Comment on “Reboot/NoFap Participants Erectile Concerns Predicted by Anxiety and Not Mediated/Moderated by Pornography Viewing”

We would like to congratulate the authors for questioning the Reboot/NoFap approach to male sexual arousal problems. As clinicians, we see a steep increase of patients asking about the sense or nonsense of trying such an approach.

The attention paid toward possible mediating or moderating effects of pornography use on the relationship between anxiety symptoms and erectile functioning goes toward the much-needed nuance in understanding the intricate interplay between mental sates, sexual arousal, erectile functioning, masturbation, and porn use.

The commented study did not find any indirect effects of the frequency of porn use on the relationship between anxiety and erectile dysfunction (ED). We agree that performance anxiety is one of the most predominant reasons why young men experience ED.

This study could have more strength if the nature of porn use (problematic or not) was taken into account. Studies have shown that the frequency of porn use has no direct association with ED.^1,3 In our own study of 2,067 sexually active young man, measuring performance anxiety, pressure and problematic porn use, a clear association with situational ED was seen with ED ranging from 12% in the lower Cyber Pornography Addiction Test (CYPAT) scores to 49.6% for the higher CYPAT scores.

An additional significant effect of both performance pressure and anxiety on the incidence of ED was seen irrespective of the CYPAT score. Still, the higher the CYPAT score, the higher the ED incidence. This makes a complex reality: while using porn might lead to performance anxiety, performance anxiety could also stimulate more or problematic porn use.

We applaud the researchers to actively link their findings to recent insights into culturally driven concepts of masculinity and how they impact sexual functioning. Their hypothesis that Reboot/NoFap men might believe that their sexual anxiety makes them more feminine links in with recent findings by Bosson et al, ⁴ showing that the status of being a “real man” is harder to win and maintain, and easier lost than the status of being a “real woman.” ⁴

Finally, stating that “perhaps men in Reboot/NoFap are not actually experiencing ED symptoms but are fearful that their erections are not good enough” is problematic. It might be that these men have normal Rigiscan erectile measurements but report ED. This does not mean that their ED symptoms are not real. It merely brings to light that their symptoms are more cognitive/mental in nature. These men do experience a real problem, albeit situational. Furthermore, the European Urological Guidelines ⁵ clearly state that situational ED limits the routine use of nocturnal erection testing for diagnostic purposes. Any successful therapeutic approach of this group needs to start from a stance of 100% acceptance of the patients’ reality, seeing them as the experts of their own problem. ⁶

The last words on porn use and sexual functioning are far from spoken. From a clinician’s point of view, the way people masturbate might be the most important factor toward understanding their problem. Clinicians need to ask about all aspects of how patients masturbate. This means including porn use, while not solely/overly focusing on it.