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Library of Congress Cataloging-in-Publication Data
Names: Rothman, Emily F., author.
Title: Pornography and public health / by Emily F. Rothman. Description: New York, NY : Oxford University Press, [2021] | Includes bibliographical references and index. | Identifiers: LCCN 2021013438 (print) | LCCN 2021013439 (ebook) | ISBN 9780190075477 (hardback) | ISBN 9780190075491 (epub) | ISBN 9780190075507 (online)
Subjects: MESH: Erotica | Public Health | Communications Media | Sex Offenses—prevention & control | United States Classification: LCC HQ472. U6 (print) | LCC HQ472. U6 (ebook) | NLM HQ 472. U6 | DDC 306.77/1—dc23
LC record available at https://lccn.loc.gov/2021013438
LC ebook record available at https://lccn.loc.gov/2021013439
DOI: 10.1093/oso/9780190075477.001.0001
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Preface
The purpose of this book is to provide information about pornography to students of public health, public policy, communications, and other fields. My intention is to introduce the reader to some of the intriguing arguments that have been made about pornography, to contextualize those arguments in history, and to encourage further critical thinking about these issues. This book is not exhaustive—there is a lot of ground yet to cover, and I hope that some of what is presented here can serve as a useful base for others who will improve upon my contribution.
Many scholars, and nonscholar activists, have picked a side in the propornography vs. anti-pornography ideological debate. I am not one of them. I’ve been researching and thinking about pornography and public health every day for nearly a decade and it has become clear to me that pornography is too diverse to either condemn or absolve. My read of the results of the existing peer-reviewed research is that some pornography is harmful to some people in some situations and may have some negative effects on social norms and other societal-level factors. However, not all pornography is inherently dangerous, and it’s harmful to the public to suppress access to sexual information and sexually explicit material in general.
The mission of this book is to enrich the discourse about pornography and public health—not to advance an anti-pornography or pro-pornography agenda. I do worry, specifically, about the impact of free, mainstream, internet pornography on youth sexual norms and the risk for sexual aggression perpetration and victimization. But I also worry about the repressive agenda of the anti-pornography movement. When we begin to chip away at sexual freedom, we start down a slippery slope that ends in tyranny. Whether pornography is harmful to public health cannot be turned into a simple question.
While this book covers 14 topics that, in my experience as a teacher, are foundational for understanding how we approach pornography in public health research and practice, there are an almost equal number of topics that I left out but are nevertheless essential for a comprehensive understanding of the issue. In particular, it is a limitation that there is no chapter on racism and pornography, no chapter about porn for, or featuring, people with disabilities, and no chapter on gay or lesbian porn. These are profoundly important topics that have not yet been adequately addressed by empirical studies.
Feminist studies scholars, film scholars, cultural studies scholars, and others have written essential reading on these topics that I have found thoughtprovoking and worthwhile. I have considered racism, ableism, homophobia, and classism in my digestion of the existing research, and I have commented on these themes to the extent possible in my chapters while focusing on peerreviewed, published studies. I am hopeful that students of public health and students from related disciplines will be able to pursue research on these topics and that 10 years from now there will be an array of evidence to review. There are other topics that I also found myself underprepared to address from an evidence-based perspective, including whether pornography causes erectile dysfunction or depression, and the extent to which condomless sex is featured in pornography. Information on virtual reality pornography, sex dolls and robots, and other technological advances in pornography would also benefit the field. These are important topics for public health consideration. I thank the individuals who generously contributed their time to review chapters: Ashley Fires, Lisa Goldblatt-Grace, Sarah Leonard, Michael Meltsner, Carol Queen, Kenneth Rothman, Alice Richmond, Richard Saitz, and Jay Wexler. Thank you to Ryan Cassidy for the research trip. Thank you to David Hemenway, Jonathan Howland, Elizabeth Miller, Deb Bowen, Megan Bair-Merritt, and Greg Stuart for mentorship. Thank you to Kim Nelson, Debra Herbenick, Jess Alder, and Nicole Daley for our collaborations. My gratitude to Sandro Galea for facilitating this opportunity. I am grateful to my parents, parents-in-law, and my siblings. I would also like to thank the three people and one dog that I love most in the world for their unending support and making it possible for me to pursue my career-related dreams. Miluji tě.
Abbreviations
AAML American Academy of Matrimonial Lawyers
AASECT American Association for Sexuality Educators, Counselors and Therapists
ACLU American Civil Liberties Union
AIM Adult Industry Medical Healthcare Foundation
AMA American Medical Association
APA American Psychiatric Association
APAC Adult Performer Advocacy Committee
APAG Adult Performers Actors Guild
ASAM American Society of Addiction Medicine
AVN Adult Video News
BBW Big Beautiful Women
BDSM bondage, discipline/dominance, submission/sadism, and masochism
BIPOC Black, indigenous, and other people of color
BRFSS Behavioral Risk Factor Surveillance System
CDA Communications Decency Act of 1996
CDC Centers for Disease Control and Prevention
COPA Child Online Protection Act
CPPA Child Pornography Prevention Act
CSBD compulsive sexual behavior disorder
DSM Diagnostic and Statistical Manual of Mental Disorders
ED erectile dysfunction
EEG Electroencephalography
ERP event-related potential
fMRI functional magnetic resonance imaging
FOSTA Fight Online Sex Trafficking Act
FSC Free Speech Coalition
GSS General Social Survey
IEAU International Entertainment Adult Union
IITAP International Institute for Trauma and Addiction Professionals
I-PACE Interaction of Person-Affect-Cognition-Execution
LPPs late positive potential
MILF Moms I’d Like to Fuck
MRI magnetic resonance imaging
MSM men who have sex with men
NCMEC National Center for Missing and Exploited Children
NFSS National Family Structure Survey
NHIS National Health Interview Survey
NIH National Institutes of Health
x Abbreviations
OSHA Occupational Safety and Health Administration
OSS Program “On Set Steward Program”
PALS Portraits of American Life Study
PASS Performer Availability Screening Services
POC Person of Color
POV Point of View
PPU problematic pornography use
RCT randomized controlled trial
RIA Relationships In America
SESTA Stop Enabling Sex Traffickers Act
SFW Safe For Work
SIECUS Sex Information and Education Council of the United States
SOCE Sexual Orientation Change Efforts
STIs sexually transmitted infections
TLDR “Too long; didn’t read”
TVPA Trafficking Victims Protection Act
VSS visual sexual stimuli
YISS Youth Internet Safety Survey
YRBS Youth Risk Behavior Surveys
1 Pornography as a US Public Health Problem
When I first proposed to teach a class on pornography and public health at the Boston University School of Public Health in 2014, the curriculum committee had a few questions for me. Specifically, they wondered how a class about pornography would complement existing courses on acknowledged public health topics like cancer prevention, maternal mortality, and health care organization and management. I understood why pornography seemed like an unserious topic in comparison. To be honest, it hadn’t been my life goal to become a pornography scholar or teacher. I find looking at pornography boring. I’ve seen some that has held my interest, but on the whole sexually explicit images don’t turn me on. That said, I’m also not outraged or disgusted by the concept of legal, consensual, erotic material. I was raised in a sex-positive family, and since an early age have been a fan of nonconformists. And, like many public health and antiviolence activists, I’m a feminist. Objectification of, and cruelty toward, other people are not merely a turn off to me—fighting them is my reason for being. So in 2011, when one of my research analyses uncovered that pornography was an important variable in a study of dating abuse, I was inspired to learn more about it. As I discovered, there was a lot to think about, and there was much that public health tools and training could add to the discourse.
But a decade ago, when I was starting out on my pornography scholarship journey, I understood why we would wrestle with devoting resources, time, or attention to the topic. Public health professionals are tasked with managing threats with high mortality rates, such as pandemics, obesity, substance use disorders, access to healthcare, pollution, climate change, and many more acute health threats. On the other hand, we don’t have the choice to continue to ignore the topic of pornography, both because of mounting scientific evidence about the ways in which some of it may influence some people’s health and because of politics. In 2016, the Republican Party platform included a section titled “Ensuring Safe Neighborhoods: Criminal Justice and Prison Reform,” which included, rather curiously—given that pornography
is not neighborhood-based, illegal, or germane to prison reform—the statement that: “pornography, with its harmful effects, especially on children, has become a public health crisis that is destroying the lives of millions. We encourage states to continue to fight this public menace and pledge our commitment to children’s safety and well-being”1 (p. 40).
Has pornography truly become a public health crisis? Whether it has or not, it is being indicted as one, and not just at the federal level. In the United States, the following states have passed resolutions affirming the crisis and condemning pornography: Utah (2016), Virginia, Tennessee, South Dakota, Louisiana, Kansas, and Arkansas (2017), Florida, Idaho, Kentucky, and Pennsylvania (2018), and Arizona, Montana, and Ohio (2019).2 State resolutions are nonbinding, meaning that there is little that changes about day-to-day life in a state when they are passed, but the 2018 and 2019 versions of the resolutions call upon state district attorneys and the US Department of Justice to enforce federal obscenity laws and call upon Congress to “address the crisis problem of children accessing pornography on the Internet,” meaning that the intention is for action to be taken, public dollars to be spent, and public officials’ time to be allocated accordingly.2 A good question is whether these expenditures in the name of public health would be worth it, diverting funds that could have been directed toward the list of other public health priorities that need to be addressed.
The professional public health community is not behind the recent push to declare pornography a public health crisis. One might think that if pornography is a public health menace, “destroying the lives of millions,”1 public health entities and professional societies must have a viewpoint on the topic, perhaps a clearly outlined health-promotion agenda related to the problem, and a strategic plan. At least one of the National Institutes of Health (NIH) must have named it as a priority, the Centers for Disease Control and Prevention (CDC) must have a branch devoted to putting a stop to it, and the World Health Organization must have at least one infographic on its harms. But none of these things exists or has happened. In fact, there is no public health professional presently in any position of public health leadership or authority who has gone on record to say that pornography is a public health topic of interest—let alone a public health crisis. In 2016, in a written statement to CNN, the CDC said it “does not have an established position on pornography as a public health issue. Pornography can be connected to other public health issues like sexual violence and occupational HIV transmission.”3 But if public health entities are not behind the movement to declare pornography a public health problem, who is? And why are they using the language of public health for their cause?
The Definition of a Public Health Crisis, Problem, and Issue
Before solving the mystery of how pornography became a public health issue without the involvement of any public health professional organizations, it makes sense to define our terms. Pornography has been called a public health crisis, emergency, problem, and issue. The definition of these words matters, because calling something a public health crisis is often used to justify muscular government action. The Oxford Handbook of Public Health Practice4 defines a public health crisis as: “an event(s) that overwhelms the capacity of local systems to maintain a community’s health. . . . Crises can range from specific health issues, such as a disease outbreak in an otherwise unaffected community, to a full-scale disaster with property destruction and/or population displacement and multiple public health issues” (pp. 210–211). Similarly, the CDC defines a crisis as an unexpected and threatening event requiring an immediate response.5
In short, a crisis is defined as a critical moment in a dangerous situation that can be reasonably expected to lead to death, infectious disease morbidity, property destruction, or population displacement, and that overwhelms the capacity of local systems to do the job of maintaining a community’s health. Consistent with this definition, the first time the word “crisis” was used in the American Journal of Public Health was in 1914, in an opinion piece about public health in a time of war. The crisis in question was World War I, which ranks among the deadliest conflicts in human history, and in which over 117,000 US lives were lost.6
Journalists are under pressure to attract attention to their articles, and it is no secret that some indulge in sensational language. By my count, in the years 2002 to 2015, media reports paired the words “public health crisis” with no fewer than 27 different topics, including AIDS, Ebola, opioids, air pollution, tainted food, energy drinks, school start times, and childhood obesity, among others. Some of these may, in fact, rise to level of true emergencies, while others may be harder to defend as crises. The harm in calling something a “public health crisis” when it is not demonstrably so is that it may motivate lawmakers to consider new policy or shifts in funding that may not be warranted and may activate the public health infrastructure to use all the tools at its disposal to address the problem. For example, government agencies may spend money to convene experts for high-level meetings; authorities may require businesses and individuals to comply with regulations, such as pulling possibly tainted food (or explicit magazines) from shelves;7 or healthcare professionals may quarantine infected individuals in a hospital. Calling
something a public health crisis means invoking a fast and potentially powerful response from federal, state, and municipal government, the press, and members of the public. Another harm is that the public may get burned out on hearing that yet another topic is a public health crisis that requires immediate action and expenditures. If the public health workforce wants to save its power to mobilize people when an acute threat is imminent (for example, when a global pandemic strikes), reserving the phrase “public health crisis” for strategic, select times is advisable.
Pornography is not always portrayed as a public health crisis or emergency. It has also been referred to as a “problem,” “issue,” and “concern.”8,9 There is no hard and fast definition of what counts as a public health problem, issue, or concern—and perhaps that’s for the best. Spending time and energy nailing down a definition of a public health problem seems futile, given that new concerns emerge all the time and warrant consideration. But, if there is no definition, should anything—can anything—count as a public health issue? For example, could any one of us declare that something is a public health issue (e.g., pumpkin spice lattes, TikTok dances), and voilà, make it so? We might be able to do that, but for reasons of avoiding wasted resources and watering down bona fide public health efforts, we shouldn’t. And for this reason, it’s a good thing that we have at least some guidance from the field about what should be counted as a public health problem, issue, concern, or priority.
In 1999, Dr. Thomas Durant argued in the journal Sociological Spectrum that it was time to view violence as a public health problem. In doing so, he laid out what constitutes a public health problem, and he wrote that a public health problem “contributes to both morbidity and mortality, mental and physical injury, and health and medical costs”10 (p. 274). Consistent with this definition, in 2013, the CDC created a guide to teach people how to prioritize public health problems. The guide uses the following criteria for determining if something should be prioritized: (1) The prevalence of the problem; (2) the potential of the problem to result in severe disability or death, using disabilityadjusted life years, for example; (3) monetary and societal costs, such as medical expenses, social services, public services, costs to employers, and loss of productivity; and (4) the availability of effective interventions (where more availability makes it more likely that something should be prioritized).11 In short, while there is no bright line that helps define which issues are worthy of public health consideration, there are some general principles that help public health professionals decide how to spend limited resources, such as money, energy, the attention of the public, and lawmakers’ time. Because pornography does not result in severe disability or death except in the rarest of cases, it is not clear that it should be considered a public health priority. Sexual
and dating violence victimization, as well as sexually transmitted infections, are without question public health issues because they demonstrably cause death and disability, and pornography may be a factor contributing to these problems. However, unless it can be established that pornography is responsible for a substantial percentage of violence victimization cases or cases of sexually transmitted infections, the public health focus should remain on these important outcomes of interest and not zero in on pornography. Pornography is one possible causal exposure for the outcomes of interest, so what would be the justification for declaring it a public health crisis when so many other possible causal exposures remain understudied?
Mary Calderone: The First to Ask the Question
The first person to ever pose the question about whether pornography should be considered a public health problem in a scholarly journal was Dr. Mary Calderone, who wrote on this theme in a 1972 issue of the American Journal of Public Health. 12 Calderone was an American physician and is famous for being the mother and champion of sex education. She worked as the medical director of Planned Parenthood from 1953 to 1964 and also served as the president and co-founder of the Sex Information and Education Council of the United States (SIECUS) from 1964 until 1982.13 She is perhaps best known for successfully fighting the American Medical Association (AMA) on their policy that physicians should not disclose information about birth control to patients, which they overturned in 1964. And, in the height of her effectiveness, she was called “witch, mistress of the Devil, prostitute of hell” by Christian opponents to sex education.14
In her 1972 discussion of pornography in a public health context, Dr. Calderone made several important points.12 First, she argued that the erotic is essential to good public health, and therefore public health professionals should recognize that while in some contexts the erotic could be harmful, in other contexts it’s not just appropriate but necessary for individuals and societies. Second, she objected to the use of the term “pornography” to lump together all kinds of erotic material, because some sexual material may be, in her words, innocent. Third, she encouraged her readers to acknowledge that what seems objectionable to one person might be entirely normal for another person, and that neither should interfere with the privacy and rights of the other. Fourth, she pointed out that because we are a pluralistic society with diverse values, it was difficult to imagine who would be qualified to arbitrate whether pornography was noxious to society.12 She also emphasized that a
public health response to pornography would be supportive of sex workers, advocate for effective sex education, partner with faith-based groups that are in favor of evidence-based and scientific approaches, and promote positive eroticism for both youth and adults alike. Even though it was 50 years ago, Calderone’s response is the same response that we should be embracing today. She answered the question “Is pornography a public health problem?” by suggesting that the context of pornography use matters and that we must be very careful not to substitute morality-based judgments about sexually explicit material for scientific conclusions about the etiology of sexual violence and sexually transmitted infections.
Surgeon General C. Everett Koop
After Calderone, the next official to offer a position on pornography as a public health issue was Surgeon General C. Everett Koop, who served under President Ronald Reagan from 1982 to 1989. Koop was a lifelong Republican and politically conservative, but he was not one-dimensional. He supported sex education in schools during the AIDS epidemic. In 1986, he convened a 3day workshop in Arlington, Virginia, on pornography and public health. The stated goal of the workshop was to summarize the evidence about the effects of pornography, particularly on children. Twenty experts from the fields of communications, medicine, mental health, and social science were in attendance, including Dolf Zillman, Ann Burgess, Albert Bandura, Jon Conte, Neil Malamuth, Edward Donnerstein, and Murray Straus. A 252-page report was produced.
In the report, the Surgeon General summarized the five papers that were presented at the conference and concluded that “pornography does stimulate attitudes and behavior that lead to gravely negative consequences for individuals and for society.”15 But a close read of the five papers reveals that Koop’s synopsis misrepresented what was presented. The experts found insufficient scientific support for the influence of pornography on violence against women (pp. 28–29), stated that the effect of pornography on children less than 12 years old was unknown (p. 37), and that it wasn’t possible to say anything definitive about the effects of pornography on children at the time (p. 38). While the experts did express concern that sexual violence may be caused, in part, by people’s attitudes about using coercion during sex—and that those attitudes may be influenced by watching pornography depicting coercive sex—they said “it is not clear that exposure to pornography is the most significant factor in the development of these attitudes”
(p. 23). But Koop’s summary statement aligned with the views of the Christian anti-pornography movement, who espoused the view that pornography was causing the “moral decline of America” and waged what has been called a “symbolic crusade” against pornography as a way to protest changing gender and sexual norms more generally.16 Anti-pornography organizations linked pornography to homosexuality and gay rights, abortion, and sex education and mobilized support against all of these issues simultaneously by invoking the idea that pornography was a threat to public health.16 Public health became a politically useful frame for those with a right-wing social agenda.
State Resolutions on Pornography as a Public Health Crisis
In 2016, Utah became the first US state to declare pornography a public health hazard.17 As of November 2020, 14 states had passed such resolutions. Here I summarize the text of the 2018 model state resolution on pornography as a public health crisis presented by the National Decency Coalition.18 The document is of interest to public health professionals because it asserts that pornography has a direct and negative influence on at least 11 measurable outcomes, such as low self-esteem, body image, acceptance of rape, difficulty maintaining intimate relationships, and others.
The resolution text begins with the statement that pornography is creating a public health crisis. It continues with the declaration that pornography “perpetuates a sexually toxic environment,” and “efforts to prevent pornography exposure and addiction, to educate individuals and families concerning its harms, and to develop recovery programs must be addressed systemically in ways that hold broader influences accountable.” Next, it builds the case against pornography and states that it contributes to the following outcomes [some paraphrased, some quoted directly]:
1. The hypersexualization of teens, and even prepubescent children, in our society
2. Low self-esteem and body image disorders
3. An increase in problematic sexual activity at younger ages
4. Greater likelihood of young adolescents’ engaging in risky sexual behavior, such as sending sexually explicit images, hookups, multiple sex partners, group sex, and using substances during sex
5. Bad information reaching children and youth about sex
6. The treatment of women as objects—“It teaches girls they are to be used and boys to be users”
7. The normalization of violence and abuse of women and children
8. The normalization and acceptance of rape and abuse—“It often depicts rape and abuse as if they were harmless”
9. The increase in the demand for sex trafficking, prostitution, and child sexual abuse images (i.e., child pornography).
10. Potential detrimental effects on pornography’s users affecting their brain development and contributing to emotional and medical illnesses
11. Influence on deviant sexual arousal
12. Difficulty in forming or maintaining intimate relationships, as well as problematic or harmful sexual behaviors and addiction
13. Biological addiction to pornography, which means the user requires more novelty, often in the form of more shocking material, in order to be satisfied; and this biological addiction leads to increasing use of pornography featuring themes of risky sexual behaviors, extreme degradation, violence, and child sexual abuse images (i.e., child pornography).
14. The lessening of desire of young men to marry, dissatisfaction in marriage, and infidelitya detrimental effect on the family unit.
The text concludes with the statement that: “Overcoming pornography’s harms is beyond the capability of the afflicted individual to address alone. . . . NOW, THEREFORE, BE IT RESOLVED, that the Legislature of the State of _ recognizes that pornography is a public health hazard leading to a broad spectrum of individual and public health impacts and societal harms.”
The remaining chapters of this book review the research evidence on several of the assertions made in this model state resolution.
Pornography from a Public Health Perspective
A typical public health strategy is to observe that there is an outcome we wish to change and then to consider the full spectrum of risk and protective factors that may influence it. For example, if the problem is diabetes, we may work on solutions that have to do with diet, exercise, access to care, and racism. One of the problems with declaring pornography a public health problem is that pornography is an exposure—not a disease, condition, or behavior. Sometimes an exposure is solidly linked to numerous health outcomes, in which case we consider the exposure itself a public health problem. Racism and lead, for example, are exposures that are considered public health problems. But
pornography is not yet clearly established as a risk factor for multiple health outcomes. Evidence suggests that certain types of pornography may cause aggression and compulsive use in some people and negatively influence youth sexual behavior, and it is implicated in some cases of human trafficking. But there are also drawbacks to, and even possible harms from, eradicating pornography—including harms to those who create it consensually and earn an income from it, harms associated with limiting the availability of information about sex generally, harm related to stigmatizing nondominant sexualities or sexual behaviors, harm in denying that eroticism is important for human health, and harms associated with controlling what adults say, do, or can see, which influence whether they can live safe, fulfilling, and free lives.
For these reasons, it is problematic when advocacy groups appropriate public health language to try to advance their cause without engaging in an authentic public health agenda-building process. However, it would be a mistake to discount what may also be real threats to health posed by pornography just because advocacy groups have framed their message in ways that do not resonate with the standard public health approach. As a field, public health has much to offer if our task is to contemplate whether pornography has relevance for individuals’ health and well-being, and excellent tools that we can use if we decide there is some aspect of pornography production, dissemination, or use that we wish to address. Below I provide my own top five ways that public health tools can be applied to questions about the impact of pornography on human health: (1) Using the four steps of a public health approach; (2) The social-ecological model; (3) Harm reduction; (4) Ethics; and (5) Coalition-building.
The Four Steps of a Public Health Approach
There is a best practice, or recommended way, to approach any public health problem.19 The first step is to define the problem, and typically the problem is a health outcome, such as becoming ill. The problem could also be engaging in a behavior that we know to be a strong risk factor for becoming ill. Once we have identified the problem in as precise terms as possible, the second step is to identify risk factors or protective factors for that problem. In the case of pornography, the outcome of interest might be sexual assault, and pornography may emerge as one of the risk factors that we seek to address. After identifying the outcome and one or more risk or protective factors, the third step is to develop and test prevention strategies. Finally, once we have evidence that our prevention strategies work, we promote adoption of those strategies. This can
be useful to us as we consider whether pornography should be part of a public health action agenda because it will guide us to start with an outcome, to consider the full constellation of potential risk and factors that may lead to that outcome, and to weigh pornography’s role in relation to the others. It will also guide us in the strategic development of prevention strategies that have a logical connection to the outcome of concern, and then to advocate for adoption of the prevention strategies only if they prove to be effective. In other words, we would not begin the process by advocating for a ban on pornography, then try to determine if pornography had ill effects on sexual assault. A logical flow of steps would be: to agree that sexual assault is an outcome of interest; to look at the array of factors that might influence it; to zero in on pornography due to its connection to sexual assault, if warranted; to develop prevention strategies that are expected to influence the impact of pornography use as it pertains to sexual assault; and to evaluate whether our prevention strategy was effective.
The Social-Ecological Model
The social-ecological model is a way of organizing risk and protective factors that emphasizes the dynamic interplay between what are referred to as levels of the social ecology.20 For example, according to this model, determinants of health problems or their solutions can be arrayed according to the following levels: intrapersonal (including, for example, personal characteristics, such as gender, sexual orientation, socioeconomic status, and psychological traits), interpersonal (including family and peer factors, such as experiences of child abuse or affiliating with a delinquent peer group), institutional factors (such as school climate or workplace policies), community factors (including neighborhood features, community resources, and the built environment), and societal-level factors (including social norms and public policies).
The social-ecological model can help us think about pornography and its possible influence on public health in different ways. First, if we are investigating sexual assault as an outcome, we can picture pornography in the community factors level, one of perhaps fifty or more factors arrayed across the multiple levels. Other factors will include self-concept and sexual drive at the intrapersonal level, experiences of parent-to-child abuse and childhood sexual abuse at the intrapersonal level, school-bonding and employment support for health and wellness in the institutional factors level, and policies that harm or help people who are convicted of sex offenses to manage their behavior at the public policy level. Visualizing pornography as one of many factors across multiple levels of the social ecology that may relate to sexual
assault helps to put into perspective the idea that we should focus all or most of our time, money, and attention on fighting pornography. A second way that we might use the social-ecological model is to think about what causes problematic pornography use. If we take problematic pornography use as the outcome, we might use a social-ecological model approach to map out intrapersonal factors that put people at risk for such problematic use, as well as interpersonal, institutional, community, and societal-level factors. Arraying risk factors for problematic pornography use this way would enable us to see that the right solution to problematic use is not simply to tell people “pornography is bad, stop using it,” but would necessitate responses that support people with intrapersonal risk factors, such as a lack of knowledge about sex, interpersonal factors, such as experiences of abuse victimization, and institutional factors, such as lack of access to behavioral healthcare through their workplace. Finally, the social-ecological model can help us to array our proposed solutions to some aspect of pornography production and use so that we ensure we have at least one or two strategies at every level, working conjointly. This type of rich and fully elaborated consideration of pornography as a risk factor for an outcome of interest has much higher odds of success than the scattershot approach currently being used by those who say that they object to pornography as a public health issue. Their approach is to say pornography is bad for many reasons, let’s declare it a problem and limit access to it. A public health-informed multilevel consideration of the potential impact of pornography on human health will yield a wider variety of, and more effective, solutions.
Harm Reduction
Harm reduction is a “pragmatic public health approach encompassing all goals of public health: improving health, social well-being, and quality of life.”21 Harm reduction was initially developed as a way to improve the lives of people who use drugs “in partnership with those served without a narrow focus on abstinence from drugs.”21 The idea is simple. Instead of an abstinence-only perspective, the public health professional embraces the idea that helping a person move one step further along the continuum of behavior change is for the best. For example, even if someone is not ready to quit chronic alcohol use, they might be ready to use less alcohol. A harm-reduction practitioner would be enthusiastic about the change from high use to low use.
When it comes to pornography use, a harm-reduction approach would celebrate small victories in moving people from harmful use toward less harmful
use—rather than insist upon an “all or nothing” outcome. The idea that all people should cease and desist from pornography use 100% is an abstinenceonly goal. The idea that people could be motivated to use less pornography, or less extreme pornography, and less frequently, is a harm-reduction goal. The harm-reduction approach has been found to be effective at reducing a number of negative health behaviors, most notably substance use.22
Ethics: Balancing Benefits over Harms for Most People
People sometimes call the public health system the “nanny state” or “big brother,” which is a way of saying that the public health infrastructure has the goal to influence and sometimes limit behavior and freedom. There are always factions of the public that object to public health regulation. For example, during the COVID-19 pandemic, many have had strong objections to wearing masks. Another example from the field of injury prevention is that there are people who do not want to wear motorcycle helmets, despite evidence that helmets can reduce brain injury and death substantially. There have been bitter debates about whether public health and government entities should have the power to impose requirements to wear helmets on people who would rather be free to enjoy riding without a helmet. There have been similar debates about seatbelt laws, lifejacket requirements on water crafts, infant car seats, texting and driving laws, and mandatory HIV testing. As a field, public health has wrestled for nearly two centuries with how to strike balances between protecting the health of the public and imposing on the public’s freedom. We agonize over how to ensure that the largest percentage of the public benefits substantially without impinging too drastically on freedoms or safety. As a result, when it comes to policy choices about pornography, trained public health ethicists and policy experts should be able to offer sound guidance. Principled action that carefully weighs the costs and consequences of controlling media against the supposed benefits is needed. Public health professionals have the right preparation and training to undertake this type of difficult determination, in collaboration with experts from other fields, and to make recommendations.
Coalition-Building to Solve Problems
A final strength that public health practice has to offer those who are grappling with whether and how to manage the influence of pornography on the
public is its capacity to bring diverse communities and individuals together. “Nothing about us without us” is a slogan that has been used for decades to express the idea that policymakers need to partner with the people affected by the proposed legislation that they craft. It was popularized in the United States in the 1990s by disability rights activists23 and was adopted by the sex worker rights movement shortly thereafter. What the slogan means in the context of pornography-related policy and intervention development is that it is best practice to be inclusive of people who have performed in pornography and who work in pornography production, retail, or businesses related to pornography sales (e.g., payment processing systems). However, sex workers are not the only stakeholders who may need to be included in policy and intervention development processes. Formerly exploited people (e.g., those who have experienced human trafficking) also deserve to contribute their experiences, as do concerned parents, youth, violence-prevention advocates, artists, first amendment experts, anti-racism activists, Internet technology specialists, and perhaps a lengthy list of others. Is it possible to have a table large enough for everyone to have a seat? And who decides which individuals are truly representative of their stakeholder groups, whether participation will be remunerated and how, and how decisions will be made in cases of disagreement? These questions are not necessarily easily answered, but the field of public health has prior experience establishing participatory processes to benefit communities and members of the public. There are best practices and how-to manuals that describe how to establish fair, inclusionary, balanced groups of collaborators who share equitable access to information and a voice in decision-making processes. With good stewardship, and grounded in the principles of social justice, even diverse groups of stakeholders who may have fundamental disagreements on particular aspects of a problem can be brought together for meaningful collaboration on public health topics. Experienced public health professionals with expertise in community-based participatory research and in policy and intervention development should take leadership to address pornography-related concerns through coalition-building.
Conclusions
Sexual violence, partner violence, anxiety, depression, compulsive pornography use, and commercial sexual exploitation are public health problems, and there is a possibility that pornography exacerbates these problems. Given that possibility, we need to know more about whether, how, and why pornography influences social norms as well as individuals’ behavior, and what we
can do to address that influence if it is harmful. It is also important to be aware that framing pornography as a public health issue has been used as a rhetorical trick by right- wing groups to promote a conservative social agenda at odds with public health goals. Public health professionals should sponsor rigorous research on the possible negative effects of pornography on society and individuals, counter misinformation, and use evidence to move forward with policy decisions.
2. National Decency Coalition. 2019. https://nationaldecencycoalition.org/updates/
3. Howard, J. 2016. “Republicans Are Calling Porn a ‘Public Health Crisis,’ But Is It Really?” https://www.cnn.com/2016/07/15/health/porn-public-health-crisis/index.html
4. Guest, C., W. Ricciardi, I. Kawachi, and I. Lang. 2013. Oxford Handbook of Public Health Practice. OUP Oxford.
5. US Centers for Disease Control and Prevention. 2014. “Crisis and Emergency Risk Communication.” https://emergency.cdc.gov/cerc/ppt/cerc_2014edition_Copy.pdf
6. Byerly, C. R. 2017. “War Losses (USA).” in: 1914–1918-online. International Encyclopedia of the FirstWorld War, ed. by Ute Daniel, Peter Gatrell, Oliver Janz, Heather Jones, Jennifer Keene, AlanKramer, and Bill Nasson, issued by Freie Universität Berlin, Berlin 2014-10-08. doi:10.15463/ie1418.10162. https://encyclopedia.1914-1918-online.net/pdf/1914-1918Online-war_losses_usa-2014-10-08.pdf
7. Kelly, K. J. 2015. “Stores Urged Not to Openly Display ‘Pornographic’ Cover.” https:// nypost.com/2015/02/10/stores-urged-not-to-openly-display-pornographic-cover/
8. Fight the New Drug. 2018. “Why Is Porn Being Considered a Public Health Concern?” https://fightthenewdrug.org/porn-considered-a-public-health-concern/
9. Caplan, A. L. 2019. “Pornography: A Public Health Problem?” http://www.medscape.com/ viewarticle/880510
10. Durant, T. J. 1999. “Violence as a Public Health Problem: Toward an Integrated Paradigm.” Sociological Spectrum 19, no. 3: 267–280.
11. US Centers for Disease Control and Prevention. 2013. “Prioritizing Public Health Problems.” https://www.cdc.gov/globalhealth/healthprotection/fetp/training_modules/4/ prioritize-problems_fg_final_09262013.pdf
12. Calderone, M. S. 1972. “ ‘Pornography’ as a Public Health Problem.” American Journal of Public Health 62, no. 3: 374–376.
13. Mary S. Calderone, Pioneer in Sex Education, Dies at 94. 2019. https://www. washingtonpost.com/ archive/ local/ 1998/ 10/ 25/ mary- s- calderone- pioneer- in- sexeducation-dies-at-94/ec3e0b6e-2b31-4ad8-85b3-e37173e9a4ef/
14. Petrzela, N. 2019. “Witches Get Stuff Done” (Podcast). https://www.caveat.nyc/podcasts/ nevertheless-she-existed/witches-get-stuff-done
16. Burke, K. 2019. “Why the Christian Right Opposes Pornography but Still Supports Trump.” http:// theconversation.com/ why- the- christian- right- opposes- pornography- but- stillsupports-trump-94156
17. Hamblin, J. 2016. “Inside the Movement to Declare Pornography a ‘Health Crisis.’” https:// www.theatlantic.com/health/archive/2016/04/a-crisis-of-education/478206/
18. National Decency Coalition. 2019. “Pornography: Public Health Crisis Resolution.” https://nationaldecencycoalition.org/updates/
19. US Centers for Disease Control and Prevention. 2019. “The Public Health Approach to Violence Prevention.” https://www.cdc.gov/violenceprevention/publichealthissue/ publichealthapproach.html
20. Bronfrenbrenner, U. 1979. The Ecology of Human Development. Cambridge, MA: Harvard University Press.
21. Stancliff, S., B. W. Phillips, N. Maghsoudi, and H. Joseph. 2015. “Harm Reduction: Front Line Public Health.” Journal of Addictive Diseases 34, no. 2-3: 206–219.
22. Dick, S., E. Whelan, M. P. Davoren, et al. 2019. “A Systematic Review of the Effectiveness of Digital Interventions for Illicit Substance Misuse Harm Reduction in Third-Level Students.” BMC Public Health 19, no. 1: 11.
23. Charlton, J. 2006. “Nothing About Us Without Us.” In Encyclopedia of Disability, edited by G. I. Albrecht. Thousand Oaks, CA: SAGE Publications.
