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Two saw a physician for their non-organic erectile dysfunction, low sexual desire, and unexplained difficulty in achieving orgasm with partners. The first mentioned variables 16 and 7listed in the preceding paragraph. The second mentioned 6 and 7. Both were free of mental health diagnoses. We also report a third active duty serviceman who saw a physician for mental health reasons.

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He mentioned variable 6. First Clinical Report A year old active duty enlisted Caucasian serviceman presented with difficulties achieving orgasm during intercourse for the previous six months. It first happened while he was deployed overseas.

He was masturbating for about an hour without an orgasm, and his penis went flaccid. His difficulties maintaining erection and achieving orgasm continued throughout his deployment.

He could achieve an erection but could not orgasm, and after 10—15 min he would lose his erection, which was not the case prior to his having ED issues. He endorsed viewing Internet pornography for stimulation. Since he gained access to high-speed Internet, he relied solely on Internet pornography. However, gradually he needed more graphic or fetish material to orgasm.

He reported opening multiple videos simultaneously and watching the most stimulating parts. When preparing for deployment about a year ago, he was worried about being away from partnered sex. This device was initially so stimulating that he reached orgasm within minutes. However, as was the case with Internet pornography, with increased use, he needed longer and longer to ejaculate, and eventually he was unable to orgasm at all.

Since returning from deployment, he reported continued masturbation one or more times per day using both Internet pornography and toy. He denied any other relationship issues. She was starting to think that he was no longer attracted to her. Medically, he had no history of major illness, surgery, or mental health diagnoses. He was not taking any medications or supplements. He denied using tobacco products but drank a few drinks at parties once or twice a month.

He had never blacked out from alcohol intoxication. He denied a history of sexually transmitted diseases.

On physical examination, his vital signs were all normal, and his genital exam was normal appearing without lesions or masses. At the conclusion of the visit, it was explained to him that use of a sex toy had potentially desensitized his penile nerves and watching hardcore Internet pornography had altered his threshold for sexual stimulation. He was advised to stop using the toy and watching hardcore Internet pornography. He was referred to urology for further evaluation.

By the time he was seen by the urologist a few weeks later, he had cut down on Internet pornography use significantly, although he said he could not completely stop. He ceased using the toy. Second Clinical Report A year old African American enlisted serviceman with 17 years of continuous active duty presented with difficulty achieving erections for the previous three months.

He reported that when he attempted to have sexual intercourse with his wife, he had difficulty achieving an erection and difficulty maintaining it long enough to orgasm. Ever since their youngest child left for college, six months earlier, he had found himself masturbating more often due to increased privacy. He formerly masturbated every other week on average, but that increased to two to three times per week. He had always used Internet pornography, but the more often he used it, the longer it took to orgasm with his usual material.

This led to him using more graphic material. He denied ever having these issues earlier in the seven years of their marriage. He was having marital issues because his wife suspected he was having an affair, which he adamantly denied. His medical history was only significant for hypertension, which was diagnosed more than two years earlier and had been well controlled with a diuretic: He took no other medications or supplements. His only surgery was an appendectomy performed three years prior.

He had no sexually transmitted diseases or mental health diagnoses. He endorsed smoking three packs of cigarettes per week for over ten years and drinking one to two drinks per week. Physical exam revealed vital signs within normal ranges, normal cardiovascular exam, and normal appearing genitals without lesions or masses.

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At the end of the exam, his issues were attributed to heightened sexual stimulation threshold from exposure to hardcore Internet pornography and frequent masturbation. He was advised to stop watching hardcore Internet pornography and decrease masturbation frequency. He said whenever he was home alone, he found himself watching Internet pornography, which would eventually lead to masturbation. He was offered a referral to sex behavioral therapy, but he declined. He wanted to try to work on his behavior on his own.

Third Clinical Report A year old junior Enlisted Sailor was admitted to the inpatient mental health unit after a suicide attempt by overdose. During his evaluation and treatment he admitted to drinking alcohol even though he was advised to not use alcohol while being treated with antidepressant medications.

His history and increasing tolerance were consistent with mild Alcohol Use Disorder due to his use while taking antidepressants. As part of the addictions portion of his history he was asked about gambling, Internet gaming and pornography addiction. He also realized that he had diminished sexual interest in his wife, manifested by his inability to maintain sustained erections, preferring to view pornography where he had no erectile issues.

When he became aware of his excessive use of pornography, he stopped viewing it completely, telling his interviewer he was afraid that if he viewed it to any extent he would find himself overusing it again. He reported that after he ceased using pornography his erectile dysfunction disappeared. In summary, intervention studies designed to reveal causation by removing the variable of Internet pornography use are much needed to investigate unexplained sexual difficulties in Internet pornography users under Male Sexual Response in the Brain While male sexual response is complex, several key brain regions are critical for achieving and maintaining erections [ 61 ].

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Hypothalamic nuclei play an important role in regulating sexual behavior and erections by acting as an integration center for brain and peripheral input [ 62 ]. The hypothalamic nuclei that facilitate erections receive pro-erectile input from the mesolimbic dopamine pathway, which comprises the ventral tegmental area VTA and the nucleus accumbens NAc [ 62 ]. Erections are dependent upon activation of dopaminergic neurons in VTA and dopamine receptors in the NAc [ 6566 ].

Excitatory glutamate inputs from other limbic structures amygdala, hippocampus and the prefrontal cortex facilitate dopaminergic activity in the VTA and NAc [ 62 ]. Reward responsive dopamine neurons also project into the dorsal striatum, a region activated during sexual arousal and penile tumescence [ 67 ].

Dopamine agonists, such as apomorphine, have been shown to induce erection in men with both normal and impaired erectile function [ 68 ]. Thus, dopamine signaling in the reward system and hypothalamus plays a central role in sexual arousal, sexual motivation and penile erections [ 656669 ]. We propose that chronic Internet pornography use resulted in erectile dysfunction and delayed ejaculation in our servicemen reported above.

We hypothesize an etiology arising in part from Internet pornography-induced alterations in the circuits governing sexual desire and penile erections. These two brain changes are consistent with chronic overconsumption of both natural rewards and drugs of abuse, and are mediated by dopamine surges in the reward system [ 707172 ]. Internet Pornography as Supernormal Stimulus Arguably, the most important development in the field of problematic sexual behavior is the way in which the Internet is influencing and facilitating compulsive sexual behavior [ 73 ].

Sexually explicit material has been around for a long time, but 1 video pornography is significantly more sexually arousing than other forms of pornography [ 7677 ] or fantasy [ 78 ]; 2 novel sexual visuals have been shown to trigger greater arousal, faster ejaculation, and more semen and erection activity compared with familiar material, perhaps because attention to potential novel mates and arousal served reproductive fitness [ 75798081828384 ]; and 3 the ability to self-select material with ease makes Internet pornography more arousing than pre-selected collections [ 79 ].

A pornography user can maintain or heighten sexual arousal by instantly clicking to a novel scene, new video or never encountered genre. Novelty registers as salient, enhances reward value, and has lasting effects on motivation, learning and memory [ 85 ]. Like sexual motivation and the rewarding properties of sexual interaction, novelty is compelling because it triggers bursts of dopamine in regions of the brain strongly associated with reward and goal-directed behavior [ 66 ].

While compulsive Internet pornography users show stronger preference for novel sexual images than healthy controls, their dACC dorsal anterior cingulate cortex also shows more rapid habituation to images than healthy controls [ 86 ], fueling the search for more novel sexual images.

Anxiety, which has been shown to increase sexual arousal [ 8994 ], may also accompany Internet pornography use.

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In short, Internet pornography offers all of these qualities, which register as salient, stimulate dopamine bursts, and enhance sexual arousal. Internet Pornography Use as Self-Reinforcing Activity As the reward system encourages organisms to remember and repeat critical behaviors, such as sex, eating, and socializing, chronic Internet pornography use may become a self-reinforcing activity [ 95 ]. Several lines of research have begun to elucidate the overlap in the neural substrates of sexual learning and addiction [].

For example, sexual behaviors and addictive drugs activate the same sets of neurons within the same reward system structures NAc, basolateral amygdala, anterior cingulated area [ ]. In contrast, very little overlap exists between other natural rewards food, water and addictive drugs, such as cocaine and methamphetamine [ ].

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Thus, methamphetamine use recruits the same mechanisms and neural substrates as does the natural reward of sexual stimulation [ ]. In another study, cocaine addicts had nearly identical brain activation patterns when viewing pornography and cues related to their addiction, but brain activation patterns when viewing nature scenes were completely different [ ].

Furthermore, both repeated sexual behaviors and repeated psychostimulant administration induce up regulation of Delta FosB, a transcription factor that promotes several neuroplastic changes that sensitize the mesolimbic dopamine system to the activity in question [ ]. In both addictive drug use and sexual reward, this up regulation in the same NAc neurons is mediated via dopamine receptors [ ]. This process renders the individual hyper-sensitized to stimuli associated with the activity increased incentive salience [ ].

In comparing sexual reward to substances of abuse, researchers Pitchers et al. To date, the potential health risks of Internet pornography are not as well understood as those for alcohol and tobacco use, and Internet pornography use is widely portrayed as both ordinary behavior and increasingly socially acceptable [].

Perhaps this is why men are slow to connect their pornography viewing with their sexual difficulties. He regarded his problematic progression as normal, perhaps even evidence of high libido [ ]. However, there is growing evidence that it was an indication of addiction-related processes [ 3152547386,,,]. In fact, various addiction experts are calling for Internet addiction to be recognized as a generalized problem with more specific subtypes such as gaming and pornography [,].

A review also concluded that Internet pornography addiction should be recognized as a subtype of Internet addiction, which belongs in the DSM [ ]. He exhibited the following: We have broken this portion of our discussion into three somewhat interrelated sections. Increased Incentive Salience for Internet Pornography Hyperactivity Hyperactivity refers to a sensitized, conditioned response to cues associated with use.

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Sensitized learning involves an enhanced mesolimbic dopamine system response that results in attribution of potentially pathological levels of incentive salience to cue-evoked seeking of drugs and natural rewards [, ]. The mesolimbic dopamine system receives glutamate inputs from various cortical and limbic regions. Current theory suggests glutamatergic synapses associated with seeking and obtaining a particular reward undergo modifications, which enhance the response of the mesolimbic dopamine system to that same reward [].

Human and animal studies suggest that when expectations are unmet a negative prediction erroractivity in the mesolimbic dopamine pathway is inhibited [,]. The latest updates are in sharp 4K quality for downloads and can be streamed in p.

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