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Journal of
Clinical Medicine
Review
Online Porn Addiction: What We Know and What We
Don’t—A Systematic Review
Rubén de Alarcón1, Javier I. de la Iglesia 1, Nerea M. Casado 1and Angel L. Montejo 1, 2, *
1Psychiatry Service, Hospital Clínico Universitario de Salamanca, Institute of Biomedical Research of
Salamanca (IBSAL), 37007 Salamanca, Spain; ruperghost@gmail.com (R.d.A.);
javidelaiglesia.jdli@gmail.com (J.I.d.l.I.); nmcasado91@gmail.com (N.M.C.)
2University of Salamanca, EUEF, 37007 Salamanca, Spain
*Correspondence: amontejo@usal.es; Tel.: +34-639754620
Received: 27 November 2018; Accepted: 10 January 2019; Published: 15 January 2019
Abstract:
In the last few years, there has been a wave of articles related to behavioral addictions;
some of them have a focus on online pornography addiction. However, despite all efforts, we are still
unable to profile when engaging in this behavior becomes pathological. Common problems include:
sample bias, the search for diagnostic instrumentals, opposing approximations to the matter, and the
fact that this entity may be encompassed inside a greater pathology (i.e., sex addiction) that may
present itself with very diverse symptomatology. Behavioral addictions form a largely unexplored
field of study, and usually exhibit a problematic consumption model: loss of control, impairment,
and risky use. Hypersexual disorder fits this model and may be composed of several sexual behaviors,
like problematic use of online pornography (POPU). Online pornography use is on the rise, with a
potential for addiction considering the “triple A” influence (accessibility, affordability, anonymity).
This problematic use might have adverse effects in sexual development and sexual functioning,
especially among the young population. We aim to gather existing knowledge on problematic online
pornography use as a pathological entity. Here we try to summarize what we know about this entity
and outline some areas worthy of further research.
Keywords:
online pornography; addiction; cybersex; internet; compulsive sexual behavior;
hypersexuality
1. Introduction
With the inclusion of “Gambling Disorder” in the “Substance Use and Addictive Disorders”
chapter of the DSM-5 [
1
], the APA publicly acknowledged the phenomenon of behavioral addiction.
Furthermore, “Internet Gaming Disorder” was placed in Section 3—conditions for further study.
This represents the ongoing paradigm shift in the field of addictions that relates to addictive
behavior, and paves the way for new research in the light of cultural changes caused by the
new technologies.
There is apparently an existing common neurobiological [
2
] and environmental [
3
] ground
between the varying addictive disorders, including both substance abuse and addictive behavior;
this can manifest as an overlapping of both entities [4].
Phenomenologically, behaviorally addicted individuals frequently exhibit a problematic
consumption model: impaired control (e.g., craving, unsuccessful attempts to reduce the behavior),
impairment (e.g., narrowing of interests, neglect of other areas of life), and risky use (persisting
intake despite awareness of damaging psychological effects). Whether these behaviors also meet
physiological criteria relating to addiction (tolerance, withdrawal) is more debatable [4–6].
J. Clin. Med. 2019,8, 91; doi:10.3390/jcm8010091 www.mdpi.com/journal/jcm
J. Clin. Med. 2019,8, 91 2 of 20
Hypersexual disorder is sometimes considered one of those behavioral addictions. It is used as an
umbrella construct that encompasses various problematic behaviors (excessive masturbation, cybersex,
pornography use, telephone sex, sexual behavior with consenting adults, strip club visitations, etc.) [
7
].
Its prevalence rates range from 3% to 6%, though it is difficult to determine since there is not a formal
definition of the disorder [8,9].
The lack of robust scientific data makes its research, conceptualization, and assessment difficult,
leading to a variety of proposals to explain it, but is usually associated with significant distress, feelings
of shame and psychosocial dysfunction [
8
], as well as other addictive behaviors [
10
] and it warrants
direct examination.
Concurrently, the rise of the new technologies has also opened up a pool of problematic addictive
behavior, mainly Internet Addiction. This addiction may focus on a specific application on the internet
(gaming, shopping, betting, cybersex . .. ) [11] with potential for risk-addictive behavior; in this case,
it would act as a channel for concrete manifestations of said behavior [
4
,
12
]. This means inevitable
escalation, providing new outlets for established addicts as well as tempting people (due to increased
privacy, or opportunity) who would not have previously engaged in these behaviors.
Online pornography use, also known as Internet pornography use or cybersex, may be one of
those Internet-specific behaviors with a risk for addiction. It corresponds to the use of Internet to engage
in various gratifying sexual activities [
13
], among which stands the use of pornography [
13
,
14
] which
is the most popular activity [
15
–
17
] with an infinite number of sexual scenarios accessible [
13
,
18
–
20
].
Continued use in this fashion sometimes derives in financial, legal, occupational, and relationship
trouble [
6
,
21
] or personal problems, with diverse negative consequences. Feelings of loss of control and
persistent use despite these adverse results constitute “online sexual compulsivity” [
22
] or Problematic
Online Pornography Use (POPU). This problematic consumption model benefits from the “Triple A”
factors [23].
Due to this model, pornography-related masturbation may be more frequent nowadays, but this
is not necessarily a sign of pathology [
21
]. We know that a considerable proportion of young male
population access Internet for pornography consumption [
24
,
25
]; in fact, it is one of their key sources
for sexual health [
26
]. Some have expressed concern about this, addressing the time gap between when
porn material is consumed for the first time ever, and an actual first sexual experience; specifically,
how the former can have an impact on sexual development [
27
] like abnormally low sexual desire
when consuming online pornography [
28
] and erectile dysfunction, which has spiked dramatically
among young men in the past few years when compared to a couple decades ago [29–33].
We systematically reviewed the existing literature on the subject of POPU to try and summarize
the various recent advances made in terms of epidemiology, clinical manifestations, neurobiological
evidence that supports this model of problematic use, its diagnostic conceptualization in relation to
hypersexual disorder, its proposed assessment instruments and treatment strategies.
2. Methods
We performed the systematic review following PRISMA guidelines (Figure 1). Given the
relatively new body of evidence regarding this subject, we conducted our review with no specific
time-delimitation. Priority was placed upon literature reviews and articles published via a newest to
oldest methodology, preferentially for already published reviews on the subject. PubMed and Cochrane
were the main databases used, though a number of articles were compiled through cross-referencing.
J. Clin. Med. 2019,8, 91 3 of 20
J. Clin. Med. 2019, 8, x FOR PEER REVIEW 3 of 21
Figure 1. PRISMA flow diagram.
Since our focus was mainly online pornography and addictive sexual behavior, we excluded
those articles that had only a peripheral association with it in our search: those with a focus on
generalized Internet addiction, those centered on the pornographic equivalent of varying paraphilias,
and those that approached the subject from a social perspective.
The following search terms and their derivatives were used in multiple combinations: cybersex,
porn* (to allow for both “pornography” and “pornographic”), addict* (to allow for both “addiction”
and “addictive”), online, internet, sex, compulsive sex, hypersexuality. The reference management
tool Zotero was used to build a database of all articles considered.
3. Results
3.1. Epidemiology
Pornography consumption in the general population proves difficult to be adequately
measured, especially since the rise of the Internet and the “triple A” factors which have allowed for
both privacy and ease of access. Wright’s study about the use of pornography in U.S. male population
using the General Social Survey (GSS) [34], and Price’s study (which expands upon Wright’s by
distinguishing among age, cohort, and period effects) [35] constitute some of the few, if not the only
ones, existing sources that track pornography use in the general population. They show the overall
increasing consumption of pornography over the years, especially among male population in contrast
to females. This is particularly prevalent among young adults, and it steadily decreases with age.
496 articles found through database
searches
152 articles selected for full-text review
138 articles match inclusion criteria
344 articles excluded after screening for
both title & abstract
184 articles included
14 articles excluded:
Focus on generalized Internet
addiction (4), focus on social
perspective (2), focus on paraphilic
sexual behavior (8)
46 additional articles identified
through cross-referencing
Figure 1. PRISMA flow diagram.
Since our focus was mainly online pornography and addictive sexual behavior, we excluded those
articles that had only a peripheral association with it in our search: those with a focus on generalized
Internet addiction, those centered on the pornographic equivalent of varying paraphilias, and those
that approached the subject from a social perspective.
The following search terms and their derivatives were used in multiple combinations: cybersex,
porn* (to allow for both “pornography” and “pornographic”), addict* (to allow for both “addiction”
and “addictive”), online, internet, sex, compulsive sex, hypersexuality. The reference management tool
Zotero was used to build a database of all articles considered.
3. Results
3.1. Epidemiology
Pornography consumption in the general population proves difficult to be adequately measured,
especially since the rise of the Internet and the “triple A” factors which have allowed for both privacy
and ease of access. Wright’s study about the use of pornography in U.S. male population using the
General Social Survey (GSS) [34], and Price’s study (which expands upon Wright’s by distinguishing
among age, cohort, and period effects) [
35
] constitute some of the few, if not the only ones, existing
sources that track pornography use in the general population. They show the overall increasing
consumption of pornography over the years, especially among male population in contrast to females.
This is particularly prevalent among young adults, and it steadily decreases with age.
J. Clin. Med. 2019,8, 91 4 of 20
Some interesting facts about pornography consumption tendencies stand out. One of them is that
the 1963 and 1972 male cohort showed only a very small decline on their usage from the year 1999
onwards, suggesting that porn consumption among these groups has remained relatively constant
since [
35
]. The other one is that 1999 is also the year the tendency for women aged 18 to 26 to consume
pornography became three times as likely than the ones aged 45 to 53, instead of just two times as
likely as it used to be up until that point [
35
]. These two facts could be related to changing tendencies
in pornography consumption motivated by technology (switching from the offline to the online model
of consumption), but it is impossible to know for sure since the original data does not account for
differences in both offline and online variants when tracking pornography usage.
As for POPU, there is no clear and reliable data in the literature reviewed that can offer a solid
estimation of its prevalence. Adding up to the already mentioned motives for lack of data on general
pornography consumption, part of it might stem from the perceived taboo nature of the topic at hand
by possible participants, the wide range of assessment tools used by researchers, and the lack of
consensus on what actually constitutes a pathological usage of pornography, which are all issues also
reviewed further into this paper.
The vast majority of studies pertaining POPU or hypersexual behavior prevalence use convenience
samples to measure it, usually finding, despite population differences, that very few users consider
this habit an addiction, and even when they do, even fewer consider that this could have a negative
effect on them. Some examples:
(1)
A study assessing behavioral addictions among substance users, found that only 9.80% out of
51 participants considered they had an addiction to sex or pornography [36].
(2)
A Swedish study that recruited a sample of 1913 participants through a web questionnaire, 7.6%
reported some Internet sexual problem and 4.5% indicated feeling ‘addicted’ to Internet for love
and sexual purposes, and that this was a ‘big problem’ [17].
(3)
A Spanish study with a sample of 1557 college students found that 8.6% was in a potential risk
of developing a pathological usage of online pornography, but that the actual pathological user
prevalence was 0.7% [37].
The only study with a representative sample to date is an Australian one, with a sample of
20,094 participants; 1.2% of the women surveyed considered themselves addicted, whereas for the
men it was 4.4% [
38
]. Similar findings also apply to hypersexual behavior outside of pornography [
39
].
Predictors for problematic sexual behavior and pornography use are, across populations: being a
man, young age, religiousness, frequent Internet use, negative mood states, and being prone to sexual
boredom, and novelty seeking [
17
,
37
,
40
,
41
]. Some of this risk factors are also shared by hypersexual
behavior patients [39,42].
3.2. Ethiopathogenical and Diagnostic Conceptualization
Conceptualizing pathological behaviors continues to be a challenge today. While several attempts
have been made regarding hypersexual behavior, the lack of robust data as of now explains the fact
that there’s no consensus on this matter [
9
]. POPU comprises a very specific set of sexual behaviors
that involve technology. Due to problematic technology use (especially online technology) being
relatively recent, we need first to talk about hypersexual behavior not related to technology in order to
understand the place of online pornography in it.
Sexuality as a behavior is vastly heterogeneous, and its potential pathological side has been
studied for centuries [
43
]. Therefore, it represents a challenge to models trying to adequately define
it, since it can incorporate practices ranging from solitary fantasizing to sexual violence [
21
]. It is
also difficult to define what constitutes an actual dysfunction and manage to avoid the possible
misuse of that definition to stigmatize and pathologize individuals [
44
]. For example, some set the
limit between normal and pathological sexual behavior at more than seven orgasms in a week [
43
]
(p. 381), but this approach focusing on quantity can be dangerous, since what constitutes normal and
J. Clin. Med. 2019,8, 91 5 of 20
pathological behavior can vastly vary between individuals. This lack of uniformity and consistency in
its classification may hinder future research on investigating hypersexual behavior [
45
] and ignore
the quality aspects that focus on the negative emotions associated with it [
46
,
47
]. There have been
proposals to redeem this issue using certain tools, already developed as part of the hypersexual
disorder proposal used in the DSM-5 field trial [43,47].
Hypersexuality generally acts as an umbrella construct [
7
]. Its nomenclature is still a matter
of debate to this day, and it is frequent to encounter several terms that refer to the same concept:
compulsive sexual behavior, sex addiction, sexual impulsivity, hypersexual behavior or hypersexual
disorder. Some authors, while recognizing the value of the terms “addiction” and “compulsivity”,
prefer to draw attention to the issue of control and its possible loss or compromise as the primary
concern about this behavior, thus referring to it as “out of control sexual behavior” [45,48,49].
Although definitions are not uniform, they usually focus on the frequency or intensity
of symptoms [
46
] of otherwise normal urges and fantasies, that would result in dysfunction.
This differentiates it from paraphilic sexual behavior, though the need for a better clarification of
possible differences, similarities, and overlap between the two types still persists [45].
Usually included in hypersexual behavior are excessive masturbation and various sexual
related behaviors, like dependence on anonymous sexual encounters, repetitive promiscuity, internet
pornography, telephone sex, and visiting strip clubs [43,44,49–51]. Bancroft particularly thought that,
in using Internet, both masturbation and these sexual activities could blend themselves, stating that
men “use it as an almost limitless extension of their out of control masturbatory behavior”.
While the possibility to diagnose hypersexual behavior was always available with “sexual disorder
not otherwise specified” in the DSM [
1
], Kafka [
43
] tried to propose it as a diagnostic entity for the
DSM-5. He presented a set of criteria for it, as part of the sexual disorders chapter. These proposed
models included hypersexual behavior as: (1) sexually motivated, (2) a behavioral addiction, (3) part of
the obsessive-compulsive spectrum disorder, (4) part of the impulsivity-spectrum disorders, and (5) an
“out of control” excessive sexual behavior. This proposal was ultimately rejected due to several reasons;
the main was said to be absence of consolidated epidemiological and neuroimaging data regarding this
behavior [
52
,
53
], but also its potential for forensic abuse, a not specific enough set of diagnostic criteria,
and potential politic and social ramifications of pathologizing an integral area of behavior to human
life [
54
]. It is interesting to compare it to the other two previous set of criteria present in the reviewed
literature, those of Patrick Carnes and Aviel Goodman [
9
]. All three share the concepts of loss of control,
excessive time spent on sexual behavior and negative consequences to self/others, but diverge on the
other elements. This reflects in broad strokes the lack of consensus in conceptualizing hypersexual
behavior across the years. Currently, the main options propose hypersexual behavior either as an
impulse control disorder or a behavioral addiction [55].
From an impulse control disorder perspective, hypersexual behavior is generally referred
to as Compulsive Sexual Behavior (CSB). Coleman [
56
] is a proponent of this theory. While he
includes paraphilic behavior under this term [
57
], and they may coexist in some cases, he distinctly
differentiates it from nonparaphilic CSB, which is what we want to focus on in this review. Interestingly,
nonparaphilic hypersexual behavior is usually as frequent, if not more, than some paraphilias [
43
,
58
].
However, more recent definitions of CSB usually refer to multiple sexual behaviors that can be
compulsive: the most commonly reported being masturbation, being followed by compulsive use of
pornography, and promiscuity, compulsive cruising, and multiple relationships (22–76%) [9,59,60].
While there are definite overlaps between hypersexuality and conditions such as
obsessive-compulsive disorder (OCD) and other impulse control disorders [
61
], there are also some
notable differences pointed out: for example, OCD behaviors do not involve reward, unlike sexual
behavior. Moreover, while engaging in compulsions might result in temporary relief for OCD
patients [
62
], hypersexual behavior is usually associated by guilt and regret after committing the act [
63
].
Also, the impulsivity that can sometimes dominate the patient’s behavior is incompatible with the
careful planning that is sometimes required in CSB (for example, in regards to a sexual encounter) [
64
].
J. Clin. Med. 2019,8, 91 6 of 20
Goodman thinks that addiction disorders lie at the intersection of compulsive disorders (which
involve anxiety reduction) and impulsive disorders (which involve gratification), with the symptoms
being underpinned by neurobiological mechanisms (serotoninergic, dopaminergic, noradrenergic,
and opioid systems) [
65
]. Stein agrees with a model combining several ethiopathogenical mechanisms
and proposes an A-B-C model (affective dysregulation, behavioral addiction, and cognitive dyscontrol)
to study this entity [61].
From an addictive behavior standpoint, hypersexual behavior relies on sharing core aspects of
addiction. These aspects, according to the DSM-5 [
1
], refer to the mentioned problematic consumption
model applied to hypersexual behavior, both offline and online [
6
,
66
,
67
]. Evidence of tolerance
and withdrawal in these patients might probably be key in characterizing this entity as an addictive
disorder [
45
]. Problematic use of cybersex is also often conceptualized as a behavioral addiction [
13
,
68
].
The term “addiction” applying to this entity is still subject to great debate. Zitzman considers
that the resistance to use the term addiction is “more a reflection of cultural sexual liberality and
permissiveness than any lack of symptomatic and diagnostic correspondence with other forms of
addiction” [
69
]. However, the term needs to be used with caution, since it can be interpreted as a
justification for an irresponsible search for gratification and hedonist pleasure, and blame the disruptive
consequences on it.
There has long been a debate between Patrick Carnes and Eli Coleman over the diagnostics of
hypersexual behavior. Coleman has considered hypersexuality to be driven by the need to reduce
some type of anxiety, not by sexual desire [
56
] having classified it in seven subtypes (one of them being
use of online pornography) [
57
], while Carnes (who defined addiction as “a pathological relationship
with a mood altering experience”) finds similitudes to other behavioral addictions like gambling,
focusing on the loss of control and continued behavior despite negative consequences [70].
A thorough review of the literature by Kraus [
71
], concluded that despite these similitudes,
significant gaps in the concept’s understanding complicate its classification as an addiction. The main
concerns are aimed towards quantity of large-scale prevalence, longitudinal and clinical data
(defining main symptoms and its diagnostic limits), supported by neuropsychological, neurobiological,
and genetic data, as well as some information regarding possible treatment screening and prevention,
and points to digital technology in hypersexual behavior as a key point for future research.
The rise of the Internet increases the possibilities for sexual interactions, and not just online
pornography (webcamming, casual sex websites). Even whether Internet use represents a conduit for
other types of repetitive behavior (e.g., sexual behavior or gambling) or constitutes a different entity in
its own right is still debated [
72
]. Nevertheless, if the case is the former, the previous evidence and
considerations could very well apply to its online counterpart.
There is currently a need for empirically derived criteria that takes into account unique factors
characterizing online (versus offline) sexual behaviors, since most of them do not have an offline
version that can be compared to [
73
]. So far, there have been mentions of new phenomena when
dealing with online sexual behavior, like the presence of online dissociation [
74
], which causes to “be
mentally and emotionally detached when engaged, with compromised time and depersonalization”.
This dissociation has already been described in relation to other online activities [
75
], which supports
the notion that cybersex problematic use could be related to both internet and sex addiction [76].
Finally, we have to mention that a diagnostic entity called “compulsive sexual behavior disorder”
is being included in the upcoming definitive edition of ICD-11, in the “impulse control disorders”
chapter [
77
]. The definition can be consulted at https://icd.who.int/dev11/l-m/en#/http%3a%2f%
2fid.who.int%2ficd%2fentity%2f1630268048.
The inclusion of this category in the ICD-11 may be a response to the relevance of this issue
and attest to its clinical utility, whereas the growing but yet inconclusive data prevents us from
properly categorizing it as a mental health disorder [
72
]. It is believed to provide a better tool (yet
in refinement process) for addressing the needs of treatment seeking patients and the possible guilt
associated [
78
], and also may reflect the ongoing debates regarding the most appropriate classification
J. Clin. Med. 2019,8, 91 7 of 20
of CSB and its limited amount of data in some areas [
55
,
71
] (Table 1). This inclusion could be the first
step towards recognizing this issue and expanding on it, one key point being undoubtedly its online
pornography subtype.
Table 1. DSM-5 and ICD-11 approaches to classifying hypersexual behavior.
DSM-5 ICD-11
Goal
Provide common research and clinical
language for mental health problems
Reflect issues of clinical utility in a
broad range of settings, global
applicability, and scientific validity [79]
Conceptualization of
hypersexual disorder Addiction model Impulse control model
Available diagnosis
No current hypersexual disorder
diagnosis, due to insufficient evidence
to categorize it as addiction
Compulsive sexual behavior disorder
3.3. Clinical Manifestations
Clinical manifestations of POPU can be summed up in three key points:
•
Erectile dysfunction: while some studies have found little evidence of the association between
pornography use and sexual dysfunction [
33
], others propose that the rise in pornography use
may be the key factor explaining the sharp rise in erectile dysfunction among young people [
80
].
In one study, 60% of patients who suffered sexual dysfunction with a real partner, characteristically
did not have this problem with pornography [
8
]. Some argue that causation between pornography
use and sexual dysfunction is difficult to establish, since true controls not exposed to pornography
are rare to find [81] and have proposed a possible research design in this regard.
•
Psychosexual dissatisfaction: pornography use has been associated with sexual dissatisfaction
and sexual dysfunction, for both males and females [
82
], being more critical of one’s body or their
partner’s, increased performance pressure and less actual sex [
83
], having more sexual partners
and engaging in paid sex behavior [
34
]. This impact is especially noted in relationships when it is
one sided [
84
], in a very similar way to marijuana use, sharing key factors like higher secrecy [
85
].
These studies are based on regular non-pathological pornography use, but online pornography
may not have harmful effects by itself, only when it has become an addiction [
24
]. This can explain
the relationship between the use of female-centric pornography and more positive outcomes for
women [86].
•
Comorbidities: hypersexual behavior has been associated with anxiety disorder, followed by
mood disorder, substance use disorder and sexual dysfunction [
87
]. These findings also apply to
POPU [
88
], also being associated with smoking, drinking alcohol or coffee, substance abuse [
41
]
and problematic video-game use [89,90].
Having some very specific pornographic content interests has been associated with an increase
in reported problems [
17
]. It has been debated if these clinical features are the consequence of direct
cybersex abuse or due to the subjects actually perceiving themselves as addicts [91].
3.4. Neurobiological Evidence Supporting Addiction Model
Collecting evidence about POPU is an arduous process; main data on this subject is still limited
by small sample sizes, solely male heterosexual samples and cross-sectional designs [
71
], with not
enough neuroimaging and neuropsychological studies [
4
], probably due to conceptual, financial
and logistic obstacles. In addition, while substance addiction can be observed and modeled in
experimental animals, we cannot do this with a candidate behavioral addiction; this may limit our
study of its neurobiological underpinnings [
72
]. Current knowledge gaps regarding the research of
hypersexual behavior, as well as possible approaches for addressing them, are expertly covered and
J. Clin. Med. 2019,8, 91 8 of 20
summarized in Kraus’ article [
71
]. Most of the studies found in our research pertain hypersexual
behavior, with pornography being only one of its accounted accessories.
This evidence is based on an evolving understanding of the neural process among
addiction-related neuroplasticity changes. Dopamine levels play an important part in this sexual
reward stimuli, as observed already in frontotemporal dementia and pro-dopaminergic medication in
Parkinson’s disease being linked with sexual behavior [92,93].
The addictive process with online pornography may be amplified by the accelerated novelty and
the “supranormal stimulus” (term coined by Nobel prize winner Nikolaas Tinbergen) that constitutes
Internet pornography [
94
]. This phenomenon would supposedly make artificial stimuli (in this case,
pornography in the way it is mostly consumed today, its online form) override an evolutionarily
developed genetic response. The theory is that they potentially activate our natural reward system
at higher levels than what ancestors typically encountered as our brains evolved, making it liable to
switch into an addictive mode [
2
]. If we consider online porn from this perspective, we can start seeing
similarities to regular substance addicts.
Major brain changes observed across substance addicts lay the groundwork for the future research
of addictive behaviors [95], including:
1. Sensitization [96]
2. Desensitization [97]
3. Dysfunctional prefrontal circuits (hypofrontality) [98]
4. Malfunctioning stress system [99]
These brain changes observed in addicts have been linked with patients with hypersexual behavior
or pornography users through approximately 40 studies of different types: magnetic resonance
imaging, electroencephalography (EEG), neuroendocrine, and neuropsychological.
For example, there are clear differences in brain activity between patients who have compulsive
sexual behavior and controls, which mirror those of drug addicts. When exposed to sexual images,
hypersexual subjects have shown differences between liking (in line with controls) and wanting (sexual
desire), which was greater [
8
,
100
]. In other words, in these subjects there is more desire only for the
specific sexual cue, but not generalized sexual desire. This points us to the sexual cue itself being then
perceived as a reward [46].
Evidence of this neural activity signalizing desire is particularly prominent in the prefrontal
cortex [
101
] and the amygdala [
102
,
103
], being evidence of sensitization. Activation in these brain
regions is reminiscent of financial reward [
104
] and it may carry a similar impact. Moreover, there are
higher EEG readings in these users, as well as the diminished desire for sex with a partner, but not
for masturbation to pornography [
105
], something that reflects also on the difference in erection
quality [
8
]. This can be considered a sign of desensitization. However, Steele’s study contains several
methodological flaws to consider (subject heterogeneity, a lack of screening for mental disorders
or addictions, the absence of a control group, and the use of questionnaires not validated for porn
use) [
106
]. A study by Prause [
107
], this time with a control group, replicated these very findings.
The role of cue reactivity and craving in the development of cybersex addiction have been corroborated
in heterosexual female [108] and homosexual male samples [109].
This attentional bias to sexual cues is predominant in early hypersexual individuals [
110
], but a
repeated exposure to them shows in turn desensitization [
111
,
112
]. This means a downregulation
of reward systems, possibly mediated by the greater dorsal cingulate [
107
,
113
,
114
]. Since the dorsal
cingulate is involved in anticipating rewards and responding to new events, a decrease in its activity
after repeated exposure points us to the development of habituation to previous stimuli. This results
in a dysfunctional enhanced preference for sexual novelty [
115
], which may manifest as attempts to
overcome said habituation and desensitization through the search for more (new) pornography as a
means of sexual satisfaction, choosing this behavior instead of actual sex [20].
J. Clin. Med. 2019,8, 91 9 of 20
These attempts at novelty seeking may be mediated through ventral striatal reactivity [
116
] and
the amygdala [
117
]. It is known that the viewing of pornography in frequent users has also been
associated with greater neural activity [
99
], especially in the ventral striatum [
116
,
118
] which plays a
major role in anticipating rewards [119].
However, connectivity between ventral striatum and prefrontal cortex is decreased [
103
,
113
];
a decrease in connectivity between prefrontal cortex and the amygdala has also been observed [
117
].
In addition, hypersexual subjects have shown reduced functional connectivity between caudate and
temporal cortex lobes, as well as gray matter deficit in these areas [
120
]. All of these alterations could
explain the inability to control sexual behavior impulses.
Moreover, hypersexual subjects showed an increased volume of the amygdala [
117
], in contrast
to those with a chronic exposure to a substance, which show a decreased amygdala volume [
121
];
this difference could be explained by the possible neurotoxic effect of the substance. In hypersexual
subjects, increased activity and volume may reflect overlapping with addiction processes (particularly
supporting incentive motivation theories) or be the consequence to chronic social stress mechanisms,
such as the behavioral addiction itself [122].
These users also have shown a dysfunctional stress response, mainly mediated through the
hypothalamus–pituitary–adrenal axis [
122
] in a way that mirror those alterations seen in substance
addicts. These alterations may be the result of epigenetic changes on classic inflammatory mediators
driving addictions, like corticotropin-releasing-factor (CRF) [
123
]. This epigenetic regulation
hypothesis considers both hedonic and anhedonic behavioral outcomes are at least partially affected by
dopaminergic genes, and possibly other candidate neurotransmitter-related gene polymorphisms [
124
].
There is also evidence of higher tumor necrosis factor (TNF) in sex addicts, with a strong correlation
between TNF levels and high scores in hypersexuality rating scales [125].
3.5. Neuropsychological Evidence
In regard to the manifestations of these alterations in sexual behavior, most neuropsychological
studies show some kind of indirect or direct consequence in executive function [
126
,
127
], possibly as a
consequence of prefrontal cortex alterations [
128
]. When applied to online pornography, it contributes
to its development and maintenance [129,130].
The specifics of this poorer executive functioning include: impulsivity [
131
,
132
], cognitive
rigidity that impedes learning processes or the ability to shift attention [
120
,
133
,
134
], poor judgment
and decision making [
130
,
135
], interference of working memory capacity [
130
], deficits in
emotion regulation, and excessive preoccupation with sex [
136
]. These findings are reminiscent
of other behavioral addictions (such as pathological gambling) and the behavior in substance
dependencies [
137
]. Some studies directly contradict these findings [
58
], but there may be some
limitations in methodology (for example, small sample size).
Approaching the factors that play a role in the development of hypersexual behavior and cybersex,
there are a number of them. We can think of cue-reactivity, positive reinforcement and associative
learning [
104
,
109
,
136
,
138
,
139
] as the core mechanisms of porn addiction development. However,
there may be factors of underlying vulnerability [
140
], like: (1) the role of sexual gratification and
dysfunctional coping in some predisposed individuals [
40
,
141
–
143
] whether it is a consequence of trait
impulsivity [144,145] or state impulsivity [146], and (2) approach/avoidance tendencies [147–149].
3.6. Prognosis
Most of the studies referenced use subjects with a long-term exposure to online
pornography
[34,81,113,114]
, so its clinical manifestations appear to be a direct and proportional
consequence of engaging in this maladaptive behavior. We mentioned difficulty in obtaining
controls to establish causation, but some case reports suggest that reducing or abandoning this
behavior may cause improvement in pornography-induced sexual dysfunction and psychosexual
J. Clin. Med. 2019,8, 91 10 of 20
dissatisfaction [
79
,
80
] and even full recovery; this would imply that the previously mentioned brain
alterations are somewhat reversible.
3.7. Assessment Tools
Several screening instruments exist for addressing CSB and POPU. They all rely on the responder’s
honesty and integrity; perhaps even more so than regular psychiatry screening tests, since sexual
practices are the most humbling due to their private nature.
For hypersexuality, there are over 20 screening questionnaires and clinical interviews. Some of
the most notable include the Sexual Addiction Screening Test (SAST) proposed by Carnes [
150
], and its
later revised version SAST-R [
151
], the Compulsive Sexual Behavior Inventory (CSBI) [
152
,
153
] and the
Hypersexual Disorder Screening Inventory (HDSI) [
154
]. The HDSI was originally used for the clinical
screening of the DSM-5 field proposal of hypersexual disorder. While further explorations of the
empirical implications regarding criteria and the refinements of cutoff scores are needed, it currently
holds the strongest psychometric support and is the best valid instrument in measuring hypersexual
disorder [151].
As for online pornography, the most used screening tool is the Internet Sex-screening
test (ISST) [
155
]. It assesses five distinct dimensions (online sexual compulsivity, online sexual
behavior-social, online sexual behavior-isolated, online sexual spending and interest in online sexual
behavior) through 25 dichotomic (yes/no) questions. However, its psychometric properties haven only
been mildly analyzed, with a more robust validation in Spanish [
156
] that has served as a blueprint for
posterior studies [157].
Other notable instruments are the problematic pornography use scale (PPUS) [
158
] which
measures four facets of POPU (including: distress and functional problems, excessive use, control
difficulties and use for escape/avoidance of negative emotions), the short internet addiction test
adapted to online sexual activities (s-IAT-sex) [
159
], a 12-item questionnaire measuring two dimensions
of POPU, and the cyber-pornography use inventory (CPUI-9) [160].
The CPUI-9 evaluates three dimensions: (1) access efforts, (2) perceived compulsivity, and
(3) emotional distress. At first considered to have convincing psychometric properties [
9
], this inventory
has more recently proved to be unreliable: the inclusion of the “emotional distress” dimension address
levels of shame and guilt, which do not belong in an addiction assessment and thus skews the scores
upward [
161
]. Applying the inventory without this dimension appears to accurately reflect to some
extent compulsive pornography use.
One of the most recent is the pornographic problematic consumption scale (PPCS) [
162
], based on
Griffith six-component addiction model [
163
], though it does not measure addiction, only problematic
use of pornography with strong psychometric properties.
Other measures of POPU that are not designed to measure online pornography use but have
been validated using online pornography users [
9
], include the Pornography Consumption Inventory
(PCI) [
164
,
165
], the Compulsive Pornography Consumption Scale (CPCS) [
166
] and the Pornography
Craving Questionnaire (PCQ) [
167
] which can assess contextual triggers among different types of
pornography user.
There are also tools for assessing pornography users’ readiness to abandon the behavior
through self-initiated strategies [
168
] and an assessment of treatment outcome in doing so [
169
],
identifying in particular three potential relapse motivations: (a) sexual arousal/boredom/opportunity,
(b) intoxication/locations/easy access, and (c) negative emotions.
3.8. Treatment
Given that still many questions remain regarding the conceptualization, assessment, and causes
of hypersexual behavior and POPU, there have been relatively few attempts to research possible
treatment options. In published studies, sample sizes are usually small and too homogeneous, clinical
controls are lacking, and the research methods are scattered, unverifiable, and not replicable [170].
J. Clin. Med. 2019,8, 91 11 of 20
Usually, combining psychosocial, cognitive–behavioral, psychodynamic, and pharmacologic
methods is considered most efficient in treatment of sexual addiction, but this non-specific approach
reflects the lack of knowledge about the subject [9].
3.8.1. Pharmacological Approaches
The studies have centered on paroxetine and naltrexone thus far. One case series involving
paroxetine on POPU helped to decrease the anxiety levels, but eventually failed to reduce the behavior
by itself [
171
]. Additionally, using SSRIs to create sexual dysfunction through their side effects is
apparently not effective, and according to clinical experience are useful only in patients with comorbid
psychiatric disorders [172].
Four case reports involving naltrexone to treat POPU have been described. Previous findings have
suggested that naltrexone could be a potential treatment for behavioral addictions and hypersexual
disorder [
173
,
174
], theoretically reducing cravings and urges by blocking the euphoria associated with
the behavior. While there is not yet a randomized controlled trial with naltrexone in these subjects,
there are four case reports. Results obtained in reducing pornography use varied from good [
175
–
177
]
to moderate [
178
]; at least in one of them the patient also received sertraline, so it is unclear how much
can be attributed to naltrexone [176].
3.8.2. Psychotherapeutic Approaches
Undoubtedly, psychotherapy can be an important tool in fully comprehending and changing a
behavior. While cognitive-behavioral therapy (CBT) is considered by many clinicians to be useful in
treating hypersexual disorder [
179
], a study that involved problematic online pornography users failed
to achieve a reduction of the behavior [
180
], even if the severity of comorbid depressive symptoms
and general quality of life was improved. This brings up the interest notion that merely reducing
pornography use may not represent the most important treatment goal [
170
]. Other approaches using
CBT to treat POPU have been made, but reoccurring methodological problems in this area prevent us
from extracting reliable conclusions [181,182].
Psychodynamic psychotherapy and others like family therapy, couples’ therapy, and psychosocial
treatments modeled after 12 step programs may prove vital when addressing themes of shame and
guilt and restoring trust among the users’ closest relationships [
170
,
172
]. The only randomized
controlled trial that exists with problematic online pornography users focuses on Acceptance and
Commitment Therapy (ACT) [
183
], an improvement from their 2010 case series [
184
], which was the
first experimental study to specifically address POPU. The study showed effective results but it is hard
to extrapolate since the sample was again too small and focused on a very specific population.
The reported success with CBT, conjoint therapy and ACT might rely on the fact that are based
on mindfulness and acceptance frameworks; depending on the context, increasing pornography use
acceptance may be equally or more important than reducing its use [170].
4. Discussion
It seems that POPU is not only one subtype of hypersexual disorder, but currently the most
prevalent since it also frequently involves masturbation. Although this is difficult to accurately
determine given the anonymity and accessibility factors that make pornography use today so pervasive,
we can at least confirm that the patron of consumption for pornography has changed for roughly the
last decade. It would not be absurd to assume its online variant has had a significant impact on its
consumers, and that the triple A factors enhance the potential risk for POPU and other sexual behaviors.
As we mentioned, anonymity is a key risk factor for this sexual behavior to develop into a problem.
We need to keep in mind that statistics regarding this problem are obviously limited to people of legal
age to engage in sexual activity, online or otherwise; but it does not escape us that sexual activity
rarely starts after this threshold, and there is a likely chance that minors still in the process of sexual
neurodevelopment are a particularly vulnerable population. The truth is that a stronger consensus
J. Clin. Med. 2019,8, 91 12 of 20
on what pathological sexual behavior constitutes, both offline and online, is necessary to adequately
measure it in a representative manner and confirm how much of a problem it is in today’s society.
As far as we know, a number of recent studies support this entity as an addiction with important
clinical manifestations such as sexual dysfunction and psychosexual dissatisfaction. Most of the
existing work is based off on similar research done on substance addicts, based on the hypothesis of
online pornography as a ‘supranormal stimulus’ akin to an actual substance that, through continued
consumption, can spark an addictive disorder. However, concepts like tolerance and abstinence are
not yet clearly established enough to merit the labeling of addiction, and thus constitute a crucial part
of future research. For the moment, a diagnostic entity encompassing out of control sexual behavior
has been included in the ICD-11 due to its current clinical relevance, and it will surely be of use to
address patients with these symptoms that ask clinicians for help.
A variety of assessment tools exist to help the average clinician with diagnostic approaches,
but delimiting what is truly pathological and not in accurate manner is still an ongoing problem.
So far, a crucial part of the three sets of criteria proposed by Carnes, Goodman, and Kafka include core
concepts of loss of control, excessive time spent on sexual behavior and negative consequences to self
and others. In some manner or other, they are also present in the majority of screening tools reviewed.
They may be an adequate structure in which to build upon. Other elements, that are considered
with varying degrees of importance, probably signal us to take individual factors into account. Devising
an assessment tool that retains some level of flexibility while also being significant for determining
what is problematic is surely another of the current challenges that we face, and will probably go in
hand with further neurobiological research that help us better understand when a specific dimension
of common human life shifts from normal behavior to a disorder.
As for treatment strategies, the main goal currently focuses on reducing pornography
consumption or abandoning it altogether, since clinical manifestations appear to be reversible. The way
to achieve this varies accordingly to the patient and might also require some individual flexibility in
the strategies utilized, with a mindfulness and acceptance-based psychotherapy being equally or more
important than a pharmacological approach in some cases.
Funding: This research received no external funding.
Conflicts of Interest:
Rubén de Alarcón, Javier I. de la Iglesia, and Nerea M. Casado declare no conflict of interest.
A.L. Montejo has received consultancy fees or honoraria/research grants in the last five years from Boehringer
Ingelheim, Forum Pharmaceuticals, Rovi, Servier, Lundbeck, Otsuka, Janssen Cilag, Pfizer, Roche, Instituto de
Salud Carlos III, and Junta de Castilla y León.
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