Kirby, M. (2021), Trends Urology & Men Health, 12: 6-10.
Abstract
Increased internet access has been accompanied by increased numbers of adolescent and adult men viewing online pornography, and there is growing concern about how this may affect their sexual development, sexual function, mental health and intimate relationships. This paper briefly reviews men’s relationship with porn and the possible impact on sexual function.
How common is the use of pornography?
Men view more online porn than women. Recent surveys suggest that in developed countries like the USA and Australia, which have unrestricted internet access, up to 76% of men and 41% of women are accessing porn,5, 6 and the number of visitors to pornographic sites is increasing every year.7
Many health care professionals have become aware of women complaining about their partner’s use of porn and how its consumption causes unrealistic expectations and sexual difficulties.
An online survey commissioned for the BBC Three series, ‘Porn Laid Bare’, asked more than 1000 18–25‐year‐olds in Great Britain about their relationship with porn. A significant 77% of men admitted to viewing X‐rated content in the last month compared with 49% of women, and 55% of men said porn had been their main source of sex education, compared with 34% of women. Some 15% of male respondents thought they watched too much porn, and 31% felt they had been addicted to it.8
An Italian study involving 1492 students in their final year of high school found that 78% of internet users watched porn and of these, 8% watched it daily, 59% perceived it as always stimulating, 22% defined it as habitual, 10% claimed it reduced sexual interest in potential real‐life partners, and 9% reported a kind of addiction.9
In a cross‐sectional online survey of 15–29‐year‐old Australians, 87% reported having viewed porn at some time, with the median age at first viewing being 13 years for men versus 16 years for women. Younger age at first viewing was associated with male gender, non‐heterosexual identity, higher education, younger current age, younger age at first sexual contact, and recent mental health issues. More frequent viewing was associated with male gender, non‐heterosexual identity, higher education, younger age, ever having anal sex, and recent mental health problems.10
Impact of porn viewing on men
Academic studies to date have focused mainly on the possible negative effects of porn consumption, with few reviewing the possible benefits. As a result, there are many gaps in the evidence base, and the area is controversial.
A comprehensive 2016 review reported a sharp rise in the rates of erectile dysfunction (ED), delayed ejaculation, decreased sexual satisfaction and diminished libido in men under 40 years old during sex with a partner, with the traditional factors that once explained these difficulties now appearing insufficient contributors.11
Erectile dysfunction has been traditionally viewed as an age‐related problem, and men under the age of 40 years do not carry the commonly associated risk factors, such as obesity, sedentary lifestyle, diabetes, hypertension, cardiovascular disease, hyperlipidaemia and smoking.12 Psychogenic ED is the most common diagnosis in this younger age group,13 typically related to psychological factors such as depression, stress, general anxiety or performance anxiety.14 However, none of the usual correlative factors associated with psychogenic ED appear to adequately account for the rapid and many‐fold increase in the sexual difficulties observed in these young men.11
Accumulating evidence suggests that increasing use of online porn may be contributing to the increased rates of sexual dysfunction.
Research has shown that hypersexuality is significantly correlated with a proneness to sexual boredom and ED.15 Theoretically, this may increase both the likelihood of using porn and the occurrence of ED when having sex with a partner.
Reduced sexual attraction to a partner, sex with a partner not meeting expectations, and personal feelings of sexual inadequacy can cause ED. These may potentially result from unrealistic body and sexual performance ideals present in some porn content.
Delayed ejaculation may be associated with porn use,7 possibly related to frequent masturbation and the significant disparity between the reality of sex with a partner and porn‐related sexual fantasy during masturbation.16
Overall, men who use porn more often tend to report less satisfaction with their sex life. The use of porn may potentially reduce sexual satisfaction due to real‐life partners not living up to the idealised images seen online, disappointment if a partner does not want to recreate pornographic scenes, disappointment stemming from the inability to obtain the range of sexual novelties seen in porn with a real partner, and pornography being chosen over sexual intercourse with a partner.7
A possible negative effect of long‐term porn use on sexual desire may stem from changes in the responsiveness of the reward system in the brain to sexual stimuli, which becomes more active as a result of porn‐associated stimuli than with real‐life sexual intercourse.7, 17, 18 However, there is a lack of consistent data to support porn as a causative factor in decreased sexual desire, and some are contradictory.7 This may be explained by the complex nature of sexual desire, which is influenced by a variety of biological, psychological, sexual, relational and cultural factors.7, 19
However, there is controversy about these findings, and a recent review7 of the evidence from purely observational studies published since 2000 found little if no evidence that pornography use induces ED or delayed ejaculation, although longitudinal studies controlling for confounding variables were lacking. The strongest evidence available was for the relationship between porn use and decreased sexual satisfaction, although the results of prospective studies were inconsistent.7 Another recent study found no consistent association between porn use and ED.20
However, the risk of ED appears to increase with the number of pornographic films viewed in the preceding year,15 and problematic use of online sexual activities (assessed by the 12‐item Short Internet Addiction Test and reflected by negative outcomes and addictive symptoms) was associated with lower erectile function and lower overall sexual satisfaction.21
With online porn, it seems the viewer profile is predictive of sexual wellbeing. A study of 830 adults,22 who completed online self‐reported measurements of online porn use and sexual wellbeing, including sexual satisfaction, compulsivity, avoidance and dysfunction, found three distinct user profiles: recreational (76%); highly distressed non‐compulsive (13%), and compulsive (11.8%). While recreational users reported higher sexual satisfaction and lower sexual compulsivity, avoidance and dysfunction, those with a compulsive profile reported lower sexual satisfaction and dysfunction, and higher sexual compulsivity and avoidance. Highly distressed, less active users reported being less satisfied sexually, having less sexual compulsivity, and more sexual dysfunction and avoidance. While women and couples were more likely to be recreational users, men were more likely to be compulsive users, and solitary users were more likely to be in the highly distressed, less active profile.22
The manner in which men satisfy their sexual desires also appears to affect their risk of sexual dysfunction. A 2016 American survey23 examined degree of porn use in relation to sexual dysfunction in 312 men aged 20–40 years, who completed an anonymous survey when presenting to a urology clinic. The survey included self‐reported medical history, demographic questions, validated questionnaires (including the 15‐question International Index of Erectile Function [IIEF‐15]) and questions addressing sexual function, pornography use and craving and obsessive behaviour. The mean age of respondents was 31 years. The typical media for viewing porn was the internet, either on a computer (72%) or a smartphone (62%). Weekly porn use varied, with 26% using it less than once weekly, 25% using it 1–2 times, 21% using it 3–5 times, 5% using it 6–10 times and 4% using it more than 11 times. When asked how they best satisfied their sexual desires, 97% of men indicated intercourse (with or without pornography), while 3% indicated masturbation to pornography. The respondents who reported a preference for masturbation to pornography rather than intercourse had statistically lower scores in all IIEF‐15 domains (p<0.05).23
The reason why these men presented to a urology clinic may be relevant. It could be possible that those who preferred masturbating to porn over having sexual intercourse with a partner did so because they had pre‐existing medical or psychological issues that made sexual intercourse with a partner difficult. Indeed, it may be helpful for men attempting to recover sexual function after pelvic surgery or radiotherapy to use ethical pornography to help them, especially if they do not have a supportive partner.
With conflicting evidence for a causal relationship between porn use and sexual dysfunction in men, it may be that men with sexual dysfunction are more likely to use porn, and use porn more frequently. More research is required to investigate this.
Regarding the effect of porn use on minors, a review of 19 studies published between 2013 and 2018 found an association between online porn use and earlier sexual debut, engaging with occasional and/or multiple partners, emulating risky sexual behaviours, assimilating distorted gender roles, dysfunctional body perception, aggression, anxiety, depression, and compulsive porn use.24 Another study has shown that compulsive use of sexually explicit internet material by adolescent boys is more likely in those with lower self‐esteem, depressive feeling and excessive sexual interest.1
A major issue with pornography is its diversity. While some content, involving willing, fully informed and consenting adults may be seen as harmless fun, more concerning aspects include exposure to unwanted content, unrealistic body ideals, unrealistic sexual performance ideals, aggression, violence, rape, other non‐consensual behaviour, token resistance (the perceived notion that women say ‘no’ when they actually intend to have sex),25 sexual coercion, inappropriate gender power dynamics, sexual solicitation, child abuse and a lack of contraception or condom use.
On a more positive note, it is possible that some porn use in adult men may have a positive impact by increasing libido and desire for a real‐life partner, relieving sexual boredom, and improving sexual satisfaction by providing inspiration for real sex.7 Watching porn with a partner may help couples explore new sexual approaches and make it easier to say what they like.
Soft porn has also been found to relieve psychosocial stress. One study found that men who flipped through mildly erotic pictures of mixed couples had significantly lower cortisol reactivity to a subsequent stress test than the controls, and they did a lot better in a maths test.26
In younger men, porn use may help them explore their sexuality, find out what they like, and boost their confidence in knowing what to do with real‐life partners. While concerns exist regarding the unrealistic nature of some porn, a survey of 18–25‐year‐olds in Great Britain found that almost three‐quarters of men considered the sex in porn not reflective of real life, and almost half agreed that porn content is creating ‘impossible’ beauty standards.8
In contrast, there is increasing interest in the educational impact of more positive forms of pornography, such as ‘feminist pornography’ and ‘sex‐positive pornography’, which show sexual consent, emphasise the real sexual pleasure of female performers, represent diversity, and provide ethical working conditions for those involved.27
With regard to causing benefit or harm though, the personality of the user, the type and amount of porn used, and the age of the user, are probably key.
Conclusion
Viewing pornography is common and frequent among men from a young age. Men view porn for different reasons and porn use affects different individuals in different ways. More research is required to provide a broader insight into the potential effects of porn use on sexual function and mental health in men of all ages.
When men under the age of 40 years present with sexual dysfunction, it is important to enquire about porn use, and their sexual function with and without it. Other considerations include lifestyle factors, such as, obesity, diabetes, poor diet, lack of exercise, smoking, excessive alcohol consumption, and recreational drug use. Physical factors, such as evidence of testosterone deficiency and penile abnormalities should be assessed. Explore mental health issues, such as relationship problems, low self‐esteem, stress, anxiety, depression, and post‐traumatic stress disorder.
Reassuringly, concerns about how inappropriate sexual content may affect the sexual and mental health of young people are reflected in government plans to introduce a broader sex education curriculum in schools from September 2020, which will include education about how to recognise ways the internet can encourage unhealthy perspectives on sex.28
As parents, we can help our children by preventing or limiting their exposure to inappropriate content where possible, via parental controls and restricted access. We can also try to help them develop critical thinking skills about pornography by talking to them about what they see online and engaging them in age‐appropriate discussions about healthy relationships, gender and power dynamics, consent, contraception and sexually transmitted diseases.
Declaration of interests
Mike Kirby has received funding from the pharmaceutical industry for research, conference attendance, lecturing and advice.
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