Sexual Dysfunctions in the Internet Era

Abstract

Among behavioral addictions, problematic Internet use and online pornography consumption are often cited as possible risk factors for sexual dysfunction, often with no definite boundary between the two phenomena. Online users are attracted to Internet pornography because of its anonymity, affordability, and accessibility, and in many cases its usage could lead users through a cybersex addiction: in these cases, users are more likely to forget the “evolutionary” role of sex, finding more excitement in self-selected sexually explicit material than in intercourse.

Full text

163
© 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: daniele.mollaioli@gmail.com; eajannini@gmail.com
A. Sansone · F. Romanelli
Department of Experimental Medicine, University of Rome Sapienza, Rome, Italy
15
Sexual Dysfunctions intheInternet Era
DanieleMollaioli, AndreaSansone, FrancescoRomanelli,
andEmmanueleA.Jannini
15.1 Introduction
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 [1], 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 [2]. 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
[3]. The DSM-IV-TR denes some behaviors with hedonic qualities, such as gambling,
shopping, sexual behaviors, Internet use, and video game use, as “impulse control disor-
ders not elsewhere classied”—although these are often described as behavioral addic-
tions [4]. 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 andSexual Dysfunctions
Among behavioral addictions, problematic Internet use and online pornography
consumption are often cited as possible risk factors for sexual dysfunction, often
without denite boundary between the two phenomena [5, 6]. Since 2007, mounting

164
evidence has suggested that Internet pornography might be a risk factor for sexual
dysfunctions, including low libido and impaired erectile and orgasmic functions [7].
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
[8]—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 [11] 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
signicantly 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” [12].
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 specic and rened tastes (Table15.1).
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.

165
Internet pornography use shares many similarities with substance addiction
[13], such as the activation of the same reward circuitry in the basolateral amyg-
dala, the anterior cingulate area, and the nucleus accumbens [14]. 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 sufcient 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 [15]. 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 ofPornography onSexual Quality
ofLife
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 [10].
Sutton etal. found that men affected by hypersexual behavior and compulsive
masturbation in association with frequent pornography use, presented also sexual
dysfunctions, reporting mostly difculties reaching orgasm during sexual inter-
course [19]. Anxiety about sexual performance may impel further reliance on por-
nography as a sexual outlet [20].
15 Sexual Dysfunctions intheInternet Era

166
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 indelity 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) [17].
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 [23].
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 ofPornography onSexual Quality ofLife
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 [28].
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-
ity [24–27].
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 [11].
D. Mollaioli et al.

167
Finally, online pornography lends itself very efciently 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 specic and well-dened sexual interests, from the most trivial
to the rarest (Table15.1), so as to build tables of frequency otherwise not compiled.
15.5 Sexual Dysfunctions andOther 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 [30];
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 [31]. 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 [32], 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 [33].
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 signicantly reduced prevalence of prema-
ture ejaculation among gamers, together with reduced sexual desire [34]. These
ndings, however, are far from conclusive and deserve further validation. Genetic
bases for addiction have been recently described [35] and might be involved in the
pathogenesis of sexual dysfunctions.
15 Sexual Dysfunctions intheInternet Era

168
15.6 Internet-Based Therapy forSexual 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 [39]:
• 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 difculty attending face-to-face
meetings due to physical or geographical constraints or for reasons related to
work.
• 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
increased self-esteem.
Although the use of Internet therapy as a potential treatment for sexual dysfunc-
tion has often been encouraged [40–42], only few scientic 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 modication of sexual behavior, the results have never been
published [46].
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 efcacy 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-
condence between pretreatment and posttreatment and were to be largely main-
tained until 3 and 6months after treatment termination [26] (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 6months follow-up [26] (Fig.15.1b).
D. Mollaioli et al.

169
25
20
15
10
25
20
15
10
10
8
6
4
10
8
6
4
Pre-
treatment
Pre-
treatment
Erectile functioning
Premature ejaculation
Sexual desire
Sexual desire
Sexual self-confidence
Sexual self-confidence
Overall sexual satisfaction
Overall sexual satisfaction
Post-
treatment
Post-
treatment
Follow-up 3
month
Follow-up 3
month
Follow-up 6
month
Follow-up 6
month
a
b
Fig. 15.1 (a) Sexual
functioning at
pretreatment,
posttreatment, and
follow-up assessment at 3
and 6months
posttreatment in
participants with ED
(means±SEM) [26]. (b)
Sexual functioning at
pretreatment,
posttreatment, and
follow-up assessment at 3
and 6months
posttreatment in
participants with PE
(means±SEM) [26]
15 Sexual Dysfunctions intheInternet Era

170
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 signicant improvements were reported in anxiety or mood [50]:
this is because these interventions are extremely focused on targeted problem areas,
such as sexual and relational.
References
1. Capogrosso P, Colicchia M, Ventimiglia E, Castagna G, Clementi MC, Suardi N, etal. One
patient out of four with newly diagnosed erectile dysfunction is a young man– worrisome
picture from the everyday clinical practice. J Sex Med. 2013;10:1833–41.
2. O’Sullivan LF, Brotto LA, Byers ES, Majerovich JA, Wuest JA.Prevalence and characteristics
of sexual functioning among sexually experienced middle to late adolescents. J Sex Med.
2014;11:630–41.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders:
DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000.
4. McCabe MP, Sharlip ID, Lewis R, Atalla E, Balon R, Fisher AD, etal. Incidence and prev-
alence of sexual dysfunction in women and men: a consensus statement from the Fourth
International Consultation on Sexual Medicine 2015. J Sex Med. 2016;13:144–52.
5. Grubbs JB, Stauner N, Exline JJ, Pargament KI, Lindberg MJ.Perceived addiction to Internet
pornography and psychological distress: examining relationships concurrently and over time.
Psychol Addict Behav. 2015;29(4):1056–67.
6. Ross MW, Mansson SA, Daneback K.Prevalence, severity, and correlates of problematic sex-
ual Internet use in Swedish men and women. Arch Sex Behav. 2012;41:459–66.
7. Landripet I, Stulhofer A.Is pornography use associated with sexual difculties and dysfunc-
tions among younger heterosexual men? J Sex Med. 2015;12:1136–9.
8. Perry SL.Does viewing pornography reduce marital quality over time? Evidence from longi-
tudinal data. Arch Sex Behav. 2017;46(2):549–59.
9. Garcia-Cruz E, Romero-Otero J, Fode M, Alcaraz A. The digital environment in men’s sexual
disorders: a systematic review. Actas Urol Esp. 2017; pii: S0210–4806(17)30177–8.
10. Blais-Lecours S, Vaillancourt-Morel MP, Sabourin S, Godbout N. Cyberpornography: time
use, perceived addiction, sexual functioning, and sexual satisfaction. Cyberpsychol Behav Soc
Netw. 2016;19(11):649–55.
11. Southern S. Treatment of compulsive cybersex behavior. Psychiatr Clin North Am.
2008;31(4):697–712.
12. Cooper A.Sexuality and the internet: surng into the new millennium. Cyberpsychol Behav.
1998;1:181–7.
13. Zou Z, Wang H, d’Oleire Uquillas F, Wang X, Ding J, Chen H.Denition of substance and
non-substance addiction. Adv Exp Med Biol. 2017;1010:21–41.
14. Rufe JK.Molecular neurobiology of addiction: what’s all the (Delta)FosB about? Am J Drug
Alcohol Abuse. 2014;40:428–37.
15. Brom M, Both S, Laan E, Everaerd W, Spinhoven P. The role of conditioning, learning and
dopamine in sexual behavior: a narrative review of animal and human studies. Neurosci
Biobehav Rev. 2014;38:38–59.
16. Doring MN.The Internet’s impact on sexuality. A critical review of 15 years of research.
Comput Hum Behav. 2009;25:1089–101.
D. Mollaioli et al.

171
17. Lim MS, Carrotte ER, Hellard ME.The impact of pornography on gender-based violence, sex-
ual health and well-being. What do we know? J Epidemiol Community Health. 2016;70:3–5.
18. Laier C, Pawlikowski M, Pekal J, Schulte FP, Brand M.Cybersex addiction. Experienced
sexual arousal when watching pornography and not real-life sexual contacts makes the differ-
ence. J Behav Addict. 2013;2:100–7.
19. Sutton KS, Stratton N, Pytyck J, Kolla NJ, Cantor JM.Patient characteristics by type of hyper-
sexuality referral: a quantitative chart review of 115 consecutive male cases. J Sex Marital
Ther. 2015;41:563–80.
20. Castellini G, Fanni E, Corona G, Maseroli E, Ricca V, Maggi M. Psychological, relational,
and biological correlates of ego-dystonic masturbation in a clinical setting. Sex Med.
2016;4:e156–65.
21. Braithwaite SR, Coulson G, Keddington K, Fincham FD.The inuence of pornography on
sexual scripts among emerging adults in college. Arch Sex Behav. 2015;44:111–23.
22. Fisher WA, Kohut T, Di Gioacchino LA, Fedoroff P.Pornography, sex crime, and paraphilia.
Curr Psychiatry Rep. 2013;15:362.
23. Park BY, Wilson G, Berger J, Christman M, Reina B, Bishop F, etal. Is Internet pornography
causing sexual dysfunctions? A review with clinical reports. Behav Sci (Basel). 2016;6(3):17.
24. Jannini EA, Limoncin E, Ciocca G, Buehler S, Krychman M.Ethical aspects of sexual medi-
cine. Internet, vibrators, and other sex aids: toys or therapeutic instruments? J Sex Med.
2012;9:2994–3001.
25. van Lankveld JJ. Internet-based interventions for women’s sexual dysfunction. Curr Sex
Health Rep. 2016;8:136–43.
26. van Lankveld JJ, Leusink P, van Diest S, Gijs L, Slob AK.Internet-based brief sex therapy for
heterosexual men with sexual dysfunctions: a randomized controlled pilot trial. J Sex Med.
2009;6:2224–36.
27. Daneback K, Sevcikova A, Månsson SA, Ross MW.Outcomes of using the Internet for sexual
purposes: fullment of sexual desires. Sex Health. 2013;10:26–31.
28. Weinberg MS, Williams CJ, Kleiner S, Irizarry Y.Pornography, normalization and empower-
ment. Arch Sex Behav. 2010;39:1389–401.
29. Scorolli C, Ghirlanda S, Enquist M, Zattoni S, Jannini EA. Relative prevalence of different
fetishes. Int J Impot Res. 2007;19:432–7.
30. Naskar S, Victor R, Nath K, Sengupta C. “One level more:” a narrative review on internet gam-
ing disorder. Ind Psychiatry J. 2016;25:145–54.
31. Palaus M, Marron EM, Viejo-Sobera R, Redolar-Ripoll D.Neural basis of video gaming: a
systematic review. Front Hum Neurosci. 2017;11:248.
32. Tian M, Chen Q, Zhang Y, Du F, Hou H, Chao F, etal. PET imaging reveals brain functional
changes in internet gaming disorder. Eur J Nucl Med Mol Imaging. 2014;41:1388–97.
33. Dong G, Li H, Wang L, Potenza MN.Cognitive control and reward/loss processing in Internet
gaming disorder: results from a comparison with recreational Internet game-users. Eur
Psychiatry. 2017;44:30–8.
34. Sansone A, Sansone M, Proietti M, Ciocca G, Lenzi A, Jannini EA, etal. Relationship between
use of videogames and sexual health in adult males. J Sex Med. 2017;14:898–903.
35. Ducci F, Goldman D.The genetic basis of addictive disorders. Psychiatr Clin North Am.
2012;35:495–519.
36. Emmelkamp PM, David D, Beckers T, Muris P, Cuijpers P, Lutz W, et al. Advancing psy-
chotherapy and evidence-based psychological interventions. Int J Methods Psychiatr Res.
2014;23:58–91.
37. Månsson KNT, Skagius Ruiz E, Gervind E, Dahlin M, Andersson G.Development and initial
evaluation of an internet-based support system for face-to-face cognitive behavior therapy: a
proof of concept study. J Med Internet Res. 2013;15:220–33.
38. Palmqvist B, Carlbring P, Andersson G.Internet-delivered treatments with or without therapist
input: does the therapist factor have implications for efcacy and cost? Exp Rev Pharmacoecon
Outcomes Res. 2007;7:291–7.
15 Sexual Dysfunctions intheInternet Era

172
39. Andersson G, Titov N.Advantages and limitations of internet-based interventions for common
mental disorders. World Psychiatry. 2014;13:4–11.
40. Cooper A, Scherer C, Mathy RM.Overcoming methodological concerns in the investigation of
online sexual activities. Cyberpsychol Behav. 2001;4:437–47.
41. Grifn-Shelley E. The Internet and sexuality: a literature review 1983–2002. Sex Relation
Ther. 2003;18:355–70.
42. Leiblum SR.Women, sex and the Internet. Sex Relation Ther. 2001;16:389–405.
43. Hall P.Online psychosexual therapy: a summary of pilot study ndings. Sex Relation Ther.
2004;19:167–78.
44. Van Diest SL, Van Lankveld JJDM, Leusink PM, Slob AK, Gijs L.Sex therapy through the
Internet for men with sexual dysfunctions: a pilot study. J Sex Marital Ther. 2007;33:115–33.
45. Abdo CH, Af-Abdo J, Otani F, Machado AC.Sexual satisfaction among patients with erectile
dysfunction treated with counseling, sildenal, or both. J Sex Med. 2008;5:1720–6.
46. Strecher V. Internet methods for delivering behavioral and health-related interventions
(eHealth). Annu Rev Clin Psychol. 2007;3:53–76.
47. McCabe MP, Price E, Piterman L, Lording D.Evaluation of an Internet-based psychological
intervention for the treatment of erectile dysfunction. Int J Impot Res. 2008;20:324–30.
48. McCabe M, Price E.Internet-based psychological and oral medical treatment compared to
psychological treatment alone for ED.J Sex Med. 2008;5:2338–46.
49. Hucker A, McCabe MP.An online, mindfulness-based, cognitive-behavioral therapy for female
sexual difculties: impact on relationship functioning. J Sex Marital Ther. 2014;40:561–76.
50. Hummel SB, van Lankveld JJ, Oldenburg HS, Hahn DE, Broomans E, Aaronson NK.Internet-
based cognitive behavioral therapy for sexual dysfunctions in women treated for breast cancer:
design of a multicenter, randomized controlled trial. BMC Cancer. 2015;15:321.
51. Jones LM, McCabe MP.The effectiveness of an Internet-based psychological treatment pro-
gram for female sexual dysfunction. J Sex Med. 2011;8:2781–92.
D. Mollaioli et al.