When Pornography Becomes a Problem: Clinical Insights
Although both internet and non-internet pornography may share features, the availability of pornography on the internet has altered consumption patterns, which may have a significant effect on psychiatric and physical health, intimate relationships, and other aspects of functioning. The contributing factors include convenience and perceived anonymity of pornography use on the internet, affordability, accessibility, and the opportunity to escape from reality. Practically speaking, the seemingly endless and diverse sexual material may fit with all sorts of sexual fantasies. The material can be accessed anonymously, irrespective of time and place—this ease of use may become problematic for individuals who have characteristics that put them at increased risk for addiction.
Classification and diagnostic criteria
Compulsive sexual behavior disorder (CSBD), including problematic pornography use, is included in ICD-11 as an impulse-control disorder. As such, problematic pornography use may be considered a form of CSBD. Although CSBD is classified as an impulse-control disorder, the diagnostic criteria for the disorder are very similar to those for disorders due to addictive behaviors. A comparison of diagnostic criteria for CSBD and disorders due to addictive behaviors (using gaming disorder as an example) is provided in Table 1.
Based on extant data, problematic pornography use may be considered a behavioral addiction. A more detailed discussion of classification and diagnostic procedures can be found in a recent systematic review of literature related to problematic pornography use.1 Prevalence estimates for CSBD have not been systematically evaluated, but may be roughly between 5% and 12%, with males being twice as likely to experience features of CSBD or related phenomena.
Prevalence estimates are currently imprecise because different scales have been used across studies; moreover, most studies do not distinguish problematic pornography use from other (hyper)sexual behaviors. However, one national sample showed “clinically relevant levels of distress and/or impairment associated with difficulty controlling sexual feelings, urges, and behaviors” in 8.6% of individuals (10.3% of men and 7.0% of women).2 In another report sexual impulsivity was acknowledged by 14.7% of individuals (18.9% of men and 10.9% of women).3 These data suggest that a large proportion of US adults are experiencing clinically relevant features of CSBD.
Problematic internet pornography use can also be a concern in individuals with normal/average socio-sexual behaviors, which means that these individuals have a specific problem in controlling their internet pornography consumption, but not hypersexual behaviors in other domains. It is therefore important to define whether problems related to pornography are only one component of CSBD that may co-exist with compulsive sexual behaviors offline (eg, frequent sexual intercourse with multiple partners, going to prostitutes, anonymous sexual contacts). When making treatment decisions, it is important to consider potentially addictive aspects of the behavior, such as experiencing gratification and cravings (eg, responses to triggers or pornography-related stimuli) as well as impaired control of pornography consumption despite adverse consequences.
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