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Frequency of Pornography Use and Sexual Health Outcomes in Sweden: Analysis of a National Probability Survey

  • Kinda Malki
    Affiliations
    Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden

    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

    Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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  • Christoffer Rahm
    Affiliations
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

    Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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  • Katarina Görts Öberg
    Affiliations
    Department of Medicine, Karolinska Institutet, Stockholm, Sweden

    Anova, Karolinska University Hospital, Stockholm, Sweden
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  • Peter Ueda
    Correspondence
    Corresponding Author: Peter Ueda, MD, PhD. Clinical Epidemiology Division, Department of Medicine, Solna, Eugeniahemmet, T2, Karolinska University Hospital, 17176, Stockholm, Sweden. Tel: +46852480000
    Affiliations
    Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden

    Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Open AccessPublished:September 12, 2021DOI:https://doi.org/10.1016/j.jsxm.2021.08.003

      ABSTRACT

      Background

      Little is known about pornography use and its relationship with sexual health outcomes in the general population.

      Aim

      To assess frequency of pornography use and the association of sexual health outcomes with frequent pornography use in Sweden.

      Methods

      Cross-sectional analysis of 14,135 participants (6,169 men and 7,966 women) aged 16–84 years in a Swedish nationally representative survey from 2017. We used logistic regression to assess the association of sexual health outcomes with use of pornography ≥3 times/wk.

      Outcomes

      Frequency of pornography use (never; less than once/mo to 3 times/mo; 1–2 times/wk; 3–5 times/wk; and daily or almost daily) and sexual health outcomes (eg, sexual satisfaction and sexual health problems).

      Results

      In total, 68.7% of men and 27.0% of women used pornography. Among men aged 16–24 years, 17.2% used pornography daily or almost daily, 24.7% used pornography 3–5 d/wk and 23.7% used pornography 1–2 d/wk. Among women aged 16–24 years, the proportions were 1.2% for daily or almost daily, 3.1% for 3–5 times/wk, and 8.6% for 1–2 times/wk. Frequency of pornography use decreased with age among both men and women. While 22.6% of all men and 15.4% of all women reported that their or a sex partner's pornography use predominantly had positive effects on their sex life, 4.7% of men and 4.0% of women reported that the effects were predominantly negative. Variables indicating sexual dissatisfaction and sexual health problems were associated with use of pornography ≥3 times/wk: for example, dissatisfaction with sex life (age-adjusted odds ratio [aOR]: men 2.90 [95% CI 2.40–3.51]; women 1.85 [95% CI 1.09–3.16]), not having sex in the preferred way (aOR: men 2.48 [95% CI 1.92–3.20]; women 3.59 [95% CI 2.00–6.42]) and erection problems (aOR: men 2.18 [95% CI 1.73–2.76]).

      Clinical Implications

      While frequent pornography use is common, potential effects on sexual health outcomes are likely to differ between individuals.

      Strength & Limitations

      We used a large and recent nationally representative survey with detailed information regarding frequency of pornography use. The temporality of associations of sexual health variables with frequency of pornography use could not be assessed.

      Conclusion

      In this analysis of a nationally representative survey in Sweden, we found that frequent pornography use was common among young men; that reporting predominantly positive effects of pornography use on the sex life was more common than reporting predominantly negative effects; and that sexual dissatisfaction and sexual health problems were associated with using pornography ≥3 times/wk.
      Malki K, Rahm C, Öberg KG, et al. Frequency of Pornography Use and Sexual Health Outcomes in Sweden: Analysis of a National Probability Survey. J Sex Med 2021;18:1735–1751.

      Key Words

      INTRODUCTION

      The increased availability of pornographic material online has made pornography use a hotly debated issue in recent years. Some suggest that frequent pornography use causes sexual problems such as erectile dysfunction
      • Park BY
      • Wilson G
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      Is internet pornography causing sexual dysfunctions? A review with clinical reports.
      and sexual dissatisfaction
      • Wright PJ
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      Pornography consumption and satisfaction: a meta-analysis.
      as well as depression,
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      Your brain on porn: internet pornography.
      relationship issues,
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      A historical and empirical review of pornography and romantic relationships: implications for family researchers.
      sexual aggression
      • Wright PJ
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      and sexist attitudes,
      • Hald GM
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      Pornography and sexist attitudes among heterosexuals.
      although the evidence regarding such causal links on the population level is conflicting.
      • Wright PJ
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      • Kraus A
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      Pornography consumption and satisfaction: a meta-analysis.
      ,
      • Wright PJ
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      A meta-analysis of pornography consumption and actual acts of sexual aggression in general population studies.
      ,
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      The use and effects of pornography in romantic relationships.
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      The positive and negative effects of pornography as attributed by consumers.
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      Pornography problems due to moral incongruence: an integrative model with a systematic review and meta-analysis.
      • Newstrom NP
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      Is pornography use related to erectile functioning? Results from cross-sectional and latent growth curve analyses.
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      Self-perceived effects of pornography consumption.
      • Prause N
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      Viewing sexual stimuli associated with greater sexual responsiveness, not erectile dysfunction.

      Ferguson CJ, Hartley RD. Pornography and sexual aggression: can meta-analysis find a link? Trauma, Violence & Abuse 2020. doi: 10.1177/1524838020942754. E-pub ahead of print.

      • Kohut T
      • Baer JL
      • Watts B.
      Is pornography really about “making hate to women”? Pornography users hold more gender egalitarian attitudes than nonusers in a representative American sample.
      Moreover, reports from online surveys, clinical practice and anecdotal data
      • Park BY
      • Wilson G
      • Berger J
      • et al.
      Is internet pornography causing sexual dysfunctions? A review with clinical reports.
      ,
      • Wilson G.
      Your brain on porn: internet pornography.
      ,
      • Newstrom NP
      • Harris SM.
      Pornography and couples: what does the research tell us?.
      ,
      • Short MB
      • Wetterneck CT
      • Bistricky SL
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      Clinicians’ beliefs, observations, and treatment effectiveness regarding clients’ sexual addiction and internet pornography use.
      • Kraus SW
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      Clinical characteristics of men interested in seeking treatment for use of pornography.
      • Lewczuk K
      • Szmyd J
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      Treatment seeking for problematic pornography use among women.
      • Vaillancourt-Morel MP
      • Blais-Lecours S
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      Profiles of cyberpornography use and sexual well-being in adults.
      • Sansone A
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      The sentiment analysis of tweets as a new tool to measure public perception of male erectile and ejaculatory dysfunctions.
      has stirred societal concern about problematic pornography use which interferes with one's health, well-being, or responsibilities. Accordingly, compulsive sexual behavior disorder was included in the International Classification of Diseases, 11th Revision,

      World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). 2020. Available at: https://www.who.int/standards/classifications/classification-of-diseases. Accessed April 25, 2020.

      although hypersexual disorder was not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-5).
      • Kor A
      • Fogel YA
      • Reid RC
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      Should hypersexual disorder be classified as an addiction?.
      ,
      • Reid RC
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      Controversies about hypersexual disorder and the DSM-5.
      Conversely, some individuals may improve sexual experiences with pornography use,
      • McKee A.
      The positive and negative effects of pornography as attributed by consumers.
      ,
      • Hald GM
      • Malamuth NM.
      Self-perceived effects of pornography consumption.
      ,
      • Vaillancourt-Morel MP
      • Blais-Lecours S
      • Labadie C
      • et al.
      Profiles of cyberpornography use and sexual well-being in adults.
      ,
      • Rissel C
      • Richters J
      • de Visser RO
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      A profile of pornography users in Australia: findings from the second Australian study of health and relationships.
      or not experience notable effects on wellbeing or sexual health.
      • Rissel C
      • Richters J
      • de Visser RO
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      A profile of pornography users in Australia: findings from the second Australian study of health and relationships.
      ,
      • Bőthe B
      • Tóth-Király I
      • Potenza MN
      • et al.
      High-frequency pornography use may not always be problematic.
      While frequent pornography use has emerged as a pressing research subject within public and sexual health, surprisingly little is known regarding its occurrence in the general population. Previous studies predominantly constitute online surveys and small samples with limited generalizability.
      • Park BY
      • Wilson G
      • Berger J
      • et al.
      Is internet pornography causing sexual dysfunctions? A review with clinical reports.
      ,
      • Wilson G.
      Your brain on porn: internet pornography.
      ,
      • Short MB
      • Wetterneck CT
      • Bistricky SL
      • et al.
      Clinicians’ beliefs, observations, and treatment effectiveness regarding clients’ sexual addiction and internet pornography use.
      • Kraus SW
      • Martino S
      • Potenza MN.
      Clinical characteristics of men interested in seeking treatment for use of pornography.
      • Lewczuk K
      • Szmyd J
      • Skorko M
      • et al.
      Treatment seeking for problematic pornography use among women.
      • Vaillancourt-Morel MP
      • Blais-Lecours S
      • Labadie C
      • et al.
      Profiles of cyberpornography use and sexual well-being in adults.
      ,
      • Miller DJ
      • Raggatt PTF
      • McBain K.
      A literature review of studies into the prevalence and frequency of men's pornography use.
      ,
      • Herbenick D
      • Fu TC
      • Wright P
      • et al.
      Diverse sexual behaviors and pornography use: findings from a nationally representative probability survey of Americans aged 18 to 60 years.
      Although reports on problematic pornography use describe individuals who view pornography daily or several times per week,
      • Park BY
      • Wilson G
      • Berger J
      • et al.
      Is internet pornography causing sexual dysfunctions? A review with clinical reports.
      ,
      • Wilson G.
      Your brain on porn: internet pornography.
      ,
      • Short MB
      • Wetterneck CT
      • Bistricky SL
      • et al.
      Clinicians’ beliefs, observations, and treatment effectiveness regarding clients’ sexual addiction and internet pornography use.
      • Kraus SW
      • Martino S
      • Potenza MN.
      Clinical characteristics of men interested in seeking treatment for use of pornography.
      • Lewczuk K
      • Szmyd J
      • Skorko M
      • et al.
      Treatment seeking for problematic pornography use among women.
      • Vaillancourt-Morel MP
      • Blais-Lecours S
      • Labadie C
      • et al.
      Profiles of cyberpornography use and sexual well-being in adults.
      publications from population-based surveys have reported whether participants have viewed pornography during the past week,
      • Regnerus M
      • Gordon D
      • Price J.
      Documenting pornography use in America: a comparative analysis of methodological approaches.
      month
      • Miller DJ
      • Raggatt PTF
      • McBain K.
      A literature review of studies into the prevalence and frequency of men's pornography use.
      ,
      • Regnerus M
      • Gordon D
      • Price J.
      Documenting pornography use in America: a comparative analysis of methodological approaches.
      ,
      • Herbenick D
      • Bowling J
      • Fu T-C J
      • et al.
      Sexual diversity in the United States: results from a nationally representative probability sample of adult women and men.
      or year
      • Rissel C
      • Richters J
      • de Visser RO
      • et al.
      A profile of pornography users in Australia: findings from the second Australian study of health and relationships.
      ,
      • Regnerus M
      • Gordon D
      • Price J.
      Documenting pornography use in America: a comparative analysis of methodological approaches.
      ,

      General Social Survey. NORC University of Chicago. General Social Survey - Codebook (Appendix A).

      and not focused on sexual health outcomes. As such, there is a scarcity of detailed information on the occurrence of frequent pornography use and its associations with sexual health outcomes in large and recent population-based samples.
      In this study, we used data from Sexual and Reproductive Health and Rights (SRHR) 2017,

      Public Health Agency of Sweden. Sexuell Och Reproduktiv Hälsa Och Rättigheter i Sverige 2017 [Swedish].; 2019.

      a Swedish nationally representative sexual health survey of over 14000 participants aged 16–84 years to describe the frequency of pornography use across sex-and-age groups, assess the association of sociodemographic variables and sexual health outcomes with frequent pornography use and examine the self-reported effects of pornography use on the sex life.

      MATERIALS AND METHODS

       Data Sources

      SRHR2017, described in detail elsewhere,

      Public Health Agency of Sweden. Sexuell Och Reproduktiv Hälsa Och Rättigheter i Sverige 2017 [Swedish].; 2019.

      • Deogan C
      • Jacobsson E
      • Mannheimer L
      • et al.
      Meeting sexual partners online and associations with sexual risk behaviors in the Swedish population.
      • Björkenstam C
      • Mannheimer L
      • Löfström M
      • et al.
      Sexual orientation–related differences in sexual satisfaction and sexual problems—a population-based study in Sweden.
      was conducted in 2017 by the Public Health Agency of Sweden; descriptive data have been presented in the survey report.

      Public Health Agency of Sweden. Sexuell Och Reproduktiv Hälsa Och Rättigheter i Sverige 2017 [Swedish].; 2019.

      In brief, using a sampling frame based on the Total Population Register
      • Ludvigsson JF
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      Registers of the Swedish total population and their use in medical research.
      and stratified random sampling, a paper-based questionnaire was sent to 49,784 individuals. The individuals also received an information letter describing the purpose of the survey, that the questionnaire would be linked with register data and that participation was voluntary and anonymous. Data on country of birth, region of residence, educational level and income were obtained from the national Longitudinal Integration Database for Health Insurance and Labour Market Studies.
      Longitudinal integration database for health insurance and labour market studies.
      15,186 individuals returned the questionnaire (response rate 30.5%); nonresponders were more likely to be men, young, born outside of Sweden and having lower educational levels.

      Public Health Agency of Sweden. Sexuell Och Reproduktiv Hälsa Och Rättigheter i Sverige 2017 [Swedish].; 2019.

      • Deogan C
      • Jacobsson E
      • Mannheimer L
      • et al.
      Meeting sexual partners online and associations with sexual risk behaviors in the Swedish population.
      • Björkenstam C
      • Mannheimer L
      • Löfström M
      • et al.
      Sexual orientation–related differences in sexual satisfaction and sexual problems—a population-based study in Sweden.
      After exclusion of 639 participants with contradictory responses, sample weights were calculated for the 14,547 remaining participants to adjust for differential probabilities of nonresponse by sex, age group, regions of residence, country of birth, and educational level. All analyzed data were anonymized. The study was approved by the Regional Ethical Review Board in Stockholm.

       Study Population and Variables

      All 14,547 participants in the SRHR2017 dataset were eligible for this analysis. We excluded those with missing data on frequency of pornography use (n = 412). In total, 14,135 participants (6,169 men and 7,966 women) were included in the study population. Survey questions and response options used for defining the study variables are shown in Appendix. The survey included the question “Do you intentionally watch pornography?” with response options ranging from “I never watch pornography” to “Daily or almost daily.” Based on the response to this question, we categorized frequency of use (never; less than once/mo to 3 times/mo: 1–2 times/wk; 3–5 times/wk; and daily or almost daily). We categorized the self-reported effects of pornography use on sex life by the response to the question “Does pornography, that you or a sexual partner watch, affect your sex life?”: predominantly negative (“Yes, predominantly negatively”); predominantly positive (“Yes, predominantly positively”); none/don't know (“None” or “Don't know”). The terms “pornography” and “affect your sex life” were not defined in the survey. Sociodemographic and sexual health variables used in the analyses are shown in Appendix (eTable 1).

       Statistical Methods

      Stata version 15.0 (StataCorp) was used. All analyses were performed separately by gender and accounted for the stratification and weighting of the samples. First, we described the frequency of pornography use by age group (16–24; 25–34; 35–49; 50–64; 65–84; 16–84 years). We then described sociodemographic and sexual health variables (Appendix [eTable 1]) by frequency of pornography use, using larger categories to preserve sample size (never to less than 3 times/mo; 1–2 times/wk; and ≥3 times/wk). We assessed the association of the variables with frequent pornography use (≥3 times/wk) using logistic regression and calculated the age-adjusted odds ratios (aORs) using frequent pornography use as a binary dependent variable and age (linear and quadratic terms), and the variable of interest as independent variables. Survey participants with missing data were excluded by variable. We performed 2 sets of additional analyses: (i) because there is no established definition of frequent pornography use,
      • Miller DJ
      • Raggatt PTF
      • McBain K.
      A literature review of studies into the prevalence and frequency of men's pornography use.
      we calculated the aORs for the selected variables using weekly pornography use as the dependent variable; (ii) to assess potential dose-response relationships between pornography use and sexual health outcomes, we calculated aORs for selected sexual health outcomes (Appendix [eTable 2]) using logistic regression with the sexual health outcome as the dependent variable and frequency of pornography use (never to less than 3 times/mo; 1–2 times/wk; and ≥3 times/wk) and age (linear and quadratic terms) as independent variables. Next, we described the proportion of individuals and socioeconomic and sexual health variables by self-reported effects of pornography use on the sex life. We used logistic regression to calculate aORs for the association of frequency of pornography use, sociodemographic and sexual health variables with reporting predominantly positive and negative effects, respectively. aORs with 95% CI that did not overlap 1 were considered as statistically significant.

      RESULTS

       Frequency of Pornography Use

      The weighted proportions of men and women by frequency of pornography use and age group are shown in Figure 1 (raw data with 95% CI are shown in Appendix [eTable 3] and unweighted data are shown in Appendix [eTable 4]). Overall, 68.7% of men and 27.0% of women reported using pornography; 18.3% of men and 1.1% of women reported frequent use (≥3 times/wk).
      Figure 1
      Figure 1Frequency of pornography use by age group among men and women.
      Among men aged 16–24 years, the proportion of pornography use was 17.2% for daily or almost daily, 24.7% for 3–5 times/wk and 23.7% for 1-2 times/wk. Frequency of pornography use decreased with age and among men aged 65–84 years, the proportions were 0.8% for daily or almost daily, 2.0% for 3–5 times/wk and 4.6% for 1–2 times/wk. Among women aged 16–24 years, the proportion of pornography use was 1.2% for daily or almost daily, 3.1% for 3–5 times/wk and 8.6% for 1–2 times/wk; these proportions decreased with age and among women aged 65–84 years, 96.5% never used pornography.

       Variables Associated With Frequent Pornography Use

      Sociodemographic and sexual health variables among individuals by frequency of pornography use are shown in Table 1 (unweighted data are shown in Appendix [eTable 5]). Several variables were associated with frequent pornography use (Table 2), for example: identifying as homosexual for men (aOR vs heterosexual 5.00 [95% CI 2.97–8.39]) and as bisexual for men (aOR vs heterosexual 2.35 [1.47–3.75]) and women (aOR vs heterosexual 3.63 [2.08–6.34]); having less sex for men (aOR for <weekly sex vs ≥weekly sex 1.41 [95% CI 1.15–1.74]; aOR for no sex during past year vs ≥weekly sex 1.47 [95% CI 1.15–1.88]), but not for women (aOR for <weekly sex vs ≥weekly sex 0.74 [95% CI 0.42–1.28]; aOR for no sex during past year vs ≥weekly sex 0.57 [95% CI 0.29–1.11]). Those with a university education of ≥4 years were less likely to report frequent pornography use (men: aOR vs high school or less 0.67 [0.49–0.91]; women: aOR vs high school or less 0.19 [0.04–0.87]) as were men earning ≥60,000 SEK per month (aOR vs <20,000 SEK per month 0.38 [0.15–0.95]) and men (aOR 3.12 [2.35–4.13]) and women (aOR 39.38 [7.87–197.11]) who ever had paid or given other types of compensation for sex.
      Table 1Sociodemographic characteristics, sexual behaviors and sexual health outcomes by frequency of pornography use. Numbers are shown as weighted percent.
      Frequency of pornography use
      MenWomen
      Never to <3 times/month1-2 times/week≥3 times/weekNever to <3 times/month1-2 times/week≥3 times/week
      Unweighted n4340875954767519992
      Sociodemographic variables
      Education
       Primary or secondary68.457.267.260.275.071.7
       Vocational or ≤3 years of university20.828.925.528.320.426.6
       ≥4 years of university10.813.97.311.54.61.7
      Monthly income in Swedish crowns
      1000 SEK = 97 EURO (April, 2021).
       <2000041.945.461.260.079.480.7
       2000 to <4000048.746.832.636.119.819.3
       40000 to <600006.86.25.72.80.90
       ≥600002.61.70.51.100
      Country of birth
       Nordic countries83.887.986.784.481.177.2
       Rest of Europe/North America/ Oceania5.84.26.47.08.71.4
       Other10.47.96.98.610.221.4
       Married53.629.318.544.319.312.4
      Sexual health and behavior
      Sexual identity
       Heterosexual97.893.188.994.970.866.9
       Homosexual0.72.65.51.04.34.3
       Bisexual1.54.35.74.124.928.8
      Frequency of having sex in past year
       Weekly or more28.629.526.626.342.143.6
       Less than weekly43.845.344.540.635.235.4
       Not at all27.725.228.933.122.721.0
      Feeling that sex is important72.477.977.858.384.386.9
      Effect of their or sex partner's pornography use on sex life
       None/Don't know78.761.560.88443.650.3
       Predominantly negative3.15.19.93.97.53.3
       Predominantly positive18.233.429.312.148.946.4
      Feeling that high expectations on their sexual performance are a problem4.96.515.14.78.219.4
      Feeling free to take initiative to sex79.578.369.279.484.474.3
      Can say no if not wanting to have sex81.385.678.991.189.988.7
      Ever paid or given other types of compensation for sex7.312.314.50.31.08.2
      Experience of sex life during past 12 months
       Satisfied with sex life62.155.247.757.562.265.8
       Dissatisfied with sex life14.325.836.612.519.924.2
       Want more sexual partners3.612.322.21.89.215.8
       Want less sexual partners0.10.40.30.10.83.2
       Not had enough sex21.838.142.217.430.833.2
       Had too much sex0.91.91.01.81.71.0
       Not had sex in the preferred way5.811.0164.612.819.7
       Had sex despite not wanting to0.91.82.04.36.68.4
       Too tired or stressed to have sex8.514.213.620.121.712.8
       Masturbated24.753.961.725.059.467.3
       Lacked sexual partner8.118.729.710.821.526.0
       Health issue that affected sex life8.36.15.88.311.84.7
      Sexual health issues during past 12 month
       No interest in sex14.319.215.732.829.221.1
       Lack of pleasure when having sex3.37.87.09.013.412.3
       Worried when having sex3.55.49.24.59.015.3
       Lack of arousal when having sex2.56.07.39.010.68.4
       Orgasm problems (not had orgasm or too long time until orgasm)5.68.412.615.428.827.8
       Too early orgasm16.822.120.52.15.04.4
       Erection problems16.915.319.0---
       Vaginal dryness---13.311.510.8
      a 1000 SEK = 97 EURO (April, 2021).
      Table 2Age-adjusted odds ratios (aOR) for frequent pornography use (≥3 times/week).
      Men

      (n=6169)
      Women

      (n=7966)
      Percent
      Percent of subgroup reporting pornography use ≥3 times/week.
      aOR (95% CI)Percent
      Percent of subgroup reporting pornography use ≥3 times/week.
      aOR (95% CI)
      Sociodemographic variables
      Education
       Primary or secondary17.7Ref.1.2Ref.
       Vocational or ≤3 years of university19.51.01 (0.83 to 1.23)1.00.97 (0.52 to 1.84)
       ≥4 years of university12.00.67 (0.49 to 0.91)0.20.19 (0.04 to 0.87)
      Monthly income in Swedish crowns
      1000 SEK = 97 EURO (April, 2021).
       <2000024.5Ref.1.5Ref.
       20000 to <4000013.20.73 (0.59 to 0.90)0.60.90 (0.42 to 1.92)
       40000 to <6000016.11.24 (0.85 to 1.81)0-
       ≥600004.760.38 (0.15 to 0.95)0-
      Country of birth
       Nordic countries18.7Ref.1.0Ref.
       Rest of Europe/North America/Australia20.71.06 (0.73 to 1.53)0.20.22 (0.03 to 1.61)
       Other13.50.42 (0.28 to 0.65)2.81.99 (0.87 to 4.57)
      Married
       No26.4Ref.1.8Ref.
       Yes7.80.48 (0.39 to 0.60)0.30.44 (0.18 to 1.08)
      Sexual health and behavior
      Sexual identity
       Heterosexual17.2Ref.0.8Ref.
       Homosexual53.55.00 (2.97 to 8.39)4.33.41 (0.91 to 12.83)
       Bisexual38.92.35 (1.47 to 3.75)6.33.63 (2.08 to 6.34)
      Frequency of having sex in past year
       Weekly or more17.3Ref.1.9Ref.
       Less than weekly18.61.41 (1.15 to 1.74)1.00.74 (0.42 to 1.28)
       Not at all19.41.47 (1.15 to 1.88)0.80.57 (0.29 to 1.11)
      Feeling that sex is important
       No15.8Ref.0.4Ref.
       Yes19.21.30 (1.04 to 1.62)1.73.68 (1.82 to 7.43)
      Effect of their or sex partner's pornography use on sex life
       None/Don't know15.4Ref.0.7Ref.
       Predominantly negative38.92.20 (1.57 to 3.09)1.01.01 (0.35 to 2.97)
       Predominantly positive23.92.22 (1.82 to 2.70)4.06.48 (3.83 to 10.97)
      Feeling that high expectations on sexual performance is a problem
       No16.4Ref.1.0Ref.
       Yes39.02.81 (2.06 to 3.84)4.42.75 (1.14 to 6.61)
      Feeling free to take initiative to sex
       No25.0Ref.1.4Ref.
       Yes16.40.63 (0.52 to 0.78)1.10.78 (0.41 to 1.51)
      Can say no if not wanting to have sex
       No20.9Ref.1.4Ref.
       Yes17.70.70 (0.56 to 0.87)1.11.00 (0.45 to 2.23)
      Ever paid or given other types of compensation for sex
       No17.3Ref.1.1Ref.
       Yes28.33.12 (2.35 to 4.13)23.839.38 (7.87 to 197.11)
      Experience of sex life during past 12 months
      Satisfied with sex life
       No23.1Ref.0.9Ref.
       Yes15.00.50 (0.42 to 0.59)1.31.21 (0.73 to 2.00)
      Dissatisfied with sex life
       No14.6Ref.1.0Ref.
       Yes33.42.90 (2.40 to 3.51)2.21.85 (1.09 to 3.16)
      Want more sexual partners
       No15.6Ref.1.0Ref.
       Yes48.73.54 (2.73 to 4.58)8.54.51 (2.47 to 8.25)
      Want less sexual partners
       No18.4Ref.1.1Ref.
       Yes22.60.82 (0.18 to 3.67)23.614.75 (3.69 to 58.92)
      Not had enough sex
       No14.8Ref.0.9Ref.
       Yes27.72.02 (1.69 to 2.42)2.11.81 (1.10 to 2.97)
      Had too much sex
       No18.4Ref.1.2Ref.
       Yes17.80.54 (0.24 to 1.18)0.70.51 (0.07 to 3.71)
      Not had sex in the preferred way
       No16.9Ref.1.0Ref.
       Yes34.62.48 (1.92 to 3.20)4.63.59 (2.00 to 6.42)
      Had sex despite not wanting to
       No18.2Ref.1.1Ref.
       Yes30.51.32 (0.71 to 2.46)2.21.62 (0.72 to 3.68)
      Too tired or stressed to have sex
       No17.7Ref.1.3Ref.
       Yes24.31.05 (0.82 to 1.34)0.70.46 (0.25 to 0.86)
      Masturbated
       No11.0Ref.0.5Ref.
       Yes31.53.21 (2.69 to 3.83)2.93.98 (2.29 to 6.90)
      Lacked sexual partner
       No15.0Ref.1.0Ref.
       Yes39.82.54 (2.05 to 3.16)2.72.15 (1.28 to 3.62)
      Health issue that affected sex life
       No18.7Ref.1.2Ref.
       Yes14.21.48 (1.04 to 2.10)0.60.60 (0.24 to 1.49)
      Sexual health issues during past 12 month
      No interest in sex
       No18.3Ref.1.3Ref.
       Yes18.80.95 (0.75 to 1.20)0.70.60 (0.31 to 1.18)
      Lack of pleasure while having sex
       No17.9Ref.1.1Ref.
       Yes27.51.28 (0.87 to 1.89)1.51.13 (0.57 to 2.22)
      Feeling worried when having sex
       No17.5Ref.1.0Ref.
       Yes34.61.7 (1.21 to 2.40)3.71.89 (1.04 to 3.45)
      Lack of arousal when having sex
       No17.7Ref.1.2Ref.
       Yes34.01.78 (1.26 to 2.52)1.10.70 (0.32 to 1.51)
      Not had orgasm or too long time until orgasm
       No17.3Ref.1.0Ref.
       Yes31.51.99 (1.50 to 2.63)2.01.23 (0.75 to 2.02)
      Too early orgasm
       No17.9Ref.1.1Ref.
       Yes20.50.82 (0.66 to 1.02)2.31.38 (0.49 to 3.85)
      Erection problems
       No17.9Ref.--
       Yes20.52.18 (1.73 to 2.76)--
      Vaginal dryness
       No--3.7Ref.
       Yes--3.10.92 (0.38 to 2.23)
      a Percent of subgroup reporting pornography use ≥3 times/week.
      b 1000 SEK = 97 EURO (April, 2021).
      Several variables indicating dissatisfaction with the quantity or quality of sexual activity were associated with frequent pornography use: for example, dissatisfaction with sex life (aOR: men 2.90 [95% CI 2.40–3.51]; women 1.85 [95% CI 1.09–3.16]), wanting more sexual partners (aOR: men 3.54 [95% CI 2.73–4.58]; women 4.51 [95% CI 2.47–8.25]), not having enough sex (aOR: men 2.02 [95% CI 1.69–2.42]; women 1.81 [95% CI 1.10–2.97]), not having sex in the preferred way (aOR: men 2.48 [95% CI 1.92–3.20]; women 3.59 [95% CI [2.00–6.42]) and feeling that high expectations on sexual performance are a problem (aOR: men 2.81 [95% CI 2.06–3.84]; women 2.75 [95% CI 1.14–6.61]). Associations with frequent pornography use were also observed for sexual health problems, including feeling worried during sex (aOR: men 1.70 [95% CI 1.21–2.4]; women 1.89 [95% CI 1.04–3.45]) and for men, lack of arousal when having sex (aOR 1.78 [95% CI 1.26–2.52]) and erection problems (aOR 2.18 [95% CI 1.73–2.76]). The findings were largely similar in the additional analyses using weekly pornography use as the dependent variable (Appendix [eTable 6]). In the analyses using sexual health outcomes as the dependent variable, the point estimates of aORs for several outcomes increased with increasing frequency of pornography use (Appendix [eTable 7]).

       Self-Reported Effects of Pornography Use on Sex Life

      Weighted proportions of men and women by self-reported effects of their or a sex partner's pornography use on the sex life are shown in Figure 2 (raw data with 95% CI are shown in Appendix [eTable 8]; unweighted data are shown in Appendix [eTable 9]). Overall, most men (72.7%) and women (82.6%) responded “none” or “don't know” regarding the effects of pornography use, and a larger proportion reported predominantly positive effects (men 22.6%; women 13.4%) than predominantly negative effects (men 4.7%; women 4.0%). Reporting predominantly positive effects was most common among those aged 50–64 years for men (30.1 %) and among those aged 35-49 years for women (20.8 %). Reporting predominantly negative effects was most common in the age group 25-34 among both men (10.6 %) and women (6.9 %).
      Figure 2
      Figure 2Self-reported effects of their or a sex partner's pornography use on the sex life by age group among men and women.
      Sociodemographic and sexual health variables by self-reported effects of pornography on the sex life are shown in Appendix (eTable 10) (unweighted data are shown in Appendix [eTable 11]). Several variables were associated with reporting predominantly positive or negative effects (Table 3 and 4), for example, frequent pornography use was associated with reporting predominantly positive effects among men (aOR for ≥3 times/wk vs never to <3 times/mo 2.94 [2.38–3.63] and women (aOR for ≥3 times/wk vs never to <3 times/mo 8.26 [4.90–13.93]), and with reporting predominantly negative effects among men (aOR for ≥3 times/wk vs never to <3 times/mo 1.86 [1.29–2.68]) but not women (aOR for ≥3 times/wk vs never to <3 times/mo 0.59 [0.21–1.68]). Compared to heterosexual individuals, homosexual men (aOR 1.70 [95% CI 1.05–2.75]) and bisexual men (aOR 1.95 [95% CI 1.28–2.97]) and bisexual women (aOR 2.65 [95% CI 1.97–3.57]) were more likely to report predominantly positive effects; bisexual women were also more likely to report predominantly negative effects (aOR 1.58 [95% CI 1.05–2.37]).
      Table 3Age-adjusted odds ratios (aOR) for reporting of predominantly negative and predominantly positive effects of their or a sex partner's pornography use on sex life among men.
      Predominantly negativePredominantly positive
      Percent
      Percent of subgroup reporting predominantly negative effects of their or a sex partner's pornography use on their sex life.
      aOR (95% CI)Percent
      Percent of subgroup reporting predominantly positive effects of their or a sex partner's pornography use on their sex life.
      aOR (95% CI)
      Frequency of pornography use
       Never to <3 times/month3.1Ref.18.2Ref.
       1-2 times/week5.11.05 (0.69 to 1.60)33.42.94 (2.41 to 3.59)
       ≥3 times/week9.91.86 (1.29 to 2.68)29.32.94 (2.38 to 3.63)
      Sociodemographic variables
      Education
       Primary or secondary3.8Ref.22.1Ref.
       Vocational or ≤3 years of university6.11.57 (1.11 to 2.21)25.11.10 (0.93 to 1.29)
       ≥4 years of university5.91.78 (1.08 to 2.93)23.90.97 (0.78 to 1.22)
      Monthly income in Swedish crowns
      1000 SEK = 97 EURO (April, 2021).
       <200005.6Ref.19.4Ref.
       2000 to <400003.80.86 (0.59 to 1.27)25.01.06 (0.89 to 1.25)
       40000 to <600004.21.15 (0.57 to 2.33)27.91.18 (0.90 to 1.55)
       ≥600003.41.11 (0.28 to 4.38)30.01.35 (0.89 to 2.05)
      Country of birth
       Nordic countries4.3Ref.23.2Ref.
       Rest of Europe/North America/Oceania5.71.25 (0.69 to 2.27)21.90.92 (0.66 to 1.29)
       Other7.41.31 (0.78 to 2.22)17.60.72 (0.49 to 1.04)
      Married
       No6.1Ref.22.5Ref.
       Yes2.90.82 (0.56 to 1.20)22.80.82 (0.71 to 0.95)
      Sexual health and behavior
      Sexual identity
       Heterosexual4.4Ref.22.7Ref.
       Homosexual5.50.96 (0.39 to 2.37)32.71.70 (1.05 to 2.75)
       Bisexual10.21.85 (0.83 to 4.10)34.41.95 (1.28 to 2.97)
      Frequency of having sex in past year
       Weekly or more4.3Ref.29Ref.
       Less than weekly5.11.44 (1.01 to 2.06)23.30.72 (0.61 to 0.85)
       Not at all4.21.19 (0.77 to 1.83)15.10.48 (0.38 to 0.59)
      Feeling that sex is important
       No3.7Ref.12.9Ref.
       Yes5.11.32 (0.90 to 1.96)26.12.19 (1.79 to 2.68)
      Feeling that high expectations on their sexual performance are a problem
       No4.1Ref.24.9Ref.
       Yes14.73.43 (2.26 to 5.19)21.30.92 (0.66 to 1.27)
      Feeling free to take initiative to sex
       No4.8Ref.14.2Ref.
       Yes4.71.08 (0.74 to 1.57)25.31.84 (1.52 to 2.22)
      Can say no if not wanting to have sex
       No4.6Ref.16.8Ref.
       Yes4.70.93 (0.62 to 1.41)24.11.44 (1.17 to 1.77)
      Ever paid or given other types of compensation for sex
       No4.5Ref.21.5Ref.
       Yes7.22.10 (1.35 to 3.28)34.51.82 (1.47 to 2.25)
      Experience of sex life during past 12 months
      Satisfied with sex life
       No5.9Ref.18.7Ref.
       Yes3.90.60 (0.44 to 0.80)25.51.42 (1.23 to 1.64)
      Dissatisfied with sex life
       No4.1Ref.23.2Ref.
       Yes7.11.60 (1.16 to 2.20)20.60.87 (0.73 to 1.04)
      Want more sexual partners
       No4.3Ref.21.6Ref.
       Yes9.51.63 (1.07 to 2.47)34.72.13 (1.68 to 2.71)
      Want less sexual partners
       No4.7Ref.22.6Ref.
       Yes7.71.19 (0.13 to 11.02)56.54.59 (1.00 to 21.00)
      Not had enough sex
       No3.9Ref.21.9Ref.
       Yes6.91.56 (1.14 to 2.12)24.71.10 (0.94 to 1.29)
      Had too much sex
       No4.6Ref.22.5Ref.
       Yes12.52.03 (0.81 to 5.07)33.91.97 (1.02 to 3.79)
      Not had sex in the preferred way
       No4.1Ref.22.2Ref.
       Yes10.72.47 (1.68 to 3.62)27.91.31 (1.04 to 1.64)
      Had sex despite not wanting to
       No4.5Ref.22.7Ref.
       Yes21.74.42 (2.06 to 9.46)18.50.79 (0.39 to 1.61)
      Too tired or stressed to have sex
       No4.0Ref.22.4Ref.
       Yes11.12.32 (1.62 to 3.31)24.71.10 (0.88 to 1.38)
      Masturbated
       No3.4Ref.17.6Ref.
       Yes7.01.71 (1.27 to 2.3)31.62.25 (1.94 to 2.61)
      Lacked sexual partner
       No4.2Ref.22.9Ref.
       Yes7.81.36 (0.92 to 2.00)21.51.12 (0.89 to 1.40)
      Health issue that affected sex life
       No4.6Ref.22.6Ref.
       Yes5.62.16 (1.31 to 3.59)23.41.05 (0.83 to 1.33)
      Sexual health issues during past 12 month
      No interest in sex
       No3.5Ref.23.0Ref.
       Yes10.53.11 (2.25 to 4.31)21.00.90 (0.74 to 1.10)
      Lack of pleasure while having sex
       No4.2Ref.22.8Ref.
       Yes12.32.56 (1.55 to 4.24)20.00.91 (0.62 to 1.34)
      Feeling worried when having sex
       No4.1Ref.22.6Ref.
       Yes15.03.07 (1.98 to 4.75)23.51.13 (0.80 to 1.59)
      Lack of arousal when having sex
       No4.1Ref.22.9Ref.
       Yes17.73.96 (2.58 to 6.08)17.40.73 (0.50 to 1.07)
      Orgasm problems (not had orgasm or too long time until orgasm)
       No4.3Ref.22.2Ref.
       Yes9.11.96 (1.29 to 2.96)28.61.44 (1.12 to 1.84)
      Too early orgasm
       No4.1Ref.22.7Ref.
       Yes7.01.36 (0.97 to 1.92)22.30.98 (0.81 to 1.19)
      Erection problems
       No4.2Ref.21.7Ref.
       Yes6.62.41 (1.69 to 3.43)27.41.36 (1.15 to 1.61)
      a Percent of subgroup reporting predominantly negative effects of their or a sex partner's pornography use on their sex life.
      b Percent of subgroup reporting predominantly positive effects of their or a sex partner's pornography use on their sex life.
      c 1000 SEK = 97 EURO (April, 2021).
      Table 4Age-adjusted odds ratios (aOR) for reporting of predominantly negative and predominantly positive effects of their or a sex partner's use of pornography use on sex life among women.
      Predominantly negativePredominantly positive
      Percent
      Percent of subgroup reporting predominantly negative effects of their or a sex partner's pornography use on their sex life.
      aOR (95% CI)Percent
      Percent of subgroup reporting predominantly positive effects of their or a sex partner's pornography use on their sex life.
      aOR (95% CI)
      Frequency of pornography use
       Never to <3 times/month3.9Ref.12.1Ref.
       1-2 times/week7.51.38 (0.74 to 2.56)48.88.20 (5.80 to 11.60)
       ≥3 times/week3.30.59 (0.21 to 1.68)46.48.26 (4.90 to 13.93)
      Sociodemographic variables
      Education
       Primary or secondary3.8Ref.12.5Ref.
       Vocational or ≤3 years of university4.71.14 (0.85 to 1.52)16.01.01 (0.85 to 1.21)
       ≥4 years of university3.30.79 (0.49 to 1.25)13.40.74 (0.57 to 0.96)
      Monthly income in Swedish crowns
      1000 SEK = 97 EURO (April, 2021).
       <200004.5Ref.11.0Ref.
       2000 to <400003.50.75 (0.55 to 1.01)17.31.22 (1.02 to 1.46)
       40000 to <600001.10.24 (0.07 to 0.85)14.20.99 (0.62 to 1.57)
       ≥600002.70.74 (0.21 to 2.61)15.01.37 (0.57 to 3.33)
      Country of birth
       Nordic countries4.2Ref.13.1Ref.
       Rest of Europe/North America/Oceania3.90.86 (0.48 to 1.56)11.00.72 (0.50 to 1.04)
       Other2.10.39 (0.17 to 0.88)19.01.23 (0.87 to 1.75)
      Married
       No4.7Ref.13.1Ref.
       Yes3.10.79 (0.58 to 1.07)13.80.96 (0.81 to 1.14)
      Sexual health and behavior
      Sexual identity
       Heterosexual3.8Ref.13.0Ref.
       Homosexual2.50.52 (0.07 to 3.96)17.01.22 (0.53 to 2.78)
       Bisexual7.81.58 (1.05 to 2.37)28.42.65 (1.97 to 3.57)
      Frequency of having sex in past year
       Weekly or more4.0Ref.20.6Ref.
       Less than weekly5.11.45 (1.08 to 1.95)14.50.66 (0.55 to 0.79)
       Not at all2.70.99 (0.65 to 1.50)6.50.40 (0.30 to 0.52)
      Feeling that sex is important
       No3.2Ref.7.0Ref.
       Yes4.61.11 (0.83 to 1.48)17.82.17 (1.78 to 2.64)
      Feeling that high expectations on their sexual performance are a problem
       No3.9Ref.15.2Ref.
       Yes15.94.01 (2.74 to 5.88)8.50.51 (0.31 to 0.84)
      Feeling free to take initiative to sex
       No3.5Ref.5.4Ref.
       Yes4.10.94 (0.64 to 1.39)15.52.13 (1.61 to 2.82)
      Can say no if not wanting to have sex
       No4.3Ref.5.7Ref.
       Yes4.00.78 (0.49 to 1.26)14.21.82 (1.21 to 2.75)
      Ever paid or given other types of compensation for sex
       No4.0Ref.13.3Ref.
       Yes3.20.69 (0.15 to 3.16)47.55.05 (1.93 to 13.23)
      Experience of sex life during past 12 months
      Satisfied with sex life
       No4.6Ref.10.7Ref.
       Yes3.60.65 (0.50 to 0.84)15.61.31 (1.10 to 1.55)
      Dissatisfied with sex life
       No3.5Ref.13.3Ref.
       Yes7.62.03 (1.51 to 2.73)15.21.01 (0.81 to 1.26)
      Want more sexual partners
       No3.9Ref.13.2Ref.
       Yes8.31.60 (0.92 to 2.79)29.72.65 (1.77 to 3.98)
      Want less sexual partners
       No4.0Ref.13.5Ref.
       Yes18.83.88 (0.80 to 18.7)22.91.63 (0.46 to 5.74)
      Not had enough sex
       No3.4Ref.12.0Ref.
       Yes6.81.68 (1.26 to 2.22)20.31.46 (1.22 to 1.76)
      Had too much sex
       No3.9Ref.13.4Ref.
       Yes10.12.47 (1.38 to 4.42)22.71.65 (1.02 to 2.67)
      Not had sex in the preferred way
       No3.8Ref.13.1Ref.
       Yes8.21.88 (1.25 to 2.83)21.51.57 (1.14 to 2.15)
      Had sex despite not wanting to
       No3.6Ref.13.3Ref.
       Yes12.73.38 (2.33 to 4.92)17.61.19 (0.84 to 1.69)
      Too tired or stressed to have sex
       No3.2Ref.12.9Ref.
       Yes7.21.9 (1.44 to 2.52)15.90.88 (0.73 to 1.06)
      Masturbated
       No3.1Ref.10.4Ref.
       Yes6.51.78 (1.37 to 2.31)22.22.21 (1.87 to 2.60)
      Lacked sexual partner
       No3.8Ref.13.6Ref.
       Yes5.41.43 (0.98 to 2.08)12.61.07 (0.83 to 1.39)
      Health issue that affected sex life
       No3.7Ref.13.4Ref.
       Yes7.32.06 (1.45 to 2.94)14.81.07 (0.81 to 1.41)
      Sexual health issues during past 12 month
      No interest in sex
       No3.0Ref.13.1Ref.
       Yes6.22.02 (1.55 to 2.64)14.60.92 (0.78 to 1.10)
      Lack of pleasure while having sex
       No3.5Ref.13.3Ref.
       Yes9.22.41 (1.75 to 3.31)16.21.10 (0.85 to 1.44)
      Feeling worried when having sex
       No3.6Ref.13.6Ref.
       Yes13.93.32 (2.32 to 4.76)12.70.83 (0.57 to 1.19)
      Lack of arousal when having sex
       No3.5Ref.13.2Ref.
       Yes9.52.41 (1.76 to 3.3)17.01.11 (0.86 to 1.44)
      Orgasm problems (not had orgasm or too long time until orgasm)
       No3.4Ref.12.6Ref.
       Yes7.71.90 (1.43 to 2.52)18.91.44 (1.18 to 1.76)
      Too early orgasm
       No4.0Ref.13.4Ref.
       Yes8.61.82 (0.99 to 3.36)20.41.44 (0.89 to 2.32)
      Vaginal dryness
       No3.9Ref.13.4Ref.
       Yes5.21.41 (1.00 to 1.99)15.01.14 (0.91 to 1.44)
      a Percent of subgroup reporting predominantly negative effects of their or a sex partner's pornography use on their sex life.
      b Percent of subgroup reporting predominantly positive effects of their or a sex partner's pornography use on their sex life.
      c 1000 SEK = 97 EURO (April, 2021).
      Those who did not have sex in the past year were less likely to report predominantly positive effects (aOR vs weekly sex or more: men 0.48 [0.38–0.59]; women 0.40 [0.30–0.52]) while such associations were not observed for reporting of predominantly negative effects. Those who were satisfied with their sex life were less likely to report predominantly negative effects (aOR: men 0.60 [0.44–0.80]; women 0.65 [0.50–0.84]) and more likely to report predominantly positive effects (aOR: men 1.42 [1.23–1.64]; women 1.31 [1.10–1.55]). While several variables indicating dissatisfaction with the quantity or quality of sexual activity were associated with both reporting of predominantly negative and positive effects with no apparent pattern, sexual health problems tended to be associated with reporting of predominantly negative effects but not positive effects. However, orgasm problems were associated with reporting of both predominantly negative effects (aOR: men 1.96 [1.29–2.96]); women 1.90 [1.43–2.52]) and positive effects (aOR: men 1.44 [1.12–1.84]; women 1.44 [1.18–1.76]). Similarly, erection problems were associated with both reporting of predominantly negative (aOR: 2.41 [1.69–3.43]) and positive (aOR 1.36 [1.15–1.61]) effects.

      DISCUSSION

      We assessed the frequency of pornography use and its association with sexual health outcomes using a large and nationally representative survey from 2017 in Sweden. In line with data presented in the survey report,

      Public Health Agency of Sweden. Sexuell Och Reproduktiv Hälsa Och Rättigheter i Sverige 2017 [Swedish].; 2019.

      around 70% of men and 30% of women aged 16–84 years used pornography; the frequency was higher in younger age groups and decreased with age. Among men aged 16–24 years, approximately 40% used pornography at least 3 times per week (of which around half used pornography daily or almost daily), and over 20% used pornography 1–2 times/wk. Among women in the same age group approximately 4% used pornography at least 3 times per week and 9% used pornography 1-2 times/wk. While less than 5% of men and women reported that their or a sex partner's pornography use had predominantly negative effects on the sex life, over 20% of men and 15% of women reported predominantly positive effects. Dissatisfaction with the quality and quantity of sexual activity and (especially among men) sexual health problems were associated with using pornography 3 times per week or more.
      Data on frequent pornography use have been scarce as most studies have used small online surveys or self-selected samples and published data from population-based surveys have not included fine grained information about the frequency of pornography use.
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      ,

      General Social Survey. NORC University of Chicago. General Social Survey - Codebook (Appendix A).

      Data on weekly or monthly pornography use have been presented for 2 US nationally representative surveys from the past decade, although these surveys have not focused on sexual health outcomes. In the Relationship in America survey from 2014, 40% of men and 19% of women aged 18-23 years had used pornography in the past week.
      • Regnerus M
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      Documenting pornography use in America: a comparative analysis of methodological approaches.
      In the New Family Structures Study from 2011 to 2012, 47% of men and 21% of women aged 18–23 years reported using pornography once a month or more.
      • Regnerus M
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      • Price J.
      Documenting pornography use in America: a comparative analysis of methodological approaches.
      While more detailed data were not presented for these US surveys, weekly pornography use in our Swedish study vs the Relationship in America survey was more common among young men and less common among young women. While it is possible that pornography use differs between the populations, there may be differences between the surveys in the type of individuals who participated and in how they reported their pornography use. Moreover, our study used more recent data (from 2017) and use of smartphone devices and the availability of online entertainment have increased rapidly in the past years.
      In accordance with previous research,
      • McKee A.
      The positive and negative effects of pornography as attributed by consumers.
      ,
      • Rissel C
      • Richters J
      • de Visser RO
      • et al.
      A profile of pornography users in Australia: findings from the second Australian study of health and relationships.
      ,
      • Hald GM
      • Malamuth NM.
      Self-perceived effects of pornography consumption.
      we found that a minority of individuals reported that their or a sex partner's pornography use had predominantly negative effects on their sex life and reporting of predominantly positive effects was substantially more common. Importantly, frequent pornography use has been subject to much societal concern due to suggested effects on sexual wellbeing and sexual health problems although the evidence regarding such claims is conflicting.
      • Wright PJ
      • Tokunaga RS
      • Kraus A
      • et al.
      Pornography consumption and satisfaction: a meta-analysis.
      ,
      • McKee A.
      The positive and negative effects of pornography as attributed by consumers.
      • Grubbs JB
      • Perry SL
      • Wilt JA
      • et al.
      Pornography problems due to moral incongruence: an integrative model with a systematic review and meta-analysis.
      • Newstrom NP
      • Harris SM.
      Pornography and couples: what does the research tell us?.
      • Grubbs JB
      • Gola M.
      Is pornography use related to erectile functioning? Results from cross-sectional and latent growth curve analyses.
      • Hald GM
      • Malamuth NM.
      Self-perceived effects of pornography consumption.
      • Prause N
      • Pfaus J.
      Viewing sexual stimuli associated with greater sexual responsiveness, not erectile dysfunction.
      ,
      • Bőthe B
      • Tóth-Király I
      • Potenza MN
      • et al.
      High-frequency pornography use may not always be problematic.
      We found associations of frequent pornography use with dissatisfaction with the quantity and quality of sexual activity and among men, with lack of arousal when having sex and erection problems. Moreover, we observed an association between frequent pornography use and not having had sex in the last year among men (which was in contrast with previous studies
      • Rissel C
      • Richters J
      • de Visser RO
      • et al.
      A profile of pornography users in Australia: findings from the second Australian study of health and relationships.
      ,
      • Ueda P
      • Mercer CH
      • Ghaznavi C
      • et al.
      Trends in frequency of sexual activity and number of sexual partners among adults aged 18 to 44 years in the US, 2000-2018.
      ), but not women. Further, while frequent pornography use was associated with reporting predominantly positive effects on the sex life among both men and women, an association with reporting predominantly negative effects was only observed for men; this is in line with previous observations indicating that self-reported problematic use of pornography is more common among men.
      Use of pornography has been associated with changes in behaviors during sexual activity
      • Herbenick D
      • Fu TC
      • Wright P
      • et al.
      Diverse sexual behaviors and pornography use: findings from a nationally representative probability survey of Americans aged 18 to 60 years.
      ,
      • Sun C
      • Bridges A
      • Johnson JA
      • et al.
      Pornography and the male sexual script: an analysis of consumption and sexual relations.
      and it has been hypothesized that frequent pornography use introduces dissatisfaction by affecting expectations on sexual activity.
      • Goldsmith K
      • Dunkley CR
      • Dang SS
      • et al.
      Pornography consumption and its association with sexual concerns and expectations among young men and women.
      ,

      Paslakis G, Chiclana Actis C, Mestre-Bach G. Associations between pornography exposure, body image and sexual body image: a systematic review. J Health Psychol. 2020. doi: 10.1177/1359105320967085. E-pub ahead of print.

      Moreover, pornography use has been suggested to decrease partnered sexual activity and long-term sexual relationships by providing a more easily available substitute.
      • Perry SL.
      Does low-cost sexual gratification make men less eager to marry? Pornography use, masturbation, hookup sex, and desire to be married among single men.
      However, it is reasonable to hypothesize that sexual dissatisfaction or not being able to find sex partners might increase pornography use.
      • Regnerus M
      • Price J
      • Gordon D
      Masturbation and partnered sex: substitutes or complements?.
      Similarly, while frequent pornography use could be hypothesized to increase the risk of sexual health problems, individuals who experience such problems may also use more pornography. The associations could also be explained by other factors (such as stress and boredom
      • Janssen E
      • McBride KR
      • Yarber W
      • et al.
      Factors that influence sexual arousal in men: a focus group study.
      ) associated with frequent pornography use and with sexual dissatisfaction, not having partnered sex (among men) and sexual health problems. In fact, erection problems and some variables indicating sexual dissatisfaction were associated with both reporting of predominantly positive and predominantly negative effects of pornography on the sex life, indicating no consistent directionality in the associations of pornography use, as experienced by the respondents, with such outcomes. While the experience of pornography use, its potential effects on sexual health outcomes and the underlying mechanisms for such possible links are likely to differ greatly between individuals, specific sexual interests and type of pornography consumed,
      • Vaillancourt-Morel MP
      • Blais-Lecours S
      • Labadie C
      • et al.
      Profiles of cyberpornography use and sexual well-being in adults.
      ,
      • Bőthe B
      • Tóth-Király I
      • Potenza MN
      • et al.
      High-frequency pornography use may not always be problematic.
      causal effects of pornography use on the group level can only be established in interventional studies. The findings from this study should be considered as hypothesis generating.

       Limitations

      We used survey data, which are subject to response and reporting bias,
      • Regnerus M
      • Gordon D
      • Price J.
      Documenting pornography use in America: a comparative analysis of methodological approaches.
      ,
      • Fenton KA.
      Measuring sexual behaviour: methodological challenges in survey research.
      although such biases might have been mitigated by the use of self-administered questionnaires

      Park A, Clery E, Curtice J, et al. British social attitudes 28.; 2012.

      • Mindell J
      • Biddulph JP
      • Hirani V
      • et al.
      Cohort profile: the health survey for England.
      • Mercer CH
      • Tanton C
      • Prah P
      • et al.
      Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal).
      and the weighting of the sample to be representative of the Swedish population with respect to the distribution of gender, age, region, country of birth and educational level. The survey did not define pornography, nor was information available about the type of pornography used and the duration and context of use. The questions used in the survey had not been validated and their interpretation may have differed between participants. Because the data were cross-sectional, we could not assess temporality of the associations of sociodemographic and sexual health variables with the frequency and self-reported effects of pornography use.

       Conclusions

      This analysis of a nationally representative survey in Sweden found that frequent pornography use was common among younger men. Reporting that pornography use had predominantly positive effects on the sex life was more common than reporting predominantly negative effects. Sexually dissatisfied individuals and those with sexual health problems were more likely to use pornography 3 times or more per week, although conclusions regarding whether the associations represent causality and if so, in which direction, cannot be drawn.

      STATEMENT OF AUTHORSHIP

      Kinda Malki: Conceptualization, Writing – Original Draft, Writing – Review & Editing; Christoffer Rahm: Conceptualization, Writing – Review & Editing, Supervision; Katarina Görts Öberg: Conceptualization, Writing – Review & Editing, Supervision; Peter Ueda: Conceptualization, Methodology, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Supervision.

      Appendix. Supplementary materials

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