Is There Any Relationship?
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Published: 02 February 2024 Volume 16, pages 19–34, (2024) Cite this article Download PDF You have full access to this open access article
Published: 02 February 2024 Volume 16, pages 19–34, (2024) Cite this article Download PDF You have full access to this open access article
Abstract
Purpose
Consensus about whether pornography use affects sexual functioning during partnered sex is lacking. In this review, we explain and define the variables under consideration (pornography use and sexual functioning), briefly elaborate the controversy, and conduct a literature search extending from 2015 to the present using diverse and all-inclusive keywords related to pornography use, problematic pornography use (PPU), and sexual functioning in men and women.Recent Findings
Twenty-eight studies directly related to the issue were identified, and another 23 studies were used as supporting material (e.g., defining or assessing variables and identifying predictors of PPU). Results were organized into two major sections, beginning with a delineation of methodological issues related to studies on the topic and followed by summaries of studies first on women and men drawn from community samples, and then on women and men drawn from samples defined by excessive, problematic, compulsive, or addictive use of pornography. In general—and consistent with prior reviews on the topic—women were more likely to show positive associations between pornography use and sexual functioning whereas men showed mixed results. Specifically, the analysis demonstrated the diversity of outcomes of pornography use, including how they currently play out differently for women and men and for problematic and non-problematic users, with this latter group—particularly when male—more likely to show mild to moderate negative associations with sexual functioning.Summary
Claims of a strong relationship between pornography use and sexual dysfunction are generally unfounded, both by the findings of studies and/or by misinterpretations of them. As part of our “Discussion”, we identify the ongoing methodological challenges in this field, unpack the meaning of PPU and how its component constructs might affect sexual functioning, and suggest a path forward that makes better and more systematic use of covariates/constructs related to both PPU components and sexual functioning.Results
Methodological Issues
One concern regarding the research that has been carried out thus far on this topic pertains to the use of methodologies that lead to vague and sometimes juxtaposing conclusions. Although not an exhaustive list of issues, problems with a number of existing studies often include one or more of the following methodological shortcomings.Sampling: The relationship between pornography use and sexual function has sometimes been investigated in clinical or patient samples, or other specialized samples. Such samples are typically biased, as they focus on individuals who are seeking help for an existing health-related problem—specifically, these individuals may already have a sexual dysfunction and/or be in poorer general health than the population at large. Beyond this, sample sizes need to be sufficiently large to ensure well-powered studies both to accommodate multivariate analyses and to enable confidence in studies that report a lack of associations/effects.
Defining/operationalizing variables: For the outcome variable (sexual function/dysfunction), standardized assessment instruments have not always been used, even when available; or cut-off scores for dichotomized outcomes (function vs dysfunction) have neither been reported nor justified; or clear justification for, and psychometrics of, an operationalizing procedure (when standardized assessments have not been used) have not been included. For non-standardized predictor and correlated variables, internal and test–retest reliability statistics are seldom reported—often, best psychometric practices are not followed.
Over-reliance on bivariate relationships: Simple bivariate associations provide little insight into the overall issue and, more importantly, may lead to erroneous conclusions, particularly given that confounding variables may better explain an outcome than pornography use. Even for studies taking a multivariate approach, the included covariates may not represent those most critical to the issue. Some studies have also failed to report effect sizes, making them uninterpretable.
Use of cross-sectional methodologies: Although not a problem in and of itself, this becomes an issue when a study infers a directional effect, for example, pornography use → sexual problem (e.g., ED) and does not seriously consider equally plausible bidirectional or opposite direction effects: for example, individuals suffering from a sexual problem sometimes turn to masturbation and concomitant pornography use for sexual pleasure when partnered sex is difficult or not readily available.
In light of the above issues, interpretation of associations between pornography use and sexual functioning merits both qualification and a humility that recognizes the inadequacies of various research designs along with the plausibility of alternative or opposing interpretations. In some instances, studies on this topic suffer from overreach—perhaps because the media is more likely to attend to sensational findings than to well-researched though more muted conclusions based on actual effect sizes. To this point, we refer the reader to Sidebar 1, which provides a real-world example of the distorted conclusions that may come about from naïve media reporting.
Findings From Major Reviews Since 2016
In this section, we briefly highlight four reviews (since 2016) on the topic of pornography use and sexual dysfunction. In their comprehensive review, Dwulit and Rzymski [39] concluded that “a causal link between porn use and ED has yet to be demonstrated…” The review arrived at similar conclusions for other sexual dysfunctions, identifying the many methodological limitations that prevented causal interpretations. In a systematic review of 44 articles, Hoaglund and Grubbs [2••] offered a qualified interpretation, indicating that pornography use has shown both positive and negative associations with sexual functioning; they further identified problematic pornography use (PPU) as a consistent predictor of lower sexual functioning. In men with sexual dysfunctions, a review dealing with the use of sex aids identified pornography use as among the more common, convenient, and effective approaches used by men [40]. An older review puts forth the conclusion that increased availability of and accessibility to pornography may account for sexual difficulties in many younger men whose origin for the difficulty is non-organic and likely not “performance-anxiety based” [34].Several relevant takeaways can be garnered from the above reviews: (1) limiting methodological designs have diminished confidence in reported relationships between pornography use and sexual functioning; (2) the relationship between pornography use and sexual functioning likely differs depending on the sample characteristics, for example, whether a community sample, a clinical/patient sample, or a sample of individuals indicating extreme or problematic pornography use; and (3) specific personality or experiential characteristics may render some individuals more vulnerable to the effects of pornography than others.
Review and Update of Research Studies
The Roadmap
Relationships between the study variables are substantially different between men and women. For this reason, we review each sex separately, presenting a reiteration of studies prior to 2019/2020 (approximately 2016–2019) as well as coverage of studies from 2019/2020 to the present, thus providing updates to the last major published reviews in 2019 and 2021 [2••, 39]. We also review the studies separately for the two sample categories: broad community-based sample, and samples tapping special populations such as problematic pornography users, porn “addicts,” and individuals showing compulsive use.Studies Based on Community Samples
Women
Women masturbate less frequently than men, use pornography less frequently than men, and represent a lower percentage of PPU [18]. Not surprisingly, negative effects of pornography use on women’s sexual response are generally less concerning than for men.We reviewed 11 studies on community samples that included women and in which—for the most part—sexual dysfunction was assessed using either a standardized assessment instrument or multiple items drawn from such instruments. Studies published between 2016 and 2020 (and reported in other reviews) tended to indicate no or slightly positive associations between pornography use and sexual functioning. For example, Berger et al. [41] reported no relationship between pornography use and sexual functioning in women patients at a urology clinic on a military base—58% of whom indicated a sexual problem. Vaillancourt-Morel et al. [42] concluded that women’s use of pornography likely improved their functioning during partnered sexual activity, with similar conclusions reached by two additional studies on sexual well-being and sexual arousal during partnered sex [43, 44]. For all three studies showing improved functioning, effect sizes—as indicated by beta coefficients or eta-squared values—were in the low/weak range. In some instances, studies categorized women into specific subtypes—some showing better sexual functioning and others showing slightly lower sexual functioning. For most such classifications, however, compared with men (in mixed sex studies), the preponderance of women fell into subgroups that were more likely to benefit from pornography use than to suffer from it. For example, frequent pornography users—whether men or women—showed better sexual functioning than problematic pornography users [45•], although effect sizes were small. Not surprisingly, the great majority of women were frequent pornography users, in contrast with men who showed a higher prevalence of problematic pornography use. Along similar lines, when recreational users of pornography were distinguished from distressed and/or compulsive users in either dyadic or solo use, recreational users of pornography showed more positive associations with sexual functioning—again, not surprisingly, women (compared with men) were more heavily represented in the recreational and dyadic pornography use categories [42]. Two other studies—though less clear about specific associations regarding women’s use of pornography—suggested that pornography use either had no negative effect on sexual functioning (e.g., arousal) or was more likely to impart slight beneficial effects than negative effects [46, 47]. Again, effect sizes were very small. Notably and not surprising, use of pornography in a partnered context was consistently associated with the most positive sexual functioning outcomes (e.g., [43]).
Four, more recent, studies on community samples have been published since 2020. First, a large national probability survey from Sweden [48] found that most women (83%) reported that pornography use did not impact their sex life, 15% of women reported a positive impact, and only 4% reported a negative impact. Further analysis relating the frequency of pornography use to items regarding sexual performance pressure, sexual arousal difficulty, and orgasmic difficulty was also carried out: only the item related to performance pressure showed significance—with no relationship with arousal or orgasmic difficulty. Second, in a study using over 600 Austrian medical students, Komlenac and Hochleitner [49] reported that frequent pornography use among women was associated with better sexual functioning, albeit only weakly. And third, Sommet and Berent [50] also reported that in women, the greater frequency of pornography use, the higher the sexual functioning. In addition, women who reported increasing pornography use successively over three years also showed higher sexual functioning compared with those showing no or decreasing use of pornography. Effects sizes—as noted by the beta coefficients—were, again, small. In contrast with the general patterns of no or slightly positive effects above, Wright et al. [51] reported an association between pornography use and orgasmic difficulty in women; however, the effect was indirect, mediated through sexual insecurity, quite small, and did not use a multivariate or standardized assessment of the sexual problem.
Evaluation and Comment on Women’s Community Sample Studies
The above body of literature on community samples of women shows an overall consistency, namely, that pornography use among women typically demonstrated no association with sexual functioning, or a weak positive association. Furthermore, most studies demonstrated various strengths, including large and diverse samples, for example, ranging from 217 couples to over 10,000 participants and using recruitment procedures that minimized a high degree of homogeneity in participants (e.g., using only university students). In addition, all but two assessed sexual functioning using standardized or multivariate instruments; the two that used [46, 51] single-item analysis of “sexual arousal difficulty” or “orgasm difficulty” were deficient, but other strengths of these studies partly compensated, for example, robust sample sizes, classification into specific relationship types, or testing of mediating covariates. Finally, effect sizes were discernible for all studies—thus despite differences in sample sizes and typically highly significant probabilities, effect sizes could be compared across studies.On the other hand, shortcomings were also notable. First, although sexual functioning differences were detectable, the placement of sexual functioning within the larger context of “functional vs. dysfunctional” categorizations was generally not clear—were some respondents dysfunctional? Did pornography use mean that these women were less dysfunctional or simply more functional (e.g., more easily aroused even though they were not dysfunctional)? Second, determination of cause-effect was not possible, yet studies seldom attempted to interpret reverse associations, for example, were women with better sexual functioning perhaps more open to the use of pornography? Although one study used longitudinal analysis [50], because a true experimental design was not used, confidence in cause-effect directionality was still limited. Finally, few studies incorporated covariates specifically related to sexual functioning in women, such as relationship quality, medical conditions, menopausal status, level of sexual interest/desire, or even frequency of masturbation. And most studies did not specify which component of sexual response improved—for example, sexual interest/desire? Psychosexual arousal? Vaginal lubrication? Orgasmic capacity? Obviously, issues still remain to be addressed.
Men
In contrast with research on women, studies examining the relationship between pornography use and sexual functioning in community samples of men show substantial variation in results. In some instances, slight beneficial associations have been found; just as frequently either no or slight-to-moderate negative associations have been reported.We reviewed 13 studies on community samples that included men and in which sexual dysfunction was assessed using a standardized assessment instrument, questions/items drawn from such instruments, or other multivariate measures. Studies published between 2016 and 2020 (and reported in other reviews) tended to show mixed results. For example, Landripet and Stulhofer [52]—in two separate studies having over 1000 participants each—reported no negative association between frequency of pornography use and sexual functioning in a sample that included multinational subgroups, and only weak and inconsistent results in a Croatian sample, an association which later disappeared when the study was repeated on a second Croatian sample. A similar lack of association was also noted in a much smaller study on couples by Vaillancourt-Morel et al. [53], although a related variable—increased partner sexual distress—showed some relationship with pornography use. Two other well-conducted studies [45•, 54] concluded that frequency of pornography use had no association with impaired sexual functioning using either cross-sectional or longitudinal methodology. Both studies placed qualifiers on their overall conclusions, as both identified a PPU group that showed mild/moderate negative associations with sexual functioning (see later section on the topic).
In contrast, two studies have suggested that pornography use by men may be associated with improved sexual functioning, with erectile function or sexual arousal scores increasing [42, 46] although, as with women, effect sizes were small. For example, Vaillencourt-Morel et al. [42] reported that recreational use of pornography was associated with lower sexual dysfunction, and Barrada et al. [46] reported a significant but weak positive association between pornography use and sexual functioning. However, both studies also identified typically small subgroups likely to suffer ill effects on sexual functioning from pornography use. Vaillancourt-Morel et al. [42] differentiated between recreational/curiosity vs. compulsive users, the former group showing higher sexual functioning but the latter group showing lower sexual functioning. Barrada et al. [46] identified a group having a more compulsive orientation toward pornography use who showed negative (though weak) associations with sexual functioning. As with women, men who used pornography with their partner tended to show the most positive associations with sexual functioning [43].
Six, more recent, studies have taken up the issue of pornography use on sexual functioning since 2020, and, to a large extent, the overall landscape has changed little. Four concluded that pornography use was associated with either no or only slightly lower sexual functioning. One study reported a moderate negative association between these variables, and one concluded only an indirect effect mediated through sexual insecurity. Regarding those showing no association, in a large national probability study in Sweden, the vast majority of male participants (72%) reported no perceived effects of pornography use on their sex life; 23% reported positive effects, and only 5% reported negative effects [48]. Furthermore, for the small minority reporting negative effects, erection problems were associated with frequency of use only at higher levels, and no direction of effect could be ascertained. In a second study of over 600 medical students in Austria, frequent pornography consumption was associated with greater sexual flexibility but neither positive nor negative associations with sexual functioning [49]. Two other studies provided comprehensive and detailed analyses of the relationship between frequency of pornography use and delayed/inhibited ejaculation and, separately, erectile dysfunction [28, 55]. These studies controlled for covariates known to affect sexual functioning such as sexual desire and anxiety/depression. For delayed/inhibited ejaculation, masturbation frequency was very weakly associated negative sexual functioning, and using stepwise discriminant analysis, frequency of pornography use added less than 1% of explained variance to the understanding of ejaculation difficulty. In contrast, other factors related to delayed ejaculation—the importance of sex, anxiety/ depression, erectile functioning, medical issues, and relationship satisfaction—all showed relatively strong associations with ejaculation difficulty. In a parallel analysis on erectile functioning, using the same strategy of statistically controlling covariates relevant to sexual functioning, no associations were found between pornography use and erectile response. For these studies, the absence of an effect occurred consistently across various subsets of men, for example, men 30 years or under, men with comorbid sexual dysfunctions, and men with lifelong vs. acquired problems.
In contrast to the above four studies that showed no meaningful associations between pornography use and sexual functioning, one study [50] reported a moderate negative association, and another [51] reported an indirect association with orgasmic difficulty mediated through sexual insecurity. The effect was fairly weak, and orgasmic difficulty was assessed with only a single item.
Evaluation and Comment on Men’s Community Sample Studies
As with women, the above body of literature on samples of men shows substantial consistency, with most studies demonstrating either no association or a weak negative association with sexual functioning. Only one study reported a moderate negative association with sexual functioning. In general, these studies had robust sample sizes, and all but two were recruited from diverse populations (the two exceptions used medical students or military personnel visiting a urology clinic). In addition, in all studies but one [51], sexual functioning was assessed using standardized or multivariate instruments. Effect sizes were included and therefore could be compared across all studies.On the other hand, shortcomings were once again apparent, often identical to those seen in studies on women. For example, although sexual functioning differences related to pornography use were sometimes detectable, the placement of sexual functioning within the larger context of “functional vs. dysfunctional” categorizations was usually not clear. Due to the use of cross-sectional designs, the direction of cause-effect for most studies was not discernible. Two studies using longitudinal analysis [50, 54] yielded disparate results, with one reporting no association between pornography use and sexual functioning and the other finding a negative association. Only two studies used covariates specifically related to sexual functioning in men [28, 55], and only three studies [28, 51, 55] actually specified which components of sexual responding were (or were not) affected.
Studies Based on Special Populations of Pornography Users (PPUs, Compulsive Users, etc.)
The findings from the community studies reported above focused primarily on the relationship between frequency of pornography use (FPU) and sexual dysfunction. However, within a number of those studies, various sub-analyses suggested that particular subgroups or characteristics (e.g., compulsive pornography use) were associated with greater vulnerability to negative effects on sexual functioning. In the next section, we turn to a discussion of studies assessing sexual functioning in special populations of self-identified problematic and/or compulsive users of pornography.Women
Few studies have examined PPU or compulsive use and sexual dysfunction in women. We identified four studies related to the topic up through 2021 (reviewed also in Hoagland and Grubbs [2••]), but only one study since then. Most studies have shown no clear association with sexual functioning; one has shown a weak positive association and one a weak negative association. Bothe et al. [45•], for example, contrasted frequent pornography users (FPU) with problematic pornography users (PPU) in over 4000 women, finding a weak/moderate positive association between FPU and sexual functioning but a moderate negative association between PPU and sexual functioning, that is, women problematic users were at moderate risk for sexual problems during partnered sex.Four other studies focused on compulsive pornography use, pornography obsession, or social media addiction, a construct presumably similar or related to (though not identical with) PPU. Barrada et al. [46] studied a cross-section of over 110 college students in Spain, specifying three types of pornography usage: compulsive, isolated, and social. Interestingly, those identified as compulsive users exhibited a number of sex-related differences, such as higher sexual dissatisfaction and higher sexual preoccupation with sex, but they did not show any differences from other groups with respect to sexual functioning. Unfortunately, however, their analysis did not examine patterns for men and women separately, so interpretation of these effects remains obscure. A second study by Vaillancourt-Morel et al. [42] investigated a subgroup of participants having a compulsive user profile (compared to recreational and distressed non-compulsive user profiles). The compulsive user profile—about 12% of the sample—was characterized by high scores on compulsivity to pornography, intense efforts to access pornography, and moderate emotional distress. While compulsive profile users reported higher distress related to pornography use and higher sexual compulsivity, they actually showed slightly better sexual functioning than the other two groups, although no effect size was provided. As with Barrada et al.’s study [46], however, this study—unfortunately—did not examine the relationship between compulsive use of pornography and sexual functioning separately for men and women. More specific to women, Berger et al. [41] also reported no association between craving or obsessive passion for pornography use and sexual functioning in women, despite a high level of sexual dysfunction (52%) reported in this relatively small sample of 44. And a fourth study—only tangentially related to compulsive or problematic use of pornography—reported that while social media addiction in women resulted in lower sexual functioning scores, pornography use was positively associated with sexual functioning, but again no effect size was presented [56].
Evaluation and Comment on Women Problematic Pornography Users
In summary, these five studies suggest no clear relationship between PPU or compulsive use and sexual functioning in women. The most parsimonious interpretation is that of no association or only a very weak association. Studies benefitted methodologically from their large sample sizes (all over 100 participants except one study), from their use of standardized assessment scales for sexual functioning, and from analytic strategies that were generally quite sophisticated, for example: Bothe et al. [45•] used multi-group structural equation modeling; Vaillancourt-Morel et al. [42] employed cluster analysis; Barrada et al. [46] used a series of analytical procedures from factor analysis to hierarchical regression.On the downside, only three of the five studies included effect sizes. Even more disappointing, two studies did not differentiate effects by sex, so conclusions specific to women were not possible. The use of covariates to determine influencers of the relationship between PPU/compulsivity and sexual functioning was sporadic across studies, although given the various methodological issues, this may be a moot point. Given the paucity of research and lack of differentiation between men and women participants, no clear conclusion regarding an association between PPU/compulsive use and sexual functioning can be drawn with any confidence.
Men
In addition to three studies reported above that included both men and women, six additional studies on PPU/compulsive use and sexual functioning in men were located. For these 9 studies, outcomes were mixed, with some investigations finding negative associations between these two variables, and others reporting none. A variety of covariates were also included in these studies.Six studies on men reported negative associations between PPU and sexual functioning. Bőthe et al. [45•] reported moderate negative associations between PPU and sexual functioning compared with non-PPU men who showed small positive associations. Three other quantitative studies have reported mild negative associations between PPU and sexual functioning. For example, Wery and Billieux [57] studied PPU in over 400 men in Belgium, reporting a moderate association with higher sexual desire but lower erectile functioning in such men compared with non-problematic users. They further reported that use of pornography for mood regulation was moderately-to-strongly associated with problematic use. Whelan and Brown [58] showed a weak association regarding self-perceived internet pornography addiction and lower sexual functioning in 942 men, and Jacobs et al. [26] reported that, in a group of 3400 + men between the ages of 18 and 35, higher problematic pornography use was associated with mild to moderate erectile problems, although the effect size was small.
Two qualitative studies suggested an association between problematic pornography use and erectile problems. Blinka et al. [59] identified individuals who sought treatment for PPU, tracking their developmental processes and cataloging various negative outcomes, among them sexual functioning. However, no systematic or standardized assessment of sexual functioning was included, so neither the pervasiveness nor size of the relationship could be assessed. A second qualitative study [25] explored the relationship between PPU and sexual functioning through a combination of topical life history method and personal online diaries in 11 men experiencing severe erectile problems and who attributed their problem to pornography use. Through retrospective description of their escalating pornography use along with implementation of changes in their pornography viewing habits, some participants experienced benefits in their sexual functioning, leading the authors to argue for a cause-effect relationship between compulsive pornography use and impaired sexual functioning. The in-depth analysis and intervention were strong points, while the use of a highly select clinical population, the lack of exploration of other potential risk factors for impaired sexual response, and the lack of a formal assessment of sexual functioning placed restraints on the study’s conclusions.
Not all studies of men with problematic or compulsive pornography report negative associations with sexual functioning. Berger et al. [41], for example, reported no association between craving for or obsessive passion for pornography use and sexual functioning scores in men, but the authors note that men who preferred masturbation with pornography to partnered sex had a significantly increased risk of sexual dysfunction. However, the numbers for this particular comparison were very small, and no effect sizes were included. Two studies reported under the “Women” section that included men but did not examine them separately reported no negative associations. Specifically, Barrada et al. [46] concluded that men who identified as compulsive users exhibited a number of sex-related differences, such as higher sexual dissatisfaction and higher sexual preoccupation with sex, but they did not show any differences from other groups with respect to sexual functioning. And Vaillancourt-Morel et al. [42] investigated a subgroup of participants having a compulsive user profile (compared to recreational and distressed non-compulsive user profiles) and reported that while compulsive profile users reported higher distress related to pornography use and higher sexual compulsivity, they actually showed slightly better sexual functioning than the other two groups, although no effect size was provided.
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