MILITARY MEDICINE, 184, 11/12:731, 2019

Survey of Sexual Function and Pornography

LCDR. Jonathan H. Berger, MC USN1; LCDR. John E. Kehoe, MC USN1; CDR. Andrew P. Doan, MC
USN2; CAPT(ret.). Donald S. Crain, MC USN1; CAPT(ret.). Warren P. Klam, MC USN3; LCDR. Michael
T. Marshall, MC USN1; CDR. Matthew S. Christman, CDR MC USN1

ABSTRACT Introduction: We aimed to explore and describe the pornography habits of young men and women. Given
recent upward trends in pornography use and erectile dysfunction, along with a plausible pathophysiology, we hypothesized that
pornography use would correlate with sexual dysfunction. Materials and Methods: Institutional Review Board approval was

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obtained. Surveys were distributed to 20–40 year old men and women presenting to a urology clinic. Information was
collected on demographics and medical history. Sexual function was evaluated with the International Index of Erectile
Function (IIEF) in men and the Female Sexual Function Index in women. Extent of potential addiction to pornography
was measured with the pornography craving questionnaire and the obsessive passion scale. Pornography use was mea-
sured based on both frequency and duration, and analyzed relative to sexual dysfunction. Results: Men used pornogra-
phy significantly more frequently than women (81.1% vs. 39%). Computer and cellular phone image viewing were the
most popular modalities in both sexes. There was no association between IIEF and craving for, or obsessive passion
for, pornography. Preference for pornography with masturbation was found to be significantly associated with erectile
dysfunction (p = 0.001). Rates of erectile dysfunction were lowest in those preferring partnered sex without pornogra-
phy (22.3%) and increased significantly when pornography was preferred over partnered sex (78%). No correlation
was found between any variables and female sexual dysfunction. Conclusions: Pornography and sexual dysfunction
are common among young people. No clear relationship exists between extent of addiction to pornography and sexual
dysfunction in either gender. However, men who prefer masturbation with pornography to partnered sex have a signifi-
cantly increased risk of sexual dysfunction. Given sexual dysfunction may be associated with mental health concerns,
further evaluation of its causes and impact on military operational readiness are warranted.

INTRODUCTION devoted solely to pornography research. What are the impli-

Pornography is increasingly ubiquitous. It’s on the internet, cations of this sociological revolution?
on the cover of Time magazine, in the news, and in many In 2014, a study of military men demonstrated that the
homes and workplaces. Although rates vary by age group rate of erectile dysfunction (ED) more than doubled in the
and methodological challenges complicate results, pornogra- preceding decade. This increase was principally due to an
phy use in the United States has been estimated at 36–75% increase in psychogenic ED.6 Video streaming websites for
in men and 16–41% in women.1–4 A recent Gallup poll porn, or “porn tube” sites, have proliferated over the last
showed that as many as 36% of Americans believe porn is decade making pornography more accessible than ever
morally acceptable with a trend of steadily increasing accep- before. Soon after these sites began appearing, Kinsey
tance in surveys over the past 6 years.5 As technological Institute researchers became the first to report on what they
advancements have radically increased accessibility, interest termed “pornography induced erectile dysfunction (PIED)”
has grown both in popular media and the academic arena. In in 2007.7 Work by others has established a plausible patho-
fact, the journal Porn Studies which was launched in 2014 is physiology of PIED, based to a large extent on studies
within the realm of addiction and behavior.8–11
We aimed to explore and describe the pornography habits
1Department of Urology, Naval Medical Center San Diego, 34800 Bob of young men and women. Given the above stated ecologic
Wilson Drive, San Diego, CA 92134.
2Department of Ophthalmology, Naval Medical Center San Diego,
and sociologic observations, along with a plausible patho-
34800 Bob Wilson Drive, San Diego, CA 92134. physiology, we hypothesized that pornography use would
3Department of Mental Health, Naval Medical Center San Diego, 34800 correlate with sexual dysfunction.
Bob Wilson Drive, San Diego, CA 92134.
The views expressed in this manuscript are those of the authors and do
not reflect the official policy or position of the Department of the Navy,
Department of Defense, or the United States Government. MATERIALS AND METHODS
Andrew Doan is a former paid speaker and is currently a volunteer Anonymous, written surveys were distributed to a cohort of
speaker for Real Battle Ministries; he has also been a public speaker on the 20–40 year old men and women presenting to the urology
benefits and harm of video games and digital media.
clinic at Naval Medical Center San Diego (NMCSD). The
doi: 10.1093/milmed/usz079
Published by Oxford University Press on behalf of the Association of study protocol was approved by the NMCSD Institutional
Military Surgeons of the United States 2019. This work is written by (a) US Review Board in compliance with all applicable federal reg-
Government employee(s) and is in the public domain in the US. ulations governing the protection of human subjects.

MILITARY MEDICINE, Vol. 184 November/December 2019 731

 Survey of Sexual Function and Pornography

Information was collected on demographics including race, TABLE I. Demographics.

ethnicity, religion, educational level, marital status, sexual
Men Women
orientation, military status, and rank. Questions pertaining to
medical history focused on risk factors for ED such as heart Heart disease 1.0% (3/292) 0% (0/43)
Peripheral vascular disease 0.0% (0/291) 0% (0/43)
disease, peripheral vascular disease, hyperlipidemia, diabe-
Hypercholesterolemia 5.5% (16/292) 5% (2/43)
tes, hypothyroidism, depression, post-traumatic stress disor- Diabetes 0.7% (2/291) 0% (0/43)
der, genitourinary trauma, and tobacco use. Hypothyroidism 1.0% (3/292) 5% (2/44)
Sexual function was evaluated with validated instruments. Depression 5.4% (16/294) 16% (7/44)
For men we used the International Index of Erectile Function Post-traumatic stress disorder 3.4% (10/293) 12% (5/43)
Trauma 2.1% (6/291) 4% (2/45)
(IIEF). This 15-item questionnaire covers the domains of: erec-
Tobacco 19.2% (59/307) 31% (15/48)
tile function, orgasmic function, sexual desire, intercourse sat- Race n = 306 n = 47

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isfaction, and overall satisfaction.12 Women were studied African-American 13.4% 13%
using the Female Sexual Function Index (FSFI) which has 19 Asian 5.6% 2%
questions across the domains of desire, arousal, lubrication, Caucasian 64.7% 62%
Hawaiin/Pacific Islander 1.3% 6%
orgasm, satisfaction, and pain. For categorical classification of
Native American 2.0% 4%
sexual function, cutoffs of less than or equal to 25 (in the erec- Other 13.1% 13%
tile function domain of the IIEF) and less than or equal to Ethnicity n = 275 n = 45
26.55 (on the FSFI) were used for erectile dysfunction and Hispanic 25.5% 24%
female sexual dysfunction (FSD), respectively in keeping with Not Hispanic 74.6% 76%
Marital status n = 311 n = 48
values used in prior studies.13 Pornography use was measured
Married 68.8% 60%
along multiple dimensions (e.g., frequency, duration, modal- Engaged 2.9% 4%
ity). The extent of potential addiction to pornography was mea- Serious relationship 12.5% 23%
sured with two previously validated tools: the pornography Casual relationship 5.5% 6%
craving questionnaire and the obsessive passion scale.14,15 To Single 10.3% 6%
Religion n = 309 n = 47
gauge volume of pornography consumption, respondents were
Agnostic 10.0% 11%
also asked details regarding frequency of pornography use and Athiest 8.7% 9%
duration of viewing episodes. To assess preferences for por- Catholic 25.2% 19%
nography, participants were asked about the use of porn as it Jewish 0.3% 0%
relates to choices between partnered sex and masturbation. Muslim 0.3% 0%
Protestant 33.0% 45%
Pornography habits were compared between men and
Other 22.3% 17%
women. Relationships between frequency of porn use, dura- Education n = 311 n = 48
tion of episode, pornography preferences, and addiction to No high school diploma 1.0% 4%
pornography were analyzed in relationship to sexual dys- High school 56.9% 44%
function. Linear regression was used when dysfunction was Associates degree 18.3% 23%
Bachelors degree 16.1% 23%
defined on a continuous scale. A multivariate model was
Graduate degree 7.7% 6%
built via forward step-wise progression; only independent Sexual orientation n = 312 n = 48
variables with p < 0.20 on univariate analysis were included. Heterosexual 97.8% 81%
Fisher’s exact test was used for categorical comparisons. Homosexual 1.0% 6%
Statistical significance was set to α ≤ 0.05. STATA12 Bisexual 1.0% 13%
Other 0.3% 0%
(College Station, TX) was used for the analysis.

basis. There was no difference in the length of pornography epi-

RESULTS sodes between men and women (p = 0.612). Most viewed porn
A total of 510 surveys were distributed (86.1%, 439/510 to for less than 15 minutes (62.9%, 154/245 for men; 72%, 13/18 for
men; 13.9%, 71/510 to women). Response rates were 71.5% women; Table II). Internet and phone were by far the most com-
(314/439) in men and 68% (48/71) in women. Of the cohort, mon media for viewing (Table II). There was no difference
96.8% of men (425/439) and 58% of women (28/48) were between men and women in media preferences, except for books.
active duty military. There was no significant difference in Sexual dysfunction was identified in 32.4%% (99/306) and 52%
response rate between genders (p = 0.485). The average age (22/42) of men and women respectively.
(years) was 30.7 ± 5.9 in men and 28.1 ± 6.3 in women. For men, partnered sex without pornography was pre-
Demographics for the study population are found in Table I. ferred as the choice to most satisfy sexual desire in 85.2%
Men used pornography significantly more frequently than (253/297), while partnered sex with pornography was pre-
women (p < 0.001), with 81.1% (244/301) and 39% (17/44) of ferred in 11.5% (34/297), and masturbation with pornogra-
men and women respectively reporting some use (Table II). A phy was preferred in 3.4% (10/297). Rates of erectile
total of 9.3% (28/301) of men reported use on an almost daily dysfunction were lowest in men who preferred partnered sex

732 MILITARY MEDICINE, Vol. 184 November/December 2019

 Sexual Function and Pornography

TABLE II. Pornography and Sexual Dysfunction. five domains of the IIEF, covering erection (p = 0.002),
orgasm (p = 0.006), libido (p = 0.004), intercourse satisfaction
Men Women
(p = 0.028), and overall satisfaction (p ≤ 0.001). No correlation
Preferences n = 297 n = 44 was found between any of these variables (of pornography use)
Partnered sex WITHOUT porn 85.2% 91%
and sexual dysfunction (FSFI) in women (Table V).
Partnered sex WITH porn 11.5% 7%
Masturbation with porn 3.4% 2%
Frequency of pornography viewing n = 301 n = 44
NONE 18.9% 61% DISCUSSION
Less than weekly 25.9% 25% A sizeable portion of the study population – including both
1 to 2x/week 24.6% 9%
3 to 5x/week 21.3% 2%
men and women – suffered from sexual dysfunction.
6 to 10x/week 5.0% 2% Additionally, these survey data demonstrated the ubiquitous

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> 10x/week 4.3% 0% nature of pornography use among young adults. Both the
Duration of pornography episode n = 245 n = 18 high prevalence of erectile dysfunction and male pornogra-
15 min or less 62.9% 72% phy use noted in our study are consistent with the reported
16–30 min 24.5% 22%
31–59 min 8.2% 0%
rates in the literature, 18–30% and 36–75% respec-
60–119 min 2.9% 6% tively.1,2,4,16,17 Rates appear higher in younger age groups
120–179 min 0.8% 0% with studies targeting college age and young adult men dem-
180 min or more 0.8% 0% onstrating 86% use.18 These prevalence rates have to be
Viewing media n = 244 n = 18 viewed with an appreciation for the inherent methodologic
Book 2.9% 17%
shortcomings and potential biases of cited studies. Defining
DVD 4.9% 6%
Computer viewing (Internet) 73.0% 68% rates of FSD is particularly difficult, if not impossible, given
Magazine 2.5% 0% significant heterogeneity of populations and definitions of
Cellular phone viewing (internet) 62.3% 56% FSD. However, the rates of FSD and pornography use
Sexual dysfunctiona n = 306 n = 48 among women in our study were within reported ranges as
27.5% 58%
well, approximately 40–50% and 16–41% respec-
a
Men: IIEF (erectile function) ≤ 25; Women: FSFI ≤ 26.55. tively.1,3,4,19,20 Similar to men, estimates of pornography use
trend higher among samples of younger populations.18
90% A strong association between sexual dysfunction and
80% preference for masturbation to pornography over relational
70%
intercourse was identified in men. This finding was consis-
60%
% of Population with tent, pervasive, and statistically significant, covering every
50% Respective Pornography
Preference
domain of the validated measure of men’s sexual health:
40%
% with Erectile erection, orgasm, libido, sexual and overall satisfaction.
30%
Dysfunction While we cannot conclude causation from our survey data,
20%
this finding could lend support to the entity termed PIED.
10%
0%
Conversely, this study failed to demonstrate an association
Sex w/o porn Sex w/ porn Masturbation between pornography use and sexual dysfunction in women.
w/porn This may suggest that other mechanisms play a role in female
FIGURE 1. Erectile dysfunction and preferences for pornography in men. sexual dysfunction or could simply result from the small sam-
Rates of erectile dysfunction were lowest in those who preferred partnered ple size of women. To our knowledge, there have been no
sex without pornography. However, these rates began to rise as pornography
was preferred and they are significantly higher in those men who prefer mas- other published studies in the literature evaluating for associa-
turbation with pornography over partnered sex, reaching almost 80%. tions between FSD (assessed by FSFI) and pornography use.
A plausible pathophysiology for PIED has been
without pornography (22.3%, 56/251) but increased signifi- described. Frohmader et al. demonstrated that sexual behav-
cantly when masturbation to pornography was preferred over ior activates the same reward system circuitry in the brain as
partnered sex (78%, 7/9, p = 0.001) as seen in Figure 1. On cocaine and methamphetamines.8 This can lead to creation
linear regression there was no association demonstrated of a self-reinforcing activity or habit. Others have shown
between sexual function (IIEF) and craving for pornography that internet pornography may act as a supernormal stimulus
(p = 0.270) or obsessive passion for pornography (p = 0.692). of this circuit.9 This heightened ability to continuously and
Categories within frequency, duration, and pornography prefer- instantaneously self-select novel and more sexually arousing
ences were found to be significant on univariate analysis images may make internet porn a uniquely potent activator.
(Table III) and were included in the multivariate model. Furthermore, internet porn has been shown to paradoxically
However, only a preference for pornography with masturbation increase sensitivity to pornographic cues as well as decrease
was found to be significantly associated with increased sexual sensitivity to normal stimuli such as partnered sex.10,11 The
dysfunction (Table IV). This finding was consistent across all hypersensitivity to cues is common among addictions, while

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 Survey of Sexual Function and Pornography

TABLE III. Univariate Analysis of Sexual Function and Pornography in Men.a

95% Confidence Interval

Coefficient Lower Limit Upper Limit p-Value
Pornography craving 0.05 −0.04 0.15 0.270
Obsessive passion for pornography 0.04 −0.16 0.24 0.692
Preferencesb
Partnered sex WITHOUT porn
Partnered sex WITH porn −0.57 −5.01 3.86 0.799
Masturbation with porn −16.11 −24.35 −7.88 <0.001
Frequency of pornography viewingc
NONE

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Less than weekly 5.44 1.10 9.78 0.014
1 to 2x/week 4.25 −0.16 8.66 0.059
3 to 5x/week 4.99 0.46 9.51 0.031
6 to 10x/week −2.46 −9.68 4.75 0.502
> 10x/week 6.07 −1.82 13.96 0.131
Duration of pornography episodec
NONE
15 min or less 5.98 2.15 9.82 0.002
16–30 min 3.69 −0.87 8.25 0.113
31–59 min 0.26 −6.27 6.80 0.937
60–119 min −7.46 −18.96 4.04 0.203
120–179 min −12.26 −30.00 5.48 0.175
180 min or more −0.26 −25.14 24.61 0.983
a
Sexual Function as measured with IIEF (all 15 questions).
b
Estimate relative to partnered sex WITHOUT porn.
c
Estimate relative to NO pornography use.

TABLE IV. Multivariate Analysis of Sexual Function and Pornography in Men.a

95% Confidence Interval

Coefficient Lower Limit Upper Limit p-Value
Preferencesb
Partnered sex WITHOUT porn
Partnered sex WITH porn −0.98 −5.81 3.86 0.691
Masturbation with porn −16.13 −25.11 −7.15 <0.001
Frequency of pornography viewingc
NONE
Less than weekly −6.97 −32.86 18.92 0.597
1 to 2x/week −7.60 −33.56 18.36 0.565
3 to 5x/week −5.94 −31.95 20.08 0.654
6 to 10x/week −9.21 −35.81 17.39 0.496
> 10x/week 0.07 −24.68 24.82 0.996
Duration of pornography episodec
NONE
15 min or less 12.85 −12.76 38.46 0.324
16–30 min 9.81 −15.79 35.41 0.451
31–59 min 8.86 −16.95 34.67 0.500
60–119 min 4.39 −23.76 32.54 0.759
120–179 min 1.93 −29.40 33.25 0.904
180 min or more Omittedd
a
Sexual Function as measured with IIEF (all 15 questions).
b
Estimate relative to partnered sex WITHOUT porn.
c
Estimate relative to NO pornography use.
d
Regression coefficients unable to be calculated due to low numbers of patients in these categories.

the later hypoactivity that is produced can be understood as prevalence of sexual dysfunction?” The answer may simply
“tolerance” in addiction medicine terms. be that not all pornography users are the same. One study has
Given a proposed mechanism for PIED, the question arises, already sought to establish subgroups of pornography users,
“if pornography use is so common, why is there not a higher utilizing cluster-analytics on survey results. Vaillancourt-

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TABLE V. Univariate Analysis of Sexual Function and Pornography in Women.a

95% Confidence Interval

Coefficient Lower Limit Upper Limit p-Value
Pornography craving 0.02 −0.19 0.23 0.859
Obsessive passion for pornography −1.12 −3.99 1.76 0.436
Preferencesb
Partnered sex WITHOUT porn
Partnered sex WITH porn 1.56 −8.39 11.51 0.752
Masturbation with porn 4.19 −12.59 20.98 0.616
Frequency of pornography viewingc
NONE

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Less than weekly 2.41 −3.83 8.65 0.438
1 to 2x/week 2.85 −6.14 11.83 0.524
3 to 5x/week 0.47 −16.54 17.48 0.955
6 to 10x/week Omittedd
> 10x/week Omittedd
Duration of pornography episodec
NONE
15 min or less 1.39 −4.59 7.37 0.640
16–30 min 6.04 −4.06 16.13 0.233
31–59 min Omittedd
60–119 min 2.57 −14.28 19.42 0.759
120–179 min Omittedd
180 min or more Omittedd
a
Sexual Function as measured with FSFI.
b
Estimate relative to partnered sex WITHOUT porn.
c
Estimate relative to NO pornography use.
d
Regression coefficients unable to be calculated due to low numbers of patients in these categories.

Morel divided internet pornography users into categories of basis or more had ED rates of 44% (12/27) compared to 22%
“recreational,” “highly distressed non-compulsive,” and “com- (47/213) for those more “casual” users (≤5x/week), reaching
pulsive,” noting decreased sexual satisfaction and increased significance on univariate analysis (p = 0.017). It may be that
sexual dysfunction in “compulsive” users versus “recrea- volume does play a role to some extent.
tional.”21 Our results align with these authors’ findings if you The issue of association versus causation deserves attention.
consider that we uncovered members of the “compulsive” or Does excessive pornography use in men result in (i.e., cause)
even “highly distressed non-compulsive” clusters by asking sexual dysfunction? Or, are there men who for one reason or
the question regarding preferred method of sexual satisfaction another already suffer from an undiagnosed pathology affecting
(i.e., masturbation to pornography versus partnered intercourse sexual function, who then turn to pornography as a form of
with or without pornography). “self-medication?” It may be that this subset of “self-medicators”
We were unable to demonstrate a dose-response in our (for arguments sake) represents a known condition such as per-
planned analysis. There was no association between the vol- formance anxiety. Unfortunately, the IIEF has not proved to reli-
ume (frequency, duration) of pornography use or the passion/ ably distinguish between specific causes of ED, including
craving for pornography, and sexual dysfunction. Other psychogenic.26 Additionally, the proposed pathophysiology of
authors have cast doubts on this association as well. In an PIED seems plausible and is based on a variety of researchers
analysis of two large cross-sectional studies of European men, work and not a small collection of researchers that might be
the authors found little evidence for an association between swayed by an ethical bias. Also supporting the “causation” side
porn use and male sexual dysfunction.22 Prause and Pfaus of the argument are reports of men regaining normal sexual func-
also found no relationship between average weekly pornogra- tion after discontinuation of excessive pornography use.27,28
phy use and IIEF in a prospective study of US men. The most common media for viewing pornography was
Conversely, the authors noted a positive relationship between phone and internet in both men and women with no statisti-
reported porn use and sexual response to porn viewed in the cally significant difference between these groups. The pre-
lab, as well as desire for sex with a partner.23 However certain dominance of phone and internet media aligns with the
methodologic concerns leave this question unsettled.24 Other suggestion of digital pornography exerting a more potent
researchers have suggested that dose may not be a principal effect. This is in keeping with research comparing modes of
finding even if pornography and sexual dysfunction are asso- pornography prior to widespread internet availability showing
ciated.25 It also seems important to note that of the pornogra- higher levels of arousal with media containing more explicit
phy users in our study, those who used on an almost daily content such as pornographic video.29

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 Survey of Sexual Function and Pornography

Only prospective studies will be able to definitively solve women. We were unable to demonstrate a clear relationship
the question of causation or association, including interven- between the extent of addiction to pornography and sexual
tional studies evaluating the success of abstention in treating dysfunction in either men or women, however the results
ED in heavy pornography users. Additional populations that convincingly demonstrate that men who prefer masturbation
warrant special consideration include adolescents. There has with pornography to partnered sex are at a significantly
been concern raised that early exposure to graphic sexual increased risk for having sexual dysfunction. Further investi-
material may affect normal development. The rate of teen- gations into this concerning association between pornogra-
agers being exposed to pornography before the age of 13 has phy and young men’s sexual health are warranted. Given
gone up three fold over the last decade, and now hovers that sexual function may be associated with mental health
around 50%.30 Future studies could focus on revealing fur- concerns, further evaluation of its causes and impact on mili-
ther subgroups of pornography users who may have associ- tary operational readiness are warranted.

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ated sexual dysfunction (not related to their general use of
pornography but to a specific aspect of the pornography
PREVIOUS PRESENTATION:
used). For example, we evaluated the medium by which por-
nography was used in our survey, but we did not consider Berger JH, Doan AP, Kehoe JE, Klam WP, Crain DS, Christman MS.
“Survey of Sexual Function and Pornography in Males.” Podium
the content of pornography (i.e., “genre”). Evaluating genre Presentation. American Urological Association Annual Meeting, Boston,
and whether it is concordant or discordant with self- MA, May 16, 2017.
described real world sexual values and behaviors may also Berger JH, Doan AP, Kehoe JE, Roger EI, McLain CA, Klam WP,
reveal other reasons individuals fall out of the “recreational” Crain DS, Christman MS. "Survey of Sexual Function and Pornography in
cluster and begin showing more signs of sexual pathology. Males." Podium Presentation. Society of Government Service Urologists
Kimbrough Urological Seminar, San Diego, CA, January 11, 2017.
A few limitations must be recognized. First, cross-
sectional studies cannot definitively establish causation. That
is to say, based on our study design, we are unable to con- REFERENCES
clude that pornography causes sexual dysfunction, although 1. Albright JM: Sex in America online: an exploration of sex, marital sta-
there is clearly an association in a select cohort. Next, this is tus, and sexual identity in internet sex seeking and its impacts. J Sex
a small sample size, particularly for women. This could Res 2008; 45(2): 175–86.
clearly affect the power of the study and the ability to draw 2. Wright PJ: U.S. males and pornography, 1973-2010: consumption, pre-
dictors, correlates. J Sex Res 2013; 50(1): 60–71.
conclusions about nonsignificant results. Additionally, the 3. Wright PJ, Bae S, Funk M: United States women and pornography
objective definition of sexual dysfunction is not as well through four decades: exposure, attitudes, behaviors, individual differ-
established in women as it is in men. Selection bias may ences. Arch Sex Behav 2013; 42(7): 1131–44.
also exist, as this was a population of young people domi- 4. Regnerus M, Gordon D, Price J: Documenting pornography use in
nated by a unique occupation presenting to a urology clinic, america: a comparative analysis of methodological approaches. J Sex
Res 2016; 53(7): 873–81.
and may not reflect the general population. However, the 5. Gallup Poll Social Series: Values and Beliefs. 2017. Accessed 5/17/2017.
rates of both sexual dysfunction (in men and women) and 6. Armed Forces Health Surveillance Center: Erectile dysfunction among
pornography use (in men) compare favorably to the litera- male active component service members, U.S. Armed Forces, 2004-
ture, so it would seem unlikely that significant bias in this 2013. MSMR 2014; 21(9): 13–6.
7. Janssen E, Bancroft J: The dual control model:the role of sexual inhibition
regard is introduced. Additionally, the validated instruments
and excitation in sexual arousal and behavior. In: The Psychophysiology of
used to assess pornography addiction were not specific to Sex. Edited by Janssen E Bloomington, IN, Indiana University Press, 2007.
internet pornography, which as our results showed, is the 8. Frohmader KS, Wiskerke J, Wise RA, Lehman MN, Coolen LM:
dominant medium for viewing porn. Better tools for specifi- Methamphetamine acts on subpopulations of neurons regulating sexual
cally evaluating internet pornography addiction could be behavior in male rats. Neuroscience 2010; 166(3): 771–84.
considered in future studies.25 There also remains the diffi- 9. Hilton DL: Pornography addiction – a supranormal stimulus considered
in the context of neuroplasticity. Socioaffect Neurosci Psychol 2013; 3:
culty in controlling for the act of masturbation itself. We 20767.
have used the terms “using pornography” and “viewing por- 10. Voon V, Mole TB, Banca P, et al: Neural correlates of sexual cue reac-
nography” to include the act of masturbation as well. tivity in individuals with and without compulsive sexual behaviours.
Separating the two (viewing pornography and masturbation) PLoS One 2014; 9(7): e102419.
may prove difficult to study given their inherent relationship, 11. Steele VR, Staley C, Fong T, Prause N: Sexual desire, not hypersexual-
ity, is related to neurophysiological responses elicited by sexual images.
however attempts to do so may be helpful in ascertaining a Socioaffect Neurosci Psychol 2013; 3: 20770.
more subtle understanding of the relationships at play. 12. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A: The
international index of erectile function (IIEF): a multidimensional scale
for assessment of erectile dysfunction. Urology 1997; 49(6): 822–30.
13. Rosen R, Brown C, Heiman J, et al: The Female Sexual Function Index
CONCLUSIONS
(FSFI): a multidimensional self-report instrument for the assessment of
We demonstrated that pornography use and sexual dysfunc- female sexual function. J Sex Marital Ther 2000; 26(2): 191–208.
tion are common in young men. Similarly, both pornography 14. Kraus S, Rosenberg H: The pornography craving questionnaire: psycho-
use and sexual dysfunction appear common in young metric properties. Arch Sex Behav 2014; 43(3): 451–62.

736 MILITARY MEDICINE, Vol. 184 November/December 2019

 Sexual Function and Pornography

15. Rosenberg H, Kraus S: The relationship of “passionate attachment” for 23. Prause N, Pfaus J: Viewing sexual stimuli associated with greater sexual
pornography with sexual compulsivity, frequency of use, and craving responsiveness, not erectile dysfunction. Sex Med 2015; 3(2): 90–8.
for pornography. Addict Behav 2014; 39(5): 1012–7. 24. Isenberg RA: Viewing sexual stimuli associated with greater sexual
16. Selvin E, Burnett AL, Platz EA: Prevalence and risk factors for erectile responsiveness, not erectile dysfunction: a comment. Sex Med 2015;
dysfunction in the US. Am J Med 2007; 120(2): 151–7. 3(3): 219–21.
17. Mialon A, Berchtold A, Michaud PA, Gmel G, Suris JC: Sexual dys- 25. Brand M, Laier C, Pawlikowski M, Schächtle U, Schöler T, Altstötter-
functions among young men: prevalence and associated factors. Gleich C: Watching pornographic pictures on the Internet: role of sex-
J Adolesc Health 2012; 51(1): 25–31. ual arousal ratings and psychological-psychiatric symptoms for using
18. Shaughnessy K, Byers ES, Walsh L: Online sexual activity experience Internet sex sites excessively. Cyberpsychol Behav Soc Netw 2011;
of heterosexual students: gender similarities and differences. Arch Sex 14(6): 371–7.
Behav 2011; 40(2): 419–27. 26. Deveci S, O’Brien K, Ahmed A, Parker M, Guhring P, Mulhall JP: Can
19. Aslan E, Beji NK, Gungor I, Kadioglu A, Dikencik BK: Prevalence and the International Index of Erectile Function distinguish between organic
risk factors for low sexual function in women: a study of 1,009 women and psychogenic erectile function? BJU Int 2008; 102(3): 354–6.

Downloaded from https://academic.oup.com/milmed/article/184/11-12/731/5477443 by guest on 01 February 2023

in an outpatient clinic of a university hospital in Istanbul. J Sex Med 27. Bronner G, Ben-Zion IZ: Unusual masturbatory practice as an etiologi-
2008; 5(9): 2044–52. cal factor in the diagnosis and treatment of sexual dysfunction in young
20. Nappi RE, Cucinella L, Martella S, Rossi M, Tiranini L, Martini E: men. J Sex Med 2014; 11(7): 1798–1806.
Female sexual dysfunction (FSD): prevalence and impact on quality of 28. Park BY, Wilson G, Berger J, et al: Is Internet pornography causing
life (QoL). Maturitas 2016; 94: 87–91. sexual dysfunctions? A review with clinical reports. Behav Sci 2016; 6:
21. Vaillancourt-Morel MP, Blais-Lecours S, Labadie C, Bergeron S, 1–25.
Sabourin S, Godbout N: Profiles of cyberpornography use and sexual 29. Koukounas E, Over R: Male sexual arousal elicited by film and fantasy
well-being in adults. J Sex Med 2017; 14(1): 78–85. matched in content. Aust J Psychol 1997; 49: 1–5.
22. Landripet I, Štulhofer A: Is pornography use associated with sexual dif- 30. Sun C, Bridges A, Johnson JA, Ezzell MB: Pornography and the male
ficulties and dysfunctions among younger heterosexual men? J Sex sexual script: an analysis of consumption and sexual relations. Arch Sex
Med 2015; 12(5): 1136–9. Behav 2016; 45(4): 983–94.

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