Medical Examiner

Why Are We Still So Worried About Wat­­ching Porn?

Decades of fearmongering almost got porn addiction added to the International Classification of Diseases. Thankfully, the World Health Organization got it right.

Woman happily watching porn on her laptop.
Photo illustration by Slate. Photo by Thinkstock.

As scientists and clinicians who study sexuality, we are often consulted by journalists about the “symptoms of porn addiction.” Often, it seems like they’re searching for sensational details so that they can better tell you about “8 Signs Your Partner Is Addicted to Porn.” Unsurprisingly, the requests for comment multiply with each new state that passes legislation regulating porn on the basis that it is a public health hazard, likening sex films to cocaine or cigarettes. They want to hear about our dramatic stories of out-of-control patients to better sell their articles to you, the audience.

We are also accustomed to the shock when journalists learn that “pornography addiction” is actually not recognized by any national or international diagnostic manual. With the publication of the latest International Classification of Diseases (version 11) in June, the World Health Organization once again decided not to recognize sex-film viewing as a disorder. “Pornography viewing” was considered for inclusion in the “problematic Internet use” category, but WHO decided against its inclusion because of the lack of available evidence for this disorder. (“Based on the limited current data, it would therefore seem premature to include it in the ICD-11,” the organization wrote.) The common American standard, the Diagnostic and Statistical Manual, made the same decision in their latest version as well; there is no listing for porn addiction in DSM-5.

Panic about pornography rolls around every few decades, from Reagan’s Meese Commission on Pornography swearing that Playboy leads to the downfall of men to David Duke claiming sex films are a Jewish conspiracy to dilute the races. Journalists covering this area have struggled to find good, evidence-based information on the reality of porn addiction, as anti-pornography groups have been well-funded, including by state governments. Scientists and clinicians who present evidence that challenges these harm-focused narratives—and we count ourselves among that group—face serious social and political opposition to their research. It can be tough for this info to make it to the public too. In his series How Not to F*ck Up Your Kids Too Bad, Stephen Marche described his experience as a journalist commissioned by two different outlets to write about the risks of pornography: When he could not find good evidence to demonize porn, “the editors killed it. What they wanted was to be scary.”

There is still a great deal of anti-sex stigma floating around in our culture, so it is not surprising that some porn consumers are worried about their viewing of sex films. Sometimes they worry about how much they watch or about the content they view (can gay porn make me gay?), and very often they worry because their partner, church, or therapist tells them they should not view sex films at all. Many men are told that viewing sex films means they are abusing women (or are likely to in the future), that they are not man enough to find “real” sex, or that they are simply perverts. They are also told that there is an epidemic of erectile dysfunction emerging in young men and that porn is the cause (though actual evidence suggests that there’s not). People are told that porn is toxic to marriages and that viewing it will destroy your sexual appetite.

Amazingly, the first nationally representative peer-reviewed study on sex-film viewing was only just published in 2017 in Australia. This study found that 84 percent of men and 54 percent of women had ever viewed sexual material. Overall, 3.69 percent of men (144 of 3,923) and 0.65 percent of women (28 of 4,218) in the study believed that they were “addicted” to pornography, and only half of this group reported that using pornography had any negative impact on their lives. This was without any clinical interview to assess why they thought they were addicted to porn, which could have ruled out scenarios in which a spouse or church told them that they were addicted when they did not personally hold this view. Distress about sex-film use is a primary criterion for any proposed mental health diagnosis, so these already low numbers may reflect the maximum of who might ever be considered for any diagnosis. Interestingly, even among the minority of users who believe they are “addicted” to pornography, remission may be spontaneous: A study following people over time found that 100 percent of women and 95 percent of men concerned about their frequent sexual behaviors (again, not assessed clinically) no longer felt that they were addicted to sex within five years despite no documented intervention.

But surely sex films are bad for relationships? In a nationally representative Dutch sample, sex-film viewing was unrelated to sexual difficulties in relationships. Similar conclusions can also be drawn from careful laboratory research, which has found that people who are worried about the frequency of their sex-film viewing actually do not struggle with the regulation of their sexual urges nor with their erectile functioning.

However, a core problem with this area of research is that the overwhelming majority of studies are cross-sectional, meaning they just ask about your life as it is now. This means that they cannot show causality. Remember the old “correlation is not causation” principle from science class? If your marriage is not going well or you stopped being intimate years ago, chances are good that someone in that relationship is masturbating to sate their unfulfilled sexual desire. This does not mean that masturbation (or the sex films you watch or the Fifty Shades of Grey hidden on your Kindle) caused your relationship to tank; rather, these coping mechanisms are more likely to be helping to hold your relationship together.

Longitudinal studies following people over time at least show if sex-film viewing occurred before a proposed effect, which is necessary to suggest that sex films caused the effect. For example, one longitudinal study showed that, on average, sex-film viewing increased the risk of relationship loss later. However, another study found that married Americans with the highest frequencies of sex-film use actually were at the lowest risk for losing their relationship (a nonlinear effect). Having a strong brain response to sex films in the lab also predicts a stronger drive to have sex with a partner months later. To date, longitudinal data have not clearly shown that increases in sex-film viewing occur before relationship deterioration.

Experimental studies can demonstrate if porn viewing really causes negative relationship effects by including controls. The first large, preregistered experiment found that viewing sexual pictures did not diminish love or desire for the current romantic partner. In other laboratory research, couples who viewed sex films, whether in the same room or apart, expressed more desire to have sex with that current partner. While one study reported that reducing pornography consumption increased commitment to a partner, no study has yet shown that this was due to the sex films themselves and not some other confounding variable, such as differences in masturbation that resulted from adjusting viewing habits. In our view, there are not yet compelling data to confirm that sexual arousal via sex films always decreases desire for the regular sex partner; certainly, under some conditions, sex films appear to stoke the fire at home.

Even if sex-film viewing has been grossly exaggerated as a national problem, might it still be a problem for some people? Of course, just as there are excellent interventions to help reduce television viewing without invoking mental illness labels, you might want to reduce your sex-film viewing in favor of other activities you value more. Research suggests that cognitive and brain-stimulation approaches might be helpful in reducing sex-film viewing without invoking mental illness. Others have proposed using a new application of psychodynamic and communication-based couples counseling and sex-therapy techniques to reduce overfocus on sex-film consumption. If a member of a couple reduces sex-film viewing without addressing the real issues underlying their concerns (e.g., body image, performance anxiety, selfishness, relationship insecurities), eliminating sex-film viewing resolves nothing. Relatedly, viewing sex films might signal avoidance related to a real mental health concern—for example, viewing sex films might take the place of socializing for someone with major depressive disorder. That doesn’t mean the sex films are to blame, even if the person in question might benefit from a reduction in their viewing.

Of course, there are real concerns about the medium that should be addressed. One concern we share about adult films is that the adult entertainment industry, while regulated like any other legal business, can attract trafficking victims or unscrupulous agents. Another concern we share is that sex education in the U.S. is so poor that younger children may struggle to understand that sex films are fiction, not documentary.

Speaking to the heart of the issue, one of the biggest problems for some porn users is shame. Shame about viewing sex films is heaped on the public by the sex-addiction treatment industry (for profit), by the media (for clickbait), and by religious groups (to regulate sexuality). Unfortunately, whether you believe porn viewing is appropriate or not, stigmatizing sex-film viewing may be contributing to the problem. In fact, an increasing number of studies show that many people who identify as “porn addicted” do not actually view sex films more than other people. They simply feel more shame about their behaviors, which is associated with growing up in a religious or sexually restrictive society. Further, labeling behaviors as a mental disorder is often stigmatizing and harmful in itself, so it should only be done when strongly warranted by evidence. If we really wanted to help such people, one of the most direct ways to do it would be to normalize and validate their sexual desires, including their interest in sex films.

As a related issue, while sex addiction was excluded from the ICD-11, sex was included as a compulsivity disorder in the impulsivity section. It is very important to note that compulsivity is not an umbrella term that includes addiction. Addiction, compulsivity, and impulsivity are all different models with different patterns of response that require different treatments. For example, addiction models predict withdrawal symptoms, but compulsivity models do not predict withdrawal. Impulsivity models predict a strong aversion to delaying decisions or delaying expected pleasure, whereas compulsivity models predict rigid, methodical perseverance. “Sex addiction” was specifically excluded from the ICD-11 for insufficient evidence. This decision is consistent with the opinions of six professional organizations with clinical and research expertise, which also found insufficient evidence to support the idea that sex or porn is addictive.

The decision to include sexual compulsivity in ICD-11 strikes us as odd because the exact diagnostic criteria that were chosen have never been tested. Specifically, the ICD-11 asserts that anyone distressed about their frequent sexual behaviors due purely to “moral judgments and disapproval about sexual impulses, urges, or behaviours” should be excluded from diagnosis. However, moral judgments and disapproval are the strongest predictors of someone believing that they are addicted to pornography in the first place. Further, paraphilias (e.g., voyeurism, exhibitionism) also are supposed to rule out this new diagnosis, which, alone, would reject 60.6 percent of clients currently being treated. Who will be left to receive this new diagnosis if patients are adequately assessed?

More importantly, we have no laboratory studies about actual sexual behaviors in those who report this difficulty. The first study of partnered sexual behaviors in the laboratory, which tests the compulsivity model, is currently under peer review at a scientific journal. (Disclosure: One of this article’s co-authors, Nicole Prause, is the lead author of that study.) The World Health Organization should wait to see if any science supports their novel diagnosis before risking pathologizing millions of healthy people.

In the latest version of the ICD, the World Health Organization has shown surprising restraint in excluding porn addiction and sex addiction—particularly given its history of pathologizing sexuality by including “homosexual behavior” and “nymphomania” in the past. We hope that the WHO exclusions will help to reduce the shame that some people experience around their normal and healthy sexual behaviors. However, it is our view that the WHO also made a risky wager on “compulsive sexuality.” This “disorder” will likely be leveraged by vested parties that wish to continue to stigmatize sexual behaviors, including pornography use, even though it remains unclear if anyone will actually meet the stringent criteria required for this diagnosis. That means it’s still up to us, professionals with actual expertise in sexuality, to continue efforts to educate—and reassure—the public about itself.