Pornography Use and Public Health: Examining the Importance of Online Sexual Behavior in the Health Sciences

In 2020, AJPH published “Should public health professionals consider pornography a public health crisis?” by Nelson and Rothman.¹ The impetus for this work was clear: in the relatively recent past, 17 states have drafted or passed resolutions calling widespread pornography use a public health crisis, with many US politicians taking the position that pornography use is a threat to public health. The reasons for this contention (i.e., that pornography use is a threat to public health) are varied, though proponents of such a position often contend that pornography is a threat to families, impedes brain development in adolescents, affects brain functioning in adults, is inherently addictive, and promotes a wide variety of illegal sexual activities.¹

Through their critical review, Nelson and Rothman’s work clearly demonstrates that such a position is untenable. Most, if not all, of the contentions made by such legislation and resolutions are entirely unsupported by current research, and pornography use does not meet standard criteria associated with threats to public health (i.e., it is not an acute event requiring immediate response; it does not immediately or directly lead to death, morbidity, or adverse health consequences; it does not overwhelm the capacity of local health care systems).¹ In short, such resolutions are wholly unsupported in both their factual claims and general arguments. Moreover, since 2020, no new states have drafted or passed such resolutions, which may be attributable to the rise of a true public health crisis in 2020.

The impact of Nelson and Rothman’s work is both obvious and subtle. Among obvious impacts, their work has been cited widely in a short period of time, generated intense public attention, inspired several op-eds and opinion pieces, and served as a starting point for thousands of conversations via social media (see https://apha.altmetric.com/details/73766659/citations for a summary of the popular media impact of this work). Central to much of this attention has been their conclusion that pornography use is not a public health crisis.

Yet, an equally important implication of the work is overlooked. Nelson and Rothman’s work, while showing that pornography is not a public health crisis, demonstrates that pornography use is a topic to be studied by public health. Whereas some disciplines have largely refused to consider pornography use as a topic relevant for inquiry (e.g., American Psychologist, the flagship journal of the American Psychological Association, has published nothing on the topic for more than 30 years), public health has engaged with this activity substantively. More directly, Nelson and Rothman demonstrate that seeking to understand pornography use and its effects is a valid domain of inquiry for public health and the health sciences more broadly.

THE SCOPE OF PORNOGRAPHY USE IN THE UNITED STATES

Several recent US nationally representative studies indicate that pornography use is a common recreational activity—equivalent with other digitally mediated behaviors (e.g., video games, social media)—with a majority of men and a sizable plurality of women reporting regular use of pornography.^2–4 Similarly, most US adolescents have seen pornography and indicate that their sexual behaviors may be influenced by pornography exposure and frequency of use.⁴

As previous systematic reviews have shown,⁵ there is clear evidence that pornography use, like most sexual behavior, is driven by pleasure-seeking motives. People use pornography to satisfy sexual drive and desire, especially when other sexual options are limited. Not surprisingly, then, for most people, pornography use and concomitant masturbation are normal recreational behaviors that are likely part of a variety of generally healthy sexual behaviors.⁵

The effects of pornography use are mixed.⁶ Use is linked to greater sexual objectification of partners, which may be negative in some circumstances.⁵ However, it is also associated with greater future openness to and engagement in a range of sexual behaviors and to greater sexual experimentation.⁵ In some cases, these links are likely positive (sexual openness being related to greater sexual satisfaction more generally), though there are also associations between pornography use and preferences for or experimentation with more violent and potentially abusive sexual behaviors.⁴ Similarly, pornography use is linked to both higher and lower sexual satisfaction,⁷ depending on the context of use (dyadic vs solitary).⁵ Finally, recent evidence suggests that pornography use is generally unrelated to sexual functioning.⁸ More simply, there is very little evidence that pornography use alone inhibits sexual functioning or performance, though this topic remains hotly debated.⁸ Collectively then, there is limited evidence that pornography use always or even consistently leads to inherently negative outcomes, but, rather, its effects seem variable depending on a range of individual and sociocultural factors.

Despite the general absence of widespread negative effects stemming from pornography use, such is often encountered in mental health treatment settings.⁹ Perhaps the most common reason that practitioners might encounter pornography use as a clinical concern is compulsive use of pornography. Whereas many people use pornography regularly without any reported adverse consequences, there is substantial evidence that pornography use may become out of control, excessive, or impairing for some users.¹⁰ Though there is no psychiatric or mental health diagnosis of “pornography addiction,” many people report that they feel as if they cannot control their pornography use or that their pornography use has caused substantial psychosocial functioning impairments.¹¹

A recent US national sample found that 10.3% of men and 7% of women at least somewhat agree with the statement “I am addicted to pornography”¹² and that between 25% and 30% of the past-year pornography users reported potential issues in regulating their pornography use.¹¹ Moreover, the 11th edition of the International Classification of Diseases (ICD-11) does include a novel diagnosis of compulsive sexual behavior disorder¹³ that may subsume compulsive or excessive pornography use, and there is strong reason to suspect that excessive pornography use will be among the most frequent target behaviors associated with the diagnosis.¹⁴ Not surprisingly, then, pornography use is often a reason for individuals seeking treatment, a target behavior for change in psychotherapy and pharmacotherapy interventions, and a commonly encountered issue by mental health practitioners.^9,15,16

Importantly, there are circumstances wherein pornography use might present as a clinical concern even when it is not deemed excessive or compulsive. For various reasons, people often find the use of pornography to be morally objectionable. However, such condemnation does not always stop people from viewing pornography, and there are now several studies confirming that many people use pornography while still disapproving of it.^17,18 The use of pornography while morally disapproving of pornography gives rise to what past work has labeled moral incongruence. A number of US studies show that, in some circumstances, moral disapproval of pornography amplifies links between use and self-reported addiction,¹⁹ and the use of pornography among those who find it morally wrong is also linked to a greater incidence of depression, lower levels of happiness, lower levels of sexual satisfaction, and greater general distress.^17,18 Ultimately, these effects of moral incongruence have led researchers and clinicians to caution about the importance of accurately assessing the reasons behind someone’s decision to seek treatment of problematic pornography use.^14,15

WHERE DO WE GO FROM HERE?

As Nelson and Rothman’s work clearly demonstrates, pornography use is a valid domain of scientific and health-related research. Yet, given the relative novelty of this research domain, particularly in public health and allied fields, there is a need for systematic approaches to understanding this behavior and its effects. Accordingly, here we lay out a series of recommendations for how public health and allied fields might systematically seek to understand pornography use and its effects.

First, we contend that a key aspect to promoting a better understanding of pornography use and its effects is a change in basic assumptions about what behaviors and domains of human functioning are considered rigorous scientific pursuits by the health sciences. Sexual health research has faced stigma in numerous domains,²⁰ and scientists and health professionals researching such topics are often perceived as unserious or strange.^21,22 Indeed, the recommendations that follow from this point all, in some way or another, presuppose a recognition of research about pornography use and its effects as valid domains of scientific and public health inquiry.

Second, we recommend increased efforts to ensure clinical competence in recognizing, assessing, and treating pornography-related concerns. Such a recommendation is especially salient given the inclusion of compulsive sexual behavior disorder in the ICD-11, which may be applied in cases of excessive pornography use.¹³ In short, we need better clinical training for mental health clinicians in recognizing both problematic pornography use and normal pornography use. To address this need, national societies and associations, state and regional licensing boards, and specialty organizations are poised to effect immediate change. Among most health and educational professions, continuing education is a mandatory component of ongoing licensure, providing unique and constantly available opportunities to increase clinical competence in these areas.

Given the frequency with which practitioners already encounter pornography use in clinical settings, it is likely that many health professionals already discuss pornography use with their clients. However, as is the case with many sexual behaviors, particularly those that are stigmatized likely because of social mores or traditional sexual values, many clients may feel uncomfortable volunteering information about their pornography use or disclosing sexual preferences. Given such qualms, we recommend that tactful but direct assessments of pornography use be incorporated in normal health screenings as they may provide an opportunity for people to disclose concerns that may have otherwise gone unmentioned. Currently, several measures have been validated in clinical and nonclinical populations, which we have cited throughout this document.^11,14 Akin to alcohol and substance use disorders, routine screening for problematic pornography use would hold many advantages for addressing co-occurring mental health issues among treatment-seeking clients and normalize querying pornography use and other sexual behaviors as a standard part of health care.

Third, we need improved sexual education related to pornography use for both adolescents and the public at large. As previous works have clearly demonstrated, many people use pornography for sexual education purposes.²³ Yet, there is little sexual education material that directly addresses pornography use itself.²⁴ For many people, particularly adolescents and young adults (aged 18–25 years), it seems that pornography is often functioning as a form of sexual education rather than a topic addressed by comprehensive sexual education. This represents a failing of US sexual education more broadly, as pornography alone is likely not the best or most accurate means of educating oneself about sex or the health risks associated with specific behaviors (e.g., condomless sex). Accordingly, there is a clear need for incorporation of pornography use and pornography-related behaviors into standard, comprehensive sexual education materials during adolescence and in more general sexual health recommendations for the public.

Building on this, given the widespread use of smartphones among US adolescents (95%) and the few safeguards set in place to restrict access to pornography use for adolescents, further work is needed to examine the role of pornography in sexual script formulations on its viewers. Such a need is even more apparent given recent work suggesting that increased pornography consumption is associated with decreased condom use among US adults.³ Though the links between pornography viewing and condomless sex are less clear in adolescent populations, adolescents are regularly viewing pornography that depicts condomless sex. This speaks to a potential need for limited access to pornography for minors (those younger than 18 years in the United States). One possible means of accomplishing such an aim could be age verification software for pornographic Web sites, like those used in the United States and abroad as a means of restricting access to Web sites that offer gambling, alcohol, and cannabis products.

Fourth, as pornography use is a common and perhaps normal part of modern sexuality, we recommend the consistent integration of pornography use measures into mainstream public health and allied professional research. A simple means of accomplishing this is the regular inclusion of basic questions about the frequency and recency of pornography use in new and ongoing research projects and national surveys for which pornography use might be of relevance. This inclusion of such materials is likely especially relevant for public health research related to sexual behaviors in general, sexual health broadly (including sexually transmitted infections), addictions and addictive behaviors, and relationships. Furthermore, we recommend that researchers begin to use a standardized set of questions when assessing the frequency and recency of pornography use as a means of increasing greater generalizability across studies. An example of such items is available in Appendix A (available as a supplement to the online version of this article at https://ajph.org).

Ultimately, these recommendations demonstrate a need for new funding mechanisms for pornography-related research across disciplines. As previous works have pointed out,⁶ it is simply impossible for the scientific and health community to fully understand the effects of pornography without adequate funding. Yet, at present, bills drafted by various states decrying pornography as a public health crisis have not resulted in any substantive funding increases for pornography research. More bluntly, despite widely professed concerns about pornography use, legislatures seem unwilling to put forth the money to support robust research efforts in this domain.

Without established funding priorities for pornography-related research from relatively unbiased agencies, a compromised research agenda could be established, particularly if partisan or ideologically motivated actors were to initiate funding in this domain. The result of biased actors filling the gap left by more traditional scientific funding agencies would likely be a flood of research born from ideology, absent of objectivity and oriented toward predetermined conclusions. Admittedly, pornography use does not currently neatly fit within the research domain criteria for the National Institute of Mental Health, nor does it explicitly comport with the priorities of most US federal funding agencies. Even so, as we have noted throughout this piece, pornography use is clearly salient to public health and allied disciplines, and, thus, it should be funded as such.

CONCLUSIONS

Pornography use is common, and Nelson and Rothman’s influential work in AJPH clearly demonstrates that, although pornography may not be a public health crisis, this behavior is a salient concern for the field of public health and the health sciences more broadly. All available evidence suggests that pornography is and will continue to be a normal aspect of human sexuality, and, as such, it should be studied rigorously across the behavioral and health sciences.

Based on this, there is a clear and present need for the health sciences and allied professions to

• 1.designate pornography use an area in need of rigorous academic inquiry;
• 2.enhance training opportunities for clinicians and professionals who might encounter pornography use in their practice;
• 3.incorporate pornography use in comprehensive sexual education materials for adolescents and in public health outreach and messaging campaigns around sexual behavior;
• 4.include questions related to pornography use in ongoing and future research related to sexual behaviors, addiction, sexual health, and relationships; and
• 5.increase public funding for pornography-related research.

Until these recommendations are met, it is likely that the true public health implications of pornography use will remain poorly understood, despite the clear relevance of the topic to the health sciences.