It’s rare indeed for a Scots lawyer to be able to contribute to a court case in the US, especially to such an important case as one against the pornography industry, but we did it. The Reward Foundation has filed an amicus [curiae] brief to the Supreme Court of the United States of America. An amicus brief means a note lodged ‘as a friend of the court’. See it here. The Sunday Times has written an article about it too. Our CEO was interviewed about it in a BBC Scotland podcast (Scotcast- Mary-v-The Porn Industry, video, audio).
Here are excerpts about the health argument:
“ARGUMENT
I. Unfettered Access to Pornography Causes Irreparable Damage to Children’s Psychological and Physical Health
Pornography use has harmful health effects for many consumers. The negative health effects are now codified in the International Classification of Diseases – 11th Revision (“ICD-11”) which was published by the World Health Organization (“WHO”) in 2018 and became generally adopted by member states on 1 January 2022 (World Health Organization, 2022).
The U.S. healthcare system is still preparing its implementation. However, over 60 countries have already adopted ICD-11. 5
The relevant diagnosis for compulsive sexual behaviour disorder (“CSBD”) is at code 6C72. 6C72 includes:
“Compulsive sexual behaviour disorder is characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it.
The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.” World Health Organization, ICD-11 International Classification of Diseases 11th Revision. (2022) https://icd.who.int/en.
In February 2022, the WHO updated the CSBD entry online to include additional clinical features including:
“Compulsive sexual behaviors disorder may be expressed in a variety of behaviors, including sexual behaviors with others, masturbation, use of pornography, cybersex (internet sex), telephone sex, and other forms of repetitive sexual behavior. Id. (Emphasis added). Individuals with compulsive sexual behaviors disorder often engage in sexual behavior in response to feelings of depression, anxiety, boredom, loneliness, or other negative affective states. Although not diagnostically determinative, consideration of the relationship between emotional and behavioral cues and sexual behaviors may be an important aspect of treatment planning.” See Id.
In other words, the WHO made it clear that pornography use and masturbation are typical behaviors that can be part of this condition. Research indicates that more than 80% of people seeking treatment for CSBD have a pornography-related issue. Beáta Bőthe, et al., Problematic pornography use across countries, genders, and sexual orientations: Insights from the International Sex Survey and comparison of different assessment tools. ADDICTION 119.5 (2024): 928-950, available at https://tinyurl.com/yc6unz4w.
The WHO does not use the term ‘addiction,’ as it is considered stigmatizing, but rather refers to ‘addictive disorder.’ However, the general public uses the term ‘addiction’ more readily when they equate ‘pornography addiction’ with compulsive sexual behavior disorder.
The term most commonly used in the academic literature to talk of people with out-of-control pornography use, unless they have been clinically assessed as having compulsive sexual behavior disorder, is problematic pornography use.
These effects are even more pronounced in children. When puberty arrives, a young person is biologically programmed to focus on learning about sex. Today’s digital natives look primarily to free, streaming Internet pornography to learn about sex. Internet pornography has succeeded in creating dependency with negative consequences for millions of children who form a substantial percentage of users.
Children are the most vulnerable to developing addictive disorders and mental health problems due to their stage of brain development. The adolescent brain is in a state of accelerated learning from puberty to mid-20s when the brain strengthens the most used pathways and prunes back unused ones. They also produce more of the ‘go-get-it’ neurochemical dopamine, and are more sensitive to it. In addition, they also produce more natural opioids and are more sensitive to them, driving craving for high levels of stimulation and risk.
Sexual dysfunction is increasingly common among teenagers and young adults. They can be aroused by hardcore pornography but not by real people. The arousal system (i.e., the autonomic nervous system) becomes desensitized over time and needs stronger material. This means that the lesser stimulation of a real person does not register as strong enough in the brain of a person with problematic pornography use to create sexual arousal. This is a form of sexual conditioning. A young user doesn’t need to have an addiction to develop sexual dysfunctions.
Professor Gunther De Win, a urologist who specializes in adolescent sexual health, has done research on erectile dysfunction in adolescents:
“…It is clear that the erectile dysfunction (ED) seen in our study is situational, as many participants experiencing some ED during partnered sex did not experience ED nor climaxing difficulties while masturbating with pornography.” “Of the participants who had started masturbating to porn at a very early age (<10 years), 58% (11/19) had some form of ED (P=.01), compared with 20.7% (61/295) in the group who started at 10-12 years old, 20.8% (173/831) in the group who started at 13-14 years old, 18.6% (97/521) in the group who started at 15-17 years old, and 24% (17/70) in the group who started at an age of 18 years or older…
Conclusions: This prevalence of ED in young men is alarming high, and the results of this study suggest a significant association with problematic pornography consumption.” (Emphasis added) Tim Jacobs, et al., Associations between online pornography consumption and sexual dysfunction in young men: multivariate analysis based on an international web-based survey. JMIR PUBLIC HEALTH SURVEILL. 7.10 (2021): e32542. https://tinyurl.com/5n873kuy.
This supports research by Cambridge clinician and researcher Professor Valerie Voon in 2014. This team found that “CSB [compulsive sexual behaviors] subjects compared to healthy volunteers had significantly more difficulty with sexual arousal and experienced more erectile difficulties in intimate sexual relationships but not to sexually explicit material.” Valerie Voon, et al., Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PLOS one 9.7 (2014): e102419. https://tinyurl.com/3p8n4kt3
Finally, researchers found that younger subjects had enhanced reward circuit activity when exposed to porn cues. Higher dopamine spikes and greater reward sensitivity are major factors in adolescents being more vulnerable to addiction. See Your Brain on Porn, Why Shouldn’t Johnny Watch Porn If He Likes? (2011) https://tinyurl.com/47sa9eh9, and sexual conditioning. See Your Brain on Porn, Adolescent Brain Meets Highspeed Internet Porn (2013b) https://tinyurl.com/hwzhf2y9.
A recent study of 6,093 US adolescents (Median age = 15.27 years) looking at relations between reality television, music videos, pornography, and active sexting behaviors (i.e., requesting and sending) found “…pornography consumption was positively related to active sexting behaviors among all gender groups.” Jennifer S. Aubrey, et al., Examining Relations Between Sexualizing Media Exposure and Sexting Attitudes and Behaviors among US Adolescents. ARCH. SEX. BEHAV. (2024): 1-14. https://tinyurl.com/2far7put.
People presenting to clinicians with CSBD are developing it faster than previously, almost certainly due to the ubiquity of online pornography. Fifteen years ago, it took around 9-10 years for it to develop, now it’s happening after 4-5 years. Mateusz Gola, How long does it take for CSBD to develop? YouTube. (2022), https://tinyurl.com/4rhu7xj7. Over 85 studies published between 2004 and 2024 link porn use to poorer mental-emotional health and poorer cognitive outcomes. See Your Brain on Porn, Studies linking porn use to poorer mental-emotional health & poorer cognitive outcomes (2024), https://tinyurl.com/4j6zh66p.
Recent Italian research shows that problematic pornography use was associated with higher levels of anxiety, depression, stress, loneliness, and suicide ideation, as well as lower life satisfaction. Mujde Altin, et al., Problematic Pornography Use, Mental Health, and Suicidality among Young Adults. INT. J. ENVIRON. RES. PUBLIC HEALTH 21.9 (2024): 1228, https://tinyurl.com/5n8p83mz. Gender comparison analysis revealed significantly higher scores for problematic pornography use and loneliness among men, while women scored higher in stress, anxiety, and life satisfaction. Id.
In sum, Internet pornography is not a safe product, especially for children. The Fifth Circuit in this case found that “[t]he record is replete with examples of the sort of damage that access to pornography does to children. One study finds that earlier use of adult pornography was correlated with an increased likelihood of engagement “with deviant pornography (bestiality or child).”“ Free Speech Coalition, Inc. v. Paxton, 95 F.4th 263, 279 (5th Cir. 2024). A “review of literature from 2013–2018 finds a correlation between “frequent use of online pornography” and “distorted gender orientations, insecurities and dissatisfaction about one’s own body image, depression symptoms, assimilation to aggressive models,” and more.” Id. As experts in the field, we agree with those findings.
To be sure, pornography is a defective product by reason of its content. Brain changes resulting from intense and sustained use of Internet pornography over months and years are cumulative. Bingeing on strong sexualised stimuli on a regular basis drives addiction-related brain changes. Pornography sites, much like social media services, hook users with constant novelty and hyper stimulating sexual content.
Tolerance and escalation are characteristic features of brain changes in any addiction. As a brain desensitizes to one level of stimulation, it needs stronger stimuli to feel excited. Just as a drug user needs stronger doses of a given drug to obtain a “high”, the equivalent stronger dose in a pornography user is more intense material. This includes violent, coercive, and demeaning themes such as gangbangs or taboo subjects such as sex with children or family members or animals, to achieve sexual arousal. The pornography industry provides endless amounts of such harmful content. Using this material is damaging children at a critical stage of their mental and physical growth, and their social sexual development.
Given all of this, we respectfully urge the Court to continue to apply, as the Fifth Circuit has, rational basis review to allow states to protect children from this scourge.”
Mary Sharpe, CEO, of The Reward Foundation was a lawyer at the European Commission in Brussels, some years ago. There she dealt with the Product Liability Directive. That is a piece of legislation that makes companies along the supply chain from product to delivery, liable in law for any defects in the product that cause harm. Thus far the product liability argument has not been used in court. We hope that going forward the evidence of causality between problematic pornography use and health issues, mental and physical, will be the foundation of successful cases in future. We want people to be able to have sustainable, loving, intimate relationships without the sex negative impact of pornography.