What Matters: Quantity or Quality of Pornography Use? Psychological and Behavioral Factors of Seeking Treatment for Problematic Pornography Use (2016)
COMMENTS: This study said it was the first to examine the associations between the amount of porn use, negative symptoms (as assessed by the Sexual Addiction Screening Test-Revised SAST-R), and other factors in individuals seeking treatment for problematic porn use. That study also surveyed non-treatment seeking porn users.
As with other studies frequency of porn use was not the primary predictor of problematic porn use. An excerpt:
"Negative symptoms associated with porn use more strongly predict seeking treatment than mere quantity of pornography consumption."
An more interesting finding: There was no correlation between religiosity and negative symptoms associated with porn use in men seeking treatment for porn addiction. Contrary to inaccurate claims by those misinterpreting Grubbs et al. 2015, being religious doesn't "cause" porn addiction, and porn addicts are not more religious.
J Sex Med. 2016 Mar 22. pii: S1743-6095(16)00346-5. doi: 10.1016/j.jsxm.2016.02.169.
MAIN OUTCOMES MEASURES:
KEYWORDS: Hypersexual Behavior; Pornography; Problematic Sexual Behavior; Psychotherapy; Treatment Seeking
According to our a priori predictions, PU may lead to negative symptoms and the severity of these symptoms lead to treatment-seeking (Fig. 1; Path B). We show that the frequency of PU, alone, is not a significant predictor of treatment-seeking for problematic pornography use when controlling for negative symptoms associated with PU (Fig. 2). Such a weak relation had been indirectly suggested by previous studies on pornography users. Cooper and colleagues  showed that, among subjects engaging in online sexual activities (not only PU, but also sex chats), 22.6% of 4278 light users (<1 h/week) reported an interference of their online sexual activity within many areas of their everyday lives, while 49% of 764 heavy users (>11 h/week) never experienced such interference.
In the second step of data analysis, we extended our model by testing four parallel mediators of a relationship between PU and negative symptoms ( onset and  number of years of PU,  subjective religiosity,  religious practices; see Fig. 3). Effects of onset and numbers of years of use demonstrated in studies on substance abuse and pathological gambling , appeared insignificant in our dataset. Lack of such findings may suggest a potentially lower longitudinal impact of PU on functioning than substance abuse or pathological gambling. This result may also be related to the methodological limitations of our study. We calculated a number of years of PU as the difference between onset of PU and the subjects’ present age. It is possible that some subjects were using pornography for only a limited time from their onset, and, thus, this measure presented within our analyses may be inaccurate. Future studies should investigate he number of years of regular PU. Another possible limitation is that, for negative symptoms, we used SAST-R as it was the only questionnaire for hypersexual behavior assessment available in the Polish language . This questionnaire had been designed to measure a wide spectrum of negative consequences related not only to PU, but also other sexual behaviors. The obtained significant relation between frequency of PU and SAST-R scores shows that, among other sexual behaviors, it also measures the negative symptoms related to PU. In the second step of data analysis, we extended our model by testing four parallel mediators of a relationship between PU and negative symptoms ( onset and  number of years of PU,  subjective religiosity,  religious practices; see Fig. 3). Effects of onset and numbers of years of use demonstrated in studies on substance abuse and pathological gambling , appeared insignificant in our dataset. Lack of such findings may suggest a potentially lower longitudinal impact of PU on functioning than substance abuse or pathological gambling. This result may also be related to the methodological limitations of our study. We calculated a number of years of PU as the difference between onset of PU and the subjects’ present age. It is possible that some subjects were using pornography for only a limited time from their onset, and, thus, this measure presented within our analyses may be inaccurate. Future studies should investigate he number of years of regular PU. Another possible limitation is that, for negative symptoms, we used SAST-R as it was the only questionnaire for hypersexual behavior assessment available in the Polish language . This questionnaire had been designed to measure a wide spectrum of negative consequences related not only to PU, but also other sexual behaviors. The obtained significant relation between frequency of PU and SAST-R scores shows that, among other sexual behaviors, it also measures the negative symptoms related to PU.
We were expecting that higher religiosity may amplify self-perceived problematic PU as it was reported in previous studies . This assumption appeared to be true for subjective religiosity measured as a declaration of the level of importance of religion in an individual’s life (Fig. 3). Interestingly, careful examination showed that this effect is significant only among non-treatment seekers. Among treatment-seekers religiosity is not related to negative symptoms. Religious practices were insignificant mediators (Fig. 3), which was surprising given that actual religious practice could be a better measure of religiosity then mere declaration. These results emphasize the previously mentioned role of religiosity in sexual behaviors and indicate the need for further studies on this topic. Up-to-date relation between religiosity and PU, and self-perceived addiction, had been investigated only in non-treatment seeking populations [36,37]. Thus, our novel finding of no such relation among treatment-seeking subjects is very interesting, yet needs to be replicated in future studies on subjects in treatment for problematic PU.
We have also examined the role of respondents’ age and time elapsed form the last dyadic sexual activity in the context of PU. Age was an insignificant predictor of frequency of PU, as well as the time elapsed from the last dyadic sexual activity. The latter variable was related to the subjects’ relationship status. Subjects in relationships (formal or informal) were characterized by shorter time elapsed since the last dyadic sexual activity, and this variable was negatively related to frequency of PU. Between-group comparison (Table 2) clearly shows that subjects seeking treatment for problematic PU, in general, were less likely to be in a relationship, declared longer time elapsed since their last dyadic sexual activity, use pornography more frequently, and experience more severe negative symptoms. Direction of those relations need further investigations. On the one hand, difficulties within relationships may be a cause of lower availability of dyadic sexual activity which could lead to more frequent PU and solitary sexual activities, causing negative symptoms. Conversely, frequent PU and negative symptoms may be causal of difficulties in relationships and dyadic sexual activity, as suggested by Carvalheira et al.  and Sun et al. .
Analysis of the extended version of our model showed 3 relationships (correlations of error terms) that we did not include in our a priori formulated hypothesis, although we mentioned them in the Introduction. 1.) Severity of negative symptoms associated with PU were related to a lower probability of having an intimate relationship. This result is in-line with previous research, indicating that excessive pornography use may be related to social isolation , loneliness , difficulties with finding an intimate partner, and maintaining a relationship [53,54]. As we showed (Fig. 2) significant correlation between frequency of PU and negative symptoms associated with PU, it seems to be probable that those negative consequences contribute to the difficulties in creating long-lasting intimate relationships [29,27,30]. Causality of this relation is yet unclear, but it can be hypothesized that problematic PU and difficulties with intimate relationships have a bidirectional relationship and reinforce each other. 2.) We may a related pattern in positive relationship between negative symptoms and time elapsed since last dyadic sexual activity.. When compared with non-treatment seekers (Table 2), problematic pornography users are characterized by having higher severity of negative symptoms associated with PU and lower chances of having intimate relationships and dyadic sexual activity (Table 2 and Fig. 3). Recent studies show that frequent PU is negatively related to the enjoyment of sexual intimate behaviors with a partner  and positively associated with frequency of masturbation, and sexual boredom in the relationship . Again, causality of relations between frequency of dyadic sexual activity and negative symptoms has to be determined.
Moreover, our study resulted in (3) detailing a positive relationship between subjective religiosity and time elapsed since the last sexual activity. Although results of some previous studies that focused on relations between religiosity and sexual activity are not entirely consistent [36, 37] with our results, most studies suggest that non-religious individuals report having more sexual experience [55,56] and earlier onset of sexual activity . These differences are observable especially among individuals who see religious and conservative values as central to their life  and, because of this, can be more apparent in relatively conservative societies with strong religious traditions, like Poland -- where the sample was recruited (see also:[30,37]). The discussed relationships definitely deserve systematic investigation about their contribution to sexual addiction in future studies.
According to our best knowledge this study is the first direct examination of associations between the frequency of PU and actual behavior of treatment-seeking for problematic PU (measured as visiting the psychologist, psychiatrist or sexologist for this purpose). Our results indicate that the future studies, and treatment, in this field should focus more on impact of PU on the life of an individual (quality) rather than its mere frequency (quantity), as the negative symptoms associated with PU (rather than PU frequency ) are the most significant predictor of treatment-seeking behavior. From the perspective of the obtained results, we postulate that such factors as negative behavioral consequences associated with PU should be taken in regard in defining, and recognizing, problematic PU (and perhaps also other out-of-control sexual behaviors). We also suggest further investigating the role of quality of sexual life in intimate relationships among problematic pornography users and possible factors causing difficulties in creating satisfactory relationships.
ARTICLE ABOUT THE STUDY
By Robert Weiss LCSW, CSAT-S ~ 4 min read
A new study by Mateusz Gola, Karol Lewczuk, and Maciej Skorko, published in The Journal of Sexual Medicine, looks at the factors that drive people into treatment for problematic porn use. In particular, Gola and his team wanted to determine if frequency of porn use or consequences related to porn use are more important. Unsurprisingly, as sex addiction treatment specialists like myself and Dr. Patrick Carnes have been stating and writing for more than a decade, when diagnosing and treating porn addicts the amount of porn a person uses is considerably less relevant than his or her porn-related consequences. In fact, Dr. Carnes and I have consistently defined porn addiction based on the following three factors:
- Preoccupation to the point of obsession with highly objectified pornographic imagery
- Loss of control over the use of pornography, typically evidenced by failed attempts to quit or cut back
- Negative consequences related to porn use—diminished relationships, trouble at work or in school, depression, isolation, anxiety, loss of interest in previously enjoyable activities, shame, sexual dysfunction with real world partners, financial woes, legal issues, etc.
As you may have noticed, none of these criteria mention how much porn a person is looking at (or any other quantitative measure). In this respect, porn addiction is like substance abuse disorders, where it’s not how much you drink/use, it’s what drinking and using does to your life.
In recent years, of course, we’ve seen numerous studies linking the amount of porn use to potential negative consequences. But until this recently published research appeared we’ve had little to no scientific support for our claim that consequences (rather than some sort of quantified usage) is the primary measure we should use when identifying and treating pornography addiction.
Data for the Gola study was collected from March 2014 through March 2015 from a sample of heterosexual male Polish citizens. The test sample of 569 men (mean age 28.71) included 132 men who self-identified as seeking treatment for problematic porn use. (The rest of the sample served as the control group.) “Negative consequences” were identified using a Polish adaptation of the Sexual Addiction Screening Test-Revised (SAST-R), with twenty yes/no questions geared toward assessment of preoccupation, affect, relationship disturbance, and feeling as if one’s sexual behavior is out of control.
The study initially looked at amount of porn use and propensity for seeking treatment, finding a significant correlation. This mirrors earlier research looking (peripherally) at this issue. For instance, studies led by Valerie Voon (Cambridge, UK) and Daisy Mechelmans (Cambridge, UK) found that a non-treatment seeking control group looked at porn approximately 1.75 hours per week, whereas treatment-seeking test subjects looked at porn approximately 13.21 hours per week. However, the Cambridge studies did not consider the relationship between amount of porn use, consequences, and seeking treatment—instead focusing on aspects of neurobiology and cue reactivity.
When Gola’s team adjusted for the full mediation effect of negative consequences, the relationship between amount of porn use and seeking treatment disappeared. Meanwhile, the link between negative consequences and seeking treatment was strong, and it stayed strong relative to multiple potentially mediating factors (age of first porn use, years of porn use, subjective religiosity, and religious practices).
These findings led Gola, Lewczuk, and Skorko to conclude: “Negative symptoms associated with porn use more strongly predict seeking treatment than mere quantity of pornography consumption. Thus, treatment of problematic porn use should address qualitative factors, rather than merely mitigating the frequency of the behavior, because frequency of porn use might not be a core issue for all patients.”
Preaching to the Choir
In some ways, this new research is simply telling us what we already know. If a person is looking at porn and that behavior is impacting his or her life in negative ways, he or she might want/need to do something about it. Conversely, if a person is looking at porn and it’s not causing problems, then he or she probably doesn’t need to make any changes in that area. And this is true regardless of the amount of porn a person is using. So, once again, it’s not the amount of porn a person is using, it’s what porn use is doing to his or her relationships, self-image, and wellbeing that counts.
Still, this study is an important step forward in terms of legitimizing sexual addiction as an official psychiatric diagnosis. After all, the American Psychiatric Association has so far turned a blind eye toward sex/porn addiction, failing to list this very real and debilitating disorder in the DSM-5 despite an APA-commissioned position paper by Harvard’s Dr. Martin Kafka recommending exactly the opposite. And the APA’s only publicly stated reason for doing so appears in the DSM-5’s introduction to the Addictive Disorders section:
Groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as “sex addiction,” “exercise addiction,” or “shopping addiction,” are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.
In reality, as Dr. Kafka rather eloquently detailed in his position paper, there is more than enough evidence for the APA to officially recognize sex/porn addiction. In fact, many of the disorders currently listed in the DSM-5 (particularly the sex-related disorders) have significantly less supportive evidence. Nevertheless, the APA has opted for “lack of research” (rather than “political/financial pressure from pharmaceutical and insurance companies”) as grounds for its obstinate, behind-the-times stance.
Happily, new research on sex addiction emerges on a relatively regular basis, including this new study from Gola, Lewczuk, and Skorko, which confirms a portion of Dr. Kafka’s recommended diagnostic criteria (and the strikingly similar criteria that sex addiction treatment specialists have been using for many years).
So is the APA likely to move forward with an addendum to the DSM-5 that officially recognizes sex/porn addiction as an identifiable and treatable disorder? Based on just this study, probably not. After all, when it comes to making significant changes to the ways in which clinicians view psychiatric disorders the APA is nearly always late to the party. But as the evidence mounts, the APA will eventually have to concede, acknowledging the growing incidence of porn addiction in all segments of the population. Until then, of course, nothing much changes. Porn addicts hoping to heal will still seek therapy and 12-step recovery, and the clinicians who treat these men and women will do so in the ways they know best, with or without the APA’s recognition and support.