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CURRENT CONTROVERSIES (PJ KLEINPLATZ AND C MOSER, SECTION EDITORS)
The Emperor Has No Clothes: A Review of the ‘Pornography
Addiction’Model
David Ley &Nicole Prause &Peter Finn
#Springer Science+Business Media, LLC 2014
Abstract The addiction model is rarely used to describe high-
frequency use of visual sexual stimuli (VSS) in research, yet
common in media and clinical practice. The theory and re-
search behind ‘pornography addiction’is hindered by poor
experimental designs, limited methodological rigor, and lack
of model specification. The history and limitations of addic-
tion models are reviewed, including how VSS fails to meet
standards of addiction. These include how VSS use can reduce
health-risk behaviors. Proposed negative effects, including
erectile problems, difficulty regulating sexual feelings, and
neuroadaptations are discussed as non-pathological evidence
of learning. Individuals reporting ‘addictive’use of VSS could
be better conceptualized by considering issues such as gender,
sexual orientation, libido, desire for sensation, with internal
and external conflicts influenced by religiosity and desire
discrepancy. Since a large, lucrative industry has promised
treatments for pornography addiction despite this poor evi-
dence, scientific psychologists are called to declare the emper-
or (treatment industry) has no clothes (supporting evidence).
When faced with such complaints, clinicians are encouraged
to address behaviors without conjuring addiction labels.
Keywords Pornography addiction .Pornography addiction
model .Visual sexual stimulus (VSS) .Libido .
Sensation-seeking .Erectile dysfunction .Addiction model .
Impulsivity .Compulsivity
Introduction
‘Pornography addiction’is one label that has been used spe-
cifically to describe the high-frequency viewing of sexual
images. Related concepts, such as ‘sex addiction’or ‘internet
addiction’refer to broader constellations of behaviors. These
address problem sexual (e.g., financial loss with high involve-
ment with sex workers) or internet (e.g., web browsing in lieu
of any family time) behaviors broadly. Competing models of
high-frequency viewing of sexual images also have been
offered, such as sexual compulsivity [1]. Some have claimed
to abdicate models by using terms like ‘hypersexual disorder’,
but these authors are still using a model of pathology. In this
manuscript, we specifically critique the addiction model of
high use of visual sexual stimuli.
Scientists investigating high-frequency sexual behaviors
rarely describe these behaviors as an addiction (37 % of
articles) [2••]. In fact, most scientists have overtly rejected
the addiction model [3,4]. The recent revision of the
Diagnostic and Statistical Manual (DSM) similarly did not
include sex addiction, citing “To include this as an addiction
would require published scientific research that does not exist
at this time”(Charles O’Brien, personal communication,
September 19, 2013). Widely cited critiques of addiction
models have been leveled against other behaviors as well,
including food [5,6], internet use [7], and gambling [8]. The
perseverance of this term in the popular press and by some
treatment providers is puzzling. The pseudoscientific practices
surrounding the treatment of ‘porn addiction’compel us to
reveal that the emperor is not wearing any clothes [9].
The overwhelming majority of patients seeking help for
high-frequency sexual problems report that frequency of
viewing sexual stimuli is their main, or primary, problem
[10]. The addiction model of visual sexual stimuli (VSS)
viewing continues to be popular in the media and appears in
the journal name of a clinical society focused on treatment
issues (Sexual Addiction and Compulsivity). The current
This article is part of the Topical Collection on Current Controversies
D. Ley (*)
New Mexico Solutions, 707 Broadway NE #500, Albuquerque,
NM 87102, USA
e-mail: nmpsychologist@yahoo.com
N. Prause
University of California, Los Angeles, CA, USA
P. Finn
Indiana University, Bloomington, IN, USA
Curr Sex Health Rep
DOI 10.1007/s11930-014-0016-8
review is specifically critical of addiction as an appropriate
model for the high-frequency viewing of VSS, sometimes
referred to as ‘pornography addiction’. (Studies of ‘addic-
tion’to sexual imagery overwhelmingly use the biased term
‘pornography’[11]. Since many benefits of sexual stimuli
also have been identified (see below), we follow the APA
recommendation to use less biased language [12••]. The
empirically accurate term ‘visual sexual stimuli’(VSS is
used instead of ‘pornography’. Other models for high-
frequency VSS viewing are suggested, including non-
pathology models.
Some have suggested that easier access to sexual films
online is responsible for creating an epidemic of porn addic-
tion [13]. Emotional images with movement significantly
increase arousal over still images across a variety of domains
[14]. Moreover, motion may be important for generating
motivated states, such as generating actual fear to phobic
objectsratherthanmereunpleasantaffect[15]. Greater com-
plexity (e.g., number of scene changes) in the films is known
to impact posterior, but not anterior, cortical sites on the brain
[16]. The more interest a person reports in a film, the greater
their frontal alpha suppression during the film [16]. This
finding was recently extended in response to sexual films
[17]. In summary, sexual films, like other emotional films,
engage the brain in ways consistent with high arousal, moti-
vated states. The brain appears to respond similarly with
sexual and other emotional films.
VSS use does not appear to be increasing despite increased
availability. Fluctuations in VSS formats and legislation in
recent decades helps to clarify this issue. VSS viewing in the
USA has remained remarkably steady (near 22 %) since 1973,
showing the greatest changewith the introduction of the VCR
after a period of legal prohibition [18]. Of those over age 18,
75 % now have regular internet access with 60 % reporting
broadband athome and 55 % accessing the internetwirelessly
[19]. In contrast to frequent claims in the popular media about
an epidemic of porn use, no change in the last 4 decades has
been noted in more detailed longitudinal data since internet
access increased [20]. Further, searches for ‘sex’(Google
Analytics) appear stable since data collection started in
2004. It is possible that something about the films has changed
over time, altering its effect. For example, those studying
video games investigate changing ‘realism’as predictors of
the changing effects of video games [21]. Given that visual
erotica has long appeared in film, realism is probably not the
best parallel for VSS changes over time. No data have yet
been offered to suggest how the VSS format or content may
have changed over decades.VSS viewing appears very stable,
with a larger change in viewing with the introduction of the
VCR, not internet availability.
The prevalence of VSS problems reported is inconsistent.
Clinicians frequently cite “up to 6 %”of the US population is
sexually addicted. This estimate comes from clinical speculation
in a popular book [22] in which the clinician/authors focusing
their practice on these issues do not clearly define the bound-
aries of this diagnosis. Empirical estimates from nationally
representative samples are that 0.8 % of men and 0.6 % of
women report out of control sexual behaviors that interfere with
their daily lives [23]. If one assumes these individuals might
seek treatment, 82 % of treatment seekers report problems with
VSS, and clinicians agree that they have a clinical problem in
about 88 % of cases [10]. Thus, VSS problems might affect
0.58 % of men and 0.43 % of women in the USA.
Positive Effects of VSS Use
While much has been written about the potential negative
effects of VSS, a number of positive effects also have been
suggested [24]. Most people who view VSS believe that it
improves their attitudes towards sexuality [25] and improves
their quality of life [26]. More VSS viewing has been related
to greater likelihood of anal and oral sex [27]andagreater
variety of sexual behaviors [28]. This increased breadth of
sexual behaviors could arise by increasing a person’sfeeling
of empowerment to suggest new sexual behaviors or by
normalizing the behaviors [29]. In any case, sexual novelty
can increase pleasure in long-term partners. VSS can also
promote pleasant feelings in the moment, such as happiness
and joy [30,31]. Additionally, VSS may provide a legal outlet
for illegal sexual behaviors or desires. Increased VSS con-
sumption or availability has been associated with a decrease in
sex offenses [32•], especially child molestation [33,34]and
inhibition of aggression [35]. On the other hand, a large
longitudinal study controlling for baseline attitudes and be-
haviors identified that VSS use accounted for only 0–1%of
the variance in gender role attitudes, permissive sexual norms,
andsexualharassmentinboysorgirls[12••]. While much has
been written about negative aspects of VSS for the general
population, the many possible benefits suggest that VSS use is
not problematic de facto.
Addiction Model
What is Addiction?
What should be labeled an addiction in the first place [36•]?
‘Addiction’is a term that is often reified, when it really is
being used as a theoretical construct or a model to describe a
cluster of behaviors. The question raised in this review is
whether VSS viewing could be described using an addiction
construct or model, so it may be helpful to consider how the
term ‘addiction’is being used with substances.
DSM-5 introduced the term ‘addiction’within the broad
category ‘Substance-Related and Addictive Disorders’over
Curr Sex Health Rep
the objections of the working group [37]. However, the term
‘addiction’was specifically rejected to describe gambling [38]
or substance use despite the section title. This suggests some
tension over the utility of the addiction framework even for
substances and gambling. Presumably, if ‘addiction’pos-
sessed diagnostic or prognostic value, it would be defined
and would distinguish clinical cases. Of course, the DSM is
hardly the only consensus rejecting the utility of addictions.
Increased modern understanding of the effects of various
substances such as cannabis has raised questions about the
scientific and clinical applicability of the concept as it has
historically been defined. As with many other clinical con-
cepts, addiction has seen significant ‘bleed’as the term has
been broadened to describe a wide range of problematic
behaviors. While there seems to be a consensus that addiction
is a useful construct to describe opiate dependence [39], the
usefulness of ‘addiction’to describe the excessive use of any
drug [40], compulsive gambling [41], and excessive video
game playing [42] has raised many concerns.
While we generally reject the usefulness of the term, if one
is pressed, some commonalities have been suggested by ad-
dictions research. A key feature of addiction is the shift from
using the drug for pleasure (liking) to using the drug due to
need (wanting) [43,44]. This transition is characterized by the
shift from substance use associated with reward and pleasur-
able effects to cue-elicited compulsive use associated with
cue-elicited craving. In other words, motivation shifts towards
relieving craving or withdrawal, while the pleasure once as-
sociated with the substance recedes [43–45]. Finally, this
pattern is associated with long-term changes in the neural
circuits involving dopamine, glutamate, and GABA in the
fronto-limbic system involving the interconnectedness of the
ventral tegmental area, nucleus accumbens, amygdala, and
prefrontal cortex [43,44,46]. Such a transition and long-
term neural changes have yet to be demonstrated in any
studies of ‘porn addiction’.
Porn Addiction?
Many have attempted to generalize the patterns related to
problem substance use to explain other behavior problems,
including use of VSS [47]. Surprisingly, a clear, falsifiable
theoretical model of ‘porn addiction’has yet to be described.
Some use addiction interchangeably with other labels such as
hypersexual disorder (HD) –also known as sexual addiction
[48]. Others define addiction broadly to refer to any substance
or behavior with evidence of excessive appetite: “appetitive
behaviour is excessive, at least in the statistical sense”[49].
Simply because a behavior is appetitive and frequently en-
gaged does not mean the behavior is a problem, let alone an
addiction. Even when consequences, distress, or dysfunction
follow such behaviors, interaction with third variables, such as
relationship status or culture, must first be examined.
Research concerning VSS use problems is also unusually
weak, making any support for an addiction model necessarily
weak. For example, studies usually fail to define the term
‘pornography’, either for participants or operationalized in
the manuscript, and do not use psychometrically tested ques-
tionnaires to assess the types of VSS consumed [50]. Döring
[51••] summarized research on VSS as “one seldom encoun-
ters more sophisticated research designs”where “one-shot
studies are the rule”, positive effects are rarely assessed, and
cross-sectional data cannot establish causality (p. 1098). A
review by Mudry et al. [2••] identified that a mere 27 % (13 of
49) of articles concerning high-frequency sexual behaviors
contained actual data. In 2013, only a single psychophysio-
logical study on the topic appeared [52]. In other words, most
publications that might be relevant for VSS addiction models
contain no data, and those that contain data generally are weak
scientifically.
Given the absence of a clear model, a substance addiction
model is used in this review as a basis to evaluate the sex
addiction model. Using a substance addiction model means
comparing the extent to which VSS ‘addictions’resemble
features of substance addictions. No doubt some will object
to this framework, but no falsifiable alternative has been
specified. For example, Griffiths [53] describes “behavioural
addictions feature the core components of addiction (i.e.,
salience, mood modification, tolerance, withdrawal, conflict
and relapse)”. Others go so far as to recommend treatment
parallel to 12-step interventions [54]. Clearly, the substance
addictions model is being applied in pornography addiction.
We specifically review the appropriateness of ‘porn addic-
tion’with respect to its possible negative consequences, lack of
control reported in viewing behaviors, and any neural evidence
supporting a shift to wanting/craving rather than liking. Not
every aspect of substance addiction models can be discussed.
After these comparisons with substance addictions, possible
alternative models of high-frequency VSS use are reviewed,
including the possibility that no pathology exists.
Negative Consequences of High Use of VSS
High levels of VSS use alone are often alleged to cause
negative life consequences, increased health-risk behaviors,
as well as social and relational difficulties. These negative
consequences are commonly identified as hallmark ‘dysfunc-
tion’criteria to support the diagnosis of porn addiction.
However, these negative consequences are not well
established, and the causal link with VSS use is not clear.
High VSS Use Associations with Health-Risk Behaviors?
Cross-sectional studies have identified relationships between
sex addiction and more unprotected anal sex [55], having
Curr Sex Health Rep
more previously unknown partners [56], and a greater likeli-
hood of having ever paid for sex [57]. However, none of these
address VSS use. In fact, some have argued that VSS use and
masturbation may red u ce health-risk behaviors by managing
sex drive effectively and safely [58,59]. Using data from the
very large, representative longitudinal General Social Survey,
Wright [60•] similarly found VSS use and engagement in
casual sex were related only in those who reported unhappi-
ness and low life satisfaction. Similarly, political ideology
moderated the apparent relationship between VSS use and
casual sex partners [20]. No study has demonstrated a direct,
causal link between VSS use and health-risk behaviors.
Erectile Dysfunction and High VSS Use?
While no empirical claims tying erectile function and ‘porn
addiction’were identified, this is a frequent media claim. Two
research groups studied erectile dysfunction (ED) specifically
in young men. In one study, 26 % of men seeking treatment
for first-onset ED were under age 40 [61•]. The main predic-
tors of ED specific to the younger men were smoking and
illicit drug use. Another study of men age 18–25 found 30 %
reported ED [62]. Again, ED appeared primarily related to
illicit drug use, but also depression and poor physical health.
Neither study measured or conjectured about VSS use.
Considering another study showed no differences during
VSS viewing in the brains of men with and without ED
[63], it is difficult to find evidence for a rise in ED in young
men attributable to VSS use.
VSS viewing is almost always accompanied by masturbation
[10], suggesting several mechanisms by which high-frequency
VSS viewing could contribute to difficulties getting or sustain-
ing an erection. However, both reflect basic physiology and
learning principles, not pathology. First, men exhibit refractory
periods. Refractory periods refer to the latency after an orgasm
during which subsequent erection and orgasm are more difficult
(for review, see Levin [64]). Sperm factors are affected posi-
tively by the latency since last ejaculation [65,66], leading to
speculation that refractory periods function to pace reproductive
copulation. Increased VSS use means more recent orgasms,
thus a male who views VSS more frequently is more likely to
be within a refractory period when partnered sex is attempted.
The other non-pathological mechanism by which VSS
viewing might contribute to decreased erections is learning.
Sexual response can be conditioned to images of a penny jar
[67], to specific sexual images using vibratory stimuli [68],
and using sexual films as the unconditioned stimulus [69].
Even rodents appear unable to behave sexually in the absence
of a conditioned jacket [70•]. Sexual responses also habituate
[71–74]. In fact, habituation to sexual stimuli is faster than
habituation to negative stimuli [75]. Physiology and learning,
not addiction, can explain any links between VSS use and
erections. In other words, increasing VSS use could lead to
ED, but the causal mechanism is most parsimoniously ex-
plained by processes other than addiction.
Failure to Inhibit VSS Use
Anecdotal reports of addiction often describe individuals
reporting difficulty controlling their use of VSS. To parallel
substance addictions, VSS use should also be difficult to
inhibit. However, a laboratory study did not identify any
relationship between the ability to self-regulate sexual arous-
al to VSS and measures of hypersexual problems [76]. This
finding was recently extended to demonstrate that sexual
desire levels, not hypersexual problems, predict how well a
person up- and down-regulates their sexual responses to
VSS [77]. Similarly, sex addiction patients report
dysexecutive problems [78], but do not actually exhibit them
when tested [79]. If there is not actually any evidence for
dysregulation, what might explain their reports of problems
regulating VSS use?
Some have cited personal religious values as providing a
conflict between their VSS use and feeling unable to stop.
Religious conflict was the main reason cited for problems
viewing VSS in one study [80]. Those who want treatment
for sex addiction are also more likely to be members of orga-
nized religion and hold strong religious values [81•,82].
However, the reverse was not true: religiosity explained little
variance (3 %) in the decision to use VSS [83]. Far more people
report a feeling of inability to control their VSS use, than
actually report life difficulties resulting from their use [23].
Feeling unable to stop may reflect personal value conflicts with
normal VSS use. No data currently support the notion that
‘porn addicts’have difficulty inhibiting their VSS use.
Neuroadaptations to VSS Use
Data consistently demonstrate the ability of substances to shift
brain response to craving, rather than liking, states. The same
cannot be said of VSS. Sexual images are known to evoke
stronger motivation than other pleasant images, manifesting in
a variety of physiological indicators [84,85]. Sexual images
and films increase blood flow to many areas of the brain,
including those associated with reward, relative to neutral
films (for review, see Kühn and Gallinat [86]). VSS also
provoke increases in dopamine-tagged ligands in PET [87,
88]. Also, VSS appear pleasant and rewarding to both men
and women in fMRI studies [89]. This appears to fulfill the
initial liking present in the development of substance addic-
tions [90] and offers some commonalities with substance
reinforcement [91], but in no case has a shift away from liking
to wanting or craving been demonstrated.
In fact, no data have demonstrated that VSS are different
from any other ‘liked’activity or object [92•]. This is
Curr Sex Health Rep
important, because pathology should be conceptually distinct,
not merely those on the high end of a construct like sexual
desire [93]. For example, Florida students respond with in-
creased late positive brain potentials to images of their adored
Gator team over images of other sports [94•]. Similarly, those
who have no problems with their eating still exhibit greater
frontal alpha asymmetry to images of delicious desserts
(EEG [95]) and striatal activity specifically increases to
preferred chocolate brands (fMRI [96]). Also, activity in
the left nucleus accumbens to delicious foods positively
predicts BMI change prospectively [97] in those without
any known eating pathology. Those who enjoy extreme
sports also show differential modulation of the brain re-
sponse (P300) not associated with pathology [98]. In sum-
mary, stronger neural responses occur to any enjoyed activ-
ity that is not pathological [99]. Thus, stronger activation to
VSS in those reporting liking VSS more are both expected
and non-pathological.
VSS processing can further be associated with state and
trait differences, which would be necessary to associate ‘ad-
dicts’responses. Activation of entorhinal cortex activity is
lesser in those who report hypoactive sexual desire problems
[100]. Left insula and right thalamus activity is lesser to VSS
in those with lower levels of sexual desire [101]. Further,
frontal alpha asymmetry to sexual films are also related to
reported sexual arousal, particularly in women [17]. However,
no shift in neural response in ‘porn addicts’has been
demonstrated.
Substance use problems appear heritable, suggesting a
biological susceptibility. For example, those with higher ge-
netic risk for alcoholism similarly are more reactive to alcohol
cues [102]. Sexual debut and risk behaviors are heritable (for
review, see Harden [103]). Sexual sensitivity also appears
heritable, such as with orgasm capacity in women [104,
105]. However, heritable components of VSS use have not
been demonstrated.
ΔFosB has recently drawn increased interest in substance
addictions. This transcription factor is implicated in epige-
netic effects in the nucleus accumbens, via direct D1 path-
ways, that occur in both normal reward learning and drug
taking [106]. This is being interpreted as a mechanism by
which drugs may chronically decrease dopamine signaling
[107]. Similar changes have been demonstrated to food
following the administration of high fat diets to rodents
[108]. Increased latency to mount and intromission, though
notejaculation,havebeenobservedinsexuallyexperienced
male rodents [109]. This was interpreted as evidence of
ΔFosB as a “critical mediator for reward reinforcement
and natural reward memory”, although sex addiction was
not discussed (p. 837). There are serious challenges to mea-
suring ΔFosB in humans, and null results have been report-
ed in humans to date (e.g., in alcoholics in Watanabe et al.
[110]). Even more problematic is that the rodent model of
hypersexuality is male on male mounting behaviors [111]. It
appears that pathologizing homosexual behaviors would be
necessary to test ΔFosB as a mediator in a rodent model of
sex addiction. ‘Porn addiction’languishes without any clear
animal model.
Alternative Models
If high-frequency VSS viewing is not usefully described as an
addiction, is there a better model to describe those who report
problems regulating their VSS viewing and experience nega-
tive consequences from it? Several alternative models have
been suggested. Before describing the possible pathology
models, it is important to note that high-frequency viewing
of VSS may not be pathological at all.First, we review several
correlates of VSS use that are inconsistent with pathology.
Next, we review compulsivity and impulsivity models of
these behaviors.
Secondary Gain
The treatment of pornography and sex addiction is a lucrative,
largely unregulated industry. The industry makes many claims
for treatment and success, with little (to no) published data.
Many treatment centers in the USA have emerged claiming to
treat sex addiction. The first 20 inpatient facilities advertising
on the internet to treat sex and/or porn addiction in the USA
were contacted. They averaged a cost of US$677 (SD =$403)
per day. They required or recommended between 9 days to
9 months minimum of inpatient stay. For example, one center
claims their sex addiction treatment is “clinically shown to
produce results that are up to 3 times faster and 11 times more
effective than traditional treatment methods”, although none
of the articles on their website (nor in the literature) actually
test sex addiction [112]. The use of medications ‘off-label’to
treat ‘pornography addiction’also appears common. Drugs
originally designed to treat alcoholism, depression, and ED
have all been suggested [113,114]. This therapeutic oppor-
tunism is well characterized [115]. Some have advocated for
transparency, requiring therapists to inform patients that such
therapies are experimental, and have not been tested for sex
addiction [116•].
Many of the treatment centers and providers also claim
religious affiliations, raising questions about the nature of
supposed pathology if it is rooted in a particular religion.
Some of the most outspoken advocates for an addiction pa-
thology model have publications making explicitly religious
arguments against VSS viewing [117–119]. Religiosity is one
of the strongest (negative) predictors of problems with internet
VSS use [82]. The risk of conflating profit motive and diag-
nosis in a population vulnerable due to their strong religious
beliefs appears high.
Curr Sex Health Rep
VSS Use and Mental Health Problems
VSS use might be elevated due to mental health problems
that are not explicitly sexual, such as depression [120].
Those with more frequent use of VSS reported more depres-
sive symptoms, poorer quality of life, lower health status and
more days that were diminished due to mental and physical
health [121] in addition to more drug and alcohol use [122].
The number of hours one spends viewing VSS also is related
(r=.24) to the severity of psychological symptoms [123].
These negative relationships appear more common in males.
Similarly, those who specifically report problems with VSS
were significantly more likely to report current or past
psychiatric treatment, mental health therapy, and suicide
ideation [124].
Given that positive effects also are common (reviewed
above) and the positive and negative effects of VSS use often
are even correlated, data are needed to address causality
between VSS use and mental health problems. Causality
could be supported by demonstrating that(i) the mental health
problems occur after the VSS use (or increase with greater
VSS use), (ii) third variables do not account for the apparent
relationship between mental health problems and VSS use,
and (iii) problems increase in a dose-response fashion with
greater VSS use. Limited data to date refute each requirement.
When examined over time, mental health problems do not
follow VSS use. In a large sample of Dutch adolescents, lower
life satisfaction predicted greater VSS use at time 2 [125]. This
is the reverse of what would be expected if VSS use were
causing life dissatisfaction.
VSS use also may be related to a number of other variables
that better account for a VSS–mental health relationship. For
example, even when loneliness was strongly predicted by
overall Internet use, researchers failed to appropriately statis-
tically control for general Internet use and attributed loneliness
to VSS use [126]. It is rare that investigators even collect data
on such third variables, however, so this study represents a
positive step.
Others have reached similar conclusions: “the high comor-
bidity rates in the present sample call into question the extent
to which it is possible to speak of Internet sex addiction as a
primary disorder or whether it is more appropriate to view it as
a symptom of another underlying mental health problem”
[127]. In summary, it is baffling that VSS use is described as
‘comorbid’with mental health issues (e.g., “comordbid hy-
persexual behavior and ADHD”in Reid et al. [128]). This
language elevates VSS use to disorder status and should be
avoided.
VSS Use Explained by Sex Drive
More VSS use is related to higher levels of libido/sexual
arousal. Individuals who report being more aroused by VSS
also use VSS more and report higher levels of sexual desire
[122,123,129,130]. Two studies directly investigating
high desire models found support for these models. In one
study, those who desired help regulating their sexual behav-
iors were only distinguished by a high sexual desire level
[81•]. In the second study, neural responses to sexual stim-
uli were related to sexual desire levels, but not any (of
three) measures of sexual addiction [52]. Indirect evidence
also comes from a study in which single women looked
longer than women in relationships at images of men [131].
Desire discrepancy, rather than low sexual desire, appears
central to couples reporting a mismatch of desire [132].
VSS may be blamed for problems really due to a mismatch
of sexual needs.
VSS Use Explained by Sensation Seeking
Higher need or desire for sensation is predictive of more
frequent use of VSS, in both adolescents and adults [12••,
133,134]. A higher need for sensation seeking may drive
individuals towards forbidden or taboo experiences, may be
connected to higher libido, may result from increased VSS
use, or may dispose individuals to use exciting sexual stimuli
or experiences as a form of emotional coping. Little informa-
tion exists as to whether sensation seeking acts as a disposing
characteristic, is a result of use of VSS and other sexually
adventurous behaviors, or is bidirectional. Future research
may further elucidate the connections between this variable
and problems related to VSS.
VSS Use as Effective Affect Regulation
Individuals report using VSS to cope with negative emotions,
and such use is frequently identified as a core symptom of sex
addiction. Although this strategy may contribute to relation-
ship conflict [124,135], VSS are likely effective for regulating
emotion. Like other emotional images, VSS capture cognitive
resources effectively [136]. Distraction is an effective method
for reducing negative affect [137]. Although distraction is
relatively less effective for regulating emotions than other
strategies [138], distraction also requires less effort than other
strategies [139]. Thus, VSS appear likely to be effective in
improving mood, possibly in similar ways to pleasant car-
toons [55]. Recent experimental evidence suggested that peo-
ple with problems regulating their viewing of VSS respond
with similarly positive emotions while viewing VSS to people
without problems [140]. Those with higher sexual compulsiv-
ity also appear more prone to respond with increased interest
(assessed by attractiveness ratings and gaze direction) to flir-
tatious faces after a shame induction than those with lower
sexual compulsivity [141]. Data have not yet demonstrated
that using VSS to regulate mood is ineffective or leads to
specific problems.
Curr Sex Health Rep
VSS Use and Sexual Orientation
Studies that examine rates of VSS use consistently find high
rates of use in men who self-identify as gay or bisexual.
Cooper et al. [142] described overrepresentation of men who
have sex with men (MSM) in groups reporting the highest
rates of use of VSS. Studies examining rates of VSS use in
nationally representative samples find higher rates of VSS use
in both adolescents and adults who identify as other than
heterosexual [133], as do studies of clinical samples [143].
Trials of DSM-5 hypersexual disorder criteria found that
MSM were more than three times as likely to be in such
treatment settings, compared with rates of MSM in compara-
ble substance abuse or mental health facilities [144].
Increased use of VSS in these populations may reflect
adaptive strategies. MSM may be more likely to seek informa-
tion and stimuli consistent with their sexual orientation. This
may reflect a common component of the ‘coming-out process’
of forming a stable sexual identity [145]. In other words, VSS
use could reflect the behaviors of a disenfranchised group
seeking safe, anonymous venues to explore their sexual needs,
or may reflect unique aspects of homosexual culture. It also
may simply reflect the higher sexual drive of men (see above).
Studies that examine use of VSS in MSM find that these men
overwhelmingly endorse these positive benefits from VSS use
[146]. Rates of VSS use in MSM may reflect unique aspects of
homosexuality, aspects of male sexuality, or both.
Impulsivity
Impulsivity broadly refers to a sudden urge to respond to a
(internal orexternal) cue with less executive mediation than is
probably appropriate. In VSS use, this might mean noticing a
sexual cue and beginning to use VSS with little consideration
for other immediate time demands. Measures of impulsivity
correlate moderately with measures of sexual compulsivity
and experiential avoidance [147] and sexual arousal reported
to VSS [148]. A pilot study (N=16) suggested that patients
made more errors on a task indicative of impulsivity than
controls [149]. A recent evoked response potential study
further supported this model, identifying that those reporting
problems regulating their VSS use exhibited decreased neural
motivation to sexual images [150]. New fMRI models suggest
impulsivity might reflect a greater isolation of prefrontal brain
areas from appetitive-associated subcortical structures [151].
A larger body of experimental work appears available to guide
future investigations testing an impulsivity model of high-
frequency VSS use.
Compulsivity
Compulsivity broadly refers to the perseveration ofbehaviors,
which could characterize repeatedly returning to VSS. Some
have argued that compulsive behaviors are best viewed as a
type of impulsivity [114]. However, perseveration is distin-
guishable from impulsive problems in the brain. Orbitofrontal
lesions in rodent models specifically provoke perseveration,
separating these from discrimination errors affected by dorsal
anterior cingulate cortex lesions [54]. Differences between
impulsive and compulsive behaviors also have strong charac-
terization in humans [116•]. Dissociations between impulsiv-
ity and compulsivity also have been used to meaningfully
differentiate clinical profiles, such as in hair-pulling [152].
Compulsivity has become a very popular term to refer to
high-frequency sexual behaviors, although little research ex-
ists to clearly support differentiating sexual behaviors as com-
pulsive. Cooper (1998) appears one of the first to use this
term. His widely-cited “Triple-A Engine”(Accessibility,
Affordability and Anonymity) is cited as driving VSS com-
pulsions, especially to relieve negative affect by ‘positive
reinforcement’[124]. However, no one has directly tested
whether compulsivity is a reasonable model for characterizing
high-frequency VSS use.
Conclusions
VSS may have a number of links to positive health outcomes,
especially through its connection to orgasm. For example,
VSS could reduce sexual risk behaviors. In a longitudinal
study, those who reported higher sexual sensation seeking
engage in more risky sexual behaviors, and sexual sensation
seeking is inversely related to VSS viewing [153]. One pos-
sibility is that those with higher sexual sensation seeking use
VSS at younger ages and broaden the content of their VSS
when sexual partners are not available to them to engage in
actual sexual risk behaviors [154]. This is consistent with
suggestions that masturbation, which almost always accom-
panies VSS viewing, could reduce risky partnered sexual
behaviors [59]. The potential risk in labeling VSS as only
addictive, and the role of VSS in regulating emotions as
inherently problematic, misses opportunities to take advan-
tage of the positive features of VSS (cp., cognitive retraining
in gaming as in Bavelier and Davidson [155]).
Based upon the empirical data reviewed herein, the tenacity
and popularity of the porn addiction concept to describe high
rates of VSS use appears to be driven by non-empirical forces.
Based upon this review, the authors suggest that this popular-
ity reflectsseveral factors. First, the concept of addiction itself
is broadly used in the media to describe any high-frequency
behavior that can be associated with problems for the individ-
ual or society. The lack of specificity makes the term nearly
useless to scientists or clinicians. Secondly, the strong desire
of most clinicians to be helpful to those in pain has been
leveraged into a large, lucrative treatment industry benefitting
from the perception that these behaviors are addictive and
Curr Sex Health Rep
require (paid) assistance to change. Finally, the ability to label
VSS use as addictive appears to serve sociocultural functions.
The label supports moralistic judgments, the stigmatization of
sexual minorities, and the suppression of certain sexual ex-
pressions and behaviors. The concept of porn addiction is one
mechanism to exert social control over sexuality as expressed
or experienced through modern technological means. Mere
conflict between a person’s preferences and social standards
should not be used to characterize pathology [156]. Moreover,
this label may distract attention from the more likely causes of
the negative consequences spuriously correlated with VSS
use.
Individuals reporting ‘addictive’use of VSS could be
conceptualized using the approach outlined here. These indi-
viduals may be likely to be male, have a non-heterosexual
orientation, have a high libido, tend towards sensation seek-
ing, and have religious values that conflict with their sexual
behaviors and desires. They may be using VSS as a means of
coping with negative emotional states or decreased life satis-
faction. When faced with such complaints, clinicians are
encouraged to address these factors without conjuring addic-
tion labels. As better models for high-frequency VSS use are
tested, we may yet be able to spin fine cloth as an effective
method for assisting these individuals without pathologizing
them or their use of VSS.
Compliance with Ethics Guidelines
Conflict of Interest David Ley has received royalties from Rowman &
Littlefield Publishers, is a paid blogger/writer for Psychology Today,and
has had travel expenses covered by various media outlets for appearances
on television shows.
Nicole Prause and Peter Finn declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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