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Rates of psychogenic ED increased more than organic ED, while rates of unclassified ED remained relatively stable [ 12 ]. A cross-sectional study of active duty, relatively healthy, male military personnel aged 21—40 employing the five-item IIEF-5 found an overall ED rate of The researchers also noted that sexual dysfunctions are subject to underreporting biases related to stigmatization [ 14 ], and that only 1. Traditionally, ED has been seen as an age-dependent problem [ 2 ], and studies investigating ED risk factors in men under 40 have often failed to identify the factors commonly associated with ED in older men, such as smoking, alcoholism, obesity, sedentary life, diabetes, hypertension, cardiovascular disease, and hyperlipidemia [ 16 ].

ED is usually classified as either psychogenic or organic. Psychogenic ED has been related to psychological factors e.

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However, none of the familiar correlative factors suggested for psychogenic ED seem adequate to account for a rapid many-fold increase in youthful sexual difficulties. For example, some researchers hypothesize that rising youthful sexual problems must be the result of unhealthy lifestyles, such as obesity, substance abuse and smoking factors historically correlated with organic ED.

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Yet these lifestyle risks have not changed proportionately, or have decreased, in the last 20 years: Obesity rates in U. Other authors propose psychological factors. Yet, how likely is it that anxiety and depression account for the sharp rise in youthful sexual difficulties given the complex relationship between sexual desire and depression and anxiety? Some depressed and anxious patients report less desire for sex while others report increased sexual desire [ 22232425 ].

Not only is the relationship between depression and ED likely bidirectional and co-occurring, it may also be the consequence of sexual dysfunction, particularly in young men [ 26 ]. While it is difficult to quantify rates of other psychological factors hypothesized to account for the sharp rise in youthful sexual difficulties, such as stress, distressed relationships, and insufficient sex education, how reasonable is it to presume that these factors are 1 not bidirectional and 2 have mushroomed at rates sufficient to explain a rapid multi-fold increase in youthful sexual difficulties, such as low sexual desire, difficulty orgasming, and ED?

Kinsey Institute researchers were among the first to report pornography-induced erectile-dysfunction PIED and pornography-induced abnormally low libido, in [ 27 ]. The researchers actually redesigned their study to include more varied clips and permit some self-selection. Since then, evidence has mounted that Internet pornography may be a factor in the rapid surge in rates of sexual dysfunction.

A study on high school seniors found that Internet pornography use frequency correlated with low sexual desire [ 29 ]. Another study of men average age Anxiety about sexual performance may impel further reliance on pornography as a sexual outlet.

Clinicians have also described pornography-related sexual dysfunctions, including PIED. For example, in his book The New Naked, urology professor Harry Fisch reported that excessive Internet pornography use impairs sexual performance in his patients [ 32 ], and psychiatry professor Norman Doidge reported in his book The Brain That Changes Itself that removal of Internet pornography use reversed impotence and sexual arousal problems in his patients [ 33 ].

InBronner and Ben-Zion reported that a compulsive Internet pornography user whose tastes had escalated to extreme hardcore pornography sought help for low sexual desire during partnered sex.

Eight months after stopping all exposure to pornography the patient reported experiencing successful orgasm and ejaculation, and succeeded in enjoying good sexual relations [ 34 ].

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To date, no other researchers have asked men with sexual difficulties to remove the variable of Internet pornography use in order to investigate whether it is contributing to their sexual difficulties. While such intervention studies would be the most illuminating, our review of the literature finds a number of studies that have correlated pornography use with arousal, attraction, and sexual performance problems [ 2731353637383940414243 ], including difficulty orgasming, diminished libido or erectile function [ 273031354344 ], negative effects on partnered sex [ 37 ], decreased enjoyment of sexual intimacy [ 374145 ], less sexual and relationship satisfaction [ 3839404344454647 ],a preference for using Internet pornography to achieve and maintain arousal over having sex with a partner [ 42 ], and greater brain activation in response to pornography in those reporting less desire for sex with partners [ 48 ].

Again, Internet pornography use frequency correlated with low sexual desire in high school seniors [ 29 ]. Two studies deserve detailed consideration here. The first study claimed to be the first nationally-representative study on married couples to assess the effects of pornography use with longitudinal data.

The marriages most negatively affected were those of men who were viewing pornography at the highest frequencies once a day or more. Assessing multiple variables, the frequency of pornography use in was the second strongest predictor of poor marital quality in [ 47 ]. The second study claimed to be the only study to directly investigate the relationships between sexual dysfunctions in men and problematic involvement in OSAs online sexual activities.

This survey of men reported that lower overall sexual satisfaction and lower erectile function were associated with problematic Internet pornography use [ 44 ]. Finally, a significant percentage of the participants Our review also included two papers claiming that Internet pornography use is unrelated to rising sexual difficulties in young men. However, such claims appear to be premature on closer examination of these papers and related formal criticism.

The first paper contains useful insights about the potential role of sexual conditioning in youthful ED [ 50 ]. However, this publication has come under criticism for various discrepancies, omissions and methodological flaws. For example, it provides no statistical results for the erectile function outcome measure in relation to Internet pornography use. Additionally, the researchers investigated only hours of Internet pornography use in the last month. A better predictor is subjective sexual arousal ratings while watching Internet pornography cue reactivityan established correlate of addictive behavior in all addictions [ 525354 ].

There is also increasing evidence that the amount of time spent on Internet video-gaming does not predict addictive behavior. A second paper reported little correlation between frequency of Internet pornography use in the last year and ED rates in sexually active men from Norway, Portugal and Croatia [ 6 ]. Yet, based on a statistical comparison, the authors conclude that Internet pornography use does not seem to be a significant risk factor for youthful ED.

This paper has been formally criticized for failing to employ comprehensive models able to encompass both direct and indirect relationships between variables known or hypothesized to be at work [ 59 ]. Incidentally, in a related paper on problematic low sexual desire involving many of the same survey participants from Portugal, Croatia and Norway, the men were asked which of numerous factors they believed contributed to their problematic lack of sexual interest.

Again, intervention studies would be the most instructive. However, with respect to correlation studies, it is likely that a complex set of variables needs to be investigated in order to elucidate the risk factors at work in unprecedented youthful sexual difficulties.

First, it may be that low sexual desire, difficulty orgasming with a partner and erectile problems are part of the same spectrum of Internet pornography-related effects, and that all of these difficulties should be combined when investigating potentially illuminating correlations with Internet pornography use.

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Clinical Reports While correlation studies are easier to conduct, the difficulty in isolating the precise variables at work in the unprecedented rise of sexual dysfunction in men under 40 suggests that intervention studies in which subjects removed the variable of Internet pornography use would better establish whether there is a connection between its use and sexual difficulties.

The following clinical reports demonstrate how asking patients with diverse and otherwise unexplained dysfunctions to eradicate Internet pornography use helps to isolate its effects on sexual difficulties. Below we report on three active duty servicemen. Two saw a physician for their non-organic erectile dysfunction, low sexual desire, and unexplained difficulty in achieving orgasm with partners. The first mentioned variables 16 and 7listed in the preceding paragraph.

The second mentioned 6 and 7. Both were free of mental health diagnoses. We also report a third active duty serviceman who saw a physician for mental health reasons. He mentioned variable 6. First Clinical Report A 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.

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His difficulties maintaining erection and achieving orgasm continued throughout his deployment. 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.

He endorsed viewing Internet pornography for stimulation. Since he gained access to high-speed Internet, he relied solely on Internet pornography. However, gradually he needed more graphic or fetish material to orgasm. He reported opening multiple videos simultaneously and watching the most stimulating parts.

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When preparing for deployment about a year ago, he was worried about being away from partnered sex. This device was initially so stimulating that he reached orgasm within minutes. However, as was the case with Internet pornography, with increased use, he needed longer and longer to ejaculate, and eventually he was unable to orgasm at all. Since returning from deployment, he reported continued masturbation one or more times per day using both Internet pornography and toy.

He denied any other relationship issues. She was starting to think that he was no longer attracted to her. Medically, he had no history of major illness, surgery, or mental health diagnoses. He was not taking any medications or supplements. He denied using tobacco products but drank a few drinks at parties once or twice a month. He had never blacked out from alcohol intoxication.

He denied a history of sexually transmitted diseases. On physical examination, his vital signs were all normal, and his genital exam was normal appearing without lesions or masses. At the conclusion of the visit, it was explained to him that use of a sex toy had potentially desensitized his penile nerves and watching hardcore Internet pornography had altered his threshold for sexual stimulation.

He was advised to stop using the toy and watching hardcore Internet pornography. He was referred to urology for further evaluation. By the time he was seen by the urologist a few weeks later, he had cut down on Internet pornography use significantly, although he said he could not completely stop. He ceased using the toy. Second Clinical Report A 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. He denied ever having these issues earlier in the seven years of their marriage.

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He was having marital issues because his wife suspected he was having an affair, which he adamantly denied. His medical history was only significant for hypertension, which was diagnosed more than two years earlier and had been well controlled with a diuretic: He took no other medications or supplements.

His only surgery was an appendectomy performed three years prior. He had no sexually transmitted diseases or mental health diagnoses. He endorsed smoking three packs of cigarettes per week for over ten years and drinking one to two drinks per week. Physical exam revealed vital signs within normal ranges, normal cardiovascular exam, and normal appearing genitals without lesions or masses.

At the end of the exam, his issues were attributed to heightened sexual stimulation threshold from exposure to hardcore Internet pornography and frequent masturbation. He was advised to stop watching hardcore Internet pornography and decrease masturbation frequency.

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