Response to Jim Pfaus’s “Trust a Scientist: Sex Addiction Is a Myth”

How about trusting addiction neuroscientists and peer-reviewed papers?

(Link to the Pfaus article)

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.

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)

Recent research reveals that behavioral addictions (food addiction, pathological gambling, video gaming, Internet addiction and porn addiction) and substance addictions share many of the same fundamental mechanisms leading to a collection of shared alterations in brain anatomy and chemistry.

This is not surprising as drugs can only enhance or inhibit existing physiological functions. The specific way a drug alters cellular function is called its “mechanism of action”. All drugs and behaviors that can potentially cause addiction share one important mechanism of action: elevation of dopamine in the nucleus accumbens (also called the reward center).

Addiction-related brain changes include:

In simple, and very broad, terms the major fundamental addiction-caused brain changes are: 1) Sensitization, 2) Desensitization, 3) Dysfunctional prefrontal circuits (hypofrontality), 4) Dysfunctional stress circuits. All 4 of these brain changes have been identified among the over 35 neuroscience-based studies on frequent porn users & sex addicts:

  1. Sensitization (cue-reactivity & cravings): Brain circuits involved in motivation and reward seeking become hyper-sensitive to memories or cues related to the addictive behavior. This results in increased “wanting” or craving while liking or pleasure diminishes. For example, cues, such as turning on the computer, seeing a pop-up, or being alone, trigger intense hard to ignore cravings for porn. Some describe a sensitized porn response as ‘entering a tunnel that has only one escape: porn’. Maybe you feel a rush, rapid heartbeat, even trembling, and all you can think about is logging onto your favorite tube site. 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. Desensitization (decreased reward sensitivity & tolerance): This involves long-term chemical and structural changes that leave the individual less sensitive to pleasure. Desensitization often manifests as tolerance, which is the need for a higher dose or greater stimulation to achieve the same response. Some porn users spend more time online, prolonging sessions through edging, watching when not masturbating, or searching for the perfect video to end with. Desensitization can also take the form of escalating to new genres, sometimes harder and stranger, or even disturbing. This is because shock, surprise or anxiety can all elevate dopamine and waning sexual arousal. Some studies use the term “habituation” — which may involve learning mechanisms or addiction mechanisms. Studies reporting desensitization or habituation in porn users/sex addicts: 1, 2, 3, 4, 5, 6.
  3. Dysfunctional prefrontal circuits (weakened willpower + hyper-reactivity to cues): Dysfunctional prefrontal cortex functioning or alterations in the connections between the reward system and the prefrontal cortex lead to reduced impulse control, yet greater cravings to use. Dysfunctional prefrontal circuits manifests as the feeling that two parts of your brain are engaged in a tug-of-war. The sensitized addiction pathways are screaming ‘Yes!’ while your ‘higher brain’ is saying, ‘No, not again!’ While the executive-control portions of your brain are in a weakened condition the addiction pathways usually win. 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. Malfunctional stress system (greater cravings & withdrawal symptoms): Some addiction experts view addiction a stress disorder, as chronic use induces multiple alterations in the brain’s stress system, and also affect circulating stress hormones (cortisol and adrenaline). A malfunctioning stress system results in even minor stress leading to cravings and relapse because it activates powerful sensitized pathways. In addition, quitting an addiction activates the brain’s stress systems leading to many of withdrawal symptoms common to all addictions, including anxiety, depression, insomnia, irritability and mood swings. Finally, an over-active stress response inhibits the prefrontal cortex and executive functions, including impulse control and the ability fully comprehend the consequences of our actions. Studies indicating a dysfunctional stress system in porn users/sex addicts: 1, 2, 3.

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.

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. ADAM definition of addiction.


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.

The American Psychiatric Association (APA) has so far dragged its feet on including addictive/compulsive porn use in its diagnostic manual. When it last updated the manual in 2013 (DSM-5), it didn’t formally consider “internet porn addiction”, opting instead to debate “hypersexual disorder”. The latter umbrella term for problematic sexual behavior was recommended for inclusion by the DSM-5’s own Sexuality Work Group after years of review. However, in an eleventh-hour “star chamber” session (according to a Work Group member), other DSM-5 officials unilaterally rejected hypersexuality, citing reasons that have been described as illogical.

In reaching this position, the DSM-5 disregarded formal evidence, widespread reports of the signs, symptoms and behaviors consistent with compulsion and addiction from sufferers and their clinicians, and the formal recommendation of thousands of medical and research experts at the American Society of Addiction Medicine.

Incidentally, the DSM has earned distinguished critics who object to its approach of ignoring underlying physiology and medical theory to ground its diagnoses solely in symptoms. The latter permits erratic, political decisions that defy reality. For example, the DSM once incorrectly classified homosexuality as a mental disorder.

Just prior to the DSM-5’s publication in 2013, Thomas Insel, then Director of the National Institute of Mental Health, warned that it was time for the mental health field to stop relying on the DSM. Its “weakness is its lack of validity,” he explained, and “we cannot succeed if we use DSM categories as the “gold standard.” He added, “That is why NIMH will be re-orienting its research away from DSM categories.” In other words, the NIMH would stop funding research based on DSM labels (and their absence).

Since the DSM-5’s publication, hundreds more internet addiction and internet gaming addiction studies, and dozens of neurological studies on porn users have come out. They continue to undercut the DSM-5’s position. Incidentally, despite media attention to the DSM-5’s stance, practitioners who work with those with problematic sexual behaviors have continued to diagnose such problems. They employ another diagnosis in the DSM-5 as well as one from the current ICD-10, the World Health Organization’s widely used diagnostic manual, the International Classification of Diseases. As pointed out in this 2016 journal article by Dr. Richard Krueger:

Diagnoses that could refer to compulsive sexual behavior have been included in the DSM and ICD for years and can now be diagnosed legitimately in the United States using both DSM-5 and the recently mandated ICD-10 diagnostic coding. Compulsive sexual behavior disorder is being considered for ICD-11.

Krueger is an associate clinical professor of psychiatry at Columbia University’s college of physicians and surgeons, and helped revise the sexual disorders section of the DSM-5.

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” as well as one for “Disorders due to addictive behaviors”. By the way, a newly created behavioral addiction category appears in the new DSM-5, with “Internet gaming disorder” under up for inclusion.

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. For example, cigarette and cocaine addicts can be thoroughly hooked, but their withdrawal experience is typically mild compared with alcoholics or heroin addicts. (What all addiction assessment tests share is, ‘continued use despite negative consequences’. It’s reliable evidence of addiction.)

That said, porn addicts consistently report withdrawal symptoms that mirror drug withdrawal. Please see multiple reports on these pages:

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.

As for tolerance, three studies have now asked porn users specifically about escalation into new genres or tolerance, confirming both (1, 2, 3). Employing various indirect methods, an additional 12 studies have reported findings consistent with habituation to “regular porn” or escalation into more extreme and unusual genres.

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. 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 over 100 articles and videos by about 120 experts (urology professors, urologists, psychiatrists, psychologists, sexologists, MDs) who have successfully treated porn-induced ED and porn-induced loss of sexual desire.

As for empirical support, 23 studies have linked porn use or porn addiction sexual problems or lower arousal. (the first four 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) 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.”

6) 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.”

7) 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.

8) 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.”

9) 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.

10) 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.

11) 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.

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) 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.”

14) 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.

15) 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.

16) 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.”

17) 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.

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

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

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

Hypersexual” behavior represents a perceived inability to control one’s sexual behavior. To investigate hypersexual behavior, an international sample of 510 self-identified heterosexual, bisexual, and homosexual men and women completed an anonymous online self-report questionnaire battery.
Thus, the data indicated that hypersexual behavior is more common for males, and those who report being younger in age, more easily sexually excited, more sexually inhibited due to the threat of performance failure, less sexually inhibited due to the threat of performance consequences, and more impulsive, anxious, and depressed

20) 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”.

21) — 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.

22) “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)

23) 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.

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). Conditioned place preference 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 the 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: It’s already established in studies on both internet porn addiction ( 1, 2, 3) and internet videogaming 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. Addiction-related brain changes or not
  11. 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.

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