Since 2016, 17 US states have introduced nonbinding resolutions declaring pornography a public health crisis (Table 1). Evidence suggests that although pornography may elevate risk for certain health outcomes, pornography itself is not a crisis.

TABLE 1— US State Resolutions Declaring Pornography a Public Health Crisis as of September 30, 2019

State Bill Year Introduced Passed House Passed Senate Signed by Governor UT SCR009 2016 2016 2016 2016 AR HR1042 2017 2017 . . . . . . FLa H0157 2017 2018 . . . . . . KS HR6016 2017 2017 . . . . . . LA HCR100 2017 2017 2017 . . . OK HCR1006 2017 2017 . . . . . . PA HR519 2017 2018 . . . . . . SD SCR4 2017 2017 2017 . . . TN SJR0035 2017 2017 2017 2017 VAa HJR549 2017 2017 . . . . . . ID HCR050 2018 2018 . . . . . . KY SR170 2018 . . . 2018 . . . MO SCR52 2018 . . . 2018 . . . AZ HCR2009 2019 2019 2019 . . . MT HR5 2019 2019 . . . . . . OHb HR180 2019 . . . . . . . . . TXc HCR126 2019 . . . . . . . . .

TERMINOLOGY Section: Choose Top of page TERMINOLOGY << US STATE RESOLUTIONS IS PORNOGRAPHY A PUBLIC H... WHAT’S THE HARM? PORNOGRAPHY FROM A PUBLIC... CONCLUSIONS REFERENCES Social scientists commonly define pornography as sexually explicit materials intended to arouse. According to the Oxford Handbook of Public Health Practice (Oxford, UK: Oxford University Press; 2013), a public health crisis has three main qualities: (1) it is an acute event that requires an immediate response; (2) the event is expected to imminently lead to death, infectious disease morbidity, property destruction, or population displacement; and (3) it overwhelms the capacity of local systems to do the job of maintaining a community’s health.

US STATE RESOLUTIONS Section: Choose Top of page TERMINOLOGY US STATE RESOLUTIONS << IS PORNOGRAPHY A PUBLIC H... WHAT’S THE HARM? PORNOGRAPHY FROM A PUBLIC... CONCLUSIONS REFERENCES In 2016, Utah became the first state to pass a resolution declaring pornography a public health crisis. All subsequent states have introduced resolutions using similar or identical language. Resolution language originated from theologically conservative Christian advocacy groups,1 not from public health agencies. Generally, the resolutions declare that pornography leads to risky sexual behavior, affects brain development and functioning, is potentially addictive, and increases infidelity. Further, they declare that pornography normalizes violence, which leads to increases in sex trafficking, prostitution, childhood sexual abuse, and child pornography. Some of these contentions are supported by research, others are partially supported, and some are unsupported. The text of the recently passed Arizona HCR2009 (http://bit.ly/2s7FoxA) provides a good example: Whereas, pornography is a crisis leading to a broad spectrum of individual and public health impacts; and Whereas, pornography perpetuates a sexually toxic environment that damages all areas of our society; and Whereas, potential detrimental effects on pornography users include toxic sexual behaviors, emotional, mental and medical illnesses and difficulty forming or maintaining intimate relationships; and Whereas, recent research indicates that pornography is potentially biologically addictive and requires increasingly shocking material for the addiction to be satisfied. This has led to increasing themes of risky sexual behaviors, extreme degradation, violence and child pornography; and Whereas, pornography is directly harming our nation’s youth by contributing to the hyper-sexualization of teens and even children; and Whereas, due to the advances in technology and the universal availability of the internet, children are being exposed to pornography at an alarming rate, leading to low self-esteem, eating disorders and an increase in problematic sexual activity at ever-younger ages; and Whereas, exposure to pornography often serves as sex education for children and shapes their sexual templates, teaching them that women are commodities for the viewer’s use; and Whereas, pornography normalizes violence and the abuse of women and children by treating them as objects, increasing the demand for sex trafficking, prostitution and child pornography; and Whereas, the use of pornography has an adverse effect on the family as it is correlated with decreased desire in young men to marry, dissatisfaction in marriage and infidelity; and Whereas, the societal damage of pornography is beyond the capability of the individual to address alone; and Whereas, to counteract these detrimental effects, this state and the nation must systemically prevent exposure and addiction to pornography, educate individuals and families about its harms and develop pornography recovery programs. Therefore, be it resolved by the House of Representatives of the State of Arizona, the Senate concurring: That the Members of the Legislature denounce pornography as a public health crisis.

IS PORNOGRAPHY A PUBLIC HEALTH CRISIS? Section: Choose Top of page TERMINOLOGY US STATE RESOLUTIONS IS PORNOGRAPHY A PUBLIC H... << WHAT’S THE HARM? PORNOGRAPHY FROM A PUBLIC... CONCLUSIONS REFERENCES On the basis of the existing evidence, we believe that some pornography harms the health of some people, but that it does not meet the criteria of a public health crisis, for the following reasons: 1. Pornography is not an acute event that requires an immediate response. Although pornography use has increased over time, the rise has been steady, even with the advent of the Internet.2 As such, there does not appear to be an acute event or tipping point that would require immediate response. 2. Pornography does not directly or imminently lead to death, infectious disease morbidity, property destruction, or population displacement. Research suggests that there may be adverse health consequences of pornography use for some, no substantial consequences for the majority, and positive effects for others.3,4 For example, for the minority predisposed to perpetrate sexual violence, viewing violent pornography may exacerbate risk.3 Additionally, individuals who frequently view pornography portraying risk behaviors (e.g., condomless sex) may be more likely to engage in them.3 Research on how pornography affects the cohesion and fidelity of relationships and sexual satisfaction is mixed, but the majority of users do not experience substantial problems.3–6 Importantly, death, infection, property destruction, and population displacement are not resulting from pornography use. And for some, pornography use is associated with health-promoting behaviors, including increased intimacy, “safer” sexual behaviors (e.g., solo masturbation), and feelings of acceptance.3,4,7 3. Pornography does not overwhelm the capacity of local systems to do the job of maintaining a community’s health. There are multiple resources within communities across the United States for individuals who believe they are negatively affected by pornography, including therapy. Our systems are not overwhelmed.

WHAT’S THE HARM? Section: Choose Top of page TERMINOLOGY US STATE RESOLUTIONS IS PORNOGRAPHY A PUBLIC H... WHAT’S THE HARM? << PORNOGRAPHY FROM A PUBLIC... CONCLUSIONS REFERENCES Calling something a “public health crisis” when it is not demonstrably so may result in unwarranted policy or funding shifts. For example, government agencies may spend money to convene experts for high-level meetings or require businesses and individuals to comply with unwarranted regulations. Moreover, pathologizing any form of sexual behavior, including pornography use, has the potential to restrict sexual freedom and to stigmatize, which is antithetical to public health. If the public health workforce wants to save its power to mobilize people when an acute threat is imminent, reserving the phrase “public health crisis” for strategic, select times is advisable.

PORNOGRAPHY FROM A PUBLIC HEALTH PERSPECTIVE Section: Choose Top of page TERMINOLOGY US STATE RESOLUTIONS IS PORNOGRAPHY A PUBLIC H... WHAT’S THE HARM? PORNOGRAPHY FROM A PUBLIC... << CONCLUSIONS REFERENCES Although pornography is not a crisis, public health has much to offer an ongoing analysis of pornography’s impact on health. The Centers for Disease Control and Prevention outlines a four-step process to approach any public health problem: (1) define and monitor the problem, (2) identify risk and protective factors, (3) develop and test prevention strategies, and (4) ensure widespread adoption of developed strategies. Pornography is an exposure of interest, not an outcome. Under this framework, the first step would be to determine the health outcome of interest, to consider the full constellation of risk and protective factors related to that outcome, and weigh pornography’s role in relation to the others. Bronfenbrenner’s (1979) social-ecological model may also prove useful. Considering pornography as one of many exposures that can influence outcomes across multiple levels of the social-ecology and developing interventions accordingly has higher odds of success than the overly simplistic approach of declaring pornography a crisis and promoting its abolishment or limited access. Harm reduction is also worth considering. The idea that people could be motivated to use less pornography—or less extreme pornography, and less frequently—is a harm reduction goal. Interventions seeking to increase pornography literacy, as opposed to trying to stop individuals from all use, could also be useful.

CONCLUSIONS Section: Choose Top of page TERMINOLOGY US STATE RESOLUTIONS IS PORNOGRAPHY A PUBLIC H... WHAT’S THE HARM? PORNOGRAPHY FROM A PUBLIC... CONCLUSIONS << REFERENCES Although research suggests that pornography use likely influences some people negatively, and it merits further research, pornography itself is not a crisis. The movement to declare pornography a public health crisis is rooted in an ideology that is antithetical to many core values of public health promotion and is a political stunt, not reflective of best available evidence.

See also Landers and Kapadia, p. 140 , and the AJPH Public Health of Pleasure section, pp. 145 – 160 .

ACKNOWLEDGMENTS K. M. Nelson is supported by the National Institute of Mental Health (K23MH109346). Note. The contents of this editorial are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health.

CONFLICTS OF INTEREST The authors have no conflicts of interest to declare.

REFERENCES Section: Choose Top of page TERMINOLOGY US STATE RESOLUTIONS IS PORNOGRAPHY A PUBLIC H... WHAT’S THE HARM? PORNOGRAPHY FROM A PUBLIC... CONCLUSIONS REFERENCES <<

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