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

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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 35 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 35 studies on porn users 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)"

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.”


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.


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, posted by Omakera

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