Hitting the Target: Considerations for Differential Diagnosis When Treating Individuals for Problematic Use of Pornography

Pornography Use and Mental Health Problems in the Chinese Population: Examining the Pornography Problems Due to Moral Incongruence Model

Pornography has become increasingly prevalent worldwide with the development of the Internet, and considerable research on the effects of pornography use has emerged. Based on existing research and the Pornography Problems Due to Moral Incongruence (PPMI) model, we examined problematic pornography use (PPU) as a mediator and moral disapproval of pornography use as a moderator in the links between pornography use frequency and mental health problems in a Chinese sample (N = 833). Our results support the completely mediated effect of PPU (ab = 0.16) and the moderated effect of moral disapproval of pornography use on the association between pornography use frequency and PPU. Pornography use frequency was strongly associated with PPU when participants experienced high moral incongruence (MI), and the indirect effect of PPU was weaker (ab = 0.13) at the lower level of moderator (-1 SD), and stronger (ab = 0.23) at the higher level of moderator (+1 SD). However, the direct effect of MI on mental health problems was not supported. This study advances our understanding of the internal mechanism between pornography use and mental health and extends the PPMI model to the Chinese cultural context (characterized as low religiosity and sexually conservative). The findings confirm the cross-cultural consistency of the PPMI model in China and highlight another important source of MI besides religiosity: cultural characteristics.

Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective

INTRODUCTION

The addition of compulsive sexual behavior disorder (CSBD) into the ICD-11 chapter on mental, behavioral, or neurodevelopmental disorders has greatly stimulated research and controversy around compulsive sexual behavior, or what has been termed "hypersexual disorder," "sexual addiction," "porn addiction," "sexual compulsivity," and "out-of-control sexual behavior."

OBJECTIVES

To identify where concerns exist from the perspective of sexual medicine and what can be done to resolve them.

METHODS

A scientific review committee convened by the International Society for Sexual Medicine reviewed pertinent literature and discussed clinical research and experience related to CSBD diagnoses and misdiagnoses, pathologizing nonheteronormative sexual behavior, basic research on potential underlying causes of CSBD, its relationship to paraphilic disorder, and its potential sexual health consequences. The panel used a modified Delphi method to reach consensus on these issues.

RESULTS

CSBD was differentiated from other sexual activity on the basis of the ICD-11 diagnostic criteria, and issues regarding sexual medicine and sexual health were identified. Concerns were raised about self-labeling processes, attitudes hostile to sexual pleasure, pathologizing of nonheteronormative sexual behavior and high sexual desire, mixing of normative attitudes with clinical distress, and the belief that masturbation and pornography use represent "unhealthy" sexual behavior. A guide to CSBD case formulation and care/treatment recommendations was proposed.

CONCLUSIONS

Clinical sexologic and sexual medicine expertise for the diagnosis and treatment of CSBD in the psychiatric-psychotherapeutic context is imperative to differentiate and understand the determinants and impact of CSBD and related "out-of-control sexual behaviors" on mental and sexual well-being, to detect forensically relevant and nonrelevant forms, and to refine best practices in care and treatment. Evidence-based, sexual medicine-informed therapies should be offered to achieve a positive and respectful approach to sexuality and the possibility of having pleasurable and safe sexual experiences.

The Role of Social Conservatism and Family Vaues Regarding the Use of Pornography Among Romanians: A Moderated Mediation Model

Objective

To develop the Pornography Problems Due to Moral Incongruence model by exploring social conservatism and family values regarding the use of pornography (FVUP).

Method

501 Romanian individuals, aged 18-76 (M = 22.77, SD = 9.29), 71.9% females.

Results

Social conservatism and FVUP provide a significant additional explanatory power, explaining 22.9% of the variance in the initial model. Moreover, social conservatism mediated the relationship between FVUP and moral disapproval of pornography, while religiosity moderated the relationships between FVUP and moral disapproval of pornography and between FVUP and social conservatism.

Conclusion

Social conservatism and FVUP significantly influence moral disapproval of pornography.

Problematic pornography use across countries, genders, and sexual orientations: Insights from the International Sex Survey and comparison of different assessment tools

BACKGROUND AND AIMS

Problematic pornography use (PPU) is a common manifestation of the newly introduced Compulsive Sexual Behavior Disorder diagnosis in the 11th edition of the International Statistical Classification of Diseases and Related Health Problems. Although cultural, gender- and sexual orientation-related differences in sexual behaviors are well documented, there is a relative absence of data on PPU outside Western countries and among women as well as gender- and sexually-diverse individuals. We addressed these gaps by (a) validating the long and short versions of the Problematic Pornography Consumption Scale (PPCS and PPCS-6, respectively) and the Brief Pornography Screen (BPS) and (b) measuring PPU risk across diverse populations.

METHODS

Using data from the pre-registered International Sex Survey [n = 82 243; mean age (Mage) = 32.4 years, standard deviation = 12.5], a study across 42 countries from five continents, we evaluated the psychometric properties (i.e. factor structure, measurement invariance, and reliability) of the PPCS, PPCS-6, and BPS and examined their associations with relevant correlates (e.g. treatment-seeking). We also compared PPU risk among diverse groups (e.g. three genders).

RESULTS

The PPCS, PPCS-6, and BPS demonstrated excellent psychometric properties [for example, comparative fit index = 0.985, Tucker-Lewis Index = 0.981, root mean square error of approximation = 0.060 (90% confidence interval = 0.059-0.060)] in the confirmatory factor analysis, with all PPCS' inter-factor correlations positive and strong (rs = 0.72-0.96). A total of 3.2% of participants were at risk of experiencing PPU (PPU+) based on the PPCS, with significant country- and gender-based differences (e.g. men reported the highest levels of PPU). No sexual orientation-based differences were observed. Only 4-10% of individuals in the PPU+ group had ever sought treatment for PPU, while an additional 21-37% wanted to, but did not do so for specific reasons (e.g. unaffordability).

CONCLUSIONS

This study validated three measures to assess the severity of problematic pornography use across languages, countries, genders, and sexual orientations in 26 languages: the Problematic Pornography Consumption Scale (PPCS, and PPCS-6, respectively), and the Brief Pornography Screen (BPS). The problematic pornography use risk is estimated to be 3.2-16.6% of the population of 42 countries, and varies among different groups (e.g. genders) and based on the measure used.

Increased sensitivity for negative emotional images in individuals with problematic pornography use

Background

Despite the frequent comorbidity of affective and addictive disorders, the significance of affective dysregulation in problematic pornography use (PPU) is commonly disregarded. The objective of this study is to investigate whether individuals with PPU demonstrate increased sensitivity to negative emotional stimuli in comparison to healthy controls (HCs).

Methods

Electrophysiological responses were captured via event-related potentials (ERPs) from 27 individuals with PPU and 29 HCs. They completed an oddball task involving the presentation of deviant stimuli in the form of highly negative (HN), moderately negative (MN), and neutral images, with a standard stimulus being a neutral kettle image. To evaluate participants' subjective feelings of valence and arousal, the Self-Assessment Manikin (SAM) was employed.

Results

Regarding subjective evaluations, individuals with PPU indicated diminished valence ratings for HN images as opposed to HCs. Concerning electrophysiological assessments, those with PPU manifested elevated N2 amplitudes in response to both HN and MN images when contrasted against neutral images. Additionally, PPU participants displayed an intensified P3 response to HN images in contrast to MN images, a distinction not evident within the HCs.

Discussion

These outcomes suggest that individuals with PPU exhibited heightened reactivity toward negative stimuli. This increased sensitivity to negative cues could potentially play a role in the propensity of PPU individuals to resort to pornography as a coping mechanism for managing stress regulation.

Taking Another Look at the Pornography Problems Due to Moral Incongruence Model: Does Gender Play a Role?

The pornography problems due to moral incongruence (PPMI) model is a premier framework for understanding problematic pornography use (PPU). However, past studies have generally examined men or entered gender as a covariate in primary analyses. Such approaches mask between-gender differences. Additionally, dysregulation constructs are also thought to be relevant to PPU, yet it is unclear the degree to which they incrementally predict PPU beyond moral incongruence constructs in non-pathological populations. We addressed these gaps by gathering a large sample of college students (n = 295 men, n = 838 women). Analyses with pornography users (n = 251 men, n = 407 women) were consistent with the PPMI model, adjusted for pornography use frequency. Findings did not change when dysregulation constructs of impulsivity and emotional resilience were added to the model. No paths significantly differed between genders. Altogether, among college student pornography users, religiosity was strongly positively correlated with moral disapproval (β = .65 men, β = .62 women), moral disapproval was moderately positively correlated with PPU (β = .41 men, β = .29 women), religiosity was initially moderately positively correlated with PPU (r = .21 men, r = .22 women), but became non-significant in the full model (β = - .21 men, β = - .04 women), and indirect effects of religiosity to PPU through moral disapproval were significant (indirect β = .27 men, β = .18 women). None of the dysregulation constructs significantly predicted PPU. The full model accounted for 23-22% of the PPU variance in men and women, respectively. Implications, future directions, and limitations are discussed.

Treatment Approaches for Problematic Pornography Use: A Systematic Review

Problematic pornography use (PPU) is an emerging condition associated with several negative psychological and sexual outcomes. This study aimed to systematically review treatment approaches for PPU. Potentially eligible studies were searched for in PubMed/MEDLINE, Embase, PsycINFO, and Web of Science up to April 1, 2023. The quality of the evidence was assessed with the use of the Joanna Briggs Institute's checklists, the Cochrane risk-of-bias tools, and the GRADE approach. A total of 8936 references were retrieved, and 28 studies were included in the systematic review (n = 500 participants). Included studies were case reports (k = 16), case series (k = 1), quasi-experimental investigations (k = 7), and randomized clinical trials (k = 4). The majority of included studies presented overall low quality and significant risk of bias, with all interventions receiving a low or very low rating according to the GRADE approach. Most studies investigated psychological interventions, with the predominance of second and third wave cognitive behavioral therapy interventions. Pharmacological treatments included opioid antagonists (naltrexone in most cases) and antidepressants, while one study investigated a protocol that included rTMS. Several investigations described the combination of psychological and pharmacological approaches. Most studies did not report on side effects, with online and self-help interventions presenting significant issues in terms of treatment adherence. Even though there are promising options that may have efficacy for the treatment of patients with PPU, the literature in the topic still presents significant limitations that compromise the reaching of more definitive conclusions.

Confirming and Expanding the Moral Incongruence Model of Compulsive Sexual Behavior

Compulsive sexual behavior (CSB) is a clinical syndrome in which repetitive sexual behaviors, urges, or thoughts cause significant distress and impairment. Moral incongruence (MI), or conflict between an individual's sexual behaviors and moral beliefs, is highly associated with self-reported problematic pornography use, a common behavioral manifestation of CSB. However, it is currently unknown whether MI is associated with other self-reported compulsive sexual behaviors, such as masturbation, sexual fantasy, and sex with multiple partners. Additionally, research on MI has not explored whether emotional responses to sexual cues (i.e., erotophilia-erotophobia) may serve as a moderating variable in the MI model. To address these gaps in the literature, this study administered an online survey to a sample of 804 American participants. Results confirmed previous research on MI indicating frequency of pornography use is more strongly associated with self-reported CSB at high levels of moral disapproval. This moderation was also replicated with frequency of sexual fantasy and number of sex partners, but not with frequency of masturbation. Results also indicated that self-reported CSB was modestly associated with positive emotional response to sexual cues (i.e., erotophilia) but offered limited support for erotophilia as a moderator in the MI model. Collectively, these findings suggest the MI model can be expanded to several behavioral manifestations of CSB, but that emotional responses to sexual cues may play a limited or more nuanced role in MI.

Clarifying and extending our understanding of problematic pornography use through descriptions of the lived experience

Problematic pornography use (PPU) is a complex and growing area of research. However, knowledge of the PPU lived experience is limited. To address this gap, we conducted an online qualitative study with 67 individuals who self-identified as having problematic pornography use (76% male; Mage = 24.70 years, SD = 8.54). Results indicated several dimensions that have not been fully explored in the literature. These included various mental and physical complaints following periods of heavy pornography use, sexual functioning deficits with real partners, and a subjectively altered state of sexual arousal while using pornography. Moreover, we expanded on current knowledge regarding the inner conflict associated with PPU and clarified the ways that users can progress to increasingly intensified patterns of pornography use, such as tolerance/escalation and pornographic binges. Our study highlights the complex and nuanced nature of PPU and provides suggestions for future research and clinical practice.

Difficulties in Emotion Regulation and Problematic Pornography Use: The Mediating Role of Loneliness

Objectives

To analyze the association between difficulties in emotion regulation and problematic pornography use (PPU) and test the mediating effect of loneliness.

Methods

All 339 participants (M = 28.53 years, SD = 10.32) completed online self-report scales assessing difficulties in emotion regulation, PPU, and loneliness.

Results

Difficulties in emotion regulation are positively correlated with PPU. Loneliness partially mediates the relationship between difficulties in emotion regulation and PPU. Gender and intimate relationship status had moderating effects on the tested mediation model.

Conclusions

Greater difficulties in emotion regulation have a significant indirect effect on PPU through loneliness.

Atypical Sexual Interests in Compulsive Sexual Behavior: Results From a Phallometric Study

The link between Compulsive Sexual Behavior (CSB) and atypical sexual interests is elusive. This study aimed to provide preliminary insights into the relationship between both aspects. The study sample comprised 61 self-identified straight men. CSB was measured through a composite self-report index assessing symptoms of CSB, whereas sexual interests -atypical and normophilic- were assessed objectively through penile plethysmography. The CSB index had small, non-significant correlation with greater sexual response to different sexual stimuli (r_{general sexual responsiveness}=.127 [95% CI: -.137, .384]). In terms of overall sexual interest, increased scores on the CSB index had small, non-significant correlation with a higher preference for younger sexual stimuli (r = -.098 [95% CI: -.499, .215]) and persuasive sex (r = .10 [95% CI: -.168, .316]). Finally, CSB had a moderate correlation with sexual response when presented with stimuli depicting "female toddler coercive" (r = .27 [95% CI: -.083, .544]). We conclude that our findings do not support the hypotheses that CSB is significantly related to an increased arousability across sexual stimuli. The study findings also suggest that CSB may be, to a small degree, predisposed to experience sexual attraction toward children. Given the preliminary nature of the study, these conclusions warrant further research. Alternative explanations for the study findings related to the particular components of CSB that may be related to typical and atypical sexual interests are also considered.

The Relation of Sexual Attitudes to Hypersexuality and Problematic Pornography Use

Previous studies have shown that specific attitudes related to moral convictions can have an important role in the development and maintenance of problematic sexual behavior symptoms. However, although other types of attitudes, like sexual attitudes, are potentially highly relevant, they have not yet been studied in this role. We investigated how four dimensions of sexual attitudes: Permissiveness, Birth Control, Communion and Instrumentality, contribute to problematic pornography use (PPU) and hypersexual disorder (HD) symptoms, controlling for religiosity, sex, age and relationship status. The study was administered through an online questionnaire and based on a representative sample of n = 1036 (M_age = 43.28, SD = 14.21; 50.3% women) Polish adult citizens. When adjusting for other variables, higher sexual Permissiveness positively predicted HD and PPU among both men (HD: β = .26, p < .001; PPU: β = .22, p < .001) and women (HD: β = .44, p < .001; PPU: β = .26; p < .001). Sexual Instrumentality positively, although weakly, contributed to HD severity among men (β = .11, p < .05). Attitudes reflecting higher support for responsible sexuality (Birth Control subscale) negatively and weakly predicted HD among women (β = - .11, p < .05). Permissiveness was also the only sexual attitude dimension that consistently predicted a higher frequency of sexual activity among men and women. Based on the cutoff criteria proposed by the authors of the used screening instruments (≥ 53 points for the Hypersexual Behavior Inventory and ≥ 4 points for the Brief Pornography Screen), the prevalence of being at risk for HD was 10.0% (men: 11.4%, women: 8.7%) and for PPU was 17.8% (men: 26.8%, women: 9.1%). Our results point to a significant contribution of sexual attitudes to problematic sexual behavior symptoms, which was not encapsulated by the previously studied influence of religious beliefs, although most of the obtained relationships were relatively weak. Particularly, a consistent link between permissive attitudes and both HD and PPU among men and women may indicate that permissive attitudes can potentially contribute to the development and maintenance of problematic sexual behavior. The prevalence of being at risk for PPU (and to some degree HD) in the current representative sample was high. Such results raise questions about the appropriateness of the proposed cutoff criteria and the risk of overpathologizing normative sexual activity, if the cutoff thresholds are not tailored adequately. The results have implications for the assessment, diagnosis and theory of problematic sexual behavior.

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

OBJECTIVES

The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD.

METHODS

An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD.

CONCLUSIONS

An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.

The Relationship between Compulsive Sexual Behavior, Religiosity, and Moral Disapproval

Compulsive sexual behavior (CSB) is associated with religiosity and moral disapproval for sexual behaviors, and religiosity and moral disapproval are often used interchangeably in understanding moral incongruence. The present study expands prior research by examining relationships between several religious orientations and CSB and testing how moral disapproval contributes to these relationships via mediation analysis. Results indicated that religious orientations reflecting commitment to beliefs and rigidity in adhering to beliefs predicted greater CSB. Additionally, moral disapproval mediated relationships between several religiosity orientations and CSB. Overall, findings suggest that religiosity and moral disapproval are related constructs that aid in understanding CSB presentations.

Symptoms of problematic pornography use among help-seeking male adolescents: Latent profile and network analysis

BACKGROUND AND AIMS

Little data exist on exploring the subgroups and characteristics of problematic pornography use (PPU) in help-seeking adolescents. The aims of the study were to classify the subgroups among help-seeking male adolescents, explore their similarities and differences, and uncover their core symptoms.

METHODS

A total of 3,468 Chinese male adolescents (Mage = 16.64 years, SD = 1.24) who were distressed about their pornography use were recruited. The Problematic Pornography Consumption Scale, the Brief Pornography Screen Scale, and Moral Disapproval of Pornography Use were used to classify them. The General Health Questionnaire, the Pornography Craving Questionnaire, and the Sexual Compulsivity Scale were used to investigate participants' negative consequence related to their pornography use; and the Online Sexual Activity Questionnaire (OSAs) and time spent on pornography use every week were considered as quantitative indicators.

RESULTS

Help-seeking male adolescents could be divided into 3 profiles, namely, self-perceived problematic (SP, n = 755), impaired control (IC, n = 1,656), and problematic use groups (PPU, n = 1,057). Frequency of OSAs was important for the identification of SP individuals, while negative consequences were more effective in identifying individuals with objective dysregulated behavior. Salience and mood modification were shared by all groups; however, in addition to this, the SP and PPU groups also showed withdrawal symptoms.

DISCUSSION AND CONCLUSION

This study's results provide support for the presence of different profiles of help-seeking individuals and information on potential intervention targets among adolescents which is lacking in the literature.

Who feels affected by "out of control" sexual behavior? Prevalence and correlates of indicators for ICD-11 Compulsive Sexual Behavior Disorder in the German Health and Sexuality Survey (GeSiD)

BACKGROUND AND AIMS

The purpose of this study was to examine the prevalence and correlates of indicators consistent with Compulsive Sexual Behavior Disorder (CSBD)-defined and operationalized according to the ICD-11 guidelines-in a large (n = 4,633; 50.5% male; 49,5% female) probability-based German national sample.

METHODS

Participants were asked if they had ever experienced "intense and recurring sexual impulses or sexual urges that I had difficulty controlling and resulted in sexual behavior" over a period of several months. Those who reported this experience were queried about the associated distress.

RESULTS

Overall, 4.9% of men [95% CI = 3.9-6.1] and 3.0% of women [95% CI = 2.3-3.9] reported experiences consistent with ICD-11 diagnostic requirements for lifetime diagnosis. In the 12 months preceding the study, 3.2% of men [95% CI = 2.4-4.2] and 1.8% of women [95% CI = 1.2-2.5] reported experiences consistent with CSBD requirements. Compared to controls and participants who reported elements of compulsive sexuality but without accompanying distress, strict religious upbringing was most prevalent in the CSBD group. The CSBD group was more likely to view sexual practices like men having sex with men as unacceptable and to report the belief that pornography has negative impacts on their sex life and life in general. Compared to the other two groups, the CSBD group was significantly more likely to have received psychiatric treatment for depression or another mental health problem during the past 12 months.

DISCUSSION AND CONCLUSIONS

The current study provides novel and important insights into the prevalence and characteristics of CSBD in the general population.

Mental and sexual health perspectives of the International Classification of Diseases (ICD-11) Compulsive Sexual Behavior Disorder •

After introduction of compulsive sexual behavior disorder (CSBD) in the ICD-11, many questions regarding etiology, classification and diagnostic criteria remain unanswered, providing rationale for further research. In this commentary, we critically review the ongoing discussion reflected in some relevant articles, and try to point out the risks of oversimplification of the broad clinical phenomenon, as well as attract attention to the neglected aspects, such as psychosexual development, intimacy disorder and the role of sexological expertise in the assessment and treatment of individuals presenting with out-of-control sexual behaviors. We also advocate for multimodal, transtheoretical approach and suggest that CSBD may be reconsidered as a condition related to sexual health.

The Association between the Quantity and Severity of Pornography Use: A Meta-analysis

Although the quantity of pornography use (QPU, i.e., frequency/time spent on pornography use) has been positively associated with the severity of pornography use (i.e., problematic pornography use, PPU), the magnitudes of relationships have varied across studies. This meta-analysis aimed to assess the overall relationships and identify potential moderating variables to explain the variation in these associations between QPU and PPU. We performed a literature search for all published and unpublished studies from 1995 to 2020 in major online scientific databases up until December 2020. Sixty-one studies were identified with 82 independent samples involving 74,880 participants. Results indicated that there was a positive, moderate relationship between QPU and PPU (r = 0.34, p < .001). The strength of relationship significantly varied across measures of PPU based on different theoretical frameworks, indicators of QPU, and sexual cultural contexts (conservative vs. permissive sexual values). Frequency was a more robust quantitative indicator of PPU than time spent on pornography use. In conservative countries, QPU showed more robust association with self-perceived PPU. Future studies are encouraged to select the measurement of PPU according to research aims and use multi-item measures with demonstrated content validity to assess pornography use. Cross-cultural (conservative/permissive) comparisons also warrant further research.

Religiosity, Perceived Effects of Pornography Use on Personal Sex Life, and Moral Incongruence: Insights from the German Health and Sexuality Survey (GeSiD)

Although online pornography use appears to be a mainstream activity, there is little information, particularly outside of the USA, about how consumers perceive its impact on their sexuality. Considering increasing concerns about pornography use, this lack of evidence has sociocultural and clinical ramifications - especially because the recently proposed Moral Incongruence model (MI) suggests that some individuals may see their pornography use as problematic independently of the frequency of use. Using data from 4,177 adults from the 2018-2019 national probability-based German Health and Sexuality Survey, we explored self-perceived impact of pornography use on personal sex life and the role of MI. Most participants (61.7%) reported no impact of pornography. Women were characterized by significantly higher odds of reporting positive relative to no impact, while men had higher odds of reporting mixed/negative compared to no impact. Participants in both the positive and the mixed impact group reported a significantly higher frequency of pornography use than participants in the no impact group. In line with the MI model, we observed a significant relationship between participants' religious upbringing and self-perceived negative (relative to mixed) impact of pornography use. Social relevance and clinical implications of the findings are discussed.

A Network Comparison of Motives behind Online Sexual Activities and Problematic Pornography Use during the COVID-19 Outbreak and the Post-Pandemic Period

Many researchers have considered whether online sexual activities (OSAs) increased over the course of the COVID-19 pandemic and whether these have led to an increase in problematic pornography use (PPU). This study investigated the impact of COVID-19 on PPU through pornography use motivations (PUMs) and OSAs to develop a better understanding of the mechanism and changes affecting PPU. Two groups of Chinese adults were recruited during the initial months of the pandemic (April 2020, n₁ = 496) and the post-pandemic period (October 2021, n₂ = 504). A network analysis was conducted to compare the structures of PPU symptoms among the two groups. The results showed that PUMs and OSAs were stronger predictors of PPU during the pandemic than post-pandemic (R²_pandemic = 57.6% vs. R²_{post-pandemic} = 28.7%). The motives of fantasy, sexual pleasure, stress reduction, and self-exploration were the prominent motivations during these two periods, but we found distinct PPU-related communities. PPU, sexual pleasure, and viewing sexually explicit materials (a type of OSAs) constituted a community during the pandemic but not in the post-pandemic’s network. The present study indicated that the pandemic may not have been the only factor impacting the higher rate of PPU. Instead, the higher frequency of OSAs during the pandemic may have been a strategy to cope with stress and to safely satisfy sexual desire.

"Pornography Addiction": Elements for Discussion of a Case Report

Can Internet pornography use (IPU) lead to addiction? "Pornography addiction" is a highly controversial concept within the scientific community. In the absence of consensus, international classifications do not consider that the concept meets the criteria to be recognized as a distinct diagnostic entity. However, the term "pornography addiction" has now become common parlance and is therefore present in the discourse of patients seeking therapy to address what they perceive as problematic pornography consumption. Drawing on a brief case vignette, presenting the case of a man who views himself as a pornography addict, we offer a critical review of this concept. Different diagnostic hypotheses will be considered. Beyond the diagnostic process, we consider the issue of "perceived addiction" and its relationship with "moral incongruence." From a psychotherapeutic view, we suggest that patients who self-identify as "porn addicts" must be supported using a more comprehensive approach that goes beyond their symptomatic behavior or the manner in which they present or perceive themselves. The proposed therapy did not seek or require an end to the behavior. The therapy approach focused on exploring the patient's history in an attempt to understand the construction of his sexuality and morality. In the case analyzed, focusing on the source of moral incongruence led to the disappearance of IPU and all associated suffering.

Psychometric Properties of the Problematic Pornography Use Scale in a Japanese Sample

Problematic pornography use (PPU) is the inability to control the use of pornography and is considered a form of compulsive sexual behavior. It can have a negative effect on one's life and is an important clinical and social issue. In Japan, there is no assessment tool to measure PPU and very little research has been done. The Problematic Pornography Use Scale is one of the scales assessing the severity of PPU. This study validated a Japanese version of the Problematic Pornography Use Scale (PPUS-J) and examined its psychometric properties in a sample of 1011 individuals through an online survey (502 men, 509 women; M_age = 35.9 years, SD = 13.75). The results of the confirmatory factor analysis indicated that the four factors in the original scale were consistent with the factors in the PPUS-J, and strict invariance could be assumed for male and female participants. With regard to reliability, internal consistency indices were appropriate both at the overall and subscale levels for male and female participants. The PPUS-J showed good convergent and divergent validity due to the relationship between the subscales and other measures such as the Sexual Compulsivity Scale. These results demonstrate the validity of the PPUS-J for assessing problematic pornography use in a Japanese sample. Given the paucity of studies conducted in non-Western cultures and on women, this study will be useful in advancing research on PPU across different cultures. Future studies should examine test-retest reliability of the PPUS-J and its use with clinical groups.

A Longitudinal Study of Adolescents' Pornography Use Frequency, Motivations, and Problematic Use Before and During the COVID-19 Pandemic

Since the beginning of the COVID-19 pandemic, an increase in pornography use has been reported based on cross-sectional findings, raising concerns about associated adverse outcomes, such as problematic pornography use (PPU). The aims of the present study were to document potential changes in adolescents' pornography use frequency, motivations, and PPU before and during the COVID-19 pandemic. As part of an ongoing study on adolescents' sexual health, we used a large sample (NTime 1 = 1771; 47.6% girls, Mage = 15.42 years, SD = 0.59) to examine changes from baseline (before the COVID-19 pandemic) to one year later (during the COVID-19 pandemic) in adolescents' self-reported pornography use frequency, motivations, and PPU, using latent change models and examining potential gender differences. No significant changes were observed in adolescents' pornography use frequency and pornography use motivations, and no gender differences were present in these trends. Although statistically significant, slight decrease was observed in boys' PPU levels, and a statistically significant, slight increase was observed in girls' PPU levels, these changes were very small, providing no practical or clinical relevance. In sum, despite previous propositions, concerns, and cross-sectional findings, longitudinal results suggest that adolescents' pornography use characteristics were rather stable between November 2019 and June 2021, and the COVID-19 pandemic and related lockdowns might not have led to general increases in adolescents' pornography use as it was expected.

Compulsive sexual behavior, religiosity, and spirituality: A systematic review

BACKGROUND AND AIMS

In recent years, increasing attention has been given to the relationship between compulsive sexual behavior (CSB), religiosity, and spirituality. This review summarizes research examining the relationship CSB has with religiosity and spirituality, clarifying how these constructs inform the assessment and treatment of this syndrome.

METHODS

The present paper reviews research published through August 1, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Only studies providing quantitative analyses were included.

RESULTS

This review identified 46 articles, subsuming 59 studies, analyzing the relationship between CSB and religiosity or spirituality. Most studies used cross-sectional designs with samples primarily composed of heterosexual White men and women. Generally, the studies found small to moderate positive relationships between religiosity and CSB. Studies considering the mediating or moderating role of moral incongruence identified stronger, indirect relationships between religiosity and problematic pornography use (PPU), a manifestation of CSB. Few studies examined the association between spirituality and CSB, but those that did either reported negative relationships between indicators of spiritual well-being and CSB or positive relationships between CSB and aspects of spiritual struggles.

DISCUSSION AND CONCLUSIONS

Although research examining CSB and religiosity has flourished, such growth is hampered by cross-sectional samples lacking in diversity. Moral incongruence assists in explaining the relationship between religiosity and PPU, but future research should consider other manifestations of CSB beyond PPU. Attention should also be given to examining other religiosity and spirituality constructs and obtaining more diverse samples in research on CSB, religiosity, and spirituality.

Hands-off: Feasibility and preliminary results of a two-armed randomized controlled trial of a web-based self-help tool to reduce problematic pornography use

BACKGROUND AND AIMS

Despite problematic pornography use (PPU) being prevalent, no previous study has examined the effectiveness of evidence-based interventions for PPU, using rigorous methods. Using a two-armed randomized controlled trial study design, we examined the feasibility and initial effectiveness of a six-week online PPU intervention.

METHODS

We recruited 264 participants (3.8% women, M age = 33.2, SD = 10.6) who were randomized and assigned to either the self-help intervention (n = 123) or waitlist control condition (n = 141), and completed self-report questionnaires at baseline and after the end of the intervention (six-week follow-up). Multivariable linear regression models were generated and tested on a complete case basis to investigate possible treatment effects. Participants provided quantitative and qualitative feedback regarding the intervention's content and appearance.

RESULTS

Participants evaluated all modules positively in the intervention in general. There were differential dropout rates (89.4% in intervention vs. 44.7% in control group) with an overall follow-up rate of 34.5%. The intervention group reported significantly lower levels of PPU (P < 0.001, d = 1.32) at the six-week follow-up. Moreover, they reported lower pornography use frequency (P < 0.001, d = 1.65), self-perceived pornography addiction (P = 0.01, d = 0.85), pornography craving (P = 0.02, d = 0.40), and higher pornography avoidance self-efficacy (P = 0.001, d = 0.87) at the six-week follow-up.

DISCUSSION AND CONCLUSIONS

The present study was only a first step in rigorous treatment studies for PPU, but the findings are promising and suggest that online interventions for PPU might help reduce PPU in some cases, even without the guidance of therapists, by reducing treatment barriers.

Frequency of use, moral incongruence and religiosity and their relationships with self-perceived addiction to pornography, internet use, social networking and online gaming

BACKGROUND AND AIMS

Moral incongruence involves disapproval of a behavior in which people engage despite their moral beliefs. Although considerable research has been conducted on how moral incongruence relates to pornography use, potential roles for moral incongruence in other putative behavioral addictions have not been investigated. The aim of this study was to investigate the role of moral incongruence in self-perceived addiction to: (i) pornography; (ii) internet addiction; (iii) social networking; and (iv) online gaming.

DESIGN

A cross-sectional, preregistered, online survey using multivariable regression.

SETTING

Online study conducted in Poland.

PARTICIPANTS

1036 Polish adults aged between 18 and 69 years.

MEASUREMENTS

Measures included self-perceived behavioral addiction to pornography, internet use, social networking and online gaming and their hypothesized determinants (moral incongruence, frequency of use, time of use, religiosity, age and gender).

FINDINGS

Higher moral incongruence (β = 0.20, P < 0.001) and higher religiosity (β = 0.08, P < 0.05) were independently associated with higher self-perceived addiction to pornography. Additionally, frequency of pornography use was the strongest of the analyzed predictors (β = 0.43, P < 0.001). A similar, positive relationship between high moral incongruence and self-perceived addiction was also present for internet (β = 0.16, P < 0.001), social networking (β = 0.18, P < 0.001) and gaming addictions (β = 0.16, P < 0.001). Religiosity was uniquely, although weakly, connected to pornography addiction, but not to other types of addictive behaviors.

CONCLUSIONS

Moral incongruence may be positively associated with self-perception of behavioral addictions including not only pornography viewing, but also internet use, social networking and online gaming.

The Short Version of the Problematic Pornography Consumption Scale (PPCS-6): A Reliable and Valid Measure in General and Treatment-Seeking Populations

To date, no short scale existed that could assess problematic pornography use (PPU) having a solid theoretical background and strong psychometric properties. Having such a short scale may be advantageous when scarce resources are available and/or when respondents' attention spans are limited. The aim of the present investigation was to develop a short scale that can be utilized to screen for PPU. The Problematic Pornography Consumption Scale (PPCS-18) was used as a basis for the development of a short measure of PPU (PPCS-6). A community sample (N₁ = 15,051), a sample of pornography site visitors (N₂ = 760), and a sample of treatment-seeking individuals (N₃ = 266) were recruited to investigate the reliability and validity of the PPCS-6. Also, its association was tested to theoretically-relevant correlates (e.g., hypersexuality, frequency of masturbation), and a cutoff score was determined. The PPCS-6 yielded strong psychometric properties in terms of factor structure, measurement invariance, reliability, correlated reasonably with the assessed variables, and an optimal cutoff was identified that could reliably distinguish between PPU and non-problematic pornography use. PPCS-6 can be considered as a short, reliable, and valid scale to assess PPU in studies when the length of a questionnaire is essential or when a brief screening for PPU is necessary.

The Pornography "Rebooting" Experience: A Qualitative Analysis of Abstinence Journals on an Online Pornography Abstinence Forum

A growing number of individuals using online forums are attempting to abstain from pornography (colloquially termed "rebooting") due to self-perceived pornography-related problems. The present qualitative study explored phenomenological experiences of abstinence among members of an online "rebooting" forum. A total of 104 abstinence journals by male forum members were systematically analyzed using thematic analysis. A total of four themes (with a total of nine subthemes) emerged from the data: (1) abstinence is the solution to pornography-related problems, (2) sometimes abstinence seems impossible, (3) abstinence is achievable with the right resources, and (4) abstinence is rewarding if persisted with. Members' primary reasons for initiating "rebooting" involved desiring to overcome a perceived addiction to pornography and/or alleviate perceived negative consequences attributed to pornography use, especially sexual difficulties. Successfully achieving and maintaining abstinence was typically experienced to be very challenging due to habitual behavior patterns and/or cravings triggered by a multiplicity of cues for pornography use, but a combination of internal (e.g., cognitive-behavioral strategies) and external (e.g., social support) resources made abstinence attainable for many members. A range of benefits attributed to abstinence by members suggest that abstaining from pornography could potentially be a beneficial intervention for problematic pornography use, although future prospective studies are needed to rule out possible third variable explanations for these perceived effects and to rigorously evaluate abstinence as an intervention. The present findings shed light on what the "rebooting" experience is like from members' own perspectives and provide insights into abstinence as an approach for addressing problematic pornography use.

Predicting problematic pornography use among male returning US veterans

Problematic Pornography Use (PPU) is the most common problem behavior among individuals with compulsive sexual behavior (CSB). Previous research suggests US veterans are at a greater risk of engaging in PPU. The present study sought to investigate further PPU among male military veterans. Data from 172 male veterans who endorsed ever watching pornography and completed the Problematic Pornography Use Scale (PPUS) were included in the study. Participants completed self-report questionnaires, including demographic information, psychiatric co-morbidities, impulsivity, as measured by the UPPS-P, pornography-related behaviors, and pornography craving as measured by Pornography Craving Questionnaire (PCQ). Younger age and lower educational attainment were associated with higher PPUS scores. Depression, anxiety, post-traumatic stress disorder (PTSD), insomnia, and impulsivity were positively associated with higher PPUS scores. There was no statistically significant association between PPU with suicidal ideation or alcohol use disorder. In the multivariable hierarchical regression, depression, frequency of use, and higher PCQ scores were associated with higher PPUS scores, although only the latter two remained significant in the final model. Understanding the risk factors via more frequent screening for PPU will help with the development of treatment protocols for this problematic behavior.

Are sexual functioning problems associated with frequent pornography use and/or problematic pornography use? Results from a large community survey including males and females

There is much debate regarding whether pornography use has positive or negative associations with sexuality-related measures such as sexual functioning problems. The present study aimed to examine differential correlates between quantity (frequency of pornography use-FPU) and severity (problematic pornography use-PPU) of pornography use with respect to sexual functioning problems among both males and females. Multi-group structural equation modeling was conducted to investigate hypothesized associations between PPU, FPU, and sexual functioning problems among males and females (N = 14,581 participants; females = 4,352; 29.8%; M_age=33.6 years, SD_age=11.0), controlling for age, sexual orientation, relationship status, and masturbation frequency. The hypothesized model had excellent fit to the data (CFI = 0.962, TLI = 0.961, RMSEA = 0.057 [95% CI = 0.056-0.057]). Similar associations were identified in both genders, with all pathways being statistically significant (p < .001). PPU had positive, moderate associations (β_males=0.37, β_females=0.38), while FPU had negative, weak associations with sexual functioning problems (β_males=-0.17, β_females=-0.17). Although FPU and PPU had a positive, moderate association, they should be assessed and discussed separately when examining potential associations with sexuality-related outcomes. Given that PPU was positively and moderately and FPU negatively and weakly associated with problems in sexual functioning, it is important to consider both PPU and FPU in relation to sexual functioning problems.

Properties of the Problematic Pornography Consumption Scale (PPCS-18) in community and subclinical samples in China and Hungary

Several scales assessing problematic pornography use (PPU) are available. However, in most previous studies, primarily nonclinical and Western samples were used to validate these scales. Thus, further research is needed to validate scales to assess problematic pornography use across diverse samples, including subclinical populations. The aim of the present study was to examine and compare the psychometric properties of the PPCS-18 in Hungarian and Chinese community samples and in subclinical men. A sample of Chinese community men (N1 = 695), a sample of subclinical men who were screened for PPU using the Brief Pornography Screen (N2 = 4651), and a sample of Hungarian community men (N3 = 9395) were recruited to investigate the reliability and validity of the PPCS-18. Item-total score correlation, confirmatory factor analyses, reliability, and measurement invariance tests showed that the PPCS-18 yielded strong psychometric properties among Hungarian and Chinese community men and indicated potential utility in the subclinical men. The network analytic approach also corroborates that the six factors of the PPCS-18 can reflect the characteristic of the participants from different cultural contexts, and participants from community and subclinical populations. In sum, the PPCS-18 demonstrated high generalizability across cultures and community and subclinical men.

Sexual addiction 25 years on: A systematic and methodological review of empirical literature and an agenda for future research

In 1998, Gold and Heffner authored a landmark review in Clinical Psychology Review on the topic of sexual addiction that concluded that sexual addiction, though increasingly popular in mental health settings, was largely based on speculation, with virtually no empirical basis. In the more than two decades since that review, empirical research around compulsive sexual behaviors (which subsumes prior research about sexual addiction) has flourished, ultimately culminating in the inclusion of a novel diagnosis of Compulsive Sexual Behavior Disorder in the eleventh edition of the World Health Organization's International Classification of Diseases. The present work details a systematic review of empirical research published between January 1st, 1995 and August 1st, 2020 related to compulsive sexual behaviors, with a specific focus on evaluating the methodologies of that literature. This review yielded 371 papers detailing 415 individual studies. In general, the present review finds that, although research related to compulsive sexual behaviors has proliferated, much of this work is characterized by simplistic methodological designs, a lack of theoretical integration, and an absence of quality measurement. Moreover, the present review finds a virtual absence of high-quality treatment-related research published within this time frame. Implications of these findings for both clinical practice and future research are discussed.

What should be included in the criteria for compulsive sexual behavior disorder?

Compulsive sexual behavior disorder (CSBD) is currently defined in the eleventh revision of the International Classification of Diseases (ICD-11) as an impulse control disorder. Criteria for hypersexual disorder (HD) had been proposed in 2010 for the fifth revision of Diagnostic and Statistical Manual (DSM-5). In this article, we compare differences between HD and CSBD and discuss their relevance.Significant differences between HD and CSBD criteria include: (1) the role of sexual behavior as a maladaptive coping and emotion regulation strategy listed in criteria for HD but not in those for CSBD; (2) different exclusionary criteria including bipolar and substance use disorders in HD but not in CSBD, and (3) inclusion of new considerations in CSBD, such as moral incongruence (as an exclusion criterion), and diminished pleasure from sexual activity. Each of these aspects has clinical and research-related implications. The inclusion of CSBD in the ICD-11 will have a significant impact on clinical practice and research. Researchers should continue to investigate core and related features of CSBD, inlcuding those not included in the current criteria, in order to provide additional insight into the disorder and to help promote clinical advances.

Three Diagnoses for Problematic Hypersexuality; Which Criteria Predict Help-Seeking Behavior?

This study aimed to assess the best combination of indicators of problematic hypersexuality (PH), in a survey (n = 58,158) targeting individuals wondering if they were sex addicted. The survey allowed for testing of criteria from three theoretical models used to conceptualize PH. Factor analyses for women and men yielded an interpretable grouping of indicators consisting of four factors. In subsequent logistic regressions, these factors were used as predictors for experiencing the need for help for PH. The factors Negative Effects and Extreme positively predicted experiencing the need for help, with Negative Effects as the most important predictor for both women and men. This factor included, among others, withdrawal symptoms and loss of pleasure. The Sexual Desire factor negatively predicted the need for help, suggesting that for the targeted population more sexual desire leads to less PH. The Coping factor did not predict experiencing the need for help. Outcomes show that a combination of indicators from different theoretical models best indicates the presence of PH. Therefore, a measurement instrument to assess existence and severity of PH should consist of such a combination. Theoretically, this study suggests that a more comprehensive model for PH is needed, surpassing existing conceptualizations of PH.

Spotlight on Compulsive Sexual Behavior Disorder: A Systematic Review of Research on Women

PURPOSE OF REVIEW

World Health Organization recently included compulsive sexual behavior disorder (CSBD) to the upcoming 11th edition of International Classification of Diseases (6C72). Despite the potential benefits of this decision (eg, the acceleration of research in the field will allow the development of effective treatments), previous research focused mainly on men, and as a result, we do not have an accurate clinical picture of compulsive sexual behavior (CSB) among women. Therefore, in this systematic review, we aim to present available knowledge on this topical subject. Literature search was conducted in the guideline of PRISMA methodology. Studies were identified from multiple databases including Academic Search Ultimate, SocINDEX, PsycARTICLES, PsycINFO, PubMed, and MEDLINE. Out of a total of 10,531 articles identified and screened, 58 were included in this review. Included studies covered the following topics: prevalence and etiology of CSB, behavioral and cognitive processes involved, comorbidities, personality traits, psychosocial and interpersonal difficulties, traumatic experiences, and treatments.

RECENT FINDINGS

Available studies indicate that CSB symptom severity is lower in women than in men. Overall, women reported consuming pornography less often than men and exhibit lower rates of feeling urges to these materials. CSB symptoms (including problematic pornography use) have been found to be positively related to trait psychopathy, impulsivity, sensation seeking, attention-deficit/hyperactivity disorder symptoms, obsessive-compulsive disorder, pathological buying, sexual dysfunctions, general psychopathology, child sexual abuse, while negatively related to dispositional mindfulness.

SUMMARY

Conclusions that can be drawn from prior studies are considerably limited. There are no accurate estimates of the CSB prevalence or severity among women, and studies have been mostly conducted on non-clinical populations, which has limited application for women diagnosed with CSBD.

Exploring the clinical profile of problematic pornography use

BACKGROUND

Although problematic pornography use (PPU) will soon be diagnosable through the International Classification for Diseases, 11th revision, its clinical profile remains contentious. The current study assessed whether PPU may be characterized by various symptoms sometimes observed among online recovery forums that currently lack empirical assessment, such as heightened cognitive-affective issues following pornography use and sexual dysfunction with partners as a result of escalating use.

METHOD

Cross-sectional surveys were completed by male PPUs (N = 138, mean age = 31.75 years, standard deviation = 10.72) recruited via online recovery communities and Amazon Mechanical Turk. Multiple regression analysis was performed using the Problematic Pornography Use Scale as the dependent variable and variables of interest (Arizona Sexual Experiences Scales modified for partnered sex and pornography use, Brunel Mood Scale, Social Interaction Anxiety Scale, and the Tolerance subscale from the Problematic Pornography Consumption Scale) and potential confounders (eg, comorbid psychopathology) as independent variables.

RESULTS

Current levels of pornography use, indicators of tolerance and escalation, greater sexual functioning with pornography, and psychological distress were uniquely associated with PPU severity, while cognitive-affective issues after pornography use, impulsivity and compulsivity were not. Although sexual dysfunction did not predict PPU severity, nearly half the sample indicated sexual dysfunction with intimate partners.

CONCLUSIONS

The present findings suggest that PPU may be characterized by tolerance and escalation (as per substance addiction models), greater sexual responsivity toward pornography, and psychological distress. Meanwhile, the high rate of partnered sexual dysfunction observed suggests that PPU might be somewhat separable from other forms of compulsive sexual behavior.

Symptoms of Problematic Pornography Use in a Sample of Treatment Considering and Treatment Non-Considering Men: A Network Approach

BACKGROUND

Pornography use may become problematic for 1-6% of the people and may be associated with adverse consequences leading to treatment-seeking behavior. Although the identification of the central symptoms of problematic pornography use (PPU) may inform treatment strategies, no prior study has applied the network approach to examine the symptoms of PPU.

AIM

To explore the network structure of PPU symptoms, identify the topological location of pornography use frequency in this network, and examine whether the structure of this network of symptoms differs between participants who considered and those who did not consider treatment.

METHODS

A large-scale online sample of 4,253 men (M_age = 38.33 years, SD = 12.40) was used to explore the structure of PPU symptoms in 2 distinct groups: considered treatment group (n = 509) and not-considered treatment group (n = 3,684).

OUTCOMES

Participants completed a self-report questionnaire about their past-year pornography use frequency and PPU measured by the short version of the Problematic Pornography Consumption Scale.

RESULTS

The global structure of symptoms did not differ significantly between the considered treatment and the not-considered treatment groups. 2 clusters of symptoms were identified in both groups, with the first cluster including salience, mood modification, and pornography use frequency and the second cluster including conflict, withdrawal, relapse, and tolerance. In the networks of both groups, salience, tolerance, withdrawal, and conflict appeared as central symptoms, whereas pornography use frequency was the most peripheral symptom. However, mood modification had a more central place in the considered treatment group's network and a more peripheral position in the not-considered treatment group's network.

CLINICAL IMPLICATIONS

Based on the results of the centrality analysis in the considered treatment group, targeting salience, mood modification, and withdrawal symptoms first in the treatment may be an effective way of reducing PPU.

STRENGTHS & LIMITATIONS

The present study appears to be the first to analyze the symptoms of PPU using a network analytic approach. Self-reported measures of PPU and pornography use frequency might have introduced some biases.

CONCLUSION

The network of PPU symptoms was similar in participants who did and those who did not consider treatment because of their pornography use, with the exception of the mood modification symptom. Targeting the central symptoms in the treatments of PPU seems to be more effective than focusing on reducing pornography use. Bőthe B, Lonza A, Štulhofer A, et al. Symptoms of Problematic Pornography Use in a Sample of Treatment Considering and Treatment Non-Considering Men: A Network Approach. J Sex Med 2020;17:2016-2028.

Which conditions should be considered as disorders in the International Classification of Diseases (ICD-11) designation of "other specified disorders due to addictive behaviors"?

BACKGROUND

Gambling and gaming disorders have been included as "disorders due to addictive behaviors" in the International Classification of Diseases (ICD-11). Other problematic behaviors may be considered as "other specified disorders due to addictive behaviors (6C5Y)."

METHODS

Narrative review, experts' opinions.

RESULTS

We suggest the following meta-level criteria for considering potential addictive behaviors as fulfilling the category of "other specified disorders due to addictive behaviors":1. Clinical relevance: Empirical evidence from multiple scientific studies demonstrates that the specific potential addictive behavior is clinically relevant and individuals experience negative consequences and functional impairments in daily life due to the problematic and potentially addictive behavior.2. Theoretical embedding: Current theories and theoretical models belonging to the field of research on addictive behaviors describe and explain most appropriately the candidate phenomenon of a potential addictive behavior.3. Empirical evidence: Data based on self-reports, clinical interviews, surveys, behavioral experiments, and, if available, biological investigations (neural, physiological, genetic) suggest that psychological (and neurobiological) mechanisms involved in other addictive behaviors are also valid for the candidate phenomenon. Varying degrees of support for problematic forms of pornography use, buying and shopping, and use of social networks are available. These conditions may fit the category of "other specified disorders due to addictive behaviors".

CONCLUSION

It is important not to over-pathologize everyday-life behavior while concurrently not trivializing conditions that are of clinical importance and that deserve public health considerations. The proposed meta-level-criteria may help guide both research efforts and clinical practice.

Validation of a Brief Pornography Screen across multiple samples

BACKGROUND AND AIMS

To address current gaps around screening for problematic pornography use (PPU), we initially developed and tested a six-item Brief Pornography Screen (BPS) that asked about PPU in the past six months.

METHODS AND PARTICIPANTS

We recruited five independent samples from the U.S. and Poland to evaluate the psychometric properties of the BPS. In Study 1, we evaluated the factor structure, reliability, and elements of validity using a sample of 224 U.S. veterans. One item from the BPS was dropped in Study 1 due to low item endorsement. In Studies 2 and 3, we further investigated the five-item the factor structure of the BPS and evaluated its reliability and validity in two national U.S. representative samples (N = 1,466, N = 1,063, respectively). In Study 4, we confirmed the factor structure and evaluated its validity and reliability using a sample of 703 Polish adults. In Study 5, we calculated the suggested cut-off score for the screen using a sample of 105 male patients seeking treatment for compulsive sexual behavior disorder (CSBD).

RESULTS

Findings from a principal components analysis and confirmatory factor analysis supported a one-factor solution which yielded high internal consistency (α = 0.89-0.90), and analyses further supported elements of construct, convergent, criterion, and discriminant validity of the newly developed screen. Results from a Receiver Operating Characteristic (ROC) curve suggested a cut-off score of four or higher for detecting possible PPU.

CONCLUSIONS

The BPS appears to be psychometrically sound, short, and easy to use in various settings with high potential for use in populations across international jurisdictions.

Occurrence and clinical characteristics of Compulsive Sexual Behavior Disorder (CSBD): A cluster analysis in two independent community samples

BACKGROUND AND AIMS

Compulsive Sexual Behavior Disorder (CSBD) is characterized by a persistent failure to control intense and recurrent sexual impulses, urges, and/or thoughts, resulting in repetitive sexual behavior that causes a marked impairment in important areas of functioning. Despite its recent inclusion in the forthcoming ICD-11, concerns regarding its assessment, diagnosis, prevalence or clinical characteristics remain. The purpose of this study was to identify participants displaying CSBD through a novel data-driven approach in two independent samples and outline their sociodemographic, sexual, and clinical profile.

METHODS

Sample 1 included 1,581 university students (females = 56.9%; Mage = 20.58) whereas sample 2 comprised 1,318 community members (females = 43.6%; Mage = 32.37). First, we developed a new composite index to assess the whole range of CSBD symptoms based on three previously validated scales. Based on this new composite index, we subsequently identified individuals with CSBD through a cluster analytic approach.

RESULTS

The estimated occurrence of CSBD was 10.12% in sample 1 and 7.81% in sample 2. Participants with CSBD were mostly heterosexual males, younger than respondents without CSBD, reported higher levels of sexual sensation seeking and erotophilia, an increased offline and especially online sexual activity, more depressive and anxious symptoms, and poorer self-esteem.

CONCLUSIONS

This research provides further evidence on the occurrence of CSBD based on an alternative data-driven approach, as well as a detailed and nuanced description of the sociodemographic, sexual, and clinical profile of adults with this condition. Clinical implications derived from these findings are discussed in detail.

High-Frequency Pornography Use May Not Always Be Problematic

BACKGROUND

Previously, variable-centered analytic approaches showed positive, weak-to-moderate associations between frequency of pornography use (FPU) and problematic pornography use (PPU). However, person-centered studies are sparse in the literature, and these could provide insight into whether there are individuals who use pornography frequently and do not experience problems or whether there are individuals with comparable high-frequency use who differ on reported experiencing of negative consequences.

AIM

The aims of the present study were (i) to identify profiles of pornography use based on FPU and PPU by applying a person-centered analytic approach and (ii) to examine whether the identified profiles could be distinguished based on theoretically relevant demographic and psychological constructs.

METHODS

Latent profile analyses were conducted on 3 nonclinical samples recruited from general websites and a pornography site (study 1: N = 14,006; study 2: N = 483; study 3: N = 672).

RESULTS

Results were consistent across all studies. 3 distinct pornography-use profiles emerged: nonproblematic low-frequency pornography use (68-73% of individuals), nonproblematic high-frequency pornography use (19-29% of individuals), and problematic high-frequency use (3-8% of individuals). Nonproblematic and problematic high-frequency-use groups showed differences in several constructs (ie, hypersexuality, depressive symptoms, boredom susceptibility, self-esteem, uncomfortable feelings regarding pornography, and basic psychological needs).

CLINICAL TRANSLATION

FPU should not be considered as a sufficient or reliable indicator of PPU because the number of people with nonproblematic high-frequency use was 3-6 times higher than that with problematic high-frequency use. These results suggest that individuals with PPU use pornography frequently; however, FPU may not always be problematic.

STRENGTHS & LIMITATIONS

Self-report cross-sectional methods have possible biases that should be considered when interpreting findings (eg, underreporting or overreporting). However, the present research included 3 studies and involved large community samples and visitors of a pornography website. The present study is the first that empirically investigated pornography-use profiles with a wide range of correlates using both severity of PPU and FPU as profile indicators on specific and general samples.

CONCLUSION

The present study is a first step in the differentiated examination of pornography-use profiles, taking into consideration both PPU and FPU, and it provides a foundation for further clinical and large-scale studies. Different psychological mechanisms may underlie the development and maintenance of FPU with or without PPU, suggesting different treatment approaches. Therefore, the present results may guide clinical work when considering reasons for seeking treatment for PPU. Bőthe B, Tóth-Király I, Potenza MN, et al. High-Frequency Pornography Use May Not Always Be Problematic. J Sex Med 2020;17:793-811.