Is there a surge in youth erectile dysfunction?

Question

A 2016 article in The Australian says that there is an increase in youth ED, and furthremore that it's due to porn:

You couldn’t make it up, right? Wrong: erectile dysfunction in men in their teens and 20s — coupled with an inability to maintain erection or achieve climax — is now “massive”, according to a leading sexual psychotherapist.

“The number of young men with performance issues has escalated in the last five years,” says Angela Gregory, who has treated men with erectile dysfunction for 16 years at Britain’s Nottingham University Hospital.

“Historically this was men in their 40s and 50s with underlying health issues: cardiovascular disease, diabetes, ME (myalgic encephalomyelitis) or prostate issues. Now I see as many men in their 20s — the split is equal. This is a massive thing.”

The cause? The tidal wave of readily available online porn and the demands it is placing on generation XXX.

“ ‘Are you watching online porn?’ is now one of my main assessment questions,” Gregory says. “And the answer is almost always yes. Some can’t achieve erection, but it also (causes) inhibited or delayed ejaculation.

“One young man has women throwing themselves at him. But he finds it overwhelming that men are expected to perform like porn stars. Lots of young women now want porn sex and these guys are either not equipped to deal with these demands or don’t want to.”

And while we’re familiar with revenge porn, Gregory is hearing from an increasing number of men who are “impotency shamed” by their girlfriends on social media. “On about 10 occasions I’ve talked to men who have been outed on Facebook, Twitter, Snapchat or Instagram for not being able to sexually perform,” she says. “Everybody in their peer group gets to know they’re a failure. For a man that’s devastating. These men are retreating from normal relationships.”

Gregory says some young men can’t achieve erection because their brains’ dopamine centres have been effectively rewired by porn, meaning real girls cannot compete with the hyper-stimulation of porn.

For this Skeptics question, I'd be satisfied if this surge in youth ED is confirmed/analyzed from multiple studies, preferably with representative samples, and preferably in the most systematic way, i.e. meta-analysis. I'm not really asking the sub-question whether this claimed surge really is due to porn... cause and effect may be harder to prove; one usually needs more than epidemiological studies for that. I just want to know first if the purported effect (increase in youth ED) is undoubtedly real.

And by the way, there is a question here whether porn can lead to ED... the top-voted & accepted answer is negative, based on two or three studies. So, that's an additional reason to try and separate the claim of increase in youth ED vs. what might have caused it.

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A similar story has appeared in the Express:

Exposure to images and films is de-sensitising men in their late teens and early 20s, leaving them unable to get aroused in the bedroom, experts have revealed.

They said part of the problem is porn is immediate accessible on smartphones and tablets.

Erectile dysfunction (ED), also known as impotence, is the inability to get and maintain an erection. It is a common condition in older men but uncommon in younger men.

However, Angela Gregory, a psychosexual therapist, said she has seen a surge in young men attending her clinic at Nottingham University Hospital.

What I've seen over the last 16 years, particularly the last five years, is an increase in the amount of younger men being referred," she said.

"Our experience is that historically men that were referred to our clinic with problems with erectile dysfunction were older men whose issues were related to diabetes, MS, cardio vascular disease.

"These younger men do not have organic disease, they've already been tested by their GP and everything is fine.

"So one of the first assessment questions I'd always ask now is about pornography and masturbatory habit because that can be the cause of their issues about maintaining an erection with a partner."

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A third story not relying on the same UK data came from an Italian clinic:

In our Sexual Medicine and Andrology Unit, established in an Endocrinology setting at the University of Florence, medical consultations for younger men are infrequent, with a prevalence of men aged less than 40 years at only 14.1% of more than 3,000 men complaining of ED. However, when considering the new referrals to our Unit during the last 6 years, we can notice a progressive increase in prevalence of men below 40 years seeking medical care for ED (Figure 1). According to these data, ED is becoming a common concern even among young men, and the clinical practitioner in sexual medicine must become aware of how to manage the problem and avoid underestimating a symptom.

So this does raise the question whether it is a Europe-wide phenomenon, restricted to some countries, etc. I'm also going to say that going just by who shows up the clinics (instead of representative samples) risks a form of Berkson's paradox.

Answer 1

This just a small addition, mainly addressing the "due to pornography" part:
As already pointed out in other Skeptics answer: porn itself is not associated as causative to negative outcomes in sexual health. (Nicole Prause: "Viewing Sexual Stimuli Associated with Greater Sexual Responsiveness, Not Erectile Dysfunction", Sexual Medicine, 2015;3:90–98.)

There might well be a rise in documented cases of ED:

In contrast to what has been reported by population studies of the prevalence of ED in young patients, our findings show that one out of four men seeking medical help for ED in the daily clinical practice of an outpatient clinic is a young man below the age of 40 years. Moreover, almost half of the young men suffered from severe ED, being this proportion comparable with that observed in older individuals. Moving to the daily clinical practice, current findings prompt us to further outline the importance of taking a compre- hensive medical and sexual history and performing a thorough physical examination in all men with ED, irrespective of their age. Likewise, given the low rate of seeking medical help for disorders related to sexual health, these results express even more the need that healthcare providers may proactively ask about potential sexual complaints, once more even in men younger than 40 years of age.
_{Paolo Capogrosso et al.: "One Patient Out of Four with Newly Diagnosed Erectile Dysfunction Is a Young Man—Worrisome Picture from the Everyday Clinical Practice", International Society for Sexual Medicine (J Sex Med) 2013;10:1833–1841. DOI: 10.1111/jsm.12179}

Among the reasons listed as possible causes is not pornography but that ED might be seen as a sentinel symptom for cardio-vascular health, arteriosclerosis, obesity, diabetes etc. That is to be read as: the patients "failed" to meet the criteria for physical diagnosis, so far. But experience suggests that one of these subclinical symptoms of disease will manifest later as an ordinary organic cause for the early onset problems now. That means: a very hard to measure or even estimate portion of those young sufferers are clinically/organically fine, but will not stay in that range of health.

Having a medical community trained on diagnosing a syndrome will lead to higher diagnosis numbers. Going to a doctor and complaining makes a diagnosis much more likely than staying at home. Comparing a

'Brain re-wiring for porn' from watching it is less influential in the direct sense. Compared to masturbating four times daily really hard and fast to glamorous pictures and then failing to perform in real life one has to consider refractory periods, desensitisation from physical stimuli, callouses etc.

Erectile dysfunction
Questions about masturbation can identify whether a man’s ED is situational which helps to diagnose whether it is primarily psychogenic in nature. Accessibility to online hard core pornography can result in high‐ frequency masturbation and negatively impact on a man’s ability to become sufficiently aroused during partnered sex. Some men also masturbate in an attempt to “test out” their erectile responses, paying little attention to feelings of sexual desire or arousal thus leading to further failure.
[…]

Over the past few years there has been an explosion of online hard core pornography that is influencing and educating people about what is “normal” and creating a cultural context to which they aspire and judge themselves against. This presents serious challenges for healthcare professionals and therapists alike. (Gregory, sb.)

But is just "porn" alone really the reason for these mental pictures? That same chapter on the same page explains that a more direct cause – and one much longer on the radar for sexual therapists – for erectile dysfunction has to be called out as "caused by Facebook" (or anti-social, mean behaviour in general?):

Case study: The use of psychosexual therapy for a man presenting with psychogenic erectile dysfunction (Box 16.1) Assessment identified: Predisposing factors: Lost his erection when he first attempted sexual intercourse aged 16 years. His partner told everyone about it via Facebook; he felt humiliated and ashamed and as a result he stopped socializing and avoided sexual relationships.
_{Angela Gregory: "Psychosexual therapy for male sexual dysfunction", Ch 16, p 133–142; in: Suks Minhas & John Mulhall (Eds): "Male Sexual Dysfunction A Clinical Guide", Wiley: Chichester, 2017. (Yes, the same specialist from the article in the question.)}

That brings up a completely different point than that raised in the popular articles in the question. Not "watching porn" is so much responsible for difficulties, but anxiety when performing in real life in partnered sex, whether from comparing performances offline to on-screen or from the ramifications of anti-social behaviour. It is not the moral panic that postulates habituation to immoral pictures, technological ease of accessibility.

Answer 2

This review article was the most authoritative one I could find. As is typical with medical subjects, it turns out to be complicated. There is evidence that more young men are reporting erectile dysfunction (ED), and pornography seems to be a part of the situation. The paper presented three case studies and references a fourth. In three the problem went away when the patients stopped using pornography, and in the third the patient was unable to stop using pornography. The paper comments that proper intervention studies are needed to find out if this is a real effect.

The biggest problem with the evidence is that the increase in availability of pornography has probably led to a large increase in men watching it, so merely observing that men presenting with psychological ED also watch a lot of pornography doesn't tell you very much; they probably also eat quite a few hot dinners, but nobody is claiming that hot dinners cause ED. At the same time the increase in reported ED may be due to an increased awareness that it exists and that help is available. That this occurred at the same time as an increase in pornography is not surprising as both are mediated by the Internet.