A prescription for porn: should sex therapists recommend pornography to patients?

A startling number of sex therapists recommend commercial pornography to patients. While it might sound surprising that trained psychologists, counsellors and sexologists prescribe porn, sex therapy and pornography have a long and intertwined history.

But with a growing recognition of the harms associated with mainstream pornography production and consumption, it’s time to question a model of sex advice that promotes inequality and limits women’s sexual autonomy.

From the founding of modern sex therapy techniques in the 1960s with the work of Masters and Johnson (made famous in the Masters of Sex series) to today, there are a variety of links between the porn and sex therapy industries.

These include the use of commercial pornography in the training of therapists, and in diagnostic work, as well as treatment options. In terms of treatment, some of the earliest reports relate to fairly horrific accounts of pornography being used as part of “conversion therapy”.

A 1970 pilot study, for example, attempted to change the sexual responses of gay men. A subject was first shown homosexual pornographic images and then deprived of water for 18 hours. Drinks were made contingent on increased erection response to being shown heterosexual pornographic imagery. The authors of the paper concluded that this kind of “therapy” facilitated stronger erections in relation to heterosexual sexual imagery and that it therefore warranted further investigation with additional subjects.

Treatment trials like these trailed off in the 1970s, after homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders, and there were significant changes in the ethical norms established by practitioners. (Although we’re left to ponder the damage done while conversion-oriented experimentation with pornography was being conducted.)

By the 1980s, the focus had shifted from trying to convert gay men to heterosexuality, to more subtlety indoctrinating women into male-dominated constructions of heterosexuality. Pornography became part of treatments for sexual dysfunctions, especially for inhibition and anorgasmia in women. In effect, these labels applied to women anxious about, or unwilling to engage in sex with their male partners and women who had not experienced an orgasm, or did not experience orgasms during coitus.

One of the primary bases for using pornography in the treatment of these issues has been the concept of desensitisation. The idea is that women who are anxious about engaging in particular kinds of heterosexual sex can be encouraged to participate by being shown images and films of these acts while practising relaxation techniques. It was thought that this would eventually lead to lessening inhibition about having sex with a male partner.

As I document in my contribution to the new collection The Sexualized Body and the Medical Authority of Pornography, there is practically no evidence base to support the efficacy of these treatments. But a lack of evidence has not dissuaded therapists from continuing to endorse the use of pornography.

Research on this topic is limited, especially in Australia, but there are certainly sex therapists based here happy to publicly characterise pornography use as inevitable or healthy.

Research elsewhere in the world shows the therapeutic use of explicit audio-visual materials, including pornography, to be widespread. One study, published in the late 1990s, found that 253 of 279 (approx. 90%) professionals surveyed in the United States and the Czech Republic reported that sexually explicit materials had been useful in their practice. (Although many therapists at this time also reported negative attitudes towards violent pornography.)

In a more recent study on this topic, from 2008, around a third of sex therapists in the US reported using pornography, even when that was specifically defined as involving violent, dehumanising or sexist content.

Some therapists such as Sharna Striar and Barbara Bartlik, suggest pornography can be helpful to “introduce a partner to a new mode of sexual experience that he or she might find otherwise distasteful or unacceptable”.

Others say porn should be studied by patients like a textbook. Overall, practitioners tend to cite education and desensitisation as primary justifications for pornography use.

But what does this education and desensitisation really involve? There is a significant normalisation of violent and degrading content in popular pornography, with 88% of scenes in bestselling pornography containing acts of physical aggression, and the targets of that aggression being “overwhelmingly” female. Surely we should question why any professionals are telling women that this is a model of sexuality they should accept, let alone emulate.

At best, the practice of prescribing pornography in sex therapy encourages women to mimic those paid to fake their own sexual enjoyment. But that’s a very generous interpretation. It’s more accurate to say that the power dynamics of therapy make it quite difficult for any patient to simply refuse this kind of “treatment” when it is recommended by a qualified professional.

And it’s a treatment that risks women being seen as non-compliant if they are not aroused by degrading pornographic content, or are not willing to re-enact it in their own lives.

While some therapists and researchers have mooted “female friendly pornography” as a potential solution to this situation, they overlook the problematic and similarly violent content of porn that is often touted as “female friendly” or “feminist”. Such arguments also ignore the broader critiques of the pornography industry that contest a commercial sexual act – which is based on following a script for money, and not on mutual pleasure – as a useful or equitable basis for everyday sexual interaction.

When a medical authority integrates pornography into treatment models, they reduce the space for reasonable objections to porn consumption in heterosexual relationships.

This also promotes a model of heterosexuality that diminishes the likelihood that women’s sexual refusals will be heard and accepted.

In a climate of increasing emphasis on respectful relationships, and addressing unhealthy cultures of sexual coercion, a woman’s right to say “no” to any sex act she feels uncomfortable with should be affirmed, rather than undermined.

Given the lack of evidence in support of therapists recommending pornography as treatment, and a growing recognition of the harms associated with even mainstream, commercial porn, we need to ask why this practice has been allowed to continue for so long and who really benefits from it.