© Springer International Publishing AG, part of Springer Nature 2018
E. A. Jannini, A. Siracusano (eds.), Sexual Dysfunctions in Mentally Ill Patients,
Trends in Andrology and Sexual Medicine, https://doi.org/10.1007/978-3-319-68306-5_15
D. Mollaioli (*) · E. A. Jannini
Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
e-mail: email@example.com; firstname.lastname@example.org
A. Sansone · F. Romanelli
Department of Experimental Medicine, University of Rome Sapienza, Rome, Italy
Sexual Dysfunctions intheInternet Era
DanieleMollaioli, AndreaSansone, FrancescoRomanelli,
Low sexual desire, reduced satisfaction in sexual intercourse, and erectile dysfunction
(ED) are increasingly common in young population. In an Italian study from 2013, up
to 25% of subjects suffering from ED were under the age of 40 , and in a similar study
published in 2014, more than half of Canadian sexually experienced men between the
age of 16 and 21 suffered from some kind of sexual disorder . At the same time,
prevalence of unhealthy lifestyles associated with organic ED has not changed signi-
cantly or has decreased in the last decades, suggesting that psychogenic ED is on the rise
. The DSM-IV-TR denes some behaviors with hedonic qualities, such as gambling,
shopping, sexual behaviors, Internet use, and video game use, as “impulse control disor-
ders not elsewhere classied”—although these are often described as behavioral addic-
tions . Recent investigation has suggested the role of behavioral addiction in sexual
dysfunctions: alterations in neurobiological pathways involved in sexual response might
be a consequence of repeated, supernormal stimuli of various origins.
15.2 Online Pornography andSexual Dysfunctions
Among behavioral addictions, problematic Internet use and online pornography
consumption are often cited as possible risk factors for sexual dysfunction, often
without denite boundary between the two phenomena [5, 6]. Since 2007, mounting
evidence has suggested that Internet pornography might be a risk factor for sexual
dysfunctions, including low libido and impaired erectile and orgasmic functions .
Case series have provided the rst hints in these regards; however, more solid evi-
dence has emerged from longitudinal studies in married couples. Pornography con-
sumption has been considered one of the strongest predictors of poor marital quality
—and, therefore, of poor sexual health. Studies aimed to directly assess the role
of Internet pornography use and male sexual dysfunction have described an associa-
tion between the two phenomena [9, 10]. Sexual dysfunctions typically manifest in
physical relationships with women and more rarely in relation to sexually explicit
material; unsurprisingly, abstinence from “cybersex” and from masturbation has
been proposed as a treatment, although evidence in support is still lacking.
Sexually explicit material is widely available on the Internet, often at no cost and
virtually without any controls for age, therefore providing a plausible reason for the
rapid increase in a condition most frequently associated with aging. It should come as
no surprise that pornography is the most common among the chief reasons for compul-
sive Internet use  and that cybersex is the third largest economic sector on the
Internet. Besides being freely available, Internet pornography features a seemingly end-
less supply of contents, providing novelty and freedom of choice: in these regards, it is
signicantly different from printed material, as any user is able to quickly access new
videos and scenes, or even genres. In short, users are attracted to Internet pornography
because of its anonymity, affordability, and accessibility—the “Triple A Engine” .
The extreme ease in nding the adult material is also accompanied by a strict cate-
gorical organization of porn videos: alongside the giants of porn online such as
Pornhub, YouPorn, and RedTube, there are a whole series of smaller sites that aggre-
gate videos, categorizing them by type of sexual act, the age of the actors, the video
quality (amateur or professional), the sexual orientation, and the body and sexual pref-
erences. This categorization has generated a sort of a constantly evolving encyclopedia
of porn, directing the user toward increasingly specic and rened tastes (Table15.1).
Table 15.1 Most researched porn categories
Amateur Amputee Anal Animal
Asian Babe Bareback BBW
BDSM Big Ass Bisexual Bizarre
Black/ebony Blowjob Bondage Bukkake
Casting Cheating Cheerleaders Creampie
Cuckold Deepthroat Dildo Doggy style
Double penetration Exhibitionist Extreme Facial
Feet FemDom Fetish Fisting
Gangbang Gay Gloryhole Granny
Group Hairy Handjob Hardcore
Hentai Homemade Interracial Ladyboy
Latin Lesbian Lingerie Lolita
Massage Mature Masturbating/solo Masturbation
Mature Menstrual Midget Milf/mom
Oral Sex Orgy Pantyhose/Stockings Pissing
POV (Point of View) Pregnant Public Reality
Schoolgirl Shaving Shemale Skinny
Slave Small tits Smoking Solo
Squirt Squirting Straight Submale
Sucking Teens Threesome Torture
Transsexual Upskirt Vampire Vintage
Vintage Voyeur Wet Young
D. Mollaioli et al.
Internet pornography use shares many similarities with substance addiction
, such as the activation of the same reward circuitry in the basolateral amyg-
dala, the anterior cingulate area, and the nucleus accumbens . Upregulation
of the truncated splice variants (ΔFosB) of the Finkel-Biskis-Jinkins (FBJ)
murine osteosarcoma viral oncogene homolog B (FosB) in the nucleus accum-
bens has been observed following both sexual stimuli and substance abuse; over-
expression of the ΔFosB is necessary and sufcient for many of the neural
adaptations commonly observed in addiction. This process allows hypersensiti-
zation to stimuli while possibly facilitating compulsive behaviors. Internet por-
nography use triggers dopamine bursts in the reward circuitry of the brain, which
increase the sense of well-being associated with masturbation while at the same
providing the neurobiological grounds for addiction; not all subjects respond to
external stimuli in the same way, but those who are predisposed to harmful or
obsessive behaviors are more likely to become addicted to pornography. Users
are more likely to forget the “evolutionary” role of sex, nding more excitement
in self-selected sexually explicit material than in intercourse: sexual condition-
ing might be the missing link between the impaired sexual function during part-
nered sexual interactions and the increased arousal coming from Internet adult
movies . Failure to meet sexual expectations, together with the inability to
obtain more stimulation by a simple “click”, may lead to a decline in dopamine
in the mesolimbic pathway, ultimately resulting in loss of interest for intercourse
and sexual dysfunction.
The increase in the vision of online pornographic content has developed a still
unsolved debate among scientists about the negative and positive effects of viewing
pornography on the users.
15.3 Negative Aspects ofPornography onSexual Quality
From a negativistic perspective, the increased access to online pornography has
been accompanied by growing concerns that may negatively affect personal, sexual,
and relational health and well-being [16, 17]. The cybersex addiction represents the
most frequent form between all the Internet addictions [16, 18].
The main feature of porn addiction is the compulsive pursuit of sexual pleasure
that the user tries to achieve when masturbating through the viewing of adult con-
tent. Individuals suffering from porn addiction are completely absorbed by their
stereotyped sexual practices: the interest is directed exclusively to nd the most
self-suitable porn content, dedicating up to several hours in researching, viewing,
and classifying the erotic material; the sexual behavior is characterized by compul-
sive masturbation, with the intention of reaching ejaculation (one or more times) to
relieve sexual tension .
Sutton etal. found that men affected by hypersexual behavior and compulsive
masturbation in association with frequent pornography use, presented also sexual
dysfunctions, reporting mostly difculties reaching orgasm during sexual inter-
course . Anxiety about sexual performance may impel further reliance on por-
nography as a sexual outlet .
15 Sexual Dysfunctions intheInternet Era
In these people the addictive consumption of pornographic material worsens sex-
ual health with a progressive interruption of sexual intimacy with the partner [21, 22].
Several studies have reported that porn addiction can negatively impact on atti-
tudes and sexual life, diminishing satisfaction and increasing cases of indelity and
occasional relationships with different partners[16–20]. It could also contribute to
an early debut of sexual activity in adolescence, exposing teens to an experience of
sexual “failure” that over time could evolve to a sexual dysfunction, like loss of
libido, erectile dysfunction (ED) and premature ejaculation (PE) for men, and prob-
lems in sexual desire and orgasm in women [21, 22].
Moreover, porn movies rarely contemplate the condom use, giving a negative
message especially among young viewers about the right ways to approach to sexu-
ality, with a potential increased risk of sexually transmitted diseases (STD) .
The severity of the effects seems to be correlated with the years of use: males
who started using cybersex at a younger age are less likely to prefer partnered sex.
The effects of sexual conditioning have similarly been described regarding risky
sexual behaviors: subjects accustomed to more extreme videos are more frequently
involved in similar acts, such as unprotected anal intercourse. It is likely, although
yet unproven, that precocious exposure to pornography might have deleterious
effects on sexual development during puberty: this is alarming, considering that
Internet pornography use is increasingly accepted as an ordinary behavior .
Although this aspect is poorly studied, several studies report that pornography,
especially the violent one, reproduces negative feminine and masculine models in
which woman is represented only as a “puppet” under the man control, emphasizing
psychological, physical, and sexual violence toward women [17, 22].
15.4 Positive Aspects ofPornography onSexual Quality ofLife
Although it is a common opinion that cybersex addiction can generate negative
outcomes from both psychological and sexual, more and more researchers point out
that pornography could also be an important therapeutic instrumental in sexological
treatments [24–26]. According to some studies, the vision of pornographic material
would act by improving the sexual fantasies through normalization and facilitating
the willingness to explore them [24, 27]. Pornography in some respects could even
improve the sexual life of men and women by reducing the feeling of unease about
sex and encouraging sexual expression .
For example, it could be used in an early phase of psychoeducation for male and
female sexuality, at a later stage of treatment (e.g., in the case of female hypoactive
sexual desire), or in couple therapy [24–27]. In favor of this perspective, it has been
highlighted that the viewing porn by women improves their sexual satisfaction in
real life as well as being a useful way to better investigate the eld of female sexual-
Pornography could be a valuable aid in the sexual eld for people with disabili-
ties and those who have some dysfunction with a strong anxious component since it
has been seen that pornography acts on the dysfunction through a reduction of anxi-
ety associated with sexual activity .
D. Mollaioli et al.
Finally, online pornography lends itself very efciently to frequency studies [28, 29].
Although there is no certainty about gender and psychopathological conditions at the
base of network access, online porn allows to evaluate a very large population, classify-
ing subjects according to specic and well-dened sexual interests, from the most trivial
to the rarest (Table15.1), so as to build tables of frequency otherwise not compiled.
15.5 Sexual Dysfunctions andOther Behavioral Addiction
Gaming is closely associated with cybersex as both are potentially addicting media.
Given the widespread availability of gaming devices, including tablets, smart-
phones, and laptops, video games reach all ages, genders, and demographics ;
for many people, playing is a means for connecting with other players or for escap-
ing from the boredom of everyday life. However, excessive use of video games
might have serious consequences for everyday life: players might be more con-
cerned with the game than with routine activities, including personal hygiene, work,
and social interaction. On this basis, despite the small prevalence of health issues
related to gaming, the American Psychiatric Association has suggested that video
game addiction might be worth investigating and has thus led Internet gaming
disorder as a “condition requiring further study” in the DSM 5.
Video game addiction, being a relatively novel issue, is still mostly unknown in
regards to both its pathogenesis and its evolution. Although overexpression of ΔFosB
has not been documented in gamers, several mechanisms might provide an explana-
tion for the addictive nature of gaming . Compulsion loops, i.e., designed chains
of activities that will be repeated to gain a neurochemical reward (such as dopamine
release), are among often used by designers in order to keep players attached to the
game (“grinding”); a similar phenomenon (“chasing losses”) has been described in
gambling, as the player will keep playing in the often unlikely event of winning. Brain
functional changes have been discovered via PET imaging in Internet gaming addic-
tion , suggesting that loss of control and similar compulsive behaviors observed in
gamers might be associated with dysregulation in D2 receptors and glucose metabo-
lism. Downregulation and reduced expression of D2 receptors have both been associ-
ated with erectile dysfunction and reduced libido, therefore suggesting that excessive
use of gaming might have negative effects on sexual health. However, at the present
time, there is little evidence suggesting a causative association between gaming and
sexual dysfunction; some authors have in fact suggested that video game addiction
might be a consequence of other mental issues, rather than a risk factor per se .
To the present date, no studies have adequately addressed whether Internet and
video game use should be considered risk factors for sexual dysfunction or if there
are “threshold” values for their consumption; likewise, little is known regarding
individual response to these stressors. The only study assessing the impact of video-
games on male sexual health has found a signicantly reduced prevalence of prema-
ture ejaculation among gamers, together with reduced sexual desire . These
ndings, however, are far from conclusive and deserve further validation. Genetic
bases for addiction have been recently described  and might be involved in the
pathogenesis of sexual dysfunctions.
15 Sexual Dysfunctions intheInternet Era
15.6 Internet-Based Therapy forSexual Dysfunctions
The use of the Internet as a clinical intervention space for male and female sexual
dysfunction has a relatively short history. Above all in recent years, the use of the
Internet in clinical practice has proved effective in resolving certain psychopatholo-
gies, such as anxiety and depressive disorders [36–38]. To a lesser extent, these
interventions have also become available in the treatment of sexual dysfunction.
The network tool has advantages over face-to-face contact :
• It can guarantee anonymity in the initial phases of the intervention, allowing many
individuals to face the problem without fear of being judged or discovered.
• No need for a coexistence of the patient and the doctor in the same space or time.
The asynchronous nature of the contact between client and therapist can in some
cases be a valuable service for those who have difculty attending face-to-face
meetings due to physical or geographical constraints or for reasons related to
• Clinical treatment is followed daily directly in the real-life environment, skip-
ping the stage where improvements are only present during the therapy session.
• The patient may feel more active and responsible in therapy, attributing to him-
self and not to the doctor any improvements in sexual functioning, resulting in
Although the use of Internet therapy as a potential treatment for sexual dysfunc-
tion has often been encouraged [40–42], only few scientic contributions are sur-
prisingly present in the literature. Most of the studies describing the results of online
sexual therapy are without a control sample [43–45].
Among these, one of the most famous online programs in the eld of sexology is
“Sexpert.” Although initial research has shown promising positive effects of the use
of “Sexpert” in the modication of sexual behavior, the results have never been
Internet-based therapy is founded on the theoretical models of psychopathology
and sexual dysfunction [38, 39]. Usually, online interventions are organized in a
website, containing informative material and individual and couple exercises, struc-
tured in a temporal way. In addition, one or more contacts with a sexual health
professional are also provided.
Studies on the Internet-based sexual therapy (IBST) for male erectile dysfunc-
tion suggest substantial equality in treatment efcacy compared to face-to-face
therapies [26, 44, 47, 48].
In the study, men with ED treated with IBST reported improvements (similar to
waiting list group) on erectile function, sexual desire, sexual satisfaction, and self-
condence between pretreatment and posttreatment and were to be largely main-
tained until 3 and 6months after treatment termination  (Fig.15.1a).
Similarly, men with PE and treated with IBST reported improvements in ejacula-
tory control, sexual desire, and satisfaction between pretreatment and posttreatment
and were maintained until 6months follow-up  (Fig.15.1b).
D. Mollaioli et al.
Overall sexual satisfaction
Overall sexual satisfaction
Fig. 15.1 (a) Sexual
follow-up assessment at 3
participants with ED
(means±SEM) . (b)
Sexual functioning at
follow-up assessment at 3
participants with PE
15 Sexual Dysfunctions intheInternet Era
In the studies investigating IBST for female sexual dysfunctions, we found simi-
lar results of male studies.
In these studies [49–51], improvements were reported after posttreatment in
sexual functioning, intimacy, and relational quality of life (with better communica-
tion and emotional intimacy). Posttreatment gains regarding sexual and relational
functioning were generally maintained until follow-up assessment [49, 51].
Curiously, no signicant improvements were reported in anxiety or mood :
this is because these interventions are extremely focused on targeted problem areas,
such as sexual and relational.
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