Studies reporting findings consistent with escalation of porn use (tolerance), habituation to porn, and withdrawal symptoms

Introduction

Compulsive porn users often describe escalation in their porn use that takes the form of greater time viewing or seeking out new genres of porn. New genres that induce shock, surprise, violation of expectations or even anxiety can function to increase sexual arousal, and in porn users whose response to stimuli is growing blunted due to overuse, this phenomenon is extremely common.

Norman Doidge MD wrote about this in his 2007 book The Brain That Changes Itself:

The current porn epidemic gives a graphic demonstration that sexual tastes can be acquired. Pornography, delivered by high-speed Internet connections, satisfies every one of the prerequisites for neuroplastic change…. When pornographers boast that they are pushing the envelope by introducing new, harder themes, what they don’t say is that they must, because their customers are building up a tolerance to the content.

The back pages of men’s risque magazines and Internet porn sites are filled with ads for Viagra-type drugs—medicine developed for older men with erectile problems related to aging and blocked blood vessels in the penis. Today young men who surf porn are tremendously fearful of impotence, or “erectile dysfunction” as it is euphemistically called. The misleading term implies that these men have a problem in their penises, but the problem is in their heads, in their sexual brain maps. The penis works fine when they use pornography. It rarely occurs to them that there may be a relationship between the pornography they are consuming and their impotence.

In 2012 reddit/nofap produced a member survey, which found that over 60% of its members’ sexual tastes experienced significant escalation, through multiple porn genres.

Q: Did your tastes in pornography change?

• My tastes did not change significantly – 29%
• My tastes became increasingly extreme or deviant and this caused me to feel shame or stress – 36%
• And… my tastes became increasingly extreme or deviant and this did not cause me to feel shame or stress – 27%

And here’s the 2017 evidence from PornHub that real sex is decreasingly interesting to porn users. Porn isn’t enabling people to find their “real” tastes; it’s driving them beyond normal into extreme novelty and “unreal” genres:

It appears that the trend is moving more toward fantasy than reality. ‘Generic’ porn is being replaced with fantasy specific or scenario specific scenes.  Is this as a result of boredom or curiosity? One thing is certain; the typical ‘in-out, in-out’ no longer satisfies the masses, who are clearly looking for something different” notes Dr Laurie Betito.

The only support for the meme that porn users do not escalate comes Ogas and Gaddam’s highly criticized book “A Billion Wicked Thoughts” and their claim that porn viewing tastes remain stable throughout life. Ogas & Gaddam analyzed AOL searches from 2006, over a brief 3-month period. Here’s an excerpt from an Ogi Ogas blog post on Psychology Today:

There is no evidence that viewing porn activates some kind of neural mechanism leading one down a slippery slope of seeking more and more deviant material, and plenty of evidence suggesting that adult men’s sexual interests are stable.

As YBOP pointed out in two critiques (1, 2):

1. Porn users must be tracked over years to pick up the kinds of changing tastes men are reporting. Three months is insufficient.
2. Most regular porn users do not use Google to find porn. Instead, they head directly to their favorite tube site. Clicking onto a new genre (located in the sidebar) occurs while the user is masturbating.

If the studies listed below aren’t sufficiently convincing, this 2017 study destroys the meme that porn users’ sexual interests remain stable: Sexually Explicit Media Use by Sexual Identity: A Comparative Analysis of Gay, Bisexual, and Heterosexual Men in the United States. Excerpt from this recent study:

The findings also indicated that many men viewed SEM content inconsistent with their stated sexual identity. It was not uncommon for heterosexual-identified men to report viewing SEM containing male same-sex behavior (20.7%) and for gay-identified men to report viewing heterosexual behavior in SEM (55.0%). It was also not uncommon for gay men to report that they viewed vaginal sex with (13.9%) and without a condom (22.7%) during the past 6 months.

In 2019, a Spanish study on 500 men and women (average age 21) reported that the majority had seen gay or lesbian porn, and found it arousing – even though most were straight.

In addition, see this article about a 2018 YOUPorn survey, which reported that straight men watch gay porn 23% of the time. Also note that the overwhelming majority of women (and 40% of men) report that their porn tastes have changed in the past 5 years. From the survey:

This study, taken together with others listed below, debunks the meme that today’s porn users eventually “discover their true sexuality” by surfing tube sites, and then stick to only one genre of porn for the rest of time. The evidence is mounting that streaming digital porn appears to alter sexual tastes in some users, and that this is due to the addiction-related brain change known as habituation or desensitization.

Employing various methodologies and approaches, the following diverse group of studies report habituation to “regular porn” along with escalation into more extreme and unusual genres. Several also report withdrawal symptoms in porn users.

Studies with relevant excerpts

FIRST STUDY: This was the first study to ask porn users directly about escalation: Online sexual activities: An exploratory study of problematic and non-problematic usage patterns in a sample of men (2016). The study reports escalation, as 49% of the men reported viewing porn that was not previously interesting to them or that they once considered disgusting. An excerpt:

Forty-nine percent mentioned at least sometimes searching for sexual content or being involved in OSAs that were not previously interesting to them or that they considered disgusting.

This Belgian study also found problematic Internet porn use was associated with reduced erectile function and reduced overall sexual satisfaction. Yet problematic porn users experienced greater cravings (OSA’s = online sexual activity, which was porn for 99% of subjects). Interestingly, 20.3% of participants said that one motive for their porn use was “to maintain arousal with my partner.” An excerpt:

This study is the first to directly investigate the relationships between sexual dysfunctions and problematic involvement in OSAs. Results indicated that higher sexual desire, lower overall sexual satisfaction, and lower erectile function were associated with problematic OSAs (online sexual activities). These results can be linked to those of previous studies reporting a high level of arousability in association with sexual addiction symptoms (Bancroft & Vukadinovic, 2004; Laier et al., 2013; Muise et al., 2013).

SECOND STUDY: The Dual Control Model: The Role Of Sexual Inhibition & Excitation In Sexual Arousal And Behavior (2007). Indiana University Press, Editor: Erick Janssen, pp.197-222.  In an experiment employing video porn, 50% of the young men couldn’t become aroused or achieve erections with porn (average age was 29). The shocked researchers discovered that the men’s erectile dysfunction was,

 related to high levels of exposure to and experience with sexually explicit materials.

The men experiencing erectile dysfunction had spent a considerable amount of time in bars and bathhouses where porn was “omnipresent,” and “continuously playing.” The researchers stated:

Conversations with the subjects reinforced our idea that in some of them a high exposure to erotica seemed to have resulted in a lower responsivity to “vanilla sex” erotica and an increased need for novelty and variation, in some cases combined with a need for very specific types of stimuli in order to get aroused.

THIRD & FOURTH STUDIES: Both found that deviant (i.e., bestiality or minor) pornography users reported a significantly younger onset of adult pornography use. These studies link earlier onset of porn use to escalation to more extreme material.

1) Does deviant pornography use follow a Guttman-like progression? (2013). An excerpt:

The findings of the current study suggest Internet pornography use may follow a Guttman-like progression. In other words, individuals who consume child pornography also consume other forms of pornography, both nondeviant and deviant. For this relationship to be a Guttman-like progression, child pornography use must be more likely to occur after other forms of pornography use. The current study attempted to assess this progression by measuring if the “age of onset” for adult pornography use facilitated the transition from adult-only to deviant pornography use.

Based on the results, this progression to deviant pornography use may be affected by the individuals “age of onset” for engaging in adult pornography. As suggested by Quayle and Taylor (2003), child pornography use may be related to desensitization or appetite satiation to which offenders begin collecting more extreme and deviant pornography. The current study suggests individuals who engage in adult pornography use at a younger age may be at greater risk for engaging in other deviant forms of pornography.

2) Deviant Pornography Use: The Role of Early-Onset Adult Pornography Use and Individual Differences (2016). Excerpts:

Results indicated that adult + deviant pornography users scored significantly higher on openness to experience and reported a significantly younger age of onset for adult pornography use compared to adult-only pornography users.

Finally, the respondents’ self-reported age of onset for adult pornography significantly predicted adult-only vs. adult + deviant pornography use. That is to day, adult + deviant pornography users selfreported a younger age of onset for nondeviant (adult-only) pornography compared to the adult-only pornography users. Overall, these findings support the conclusion drawn by Seigfried-Spellar and Rogers (2013) that Internet pornography use may follow a Guttman-like progression in that deviant pornography use is more likely to occur after the use of nondeviant adult pornography.

FIFTH STUDY: Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn   (Kuhn & Gallinat, 2014) – This Max Planck Institute fMRI study found less grey matter in the reward system (dorsal striatum) correlating with the amount of porn consumed. It also found that more porn use correlated with less reward circuit activation while briefly viewing sexual photos. Researchers believe their findings indicated desensitization, and possibly tolerance, which is the need for greater stimulation to achieve the same level of arousal. Lead author Simone Kühn said the following about her study:

This could mean that regular consumption of pornography dulls the reward system. … We therefore assume that subjects with high pornography consumption require ever stronger stimuli to reach the same reward level …. This is consistent with the findings on the functional connectivity of the striatum to other brain areas: high pornography consumption was found to be associated with diminished communication between the reward area and the prefrontal cortex. The prefrontal cortex, together with the striatum, is involved in motivation and appears to control the reward-seeking drive.

Furthermore, in May, 2016. Kuhn & Gallinat published this review – Neurobiological Basis of Hypersexuality. In the review Kuhn & Gallinat describe their 2014 fMRI study:

In a recent study by our group, we recruited healthy male participants and associated their self-reported hours spent with pornographic material with their fMRI response to sexual pictures as well as with their brain morphology (Kuhn & Gallinat, 2014). The more hours participants reported consuming pornography, the smaller the BOLD response in left putamen in response to sexual images. Moreover, we found that more hours spent watching pornography was associated with smaller gray matter volume in the striatum, more precisely in the right caudate reaching into the ventral putamen. We speculate that the brain structural volume deficit may reflect the results of tolerance after desensitization to sexual stimuli.

SIXTH STUDY: Novelty, conditioning and attentional bias to sexual rewards (2015). Cambridge University fMRI study reporting greater habituation to sexual stimuli in compulsive porn users. An excerpt:

Online explicit stimuli are vast and expanding, and this feature may promote escalation of use in some individuals. For instance, healthy males viewing repeatedly the same explicit film have been found to habituate to the stimulus and find the explicit stimulus as progressively less sexually arousing, less appetitive and less absorbing (Koukounas and Over, 2000). … We show experimentally what is observed clinically that Compulsive Sexual Behavior is characterized by novelty-seeking, conditioning and habituation to sexual stimuli in males.

FROM THE RELATED PRESS RELEASE:

The researchers found that sex addicts were more likely to choose the novel over the familiar choice for sexual images relative to neutral object images, whereas healthy volunteers were more likely to choose the novel choice for neutral human female images relative to neutral object images.

“We can all relate in some way to searching for novel stimuli online – it could be flitting from one news website to another, or jumping from Facebook to Amazon to YouTube and on,” explains Dr Voon. “For people who show compulsive sexual behaviour, though, this becomes a pattern of behaviour beyond their control, focused on pornographic images.”

In a second task, volunteers were shown pairs of images – an undressed woman and a neutral grey box – both of which were overlaid on different abstract patterns. They learned to associate these abstract images with the images, similar to how the dogs in Pavlov’s famous experiment learnt to associate a ringing bell with food. They were then asked to select between these abstract images and a new abstract image.

This time, the researchers showed that sex addicts where more likely to choose cues (in this case the abstract patterns) associated with sexual and monetary rewards. This supports the notion that apparently innocuous cues in an addict’s environment can ‘trigger’ them to seek out sexual images.

“Cues can be as simple as just opening up their internet browser,” explains Dr Voon. “They can trigger a chain of actions and before they know it, the addict is browsing through pornographic images. Breaking the link between these cues and the behaviour can be extremely challenging.”

The researchers carried out a further test where 20 sex addicts and 20 matched healthy volunteers underwent brain scans while being shown a series of repeated images – an undressed woman, a £1 coin or a neutral grey box.

They found that when the sex addicts viewed the same sexual image repeatedly, compared to the healthy volunteers they experienced a greater decrease of activity in the region of the brain known as the dorsal anterior cingulate cortex, known to be involved in anticipating rewards and responding to new events. This is consistent with ‘habituation’, where the addict finds the same stimulus less and less rewarding – for example, a coffee drinker may get a caffeine ‘buzz’ from their first cup, but over time the more they drink coffee, the smaller the buzz becomes.

This same habituation effect occurs in healthy males who are repeatedly shown the same porn video. But when they then view a new video, the level of interest and arousal goes back to the original level. This implies that, to prevent habituation, the sex addict would need to seek out a constant supply of new images. In other words, habituation could drive the search for novel images.

“Our findings are particularly relevant in the context of online pornography,” adds Dr Voon. “It’s not clear what triggers sex addiction in the first place and it is likely that some people are more pre-disposed to the addiction than others, but the seemingly endless supply of novel sexual images available online helps feed their addiction, making it more and more difficult to escape.” [emphasis added]

SEVENTH STUDY: Exploring the effect of sexually explicit material on the sexual beliefs, understanding and practices of young men: A qualitative surve (2016). An excerpt:

Findings suggest that the key themes are: increased levels of availability of SEM, including an escalation in extreme content (Everywhere You Look) which are seen by young men in this study as having negative effects on sexual attitudes and behaviours (That’s Not Good). Family or sex education may offer some ‘protection’ (Buffers) to the norms young people see in SEM. Data suggests confused views (Real verses Fantasy) around adolescents’ expectations of a healthy sex life (Healthy Sex Life) and appropriate beliefs and behaviours (Knowing Right from Wrong). A potential causal  pathway is described and areas of intervention highlighted.

EIGHTH STUDY: Modulation of late positive potentials by sexual images in problem users and controls inconsistent with “porn addiction” (Prause et al., 2015.)

A second EEG study from Nicole Prause’s team. This study compared the 2013 subjects from Steele et al., 2013 to an actual control group (yet it suffered from the same methodological flaws named above). The results: Compared to controls “individuals experiencing problems regulating their porn viewing” had lower brain responses to one-second exposure to photos of vanilla porn. The lead author claims these results “debunk porn addiction.” What legitimate scientist would claim that their lone anomalous study has debunked a well established field of study?

In reality, the findings of Prause et al. 2015 align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn. Prause et al. findings also align with Banca et al. 2015. Moreover, another EEG study found that greater porn use in women correlated with less brain activation to porn. Lower EEG readings mean that subjects are paying less attention to the pictures. Put simply, frequent porn users were desensitized to static images of vanilla porn. They were bored (habituated or desensitized). See this extensive YBOP critique. Nine peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (consistent with addiction): Peer-reviewed critiques of Prause et al., 2015

NINTH STUDY: Unusual masturbatory practice as an etiological factor in the diagnosis and treatment of sexual dysfunction in young men (2014). One of the 4 case studies in this paper reports on a man with porn-induced sexual problems (low libido, multiple porn fetishes, anorgasmia). The sexual intervention called for a 6-week abstinence from porn and masturbation. After 8 months the man reported increased sexual desire, successful sex and orgasm, and enjoying “good sexual practices. Excerpts from the paper documenting the patient’s habituation and escalation into what he described as more extreme porn genres:

When asked about masturbatory practices, he reported that in the past he had been masturbating vigorously and rapidly while watching pornography since adolescence. The pornography originally consisted mainly of zoophilia, and bondage, domination, sadism, and masochism, but he eventually got habituated to these materials and needed more hardcore pornography scenes, including transgender sex, orgies, and violent sex. He used to buy illegal pornographic movies on violent sex acts and rape and visualized those scenes in his imagination to function sexually with women. He gradually lost his desire and his ability to fantasize and decreased his masturbation frequency.

An excerpt from the paper documents the patient’s recovery from porn-induced sexual problems and fetishes:

In conjunction with weekly sessions with a sex therapist, the patient was instructed to avoid any exposure to sexually explicit material, including videos, newspapers, books, and internet pornography. After 8 months, the patient reported experiencing successful orgasm and ejaculation. He renewed his relationship with that woman, and they gradually succeeded in enjoying good sexual practices.

TENTH STUDY: Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016) – is an extensive review of the literature related to porn-induced sexual problems. Authored by US Navy doctors, the review provides the latest data revealing a tremendous rise in youthful sexual problems. It also reviews the neurological studies related to porn addiction and sexual conditioning via Internet porn. The doctors include 3 clinical reports of servicemen who developed porn-induced sexual dysfunctions. Two of the three servicemen healed their sexual dysfunctions by eliminating porn use while the third man experienced little improvement as he was unable to abstain from porn use. Two of the three servicemen reported habituation to current porn and escalation of porn use. The first servicemen describes his habituation to “soft porn” followed by escalation into more graphic and fetish porn:

A 20-year old active duty enlisted Caucasian serviceman presented with difficulties achieving orgasm during intercourse for the previous six months. It first happened while he was deployed overseas. He was masturbating for about an hour without an orgasm, and his penis went flaccid. His difficulties maintaining erection and achieving orgasm continued throughout his deployment. Since his return, he had not been able to ejaculate during intercourse with his fiancée. He could achieve an erection but could not orgasm, and after 10–15 min he would lose his erection, which was not the case prior to his having ED issues.

Patient endorsed masturbating frequently for “years”, and once or twice almost daily for the past couple of years. He endorsed viewing Internet pornography for stimulation. Since he gained access to high-speed Internet, he relied solely on Internet pornography. Initially, “soft porn”, where the content does not necessarily involve actual intercourse, “did the trick”. However, gradually he needed more graphic or fetish material to orgasm. He reported opening multiple videos simultaneously and watching the most stimulating parts. [emphasis added]

The second serviceman describes increased porn use and escalation into more graphic porn. Soon thereafter sex with his wife “not as stimulating as before”:

A 40-year old African American enlisted serviceman with 17 years of continuous active duty presented with difficulty achieving erections for the previous three months. He reported that when he attempted to have sexual intercourse with his wife, he had difficulty achieving an erection and difficulty maintaining it long enough to orgasm. Ever since their youngest child left for college, six months earlier, he had found himself masturbating more often due to increased privacy.

He formerly masturbated every other week on average, but that increased to two to three times per week. He had always used Internet pornography, but the more often he used it, the longer it took to orgasm with his usual material. This led to him using more graphic material. Soon thereafter, sex with his wife was “not as stimulating” as before and at times he found his wife “not as attractive”. He denied ever having these issues earlier in the seven years of their marriage. He was having marital issues because his wife suspected he was having an affair, which he adamantly denied. [emphasis added]

ELEVENTH STUDY: Shifting Preferences In Pornography Consumption (1986) – Six weeks of exposure to nonviolent pornography resulted in subjects having little interest in vanilla porn, electing to almost exclusively watch “uncommon pornography” (bondage, sadomasochism, bestiality). An excerpt:

Male and female students and nonstudents were exposed to one hour of common, nonviolent pornography or to sexually and aggressively innocuous materials in each of six consecutive weeks. Two weeks after this treatment, they were provided with an opportunity to watch videotapes in a private situation. G-rated, R-rated, and X-rated programs were available. Subjects with considerable prior exposure to common, nonviolent pornography showed little interest in common, nonviolent pornography, electing to watch uncommon pornography (bondage, sadomasochism, bestiality) instead. Male nonstudents with prior exposure to common, nonviolent pornography consumed uncommon pornography almost exclusively. Male students exhibited the same pattern, although somewhat less extreme. This consumption preference was also in evidence in females, but was far less pronounced, especially among female students. [emphasis added]

TWELFTH STUDY: Examining Correlates of Problematic Internet Pornography Use Among University Students (2016) – Addictive use of internet porn, which is associated with poorer psychosocial functioning, emerges when people begin to use IP daily.

Age of first exposure to IP was found to be significantly correlated with frequent and addictive IP use (see Table 2). Participants who were exposed to IP at an earlier age were more likely to use IP more frequently, have longer IP sessions, and more likely to score higher on Adapted DSM-5 Internet Pornography Addiction Criteria and CPUI-COMP measures. Finally, total IP exposure was found to be significantly correlated with higher frequency of IP use. Participants who had longer total exposure to IP were also more likely to have more IP sessions per month.

THIRTEENTH STUDY: The Relationship between Frequent Pornography Consumption, Behaviors, and Sexual Preoccupancy among Male Adolescents in Sweden (2017) – Porn use in 18-year old males was universal, and frequent porn users preferred hard-core porn. Does this indicate escalation of porn use?

Among frequent users, the most common type of pornography consumed was hard core pornography (71%) followed by lesbian pornography (64%), while soft core pornography was the most commonly selected genre for average (73%) and infrequent users (36%). There was also a difference between the groups in the proportion who watched hard core pornography (71%, 48%, 10%) and violent pornography (14%, 9%, 0%).

The authors suggest that frequent porn may ultimately lead to a preference for hard-core or violent pornography:

It is also noteworthy that a statistically significant relationship was found between fantasizing about pornography several times a week and watching hard core pornography. Since verbal and physical sexual aggression is so commonplace in pornography, what most adolescents considered hard core pornography could likely be defined as violent pornography. If this is the case, and in light of the suggested cyclical nature of sexual preoccupancy in Peter and Valkenburg, it may be that rather than ‘purging’ individuals of their fantasies and inclinations of sexual aggression, watching hard core pornography perpetuates them, thereby increasing the likelihood of manifested sexual aggression.

FOURTEENTH STUDY: The Development of the Problematic Pornography Consumption Scale (PPCS) (2017) – This paper developed and tested a problematic porn use questionnaire that was modeled after substance addiction questionnaires. Unlike previous porn addiction tests, this 18-item questionnaire assessed tolerance and withdrawal with the following 6 questions:

———-

Each question was scored from one to seven on a likert scale: 1- Never, 2- Rarely, 3- Occasionally, 4- Sometimes, 5- Often, 6- Very Often, 7- All the Time. The graph below grouped porn users into 3 categories based on their total scores:  “Nonprobelmatic,” “Low risk,” and “At risk.” The yellow line indicates no problems, which means that the “Low risk” and “At risk” porn users reported both tolerance and withdrawal. Put simply, this study actually asked about escalation (tolerance) and withdrawal – and both are reported by some porn users. End of debate.

STUDY FIFTEEN: Out-of-control use of the internet for sexual purposes as behavioural addiction? – An upcoming study (presented at the 4th International Conference on Behavioral Addictions February 20–22, 2017) which asked about tolerance and withdrawal. It found both in “porn addicts”.

Anna Ševčíková1, Lukas Blinka1 and Veronika Soukalová1

1Masaryk University, Brno, Czech Republic

Background and aims:

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

Methods:

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

Results:

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

Conclusions:

The study indicates a usefulness for the behavioural addiction framework

STUDY SIXTEEN: (review by UK psychiatrist): Internet pornography and paedophilia (2013) – Excerpt:

Clinical experience and now research evidence are accumulating to suggest that the Internet is not simply drawing attention to those with existing paedophilic interests, but is contributing to the crystallisation of those interests in people with no explicit prior sexual interest in children.

STUDY SEVENTEEN: How difficult is it to treat delayed ejaculation within a short-term psychosexual model? A case study comparison (2017) – A report on two “composite cases” illustrating the causes and treatments for delayed ejaculation (anorgasmia). “Patient B” represented several young men treated by the therapist. Interestingly, the paper states that Patient B’s “porn use had escalated into harder material”, “as is often the case”. The paper says that porn-related delayed ejaculation is not uncommon, and on the rise. The author calls for more research on porn’s effects of sexual functioning. Patient B’s delayed ejaculation was healed after 10 weeks of no porn. Excerpts related to escalation:

The cases are composite cases taken from my work within the National Health Service in Croydon University Hospital, London. With the latter case (Patient B), it is important to note that the presentation reflects a number of young males who have been referred by their GPs with a similar diagnosis. Patient B is a 19-year-old who presented because he was unable to ejaculate via penetration. When he was 13, he was regularly accessing pornography sites either on his own through internet searches or via links that his friends sent him. He began masturbating every night while searching his phone for image…If he did not masturbate he was unable to sleep. The pornography he was using had escalated, as is often the case (see Hudson-Allez, 2010), into harder material (nothing illegal)…

Patient B was exposed to sexual imagery via pornography from the age of 12 and the pornography he was using had escalated to bondage and dominance by the age of 15.

We agreed that he would no longer use pornography to masturbate. This meant leaving his phone in a different room at night. We agreed that he would masturbate in a different way….The article calls for research into pornography usage and its effect on masturbation and genital desensitisation.

STUDY EIGHTEEN: Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017) – The study assessed porn user’s responses (EEG readings & Startle Response) to various emotion-inducing images – including erotica. The authors believe two findings indicate habituation in the more frequent porn users.

4.1. Explicit Ratings

Interestingly, the high porn use group rated the erotic images as more unpleasant than the medium use group. The authors suggest this may be due to the relatively “soft-core” nature of the “erotic” images contained in the IAPS database not providing the level of stimulation that they may usually seek out, as it has been shown by Harper and Hodgins [58] that with frequent viewing of pornographic material, many individuals often escalate into viewing more intense material to maintain the same level of physiological arousal. The “pleasant” emotion category saw valence ratings by all three groups to be relatively similar with the high use group rating the images as slightly more unpleasant on average than the other groups.

This may again be due to the “pleasant” images presented not being stimulating enough for the individuals in the high use group. Studies have consistently shown a physiological downregulation in processing of appetitive content due to habituation effects in individuals who frequently seek out pornographic material [3,7,8]. It is the authors’ contention that this effect may account for the results observed.

4.3. Startle Reflex Modulation (SRM)

The relative higher amplitude startle effect seen in the low and medium porn use groups may be explained by those in the group intentionally avoiding the use of pornography, as they may find it to be relatively more unpleasant. Alternatively, the results obtained also may be due to a habituation effect, whereby individuals in these groups do watch more pornography than they explicitly stated—possibly due to reasons of embarrassment among others, as habituation effects have been shown to increase startle eye blink responses [41,42].

STUDY NINETEEN: Exploring the Relationship between Sexual Compulsivity and Attentional Bias to Sex-Related Words in a Cohort of Sexually Active Individuals (2017) – This study replicates the findings of this 2014 Cambridge University study that compared the attentional bias of porn addicts to healthy controls. Here’s what’s new: The study correlated the “years of sexual activity” with 1) the sex addiction scores and also 2) the results of the attentional bias task. Among those scoring high on sexual addiction, fewer years of sexual experience were related to greater attentional bias. So higher sexual compulsivity scores + fewer years of sexual experience = greater signs of addiction (greater attentional bias, or interference). But attentional bias declines sharply in the compulsive users, and disappears at the highest number of years of sexual experience.

The authors concluded that this result could indicate that more years of “compulsive sexual activity” lead to greater habituation or a general numbing of the pleasure response (desensitization). An excerpt from the conclusion section:

“One possible explanation for these results is that as a sexually compulsive individual engages in more compulsive behaviour, an associated arousal template develops [36–38] and that over time, more extreme behaviour is required for the same level of arousal to be realised. It is further argued that as an individual engages in more compulsive behaviour, neuropathways become desensitized to more ‘normalised’ sexual stimuli or images and individuals turn to more ‘extreme’ stimuli to realise the arousal desired. This is in accordance with work showing that ‘healthy’ males become habituated to explicit stimuli over time and that this habituation is characterised by decreased arousal and appetitive responses [39].

This suggests that more compulsive, sexually active participants have become ‘numb’ or more indifferent to the ‘normalised’ sex-related words used in the present study and as such display decreased attentional bias, while those with increased compulsivity and less experience still showed interference because the stimuli reflect more sensitised cognition.”

STUDY TWENTY: A qualitative study of cybersex participants: Gender differences, recovery issues, and implications for therapists (2000) – Excerpts:

Some respondents described a rapid progression of a previously existing compulsive sexual behavior problem, whereas others had no history of sexual addiction but became rapidly involved in an escalating pattern of compulsive cybersex use after they discovered Internet sex. Adverse consequences included depression and other emotional problems, social isolation, worsening of their sexual relationship with spouse or partner, harm done to their marriage or primary relationship, exposure of children to online pornography or masturbation, career loss or decreased job performance, other financial consequences, and in some cases, legal consequences.

One of the examples:

A 30-year-old man with a previous history of “porn, masturbation, and frequent sexual thoughts,” wrote about his cybersex experience: In the last couple of years, the more porn I’ve viewed, the less sensitive I am to certain porn that I used to find offensive. Now I get turned on by some of it (anal sex, women peeing, etc.) The sheer quantity of porn on the Net has done this. It’s so easy to click on certain things out of curiosity in the privacy of your home, and the more you see them, the less sensitized you are. I used to only be into softcore porn showing the beauty of the female form. Now I’m into explicit hardcore.

STUDY TWENTY ONE: Sexual Arousal and Sexually Explicit Media (SEM): Comparing Patterns of Sexual Arousal to SEM and Sexual Self-Evaluations and Satisfaction Across Gender and Sexual Orientation (2017). In this study participants were asked about their sexual arousal related to 27 genres (themes) of porn. Why the researchers chose these 27 particular genres is known only to them. How they determined which genres were “mainstream” which were “non-mainstream” also remains a mystery, given their seemingly random categorization. (See the researchers’ arbitrary categorization porn genres.)

No matter, this study debunks the claim that porn users like only a narrow range of genres. While it doesn’t directly ask about escalation over time, the study found that subjects they categorized as “non-mainstream” porn viewers like many different types of porn . A few relevant excerpts:

The findings suggest that in classified non-mainstream Sexually Explicit Media [porn] groups, patterns of sexual arousal might be less fixated and category specific than previously assumed.

Particularly for heterosexual men and non-heterosexual women, who were characterized by substantial levels of sexual arousal to non-mainstream SEM themes, the findings suggest that patterns of sexual arousal induced by SEM in non-laboratory settings might be more versatile, less fixed, and less category specific than previously assumed. This supports a more generalized SEM arousability and indicates that non-mainstream SEM group participants also are aroused by more mainstream (“vanilla”) themes.

The study is saying that so-called “non-mainstream porn viewers” are aroused by all sorts of porn, whether it’s so-called “mainstream” (Bukkake, Orgy, Fist-fucking) or so-called “non-mainstream” (Sadomasochism, Latex). This finding debunks the often repeated meme that frequent porn users stick to one type of porn. (An example of the unfounded claim about “fixed” tastes is Ogas and Gaddam’s highly criticized book A Billion Wicked Thoughts.)

STUDY TWENTY TWO: The Development and Validation of the Bergen-Yale Sex Addiction Scale With a Large National Sample (2018). This paper developed and tested a “sex addiction” questionnaire that was modeled after substance addiction questionnaires. As the authors explained, previous questionnaires have omitted key elements of addiction:

Most previous studies have relied on small clinical samples. The present study presents a new method for assessing sex addiction—the Bergen–Yale Sex Addiction Scale (BYSAS)—based on established addiction components (i.e., salience/craving, mood modification, tolerance, withdrawal, conflict/problems, and relapse/loss of control).

The authors expand on the six established addiction components assessed, including tolerance and withdrawal.

The BYSAS was developed utilizing the six addiction criteria emphasized by Brown (1993), Griffiths (2005), and American Psychiatric Association (2013) encompassing salience, mood modification, tolerance, withdrawal symptoms, conflicts and relapse/loss of control…. In relation to sex addiction, these symptoms would be: salience/craving—over-preoccupation with sex or wanting sex, mood modification—excessive sex causing changes in mood, tolerance—increasing amounts of sex over time, withdrawal—unpleasant emotional/physical symptoms when not having sex, conflict—inter-/intrapersonal problems as a direct result of excessive sex, relapse—returning to previous patterns after periods with abstinence/control, and problems—impaired health and well-being arising from addictive sexual behavior.

The most prevalent “sex addiction” components seen in the subjects were salience/craving and tolerance, but the other components, including withdrawal, also showed up to a lesser degree:

Salience/craving and tolerance were more frequently endorsed in the higher rating category than other items, and these items had the highest factor loadings. This seems reasonable as these reflect less severe symptoms (e.g., question about depression: people score higher on feeling depressed, then they plan committing suicide). This may also reflect a distinction between engagement and addiction (often seen in the game addiction field)—where items tapping information about salience, craving, tolerance, and mood modification are argued to reflect engagement, whereas items tapping withdrawal, relapse and conflict more measure addiction. Another explanation could be that salience, craving, and tolerance may be more relevant and prominent in behavioral addictions than withdrawal and relapse.

This study, along with the 2017 study that developed and validated the “Problematic Pornography Consumption Scale,” refutes the often-repeated claim that porn and sex addicts do not experience either tolerance or withdrawal symptoms.

STUDY TWENTY THREE: Exposure to online sexual materials in adolescence and desensitization to sexual content (2018) – A rare longitudinal study where exposure to porn led to desensitization or habituation. Abstract:

It is well known that adolescents use the Internet for sexual purposes, for example viewing sexually explicit materials, a practice which increases with age. Prior research has suggested a link between cognitive and behavioral effects on the one hand and viewing sexually explicit materials on the Internet on the other. The present study aimed to explore exposure to sexually explicit materials on the Internet and a possible desensitizing effect on the perception of online sexual content over time. The study design was longitudinal; data were collected in 3 waves at 6 months intervals starting in 2012. The sample included 1134 respondents (girls, 58.8%; mean age, 13.84 ± 1.94 years) from 55 schools. A multivariate growth model was used for analyzing data.

The results showed that the respondents changed their perception of sexually explicit material on the Internet over time depending on age, frequency of exposure and whether exposure was intentional. They became desensitized in terms of being less bothered by the sexual content. The results may indicate a normalization of sexually explicit material on the Internet during adolescence.

STUDY TWENTY FOUR: Pornographic binges as a key characteristic of males seeking treatment for compulsive sexual behaviors: Qualitative and quantitative 10-week-long diary assessment (2018) – This study conducted interviews with nine treatment-seeking males aged 22–37 years, who were followed by a questionnaire and a 10-week-long diary assessment. The following excerpt describes escalation of use:

All patients suffered from recurrent sexual fantasies/behaviors and admitted that their sexual behavior resulted in the mishandling of important life duties. All patients noticed a gradual progression of the problem and admitted using sexual behaviors (mostly pornography viewing accompanied by masturbation) to cope with stressful life events. Each of the patients reported multiple attempts to limit or terminate CSB. Usually, effects were poor and temporary, but some reported longer periods of sexual abstinence (several months up to 1 year) followed by relapses.

STUDY TWENTY FIVE: Structural Therapy With a Couple Battling Pornography Addiction (2012) – Discusses both tolerance and withdrawal

Similarly, tolerance can also develop to pornography. After prolonged consumption of pornography, excitatory responses to pornography diminish; the repulsion evoked by common pornography fades and may be lost with prolonged consumption (Zillman, 1989). Thus, what initially led to an excitatory response does not necessarily lead to the same level of enjoyment of the frequently consumed material. There-fore, what aroused an individual initially may not arouse them in the later stages of their addiction. Because they do not achieve satisfaction or have the repulsion they once did, individuals addicted to pornography generally seek increasingly novel forms of pornography to achieve the same excitatory result.

For example, pornography addiction may begin with non-pornographic but provocative images and can then progress to more sexually explicit mages. As arousal diminishes with each use, an addicted individual may move on to more graphic forms of sexual images and erotica. As arousal again diminishes, the pattern continues to incorporate increasingly graphic, titillating, and detailed depictions of sexual activity through the various forms of media. Zillman (1989) states that prolonged pornography use can foster a preference for pornography featuring less common forms of sexuality (e.g., violence), and may alter perceptions of sexuality. Although this pattern typifies what one would expect to see with pornography addiction, not all pornography users experience this cascade into an addiction.

Withdrawal symptoms from pornography use may include depression, irritability, anxiety, obsessive thoughts, and an intense longing for pornography. Due to these often intense withdrawal symptoms, cessation from this reinforcement can be extremely difficult for both the individual and the couple’s relationship.

STUDY TWENTY SIX: Consequences of Pornography Use (2017) – This study asked if internet users experienced anxiety when they couldn’t access porn on the internet (a withdrawal symptom): 24% experienced anxiety. One third of the participants had suffered negative consequences related to their porn use. Excerpts:

The objective of this study is to obtain a scientific and empirical approximation to the type of consumption of the Spanish population, the time they use in such consumption, the negative impact it has on the person and how anxiety is affected when it is not possible to access to it. The study has a sample of Spanish internet users (N = 2.408). An 8-item survey was developed through an online platform that provides information and psychological counselling on the harmful consequences of pornography consumption. To reach diffusion among the Spanish population, the survey was promoted through social networks and media.

The results show that one third of the participants had suffered negative consequences in family, social, academic or work environment. In addition, 33% spent more than 5 hours connected for sexual purposes, using pornography as a reward and 24% had anxiety symptoms if they could not connect.

STUDY TWENTY SEVEN: So why did you do it?: Explanations provided by Child Pornography Offenders (2013) – From the “Explanations provided for CP Offending” section – prolonged exposure and potential desensitization to legal pornography lead to the offender using child pornography (CP):

Progression from legal material. For nine participants, their CP offending appeared to be the result of prolonged exposure and potential desensitisation to legal pornography. Some participants provided fairly detailed responses of their journey:

“The gradual escalation from normal adult material to more extreme material (dehumanising) after first accessing the internet, that I used it to cope with emotional and stressful situations. Followed by viewing younger and younger woman, girls and preteen, i.e. child modeling [sic] and cartoons showing extreme adult and other abusive subject matter. (Case 5164)”

Again, some of the responses clearly linked back to a developing sexual interest in children, based on increasing exposure to the material…. Overall, this theme shared some similarities with the previous theme in that CP, used as a source of sexual satisfaction, acts as a potential stress reliever. However, for offenders belonging to this thematic group, CP had been approached via progression through other forms of pornography, which may still be used.

STUDY TWENTY EIGHT: Effect of Pornography Exposure on Junior High School Teenagers of Pontianak in 2008 (2009) – Malaysian porn use study on junior high students. Unique in that this is the only study to report escalation into more extreme material, desensitization (tolerance), and porn addiction in a teen population. (It’s the only study to ask teens these questions.) Excerpts:

A total of 83.3% of junior high school adolescents in Pontianak City have exposed to pornography, and from being exposed as many as 79.5% experience the effects of exposure to pornography. Teenagers who experience the effects of exposure to pornography as much as 19.8% were in the addiction stage, [among the addicted] adolescents 69.2% is at the escalation stage, [among those who escalated] 61.1% is at the desensitization stage, and [among those who reported desensitization] 31.8% was at the stage of act out.

Pornography can affect teens to do shape behavior, consciously or unconsciously, has changing perceptions and even the behavior of adolescent life daily especially in terms of sexuality The results of this study show that as many as 52 (19.78%) of junior high school students in Pontianak City has experienced the effects of exposure to pornography is on stage addiction.

The next change in attitude or behavior is escalation. The results showed 36 people (69.2%) of 52 adolescents who are addicted to the stage escalation / increased needs. After all this time consume pornography, adolescents who are hooked will experienced an increase in the need for sex material which is heavier, more explicit, more sensational and more distorted than previously consumed. This increase in demand is not in terms of quantity but especially the quality of which is increasingly explicit, then it is will be more satisfied. If before he had enough satisfied watching the image of a woman naked, then want to see a movie that contains a sex scene.

Once saturated, he wants to see that sex scene different ones that are sometimes more wild and distorted than which he had seen. Also in accordance with the results study Zillman & Bryant (1982, in Thornburgh & Herbert, 2002) which states that when someone is exposed to repeated pornography, they are will show a tendency to have distorted perceptions of sexuality also occur increased need for more pornographic types hard and distorted.

The next stage of desensitization has been experienced by 22 people (61.11%) teenagers from 36 people who experiencing stage escalation. At this stage, sex material which was taboo, immoral and degrading/humiliating human dignity, gradually considered to be something that is considered normal which means the longer it becomes insensitive again.

The results of this study further found from 22 people in the desensitization stage exist as many as 7 people (31.8%) are in actout stage. At this stage there is a tendency to engage in sexual behavior such as pornography he has been watching for real life

STUDY TWENTY NINE: Clinical encounters with internet pornography (2008) – Comprehensive paper, with four clinical cases, written by a psychiatrist who became aware of the negative effects internet porn was having on some of his male patients. The excerpt below describes a 31 year old man who escalated into extreme porn and developed porn-induced sexual tastes and sexual problems. This is one of the first peer-reviewed papers to depict porn use leading to tolerance, escalation, and sexual dysfunctions.

A 31-year-old male in analytic psychotherapy for mixed anxiety problems reported that he was experiencing difficulty becoming sexually aroused by his current partner. After much discussion about the woman, their relationship, possible latent conflicts or repressed emotional content (without arriving at a satisfactory explanation for his complaint), he provided the detail that he was relying on a particular fantasy to become aroused. Somewhat chagrined, he described a “scene” of an orgy involving several men and women that he had found on an Internet pornography site that had caught his fancy and become one of his favorites. Over the course of several sessions, he elaborated upon his use of Internet pornography, an activity in which he had engaged sporadically since his mid-20s.

Relevant details about his use and the effects over time included clear descriptions of an increasing reliance on viewing and then recalling pornographic images in order to become sexually aroused. He also described the development of a “tolerance” to the arousing effects of any particular material after a period of time, which was followed by a search for new material with which he could achieve the prior, desired level of sexual arousal.

As we reviewed his use of pornography, it became evident that the arousal problems with his current partner coincided with use of pornography, whereas his “tolerance” to the stimulating effects of particular material occurred whether or not he was involved with a partner at the time or was simply using pornography for masturbation. His anxiety about sexual performance contributed to his reliance on viewing pornography. Unaware that the use itself had become problematic, he had interpreted his waning sexual interest in a partner to mean that she was not right for him, and had not had a relationship of greater than two months’ duration in over seven years, exchanging one partner for another just as he might change websites.

He also noted that he now could be aroused by pornographic material that he once had no interest in using. For example, he noted that five years ago he had little interest in viewing images of anal intercourse but now found such material stimulating. Similarly, material that he described as “edgier,” by which he meant “almost violent or coercive,” was something that now elicited a sexual response from him, whereas such material had been of no interest and was even off-putting. With some of these new subjects, he found himself anxious and uncomfortable even as he would become aroused.

STUDY THIRTY: Exploring the way sexually explicit material informs sexual beliefs, understanding and practices of young men: a qualitative survey (2018) – Small qualitative study on men ages 18-25 meant to explore the self-reported influence of exposure to porn. Several reported negative effects, including concerns about tolerance and resulting escalation. An excerpt:

In addition, participants talked about the ever increasing levels of extremity within SEM content online. SEM could therefore be seen as an influential force in the moulding of more extreme sexual preferences.

“due to the ever increasing availability of porn, the videos are becoming more and more  adventurous and shocking in order to keep up with the demand for it to still be deemed exciting”. – Jay

“It has probably made me case hardened. It takes a lot to shock me now, Because of the amount I have seen it doesn’t affect me as much as it used to” – Tom

STUDY THIRTY ONE: Technology-mediated addictive behaviors constitute a spectrum of related yet distinct conditions: A network perspective (2018) – Study assessed the overlap between 4 types of technology addiction: Internet, smartphone, gaming, cybersex. Found that each is a distinct addiction, yet all 4 involved withdrawal symptoms – including cybersex addiction. Excerpts:

To test the spectrum hypothesis and to have comparable symptoms for each technology-mediated behavior, the first and the last author linked each scale item with the following “classical” addiction symptoms: continued use, mood modification, loss of control, preoccupation, withdrawal, and consequences technology-mediated addictive behaviors were investigated using symptoms derived from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) and the component model of addiction: Internet, smartphone, gaming, and cybersex.

Between-conditions edges often connected the same symptoms through Internet addiction symptoms. For example, Internet addiction withdrawal symptoms were connected with withdrawal symptoms of all other conditions (gaming addiction, smartphone addiction, and cybersex addiction) and adverse consequences of Internet addiction were also connected with adverse consequences of all other conditions.

STUDY THIRTY TWO: Sexual Interests of Child Sexual Exploitation Material (CSEM) Consumers: Four Patterns of Severity Over Time (2018) – Study analyzed the evolution over time of the activity of consumers of child porn, using data extracted from the hard drives of 40 convicted individuals. Found that the most prevalent pattern was a drop in age of the person depicted and a rise in the extremeness of the sexual acts. The researchers discuss habituation and escalation, as well as the literature demonstrating that porn collectors have escalated to more extreme sexual interests than contact offenders. Excerpts:

37.5% of the collections exhibited increased severity in terms of both age and COPINE [extremeness] score: The children depicted became younger, and the acts became more extreme.

… It should be noted that all the child pornography collections included mainstream pornography content.

The main objective of this study was to analyse the evolution of the child-pornography collections of individuals convicted of child-pornography offences. In light of the results, we propose four explanations of the nature of, and variations in, child-pornography collections.

…The most prevalent pattern was a progressive decrease in the age of the person depicted and a progressive increase in the severity of the sexual acts. …

The first explanation is that child-pornography collections are an indicator of the sexual interests of the collector (Seto, 2013). This explanation implies that the collector would focus on content that is sexually arousing for him….

A second explanation that is also related to the sexual interest explanation is that collectors become habituated to low-severity pornography, which is congruent with the patterns 1, 2, and 3 of the current study. It has been suggested that habituation to pornographic content leads to boredom, which in turn impels the pornography consumer to seek out new content that is more severe (Reifler et al., 1971; Roy, 2004; Seto, 2013; Taylor & Quayle, 2003). According to Laws and Marshall (1990),

a previously conditioned sexual fantasy (conditional stimulus, CS1) plus masturbatory stimulation (unconditioned stimulus, UCS) can produce high sexual arousal plus orgasm. Minor variations of the original fantasy (CS2) successively substitute for the original one (perhaps to avoid boredom) and paired with masturbation, can elicit the same response. (p. 212)

Thus, to maintain their degree of sexual arousal, child-pornography collectors may be driven to explore other age categories and sexual acts. This discovery process presumably takes the form of trial and error in which they establish how congruent the new content is with their evolving sexual interests.

…During masturbatory activities, CSEM collectors have the possibility of exploring a wider range of sexual interests than offline sexual offenders, who are limited by the  availability of victims. Consequently, they may become motivated to search for new illegal content to nourish their sexual fantasies. This explanation is in agreement with  Babchishin et al.’s (2015) meta-analysis, which reveals that online offenders have more deviant sexual interests than offline offenders.

STUDY THIRTY THREE: Gender Differences in the Automatic Attention to Romantic Vs Sexually Explicit Stimuli (2018) – Higher levels of porn use affected the outcome of an experimental task, indicating that higher levels of porn use resulted in habituation effects to pornographic images. Relevant excerpts:

Scores on pornography consumption were introduced as covariate in the analysis pertaining the automatic attention task because the task may have been influenced by the habituation to sexually explicit stimuli.

Findings revealed that sexually explicit pictures yielded more automatic attention capture. However, this effect was superseded by pornography consumption, which likely reflects a habituation mechanism

These findings align with the Sexual Content Induced Delay, an effect that has been consistently reported in literature and shows that individuals present delayed responses when exposed to sexual stimuli—therefore signaling an attentional bias toward sexual stimuli—as compared with other types of stimuli. However, the introduction of pornography consumption as covariate reduced the impact of the sexually explicit pictures (to the level of nonstatistical significance), thus revealing a habituation mechanism in automatic attention to erotic stimuli.

STUDY THIRTY FOUR: Pornography Induced Erectile Dysfunction Among Young Men (2019) – Study on men with porn-induced erectile dysfunction (PIED) reveals tolerance (declining arousal) and escalation (needing more extreme material to be aroused) in all the subjects. From the abstract:

This paper explores the phenomenon of pornography induced erectile dysfunction (PIED), meaning sexual potency problems in men due to Internet pornography consumption. Empirical data from men who suffer from this condition have been collected….  they report that an early introduction to pornography (usually during adolescence) is followed by daily consumption until a point is reached where extreme content (involving, for example, elements of violence) is needed to maintain arousal. A critical stage is reached when sexual arousal is exclusively associated with extreme and fast-paced pornography, rendering physical intercourse bland and uninteresting. This results in an inability to maintain an erection with a real-life partner, at which point the men embark on a “re-boot” process, giving up pornography. This has helped some of the men to regain their ability to achieve and sustain an erection.

Introduction to the results section:

Having processed the data, I have noticed certain patterns and recurring themes, following a chronological narrative in all of the interviews. These are: Introduction. One is first introduced to pornography, usually before puberty. Building a habit. One begins to consume pornography regularly. Escalation. One turns to more “extreme” forms of pornography, content-wise, in order to achieve the same effects previously achieved through less “extreme” forms of pornography.Realization. One notices sexual potency problems believed to be caused by pornography use. “Re-boot” process. One tries to regulate pornography use or eliminate it completely in order to regain one’s sexual potency. The data from the interviews are presented based on the above outline.

STUDY THIRTY FIVE (not peer-reviewed): xHamster Report on Digital Sexuality, Part 1: Bisexuality (2019)  – A surprising study by porn-tube site Xhamster suggests that heavy porn use can lead to some users believing they may be bisexual. While this finding is politically incorrect, YBOP has documented many instances of chronic porn users who believed themselves to be bisexual, yet no longer believed this after extended periods away from porn. These pages contain many examples of eliminating porn leading a reversal of sexual tastes:

• I’m straight, but attracted to transsexual or gay porn (or gay attracted to straight porn). What’s up?
• Is my fetish porn-induced?
• Can You Trust Your Johnson? (2011)

Excerpts from the Xhamster article (which contains several graphs):

Does watching too much porn make you gay? No, but it might make you bi.

Earlier this month, xHamster launched an ambitious internal study — the xHamster Report on Digital Sexuality — compiling data on our porn users age, gender, sexuality, relationship status, political views, viewing habits and more, to try to understand just who watches what and why. Over 11,000 users completed this survey.

While we’re just beginning to process the data, one number jumped out at us immediately. Over 22.3% of all US-based xHamster visitors consider themselves bisexual. Only 67% consider themselves to be entirely “straight.”

At first, we thought there was something wrong with the numbers, or the study design. But as we dug deeper, we saw a consistency with their answers — from relationship status, to what porn they viewed, to where they lived — that supported the numbers…….

So we wondered, is there something about watching porn that opens up users to the idea of a more fluid sexuality. The answer is … it may.

We compared responses from users who watch porn once a week, with users who report watching it several times a day. Porn fans who watched multiple times a day were more than twice as likely to identify as bisexual as porn fans who watched only once a week (27% vs 13%).

As you can see, there’s a direct correlation between the amount of time a person spends watching porn, and whether or not they identified as bisexual. (It doesn’t seem to have an affect on gay identity — that stays in a pretty narrow range.)

We also wondered if there was some way that women porn fans — 38% of whom in our study identified as bisexual — might be somehow skewing the data. So we repeated the calculations with just men. The results were even more dramatic.

Just 10.8% of men who watched porn once a week identified as bisexual, but 27.2% of men who watch porn multiple times a day identify as bisexual. (After all, if you’re looking at naked men all day — even if there’s a woman in the picture — maybe it opens you up to a broader ideas about human sexuality.)

Now, we should stress that correlation is not causation. Bisexual and gay people both report greater frequency of viewing of porn, and a lower stigma associated with watching it. (Both groups are also less likely to be married, and thus might have greater freedom to watch. But again — we didn’t see any significant correlation between frequency of viewing, and gay identification.)……

STUDY THIRTY SIX: Pornography Use by Sex Offenders at the Time of the Index Offense: Characterization and Predictors (2019) – Excerpts:

The purpose of this study was to characterize and predict sex offenders’ pornography consumption at the time of the index offense. Participants were 146 male sex offenders incarcerated in a Portuguese prison establishment. A semi-structured interview and the Wilson Sex Fantasy Questionnaire were administered.

Thus, for those individuals, pornography had a conditioning effect, making them want to try out those behaviors. This is of importance, since 45% used pornography that featured forced sex and 10% that included children at least once at the time of the index offense. It appears that for some individuals with specific characteristics using pornography may help disinhibit their sexual desires. It was not the subject of this investigation to assess what those characteristics were, but past research has delved on this matter (e.g. Seto et al., 2001)….

Contrariwise, while some studies point to the “catharsis” role of pornography as a means of relief (Carter et al., 1987; D’Amato, 2006), that does not appear to be equal for all individuals, since for some it was not enough and made them try to reproduce the visualized contents. This is of specific importance for clinicians when tailoring treatment strategies for sex offenders of child pornography, for instance, as the motivation for using pornography needs to be fully assessed beforehand. A better understanding of the dynamics surrounding pornography consumption prior to an individual’s perpetration of sexual offenses is of utmost importance, due to its relationship with sexual aggression (Wright et al., 2016) and violent recidivism (Kingston et al., 2008)….

STUDY THIRTY SEVEN: Pornography: an experimental study of effects (1971) – Abstract:

The authors studied the effect of repeated exposure to pornographic material on young men. The 23 experimental subjects spent 90 minutes a day for three weeks viewing pornographic films and reading pornographic materials. Before-and-after measurements on these subjects and a control group of nine men included penile circumference changes and acid phosphatase activity in response to pornographic films. The data support the hypothesis that repeated exposure to pornography results in decreased interest in it and responsiveness to it. A variety of psychological tests and scales discerned no lasting effects on the subjects’ feelings or behavior other than feeling bored by pornography, both immediately following the study and eight weeks later.

STUDY THIRTY EIGHT: Finding Lolita: A Comparative Analysis of Interest in Youth-Oriented Pornography (2016) – Abstract:

The way we access pornography has certainly changed over time, as has the depth and breadth of pornographic content. Yet, despite decades of research on the effects of pornography, far less is known about specific genres, consumption patterns, and the characteristics of those consuming varying types of content. Utilizing Google search trends and image searches, this research explores the interest and relationships at the macro level within the niche of youth-oriented pornography. Results indicate that interest varies based on gender, age, geographic origin, and income.

Excerpt:

As our current research here can only speak to the trends illuminated from our analysis, future studies must be conducted in order to ascertain information regarding actual attitudes and behaviors associated with consuming youth-oriented pornography. Overall, the results indicate all three hypotheses were supported. We found that there has been a significant increase in the rate of interest within teenage pornography, amateur pornography, and Hentai inspired pornography, which is unsurprising given the popularity of the niches among and widespread availability content via pornographic hubs (Ogas and Gaddam 2011).

Clearly the interest in youth-oriented pornography has increased over the past decade, and that increase appears to coincide with what Gill (2008, 2012) and others argue is the continued ‘‘sexualization of culture’’. Only the search interest in Lolita pornography has decreased, most likely a result of the antiquated terminology and decrease in popularity, as more specific queries have arisen. Moreover, the evidence supports our hypothesis that those seeking out these subgenres within the niche of teenage pornography are a heterogeneous population rather than a homogenous group. Not only does the interest in types of youth-oriented pornography vary, but so too do the characteristics of the consumers seeking out the varying niches examined here.

STUDY THIRTY NINE: Facets of impulsivity and related aspects differentiate among recreational and unregulated use of Internet pornography (2019) – Relevant excerpt:

A further interesting result is that the effect size for post-hoc tests duration in minutes per session, when comparing unregulated [problematic] users with recreational–frequent users, was higher [in problematic users] in comparison to the frequency per week. This might indicate that individuals with unregulated IP [internet porn] use especially have difficulties to stop watching IP during a session or need longer time to achieve the desired reward, which might be comparable with a form of tolerance in substance use disorders.

STUDY FORTY: Prevalence, Patterns and Self-Perceived Effects of Pornography Consumption in Polish University Students: A Cross-Sectional Study (2019). The study reported everything the naysayers claim do not exist: tolerance/habituation, escalation of use, needing more extreme genres to be sexually aroused, withdrawal symptoms when quitting, porn-induced sexual problems, porn addiction, and more. A few excerpts related to tolerance/habituation/escalation:

The most common self-perceived adverse​ effects of pornography use included: the need for longer stimulation (12.0%) and more sexual stimuli​ (17.6%) to reach orgasm, and a decrease in sexual satisfaction (24.5%)…

The present study also suggests that earlier exposure may be associated with potential desensitization to sexual stimuli as indicated by a need for longer stimulation and more sexual stimuli required to reach orgasm when consuming explicit material, and overall decrease in sexual satisfaction…..

Various changes of pattern of pornography use occurring in the course of the exposure period were reported: switching to a novel genre of explicit material (46.0%), use of materials that do not​ match sexual orientation (60.9%) and need to use more extreme (violent) material (32.0%). The latter was more frequently reported by females considering themselves as curious compared to​those regarding themselves as uninquisitive

the present study found that a need to use more extreme pornography material was more frequently ​reported by males describing themselves as aggressive.

Additional signs of tolerance/escalation: needing multiple tabs open and using porn outside of home:

The majority of students admitted to use of private mode (76.5%, n = 3256) and multiple windows (51.5%, n = 2190) when browsing online pornography. Use of porn outside residence was declared by 33.0% (n = 1404).

Earlier age of first use related to greater problems and addiction (this indirectly indicates tolerance-habituation-escalation):

Age of first exposure to explicit material was associated with increased likelihood of negative effects of pornography in young adults—the highest odds were found for females and males exposed at 12 years or below. Although a cross-sectional study does not allow an assessment of causation, this finding may indeed indicate that childhood association with pornographic content may have long-term outcomes….

Addiction rates were relatively high, even though it was “self-perceived”:

Daily use and self-perceived addiction was reported by 10.7% and 15.5%, respectively.

The study reported withdrawal symptoms, even in non-addicts (a definitive sign of addiction-related brain changes):

Among those surveyed who declared themselves to be current pornography consumers (n = 4260), 51.0% admitted to making at least one attempt to give up using it with no difference in the frequency of these attempts between males and females. 72.2% of those attempting to quit pornography use indicated the experience of at least one associated effect, and the most frequently observed included erotic dreams (53.5%), irritability (26.4%), attention disturbance (26.0%), and sense of loneliness (22.2%) (Table 2).

Many of the participants believed that porn is a public health issue:

In the present study, the surveyed students often indicated that pornography exposure may have an adverse outcome on social relationships, mental health, sexual performance, and may affect psychosocial development in childhood and adolescence. Despite this, the majority of them did not support any need for restrictions to pornography access….

Debunking the claim that pre-existing conditions are the real issue, not porn use, the study found that personality traits were not related to outcomes:

With some exceptions, none of personality traits, which were self-reported in this study, differentiated the studied parameters of pornography. These findings support the notion that access and exposure to pornography are presently issues too broad to specify any particular psychosocial characteristics of its users. However, an interesting observation was made regarding consumers who reported a need to view increasingly extreme pornographic content. As shown, frequent use of explicit material may potentially be associated with desensitization leading to a need to view more extreme content to reach similar sexual arousal.

STUDY FORTY ONE: Prevalence and Determinants of Problematic Online Pornography Use in a Sample of German Women (2019) – Study reported that porn addiction was significantly related to diversity of porn genres. The authors believe this indicates tolerance leading to seeking out novel genres to achieve the same effects. Excerpts:

In line with our hypothesis, problematic online pornography use was associated with the amount of time spent viewing online pornography. The greater the overall online pornography use, the higher the s-IATsex score. Of note, the correlation explains only 18% of the common variance, leaving a large percentage of the variance unexplained. As a result, the total time spent viewing online pornography (hours per week) cannot be equated to problematic online pornography use, as has been done in some previous studies. Nonetheless, our data show that overall, the amount of time spent viewing online pornography is a significant predictor of problematic online pornography use.

We also identified a greater variance in pornography categories as a good predictor of problematic online pornography use—that is, the more diverse material a participant watched, the higher her s-IATsex score. This demonstrates that women with problematic online pornography use seek more diverse material, which could be an indicator for habituation effects. Habituation in turn could lead to tolerance building, leading consumers to explore new material to elicit the same neuronal response to pornography as when they initially started watching.

Our findings add to the growing body of literature suggesting that problematic online pornography use might constitute a clinically relevant phenomenon. Although in 2013 the editors of the revised Diagnostic and Statistical Manual, Fifth Edition declined to add “hypersexual disorder” as a diagnosis, more recent research has led to the likely inclusion of the diagnosis “compulsive sexual behavior disorder” in the upcoming revision of the International Classification of Diseases and Related Health Problems.

STUDY FORTY TWO: Abstinence or Acceptance? A Case Series of Men’s Experiences With an Intervention Addressing Self-Perceived Problematic Pornography Use (2019) – The paper reports on six cases of men with porn addiction as they underwent a mindfulness-based intervention program (meditation, daily logs & weekly check-ins). All subjects appeared to benefit from meditation. Relevant to this list of studies, 3 described escalation of use (habituation) and one described withdrawal symptoms. (Not below – two more reported porn-induced ED.)

An excerpt from the case reporting withdrawal symptoms:

Perry (22, P_akeh_a):

Perry felt he had no control over his pornography use and that viewing pornography was the only way he could manage and regulate emotions, specifically anger. He reported outbursts at friends and family if he abstained from pornography for too long, which he described as a period of roughly 1 or 2 weeks. 

Excerpts from the 3 cases reporting escalation or habituation:

Preston (34, M_aori)

Preston self-identified with SPPPU because he was concerned with the amount of time he spent watching and ruminating on pornography. To him, pornography had escalated beyond a passionate hobby and reached a level where pornography was the center of his life. He reported watching pornography for multiple hours a day, creating and implementing specific viewing rituals for his viewing sessions (e.g., setting up his room, lighting, and chair in a specific and orderly way before viewing, clearing his browser history after viewing, and cleaning up after his viewing in a similar way), and investing significant amounts of time in maintaining his online persona in a prominent online pornography community on PornHub, the world’s largest Internet pornography website…

Patrick (40, P_akeh_a)

Patrick volunteered for the present research because he was concerned with the duration of his pornography viewing sessions, as well as the context in which he viewed. And Patrick regularly watched pornography for several hours at a time while leaving his toddler son unattended in the living room to play and/or watch television…

Peter (29, P_akeh_a)

Peter was concerned with the type of pornographic content he was consuming. He was attracted to pornography made to resemble acts of rape. The more real and realistically depicted the scene, the more stimulation he reported experiencing when viewing it. Peter felt his specific tastes in pornography were a violation of the moral and ethical standards he held for himself…

STUDY FORTY THREE: Hidden in Shame: Heterosexual Men’s Experiences of Self-Perceived Problematic Pornography Use (2019)  – Study involving interviews of 15 male porn users. Several of the men reported porn addiction, escalation of use, habituation, poorer sexual satisfaction and porn-induced sexual problems. Excerpts relevant to escalation of use and habituation, and porn use altering sexual tastes.

The participants talked about how pornography influenced the various aspects of their sexuality and sexual experiences. Michael discussed how pornography had influenced his sexual behaviors, specifically about the acts he would attempt to recreate with women that he had watched in pornography. He openly discussed the sexual acts he regularly engaged in, and questioned how natural these acts were:

Michael: I sometimes cum on a girl’s face, which serves no biological purpose, but I got it from porn. Why not the elbow? Why not the knee? There’s a level of disrespect to it. Even though the girl consents, it’s still disrespectful. (23, Middle-Eastern, Student)

The data provided by the participants seem to align with literature, with pornography impacting sexual expectations, sexual preferences, and sexual objectification of women…. After years of watching pornography, some of the men began to get uninterested in everyday sex because it did not measure up to the expectations set by pornography:

Frank: I feel like real sex isn’t as good because the expectations are too high. The stuff I would expect her to do in bed. Porn is an unrealistic portrayal of a regular sex life. When I got used to unrealistic images, you expect your real sex life to match the intensity and pleasure of porn. But that doesn’t happen, and when it doesn’t happen, I get a little disappointed. (27, Asian, Student)

George: I think the expectations I have about how whizz, bang, wonderful things should be during sex are not the same in real life    [. . .] And it’s harder for me when what I get used is something that’s not real, and staged. Porn sets up unrealistic expectations for sex. (51, Pa¯keha¯, Mentor)

Frank and George highlight an aspect of pornography that is referred to as “Pornotopia,” a fantasy world where an endless supply of “lusty, gorgeous, and always orgasmic women” are readily available for male viewing (Salmon, 2012). For these men, pornography created a sexual fantasy world that could not be met in “reality.”…. When these expectations were not met, some of the men were disappointed and became less sexually aroused:

Albert: Because I’ve seen so many images and videos of women I find attractive, I find it difficult to be with women that do not match the quality of the women I watch in videos or see in images. My partners do not match up to the behaviors that I watch in the videos [. . .] When you watch porn very often, I’ve noticed that women are always dressed very sexy, in sexy high heels and lingerie, and when I do not get that in bed I get less aroused. (37, Pa¯keha¯, Student)

Participants also discussed how their sexual preferences evolved as a result of their pornography use. This could involve an “escalation” in pornographic preferences:

David: At first it was one person getting progressively naked, then it progressed to couples having sex, and from quite early on, I started narrowing down to heterosexual anal sex. This all happened within a couple years of starting my porn viewing [. . .] From there, my viewing got more and more extreme. I found that the more believable expressions were those of pain and discomfort, and the videos I viewed started to get more and more violent. Such as, videos that are made to look like rape. What I was going for was the homemade stuff, amateur style. It looked believable, like a rape was actually happening. (29, Pa¯keha¯, Professional)

Literature has suggested that compulsive and/or problematic pornography users often experience a phenomenon where their pornography use escalates and takes the form of greater time spent viewing or seeking out new genres that induce shock, surprise, or even violation of expectations (Wéry & Billieux, 2016). Consistent with literature, David attributed his niche pornographic preferences to pornography. Indeed, the escalation from nudity to realistic looking rape was the primary reason David perceived his use to be problematic. Like David, Daniel also noticed that what he found sexually arousing had evolved after years of watching pornography. Daniel discussed his extensive exposure to pornographic scenes, specifically of penises penetrating vaginas, and subsequently becoming sexually stimulated by the sight of a penis:

Daniel: When you watch enough porn, you begin getting aroused by the sights of penises as well, since they’re on the screen so much. Then a penis becomes a conditioned and automatic source of stimulation and arousal. For me it’s fascinating just how localized my attraction is to the penis, and nothing else of a man. So like I said, I derive nothing from men, other than the penis. If you copy and paste it onto a woman, then that’s excellent. (27, Pasifika, Student)

Over time, as their pornographic preferences evolved, both men sought to explore their preferences in real life. David reenacted some of his pornographic preferences with his partner, specifically anal sex. David reported feeling very relieved when his partner was accepting of sexual desires, which is certainly not always the case in such instances. However, David did not disclose his preference for rape pornography with his partner. Daniel, like David, also reenacted his pornographic preferences and experimented by engaging in sexual acts with a transgender woman. According to literature pertaining to pornographic content and real-life sexual experiences, however, the cases of both David and Daniel do not necessarily represent the norm. Although there is a link between less conventional practices, a significant proportion of individuals have no interest in reenacting the pornography acts— especially the unconventional acts—they enjoy viewing (Martyniuk, Okolski, & Dekker, 2019).

Lastly, men reported the impacts pornography had had on their sexual function, something that has only recently been examined within the literature. For example, Park and colleagues (2016) found that Internet pornography viewing might be associated with erectile dysfunction, decreased sexual satisfaction, and diminished sexual libido. Participants in our study reported similar sexual dysfunctions, which they attributed to pornography use.

STUDY FORTY FOUR: Signs and symptoms of cybersex addiction in older adults (2019) – In Spanish, except for the abstract. Average age was 65. Contains surprising findings that thoroughly support the addiction model, including 24% reported symptoms of withdrawal when unable to access porn (anxiety, irritability, depression, etc.). From the abstract: 

Thus, the aim of this work was double: 1) to analyze the prevalence of older adults at risk of developing or showing a pathological profile of cybersex use and 2) to develop a profile of signs and symptoms that characterize it in this population. 538 participants (77% men) over 60 years of age (M = 65.3) completed a series of online sexual behavior scales. 73.2% said they used the Internet with sexual aim. Among them, 80.4% did it recreationally whereas a 20% showed a risk consumption. Among the main symptoms, the most prevalent were the perception of interference (50% of participants), spending >5 hours a week on the Internet for sexual purposes (50%), recognize that they may be doing it excessively (51%) or presence of symptoms of withdrawal (anxiety, irritability, depression, etc.) (24%). This work highlights the relevance of visualizing online risky sexual activity in a silent group and usually outside any intervention for the promotion of online sexual health.

STUDY FORTY FIVE: Effect of pornography on married couples (2019) – A rare Egyptian study. While the study reports porn use increasing parameters of arousal, the long-term effects don’t match porn’s short-term effects. The conclusion:

Conclusion: Pornography has a negative effect on marital relation.

Excerpts related to tolerance or escalation:

The study shows that watching pornography has a statistically positive correlation with years of marriage. This was in agreement with Goldberg et al. ¹⁴ who stated that pornography is highly addictive. This was also in agreement with Doidge ¹⁵ who said that the body develops tolerance to dopamine released while watching pornography by time.

There is a highly negative correlation between satisfaction of sexual life and watching pornography as 68.5% of positive watchers are not satisfied with their sexual life. This was in agreement with Bergner and Bridges ¹⁷ who found that there is a decrease in sexual desire and satisfaction with pornography users.

In the current study although pornography increases desire and frequency of intercourse, it does not help the user to reach orgasm. This was in agreement with Zillman ²⁴ who found that habitual use of pornography leads to greater tolerance of sexually explicit materials, thus requiring more novel and bizarre materials to achieve the same level of arousal and interest, which was also in agreement with Henderson ²⁵, who found that materials which was used to produce arousal and stimulation no longer does so and therefore more materials and longer viewing time and more degrading materials are sought to achieve the same degree of stimulation and satisfaction.

STUDY FORTY SIX: The Assessment of Problematic Internet Pornography Use: A Comparison of Three Scales with Mixed Methods (2020) – New Chinese study comparing the accuracy of 3 popular porn addiction questionnaires. Interviewed 33 porn users & therapists, and assessed 970 subjects. Relevant findings:

• 27 of 33 interviewees mentioned withdrawal symptoms.
• 15 of 33 interviewees mentioned escalation to more extreme content.

Graph of interviewees ratings the six dimensions of the porn questionnaire that assessed tolerance and withdrawal (The PPCS):

The most accurate of the 3 questionnaire was the “PPCS” which is modeled after substance addiction questionnaires. Unlike the other 2 questionnaires, and previous porn addiction tests, the PPCS assesses tolerance & withdrawal. An excerpt describing importance of assessing tolerance and withdrawal:

The more robust psychometric properties and higher recognition accuracy of the PPCS may be attributable to the fact that it has been developed in accordance with Griffiths’s six-component structural theory of addiction (i.e., in contrast to the PPUS and s-IAT-sex). The PPCS has a very strong theoretical framework, and it assesses more components of addiction [11]. In particular, tolerance and withdrawal are the important dimensions of problematic IPU that are not assessed by the PPUS and s-IAT-sex;

The interviewees see withdrawal as a common and important feature of problematic porn use:

It also can be inferred from Figure 1 that both volunteers and therapists emphasized the centrality of conflict, relapse and withdrawal in IPU (basing the frequency of mentions); at the same time, they weighted the mood modification, relapse and withdrawal as more important features in the problematic use (basing the important rating).

STUDY FORTY SEVEN: Attenuation of Deviant Sexual Fantasy across the Lifespan in U.S. Adult Males (2020) – Study reported that the 18–30 year-old group reported the highest mean of deviant sexual fantasy followed by those 31–50, then those 51–76 years of age. Put simply, the age group with the highest rates of porn use (and who grew up using tube sites) report the highest rates of sexual deviant fantasies (rape, fetishism, sex with children). Excerpt from the discussion section suggests that porn use may be the reason:

Additionally, a possible explanation for why those under 30 years of age endorsed more deviant sexual fantasies than those over the age of 30 could be due to increased pornography consumption among younger men. Researchers found that pornography consumption has increased since the 1970s, rising from 45% to 61%, with change over time being the smallest for older age groups for which pornography consumption decreases (Price, Patterson, Regnerus, & Walley, 2016). Additionally, in a study of pornography consumption among 4339 Swedish young adults, less than one third of participants reported viewing deviant sexual pornography of violence, animals and children (Svedin, Åkerman, & Priebe, 2011).

Although pornography exposure and usage were not assessed in the current study, those under 30 years in our sample could be viewing more pornography, as well as more deviant forms of pornography, than those over the age of 51 years as pornography usage in young adulthood has become more socially accepted (Carroll et al., 2008).

STUDY FORTY EIGHT: Motivational pathways underlying the onset and maintenance of viewing child pornography on the Internet (2020) – New study reports large % of child porn (CP) users have no sexual interest in children. It was only after years of viewing adult porn, resulting in habituation to new genre after new genre, that porn users eventually sought even more extreme material, genres, eventually escalating into CP. Researchers point to the nature of internet porn (endless novelty via tube sites) as playing a substantial role in conditioning sexual arousal to the most extreme content, such as CP. Relevant excerpts:

The nature of the internet promotes non-pedophiles to eventually escalate:

Here we discuss men’s self-identified subjective motivations for the onset and maintenance of viewing CP on the Internet. We focus specifically on Internet-based sexual stimuli due to previous assertions that the Internet itself may introduce unique factors contributing to this behavior (Quayle, Vaughan, & Taylor, 2006).

Escalation as a pathway to CP use:

Several participants reported being sexually interested in pornography that they described as ‘taboo’ or ‘extreme’, meaning it fell outside the range of what they considered traditional sexual activities or behaviors. For example, Mike reported searching for “anything unusual really, as long as it wasn’t … regular looking things.” Participants often started by viewing Internet pornography on the lower end of the taboo spectrum (e.g., spanking, transvestism), and described a gradual progression to viewing more extreme sexual stimuli in response to what appeared to be habituation to these sexual activities or themes.

As shown in Figure 1, the drive to discover increasingly taboo pornography ultimately facilitated the use of CP for some participants, following their habituation to a myriad of pornographic themes, including illicit but non-pedophilic behaviors (e.g., incest, bestiality). As Jamie described, “I’d look at BDSM things, and then get to more really sadistic things and other taboos, and then eventually just kind of feel like, ‘well, again, fuck it. I’ll take the plunge’”. The fact that CP is illegal actually increased some participants’ arousal, such as Ben who explained, “I felt like what I was doing was illegal, and it gave me a tremendous rush”, and Travis, who noted, “Sometimes it felt good to do something you’re not supposed to be doing.”

Hyperfocused sexual arousal

Once in this state of hyperfocused sexual arousal, participants found it easier to justify viewing increasingly taboo and eventually illegal pornography. This finding is supported by previous research suggesting that ‘visceral’ states of arousal allow people to ignore factors that would otherwise prevent specific sexual behaviors (Loewenstein, 1996). …. Once participants were no longer in this state of hyperfocused sexual arousal, they reported that the CP they had been viewing became unappealing and aversive, a phenomenon that has also been reported by Quayle and Taylor (2002).

Seeking novelty

Participants explained that as their exposure to Internet pornography intensified, they found themselves increasingly uninterested in the genres of (legal) pornography that they had traditionally preferred. Consequently, participants began to desire and seek out sexual stimuli involving new sexual themes and activities. The Internet appeared to contribute to participants’ sense of boredom and desire for novel sexual stimuli, as the vastness of the Internet suggested the existence of an endless amount of pornography, any or all of which could be more exciting or arousing than what they were currently viewing. In describing this process, John explained:

It started just with normal adult men with women kind of thing, and it’s a bit dull, so then maybe you watch some lesbian stuff for a while, and it gets a bit dull, and then you start exploring.

Desensitization (habituation) leading to escalation:

In their attempts to find novel and sexually exciting stimuli, participants began exploring categories of pornography involving a broader range of sexual behaviors, partners, roles, and dynamics than they would previously have considered viewing. This may reflect a slight broadening of the moral or legal boundaries that a person (consciously or unconsciously) sets for themselves regarding the types of pornography they consider ‘acceptable’. As Mike explained, “You just keep crossing boundaries and crossing boundaries – [you tell yourself] ‘you’ll never do that’, but then you do it.”

The progression that Mike and other participants described suggests the possibility of a habituation effect, as many participants reported that eventually they required increasingly taboo or extreme pornography in order to achieve the same degree of arousal. As Justin explained, “I found myself kind of slipping downhill where it just, it needed to be a bigger thrill to have any sort of an impact on you.” Many participants in our study reported viewing a myriad of different types of pornography prior to seeking out CP, which is similar to previous research indicating that people with CP offenses may begin by using legal pornography and gradually progress to viewing illegal materials, possibly resulting from extensive exposure and boredom (Ray et al., 2014).

Habituation leads to CP:

As shown in Figure 1, participants often cycled between seeking novelty and habituation multiple times before they began actively seeking CP. After discovering a new and highly arousing genre of pornography, participants would spend many hours searching, viewing, and collecting stimuli of this nature, essentially ‘binge’ watching these materials.Participants explained that due to this extensive exposure, they reached a point when this genre of pornography no longer provided a strong degree of sexual arousal, causing them to resume the search for novel sexual stimuli:

I think at first, I got bored. Like, I would find a theme that I was interested in … and very easily I would get sort of, I don’t know, I’d use up the theme – I’m not interested, I’ve seen so much – and then I’d move onto more. (Jamie)

I started looking at pictures of younger [adult] women when I was first looking at pornography on the Internet, and then I just kept getting into looking at younger and younger girls, and eventually children. (Ben)

The habituation effect is well-established in other areas of psychology and has previously been discussed in relation to viewing pornography. Elliott and Beech describe this process as, “… a reduction in arousal levels to the same stimuli over repeated exposures – where, in viewing sexual images, offenders are likely to seek out novel, more extreme images over time to feed their arousal levels,” Elliott and Beech, (2009, p. 187).

As with other genres of pornography, extensive exposure to CP eventually caused most participants to describe habituating to these materials, including participants who reported a sexual interest in children (just as participants interested in adults habituated to genres of adult pornography). This often led participants to seek out CP involving younger victims and/or more graphic sexual depictions in an attempt to evoke the same degree of arousal originally experienced in response to viewing these materials. As Justin explained, “You try to look for something that will give you some spark, or some feeling, and initially, it didn’t. As you get younger and younger, it did.”

Some participants reported reaching a point where they began seeking CP involving children who would previously have been too young for them to find arousing. Travis commented, “Over time, the models did get younger … before, I would not even consider anything under 16.” It is particularly interesting that, unlike other types of pornography, participants reported continuing to view CP even after their arousal to these materials had diminished. This raises questions regarding the personal and situational factors involved in maintaining this behavior.

Sexual conditioning:

Several participants who reported no known pre-existing sexual interest in children prior to viewing CP believed that repeated exposure to these materials essentially ‘conditioned’ them to develop a sexual interest in children.

Since nearly all participants reported no desire to engage in contact sexual offenses, it is possible that this process conditioned participants to develop an interest in CP, rather than in children themselves (and by extension child sexual abuse). Participants provided varying descriptions of how they perceived this conditioning process:

It’s kind of like … when you have your first sip of gin, or whatever. You think, ‘this is horrible’, but you keep going and eventually you start to like gin. (John).

The circuits in my brain that were related to sexual arousal, the circuits that were firing when I was looking at pictures of children … years of doing that probably caused things in my brain to change. (Ben)

As their interest in CP increased, participants who had previously viewed both adult and child pornography reported finding it increasingly difficult to become aroused to sexual stimuli involving adults.

At face value, this conditioning process may seem contradictory to the experience of habituation described earlier. However, it is important to understand that for people without a sexual interest in children, the conditioning process seemed to occur between the onset of viewing CP and participants’ eventual habituation to these materials.

Their compulsion to us looks like addiction is several ways:

Perhaps one of the most interesting findings relates to participants’ described inability to ‘progress’ from CP following their habitation and diminished response to these materials. The perceived inability to desist from this behavior led some participants to regard their use of CP as a ‘compulsion’ or ‘addiction’. As Travis described:

I don’t know if there’s such a thing as an addiction…where you do something you don’t want to do, but I always found myself compulsively checking over and over again these sites … I’d be up late at night doing this, because I’d have to go back and check.

It should be noted, however, that none of the participants described true obsessive–compulsive behaviors or reported any symptoms of withdrawal upon discontinuing their use of CP, suggesting that this behavior is not an addiction in the traditional use of the term….

The search for novelty, due to habituation, was more arousing than viewing CP.

One manifestation of this ‘compulsion’ is reflected by our finding that nearly all participants, regardless of their original motivation for viewing CP, reported that the act of searching the Internet for new sexual stimuli eventually superseded the enjoyment of actually viewing these materials. Following from our proposed behavioral facilitation process, we suggest the possibility that participants began to prefer the search for CP over the act of viewing it because by the time participants reached the stage of actively seeking CP – arguably the most taboo type of pornography – they had progressed through (and habituated to) numerous genres of pornography and could no longer conceive of any sexual themes or activities that would be sufficiently taboo or extreme to evoke the intense sexual response they desired.

Consequently, we suggest that the excitement and anticipation associated with potentially discovering novel and highly arousing pornography becomes more intense than the feelings experienced in response to viewing these materials. This, in turn, is expected to fuel participants’ desire to continue seeking CP (even past the point of habituation), and an inability to find strongly arousing pornography may underlie participants’ perceived compulsion to engage in this behavior. As Dave described:

I had to flip, like from one [image/video] to another, because once I started watching one, I’d get bored and I’d have to go to another one. And that’s how it was. And it took over my life.

STUDY FORTY NINE: Inhibitory control and problematic Internet-pornography use – The important balancing role of the insula (Anton & Brand, 2020) – The authors state their results indicate tolerance, a hallmark of an addiction process. Relevant excerpts:

Our current study should be seen as a first approach inspiring future investigations regarding the associations between psychological and neural mechanisms of craving, problematic IP use, motivation to change behavior, and inhibitory control.

Consistent with previous studies (e.g., Antons & Brand, 2018; Brand, Snagowski, Laier, & Maderwald, 2016; Gola et al., 2017; Laier et al., 2013), we found a high correlation between subjective craving and symptom severity of problematic IP use in both conditions. However, the increase in craving as measure for cue-reactivity was not associated with symptom severity of problematic IP use, this may relate to tolerance (cf. Wéry & Billieux, 2017) given that the pornographic images used in this study were not individualized in terms of subjective preferences. Therefore, the standardized pornographic material used may not be strong enough for inducing cue-reactivity in individuals with high symptom severity associated with low effects on the impulsive, reflective, and interoceptive systems as well as inhibitory control ability.

Effects of tolerance and motivational aspects may explain the better inhibitory control performance in individuals with higher symptom severity which was associated with differential activity of the interoceptive and reflective system. Diminished control over IP use presumably results from the interaction between the impulsive, reflective, and interoceptive systems.

Taken together, the insula as the key structure representing the interoceptive system plays a pivotal role in inhibitory control when pornographic images are present. Data suggest that individuals with higher symptom severity of problematic IP use performed better in the task due to decreased insula activity during image processing and increased activity during inhibitory control processing.

This pattern of activity might be based on effects of tolerance, that is, less hyperactivity of the impulsive system causes less controlling resources of the interoceptive and reflective system. Hence, a shift from impulsive to compulsive behaviors as a consequence of developing problematic IP use or a motivational (avoidance-related) aspect might be relevant, so that all resources were focused on the task and away from pornographic images. The study contributes to a better understanding of diminished control over IP use which is presumably not only a result of an imbalance between dual systems but of the interaction between impulsive, reflective, and interoceptive systems.

STUDY FIFTY: Exploring the Lived Experience of Problematic Users of Internet Pornography: A Qualitative Study (2020)

A few excerpts related to escalation and habituation:

The participants reported experiencing symptoms of feeling “addicted” to IP. The language of dependency, i.e., “cravings,” being “sucked in,” and “habit,” was used often. Participants also reported symptoms and experiences consistent with addictive disorders such as; an inability to reduce use of IP, increased use of IP over time or needing to use more extreme forms of IP to get the same effect, use of IP as a way to manage discomfort or gain a sense of satisfaction or “high,” and continuing to use IP despite negative consequences and life outcomes. The following sub-themes illustrate these phenomena.

Escalation was often described as either spending more time on IP or finding it necessary to view more extreme content in order to experience the same “high” over time, as this participant disclosed, “At first, I watched relatively soft porn, and as years passed by, I moved towards more brutal and degrading kinds of porn.”

This escalation to more extreme, novel, and often violent content also contributed to participants’ feelings of shame associated with their IP use

Escalation was often described as either spending more time on IP or finding it necessary to view more extreme content in order to experience the same “high” over time

Escalation of porn use was also linked to erectile dysfunction in some of the participants, as they found that after a time, no amount or genre of porn was able to cause them to have an erection, as described in the next subtheme.

Symptoms such as erectile dysfunction- conceptualized as an inability to gain an erection without porn or with a real-life partner- were often described: “I couldn’t get an erection with women I found attractive. And even when I did, it didn’t last long at all.” These symptoms were often lamented by the participants, with one participant declaring, “It has kept me from having sex! Lots of times! Because I can’t stay erect. Enough said.”

Participants reported spending more extended amounts of time viewing IP and consequently neglecting other areas in life, reducing time spent pursuing relationships with others, personal development goals, career goals, or other activities, “Mainly, it takes time away from me,” said one participant. “Watching porn takes away study time, work time, time with friends, rest time, etc.” Another participant noted that the time taken up by viewing IP had a negative effect on his productivity; “Then there is the sheer amount of time I have spent viewing internet porn rather than doing something constructive.” The impact of lost time is hard to quantify, as this participant stated, “I lost count of the times when I was watching porn and was supposed to be doing something else which was really important.

STUDY FIFTY ONE: ‘Accessing something that’s meant to be inaccessible’: pornography viewers’ reconciliation between early pornographic memories and pornography’s perceived risk (2020) – Mainly an interview study. A few relevant excerpts describing escalation, conditioning and habituation:

 These extracts offer a significant challenge to the idea that pornography’s impact upon others might be over-rated, as the following extracts suggest that there are those for whom the effects of pornography have been self-ascribed:

I am currently very confused as to where I sit with my pornography use. Up until about six months ago, I would not have thought about the negative effects of its use. I believe it was one of the contributing factors that led me to break up with my girlfriend of four years, I saw a psychologist for pornography addiction in aid of trying to keep our relationship together but this did not seem to help…. [Survey response 194, Q2].

Media has influenced me a bit on this and I do sometimes feel like I consume too much porn. I also feel like it desensitises me to my real life sexual experiences. My real life sexual experiences are always better when I’ve had a break from porn. I also worry the type of porn I watch influences my desire to have vanilla sex. [Survey response 186, Q2].

For example, the following interview with a man who wondered whether he was ‘addicted’ to pornography, as a result of spending too much time viewing it, indicates an explicit rejection of the idea that pornography addiction is a problem of escalating content – for himself at least:

C: Well, you know, I don’t think that there’s anything unusual about my scenario in that I think I can relate to all people my age and those guys I grew up with is you go from looking at soft focus nudie pictures –

Interviewer: Yeah like Penthouse and –

C: Yeah, well even less than that and then it just goes up and up. You go from Playboy to Penthouse to uurgh I dunno, and then it’s turned into vids umm, and it’s getting stronger and stronger.

Interviewer: Mmm but there’s a point that you stop though isn’t there? Because –

C: Aww, well that was my choice umm, because I just thought ‘urgh that’s enough for me

Interviewer: And – is there a concern that other people won’t be able to make that –

C: I – well I think the fact that there’s so much bondage and abuse type of stuff on these sites – says there’s a market. I don’t – I assume that those people started off like me just looking at nudie pictures of girls and went from there.

Interviewer: Yeah, and then at some point you ended up –

C: Into real real hardcore.

Here C’s ‘choice’ to halt the progression from stronger and stronger content is contrasted with those who might have started by viewing the same pornography that he had, but had ended up in the ‘real hardcore’. Such concerns were explicitly made clear in relation to both how the internet has changed pornography’s content, and how young people’s experiences might contrast with that of the speaker….

Here, E describes his early experiences with pornography through the familiar index of pornography sources (i.e. a friend’s father), suggesting that this early exposure made things ‘a lot easier’ as he grew older. However, at a later stage in the interview, E also suggests that such early exposure to pornography can actually be detrimental to ‘other’ young people:

Interviewer: Or like what about violence or like –

E: Yeah, well, it’s the same thing. Like you know that violence is wrong as a child when you see – you know, ‘Don’t hit Ji – Johnny ‘cause he didn’t give you the donut’, you know, you know it’s wrong. So, it’s like that kind of behaviour is – you should be but the hard part of course is um the youth, before they get a cognitive brain before they’re 23, 24, um struggle often to make the distinction between um acceptable behaviour and non-acceptable behaviour and consequences to their behaviour. So, they might think that it’s okay for three guys to take some girl and bang her in the back of the car because that’s what they’ve seen on video you know, like on the internet, and they might think that but they haven’t really grasped the concept of what it actually means for what they’ve done to that girl and so on and so forth.

Interviewer: So in your experience though when you were like 13 you said you’d seen like multiple partners, let’s say. So – but were you ever like tempted to, you know, as you said, like, you know, get some friends together and –

E: Oh, and go after a – no.

Interviewer: Or, I mean, like in terms of the influence of what you’d seen in – in the pornography?

E: No. I just thought that, well, that’d be pretty cool you know. [Laughs]

Interviewer: Yeah. But you weren’t gonna be like, oh, you know, ‘Come on guys’ –

E: Yeah. No.

Interviewer: No. [Laughs]

E: No, and I – I think that – and it – I – it’s – it’s like I said before, I mean, I think that people um – people’s behaviour, it comes down to um their intelligence, you know, and how they’ve been treated. If you have the wro – wrong kind of upbringing then you might do exactly that, you might, ‘Come on dudes, let’s get this chick’, you know. You know, blah blah blah ‘cause you can’t relate to anything other than the – the – that little split second of time, you know. And some people never grow out of it.

Thus, again, the problem of pornography is both the changes to the medium over time and the (in)ability of young people to make sense of this new medium. In the first instance,  E suggests that pornography in magazine form was helpful to his sexual development, before then suggesting that exposure to similar pornography – specifically group sex scenes – could lead young men to ‘take some girl and bang her in the back of the car’.

STUDY FIFTY TWO: Online Sexual Offenders: Typologies, Assessment, Treatment, and Prevention (2020) – Abstract seems to be saying that non-pedophiles escalate into child pornography:

To shed light on men who sexually offend online, this chapter synthesizes the research on this subgroup of sexual offenders against children, with a focus on typologies, assessment, treatment issues, and prevention strategies for online offenders. It reviews the typologies proposed for three large groups of offenders against children—consumers of child sexual exploitation material (CSEM), sexual solicitors of children, and contact sexual offenders—recognizing that while typologies provide a helpful summary of research findings, individual offenders may display features of more than one offender type or may change from one set of motives and behaviors to another. For some men, use of legal pornography precedes use of CSEM. However, for various reasons, surfing legal pornography websites sometime leads to consumption of CSEM. The majority of intervention programs for online sexual offenders represent adaptations of existing programs for contact offenders, with adjustment of the overall intensity of the treatment and some specific components.

STUDY FIFTY THREE: A psychometric approach to assessments of problematic use of online pornography and social networking sites based on the conceptualizations of internet gaming disorder (2020) – Study validating a modified Gaming Addiction assessment for use a porn addiction questionnaire. A significant percentage subjects endorsed several criteria for addiction, including tolerance and escalation: 161 of the 700 subjects experienced tolerance – needing more porn or “more exciting” porn to achieve the same levels of excitement.

STUDY FIFTY FOUR: Male psychogenic sexual dysfunction: the role of masturbation (2003) – Relatively old study on men with so-called ‘psychogenic’ sexual problems (ED, DE, inability to be aroused by real partners). While the data is even older than 2003,  interviews revealed tolerance and escalation related to “erotica” use:

Participants themselves had begun to question whether there may be a link between masturbation and the difficulties they were experiencing. Jim wonders whether reliance on masturbation and erotica during the 2 year period of celibacy preceding the onset of his problem has contributed to its cause:

J: . . . that two year period I was masturbating while I wasn’t in a regular relationship, umm and perhaps there were more images on television, so it wasn’t you had to buy a magazine – or – its just more available.

Additional excerpts:

Although inspiration could develop from their own experience, most participants used visual or literary erotica to enhance their fantasies and increase arousal. Jim, who is ‘not good at mental visualizations’, explains how his arousal is enhanced by erotica during masturbation:

J: I mean quite often there are times when I’m stimulating myself there’s some sort of aid; watching a TV programme, reading a magazine, something like that.

B: Sometimes the excitement of being with other people is enough, but as the years go by you need a book, or you see a film, or you have one of those dirty magazines, so you close your eyes and you fantasize about these things.

More excerpts:

The effectiveness of erotic stimuli in creating sexual arousal has been noted by Gillan (1977). The use of erotica by these participants was restricted to masturbation in the main. Jim is aware of a heightened level of arousal during masturbation as compared to sex with his partner.

During sex with his partner, Jim fails to achieve levels of erotic arousal sufficient to trigger orgasm, during masturbation the use of erotica significantly increases levels of erotic arousal and orgasm is achieved. Fantasy and erotica increased erotic arousal and were used freely during masturbation but its use was restricted during sex with a partner.

Paper continues:

Many participants ‘could not imagine’ masturbating without the use of fantasy or erotica, and many recognized the need progressively to extend fantasies (Slosarz, 1992) in an attempt to maintain levels of arousal and prevent ‘boredom’. Jack describes how he has become desensitized to his own fantasies:

J: Latterly in the last five, ten years, I, I, I’d be hard pushed to get stimulated enough by any fantasy that I might create myself.

Based on erotica, Jack’s fantasies have become highly stylised; scenarios involving women with a specific ‘body type’ in particular forms of stimulation. The reality of Jack’s situation and partners is very different, and fails to match his ideal created on the basis of porno perception (Slosarz, 1992); the real partner may not be erotically arousing enough.

Paul compares the progressive extension of his fantasies to his need for progressively ‘stronger’ erotica to produce the same response:

P: You get bored, it’s like those blue movies; you’ve got to get stronger and stronger stuff all the time, to cheer yourself up.

By changing the content, Paul’s fantasies retain their erotic impact; despite masturbating several times a day, he explains:

P: You can’t keep doing the same thing, you get bored with one scenario and so you’ve got to (change) – which I was always good at ’cause . . . I always lived in a land of dreams.

From the summary sections of the paper:

This critical analysis of participants’ experiences during both masturbation and partner sex has demonstrated the presence of a dysfunctional sexual response during sex with a partner, and a functional sexual response during masturbation. Two interrelated theories emerged and are summarized here… During partner sex, dysfunctional participants focus on non-relevant cognitions; cognitive interference distracts from the ability to focus on erotic cues. Sensate awareness is impaired and the sexual response cycle is interrupted resulting in sexual dysfunction.

In the absence of functional partner sex, these participants have become masturbation dependant. Sexual response has become conditional; learning theory does not postulate specific conditions, it merely identifies conditions of acquisition of the behaviour. This study has highlighted frequency and technique of masturbation, and the ability to focus on task relevant cognitions (supported by the use of fantasy and erotica during masturbation), as such conditional factors.

This study has highlighted the relevance of detailed questioning in two main areas; behaviour and cognitions. Firstly details of the specific nature of masturbatory frequency, technique and accompanying erotica and fantasy provided an understanding of how the individual’s sexual response has become conditional on a narrow set of stimuli; such conditioning appears to exacerbate difficulties during sex with a partner. It is acknowledged that as part of their formulation, practitioners routinely ask whether an individual masturbates: this study suggests that also asking precisely how the individual’s idiosyncratic masturbatory style has developed provides relevant information.

STUDY FIFTY FIVE: Symptoms of Problematic Pornography Use in a Sample of Treatment Considering and Treatment Non-Considering Men: A Network Approach (2020) – Study reports withdrawal and tolerance in porn users. In fact, withdrawal and tolerance were central components of problematic porn use.

A large-scale online sample of 4,253 men ( M _age = 38.33 years, SD = 12.40) was used to explore the structure of PPU symptoms in 2 distinct groups: considered treatment group ( n = 509) and not-considered treatment group (n = 3,684).

The global structure of symptoms did not differ significantly between the considered treatment and the not-considered treatment groups. 2 clusters of symptoms were identified in both groups, with the first cluster including salience, mood modification, and pornography use frequency and the second cluster including conflict, withdrawal, relapse, and tolerance. In the networks of both groups, salience, tolerance, withdrawal, and conflict appeared as central symptoms, whereas pornography use frequency was the most peripheral symptom. However, mood modification had a more central place in the considered treatment group’s network and a more peripheral position in the not-considered treatment group’s network.

STUDY FIFTY SIX: Properties of the Problematic Pornography Consumption Scale (PPCS-18) in community and subclinical samples in China and Hungary (2020)

In the three samples’ networks, withdrawal was the most central node, while tolerance was also a central node in the subclinical individuals’ network. In support of these estimates, withdrawal was characterized by high predictability in all networks (Chinese community men:76.8%, Chinese subclinical men: 68.8%, and Hungarian community men: 64.2%).

Centrality estimates indicated that the subclinical sample’s core symptoms were withdrawal and tolerance, but only the withdrawal domain was a central node in both community samples.

Consistent with previous studies (Gola & Potenza, 2016; Young et al., 2000), worse mental health scores and more compulsive sexual behaviors correlated with higher PPCS scores. These results suggest it may be advisable to consider craving, mental health factors, and compulsive use in screening and diagnosing PPU (Brand, Rumpf et al., 2020).

Additionally, centrality estimates in the six factors of the PPCS-18 displayed withdrawal as the most crucial factor in all three samples. According to the strength, closeness, and betweenness centrality results among subclinical participants, tolerance also contributed importantly, being second only to withdrawal. These findings suggest that withdrawal and tolerance are particularly important in subclinical individuals. Tolerance and withdrawal are considered as physiological criteria relating to addictions (Himmelsbach, 1941). Concepts like tolerance and withdrawal should constitute a crucial part of future research in PPU (de Alarcón et al., 2019; Fernandez & Griffiths, 2019). Griffiths (2005) postulated that tolerance and withdrawal symptoms should be present for any behavior to be considered addictive. Our analyses support the notion that withdrawal and tolerance domains are important clinically for PPU. Consistent with Reid’s view (Reid, 2016), evidence of tolerance and withdrawal in patients with compulsive sexual behaviors may be an important consideration in characterizing dysfunctional sexual behaviors as addictive.

STUDY FIFTY SEVEN: Three Diagnoses for Problematic Hypersexuality; Which Criteria Predict Help-Seeking Behavior? (2020) – From the conclusion:

Despite the limitations mentioned, we think that this research contributes to the field of PH research and to the exploration of new perspectives on (problematic) hypersexual behavior in society. We stress that our research showed that “Withdrawal” and “Loss of pleasure”, as part of the “Negative Effects” factor, can be important indicators of PH (problematic hypersexuality). On the other hand, “Orgasm frequency”, as part of the “Sexual Desire” factor (for women) or as a covariate (for men), did not show discriminative power to distinguish PH from other conditions. These results suggest that for the experience of problems with hypersexuality, attention should focus more on “Withdrawal”, “Loss of pleasure”, and other “Negative Effects” of hypersexuality, and not so much on sexual frequency or “excessive sexual drive” [60] because it is mainly the “Negative Effects” that are associated with experiencing hypersexuality as problematic.

STUDY FIFTY EIGHT: Variability of Pornographic Content Consumed and Longest Session of Pornography Use Associated With Treatment Seeking and Problematic Sexual Behavior Symptoms (2020) – Excerpts:

Following the substance addiction framework, it has been postulated that extensive pornography use may lead to tolerance.33,34,39 In line with the models of addictive sexual behavior, tolerance can manifest in 1 of 2 ways: (i) higher frequency or time devoted to pornography use, in an attempt to achieve the same level of arousal, (ii) seeking and consuming more stimulating pornographic material, as one becomes desensitized and searches for more arousing stimuli.33,34,40 While the first manifestation of tolerance is tightly related to duration and frequency of use, the second is not. It is better operationalized by the variability of consumed pornographic content, especially when this variability pertains to consumption of violent, paraphilic or even lawfully prohibited types of pornographic content (eg, pornographic scenes including minors). However, despite the mentioned theoretical claims, in relation to problematic pornography use and/or compulsive sexual behavior, the characteristics and variability in the content of consumed pornography have rarely been studied.

Discussion

Broadly, our results indicate the importance of prolonged engagement in pornography viewing and variability in consumed pornographic content for treatment seeking, as well as the severity of problematic sexual behavior symptoms. This importance is not captured in the amount of time devoted to pornography use, suggesting that the mentioned indicators contribute to explaining problematic pornography use–related symptoms and treatment seeking…

…Variability of pornographic content consumed (operationalized in the present study as consumption of pornography scenes counter to one’s sexual orientation – scenes containing homosexual sex, containing violence, group sex scenes, scenes of sex with minors) significantly predicted the decision to seek treatment and the severity of symptoms among the study participants.

One possible explanation for this result is that said variability is simply a function of time devoted to pornography use – people who devote more time to this activity can consume a higher number of pornographic content genres, types, or categories. Our results rule out this explanation and show that the relationship between variability of consumed pornographic content and dependent variables is significant even when time devoted to pornography use is controlled. Moreover, a bivariate correlation between variability of consumed explicit content and time devoted to this consumption in the whole sample was surprisingly weak. This further supports the distinctiveness of these 2 indicators and the need to study them both to obtain a better picture of pornography use habits.

Although the described result by itself does not directly imply increased tolerance or desensitization, as the propensity to consume pornographic material with specific characteristics may reflect a more basic, initial preference, it does seem to be at least potentially consistent with addictive models of problematic pornography use.33,34 Future research should investigate the trajectories of pornography use depending on the characteristics of explicit content and verify if the preference for certain types of pornographic content is acquired as a result of being exposed to explicit content throughout the lifetime or is better explained by initial preferences. This issue seems to be both clinically important and scientifically interesting and should attract more research attention.

STUDY FIFTY NINE: The Pornography “Rebooting” Experience: A Qualitative Analysis of Abstinence Journals on an Online Pornography Abstinence Forum (2021) – Excellent paper analyzes more than 100 rebooting experiences and highlights what people are undergoing on recovery forums. Contradicts much of the propaganda about recovery forums (such as the nonsense that they’re all religious, or strict semen-retention extremists, etc.). Paper reports tolerance and withdrawal symptoms in men attempting to quit porn. Relevant excerpts:

One primary self-perceived problem related to pornography use concerns addiction-related symptomatology. These symptoms generally include impaired control, preoccupation, craving, use as a dysfunctional coping mechanism, withdrawal, tolerance, distress about use, functional impairment, and continued use despite negative consequences (e.g., Bőthe et al., 2018; Kor et al., 2014).

Withdrawal:

Abstaining from pornography was perceived to be difficult largely due to the interaction of situational and environmental factors, and the manifestation of addiction-like phenomena (i.e., withdrawal-like symptoms, craving, and loss of control/relapse) during abstinence (Brand et al., 2019; Fernandez et al., 2020).

Some members reported that they experienced heightened negative affect during abstinence. Some interpreted these negative affective states during abstinence as being part of withdrawal. Negative affective or physical states that were interpreted as being (possible) “withdrawal symptoms” included depression, mood swings, anxiety, “brain fog,” fatigue, headache, insomnia, restlessness, loneliness, frustration, irritability, stress, and decreased motivation. Other members did not automatically attribute negative affect to withdrawal but accounted for other possible causes for the negative feelings, such as negative life events (e.g., “I find myself getting agitated very easily these past three days and I don’t know if it’s work frustration or withdrawal” [046, 30s]). Some members speculated that because they had previously been using pornography to numb negative emotional states, these emotions were being felt more strongly during abstinence (e.g., “Part of me wonders if these emotions are so strong because of the reboot” [032, 28 years]). Notably, those in the 18–29 years age range were more likely to report negative affect during abstinence compared to the other two age groups, and those 40 years and above were less likely to report “withdrawal-like” symptoms during abstinence compared to the other two age groups. Regardless of the source of these negative emotions (i.e., withdrawal, negative life events, or heightened preexisting emotional states), it appeared to be very challenging for members to cope with negative affect during abstinence without resorting to pornography to self-medicate these negative feelings.

Tolerance/Habituation:

Three main consequences attributed to excessive pornography use were cited by members as motivations for initiating abstinence. First, for many members (n = 73), abstinence was motivated by a desire to overcome a perceived addictive pattern of pornography use (e.g., “I’m 43 now and I’m addicted to porn. I think the moment to escape from this horrible addiction has arrived” [098, 43 years]). Accounts of addiction were characterized by the experience of compulsivity and loss of control (e.g., “I’m trying to stop but it is so hard I feel that there is something pushing me to porn” [005, 18 years]), desensitization and tolerance to the effects of pornography over time (e.g., “I don’t really feel anything anymore when watching porn. It is sad that even porn has become so unexciting and unstimulating” [045, 34 years]), and distressing feelings of frustration and disempowerment (“I hate that I don’t have the strength to JUST STOP…I hate that I have been powerless against porn and I want to regain and assert my power” [087, 42 years].

It is interesting to note that paradoxically, close to one-third of members reported that instead of experiencing increased sexual desire, they experienced diminished sexual desire during abstinence, which they called the “flatline.” The “flatline” is a term that members used to describe a significant decrease or loss of libido during abstinence (although some appeared to have a broader definition for this to also include accompanying low mood and a sense of disengagement in general: (e.g., “I feel like I’m probably in a flatline right now as the desire to engage in any sort of sexual activity is almost nonexistent” [056, 30s]).

STUDY SIXTY: Three Diagnoses for Problematic Hypersexuality; Which Criteria Predict Help-Seeking Behavior? (2020) – Tolerance and withdrawal symptoms were related to “problematic hypersexuality” (sex/porn addiction), yet sexual desire had little bearing.

The factors Negative Effects and Extreme positively predicted experiencing the need for help, with Negative Effects as the most important predictor for both women and men. This factor included, among others, withdrawal symptoms and loss of pleasure.

Despite the limitations mentioned, we think that this research contributes to the field of PH research and to the exploration of new perspectives on (problematic) hypersexual behavior in society. We stress that our research showed that “Withdrawal” and “Loss of pleasure”, as part of the “Negative Effects” factor, can be important indicators of PH. On the other hand, “Orgasm frequency”, as part of the “Sexual Desire” factor (for women) or as a covariate (for men), did not show discriminative power to distinguish PH from other conditions. These results suggest that for the experience of problems with hypersexuality, attention should focus more on “Withdrawal”, “Loss of pleasure”, and other “Negative Effects” of hypersexuality, and not so much on sexual frequency or “excessive sexual drive” [60] because it is mainly the “Negative Effects” that are associated with experiencing hypersexuality as problematic. Based on the current research, we recommend to incorporate items addressing these characteristics in a measurement instrument for PH.

Additional evidence of tolerance: More extreme porn use and declining sexual desire were correlated with wanting help for one’s “problematic hypersexuality”:

STUDY SIXTY ONE: Online Sex Addiction: A Qualitative Analysis of Symptoms in Treatment-Seeking Men (2022)

– Qualitative study on 23 problematic porn users seeking treatment. Found evidence of tolerance and withdrawal. From study:

“In our study, experience with these symptoms was common. The tolerance manifested as increasing time devoted to the problematic activity, increasing willingness to push the boundaries of what would be considered safe, and especially as the increasing roughness of the consumed erotic materials. The erotic content sometimes reached the levels of being close to paraphilic content. However, the participants themselves did not consider themselves to be paraphilics nor that the paraphilic content (i.e., eliciting sexual arousal patterns that focus on non-consenting others) was their sexual preference. Furthermore, the periods of increased engagement in the activity were regularly superseded by the periods of the diminished effectiveness of the erotic materials used to induce arousal. This effect is labeled as a temporary satiation (39). Concerning the withdrawal symptoms, they manifested as mild distress–nervousness, irritability, and, occasionally, physical symptoms due to somatization.”

“In general, symptoms included increased emotionality, like nervousness and the inability to focus, and increased irritability/frustration, which emerged when they could not watch porn, could not find an adequate sexual object, and had no privacy for masturbation.”

STUDY SIXTY TWO: Withdrawal and tolerance as related to compulsive sexual behavior disorder and problematic pornography use – Preregistered study based on a nationally representative sample in Poland (2022)

STUDY SIXTY FOUR: Pornography Use Could Lead to Addiction and Was Associated With Reproductive Hormone Levels and Semen Quality: A Report From the MARHCS Study in China

• Early contact, frequent use, greater time spent using, and frequent masturbation during pornography use correlated with addiction.
• More than 30% reported needing longer to orgasm to porn than they had needed 3 months earlier.

STUDY SIXTY FIVE: Clarifying and extending our understanding of problematic pornography use through descriptions of the lived experience

Our findings corroborate increasing evidence that many individuals with PPU experience tolerance and desensitisation effects, which can lead to escalating use [evidence of addiction]. [PPU may be] driven by unique underlying mechanisms, including the structural features of Internet pornography that potentially accelerate addiction-related psychological and appetitive mechanisms.

Common themes included “diminished sensitivity or pleasure,” “need for greater stimulation over time,” frequently moving between stimuli…typically to heighten/maintain arousal,” and “binges and edging.”

Lists of related studies:

• Porn/sex addiction? This page lists over 50 neuroscience-based studies (MRI, fMRI, EEG, neuropsychological, hormonal). All provide strong support for the addiction model as their findings mirror the neurological findings reported in substance addiction studies.
• The real experts’ opinions on porn/sex addiction? This list contains dozens of neuroscience-based literature reviews & commentaries by some of the top neuroscientists in the world. All support the addiction model.
• Additional page with 15 studies reporting withdrawal symptoms in porn users.
• An official diagnosis? The world’s most widely used medical diagnostic manual, The International Classification of Diseases (ICD-11), contains a diagnosis suitable for porn addiction: “Compulsive Sexual Behavior Disorder.”