The assessment and treatment of adult heterosexual men with self-perceived problematic pornography use: A review
Introduction
Burgeoning neurobiological research has called into question the concept of addiction, which has traditionally been associated with the problematic consumption of alcohol and other substances (Love, Laier, Brand, Hatch, & Hajela, 2015). Evidence suggests, however, that various behaviors can also be classified as an addiction because of the common neurobiological mechanisms and motivational processes at play with both substances and addictive behaviors (Grant et al., 2006, Koob and Le Moal, 2008, Robinson and Berridge, 2008). This radical shift in the understanding of addiction has been accompanied by significant implications for clinical and therapeutic assessment and treatment (Love et al., 2015). This is evidenced by the American Psychiatric Association (APA) acknowledging one behavioral addiction, Gambling Disorder, with its own official classification and another, Internet Gaming Disorder, as a ‘Condition for Further Study’ within the DSM-5 (APA, 2013). The APA has not, however, provided researchers and clinicians with an overarching framework for evaluating other emerging and potentially addictive behaviors. One such behavior is compulsive pornography use, which may have the highest addictive potential of all Internet-related behaviors (Griffiths, 2012, Meerkerk et al., 2006).
Problematic pornography consumption, often referred to as ‘porn addiction’ or ‘internet porn addiction’, can be conceptualized as any use of pornography that leads to and/or produces significant negative interpersonal, vocational, or personal consequences for the user (Grubbs et al., 2015, Grubbs et al., 2015). Increasing evidence suggests that excessive and compulsive pornography consumption has similar effects to substance-dependencies, including interference with working memory performance (Laier, Schulte, & Brand, 2013), neuroplastic changes that reinforce use (Hilton, 2013, Love et al., 2015), and the significant negative association between consumption and grey matter volume in the brain (Kühn & Gallinat, 2014). Indeed, brain scan studies have shown that the brains of self-perceived pornography addicts are comparable to individuals with substance dependence in terms of brain activity as monitored by functional magnetic imaging (fMRI) data (Gola et al., 2017, Voon et al., 2014).
Sexual disorders, in general, have been excluded from formal classification in the DSM-5. In 2010, Kafka's proposal for hypersexual disorder (Kafka, 2010), even though a subsequent field trial supported the reliability and validity of criteria for hypersexual disorder (Reid et al., 2012). Pornography addiction, similarly, has been excluded from formal classification because of the lack of published scientific literature in the field (Ley, Prause, & Finn, 2014), and because compulsive pornography use is often considered a subset of other sexual disorders, i.e. Hypersexual Disorder (Kraus, Voon, & Potenza, 2016). Much of the current scientific research pertaining to problematic pornography viewing has been conceptualized as sexual addiction (Orzack & Ross, 2000), sexual impulsivity (Mick & Hollander, 2006), sexual compulsivity (Cooper, Putnam, Planchon, & Boies, 1999), or hypersexual behavior (Rinehart & McCabe, 1998), suggesting there may be similarities among the criteria of these other, related classifications. Kraus and colleagues have suggested the adoption of the term Compulsive Sexual Behavior (CSB) to reflect a broader category of problematic sexual behaviors (including pornography use) that incorporates all of the above terms (Kraus, Voon, et al., 2016). Despite similarities, however, literature suggests that problematic pornography use may be distinct and different from other sexual disorders (Duffy, Dawson, & das Nair, 2016). For example, problematic pornography use can differ from general sexual addiction because sexual activity involving human contact may be more anxiety-provoking than the ease of anonymously, privately, and inexpensively consuming pornography online (Short, Wetterneck, Bistricky, Shutter, & Chase, 2016).
Even though problematic pornography use can impact sexual behaviors, create sexual difficulties, and negatively alter attitudes related to sexuality (Cotiga & Dumitrache, 2015), therapists and clinicians are underprepared when it comes to managing problematic pornography use. Individuals who perceive themselves to have problematic use of pornography face a difficult situation in which therapists lack the sufficient training necessary to manage pornography use (Ayres & Haddock, 2009), even though clinicians believe such consumption patterns are worthy of treatment and intervention (Pyle & Bridges, 2012) and clients continue to regularly disclose habitual pornography use in sessions (Ayres & Haddock, 2009). Without an appropriate understanding of the assessment and treatment of problematic pornography use, the possibility for unethical treatment increases since therapist treatment approaches are more likely to be influenced by personal biases and beliefs (Ayres & Haddock, 2009).
Self-perceived problematic pornography use (SPPPU), or self-perceived pornography addiction, has increasingly emerged as a topic in scientific research, despite lacking formal recognition as a disorder and continued disagreements about its definition, or even existence (Duffy et al., 2016). An individual can experience pornography use as problematic for a myriad of reasons. These include personal or moral, social and relationship, time spent viewing, or viewing in inappropriate contexts such as at work (Twohig & Crosby, 2010). Consequently, even though the consumption habits and behaviors may not be inherently problematic, the costs for individuals for whom it is problematic may be significant (Twohig & Crosby, 2010).
SPPPU refers to the extent to which an individual self-identifies as addicted to pornography and feels they are unable to regulate their pornography use. This definition relies on the user's subjective self-perception and experiences when determining the extent to which the pursuit and subsequent consumption of pornography interferes with everyday life (Grubbs et al., 2015, Grubbs et al., 2015). Many individuals perceiving themselves to suffer from problematic pornography use feel they do not have viable treatment options; otherwise they would seek help (Ross, Månsson, & Daneback, 2012). This is typically because they feel their pornography use is out of control and have experienced failed attempts at either cutting back or quitting (Kraus, Martino, & Potenza, 2016). Of the small percentage of individuals who seek treatment, most indicated treatment was only marginally helpful (Kraus, Martino, et al., 2016). The purpose of this literature review is to gather, synthesize, and analyze the current literature addressing the treatment of SPPPU in adult heterosexual men, with the principle aim of contributing towards recommendations for clinicians, therapists, and future research in the field.
For purposes of this review, the term ‘porn’, ‘pornography’, or ‘internet porn’, is defined as professionally produced or consumer-generated pictures or videos intended to sexually arouse the viewer (Peter & Valkenburg, 2011). Specifically, pornography usually portrays a variety of sexual activities, including but not limited to, masturbation, oral sex, vaginal and anal intercourse, most often with a focus on the genitals (Morgan, 2011, Peter and Valkenburg, 2016).
Since its arrival, the Internet has had a huge impact on the way pornography is consumed, with most current pornographic material accessed via the Internet (Peter & Valkenburg, 2016). The Internet is credited for having provided pornography the necessary platform for unprecedented dissemination (Cooper, 1998). Some evidence suggests that the Internet has served as a catalyst for changing the fundamental relationship between the individual and pornographic material, allowing access to a seemingly endless supply of free and diverse content (Wood, 2011). The qualities specific to Internet pornography credited for this global dissemination is known as the Triple-A Engine: accessibility, affordability, and anonymity (Cooper, 1998). All indications suggest that the ever-present access to cheap and diverse pornographic material is a reality that will not change.
Problematic pornography use presents a difficult challenge for clinicians. Firstly, even though the words ‘pornography’ and ‘porn’ are often seen as negative, research has shown that self-perceived effects of pornography are generally positive, with little, if any, negative effects (Hald & Malamuth, 2008). Even persistent and frequent use can be considered a healthy form of ‘passionate attachment’ to a highly valued activity and reflect a harmonious passion, as opposed to a compulsive or obsessive behavior (Rosenberg & Kraus, 2014). While at least a portion of the overall self-perceived positive effects of pornography consumption could be explained by biased optimism, cultural bias of study participants (Hald & Malamuth, 2008), and mainstream culture becoming more pornographic in general (Weinberg, Williams, Kleiner, & Irizarry, 2010), evidence suggests that viewing pornography can, nevertheless, become problematic for a small, but significant, percentage of individuals (Cooper et al., 2000, Ross et al., 2012). For those individuals, pornography use has created problems in at least one major life domain, with the greatest implications in psychological/spiritual, behavioral, relational domains (Twohig, Crosby, & Cox, 2009).
Research suggests that individuals who are very vulnerable to the particular stimulus produced by pornography includes those with underlying comorbidities such as depression or anxiety disorders (Wood, 2011), impulsivity (Grant & Chamberlain, 2015), compulsivity (Wetterneck, Burgess, Short, Smith, & Cervantes, 2012), or those displaying deficient self-regulation (Sirianni & Vishwanath, 2016), high levels of neuroticism (Egan & Parmar, 2013), or high levels of narcissism (Kasper, Short, & Milam, 2015). Those that seek treatment are more likely to be Caucasian than from other ethnic backgrounds (Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015), believe their pornography use to be a religious or moral transgression (Grubbs et al., 2015, Grubbs et al., 2015), and report both early adolescent exposure to pornography, as well as participating in risky sexual behavior during adolescence (Doornwaard, Eijnden, Baams, Vanwesenbeeck, & Bogt, 2016). When individuals with SPPPU consume pornography, research indicates a it may be a maladaptive coping strategy and form of experiential avoidance, which is an effort to cope with and manage unwanted thoughts or negative feelings even though the coping strategy itself leads to additional harm (Wetterneck et al., 2012). Lastly, many of those who report with SPPPU are either married, in a committed relationship, or dating, and that their viewing caused problems within their relationship (Daneback, Ross, & Månsson, 2006).
Overall, studies indicate that between 2% and 17% or pornography consumers meet previously established thresholds for compulsive and/or problematic pornography use (Albright, 2008, Ross et al., 2012). Problematic pornography use has been quantified as spending at least 11 h per week viewing pornography (Cooper et al., 2000), consuming daily (Harper & Hodgins, 2016), or surpassing a threshold of seven orgasms per week (Kafka, 2010). It was found that around 9% of consumers of Internet pornography met this quantitative criteria (Cooper, Griffin-Shelley, Delmonico, & Mathy, 2001). Other researchers believe qualitative factors can help determine problematic use since the frequency of consumption might not be the core issue for patients, and because negative symptoms more strongly predict seeking treatment (Gola, Lewczuk, & Skorko, 2016).
The prevalence and nature of problematic pornography consumption seems to warrant a separate and distinct framework for assessment and treatment. Clinicians, therapists, and researchers, however, are faced with the difficult task of examining a multitude of scattered and conflicting studies on pornography and potentially harmful consequences associated with its problematic consumption. The current review seeks to assimilate and analyze the current studies and interventions that have addressed SPPPU in order to analyze approaches that have been utilized, as well as to assess their relative effectiveness for addressing problematic use.
Section snippets
Method
EBSCOhost, an online reference system with access to a broad range of academic, medical, and scientific databases, was used to access a range of databases, including: Academic Search Premier, CINAHL Plus, MEDLINE, Psychology and Behavioral Sciences Collection, and Academic Search Alumni Edition for researching in April 2017. The primary keyword search used for research was: ‘internet porn’ OR ‘porn*’ OR Internet-enabled sexual behavior OR sex* addict* within the ‘Title’ field. Studies that
Results
This search resulted in 198 relevant articles after being refined for additional parameters, such as studies only in English, only peer reviewed articles and after exact duplicates were removed from query results. 64 studies remained that were relevant and whose abstracts were scanned in order to determine relevance. Out of the 64 relevant studies, 11 studies were used in the review as they specifically addressed the treatment of problematic pornography consumption. Seven of the studies dealt
Discussion
The case for pharmacological approaches as a potential treatment option for SPPPU lacks the scientific rigor necessary for widespread clinical implementation. Gola and Potenza conducted a case series for three heterosexual men utilizing paroxetine, a serotonin reuptake inhibitor commonly used as anxiety medication, along with Cognitive Behavioral Therapy (CBT). All three men reported significantly lower levels of anxiety and decreased pornography consumption, which could be the result of
Conclusion
Even though SPPPU is not currently a diagnosable disorder, like other potentially problematic behaviors, it can adversely impact functioning in a variety of significant life domains. SPPPU will likely be a growing problem because an ever-increasing number of people are accessing the Internet, where a diverse and seemingly unlimited quantity of free pornography content can be accessed privately and anonymously. While the case for the existence and prevalence of SPPPU is strong, many questions
Role of funding sources
Funding for this research was provided by the Auckland University of Technology in Auckland, New Zealand. The funding sponsor had no role in study design, collection, analysis, or interpretation of data, writing the manuscript, or the decision to submit the manuscript for publication.
Contributors
Luke Sniewski conducted literature searches and provided summaries of previous research studies. Luke Sniewski wrote the first draft of the manuscript and Panteá Farvid and Phil Carter contributed to editing, strategic direction, literature review study design, and approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
References (76)
- et al.
Internet sex addiction treated with naltrexone
Mayo Clinic Proceedings
(2008) - et al.
The role of thought suppression in the relationship between mindfulness meditation and alcohol use
Addictive Behaviors
(2007) - et al.
Acceptance and commitment therapy for problematic internet pornography use: A randomized trial
Behavior Therapy
(2016) - et al.
Pornography addiction in adults: A systematic review of definitions and reported impact
The Journal of Sexual Medicine
(2016) - et al.
What matters: Quantity or quality of pornography use? Psychological and behavioral factors of treatment seeking for problematic pornography consumption
The Journal of Sexual Medicine
(2016) - et al.
Self-regulation and alcohol use involvement: A latent class analysis
Addictive Behaviors
(2014) - et al.
Report of findings in a DSM-5 field trial for hypersexual disorder
The Journal of Sexual Medicine
(2012) - et al.
The relationship of “passionate attachment” for pornography with sexual compulsivity, frequency of use, and craving for pornography
Addictive Behaviors
(2014) - et al.
Acceptance and commitment therapy as a treatment for problematic internet pornography viewing
Behavior Therapy
(2010) - et al.
Naltrexone: A pan-addiction treatment?
CNS Drugs
(2016)
Sex in America online: An exploration of sex, marital status, and sexual identity in internet sex seeking and its impacts
Journal of Sex Research
Diagnostic and statistical manual of mental disorders
Therapists' approaches in working with heterosexual couples struggling with male partners' online sexual behavior
Sexual Addiction & Compulsivity
Deficits in emotion-regulation skills predict alcohol use during and after cognitive behavioral therapy for alcohol dependence
Journal of Consulting and Clinical Psychology
Naltrexone for the treatment of comorbid tobacco and pornography addiction
The American Journal on Addictions
Shame and the x-rated addiction: The role of spirituality in treating male pornography addiction
Sexual Addiction & Compulsivity
Sexuality and the Internet: Surfing into the new millennium
Cyberpsychology & Behavior
Cybersex users, abusers, and compulsives: New findings and implications
Sexual Addiction & Compulsivity: The Journal of Treatment and Prevention
Online sexual problems: Assessment and predictive variables
Sexual Addiction and Compulsivity: Journal of Treatment and Prevention
Online sexual compulsivity
Sexual Addiction and Compulsivity
Men's sexual life and repeated exposure to pornography. A new issue?
Journal of Experiential Psychotherapy
Characteristics and behaviors of sexual compulsives who use the internet for sexual purposes
Sexual Addiction & Compulsivity
Lower psychological well-being and excessive sexual interest predict symptoms of compulsive use of sexually explicit internet material among adolescent boys
Journal of Youth & Adolescence
Alcohol use and alcohol-related consequences: Associations with emotion regulation difficulties
American Journal of Drug & Alcohol Abuse
Dirty habits? Online pornography use, personality, obsessionality, and compulsivity
Journal of Sex & Marital Therapy
An Adlerian perspective on problematic internet pornography use
Journal of Individual Psychology
Structural therapy with a couple battling pornography addiction
American Journal of Family Therapy
The roles of shame and guilt in hypersexual behavior
Sexual Addiction & Compulsivity
Paroxetine treatment of problematic pornography use: A case series
Journal of Behavioral Addictions
Can pornography be addictive? An fMRI study of men seeking treatment for problematic pornography use
The neurobiology of substance and behavioral addictions
CNS Spectrums: The International Journal of Neuropsychiatric Medicine
Psychopharmacological options for treating impulsivity
Psychiatric Times
A promising debut for computerized therapies
American Journal of Psychiatry
Internet sex addiction: A review of empirical research
Addiction Research and Theory
Transgression as addiction: Religiosity and moral disapproval as predictors of perceived addiction to pornography
Archives of Sexual Behavior
Internet pornography use: Perceived addiction, psychological distress, and the validation of a brief measure
Journal of Sex & Marital Therapy
Self-perceived effects of pornography consumption
Archives of Sexual Behavior
Cited by (65)
Treatment Approaches for Problematic Pornography Use: A Systematic Review
2024, Archives of Sexual BehaviorTargeting Mechanisms for Problematic Pornography Use Interventions
2024, Sexual Health and CompulsivityBehavioral Posology: A Novel Paradigm for Modeling the Healthy Limits of Behaviors
2023, Advanced Theory and SimulationsPornography Consumption and Cognitive-Affective Distress
2023, Journal of Nervous and Mental Disease