correlative. To "prove" porn use is causing  erectile dysfunction or addiction-related brain changes you would have to do one of two things:

  1. Have two large groups of identical twins separated at birth. Make sure one group never watches porn. Make sure that every individual in the other group watches the exact same type of porn, for exact same hours, and the exact same age. Continue the experiment for 30 years or so, followed by assessment of the differences.
  2. Eliminate the variable whose effects you wish to measure. Specifically, have porn users stop, and assess the changes months (years?) later. This is exactly what is occurring as thousands of young men stop porn as a way to alleviate chronic non-organic erectile dysfunction (caused by porn use).

To this date only 6 studies have removed porn and observed the results. All 6 found significant changes. Four of those studies demonstrated causation as compulsive porn users healed severe sexual dysfunctions by quitting porn.

  1. Trading Later Rewards for Current Pleasure: Pornography Consumption and Delay Discounting (2015)” – This study reported that greater porn use was correlated with less ability to delay gratification. The researchers assessed porn users a month later and found that continued porn use correlated with less ability to delay gratification. Finally, researchers divided subjects into 2 groups: Half tried to abstain from their favorite food; half tried to abstain from porn. The subjects who tried to abstain from porn experience big changes: they scored much better on their ability to delay gratification. The study said:

“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.”

  1. A Love That Doesn’t Last: Pornography Consumption and Weakened Commitment to One’s Romantic Partner (20120” – The study had subjects try to abstain from porn use for 3 weeks. Comparing the two groups, those who continued using pornography reported lower levels of commitment than control participants.
  2. 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 article 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.
  3. 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 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
  4. 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. Eliminating porn-based masturbation led to remission of sexual dysfunctions on 19 of the 35 men. The remaining 16 men stopped therapy or could not quit using porn. 
  5. 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.

Ley's claim that addiction-induced brain changes are no different from those induced by other forms of entertainment is downright scary. In reality, the brain changes caused by addiction are quite distinct from those caused by watching "Gilligan's Island". Reality: The mechanisms of addiction have been studied for nearly 60 years. The very specific brain changes caused by addiction have been elucidated down to the cellular, protein, and epigenetic levels. These brain changes have been correlated over and over with the behaviours collectively known as the "addiction phenotype." Addiction-like behaviors can be induced in animals simply by increasing a single protein within the reward center (Deltafosb). In short, a lot is known about the biology of addiction - more than any other mental disorder - even if it remains unknown to Dr. Ley.

Four major brain changes are involved with both drug and behavioral addictions, as outlined in this paper published this week in The New England Journal of Medicine: "Neurobiologic Advances from the Brain Disease Model of Addiction (2016)". This landmark review by the Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) George F. Koob, and the director of the National Institute on Drug Abuse (NIDA) Nora D. Volkow, not only outlines the brain changes involved in addiction, it also states in 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)...."

In simple, and very broad, terms the major fundamental brain changes are: 1) Sensitization, 2) Desensitization, 3) Hypofrontality, 4) Dysfunctional stress circuits. All 4 of these brain changes have been identified among the 37 neuroscience studies on porn users:

  1. Studies reporting sensitization or cue-reactivity 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.
  2. Studies reporting desensitization or habituation in porn users/sex addicts: 1, 2, 3, 4, 5, 6.
  3. 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.
  4. Studies reporting dysfunctional stress responses in porn users: 1, 2, 3.

I find it interesting that Dr. Ley seems to always claim that there's no scientific support for porn addiction, yet not only do 22 studies provide support for porn/sex addiction, the world's top addiction experts do also. The little bubble he has carved out where porn addiction cannot possibly exist is quickly becoming irrelevant.


LEY: "I agree, watching lots of porn, television or sports IS likely to affect your brain. This is called “learning.

RESPONSE: This is a typical tactic - to absurdly suggest that all learning is equal. PTSD involves learning. Would Dr. Ley advise men with battle-induced PTSD to "just get over it," because it's really no different than the learning that occurs while watching soccer on TV? Reality: The mechanisms of addiction in the addicted have been studied for nearly 60 years, in comparison with normal controls. Again, the differences (from normal brains) have been elucidated down to the cellular, protein, and epigenetic levels.

While learning and memory are most certainly involved in addiction, addiction involves a very specific type of pathological learning addiction neuroscientist refer to as "sensitization." This type of learning involves set changes in the reward canter which lead to cravings to use. The incentive sensitization theory of addiction is the predominant model of addiction. 19 of the 37 neuroscience-based studies on this page looked for sensitization in porn addicts - and found it. (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20.)

As mentioned above, the 37 studies reported other major addiction-related brain changes (sensitization, desensitization, hypofrontality and dysfunctional stress circuits) in porn/sex addicts. No, Dr. Ley, these brain changes are not caused by "I Love Lucy" reruns. Together these 4 multifaceted brain alterations manifest behaviorally as what we recognize as addiction: 1) Compulsion to use, 2) Continued use in spite of adverse consequences, 3) Inability to Control use, 4) Cravings - psychological or physical.

Ley's talking point is very similar to waht sexologist Marty Klein said in reply to a Zimbardo & Wilson article where he claimed that the brain response to watching porn is no different than watching a sunset:

"Besides, our brain responds in this same observable way when we cuddle a grandchild or enjoy a sunset."

The Ley and Klein claim was long ago tested and debunked, in a 2000 fMRI study: "Cue-induced cocaine craving: neuroanatomical specificity for drug users and drug stimuli. The study had cocaine addicts and healthy controls view films of: 1) individuals smoking crack cocaine, 2) outdoor nature scenes, and 3) explicit sexual content. The results: cocaine addicts had nearly identical brain activation patterns when viewing porn and viewing cues related to their addiction. (Incidentally, both cocaine addicts and healthy controls had the same brain activation patterns for porn.) However, for bot

h the addicts and controls, brain activation patterns when viewing nature scenes were completely different from the patterns when viewing for porn. Goodbye silly talking point!


LEY: "Perhaps you can start with the brain changes caused by conservativism"

RESPONSE: I am a far left liberal and an agonistic, but this isn't about me. However, Ley's comment was under a post about r/NoFap. Contrary to Ley's chronic mischaracterizations of NoFap, the largest survey conducted on NoFap members found that:

  • 60% of r/NoFap members identify as atheists or agnostics.
  • Only 11% of r/nofap members said they were quitting porn for religious or moral reasons.

The facts don't fit the spin promulgated in Dr. Ley's Psychology Today hit piece on r/NoFap. Notice that Ley refused to allow comments under his NoFap blog post, which is almost unheard of for a Psychology Today post. See this thread on NoFap.org concerning Ley's blog post:


LEY: "I recently had the opportunity to interview Isaac Abel, who famously wrote a few popular pieces on Porn-Related ED. Two years later, he’s still not watching porn, but still struggles with ED"

RESPONSE: That's really sad. This may point to the vulnerability of the adolescent brain. I have read recovery stories of young men who grew up using internet porn needing 2-3 years to regain erectile health. Even after 3 years they continue to see improvements. Older men, who did not have access to streaming videos during adolescence, may need only a month or two to regain normal sexual functioning. FYI - below are over 4,000 documented stories of recovery from porn-induced sexual problems. Perhaps you could interview one these guys:

I find it telling that Ley ignores thousands of documented accounts of young men regaining erectile function and libido by removing a single variable (porn use), yet places tremendous value in a single story where the young man has yet to heal his ED.


Update: It should be noted that both David Ley profits from denying sex and porn addiction. At the end of this Psychology Today blog post Ley states:

"Disclosure: David Ley has provided testimony in legal cases involving claims of sex addiction."

Ley also makes money selling two books which deny sex and porn addiction ("The Myth of Sex Addiction", 2012 and "Ethical Porn for Dicks", 2016). Pornhub (which is owned by porn ginat mindgeek) is one of the five Amazon.com endorsements listed for Ley's 2016 book about porn. Finally, David Ley makes money via CEU seminars, where he promotes the ideas presented in his two books.

Eliminate Chronic Internet Pornography Use to Reveal Its Effects (2016)

Author/s: DOI: 10.15805/addicta.2016.3.0107 Year: 2016 Vol: 3 Number: 2

LINK TO ABSTRACT

LINK TO PDF OF FULL PAPER

Abstract

There’s growing evidence that today’s streaming pornography videos are sui generis, with unique properties such as inexhaustible sexual novelty at a swipe, effortless escalation to more extreme material, and accessibility by youthful viewers, and that these unique properties are giving rise to severe symptoms in some consumers.

Formal research on internet pornography (IP) has thus far failed to illuminate the phenomenon adequately. The usual correlation studies cannot establish which related factor causes another (or whether an effect is bi-directional). Yet establishing causation is critically important lest symptoms caused by IP overuse be confounded with evidence of psychological traits and indications of mental disorders. The most effective way to reveal the effects of IP is to ask study participants to give up IP use for an extended period and compare them with controls. A possible research design is described.

Keywords:  Internet pornography, Sexually explicit material, Pornography effects, Pornography addiction, Study design, Erectile dysfunction, Psychological health, Visual sexual stimuli

This post is also available in: Turkish (Türkçe)

Internet Addiction Studies With Excerpts About Porn Use

EXCERPTS FROM SELECTED STUDIES


Predicting Compulsive Internet Use: It's All About Sex! (2006)

Meerkerk GJ, Van Den Eijnden RJ, Garretsen HF.

Cyberpsychol Behav. 2006 Feb;9(1):95-103.

The objective of this research was to assess the predictive power of various Internet applications on the development of compulsive Internet use (CIU). The study has a two-wave longitudinal design with an interval of 1 year.

On a cross-sectional basis, gaming and erotica seem the most important Internet applications related to CIU. On a longitudinal basis, spending a lot of time on erotica predicted an increase in CIU 1 year later. The addictive potential of the different applications varies; erotica appears to have the highest potential.


Watching Pornographic Pictures on the Internet: Role of Sexual Arousal Ratings and Psychological-Psychiatric Symptoms for Using Internet Sex Sites Excessively (2011)

Cyberpsychol Behav Soc Netw. 2011 Jun;14(6):371-7. doi: 10.1089/cyber.2010.0222.

The Internet Addiction Test (IAT) and a modified version of the IAT for online sexual activities (IATsex), as well as several further questionnaires measuring psychological symptoms and facets of personality were also administered to the participants.

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.

Although the topic of cybersex addiction has high clinical relevance, it has been almost neglected in previous research. 16,17 In most of the studies on cognitive or personality correlates of Internet activities in general, online/computer gamers were primarily included in the samples18–20 or no distinction between different online activities has been made.21–24 Studies that particularly investigate experimentally potential mechanisms of cybersex addiction are missing.

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 or behavioral addiction (e.g., pathological gambling). For instance, it is known that the brain of subjects with alcoholism or other substance dependence reacts emotionally (activations of the ventral striatum) when being confronted with alcohol- or drug-related pictures.30–32 Other studies also emphasize that craving reactions (cue-reactivity) can be found in subjects with behavioral addictions, such as pathological gambling33 and—most recently—even in subjects who excessively play World of Warcraft19 or other computer games.18 These studies converge to the view that craving reactions on watching addiction-related stimuli are important correlates of the addictive behavior.

Therefore, it seems plausible that those brain regions involved in processing sexual stimuli, and sexual arousal and activity, as well as in craving reactions in individuals with behavioral addictions, are also crucially relevant for development and maintenance of addictive behavior in the context of cybersex.

Discussion

We found a positive relationship between subjective sexual arousal when watching Internet pornographic pictures and the self-reported problems in daily life due to the excessiveness of cybersex as measured by the IATsex. Subjective arousal ratings, the global severity of psychological symptoms, and the number of sex applications used were significant predictors of the IATsex score, while the time spent on Internet sex sites did not significantly contribute to explanation of variance in the IATsex score.

The finding that subjective sexual arousal ratings while watching Internet pornographic pictures is related to self-reported problems in daily life due to excessive use of cybersex sites may be interpreted in the light of previous studies on cue reactivity in individuals with substance dependency or behavioral addictions.

As outlined in the introduction, cue reactivity as a mechanism potentially contributing to the maintenance of addicted behavior has been demonstrated in several patient groups with either substance dependence or behavioral addiction. 18,19,30–33 These studies converge to the view that craving reactions on watching addiction-related stimuli are important correlates of the addictive behavior.

Although we did not examine brain correlates of watching Internet pornographic pictures in our study, we found the first experimental evidence for the potential link between subjective reactivity on Internet pornographic stimuli and a tendency toward cybersex addiction.


Pornographic Picture Processing Interferes with Working Memory Performance (2012)

J Sex Res. 2012 Nov 20.

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.

Furthermore, hierarchical regression analysis indicated an explanation of variance of the sensitivity in the pornographic picture condition by the subjective rating of the pornographic pictures as well as by a moderation effect of masturbation urges. Results contribute to the view that indicators of sexual arousal due to pornographic picture processing interfere with WM performance. Findings are discussed with respect to Internet addiction because WM interference by addiction-related cues is well known from substance dependencies.


Sexual Picture Processing Interferes with Decision-Making Under Ambiguity (2013).

Arch Sex Behav. 2013 Jun 4.

When browsing for sexual stimuli, individuals have to make several decisions, all possibly leading to positive or negative consequences. Decision-making research has shown that decisions under ambiguity are influenced by consequences received following earlier decisions. Sexual arousal might interfere with the decision-making process and should therefore lead to disadvantageous decision-making in the long run. In the current study, 82 heterosexual, male participants watched sexual pictures, rated them with respect to sexual arousal, and were asked to indicate their current level of sexual arousal before and following the sexual picture presentation. Afterwards, subjects performed one of two modified versions of the Iowa Gambling Task in which sexual pictures were displayed on the advantageous and neutral pictures on the disadvantageous card decks or vice versa (n = 41/n = 41). 

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.


Cybersex addiction: Experienced sexual arousal when watching pornography and not real-life sexual contacts makes the difference (2013)

Journal of Behavioral Addictions.

Cybersex addiction is discussed controversially, while empirical evidence is widely missing. With respect to its mechanisms of development and maintenance Brand et al. (2011) assume that reinforcement due to cybersex should lead to the development of cue-reactivity and craving explaining recurrent cybersex use in the face of growing but neglected negative consequences. To support this hypothesis, two experimental studies were conducted.

The aim of the second study was to verify the findings of the first study by comparing healthy (n=25) and problematic (n=25) cybersex users.

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.


Cybersex addiction in heterosexual female users of internet pornography can be explained by gratification hypothesis (2014)

Cyberpsychol Behav Soc Netw. 2014 Aug;17(8):505-11.

In the context of Internet addiction, cybersex is considered to be an Internet application in which users are at risk for developing addictive usage behavior. Regarding males, experimental research has shown that indicators of sexual arousal and craving in response to Internet pornographic cues are related to severity of cybersex addiction in Internet pornography users (IPU). Since comparable investigations on females do not exist, the aim of this study is to investigate predictors of cybersex addiction in heterosexual women.

We examined 51 female IPU and 51 female non-Internet pornography users (NIPU).

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.


Empirical Evidence and Theoretical Considerations on Factors Contributing to Cybersex Addiction From a Cognitive-Behavioral View (2014)

Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention, Volume 21, Issue 4, 2014

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.


Prefrontal control and internet addiction: a theoretical model and review of neuropsychological and neuroimaging findings (2015)

Front Hum Neurosci. 2014 May 27;8:375.

Most people use the Internet as a functional tool to perform their personal goals in everyday-life such as making airline or hotel reservations. However, some individuals suffer from a loss of control over their Internet use resulting in personal distress, symptoms of psychological dependence, and diverse negative consequences. This phenomenon is often referred to as Internet addiction. Only Internet Gaming Disorder has been included in the appendix of the DSM-5, but it has already been argued that Internet addiction could also comprise problematic use of other applications with cybersex, online relations, shopping, and information search being Internet facets at risk for developing an addictive behavior.

Neuropsychological investigations have pointed out that certain prefrontal functions in particular executive control functions are related to symptoms of Internet addiction, which is in line with recent theoretical models on the development and maintenance of the addictive use of the Internet. Control processes are particularly reduced when individuals with Internet addiction are confronted with Internet-related cues representing their first choice use. For example, processing Internet-related cues interferes with working memory performance and decision making. 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. The neuropsychological and neuroimaging results have important clinical impact, as one therapy goal should enhance control over the Internet use by modifying specific cognitions and Internet use expectancies.

Regarding the development and maintenance of an addictive use of specific Internet applications (SIA), we argue – consistent with previous research and in accordance with the model by Davis (2001) – that psychopathological symptoms are particularly involved (Brand et al., 2011; Kuss and Griffith, 2011; Pawlikowski and Brand, 2011; Laier et al., 2013a; Pawlikowski et al., 2014). We also hypothesize that specific person’s predispositions increase the probability that an individual receives gratification from the use of certain applications and overuses these applications again. One example for such a specific predisposition is a high sexual excitation (Cooper et al., 2000a,b; Bancroft and Vukadinovic, 2004; Salisbury, 2008; Kafka, 2010), which makes it more likely that an individual uses Internet pornography, because he/she anticipates sexual arousal and gratification (Meerkerk et al., 2006; Young, 2008). We believe that the expectancy that such Internet applications can satisfy certain desires increases the likelihood that these Internet applications are used frequently, as assumed in addictive behavior in general (Robinson and Berridge, 2000, 2003; Everitt and Robbins, 2006) and that the individual can develop a loss of control over his/her use of such applications. As a result, gratification is experienced and consequently the use of such applications and also the specific Internet use expectancies and the coping style are reinforced positively. This has already been shown, for example for cybersex addiction (Brand et al., 2011; Laier et al., 2013a) and is most likely also a mechanism for online gaming (e.g., Tychsen et al., 2006; Yee, 2006). The more general psychopathological tendencies (e.g., depression and social anxiety) are supposed to be negatively reinforced. This may be due to the fact that also specific Internet applications (e.g., Internet pornography) can be used to distract from problems in the real life or to avoid negative feelings, such as loneliness or social isolation. The main arguments of our model are summarized in Figure ​Figure11.


Getting stuck with pornography? Overuse or neglect of cybersex cues in a multitasking situation is related to symptoms of cybersex addiction (2015)

J Behav Addict. 2015 Mar;4(1):14-21.

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. 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.

The results of the current study point towards a role of executive control functions, i.e. functions mediated by the prefrontal cortex, for the development and maintenance of problematic cybersex use (as suggested by Brand et al., 2014). Particularly a reduced ability to monitor consumption and to switch between pornographic material and other contents in a goal adequate manner may be one mechanism in the development and maintenance of cybersex addiction.


Implicit associations in cybersex addiction: Adaption of an Implicit Association Test with pornographic pictures (2015)

Addict Behav. 2015 May 16;49:7-12.

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 modified with pornographic pictures. 

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.


Symptoms of cybersex addiction can be linked to both approaching and avoiding pornographic stimuli: results from an analog sample of regular cybersex users (2015)

Front Psychol. 2015 May 22;6:653.

There is no consensus regarding the phenomenology, classification, and diagnostic criteria of cybersex addiction. 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.

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.


Mental - and physical-health indicators and sexually explicit media use behavior by adults (2011)

J Sex Med. 2011 Mar;8(3):764-72.

Essentially unexplored, and the focus here, are potential relationships between SEMB and nonsexual mental- and physical-health indicators.

Variability in six continuously measured health indicators (depressive symptoms, mental- and physical-health diminished days, health status, quality of life, and body mass index) was examined across two levels (users, nonusers) of SEMB.

 A sample of 559 Seattle-Tacoma Internet-using adults was surveyed in 2006. Multivariate general linear models parameterized in a SEMB by respondent gender (2 × 2) factorial design were computed incorporating adjustments for several demographics.

RESULTS: SEMB was reported by 36.7% (n = 205) of the sample. Most SEMB users (78%) were men. After adjusting for demographics, SEMB users, compared to nonusers, reported greater depressive symptoms, poorer quality of life, more mental- and physical-health diminished days, and lower health status.


Reduced Striatal Dopamine Transporters in People with Internet Addiction Disorder (2012)

Journal of Biomedicine and Biotechnology, Volume 2012

In recent years, internet addiction disorder (IAD) has become more prevalent worldwide and the recognition of its devastating impact on the users and society has rapidly increased. The present study was designed to determine if the striatal dopamine transporter (DAT) levels measured by 99mTc-TRODAT-1 single photon emission computed tomography (SPECT) brain scans were altered in individuals with IAD. SPECT brain scans were acquired on 5 male IAD subjects and 9 healthy age-matched controls.

The IAD subjects used the internet almost everyday, and spend more than 8 hours (mean?±?SD, 10.20±1.48 hours) everyday in front of the monitor, mostly for chatting with cyber friends, playing online games, and watching online pornographies or adult movies. These subjects were initially familiar with internet mostly at the early stage of their adolescence (mean age ± SD, 12.80±1.92 years old) and had the indications of IAD for more than 6 years (mean±SD, 7.60±1.52 years).

It was displayed that DAT expression level of striatum was significantly decreased and the V, W, and Ra were greatly reduced in the individuals with IAD compared to controls. Taken together, these results suggest that IAD may cause serious damages to the brain and the neuroimaging findings further illustrate IAD is associated with dysfunctions in the dopaminergic brain systems. Our findings also support the claim that IAD may share similar neurobiological abnormalities with other addictive disorders


Differential psychological impact of internet exposure on internet addicts (2013)

PLoS One. 2013;8(2):e55162. doi: 10.1371/journal.pone.0055162.

The study explored the immediate impact of internet exposure on the mood and psychological states of internet addicts and low internet-users. Participants were given a battery of psychological tests to explore levels of internet addiction, mood, anxiety, depression, schizotypy, and autism traits. They were then given exposure to the internet for 15 min, and re-tested for mood and current anxiety.

High internet-users also showed a pronounced decrease in mood following internet use compared to the low internet-users. The immediate negative impact of exposure to the internet on the mood of internet addicts may contribute to increased usage by those individuals attempting to reduce their low mood by re-engaging rapidly in internet use.

Similarly, exposure to the object of the problematic behaviours has been found to reduce mood [26], especially in individuals addicted to pornography [5], [27]. As both of these reasons (i.e. gambling and pornography) for use of the internet are strongly associated with problematic internet use [2], [3], [14], it may well be that these factors may also contribute to internet addiction [14]. Indeed, it has been suggested that such negative impacts of engagement in problematic behaviour may, in themselves, generate further engagement in these high probability problematic behaviours in an attempt to escape these negative feelings [28].

The results showed a striking negative impact of internet exposure on the positive mood of ‘internet addicts’. This effect has been suggested in theoretical models of ‘internet addiction [14], [21], and a similar finding has also been noted in terms of the negative effect of exposure to pornography on internet sex addicts [5], which may suggest commonalities between these addictions. It is also worth suggesting that this negative impact on mood could be considered as akin to a withdrawal effect, suggested as needed for the classification of addictions [1], [2], [27].

It should be pointed out that, as two of the key uses of the internet for a sizable number of internet users are to gain access to pornography and gambling [4], [5], and these latter activities are clearly subject to potentially-addictive states, it may be that any results relating to ‘internet addiction’ are actually manifestations of other forms of addiction (i.e. to pornography or gambling).


Evolution of Internet addiction in Greek adolescent students over a two year period the impact of parental bonding (2012)

Eur Child Adolesc Psychiatry. 2012 Feb 4.

We present results from a cross-sectional study of the entire adolescent student population aged 12-18 of the island of Kos and their parents, on Internet abuse.

Our results indicate that Internet addiction is increased in this population where no preventive attempts were made to combat the phenomenon from the initial survey, 2 years ago. This increase is parallel to an increase in Internet availability.

Parents tend to underestimate the level of computer involvement when compared to their own children estimates. Parental safety measures on Internet browsing have only a small preventive role and cannot protect adolescents from Internet addiction. The three online activities most associated with Internet addiction were watching online pornography, online gambling and online gaming.


Internet addiction (2012)

Duodecim. 2012;128(7):741-8.

Internet addiction is defined as uncontrolled and harmful use of Internet, which manifests in three forms: gaming, various sexual activities and excessive use of emails, chats or SMS messaging. In boys and men depression may be more a consequence of the addiction than a cause for it. ADHD seems to be a significant background factor for developing the condition.


Problematic Internet Use and Its Correlates Among Students from Three Medical Schools Across Three Countries (2015)

Acad Psychiatry. 2015 Jul 1.

The authors aimed to assess and compare problematic internet use among medical students enrolled in a graduate degree course in one school each from Croatia, India, and Nigeria and to assess correlates of problematic use among these students. The questionnaire included a sociodemographic profile of participants and Young's Internet Addiction Test.

The final analysis included 842 subjects. Overall, 38.7 and 10.5 % of respondents scored in the mild and moderate categories. Only a small fraction (0.5 %) of students scored in the severe category. Moreover, a significantly higher proportion of participants who scored above the cutoff used the Internet for browsing, social networking, chatting, gaming, shopping, and viewing pornography. However, there was no difference between the two groups with regard to using the internet for e-mailing or academic activities.


Pathological Internet use – It is a multidimensional and not a unidimensional construct (2013)

May 15, 2013 ADDICTION RESEARCH &THEORY

It is still a topic of debate whether pathological Internet use (PIU) is a distinct entity or whether it should be differentiated between pathological use of specific Internet activities like playing Internet games and spending time on Internet sex sites. The aim of the current study was to contribute to a better understanding of common and differential aspects of PIU in relation to different specific Internet activities. Three groups of individuals were examined which differed with respect to their use of specific Internet activities: one group of 69 subjects used exclusively Internet games (IG) (but not Internet pornography (IP)), 134 subjects used IP (but not IG), and 116 subjects used both IG and IP (i.e., unspecific Internet use).

The results indicate that shyness and life satisfaction are significant predictors for a tendency towards pathological use of IG, but not pathological use of IP. Time spent online was a significant predictor for problematic use of both IG and IP. Additionally, no correlation was found between symptoms of pathological use of IG and IP. We conclude that games may be used to compensate social deficits (e.g., shyness) and life satisfaction in real life, whereas IP is primarily used for gratification in terms of achieving stimulation and sexual arousal.

These results support the demand for differentiating the various facets of Internet use in future studies instead of considering PIU as a unitary phenomenon.


Influence of dopaminergic system on internet addiction (2011)

Acta Medica Medianae 2011;50(1):60-66.

FULL PDF

Phenomenological, neurobiological, and pharmacological data indicates similarities in pathopsychology of substance addiction and pathological gambling, which are indirectly related to the similarity with the Internet addiction. Responding to stimuli from the game, addicts have shown more brain activity in the nape region, left dorsolateral, prefrontal cortex, and left parachipocampal gyrus than in the control group. After the six-week bupropion therapy, desire to play Internet and video games, the total duration of playing, and induced brain activity in dorsolateral prefrontal cortex are lowered with the addicts.

Subtypes of Internet Addiction (18) Generalized Internet addiction is not as common and it includes a multidimensional, excessive usage of Internet service and content, commonly without a specific goal of this usage. This form is mostly related to the social interaction such as chatting, instant messaging, forums and discussion groups, and general addiction for the computer and Internet, such as online surfing, search engine usages based on hobbies etc. However, it is more common that people grow addicted to the specific online content and activities rather than general Internet usage.

There is no consensus with regards to the exact number of assumptions of the subtypes of Internet abuse. However, four or five types are most commonly defined, and, in his work, Hinić accentuates concept 6+1 subtypes:

1. Cyber-Relational Addiction

2. Cybersexual Addiction

3. Information Overload

4. Net Gaming

5. Compulsive Online Shopping

6. Computer and IT Addiction

7. Mixed type of addiction


Internet Sex Addiction: Risk Factors, Stages of Development, and Treatment

American Behavioral Scientist, September 2008 vol. 52 no. 1 21-37

Kimberly S. Young

Internet sex addiction typically involves viewing, downloading, and trading online pornography or engagement in adult fantasy role-play rooms. Adult Web sites comprise the largest segment of electronic commerce catering to a wide variety of sexual interests. Given the widespread availability of sexually explicit material online, Internet sex addiction is the most common form of problem online behavior among users.


Internet use and pathological internet engagement in a sample of college students

Psychiatrike. 2011 Jul-Sep;22(3):221-30.

[Article in Greek, Modern]

Participants were 514 college students from the University of Athens who completed a questionnaire covering various aspects of internet use, Young's Internet Addiction Test, scales investigating online gambling addiction and cybersexual addiction and scales investigating suicidal ideation and the use of psychoactive substances.

Subjects at risk for developing pathological internet engagement had significantly higher levels of online gambling addiction, cybersexual addiction, suicidal ideation and alcohol abuse, compared with other groups. Pathological internet engagement, particularly in young people, is a new psychopathological parameter that should be incorporated in the diagnostic and therapeutic horizon of mental health professionals.


Problematic Internet Use among Greek university students: an ordinal logistic regression with risk factors of negative psychological beliefs, pornographic sites, and online games (2011)

Cyberpsychol Behav Soc Netw. 2011 Jan-Feb;14(1-2):51-8.

On average, problematic Internet users use MSN, forums, YouTube, pornographic sites, chat rooms, advertisement sites, Google, Yahoo!, their e-mail, ftp, games, and blogs more than non-problematic Internet usersSignificant risk factors for PIU were being male, enrolment in unemployment programs, presence of negative beliefs, visiting pornographic sites, and playing online games. Thus PIU is prevalent among Greek university students and attention should be given to it by health officials.


Risk factors and psychosocial characteristics of potential problematic and problematic internet use among adolescents: A cross-sectional study (2011)

BMC Public Health. 2011; 11: 595.

The study findings indicated that potential PIU and PIU were independently associated with utilizing the internet for the purposes of retrieving sexual information, socialization, and entertainment, including interactive game-playing. Moreover, it is noteworthy that potential PIU was inversely associated with utilizing the internet for educational purposes. Previous reports indicate that more than one quarter of frequent internet users utilize the internet for accessing sexual information and education [19,37,38].

Both frequent internet use and accessing the internet for the purposes of sexual education have been found to be significant predictors of pornographic internet site use [39,40] and consequent PIU [41]. Hence, it is proposed that PIU may develop and/or manifest secondary to the specific content of internet sites accessed, rather than to the internet per se.


Predictive factors and psychosocial effects of Internet addictive behaviors in Cypriot adolescents (2014)

Int J Adolesc Med Health. 2014 May 6.

A cross-sectional study design was applied among a random sample (n=805) of Cypriot adolescents (mean age: 14.7 years).

Among the study population, the prevalence rates of borderline addictive Internet use (BIU) and addictive Internet use (AIU) were 18.4% and 2%, respectively. The determinants of BIU and AIU included accessing the Internet for the purposes of retrieving sexual information and participating in games with monetary awards

Both BIU and AIU were adversely associated with notable behavioral and social maladjustment among adolescents.


The Internet Process Addiction Test: Screening for Addictions to Processes Facilitated by the Internet (2015)

Behav Sci (Basel). 2015 Jul 28;5(3):341-352.

The Internet Process Addiction Test (IPAT) was created to screen for potential addictive behaviors that could be facilitated by the internet. The IPAT was created with the mindset that the term "Internet addiction" is structurally problematic, as the Internet is simply the medium that one uses to access various addictive processes. The role of the internet in facilitating addictions, however, cannot be minimized.A new screening tool that effectively directed researchers and clinicians to the specific processes facilitated by the internet would therefore be useful. This study shows that the Internet Process Addiction Test (IPAT) demonstrates good validity and reliability. Four addictive processes were effectively screened for with the IPAT: Online video game playing, online social networking, online sexual activity, and web surfing. Implications for further research and limitations of the study are discussed.


Sexual Excitability and Dysfunctional Coping Determine Cybersex Addiction in Homosexual Males (2015)

Cyberpsychol Behav Soc Netw. 2015 Sep 16

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.


Internet Addiction, Psychological Distress, and Coping Responses Among Adolescents and Adults (2017)

Cyberpsychol Behav Soc Netw. 2017 Apr 17. doi: 10.1089/cyber.2016.0669.

As Internet use grows, so do the benefits and also the risks. Thus, it is important to identify when individuals' Internet use is problematic. In the present study, 449 participants aged from 16 to 71 years of age were sourced from a wide range of English-speaking Internet forums, including social media and self-help groups. Of these, 68.9% were classified as nonproblematic users, 24.4% as problematic users, and 6.7% as addictive Internet users. High use of discussion forums, high rumination levels, and low levels of self-care were the main contributing factors to Internet addiction (IA) among adolescents. For adults IA was mainly predicted through engagement in online video gaming and sexual activity, low email use, as well as high anxiety and high avoidant coping. Problematic Internet users scored higher on emotion and avoidance coping responses in adults and higher on rumination and lower on self-care in adolescents. Avoidance coping responses mediated the relationship between psychological distress and IA. These findings may assist clinicians with designing interventions to target different factors associated with IA.


Pathological Internet use, cyberbullying and mobile phone use in adolescence: a school-based study in Greece (2017)

Int J Adolesc Med Health. 2017 Apr 22. pii: /j/ijamh.ahead-of-print/ijamh-2016-0115/ijamh-2016-0115.xml. doi:

This study investigated the prevalence of Internet addiction (IA) and cyberbullying and examined profiles of adolescents with increased risk to develop pathological behaviors. In this cross-sectional, school-based study, 8053 students of 30 middle and 21 high schools (12-18 years old) were invited to participate, based on a multistage stratified random sampling technique. The Internet aiddiction test (IAT) was used along with information on socio-demographics, Internet activities and cyberbullying experience.

Five thousand five hundred and ninety students participated (response rate 69.4%). Pathological Internet use (IAT ≥50) was found in 526 (10.1%), while 403 (7.3%) experienced cyberbullying as victims and 367 (6.6%) as perpetrators during the last year. In multivariable models, the odds of IA increased with online hours on mobile phones and Internet use during weekends, Internet café visits, chatrooms usage and engagement in cyberbullying. Cyberbullying victims were more likely to be older, female, Facebook and chatrooms users, while perpetrators were more likely to be male, older Internet users and fans of pornographic sites. A perpetrator was significantly more likely to have also been a victim [odds ratio (OR) = 5.51, confidence interval (CI): 3.92-7.74].


Problematic internet use among high school students: Prevalence, associated factors and gender differences (2017)

Psychiatry Res. 2017 Jul 24;257:163-171. doi: 10.1016/j.psychres.2017.07.039.

This study aimed to measure the prevalence of Problematic Internet Use (PIU) among high school students and to identify factors associated with PIU underlining gender differences. The students filled a self-administered, anonymous questionnaire collecting information on demographic characteristics and patterns of Internet use. Multiple logistic regression analysis was performed to identify factors associated with PIU in the overall sample and by gender.

Twenty-five schools and 2022 students participated in the survey. Prevalence of PIU was 14.2% among males and 10.1% among females. Males 15-year-olds and females 14-year-olds had the highest PIU prevalence that progressively lowered with age among females. Only 13.5% of pupils declared parents controlled their Internet use. The sensation of feeling lonely, the frequency of use, the number of hours of connection, and visiting pornographic websites were associated with the risk of PIU in both genders. Attending vocational schools, the activities of chatting and file downloading, and the location of use at Internet point among males, and younger age among females were associated with PIU, whilst information searching was protective among females. PIU could become a public health problem in the next years. The physical and mental health consequences should be studied.


Video game addiction in emerging adulthood: Cross-sectional evidence of pathology in video game addicts as compared to matched healthy controls (2017)

J Affect Disord. 2017 Aug 18;225:265-272. doi: 10.1016/j.jad.2017.08.045.

Stockdale L1, Coyne SM2.

The Internet Gaming Disorder Scale (IGDS) is a widely used measure of video game addiction, a pathology affecting a small percentage of all people who play video games. Emerging adult males are significantly more likely to be video game addicts. Few researchers have examined how people who qualify as video game addicts based on the IGDS compared to matched controls based on age, gender, race, and marital status.

Addicts had poorer mental health and cognitive functioning including poorer impulse control and ADHD symptoms compared to controls. Additionally, addicts displayed increased emotional difficulties including increased depression and anxiety, felt more socially isolated, and were more likely to display internet pornography pathological use symptoms. Female video game addicts were at unique risk for negative outcomes.


Problematic internet use as an age-related multifaceted problem: Evidence from a two-site survey (2018)

Addict Behav. 2018 Feb 12;81:157-166. doi: 10.1016/j.addbeh.2018.02.017.

Problematic internet use (PIU; otherwise known as Internet Addiction) is a growing problem in modern societies. Our aim was to identify specific internet activities associated with PIU and explore the moderating role of age and gender in those associations. We recruited 1749 participants aged 18 and above via media advertisements in an Internet-based survey at two sites, one in the US, and one in South Africa; we utilized Lasso regression for the analysis.

Specific internet activities were associated with higher problematic internet use scores, including general surfing (lasso β: 2.1), internet gaming (β: 0.6), online shopping (β: 1.4), use of online auction websites (β: 0.027), social networking (β: 0.46) and use of online pornography (β: 1.0). Age moderated the relationship between PIU and role-playing-games (β: 0.33), online gambling (β: 0.15), use of auction websites (β: 0.35) and streaming media (β: 0.35), with older age associated with higher levels of PIU. There was inconclusive evidence for gender and gender × internet activities being associated with problematic internet use scores. Attention-deficit hyperactivity disorder (ADHD) and social anxiety disorder were associated with high PIU scores in young participants (age ≤ 25, β: 0.35 and 0.65 respectively), whereas generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) were associated with high PIU scores in the older participants (age > 55, β: 6.4 and 4.3 respectively).

Many types of online behavior (e.g. shopping, pornography, general surfing) bear a stronger relationship with maladaptive use of the internet than gaming supporting the diagnostic classification of problematic internet use as a multifaceted disorder. Furthermore, internet activities and psychiatric diagnoses associated with problematic internet use vary with age, with public health implications.

To summarize, DSM-5 highlights internet gaming disorder as a candidate disorder, but other types of online behavior (e.g. shopping, pornography, general surfing) bear a stronger relationship with maladaptive use of the internet than gaming. Psychiatric diagnoses and internet activities associated with Problematic internet use vary with age, a finding that has public health implications. These results contribute to the limited knowledge about internet activities associated with problematic internet use and may contribute to the diagnostic classification of problematic internet use as a multifaceted disorder.


Impulsivity traits and addiction-related behaviors in youth (2018)

J Behav Addict. 2018 Apr 12:1-14. doi: 10.1556/2006.7.2018.22.

Rømer Thomsen K1, Callesen MB1, Hesse M1, Kvamme TL1, Pedersen MM1, Pedersen MU1, Voon V2.

Background and aims

Impulsivity is a risk factor for addictive behaviors. The UPPS-P impulsivity model has been associated with substance addiction and gambling disorder, but its role in other non-substance addiction-related behaviors is less understood. We sought to examine associations between UPPS-P impulsivity traits and indicators of multiple substance and non-substance addiction-related behaviors in youth with varying involvement in these behaviors.

Methods

Participants (N = 109, aged 16-26 years, 69% males) were selected from a national survey based on their level of externalizing problems to achieve a broad distribution of involvement in addiction-related behaviors. Participants completed the UPPS-P Questionnaire and standardized questionnaires assessing problematic use of substances (alcohol, cannabis, and other drugs) and non-substances (Internet gaming, pornography, and food). Regression analyses were used to assess associations between impulsivity traits and indicators of addiction-related behaviors.

Results

The UPPS-P model was positively associated with indicators of all addiction-related behaviors except problematic Internet gaming. In the fully adjusted models, sensation seeking and lack of perseverance were associated with problematic use of alcohol, urgency was associated with problematic use of cannabis, and lack of perseverance was associated with problematic use of other drugs than cannabis. Furthermore, urgency and lack of perseverance were associated with binge eating and lack of perseverance was associated with problematic use of pornography.

Discussion and conclusions

We emphasize the role of trait impulsivity across multiple addiction-related behaviors. Our findings in at-risk youth highlight urgency and lack of perseverance as potential predictors for the development of addictions and as potential preventative therapeutic targets.

PMID: 29642723

DOI: 10.1556/2006.7.2018.22

 

Porn Use Rates (mostly, but not exclusively adolescents)

This page collects data on porn use from numerous studies. The first two tables appeared in recent research (references below the tables). The subsequent list is of other studies.

 

FOOTNOTES for tables above:

23 Shek, D.T. and Cheung, B.P. Developmental issues of university students in Hong Kong. International Journal of Adolescent Medicine and Health. 2013, 25, 345-351.

24 Green, L.; Brady, D.; Olafsson, K.; Hartley, J. and Lumby, C. . Risks and safety for Australian children on the internet: Full findings from the AU Kids Online survey of 9-16 year olds and their parents. Cultural Science, 2011, 4, 1-73.

25 Lopez, J.R.; Mukaire, P.E. and Mataya, R.H. Characteristics of youth sexual and reproductive health and risky behaviors in two rural provinces of Cambodia. Reproductive health.  2015. 12.

26 Ma, C.M.S. and Shek, D.T.L. Consumption of pornographic materials in early adolescents in Hong Kong. Journal of Pediatric and Adolescent Gynecology, 2013, 26, S18-S25.

27 Peter, J. and Valkenburg, P.M. The use of sexually explicit internet material and its antecedents: A longitudinal comparison of adolescents and adults. Archives of Sexual Behavior, 2011, 40, 1015-1025.

28 Skakoon-Sparling, S.; Cramer, K.M. and Shuper, P.A. The impact of sexual arousal on sexual risk-taking and decision-making in men and women. Archives of Sexual Behavior, 2016. Jan;45(1):33-42. doi: 10.1007/s10508-015-0589-y.

29 Stanley, N.; Barter, C.; Wood, M.; Aghtaie, N.; Larkins, C. and Lanau, A. Pornography, Sexual Coercion and Abuse and Sexting in Young People’s Intimate Relationships: A European Study. J Interpers Violence. 2016. March 6. Published online before print March 6, 2016, doi:10.1177/0886260516633204.

30 Kadri, N.; Benjelloun, R.; Kendili, I.; Khoubila, A. and Moussaoui, D. Internet and sexuality in Morocco, from cyber habits to psychopathology. Sexologies 2013, 22, e49-e53.

31 Ševčíková, A. and Daneback, K. Online pornography use in adolescence: Age and gender differences. Eur. J. Dev. Psychol. 2014, 11, 674-686.

32 Hald, G.M.; Kuyper, L.; Adam, P.C. and de Wit, J.B. Does viewing explain doing? Assessing the association between sexually explicit materials use and sexual behaviors in a large sample of Dutch adolescents and young adults. The Journal of Sexual Medicine 2013, 10, 2986-2995.

33 Romito, P. and Beltramini, L. Factors associated with exposure to violent or degrading pornography among high school students. J. Sch. Nurs. 2015, 31, 280-290.

34 Kastbom, A.A.; Sydsjö, G.; Bladh, M.; Priebe, G. and Svedin, C.G. Sexual debut before the age of 14 leads to poorer psychosocial health and risky behaviour in later life. Acta Paediatrica, International Journal of Paediatrics. 2015, 104, 91-100.

35 Svedin, C.G.; Åkerman, I. and Priebe, G. Frequent users of pornography. A population based epidemiological study of Swedish male adolescents. Journal of Adolescence. 2011, 34, 779-788.

36 Weber, M.; Quiring, O. and Daschmann, G. Peers, parents and pornography: Exploring adolescents' exposure to sexually explicit material and its developmental correlates. Sexuality and Culture. 2012, 16, 408-427.

37 Mattebo, M. Use of pornography and its associations with sexual experiences, lifestyles and health among adolescents. Digital Comprehensive Summaries of Uppsala Dissertations, Uppsala University, Uppsala, 2014.


MORE STUDIES WITH RATES OF PORN USE

Study on Australians ages 15-29 found that 100% of the men (82% of women) had viewed porn. Also, 69 percent of males and 23 percent of females first viewed porn at age 13 or younger. In addition this study reported that more frequent pornography viewing correlated with mental health problems.

Excerpt: Nearly 9 out of 10 (87%) young men and nearly one third (31%) of young women reported using pornography.

Excerpt: Males reported more sexual fantasies (84.6%), solitary masturbation (70.3%), and using pornographic videos (86.3%). Note: porn is officially banned in China.

Excerpt: In Denmark 97.8% of males and 79.5% of females watched pornography among 1002 people aged from 18–30 years old.

Excerpt: Average age 13.5: Two-thirds (66%) of males and more than one-third (39%) of females had seen at least one form of sexually explicit media in the past year.

Excerpt: 71% of the male adolescents and 40% of the female adolescents had been exposed to some kind of online sexually explicit material in the 6 months prior to the interview.

Excerpt: Almost all boys, 96% (n = 453), had watched pornography. Frequent users of pornography (everyday) (10%, n = 47) differed from average users (63%, n = 292) and nonfrequent users (27%, n = 126).

Excerpt: Online cross-sectional survey study of 4,600 young people, 15–25 years of age ... found that 88% of men and 45% of women had consumed SEM in the past 12 months.

Excerpt: In the Shaughnessy et al. (2011) study of young Canadians, aged 18 to 28 years, 85.8% of males and 39.3% of females said they had searched Internet for pornography.

Excerpt: Our research indicates that a majority of men (58.7%) use pornography weekly, mostly via the internet. ... We also found an earlier onset of first exposure to pornography compared to prior studies. Previous research (Sabina et al.,2008) found that 14.4%of boys had exposure prior to the age of 13; we found that 48.7%of men in our sample had similar early exposure.

Excerpt: Data from the Second Australian Study of Health and Relationships (ASHR2) were used: computer-assisted telephone interviews (CASIs) completed by a representative sample of 9,963 men and 10,131 women aged 16 to 69 years from all Australian states and territories, with an overall participation rate of 66%. Most men (84%) and half of the women (54%) had ever looked at pornographic material. Three-quarters of these men (76%) and more than one-third of these women (41%) had looked at pornographic material in the past year.

Excerpt: The results showed that all students had contact with pornography, mainly through internet network, as many as 264 respondents (82.2%) were frequently exposed to pornography media and 57 respondents (17.8%) were rarely exposed to pornographic media.

Recent Studies Describing Porn or Sex Addiction Rates

Online sexual activities: An exploratory study of problematic and non-problematic usage patterns in a sample of men (2016)

Computers in Human Behavior

Volume 56, March 2016, Pages 257–266

COMMENTS: This Belgian study (Leuven) found that 27.6% of subjects who had used porn in the last 3 months self-assessed their online sexual activities as problematic. An excerpt:

The proportion of participants who reported experiencing concerns regarding their involvement in OSAs was 27.6% and of these, 33.9% reported that they had already thought to ask for help for OSA use.


Cybersex Addiction Among College Students: A Prevalence Study (2017)

Sexual Addiction & Compulsivity Pages 1-11 | Published online: 28 Mar 2017 http://dx.doi.org/10.1080/10720162.2017.1287612

Amanda L. Giordano & Craig S. Cashwell

COMMENTS: In a cross-disciplinary survey of students (avg. age 23), 10.3% scored in the clinical range for cybersex addiction (19% of men and 4% of women). It's important to note that this survey did not limit its participants to porn users. (Two other recent studies on rates of porn addiction limited their sample to subjects who had used porn at least once in the last 3 months or 6 months. Both studies reported addiction/problematic porn use rates of ~28%.)


Clinical Characteristics of Men Interested in Seeking Treatment for Use of Pornography (2016)

J Behav Addict. 2016 Jun;5(2):169-78. doi: 10.1556/2006.5.2016.036.

Kraus SW1,2,3, Martino S2,3, Potenza MN3,4.

COMMENTS: A study on men over 18 who had viewed pornography at least once in the last 6 months. The study reported that 28% of men scored at (or above) the cutoff for possible hypersexual disorder.


Who’s a Porn Addict? Examining the Roles of Pornography Use, Religiousness, and Moral Incongruence

(2017, not yet published, but available in full online: https://psyarxiv.com/s6jzf/)

By Joshua B. Grubbs, Jennifer T. Grant, Joel Engelman (Bowling Green State University)

Rates of male porn users who answered “yes” to one of the following questions ranged from 8-20% in three large samples: “I believe that I am addicted to internet pornography.” or “I would call myself an internet pornography addict.”


Emotion Regulation and Sex Addiction among College Students (2017)

International Journal of Mental Health and Addiction. February 2017, Volume 15, Issue 1, pp 16–27

The study utilized the SAST-R "Core Scale" to assess sexual addiction.Among a sample of 337 college students, 57 (16.9 %) scored in the clinical range of sexual addiction. Breaking this down by gender, 17.8% of males and 15.5% of females in the sample surpassed the clinical cutoff.


Cyber Pornography Addiction Amongst Medical Students of Western Rural Maharashtra (2018)

International Journal of Clinical and Biomedical Research (IJCBR) 3, no. 2 (2017): 10-14.

A prospective cross sectional study was conducted after obtaining an ethical approval from the institute and an informed consent from volunteers fulfilling the eligibility criteria. The Internet sex screening test (ISST) questionnaire with score sheet was used and was collected by complete anonymity and confidentiality. 300 medical students were considered for the study and data collected was analysed by Microsoft-office excel. 

Results: 57.15% of the volunteers are in low-risk group whereas 30% are vulnerable and 12.85% are in highest-risk group. For boys, 65% are vulnerable whereas 21% in low-risk and the remaining 14% are in highest-risk group. For girls, 73% are in a low-risk, 19% are vulnerable and 8% are in highest-risk group.


Masturbation and Pornography Use Among Coupled Heterosexual Men With Decreased Sexual Desire: How Many Roles of Masturbation? (2015)

J Sex Marital Ther. 2015;41(6):626-35. doi: 10.1080/0092623X.2014.958790.

Frequent porn was related with decreased sexual desire and low relationship intimacy. Excerpts:

Analyses were carried out on a subset of 596 men with decreased sexual desire (mean age = 40.2 years) who were recruited as part of a large online study on male sexual health in 3 European countries. A majority of the participants (67%) reported masturbating at least once a week.

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.

COMMENTS: Stats were for a subset of men with decreased sexual desire: 26.1% reported that they were unable to control their pornography use


Interrelation of Consumption of Internet Pornography to Sexual Addiction and Sexual Functions (2018)

[Abstract from Journal of Sexual Medicine only is available so far. See image below]

...Sexual addiction suspected by PATHOS questionnaire was 28.6% (116/405 [total subjects])

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Co-occurring substance-related and behavioral addiction problems: A person-centered, lay epidemiology approach (2016)

J Behav Addict. 2016 Dec;5(4):614-622. doi: 10.1556/2006.5.2016.079.

Background and aims: The aims of this study were (a) to describe the prevalence of single versus multiple addiction problems in a large representative sample and (b) to identify distinct subgroups of people experiencing substance-related and behavioral addiction problems.

Methods: A random sample of 6,000 respondents from Alberta, Canada, completed survey items assessing self-attributed problems experienced in the past year with four substances (alcohol, tobacco, marijuana, and cocaine) and six behaviors (gambling, eating, shopping, sex, video gaming, and work). Hierarchical cluster analyses were used to classify patterns of co-occurring addiction problems on an analytic subsample of 2,728 respondents (1,696 women and 1032 men; Mage = 45.1 years, SDage = 13.5 years) who reported problems with one or more of the addictive behaviors in the previous year.

Results: In the total sample, 49.2% of the respondents reported zero, 29.8% reported one, 13.1% reported two, and 7.9% reported three or more addiction problems in the previous year. Cluster-analytic results suggested a 7-group solution.

COMMENTS: This study assessed the self-reported rates of substance and behavioral addictions in a representative sample of Canadians. It's important to note that self assessment would tend to under report addiction rates. The findings: about 4.8% thought they had a "sex addiction" (in reality, 9.5% of the group that had at least one addiction thought their primary addiction was porn or sex). The excerpt describing addiction rates:

Classifying co-occurring addiction problems

The results of the cluster analysis suggested a seven-cluster solution. As shown in Table 5, the first cluster (26.0% of the sample used when conducting the clustering) represented individuals with smoking as their shared problem behavior. The second cluster (21.8%) consisted of participants reporting excessive eating as their only problem behavior. The third cluster (16.2%) represented individuals with work problems, while the fourth cluster (13.0%) consisted of participants characterized by a large number of different addiction problems without a clearly dominant behavior. The fifth cluster (9.5%) represented mainly individuals reporting excessive sexual behavior, while the sixth (8.9%) and seventh (4.7%) clusters consisted of participants with shopping and video gaming as their shared behavioral problem, respectively. Highest average number of past-year addictive behaviors was observed among excessive video game players (Cluster VII), while the lowest was found among excessive eaters (Cluster II). Detailed information on the addiction characteristics of each cluster are described in Table 5.

A few possible reasons why the rate wasn't higher:

  • The average age was 44
  • Only 38% of the subjects were males
  • The survey was done in 2009
  • Most porn users fail to recognize the negative effects related to their porn use or that the signs and symptoms of an addiction

 

A Profile of Pornography Users in Australia: Findings From the Second Australian Study of Health and Relationships (2016)

COMMENTS: Some claim this study supports the argument that Internet porn doesn't really cause serious problems. For example, only 4% of the men felt they were addicted to porn. There are reasons to take the headlines with a grain of salt.

Check out the study's conclusion:

Looking at pornographic material appears to be reasonably common in Australia, with adverse effects reported by a small minority.

However, for participants aged 16-30, it's not such a small minority. According to Table 5 in the study, 17% of this age group reported that using pornography had a bad effect on them. (In contrast, among people 60-69, only 7.2% thought  porn had a bad effect.)

How different would the headlines from this study have been if the authors had emphasized their finding that nearly 1 in 5 young people believed that porn use had a "bad effect on them"? Why did they attempt to downplay this  finding by ignoring it and focusing on cross-sectional results - rather than the group most at risk for internet problems?

A few caveats about this study:

  1. This was a cross-sectional representative study spanning age groups 16-69, males and females. It's well established that young men are the primary users of internet porn. So, 25% of the men and 60% of the women had not viewed porn at least once in the last 12 months. Thus the statistics gathered minimize the problem by veiling the at-risk users.
  2. The single question, which asked participants if they had used porn in the last 12 months, doesn't meaningfully quantify porn use. For example, a person who bumped into a porn site pop-up is considered no different from someone who masturbates 3 times a day to hardcore porn.
  3. However, when the survey enquired of those who "had ever viewed porn" which ones had viewed porn in the past year, the highest percentage was the teen group. 93.4% of them had viewed in the last year, with 20-29 year olds just behind them at 88.6.
  4. Data was gathered between October 2012 and November 2013. Things have changed a lot in the last 4 years, thanks to smartphone penetration - especially in yournger users.
  5. Questions were asked in computer-assisted telephone interviews. It's human nature to be more forthcoming in completely anonymous interviews, especially when interviews are about sensitive subjects such as porn use and porn addiction.
  6. The questions are based purely upon self-perception. Keep in mind that addicts rarely see themselves as addicted. In fact, most internet porn users are unlikely to connect their symptoms to porn use unless they quit for an extended period.
  7. The study did not employ standardized questionnaires (given anonymously), which would more accurately have assessed both porn addiction and porn's effects on the users.

Once again, few regular porn users realize how porn has affected them until well after they cease using. Often ex-users need several months to fully recognize the negative effects. Thus, a study like this one has major limitations.


 

Technology addiction among treatment seekers for psychological problems: implication for screening in mental health setting (2017)

The mean age of the sample was 26.67 with the standard deviation of 6.5. The age distribution was 16 years to 40 years. The sample had 45 males (60%) and 30 females (40%). 17 were married (22.67%), 57 were unmarried (76%), and 1 was divorced (1.33%). All the subjects had 10 and more year of education. 36% were from the rural area and the 64% were from the urban area.

In Table 3, Type of Addiction, Pornography Addiction was as follows:

  • Proness to addiction: 8%
  • High risk to addiction: 6.7%
  • Addicted to pornography: 4%

Studies: Hours of Use Not Correlated With Addiction

Watching Pornographic Pictures on the Internet: Role of Sexual Arousal Ratings and Psychological-Psychiatric Symptoms for Using Internet Sex Sites Excessively (2011)

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


 

Sexual Excitability and Dysfunctional Coping Determine Cybersex Addiction in Homosexual Males (2015)

Cybersex addiction (CA) has been mostly investigated in heterosexual males. Recent findings have demonstrated an association between 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. Seventy-one homosexual males were surveyed online. 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.


Problematic Game Play: The Diagnostic Value of Playing Motives, Passion, and Playing Time in Men (2015)

Abstract:

Internet gaming disorder is currently listed in the DSM—not in order to diagnose such a disorder but to encourage research to investigate this phenomenon. Even whether it is still questionable if Internet Gaming Disorder exists and can be judged as a form of addiction, problematic game play is already very well researched to cause problems in daily life. Approaches trying to predict problematic tendencies in digital game play have mainly focused on playing time as a diagnostic criterion. However, motives to engage in digital game play and obsessive passion for game play have also been found to predict problematic game play but have not yet been investigated together. The present study aims at (1) analyzing if obsessive passion can be distinguished from problematic game play as separate concepts, and (2) testing motives of game play, passion, and playing time for their predictive values for problematic tendencies. We found (N = 99 males, Age: M = 22.80, SD = 3.81) that obsessive passion can be conceptually separated from problematic game play. In addition, the results suggest that compared to solely playing time immersion as playing motive and obsessive passion have added predictive value for problematic game play. The implications focus on broadening the criteria in order to diagnose problematic playing.

In this study, game play motives, passion for game play as well as playing time were analyzed as predictors for problematic game play. Our results showed that immersion as playing motive and obsessive passion for game play have significant predictive value for problematic game play while playing time had only significant influence on problematic game play if used as single predictor. Concerning the development of future diagnostic instruments, game play motives and passion should be discussed as criteria.


 

Reframing video gaming and Internet use addiction: Empirical cross-national comparison of heavy use over time and addiction scales among young users (2014).

2015 Oct 9. doi: 10.1111/add.13192. 

Baggio S1, Dupuis M2, Studer J3, Spilka S4, Daeppen JB2, Simon O5, Berchtold A1,6, Gmel G3,7,8,9.

 

BACKGROUND AND AIMS:

Evidence-based and reliable measures of addictive disorders are needed in general population-based assessments. One study suggested that heavy use over time (UOT) should be used instead of self-reported addiction scales (AS). This study empirically compared UOT and AS regarding video gaming and Internet use, using associations with comorbid factors.

DESIGN:

Cross-sectional data from the 2011 French ESCAPAD survey; cross-sectional data from the 2012 Swiss ado@internet.ch study; and two waves of longitudinal data (2010-2013) of the Swiss Longitudinal Cohort Study on Substance Use Risk Factors (C-SURF).

SETTING:

Three representative samples from the general population of French and Swiss adolescents, and young Swiss men, respectively aged around 17, 14, and 20.

PARTICIPANTS:

ESCAPAD: n = 22,945 (47.4% men); ado@internet.ch: n = 3,049 (50% men); C-SURF: n = 4,813 (baseline + follow-up, 100% men).

MEASUREMENTS:

We assessed video gaming/Internet UOT (ESCAPAD and ado@internet.ch: number of hours spent online per week, C-SURF: latent score of time spent gaming/using Internet) and AS (ESCAPAD: Problematic Internet Use Questionnaire, ado@internet.ch: Internet Addiction Test, C-SURF: Gaming AS). Comorbidities were assessed with health outcomes (ESCAPAD: physical health evaluation with a single item, suicidal thoughts, and appointment with a psychiatrist; ado@internet.ch: WHO-5 and somatic health problems; C-SURF: SF12 and MDI).

FINDINGS:

UOT and AS were moderately correlated (ESCAPAD: r = 0.40, ado@internet.ch: r = 0.53, and C-SURF: r = 0.51). Associations of AS with comorbidity factors were higher than those of UOT in cross-sectional (AS: 0.006 ≤ |b| ≤ 2.500, UOT: 0.001 ≤ |b| ≤ 1.000) and longitudinal analyses (AS: 0.093 ≤ |b| ≤ 1.079, UOT: 0.020 ≤ |b| ≤ 0.329). The results were similar across gender in ESCAPAD and ado@internet.ch (men: AS: 0.006 ≤ |b| ≤ 0.211, UOT: 0.001 ≤ |b| ≤ 0.061; women: AS: 0.004 ≤ |b| ≤ .155, UOT: 0.001 ≤ |b| ≤ 0.094).

CONCLUSIONS:

The measurement of heavy use over time (UOT) captures part of addictive video gaming/Internet use without overlapping to a large extent with the results of measuring by self-reported addiction scales (AS). Measuring addictive video gaming/Internet use via self-reported AS relates more strongly to comorbidity factors than heavy UOT.

This article is protected by copyright. All rights reserved.

 

Studies Find Escalation and Habituation in Porn Users (Tolerance)

Introduction

Compulsive porn users often describe escalation in their porn use that takes the form of greater time viewing or seeking out new genres of porn. New genres that induce shock, surprise, violation of expectations or even anxiety can function to increase sexual arousal, and in porn users whose response to stimuli is growing blunted due to overuse, this phenomenon is extremely common.

Norman Doidge MD wrote about this in his  2007 book The Brain That Changes Itself:

The current porn epidemic gives a graphic demonstration that sexual tastes can be acquired. Pornography, delivered by high-speed Internet connections, satisfies every one of the prerequisites for neuroplastic change.... 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. The back pages of men's risque magazines and Internet porn sites are filled with ads for Viagra-type drugs—medicine developed for older men with erectile problems related to aging and blocked blood vessels in the penis. Today young men who surf porn are tremendously fearful of impotence, or “erectile dysfunction” as it is euphemistically called. The misleading term implies that these men have a problem in their penises, but the problem is in their heads, in their sexual brain maps. The penis works fine when they use pornography. It rarely occurs to them that there may be a relationship between the pornography they are consuming and their impotence.

In 2012 reddit/nofap produced a member survey, which found that over 60% of its members' sexual tastes experienced significant escalation, through multiple porn genres.

Q: Did your tastes in pornography change?

  • My tastes did not change significantly - 29%
  • My tastes became increasingly extreme or deviant and this caused me to feel shame or stress - 36%
  • My tastes became increasingly extreme or deviant and this did not cause me to feel shame or stress - 27%

And here's the 2017 evidence from PornHub that real sex is decreasingly interesting to porn users. Porn isn't enabling people to find their "real" tastes; it's driving them beyond normal into extreme novelty and "unreal" genres:

It appears that the trend is moving more toward fantasy than reality. ‘Generic’ porn is being replaced with fantasy specific or scenario specific scenes.  Is this as a result of boredom or curiosity? One thing is certain; the typical ‘in-out, in-out’ no longer satisfies the masses, who are clearly looking for something different” notes Dr Laurie Betito.

The only support for the meme that porn users do not escalate comes Ogas and Gaddam's highly criticized book "A Billion Wicked Thoughts" and their claim that porn viewing tastes remain stable throughout life. Ogas & Gaddam analyzed AOL searches from 2006, over a brief 3-month period. Here's an excerpt from an Ogi Ogas blog post on Psychology Today:

There is no evidence that viewing porn activates some kind of neural mechanism leading one down a slippery slope of seeking more and more deviant material, and plenty of evidence suggesting that adult men's sexual interests are stable.

As YBOP pointed out in two critiques (1, 2):

  1. Porn users must be tracked over years to pick up the kinds of changing tastes men are reporting. Three months is insufficient.
  2. Most regular porn users do not use Google to find porn. Instead, they head directly to their favorite tube site. Clicking onto a new genre (located in the sidebar) occurs while the user is masturbating.

If the studies listed below aren't sufficiently convincing, this 2017 study destroys the meme that porn users sexual interests remain stable: Sexually Explicit Media Use by Sexual Identity: A Comparative Analysis of Gay, Bisexual, and Heterosexual Men in the United States. Excerpt from this recent study:

The findings also indicated that many men viewed SEM content inconsistent with their stated sexual identity. It was not uncommon for heterosexual-identified men to report viewing SEM containing male same-sex behavior (20.7%) and for gay-identified men to report viewing heterosexual behavior in SEM (55.0%). It was also not uncommon for gay men to report that they viewed vaginal sex with (13.9%) and without a condom (22.7%) during the past 6 months.

This study, taken together with others listed below, debunks the meme that today's porn users eventually "discover their true sexuality" by surfing tube sites, and then stick to only one genre of porn for the rest of time. The evidence is mounting that streaming digital porn appears to alter sexual tastes in some users, and that this is due to the addiction-related brain change known as habituation or desensitization.

Employing various methodologies and approaches, the following diverse group of studies report habituation to "regular porn" along with escalation into more extreme and unusual genres. A few also report withdrawal symptoms.


FIRST STUDY: This was the first study to ask porn users directly about escalation: "Online sexual activities: An exploratory study of problematic and non-problematic usage patterns in a sample of men" (2016). The study reports escalation, as 49% of the men reported viewing porn that was not previously interesting to them or that they once considered disgusting. An excerpt:

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.

This Belgian study also found problematic Internet porn use was associated with reduced erectile function and reduced overall sexual satisfaction. Yet problematic porn users experienced greater cravings (OSA's = online sexual activity, which was porn for 99% of subjects). Interestingly, 20.3% of participants said that one motive for their porn use was "to maintain arousal with my partner." An excerpt:

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).


SECOND STUDY: "The Dual Control Model: The Role Of Sexual Inhibition & Excitation In Sexual Arousal And Behavior," 2007. Indiana University Press, Editor: Erick Janssen, pp.197-222.  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.


THIRD & FOURTH STUDIES: Both found that deviant (i.e., bestiality or minor) pornography users reported a significantly younger onset of adult pornography use. These studies link earlier onset of porn use to escalation to more extreme material.

1) "Does deviant pornography use follow a Guttman-like progression?" (2013). An excerpt:

The findings of the current study suggest Internet pornography use may follow a Guttman-like progression. In other words, individuals who consume child pornography also consume other forms of pornography, both nondeviant and deviant. For this relationship to be a Guttman-like progression, child pornography use must be more likely to occur after other forms of pornography use. The current study attempted to assess this progression by measuring if the “age of onset” for adult pornography use facilitated the transition from adult-only to deviant pornography use. Based on the results, this progression to deviant pornography use may be affected by the individuals “age of onset” for engaging in adult pornography. As suggested by Quayle and Taylor (2003), child pornography use may be related to desensitization or appetite satiation to which offenders begin collecting more extreme and deviant pornography. The current study suggests individuals who engage in adult pornography use at a younger age may be at greater risk for engaging in other deviant forms of pornography.

2) "Deviant Pornography Use: The Role of Early-Onset Adult Pornography Use and Individual Differences" (2016). Excerpts:

Results indicated that adult + deviant pornography users scored significantly higher on openness to experience and reported a significantly younger age of onset for adult pornography use compared to adult-only pornography users.

Finally, the respondents’ self-reported age of onset for adult pornography significantly predicted adult-only vs. adult + deviant pornography use. That is to day, adult + deviant pornography users selfreported a younger age of onset for nondeviant (adult-only) pornography compared to the adult-only pornography users. Overall, these findings support the conclusion drawn by Seigfried-Spellar and Rogers (2013) that Internet pornography use may follow a Guttman-like progression in that deviant pornography use is more likely to occur after the use of nondeviant adult pornography.


FIFTH STUDY: "Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn" (Kuhn & Gallinat, 2014) - This Max Planck Institute fMRI study found less grey matter in the reward system (dorsal striatum) correlating with the amount of porn consumed. It also found that more porn use correlated with less reward circuit activation while briefly viewing sexual photos. Researchers believe their findings indicated desensitization, and possibly tolerance, which is the need for greater stimulation to achieve the same level of arousal. Lead author Simone Kühn said the following about her study:

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

Furthermore, in May, 2016. Kuhn & Gallinat published this review - Neurobiological Basis of Hypersexuality. In the review Kuhn & Gallinat describe their 2014 fMRI study:

In a recent study by our group, we recruited healthy male participants and associated their self-reported hours spent with pornographic material with their fMRI response to sexual pictures as well as with their brain morphology (Kuhn & Gallinat, 2014). 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.


SIXTH STUDY: "Novelty, conditioning and attentional bias to sexual rewards" (2015). Cambridge University fMRI study reporting greater habituation to sexual stimuli in compulsive porn users. An excerpt:

Online explicit stimuli are vast and expanding, and this feature may promote escalation of use in some individuals. For instance, healthy males viewing repeatedly the same explicit film have been found to habituate to the stimulus and find the explicit stimulus as progressively less sexually arousing, less appetitive and less absorbing (Koukounas and Over, 2000). ... We show experimentally what is observed clinically that Compulsive Sexual Behavior is characterized by novelty-seeking, conditioning and habituation to sexual stimuli in males.

FROM THE RELATED PRESS RELEASE:

The researchers found that sex addicts were more likely to choose the novel over the familiar choice for sexual images relative to neutral object images, whereas healthy volunteers were more likely to choose the novel choice for neutral human female images relative to neutral object images.

"We can all relate in some way to searching for novel stimuli online – it could be flitting from one news website to another, or jumping from Facebook to Amazon to YouTube and on," explains Dr Voon. "For people who show compulsive sexual behaviour, though, this becomes a pattern of behaviour beyond their control, focused on pornographic images."

In a second task, volunteers were shown pairs of images – an undressed woman and a neutral grey box – both of which were overlaid on different abstract patterns. They learned to associate these abstract images with the images, similar to how the dogs in Pavlov's famous experiment learnt to associate a ringing bell with food. They were then asked to select between these abstract images and a new abstract image.

This time, the researchers showed that sex addicts where more likely to choose cues (in this case the abstract patterns) associated with sexual and monetary rewards. This supports the notion that apparently innocuous cues in an addict's environment can 'trigger' them to seek out sexual images.

"Cues can be as simple as just opening up their internet browser," explains Dr Voon. "They can trigger a chain of actions and before they know it, the addict is browsing through pornographic images. Breaking the link between these cues and the behaviour can be extremely challenging."

The researchers carried out a further test where 20 sex addicts and 20 matched healthy volunteers underwent brain scans while being shown a series of repeated images – an undressed woman, a £1 coin or a neutral grey box.

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." [emphasis added]


SEVENTH STUDY: Exploring the effect of sexually explicit material on the sexual beliefs, understanding and practices of young men: A qualitative surve (2016). An excerpt:

Findings suggest that the key themes are: increased levels of availability of SEM, including an escalation in extreme content (Everywhere You Look) which are seen by young men in this study as having negative effects on sexual attitudes and behaviours (That's Not Good). Family or sex education may offer some ‘protection’ (Buffers) to the norms young people see in SEM. Data suggests confused views (Real verses Fantasy) around adolescents’ expectations of a healthy sex life (Healthy Sex Life) and appropriate beliefs and behaviours (Knowing Right from Wrong). A potential causal  pathway is described and areas of intervention highlighted.


EIGHTH STUDY: "Modulation of late positive potentials by sexual images in problem users and controls inconsistent with "porn addiction" (Prause et al., 2015.)

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, Nicole Prause, claims these results "debunk porn addiction." If porn use had no effect on Prause et al's. subjects, we would expect controls and the frequent porn users to have the same LPP amplitude in response to sexual photos. Instead, the more frequent porn users had less brain activation (lower LPP). 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's findings also align with Banca et al. 2015 which is #6 above. 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). Six peer-reviewed papers agree with this extensive critique that Prause actually found desensitization/habituation in frequent porn users: 1, 2, 3, 4, 5, 6.


NINTH STUDY: 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, multiple porn 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. Excerpts from the paper documenting the patient's habituation and escalation into what he described as more extreme porn genres:

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.

An excerpt from the paper documents the patient's recovery from porn-induced sexual problems and fetishes:

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.


TENTH STUDY: Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016) is an extensive review of the literature related to porn-induced sexual problems. Authored by 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 include 3 clinical reports of servicemen who developed porn-induced sexual dysfunctions. Two of the three servicemen healed their sexual dysfunctions by eliminating porn use while the third man experienced little improvement as he was unable to abstain from porn use. Two of the three servicemen reported habituation to current porn and escalation of porn use. The first servicemen describes his habituation to "soft porn" followed by escalation into more graphic and fetish porn: 

A 20-year old active duty enlisted Caucasian serviceman presented with difficulties achieving orgasm during intercourse for the previous six months. It first happened while he was deployed overseas. He was masturbating for about an hour without an orgasm, and his penis went flaccid. His difficulties maintaining erection and achieving orgasm continued throughout his deployment. Since his return, he had not been able to ejaculate during intercourse with his fiancée. He could achieve an erection but could not orgasm, and after 10–15 min he would lose his erection, which was not the case prior to his having ED issues.

Patient endorsed masturbating frequently for “years”, and once or twice almost daily for the past couple of years. He endorsed viewing Internet pornography for stimulation. Since he gained access to high-speed Internet, he relied solely on Internet pornography. Initially, “soft porn”, where the content does not necessarily involve actual intercourse, “did the trick”. However, gradually he needed more graphic or fetish material to orgasm. He reported opening multiple videos simultaneously and watching the most stimulating parts. [emphasis added]

The second servicemen describes increased porn use and escalation into more graphic porn. Soon thereafter sex with his wife “not as stimulating as before":

A 40-year old African American enlisted serviceman with 17 years of continuous active duty presented with difficulty achieving erections for the previous three months. He reported that when he attempted to have sexual intercourse with his wife, he had difficulty achieving an erection and difficulty maintaining it long enough to orgasm. Ever since their youngest child left for college, six months earlier, he had found himself masturbating more often due to increased privacy. He formerly masturbated every other week on average, but that increased to two to three times per week. He had always used Internet pornography, but the more often he used it, the longer it took to orgasm with his usual material. This led to him using more graphic material. Soon thereafter, sex with his wife was “not as stimulating” as before and at times he found his wife “not as attractive”. He denied ever having these issues earlier in the seven years of their marriage. He was having marital issues because his wife suspected he was having an affair, which he adamantly denied. [emphasis added]


ELEVENTH STUDY: Shifting Preferences In Pornography Consumption (1986) Six weeks of exposure to nonviolent pornography resulted in subjects having little interest in vanilla porn, electing to almost exclusively watch "uncommon pornography" (bondage, sadomasochism, bestiality). An excerpt:

Male and female students and nonstudents were exposed to one hour of common, nonviolent pornography or to sexually and aggressively innocuous materials in each of six consecutive weeks. Two weeks after this treatment, they were provided with an opportunity to watch videotapes in a private situation. G-rated, R-rated, and X-rated programs were available. Subjects with considerable prior exposure to common, nonviolent pornography showed little interest in common, nonviolent pornography, electing to watch uncommon pornography (bondage, sadomasochism, bestiality) instead. Male nonstudents with prior exposure to common, nonviolent pornography consumed uncommon pornography almost exclusively. Male students exhibited the same pattern, although somewhat less extreme. This consumption preference was also in evidence in females, but was far less pronounced, especially among female students. [emphasis added]


TWELFTH STUDY: Examining Correlates of Problematic Internet Pornography Use Among University Students (2016) Addictive use of internet porn, which is associated with poorer psychosocial functioning, emerges when people begin to use IP daily.

Age of first exposure to IP was found to be significantly correlated with frequent and addictive IP use (see Table 2). Participants who were exposed to IP at an earlier age were more likely to use IP more frequently, have longer IP sessions,and more likely to score higher on Adapted DSM-5 Internet Pornography Addiction Criteria and CPUI-COMP measures. Finally, total IP exposure was found to be significantly correlated with higher frequency of IP use. Participants who had longer total exposure to IP were also more likely to have more IP sessions per month.


THIRTEENTH STUDY: The Relationship between Frequent Pornography Consumption, Behaviors, and Sexual Preoccupancy among Male Adolescents in Sweden (2017) Porn use in 18-year old males was universal, and frequent porn users preferred hard-core porn. Does this indicate escalation of porn use?

Among frequent users, the most common type of pornography consumed was hard core pornography (71%) followed by lesbian pornography (64%), while soft core pornography was the most commonly selected genre for average (73%) and infrequent users (36%). There was also a difference between the groups in the proportion who watched hard core pornography (71%, 48%, 10%) and violent pornography (14%, 9%, 0%).

The authors suggest that frequent porn may ultimately lead to a preference for hard-core or violent pornography:

It is also noteworthy that a statistically significant relationship was found between fantasizing about pornography several times a week and watching hard core pornography. Since verbal and physical sexual aggression is so commonplace in pornography, what most adolescents considered hard core pornography could likely be defined as violent pornography. If this is the case, and in light of the suggested cyclical nature of sexual preoccupancy in Peter and Valkenburg, it may be that rather than ‘purging’ individuals of their fantasies and inclinations of sexual aggression, watching hard core pornography perpetuates them, thereby increasing the likelihood of manifested sexual aggression.


FOURTEENTH STUDY: The Development of the Problematic Pornography Consumption Scale (PPCS) (2017) - This paper developed and tested a problematic porn use questionnaire that was modeled after substance addiction questionnaires. Unlike previous porn addiction tests, this 18-item questionnaire assessed tolerance and withdrawal with the following 6 questions:

 

 

 

 

 

 

----------

 

 

 

 

 

 

Each question was scored from one to seven on a likert scale: 1- Never, 2- Rarely, 3- Occasionally, 4- Sometimes, 5- Often, 6- Very Often, 7- All the Time. The graph below grouped porn users into 3 categories based on their total scores:  "Nonprobelmatic," "Low risk," and "At risk." The yellow line indicates no problems, which means that the "Low risk" and "At risk" porn users reported both tolerance and withdrawal. Put simply, this study actually asked about escalation (tolerance) and withdrawal - and both are reported by some porn users. End of debate.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


STUDY FIFTEEN: Out-of-control use of the internet for sexual purposes as behavioural addiction? An upcoming study (presented at the 4th International Conference on Behavioral Addictions February 20–22, 2017) which asked about tolerance and withdrawal. It found both in "porn addicts". 

Anna Ševčíková1, Lukas Blinka1 and Veronika Soukalová1

1Masaryk University, Brno, Czech Republic

Background and aims:

There is an ongoing debate whether excessive sexual behaviour should be understood as a form of behavioural addiction (Karila, Wéry, Weistein et al., 2014). The present qualitative study aimed at analysing the extent to which out-of-control use of the internet for sexual purposes (OUISP) may be framed by the concept of behavioural addiction among those individuals who were in treatment due to their OUISP.

Methods:

We conducted in-depth interviews with 21 participants aged 22–54 years (Mage = 34.24 years). Using a thematic analysis, the clinical symptoms of OUISP were analysed with the criteria of behavioural addiction, with the special focus on tolerance and withdrawal symptoms (Griffiths, 2001).

Results:

The dominant problematic behaviour was out-of-control online pornography use (OOPU). Building up tolerance to OOPU manifested itself as an increasing amount of time spent on pornographic websites as well as searching for new and more sexually explicit stimuli within the non-deviant spectrum. Withdrawal symptoms manifested themselves on a psychosomatic level and took the form of searching for alternative sexual objects. Fifteen participants fulfilled all of the addiction criteria.

Conclusions:

The study indicates a usefulness for the behavioural addiction framework


STUDY SIXTEEN: (actually a review by UK psychiatrist): Internet pornography and paedophilia (2013) - Excerpt:

Clinical experience and now research evidence are accumulating to suggest that the Internet is not simply drawing attention to those with existing paedophilic interests, but is contributing to the crystallisation of those interests in people with no explicit prior sexual interest in children.


STUDY SEVENTEEN: 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 related to escalation:

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….The article calls for research into pornography usage and its effect on masturbation and genital desensitisation.


STUDY EIGHTEEN: Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017) – The study assessed porn user's responses (EEG readings & Startle Response) to various emotion-inducing images - including erotica. The authors believe two findings indicate habituation in the more frequent porn users.

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].


STUDY NINETEEN: Exploring the Relationship between Sexual Compulsivity and Attentional Bias to Sex-Related Words in a Cohort of Sexually Active Individuals (2017) - This study replicates the findings of this 2014 Cambridge University study that 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. 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 section:

"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."


STUDY TWENTY: A qualitative study of cybersex participants: Gender differences, recovery issues, and implications for therapists (2000) - Excerpts:

Some respondents described a rapid progression of a previously existing compulsive sexual behavior problem, whereas others had no history of sexual addiction but became rapidly involved in an escalating pattern of compulsive cybersex use after they discovered Internet sex. Adverse consequences included depression and other emotional problems, social isolation, worsening of their sexual relationship with spouse or partner, harm done to their marriage or primary relationship, exposure of children to online pornography or masturbation, career loss or decreased job performance, other financial consequences, and in some cases, legal consequences.

One of the examples:

A 30-year-old man with a previous history of “porn, masturbation, and frequent sexual thoughts,” wrote about his cybersex experience: In the last couple of years, the more porn I’ve viewed, the less sensitive I am to certain porn that I used to find offensive. Now I get turned on by some of it (anal sex, women peeing, etc.) The sheer quantity of porn on the Net has done this. It’s so easy to click on certain things out of curiosity in the privacy of your home, and the more you see them, the less sensitized you are. I used to only be into softcore porn showing the beauty of the female form. Now I’m into explicit hardcore.


STUDY TWENTY ONE: Sexual Arousal and Sexually Explicit Media (SEM): Comparing Patterns of Sexual Arousal to SEM and Sexual Self-Evaluations and Satisfaction Across Gender and Sexual Orientation (2017). In this study participants were asked about their sexual arousal related to 27 genres (themes) of porn. Why the researchers chose these 27 particular genres is known only to them. How they determined which genres were “mainstream” which were “non-mainstream” also remains a mystery, given their seemingly random categorization. (See the researchers' arbitrary categorization porn genres.)

No matter, this study debunks the claim that porn users like only a narrow range of genres. While it doesn't directly ask about escalation over time, the study found that subjects they categorized as "non-mainstream" porn viewers like many different types of porn . A few relevant excerpts:

The findings suggest that in classified non-mainstream Sexually Explicit Media [porn] groups, patterns of sexual arousal might be less fixated and category specific than previously assumed.

Particularly for heterosexual men and non-heterosexual women, who were characterized by substantial levels of sexual arousal to non-mainstream SEM themes, the findings suggest that patterns of sexual arousal induced by SEM in non-laboratory settings might be more versatile, less fixed, and less category specific than previously assumed. This supports a more generalized SEM arousability and indicates that non-mainstream SEM group participants also are aroused by more mainstream (“vanilla”) themes.

The study is saying that so-called "non-mainstream porn viewers" are aroused by all sorts of porn, whether it’s so-called "mainstream" (Bukkake, Orgy, Fist-fucking) or so-called "non-mainstream" (Sadomasochism, Latex). This finding debunks the often repeated meme that frequent porn users stick to one type of porn. (An example of the unfounded claim about "fixed" tastes is Ogas and Gaddam's highly criticized book A Billion Wicked Thoughts.)


STUDY TWENTY TWO: The Development and Validation of the Bergen-Yale Sex Addiction Scale With a Large National Sample (2018). This paper developed and tested a "sex addiction" questionnaire that was modeled after substance addiction questionnaires. As the authors explained, previous questionnaires have omitted key elements of addiction:

Most previous studies have relied on small clinical samples. The present study presents a new method for assessing sex addiction—the Bergen–Yale Sex Addiction Scale (BYSAS)—based on established addiction components (i.e., salience/craving, mood modification, tolerance, withdrawal, conflict/problems, and relapse/loss of control).

The authors expand on the six established addiction components assessed, including tolerance and withdrawal.

The BYSAS was developed utilizing the six addiction criteria emphasized by Brown (1993), Griffiths (2005), and American Psychiatric Association (2013) encompassing salience, mood modification, tolerance, withdrawal symptoms, conflicts and relapse/loss of control.... In relation to sex addiction, these symptoms would be: salience/craving—over-preoccupation with sex or wanting sex, mood modification—excessive sex causing changes in mood, tolerance—increasing amounts of sex over time, withdrawalunpleasant emotional/physical symptoms when not having sex, conflict—inter-/intrapersonal problems as a direct result of excessive sex, relapse—returning to previous patterns after periods with abstinence/control, and problems—impaired health and well-being arising from addictive sexual behavior.

The most prevalent "sex addiction" components seen in the subjects were salience/craving and tolerance, but the other components, including withdrawal, also showed up to a lesser degree:

Salience/craving and tolerance were more frequently endorsed in the higher rating category than other items, and these items had the highest factor loadings. This seems reasonable as these reflect less severe symptoms (e.g., question about depression: people score higher on feeling depressed, then they plan committing suicide). This may also reflect a distinction between engagement and addiction (often seen in the game addiction field)—where items tapping information about salience, craving, tolerance, and mood modification are argued to reflect engagement, whereas items tapping withdrawal, relapse and conflict more measure addiction. Another explanation could be that salience, craving, and tolerance may be more relevant and prominent in behavioral addictions than withdrawal and relapse.

This study, along with the 2017 study that developed and validated the "Problematic Pornography Consumption Scale," refutes the often-repeated claim that porn and sex addicts do not experience either tolerance or withdrawal symptoms.


 

Studies linking porn use or porn/sex addiction to sexual dysfunctions, lower arousal, and lower sexual & relationship satisfaction

Reality Check - Regardless of what you may read in some journalistic accounts, multiple studies reveal a link between porn use and sexual performance problems, relationship and sexual dissatisfaction, and reduced brain activation to sexual stimuli.

Let's start with sexual dysfunctions. Studies assessing young male sexuality since 2010 report historic levels of sexual dysfunctions, and startling rates of a new scourge: low libido. Documented in this lay article and in this peer-reviewed paper involving 7 US Navy doctors - Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016)

Erectile dysfunction rates in these recent studies range from 14% to 35%, while rates for low libido (hypo-sexuality) range from 16% to 37%. Some studies involve teens and men 25 and under, while other studies involve men 40 and under.

Prior to the advent of free streaming porn (2006), cross-sectional studies and meta-analysis consistently reported erectile dysfunction rates of 2-5% in men under 40. That's nearly a 1000% increase in youthful ED rates in the last 10-15 years. What variable has changed in the last 15 years that could account for this astronomical rise?

Below are two lists:

  1. List one: 24 studies linking porn use or porn addiction to sexual problems and lower arousal in response to sexual stimuli or partnered sex (5 demonstrate causation).
  2. List two: Over 55 studies linking porn use to lower relationship or sexual satisfaction.

Studies linking porn use or porn addiction to ED, anorgamsia, low sexual desire, delayed ejaculation, and lower arousal to sexual stimuli.

In addition to the studies below, this page contains articles and videos by over 100 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 5 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) 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."

7) 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.

8) 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."

9) 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.

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."

11) 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.)

12) 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.

13) 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.

14) 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.

15) 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."

16) 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 addiction. Not so. In line with the Cambridge University brain scan studies, this EEG study reported greater cue-reactivity to porn correlated with less desire for partnered sex. To put another way - individuals with more brain activation and cravings for 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 (their desire for partnered sex was dropping in relation to signs of addiction). Five peer-reviewed papers expose the truth: 1, 2, 3, 4, 5. Also see the extensive YBOP critique.

17) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015) - Another Nicole Prause EEG study. This time comparing the 2013 subjects from the above study to an actual control group. The results: compared to controls, "porn addicts" had less response to one-second exposure to photos of vanilla porn. The lead author, Nicole Prause, claimed these results debunk porn addiction (contrary to caims no studies falsify the porn addiction model). However, these findings align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. Put simply, frequent porn users were desensitized to static images of vanilla porn. They were bored (habituated or desensitized). Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users: 1, 2, 3, 4. 5, 6. (also see this extensive YBOP critique). By the way, another EEG study found that greater porn use in women correlated with less brain activation to porn.

18) 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.

19) 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.

20) 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.

21) 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

22) 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".

23) 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.

24) “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)

25) 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.

26) (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)


Studies reporting links between porn use and less sexual or relationship satisfaction:

As of 2018, over fifty-five studies have linked porn use to poorer sexual and relationship satisfaction. While a few studies correlated greater porn use in females to better (or neutral) sexual satisfaction, most have not (see this list: Porn studies involving female subjects: Negative effects on arousal, sexual satisfaction, and relationships). As far as we know all studies involving males have reported porn use linked to poorer sexual or relationship satisfaction.

In the first section below, studies 1 & 2 are meta-analyses, study #3 had porn users attempt to quit using porn for 3 weeks, and studies 4 through 8 are longitudinal:

1) Pornography Consumption and Satisfaction: A Meta-Analysis (2017) - This meta-analysis of various other studies assessing sexual and relationship satisfaction reported that porn use was consistently related to lower sexual and relationship satisfaction (interpersonal satisfaction). While some studies report little negative effect of porn use on sexual and relationship satisfaction in women, it's important to know that a relatively small percentage of coupled females (across the population) regularly consume internet porn. Cross-sectional data from the largest US survey (General Social Survey) suggest that only 2.6% of women had visited a "pornographic website" in the last month (2002-2004). An excerpt:

However, pornography consumption was associated with lower interpersonal satisfaction outcomes in cross-sectional surveys, longitudinal surveys, and experiments. Associations between pornography consumption and reduced interpersonal satisfaction outcomes were not moderated by their year of release or their publication status. But analyses by sex indicted significant results for men only.

2) Women's perceptions of their male partners’ pornography consumption and relational, sexual, self, and body satisfaction: toward a theoretical model (2017) - Excerpts:

This paper’s meta-analysis of quantitative studies conducted to date primarily supports the hypothesis that the majority of women are negatively impacted by the perception that their partner is a pornography consumer. In main analyses including all of the available studies, perceiving partners as pornography consumers was significantly associated with less relational, sexual, and body satisfaction. The association for self satisfaction was also negative. The results also suggested that women’s satisfaction will generally decrease in correspondence with the perception that their partners are consuming pornography more frequently.

Perceiving male partners as more frequent consumers of pornography was significantly associated with less relational and sexual satisfaction.

Finally, the possibility of a publication bias was also explored. Taken in totality, the results did not suggest that publication bias is a significant concern in this literature.

3) A Love That Doesn’t Last: Pornography Consumption and Weakened Commitment to One’s Romantic Partner (2012) – The study had subjects try to abstain from porn use for 3 weeks. Upon comparing the two groups, those who continued using pornography reported lower levels of commitment than those who tried to abstain. Excerpts:

Study 1 found that higher pornography consumption was related to lower commitment

Study 3 participants were randomly assigned to either refrain from viewing pornography or to a self-control task. Those who continued using pornography reported lower levels of commitment than control participants.

Study 5 found that pornography consumption was positively related to infidelity and this association was mediated by commitment. Overall, a consistent pattern of results was found using a variety of approaches including cross-sectional (Study 1), observational (Study 2), experimental (Study 3), and behavioral (Studies 4 and 5) data.

4) Internet pornography and relationship quality: A longitudinal study of within and between partner effects of adjustment, sexual satisfaction and sexually explicit internet material among newly-weds (2015) - Longitudinal study. Excerpt:

The data from a considerable sample of newlyweds showed that SEIM use has more negative than positive consequences for husbands and wives. Importantly, husbands’ adjustment decreased SEIM use over time and SEIM use decreased adjustment. Furthermore, more sexual satisfaction in husbands predicted a decrease in their wives’ SEIM use one year later, while wives’ SEIM use did not change their husbands’ sexual satisfaction.

5) Does Viewing Pornography Reduce Marital Quality Over Time? Evidence from Longitudinal Data (2016) - First longitudinal study on a representative cross-section of married couples. It found significant negative effects of porn use on marriage quality over time. Excerpt:

This study is the first to draw on nationally representative, longitudinal data (2006-2012 Portraits of American Life Study) to test whether more frequent pornography use influences marital quality later on and whether this effect is moderated by gender. In general, married persons who more frequently viewed pornography in 2006 reported significantly lower levels of marital quality in 2012, net of controls for earlier marital quality and relevant correlates. Pornography's effect was not simply a proxy for dissatisfaction with sex life or marital decision-making in 2006. In terms of substantive influence, frequency of pornography use in 2006 was the second strongest predictor of marital quality in 2012. Interaction effects revealed, however, that the negative effect of porn use on marital quality applied to husbands, but not wives.

Note: When the author was asked privately about the raw numbers of women who reported increased satisfaction as porn use increased, he said:

I can't remember the exact number off the top of my head, but I recall it being pretty small.

6) Till Porn Do Us Part? Longitudinal Effects of Pornography Use on Divorce (2017) - This longitudinal study used nationally representative General Social Survey panel data collected from thousands of American adults. Respondents were interviewed three times about their pornography use and marital status -- every two years from 2006-2010, 2008-2012, or 2010-2014. Excerpts:

Beginning pornography use between survey waves nearly doubled one's likelihood of being divorced by the next survey period, from 6 percent to 11 percent, and nearly tripled it for women, from 6 percent to 16 percent. Our results suggest that viewing pornography, under certain social conditions, may have negative effects on marital stability. Conversely, discontinuing pornography use between survey waves was associated with a lower probability of divorce, but only for women.

Additionally, the researchers found that respondents' initially reported level of marital happiness played an important role in determining the magnitude of pornography's association with the probability of divorce. Among people who reported they were "very happy" in their marriage in the first survey wave, beginning pornography viewership before the next survey was associated with a noteworthy increase -- from 3 percent to 12 percent -- in the likelihood of getting divorced by the time of that next survey.

Additional analyses also showed that the association between beginning pornography use and the probability of divorce was particularly strong among younger Americans, those who were less religious, and those who reported greater initial marital happiness.

7) Pornography Use and Marital Separation: Evidence from Two-Wave Panel Data (2017) – Longitudinal study. Excerpts:

Drawing on data from the 2006 and 2012 waves of the nationally representative Portraits of American Life Study, this article examined whether married Americans who viewed pornography in 2006, either at all or in greater frequencies, were more likely to experience a marital separation by 2012. Binary logistic regression analyses showed that married Americans who viewed pornography at all in 2006 were more than twice as likely as those who did not view pornography to experience a separation by 2012, even after controlling for 2006 marital happiness and sexual satisfaction as well as relevant sociodemographic correlates. The relationship between pornography use frequency and marital separation, however, was technically curvilinear. The likelihood of marital separation by 2012 increased with 2006 pornography use to a point and then declined at the highest frequencies of pornography use.

8) Are Pornography Users More Likely to Experience A Romantic Breakup? Evidence from Longitudinal Data (2017) – Longitudinal study. Excerpts:

This study examined whether Americans who use pornography, either at all or more frequently, are more prone to report experiencing a romantic breakup over time. Longitudinal data were taken from the 2006 and 2012 waves of the nationally representative Portraits of American Life Study. Binary logistic regression analyses demonstrated that Americans who viewed pornography at all in 2006 were nearly twice as likely as those who never viewed pornography to report experiencing a romantic breakup by 2012, even after controlling for relevant factors such as 2006 relationship status and other sociodemographic correlates. This association was considerably stronger for men than for women and for unmarried Americans than for married Americans. Analyses also showed a linear relationship between how frequently Americans viewed pornography in 2006 and their odds of experiencing a breakup by 2012.

The remaining studies are listed by date of publication:

1) Effect of Erotica on Young Men's Aesthetic Perception of Their Female Sexual Partners (1984) - Excerpt:

Male undergraduates were exposed to (a) nature scenes or (b) beautiful versus (c) unattractive females in sexually enticing situations. Thereafter, they assessed their girl friends' sexual appeal and evaluated their satisfaction with their mates. On pictorial measures of bodily appeal profiles of flat through hypervoluptuous breast and buttock, preexposure to beautiful females tended to suppress mates' appeal, while preexposure to unattractive females tended to enhance it. After exposure to beautiful females, mates' aesthetic value fell significantly below assessments made after exposure to unattractive females; this value assumed an intermediate position after control exposure. Changes in mates' aesthetic appeal did not correspond with changes in satisfaction with mates, however.

2) Effects of Prolonged Consumption of Pornography on Family Values (1988) - Excerpt:

Male and female students and nonstudents were exposed to videotapes featuring common, nonviolent pornography or innocuous content. Exposure was in hourly sessions in six consecutive weeks. In the seventh week, subjects participated in an ostensibly unrelated study on societal institutions and personal gratifications. Marriage, cohabitational relationships, and related issues were judged on an especially created Value-of-Marriage questionnaire. The findings showed a consistent impact of pornography consumption. Exposure prompted, among other things, greater acceptance of pre- and extramarital sex and greater tolerance of nonexclusive sexual access to intimate partners. It enhanced the belief that male and female promiscuity are natural and that the repression of sexual inclinations poses a health risk. Exposure lowered the evaluation of marriage, making this institution appear less significant and less viable in the future. Exposure also reduced the desire to have children and promoted the acceptance of male dominance and female servitude. With few exceptions, these effects were uniform for male and female respondents as well as for students and nonstudents.

3) Pornography’s Impact on Sexual Satisfaction (1988) - Excerpt:

Male and female students and nonstudents were exposed to videotapes featuring common, nonviolent pornography or innocuous content. Exposure was in hourly sessions in six consecutive weeks. In the seventh week, subjects participated in an ostensibly unrelated study on societal institutions and personal gratifications. [Porn use] strongly impacted self-assessment of sexual experience. After consumption of pornography, subjects reported less satisfaction with their intimate partners—specifically, with these partners' affection, physical appearance, sexual curiosity, and sexual performance proper. In addition, subjects assigned increased importance to sex without emotional involvement. These effects were uniform across gender and populations.

4) Influence of popular erotica on judgments of strangers and mates (1989) - Excerpt:

In Experiment 2, male and female subjects were exposed to opposite sex erotica. In the second study, there was an interaction of subject sex with stimulus condition upon sexual attraction ratings. Decremental effects of centerfold exposure were found only for male subjects exposed to female nudes. Males who found the Playboy-type centerfolds more pleasant rated themselves as less in love with their wives.

5) Men’s leisure and women’s lives: The impact of pornography on women (1999) - Excerpt:

The section of the interview where the women discussed their own current or past relationships with men revealed additional insight into the effect of pornography on such relationships. Fifteen of the women were in, or had been in, relationships with men who rented or bought pornography at least on an occasional basis. Of these 15 women, four expressed strong dislike of their husband’s or partner’s leisure time interest in pornography. It was clear that the husbands’ use of pornography affected the wives’ feeling about themselves, their sexual feelings, and their marital relationships in general

6) Adult Social Bonds and Use of Internet Pornography (2004) - Excerpt:

Complete data on 531 Internet users are taken from the General Social Surveys for 2000. Social bonds measures include religious, marital, and political ties. Measures of participation in sexual and drug-related deviant lifestyles, and demographic controls are included. The results of a logistic regression analysis found that among the strongest predictors of use of cyberporn were weak ties to religion and lack of a happy marriage.

7) Sex in America Online: An Exploration of Sex, Marital Status, and Sexual Identity in Internet Sex Seeking and Its Impacts (2008) - Excerpt:

This was an exploratory study of sex and relationship seeking on the Internet, based on a survey of 15,246 respondents in the United States Seventy-five percent of men and 41% of women had intentionally viewed or downloaded porn. Men and gays/lesbians were more likely to access porn or engage in other sex-seeking behaviors online compared with straights or women. A symmetrical relationship was revealed between men and women as a result of viewing pornography, with women reporting more negative consequences, including lowered body image, partner critical of their body, increased pressure to perform acts seen in pornographic films, and less actual sex, while men reported being more critical of their partners' body and less interested in actual sex.

8) Adolescents’ Exposure to Sexually Explicit Internet Material and Sexual Satisfaction: A Longitudinal Study (2009) - Excerpt:

Between May 2006 and May 2007, we conducted a three-wave panel survey among 1,052 Dutch adolescents aged 13–20. Structural equation modeling revealed that exposure to SEIM consistently reduced adolescents’ sexual satisfaction. Lower sexual satisfaction (in Wave 2) also increased the use of SEIM (in Wave 3). The effect of exposure to SEIM on sexual satisfaction did not differ among male and female adolescents.

9) Wives' Experience of Husbands' Pornography Use and Concomitant Deception as an Attachment Threat in the Adult Pair-Bond Relationship (2009) - Excerpt:

Evidence is growing that pornography use can negatively impact attachment trust in the adult pair-bond relationship. Analyses uncovered three attachment-related impacts from husbands' pornography use and deception: (1) the development of an attachment fault line in the relationship, stemming from perceived attachment infidelity; (2) followed by a widening attachment rift arising from wives' sense of distance and disconnection from their husbands; (3) culminating in attachment estrangement from a sense of being emotionally and psychologically unsafe in the relationship. Overall, wives reported global mistrust indicative of attachment breakdown.

10) Sexual media use and relational satisfaction in heterosexual couples (2010) - Sharing porn was better than using alone. But how many couples use porn together? Not too many. Porn use is still bad for men. Excerpt:

This study assessed how sexual media use by one or both members of a romantic dyad relates to relationship and sexual satisfaction. A total of 217 heterosexual couples completed an Internet survey that assessed sexual media use, relationship and sexual satisfaction, and demographic variables. Results revealed that a higher frequency of men's sexual media use related to negative satisfaction in men, while a higher frequency of women's sexual media use related to positive satisfaction in male partners. Reasons for sexual media use differed by gender: Men reported primarily using sexual media for masturbation, while women reported primarily using sexual media as part of lovemaking with their partners. Shared sexual media use was associated with higher relational satisfaction compared to solitary sexual media use.

11) Exploring actor and partner correlates of sexual satisfaction among married couples (2010) - Excerpt:

Using the Interpersonal Exchange Model of Sexual Satisfaction, we consider how infidelity, pornography consumption, marital satisfaction, sexual frequency, premarital sex, and cohabitation are associated with married couples’ sexual satisfaction. Data from 433 couples are analyzed with structural equation models to determine the contributions. Finally, some evidence suggests that pornography consumption is costly for own and spouse’s sexual satisfaction, especially when pornography is used by only one spouse.

12) Individuals who never viewed SEM reported higher relationship quality on all indices than those who viewed SEM alone (2011) - Excerpt:

As expected, individuals who did not view SEM (sexually explicit material) at all reported lower negative communication and higher dedication than individuals who viewed SEM alone or both alone and with their partner.

13) Associations between young adults’ use of sexually explicit materials and their sexual preferences, behaviors, and satisfaction (2011) - Excerpts:

Higher frequencies of sexual explicit material (SEM) use were associated with less sexual and relationship satisfaction. The frequency of SEM use and number of SEM types viewed were both associated with higher sexual preferences for the types of sexual practices typically presented in SEM. These findings suggest that SEM use can play a significant role in a variety of aspects of young adults' sexual development processes.

Specifically, higher viewing frequency was associated with less sexual and relationship satisfaction when controlling for gender, religiosity, dating status and the number of SEM types viewed.

Because a substantial proportion of the young adults in this study reported using SEM, the potential implications are especially noteworthy, particularly for young men.

14) Viewing Sexually-Explicit Materials Alone or Together: Associations with Relationship Quality (2011) - Excerpt:

This study investigated associations between viewing sexually-explicit material (SEM) and relationship functioning in a random sample of 1291 unmarried individuals in romantic relationships. More men (76.8%) than women (31.6%) reported that they viewed SEM on their own, but nearly half of both men and women reported sometimes viewing SEM with their partner (44.8%). 

Individuals who never viewed SEM reported higher relationship quality on all indices than those who viewed SEM alone. Those who viewed SEM only with their partners reported more dedication and higher sexual satisfaction than those who viewed SEM alone. The only difference between those who never viewed SEM and those who viewed it only with their partners was that those who never viewed it had lower rates of infidelity.

15) 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 (2012) - Excerpt:

The purpose of this study was to examine the relationships between men’s pornography use, both frequency and problematic use, on their heterosexual female partner’s psychological and relational well-being among 308 young adult college women. Results revealed women’s reports of their male partner’s frequency of pornography use were negatively associated with their relationship quality. More perceptions of problematic use of pornography was negatively correlated with self-esteem, relationship quality, and sexual satisfaction.

16) Pornography use: who uses it and how it is associated with couple outcomes (2013) - Excerpt:

This study examined associations among pornography use, the meaning people attach to its use, sexual quality, and relationship satisfaction. Participants were couples (N = 617 couples) who were either married or cohabiting at the time the data were gathered. Overall results from this study indicated substantial gender differences in terms of use profiles, as well as pornography's association with relationship factors. Specifically, male pornography use was negatively associated with both male and female sexual quality, whereas female pornography use was positively associated with female sexual quality.

17) Internet Pornography Exposure and Women's Attitude Towards Extramarital Sex: An Exploratory Study (2013) - Excerpt:

This exploratory study assessed the association between adult U.S. women's exposure to Internet pornography and attitude towards extramarital sex using data provided by the General Social Survey (GSS). A positive association between Internet pornography viewing and more positive extramarital sex attitudes was found.

18) Pornography and Marriage (2014) - The abstract:

We used data on 20,000 ever-married adults in the General Social Survey to examine the relationship between watching pornographic films and various measures of marital well-being. We found that adults who had watched an X-rated movie in the past year were more likely to be divorced, more likely to have had an extramarital affair, and less likely to report being happy with their marriage or happy overall. We also found that, for men, pornography use reduced the positive relationship between frequency of sex and happiness.

Finally, we found that the negative relationship between pornography use and marital well-being has, if anything, grown stronger over time, during a period in which pornography has become both more explicit and more easily available.

19) More than a dalliance? Pornography consumption and extramarital sex attitudes among married U.S. adults (2014) - Excerpts:

This brief report used national panel data gathered from two separate samples of married U.S. adults. Data were gathered from the first sample in 2006 and in 2008. Data were gathered from the second sample in 2008 and in 2010. Consistent with a social learning perspective on media, prior pornography consumption was correlated with more positive subsequent extramarital sex attitudes in both samples, even after controlling for earlier extramarital sex attitudes and nine additional potential confounds.

In total, the results of the present study are consistent with the theoretical premise that pornography consumption leads to the acquisition and activation of sexual scripts, which are then used by many consumers to inform their sexual attitudes (Wright, 2013a; Wright et al., 2012a).

20) Korean Men’s Pornography use, Their Interest in Extreme Pornography, and Dyadic Sexual Relationships (2014) - Excerpt:

Six-hundred eighty-five heterosexual South Korean male college students participated in an online survey. The majority (84.5%) of respondents had viewed pornography, and for those who were sexually active (470 respondents), we found that higher interest in degrading or extreme pornography was associated with the experience of role-playing sexual scenes from pornography with a partner, and a preference for using pornography to achieve and maintain sexual excitement over having sex with a partner.

We found that higher interest in viewing degrading or extreme pornography ... has a significant positive ... association with sexual concerns.

21) Pornography and the Male Sexual Script: An Analysis of Consumption and Sexual Relations (2014) - Excerpt:

We argue pornography creates a sexual script that then guides sexual experiences. To test this, we surveyed 487 college men (ages 18-29 years) in the United States to compare their rate of pornography use with sexual preferences and concerns. Results showed the more pornography a man watches, the more likely he was to use it during sex, request particular pornographic sex acts of his partner, deliberately conjure images of pornography during sex to maintain arousal, and have concerns over his own sexual performance and body image. Further, higher pornography use was negatively associated with enjoying sexually intimate behaviors with a partner.

22) Psychological, Relational, and Sexual Correlates of Pornography Use on Young Adult Heterosexual Men in Romantic Relationships (2014) - Excerpt:

Thus, the purpose of this study was to examine theorized antecedents (i.e., gender role conflict and attachment styles) and consequences (i.e., poorer relationship quality and sexual satisfaction) of men's pornography use among 373 young adult heterosexual men. Findings revealed that both frequency of pornography use and problematic pornography use were related to greater gender role conflict, more avoidant and anxious attachment styles, poorer relationship quality, and less sexual satisfaction. In addition, the findings provided support for a theorized mediated model in which gender role conflict was linked to relational outcomes both directly and indirectly via attachment styles and pornography use.

23) Associations between relational sexual behaviour, pornography use, and pornography acceptance among US college students (2014) - Excerpt:

Using a sample of 792 emerging adults, the present study explored how the combined examination of pornography use, acceptance, and sexual behaviour within a relationship might offer insight into emerging adults' development. Results suggested clear gender differences in both pornography use and acceptance patterns.

High male pornography use tended to be associated with high engagement in sex within a relationship and was associated with elevated risk-taking behaviours.

High female pornography use was not associated with engagement in sexual behaviours within a relationship and was general associated with negative mental health outcomes.

24) Factors Predicting Cybersex Use and Difficulties in Forming Intimate Relationships among Male and Female Users of Cybersex (2015) - Excerpt:

This study used the Cybersex addiction test, Craving for pornography questionnaire, and a Questionnaire on intimacy among 267 participants (192 males and 75 females) mean age for males 28 and for females 25, who were recruited from special sites that are dedicated to pornography and cybersex on the Internet.

Results of regression analysis indicated that pornography, gender, and cybersex significantly predicted difficulties in intimacy and it accounted for 66.1% of the variance of rating on the intimacy questionnaire. Second, regression analysis also indicated that craving for pornography, gender, and difficulties in forming intimate relationships significantly predicted frequency of cybersex use and it accounted for 83.7% of the variance in ratings of cybersex use.

25) Male Partners’ Perceived Pornography Use and Women’s Relational and Psychological Health: The Roles of Trust, Attitudes, and Investment (2015) - Excerpt:

Results revealed that women’s reports of their male partners’ pornography use were related to less relationship satisfaction and more psychological distress. Results from the moderation analyses indicated that the direct effect of male partners’ perceived pornography use and relationship trust and the conditional indirect effects of male partners’ perceived pornography use on both relationship satisfaction and psychological distress were contingent on relationship investment.

These findings indicated that when male partners’ perceived pornography use is high, women who have low or mean levels of relationship investment have less relationship trust. Finally, our results revealed that the relationship between male partners’ perceived pornography use and relational and psychological outcomes exist regardless of women’s own attitudes toward pornography

26) Relationship of love and marital satisfaction with pornography among married university students in Birjand, Iran (2015) - Excerpts:

This descriptive-correlation study was conducted on 310 married students studying at private and public universities in Birjand, in 2012-2013 academic year using random quota sampling method. It appears that pornography has a negative impact on love and marital satisfaction.

27) From Bad to Worse? Pornography Consumption, Spousal Religiosity, Gender, and Marital Quality (2016) - Excerpts:

I test the above hypotheses using data from Wave 1 of the Portraits of American Life Study (PALS), which was fielded in 2006. PALS is a nationally representative panel survey with questions focusing on a variety of topics.... Looking at bivariate correlations, for the full sample, viewing pornography is negatively associated with overall marital satisfaction, suggesting that those who view pornography more often tend to be less satisfied in their marriage than those who view pornography less often or never

28) Sexually explicit media use and relationship satisfaction a moderating role of emotional intimacy? (2016) - The authors attempted to obfuscate their findings in the abstract by stating that once sexual and relationship variables were "controlled for," they found no link between porn use and relationship satisfaction. Reality: The study found significant correlations between porn use and poorer relationship and sexual satisfaction in both males and females. Excerpt from discussion section:

For both men and women, significant, yet modest negative zero-order correlations between SEM use and relationship satisfaction were found, indicating that increased SEM use was associated with lower relationship satisfaction across gender.

29) Effect of soft core pornography on female sexuality (2016) - Excerpt:

An overall 51.6% of participants who were aware that their husbands were positive watchers reported experiencing negative emotions (depression, jealous), whereas 77% reported changes in their husbands’ attitude. Non-watchers watchers were more satisfied with their sexual life compared with their counterparts. Although watching soft-core pornography had a statistically significant effect on sexual desire, vaginal lubrication, ability to reach orgasm, and masturbation, it had no statistically significant effect on coital frequency. Watching soft-core pornography affects female sexual life by increasing sexual boredom in both men and women, causing relational difficulties.

30) A Common-Fate Analysis of Pornography Acceptance, Use, and Sexual Satisfaction Among Heterosexual Married Couples (2016) - Excerpt:

Results indicated that the shared variance of pornography acceptance was positively associated with both spouses' pornography use and that spouses' pornography use was negatively associated with their own sexual satisfaction. Wives' pornography use was found to be positively associated with the couple's shared variance of sexual satisfaction, but pornography use did not significantly mediate the relationship between pornography acceptance and sexual satisfaction.

31) Differences in Pornography Use Among Couples: Associations with Satisfaction, Stability, and Relationship Processes (2016) - Excerpt:

The present study utilized a sample of 1755 adult couples in heterosexual romantic relationships to examine how different patterns of pornography use between romantic partners may be associated with relationship outcomes. While pornography use has been generally associated with some negative and some positive couple outcomes, no study has yet explored how differences between partners may uniquely be associated with relationship well-being.

Results suggested that greater discrepancies between partners in pornography use were related to less relationship satisfaction, less stability, less positive communication, and more relational aggression. Mediation analyses suggested that greater pornography use discrepancies were primarily associated with elevated levels of male relational aggression, lower female sexual desire, and less positive communication for both partners which then predicted lower relational satisfaction and stability for both partners.

32) Internet Pornography Consumption and Relationship Commitment of Filipino Married Individuals (2016) - Excerpt:

Internet pornography has many adverse effects, especially to the relationship commitment. The use of pornography directly correlates to a decrease in sexual intimacy. Hence, this might lead to weakening of the relationship of their partner. To find out the relevance of the claim, the researchers aimed to explore the relationship of Internet pornography consumption to the relationship commitment of married individuals in the Philippines.

It is revealed that Internet pornography consumption has an adverse effect on the relationship commitment of married Filipino couples. Furthermore, watching porn online weakened the relationship commitment that leads to an unstable relationship. This investigation found out that internet pornography consumption has a nominal negative effect on the relationship commitment of Filipino married individuals.

33) Perceptions of relationship satisfaction and addictive behavior: Comparing pornography and marijuana use (2016) - Excerpt:

This study contributes to the broader literature on how pornography use impacts perceptions of romantic relationships. This study examined if negative outcomes due to a romantic partner’s excessive pornography use are different than negative outcomes produced by other compulsive or addictive behaviors, specifically marijuana use. This study suggests that problematic partner pornography use and problematic partner marijuana use are perceived to similarly impact romantic relationships and contribute to a decrease in relationship satisfaction.

34) The effects of sexually explicit material use on romantic relationship dynamics (2016) - Excerpts:

More specifically, couples, where no one used, reported more relationship satisfaction than those couples that had individual users. This is consistent with the previous research (Cooper et al., 1999; Manning, 2006), demonstrating that the solitary use of sexually explicit material results in negative consequences.

With gender effects held constant, individual users reported significantly less intimacy and commitment in their relationships than non-users and shared users.

Overall, how frequently someone views sexually explicit material can have an impact on users’ consequences. Our study found that high frequency users are more likely to have lower relationship satisfaction and intimacy in their romantic relationships.

35) Cyberpornography: Time Use, Perceived Addiction, Sexual Functioning, and Sexual Satisfaction (2016) - Excerpt:

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

36) Relationship quality predicts online sexual activities among Chinese heterosexual men and women in committed relationships (2016) - Excerpt:

In this study, we examined the online sexual activities (OSAs) of Chinese men and women in committed relationships, with a focus on the characteristics of OSAs and the factors prompting men and women with steady partners to engage in OSAs. Almost 89% of the participants reported OSA experiences in the past 12 months even when they had a real-life partner. As predicted, individuals with lower relationship quality in real life, including low relationship satisfaction, insecure attachment, and negative communication patterns, engaged in OSAs more frequently. Overall, our results suggest that variables influencing offline infidelity may also influence online infidelity.

37) The Role of Internet Pornography Use and Cyber Infidelity in the Associations between Personality, Attachment, and Couple and Sexual Satisfaction (2017) - Excerpts:

Our results indicated that pornography use is associated with couple and sexual difficulties through increased cyber infidelity.

Pornography use was negatively related to sexual satisfaction for men, but positively for women. In men, pornography use is associated with higher sexual desire, stimulation, and gratification. However, these effects may lead to decreased sexual desire their partner and decreased sexual satisfaction within the couple.

38) The Development of the Problematic Pornography Consumption Scale (PPCS) (2017) - This paper's goal was the creation of a problematic porn use questionnaire. In the process of validating the instruments, the researchers found that higher scores on the porn use questionnaire were related to lower sexual satisfaction. An excerpt:

Satisfaction with sexual life was weakly and negatively correlated with PPCS scores.

39) Explicit Sexual Movie Viewing in the United States According to Selected Marriage and Lifestyle, Work and Financial, Religion and Political Factors (2017) - Excerpts:

Analyses involved 11,372 adults who responded to questions about demographics and explicitly sexual movie use in the General Social Survey (GSS) from 2000 to 2014. Viewing such movies was related to less happiness in marriage, multiple sex partners in past year, less satisfaction with one’s financial situation, no religious preference, and a more liberal political orientation.

Explicit sexual movie viewing is associated with factors from diverse domains, including poorer relationship quality, more liberal sexual views and practices, poorer economic conditions, lower religious orientation or commitment, and more liberal political views.

40) Associative pathways between pornography consumption and reduced sexual satisfaction (2017) - Excerpt:

Guided by sexual script theory, social comparison theory, and informed by prior research on pornography, socialization, and sexual satisfaction, the present survey study of heterosexual adults tested a conceptual model linking more frequent pornography consumption to reduced sexual satisfaction via the perception that pornography is a primary source of sexual information, a preference for pornographic over partnered sexual excitement, and the devaluation of sexual communication. The model was supported by the data for both men and women.

Pornography consumption frequency was associated with perceiving pornography as a primary source of sexual information, which was associated with a preference for pornographic over partnered sexual excitement and the devaluation of sexual communication. Preferring pornographic to partnered sexual excitement and devaluing sexual communication were both associated with less sexual satisfaction.

41) The use of pornography and sexual behaviour among Norwegian men and women of differing sexual orientation (2013) - Hidden away in the study: Greater pornography use in men was correlated with lower sexual satisfaction (or "greater sexual dissatisfaction").

42)  IASR Fortieth Annual Meeting Book of Abstracts - Dubrovnik, Hrvatska, 25.-28. lipnja, 2014 - This is an abstract of a presentation given by Landripet and Stulhofer at a sexology conference. These 2 researchers published a portion of their data in this "brief communication," which is cited as finding no relationship between porn use and sexual problems. In reality, their "brief communication" doesn't mention a pretty important correlation mentioned in their paper: 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. In a shocking move, Landripet & Stulhofer omitted three other correlations between porn use and sexual problems which they presented to at the Dubrovnik 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 significant correlation between erectile dysfunction and preferences for specific genres of porn from their "brief" 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 in this review of the literature (and this critique of Landripet & Stulhofer), 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 year.

43) The pervasive role of sex mindset: Beliefs about the malleability of sexual life is linked to higher levels of relationship satisfaction and sexual satisfaction and lower levels of problematic pornography use (2017) - Excerpt:

The examined model showed that growth sex mindset had moderate positive association with sexual satisfaction and relationship satisfaction while problematic pornography use only showed a negative, but weak one.

44) He’s Just Not That Into Anyone: the Impact of Sex Fantasy on Attraction (2017) - This "extended abstract" discusses 4 experiments that involved fantasizing about sexual stimuli. All results suggested that sexual fantasy reduces desire for romantic relationships. Excerpt:

Engaging in sexual fantasy increases attraction to sexual targets, but decreases attraction to romantic targets. This research adds to the literature on sex fantasy, attraction, and offers practical implications on porn watching, sex in advertising, and relationships.

45) Is the Relationship Between Pornography Consumption Frequency and Lower Sexual Satisfaction Curvilinear? Results From England and Germany (2017) - Excerpts:

Several studies using different methods have found that pornography consumption is associated with lower sexual satisfaction. The language used by media-effects scholars in discussions of this association implies an expectation that lowered satisfaction is primarily due to frequent-but not infrequent-consumption. Actual analyses, however, have assumed linearity. Linear analyses presuppose that for each increase in the frequency of pornography consumption there is a correspondingly equivalent decrease in sexual satisfaction.

Survey data from two studies of heterosexual adults, one conducted in England and the other in Germany, were employed. Results were parallel in each country and were not moderated by gender. Simple slope analyses suggested that when the frequency of consumption reaches once a month, sexual satisfaction begins to decrease, and that the magnitude of the decrease becomes larger with each increase in the frequency of consumption.

46) Personal Pornography Viewing and Sexual Satisfaction: A Quadratic Analysis (2017) - Excerpts

This article presents results from a survey of approximately 1,500 U.S. adults. Quadratic analyses indicated a curvilinear relationship between personal pornography viewing and sexual satisfaction in the form of a predominately negative, concave downward curve. The nature of the curvilinearity did not differ as a function of participants' gender, relationship status, or religiosity.

For all groups, negative simple slopes were present when viewing reached once a month or more. These results are correlational only. However, if an effects perspective were adopted, they would suggest that consuming pornography less than once a month has little or no impact on satisfaction, that reductions in satisfaction tend to initiate once viewing reaches once a month, and that additional increases in the frequency of viewing lead to disproportionately larger decrements in satisfaction.

47) The Survey of Sexual Health and Pornography among Divorce-Asking Women in West Azerbaijan-Iran: A Cross-Sectional Study (2017) - Excerpts:

One of the factors affecting the incidence of divorce and relationship problems between couples is the sexual and marital behaviors. There are several different reasons to suspect that pornography might affect divorce in either a positive or a negative way. Therefore this study evaluated the sexual health of divorce-asking in Urmia, Iran.

Conclusions: The results of the study indicated that who had low sexual satisfaction score, had higher rate of watching pornography clips. Based on current study, paying attention to family education and counseling programs especially in the sexual field will be more fruitful.

48) Pornography consumption of young adults in the context of gender stereotypes and sexual behaviour (2017) - Excerpts:

In the empirical study an online questionnaire about consumption habits and sexual behaviour was filled in by 130 young adults between 18 and 30 years.  While there are less accurate coherences of female pornography consumption habits, males could feel possible influences in their sex-life, because of an higher pornography consumption frequency. The pornography consumption habits of men are correlating negatively with the reported frequency of sexual intercourse and ratings of their sexual life.

49) Pornography Use: Its Impact On Heterosexual Men’s Lives & Romantic Relationship (2018) - Excerpts:

180 males aged 18 - 29 years responded to the Pornography Use Scale, Pornography Consumption Effect Scale (PCES), and Investment Model Scale. Our study demonstrates that the more pornography males used, the more problems it created in their lives. Similarly, the men’s perception of negative effects of pornography increased and their perception of the positive effects of pornography decreased with increased use of pornography.

As pornography use in males increase, their commitment, satisfaction and investment in their romantic relationships decrease, while their perception of attractive alternatives outside their relationship increases.

Excerpts from a 2018 review of the literature (Pornography, Pleasure, and Sexuality: Towards a Hedonic Reinforcement Model of Sexually Explicit Internet Media Use, summarizing porn's effects on sexual satisfaction:

Sexual Satisfaction:

Another domain in which the present model may also have implications is sexual satisfaction. As hedonic sexual motives are often focused on obtaining sexual satisfaction, one would expect an increase in such motives to be associated with sexual satisfaction outcomes. However, given the immense number of factors that contribute to sexual satisfaction (e.g., relational intimacy, commitment, self-confidence, self-esteem), it also likely that these relationships between IPU and satisfaction will be complex. For some individuals, an increase in hedonic sexual motives may be associated with actual decreases in sexual satisfaction, as high levels of desire may be met with frustration, particularly if such increases are not met with increases in the satisfaction associated with partnered sexual activity (Santtila et al., 2007). Alternatively, if one were to start with low levels of hedonic sexual motivation, an increase in such motivation may be associated with greater sexual satisfaction as the individual becomes more focused on obtaining pleasure in a sexual encounter.

In contrast to many of the previously discussed domains related to IPU and motivations, in which research is still burgeoning, the relationships between IPU and sexual satisfaction have been extensively studied, with dozens of publications addressing the topic. Rather than exhaustively review the list of studies examining IPU and sexual satisfaction, the findings of these studies are summarized in Table 1.

In general, as indicated in Table 1, the relationships between IPU and personal sexual satisfaction are complex, but consistent with the supposition that IP may promote more hedonic sexual motivations, particularly as use increases. Among couples, there is limited support for the idea that IPU may enhance sexual satisfaction, but only when it is incorporated into partnered sexual activities. On an individual level, there is consistent evidence that IPU is predictive of lower sexual satisfaction in men, with both cross-sectional and longitudinal works pointing to the associations of such use with diminished satisfaction for men. Regarding women, scattered evidence suggests that IPU may enhance sexual satisfaction, have no effect on satisfaction, or diminish satisfaction over time. Despite these mixed findings, the conclusion of no significant effect of IPU on sexual satisfaction in women is the most common finding. These results have also been confirmed by a recent meta-analysis (Wright, Tokunaga, Kraus, & Klann, 2017). Reviewing 50 studies of pornography consumption and various satisfaction outcomes (e.g., life satisfaction, personal satisfaction, relational satisfaction, sexual satisfaction), this meta-analysis found that pornography consumption (not internet-specific) was consistently related to and predictive of lower interpersonal satisfaction variables, including sexual satisfaction, but for men only. No significant findings were found for women. Collectively, such mixed results preclude definitive conclusions about the role of IP in influencing satisfaction for women.

One of the most important findings of recent works examining IPU and sexual satisfaction is that there appears to be a curvilinear relationship between use and satisfaction, so that satisfaction decreases more sharply as IPU becomes more common (e.g., Wright, Steffen, & Sun, 2017; Wright, Brigdes, Sun, Ezzell, & Johnson, 2017). The details of these studies are reflected in Table 1. Given clear evidence across multiple international samples, it seems reasonable to accept the conclusion that as IPU increases to more than once per month, sexual satisfaction decreases. Furthermore, although these studies (Wright, Steffen, et al., 2017; Wright, Bridges et al., 2017) were cross-sectional, given the number of longitudinal studies (e.g., Peter & Valkenburg, 2009) linking IPU to lower sexual satisfaction, it is reasonable to infer that these associations are causal in nature. As IPU increases, interpersonal sexual satisfaction appears to decrease, which is consistent with the present model’s contention that IPU is associated with more hedonic and self-focused sexual motivation.


Finally, this anomalous 2016 study is often cited as evidence that porn use offers primarily benefits to couples: Perceived Effects of Pornography on the Couple Relationship: Initial Findings of Open-Ended, Participant-Informed, "Bottom-Up" Research. (2016). Click on the link to read more.

Two glaring methodical flaws produce meaningless results:

1) The study does not rest on a representative sample. Whereas most studies show that a tiny minority of porn users' female partners use porn, in this study 95% of the women used porn on their own. And 85% of the women had used porn since the beginning of the relationship (in some cases for years). Those rates are higher than in college-aged men! In other words, the researchers appear to have skewed their sample to produce the results they were seeking. Reality: Cross-sectional data from the largest US survey (General Social Survey) reported that only 2.6% of women had visited a "pornographic website" in the last month. Data from 2000, 2002, 2004. For more see - Pornography and Marriage (2014)

2) The study used "open ended" questions where the subject could ramble on and on about porn. Then the researchers read the ramblings and decided, after the fact, what answers were "important," and how to present (spin?) them in their paper. Then the researchers then had the gall to suggest that all the other studies on porn and relationships, which employed more established, scientific methodology and straightforward questions about porn's effects, were flawed. How is this method justified?

Despite these fatal flaws several couples reported significant negative effects from porn use, such as:

  • Pornography is easier, more interesting, more arousing, more desirable, or more gratifying than sex with a partner
  • Pornography use is desensitizing, decreases the ability to achieve or maintain sexual arousal, or to achieve orgasm.
  • Some said that specifically described desensitization as the effect of pornography use
  • Some were concerned a loss of intimacy or love.
  • It was suggested that pornography makes real sex more boring, more routine, less exiting, or less enjoyable

For some reason these negative effects did not appear in articles about the study. The lead author’s new website and his attempt at fundraising raise a few questions.


Thousands of recovery stories consistent with the above research can be found on these pages:


 

Porn use studies involving female subjects: Effects on arousal, sexual satisfaction, and relationships

Comments: While a few studies report little effect of women's porn use on women's sexual and relationship satisfaction, most do report negative effects. This page contains studies linking female porn use to lower sexual or relationship satisfaction.

When evaluating the research, it's important to know that a relatively small percentage of all coupled females regularly consumes internet porn. Large, nationally representative data are scarce, but the General Social Survey reported that only 2.6% of all US women had visited a "pornographic website" in the last month. The question was only asked in 2002 and 2004 (see Pornography and Marriage, 2014). While rates of porn use by some age groups of adult women have increased since 2004, be careful when comparing rates from other studies. Very few studies are nationally representative (all age groups), and often ask if the subject has seen pornography in the last 12 months. The takeaway is that studies reporting positive or neutral effects on relationship satisfaction (or other variables) are deriving this correlation from the small percentage of females who are: (1) regular porn users, and, (2) in long-term relationships (perhaps 3-5% of adult females).

Also, It may be that coupled use is less detrimental to users, and coupled use of porn is more common in women (as compared with men).

In any case, in contrast with the few studies reporting no decreased sexual/relationship dissatisfaction in female porn users, below are the many studies linking porn use in women to poorer relationship and sexual satisfaction outcomes in women.

Studies on relationships and sexual satisfaction:


Associative pathways between pornography consumption and reduced sexual satisfaction (2017) - 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:

Guided by sexual script theory, social comparison theory, and informed by prior research on pornography, socialization, and sexual satisfaction, the present survey study of heterosexual adults tested a conceptual model linking more frequent pornography consumption to reduced sexual satisfaction via the perception that pornography is a primary source of sexual information, a preference for pornographic over partnered sexual excitement, and the devaluation of sexual communication. The model was supported by the data for both men and women.

Pornography consumption frequency was associated with perceiving pornography as a primary source of sexual information, which was associated with a preference for pornographic over partnered sexual excitement and the devaluation of sexual communication. Preferring pornographic to partnered sexual excitement and devaluing sexual communication were both associated with less sexual satisfaction.

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.


Till Porn Do Us Part? Longitudinal Effects of Pornography Use on Divorce (2017) - This longitudinal study used nationally representative General Social Survey panel data collected from thousands of American adults. Respondents were interviewed three times about their pornography use and marital status -- every two years from 2006-2010, 2008-2012, or 2010-2014. Excerpts:

Our study is the first to examine how viewing pornography could be associated with marital stability using data that are nationally representative and longitudinal. Using a doubly robust approach that allows us to isolate the longitudinal association between viewing pornography and likelihood of divorce, we find that the likelihood of divorce roughly doubles for those who begin pornography use between waves. While this association looks slightly stronger for women in terms of predicted probabilities, men and women did not differ significantly from one another. Conversely, we found that ending porn use was associated with a lower likelihood of divorce, but only for women

Beginning pornography use between survey waves nearly doubled one's likelihood of being divorced by the next survey period, from 6 percent to 11 percent, and nearly tripled it for women, from 6 percent to 16 percent. Our results suggest that viewing pornography, under certain social conditions, may have negative effects on marital stability. Conversely, discontinuing pornography use between survey waves was associated with a lower probability of divorce, but only for women.

Additional analyses also showed that the association between beginning pornography use and the probability of divorce was particularly strong among younger Americans, those who were less religious, and those who reported greater initial marital happiness


Are Pornography Users More Likely to Experience A Romantic Breakup? Evidence from Longitudinal Data (2017) - Excerpt:

This study examined whether Americans who use pornography, either at all or more frequently, are more prone to report experiencing a romantic breakup over time. Longitudinal data were taken from the 2006 and 2012 waves of the nationally representative Portraits of American Life Study. Binary logistic regression analyses demonstrated that Americans who viewed pornography at all in 2006 were nearly twice as likely as those who never viewed pornography to report experiencing a romantic breakup by 2012, even after controlling for relevant factors such as 2006 relationship status and other sociodemographic correlates. This association was considerably stronger for men than for women and for unmarried Americans than for married Americans. Analyses also showed a linear relationship between how frequently Americans viewed pornography in 2006 and their odds of experiencing a breakup by 2012.

While the likelihood of women experiencing a breakup only rose about 34 percent with earlier porn viewing (from 15.4 percent to 23.5 percent), the likelihood of male porn users experiencing a breakup was over 3.5 times that of non-porn users (22.5 percent compared to 6.3 percent).


The Development of the Problematic Pornography Consumption Scale (PPCS) (2017) - This paper's goal was the creation of a problematic porn use questionnaire. In the process of validating the instruments, the researchers found that higher scores on the porn use questionnaire were related to lower sexual satisfaction. Gender differences in relationship satisfaction were not mentioned. An excerpt:

Therefore, a total of 772 participants (females = 390, 50.5%; males = 382, 45.5%) were retained for further analyses who were between ages 18 and 54

Satisfaction with sexual life was weakly and negatively correlated with PPCS scores


Relationship quality predicts online sexual activities among Chinese heterosexual men and women in committed relationships (2016) - An excerpt:

Three hundred and forty-four participants with steady partners (i.e., dating or married) in China volunteered to take part in the study, including 178 men and 166 women from 29 provinces/regions in China. In this study, we examined the online sexual activities (OSAs) of Chinese men and women in committed relationships, with a focus on the characteristics of OSAs and the factors prompting men and women with steady partners to engage in OSAs. Almost 89% of the participants reported OSA experiences in the past 12 months even when they had a real-life partner.

As predicted, individuals with lower relationship quality in real life, including low relationship satisfaction, insecure attachment, and negative communication patterns, engaged in OSAs more frequently. Additionally, dyadic satisfaction significantly predicted OSAs among both men and women. Overall, our results suggest that variables influencing offline infidelity may also influence online infidelity.


Sexually explicit media use and relationship satisfaction a moderating role of emotional intimacy? (2016) - The authors attempt to obfuscate their findings in the abstract by stating that once sexual and relationship variables were "controlled for", they found no link between between porn use and relationship satisfaction. Reality: The study found significant correlations between porn use and poorer relationship & sexual satisfaction in both males and females. Excerpt from discussion section:

For both men and women, significant, yet modest negative zero-order correlations between SEM use and relationship satisfaction were found, indicating that increased SEM use was associated with lower relationship satisfaction across gender.


Effect of soft core pornography on female sexuality (2016) - Excerpt:

This is a cross-sectional study in which 200 sexually active married women were administered a self-filling questionnaire covering different aspects of female sexuality. All participants were free from any disease known to affect sexual function. In total 52% of the participants and 59.5% of their husbands were positive watchers.

An overall 51.6% of participants who were aware that their husbands were positive watchers reported experiencing negative emotions (depression, jealous), whereas 77% reported changes in their husbands’ attitude. Non-watchers watchers were more satisfied with their sexual life compared with their counterparts. Although watching soft-core pornography had a statistically significant effect on sexual desire, vaginal lubrication, ability to reach orgasm, and masturbation, it had no statistically significant effect on coital frequency. Watching soft-core pornography affects female sexual life by increasing sexual boredom in both men and women, causing relational difficulties.


Internet Pornography Consumption and Relationship Commitment of Filipino Married Individuals (2016) - Excerpt:

A self-administered survey was distributed to 400 selected Filipino married individuals who were married individuals that are watching pornography on the Internet who are living in Quezon City.

Internet pornography has many adverse effects, especially to the relationship commitment. The use of pornography directly correlates to a decrease in sexual intimacy. Hence, this might lead to weakening of the relationship of their partner. To find out the relevance of the claim, the researchers aimed to explore the relationship of Internet pornography consumption to the relationship commitment of married individuals in the Philippines. It is revealed that Internet pornography consumption has an adverse effect on the relationship commitment of married Filipino couples. Furthermore, watching porn online weakened the relationship commitment that leads to an unstable relationship. This investigation found out that internet pornography consumption has a nominal negative effect on the relationship commitment of Filipino married individuals.


Cyberpornography: Time Use, Perceived Addiction, Sexual Functioning, and Sexual Satisfaction (2016) - Excerpt:

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

Our results highlight that psychosexual outcomes are similar for men and women. Thus, we observed negative psychosexual functioning in both women and men.


The effects of sexually explicit material use on romantic relationship dynamics (2016) - Excerpts:

Participants included 75 males (25%) and 221 females (75%) aged 18–87 years

More specifically, couples, where no one used, reported more relationship satisfaction than those couples that had individual users. This is consistent with the previous research (Cooper et al., 1999; Manning, 2006), demonstrating that the solitary use of sexually explicit material results in negative consequences.

With gender effects held constant, individual users reported significantly less intimacy and commitment in their relationships than non-users and shared users.

Overall, how frequently someone views sexually explicit material can have an impact on users’ consequences. Our study found that high frequency users are more likely to have lower relationship satisfaction and intimacy in their romantic relationships.


Factors Predicting Cybersex Use and Difficulties in Forming Intimate Relationships among Male and Female Users of Cybersex (2015) - Excerpt:

This study used the Cybersex addiction test, Craving for pornography questionnaire, and a Questionnaire on intimacy among 267 participants (192 males and 75 females) mean age for males 28 and for females 25, who were recruited from special sites that are dedicated to pornography and cybersex on the Internet. Results of regression analysis indicated that pornography, gender, and cybersex significantly predicted difficulties in intimacy and it accounted for 66.1% of the variance of rating on the intimacy questionnaire.

Second, regression analysis also indicated that craving for pornography, gender, and difficulties in forming intimate relationships significantly predicted frequency of cybersex use and it accounted for 83.7% of the variance in ratings of cybersex use.

Third, men had higher scores of frequency of using cybersex than women and higher scores of craving for pornography than women and no higher scores on the questionnaire measuring difficulties in forming intimate relationship than women.


Relationship of love and marital satisfaction with pornography among married university students in Birjand, Iran (2015) - Excerpts:

This descriptive-correlation study was conducted on 310 married students studying at private and public universities in Birjand, in 2012-2013 academic year using random quota sampling method.

Conclusion: It appears that pornography has a negative impact on love and marital satisfaction..... There was no significant gender-difference in overall mean scores of marital satisfaction.


Pornography and Marriage (2014) - All bad news, and it's getting worse. Excerpts:

We used data on 20,000 ever-married adults in the General Social Survey to examine the relationship between watching pornographic films and various measures of marital well-being. We found that adults who had watched an X-rated movie in the past year were more likely to be divorced, more likely to have had an extramarital affair, and less likely to report being happy with their marriage or happy overall. We also found that, for men, pornography use reduced the positive relationship between frequency of sex and happiness. Finally, we found that the negative relationship between pornography use and marital well-being has, if anything, grown stronger over time, during a period in which pornography has become both more explicit and more easily available.

Our results were similar when we control for gender, age, race, education, and number of children, and they shrank by about one third when we included controls for frequency of religious attendance.

For women, all of the coefficients have the same sign but were generally smaller in magnitude than those of men. Women who reported using pornography had 10% higher odds of being divorced, 95 % higher odds of having had an extramarital affair, 8% lower odds of reporting having a very happy marriage, and about 2% lower odds of being very happy with their life overall


Associations between relational sexual behaviour, pornography use, and pornography acceptance among US college students (2014) - Excerpt:

Using a sample of 792 emerging adults, the present study explored how the combined examination of pornography use, acceptance, and sexual behaviour within a relationship might offer insight into emerging adults' development. Results suggested clear gender differences in both pornography use and acceptance patterns. High male pornography use tended to be associated with high engagement in sex within a relationship and was associated with elevated risk-taking behaviours. High female pornography use was not associated with engagement in sexual behaviours within a relationship and was general associated with negative mental health outcomes.


Internet Pornography Exposure and Women's Attitude Towards Extramarital Sex: An Exploratory Study (2013) - Excerpt:

This exploratory study assessed the association between adult U.S. women's exposure to Internet pornography and attitude towards extramarital sex using data provided by the General Social Survey (GSS). A positive association between Internet pornography viewing and more positive extramarital sex attitudes was found.


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 (2012) - Excerpt:

The purpose of this study was to examine the relationships between men’s pornography use, both frequency and problematic use, on their heterosexual female partner’s psychological and relational well-being among 308 young adult college women. Results revealed women’s reports of their male partner’s frequency of pornography use were negatively associated with their relationship quality. More perceptions of problematic use of pornography was negatively correlated with self-esteem, relationship quality, and sexual satisfaction.


A Love That Doesn’t Last: Pornography Consumption and Weakened Commitment to One’s Romantic Partner (2012) – The study had subjects try to abstain from porn use for 3 weeks. Upon comparing the two groups, those who continued using pornography reported lower levels of commitment than those who tried to abstain. Excerpts:

Participants were 367 undergraduates (300 female) from a Southeastern university who participated in the study for partial course credit in a family development course. Participants ranged in age from 17 to 26 with a median age of 19 and reported being in a heterosexual, romantic relationship.

Study 1 found that higher pornography consumption was related to lower commitment

Study 3 participants were randomly assigned to either refrain from viewing pornography or to a self-control task. Those who continued using pornography reported lower levels of commitment than control participants.

Study 5 found that pornography consumption was positively related to infidelity and this association was mediated by commitment. Overall, a consistent pattern of results was found using a variety of approaches including cross-sectional (Study 1), observational (Study 2), experimental (Study 3), and behavioral (Studies 4 and 5) data.


Associations between young adults’ use of sexually explicit materials and their sexual preferences, behaviors, and satisfaction (2011) - Excerpts:

In this study, 92% of young men and 50% of young women reported having ever used a variety of types of SEM.

Higher frequencies of sexual explicit material (SEM) use were associated with less sexual and relationship satisfaction. The frequency of SEM use and number of SEM types viewed were both associated with higher sexual preferences for the types of sexual practices typically presented in SEM. These findings suggest that SEM use can play a significant role in a variety of aspect