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The Addictive Nature of Compulsive Sexual Behaviours and Problematic Online Pornography Consumption: A Review

Mauer-Vakil, Dane BSc1; Bahji, Anees MD2

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The Canadian Journal of Addiction: September 2020 - Volume 11 - Issue 3 - p 42-51
doi: 10.1097/CXA.0000000000000091
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Compulsive sexual behavioural disorder (CSBD) was recently categorized as an impulse-control disorder in the International Classification of Diseases 11th edition (ICD-11).1 The criteria for CSBD include repetitive sexual behaviours stemming from a failure to control sexual impulses or urges; prioritization of sexual activities over other major responsibilities; unsuccessful efforts to reduce sexual behaviour despite negative consequences; persistent impairment or distress lasting at least 6 months; and ruling out distress due to religious or moral grounds.1 Problematic online pornography use (POPU) is considered by many to be the main behavioural symptom of CSBD.2–10

The decision to introduce CSBD to the ICD-11 represents a major medical milestone given the functional impairment that this condition can bring to affected individuals.8 However, the decision to create a diagnostic category that seemingly pathologizes the over-expression of human sexuality has received some controversy.11,12 Given that some CSBD characteristics are addiction-like,13 POPU and CSBD is often used synonymously with the term. Still, the issue of CSBD or POPU as a behavioural addiction has been much debated,14 and there remains significant disagreement among researchers and clinicians regarding its definition and existence.15 To that end, there are many ways in which CSBD is operationalized in the literature, including “excessive pornography use”, “negative consequences of pornography use”, “self-perceived porn addiction”, and “sexual addiction”.15,16

While there is no CSBD analogue in the DSM-5, a similar diagnosis termed “hypersexual disorder” (HD) was proposed.17 HD was conceptualized as a nonparaphilic, sexual desire disorder with an impulsivity component.18 Several of the key features of HD, including the increased frequency and intensity of fantasies, arousals, urges and behaviours, loss of control, progressive risk-taking behaviours, and tolerance, were consistent with features of behavioural addictions, like gambling disorder.19 The proposed HD criteria demonstrated high reliability and validity in a diagnostic field trial,20 however, there was a lack of empirical justification18,21,22 among concerns of redundancy,23 a lack of reliable severity assessments,24 and an absence of suitable diagnostic markers.21 In light of these limitations, the proposal to include HD in the DSM-5 was ultimately rejected by the American Psychiatric Association.22

Despite the lack of diagnostic status, POPU, HD, CSBD, and “sex addiction” are often used as interchangeable, umbrella constructs to encompass various types of problematic sexual behaviors in the literature—including excessive masturbation, cybersex, sexual behavior with consenting adults, and pornography consumption.16 The debate about whether any or all of these constructs are distinct behavioural addictions has led some to revisit the definition of addiction.25 For example, the DSM-5 defines addictive disorders (in the context of substance use) as a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.9,10,26,27 The DSM-5 has extended this definition to some process or behavioural addictions, like gambling disorder28 and potentially, internet gaming disorder, which is mentioned in the “Conditions for further study” section of the DSM-5.26 The DSM-5 Working Group also noted that the use of the Internet may serve as a delivery system for several forms of impulse control issues, such as POPU.29 Thus, more nosological emphasis is needed on the characteristics of the internet as these may facilitate POPU.14


While neither CSBD nor POPU are formally recognized by the DSM-5, the aim of the present review is to explore nosological, epidemiological, neurobiological, and clinical aspects of CSBD and POPU that could support their inclusion as formal addictive disorders in future editions of the DSM.


To identity relevant articles, we used a keyword search—involving “erotica”, “pornography”, “addiction”, “sex addiction”, “behavioural addiction”, and “addictive disorder”—in PubMed and Google Scholar in October 2019 and updated in May 2020. We restricted eligibility to articles published in the English language, to those that were obtained from peer-reviewed journals, and to those that were of relevance to our primary topic. Reference lists of previously published review articles were hand searched to uncover additional relevant articles. In total, we identified 178 studies through the searches. In the first stage of article screening, we excluded citations if their primary focus did not involve an aspect of pornography addiction. To that end, one reviewer (DMV) independently determined eligibility, while the second reviewer (AB) confirmed the relevance of the included articles and also confirmed the list of excluded articles. In the second stage of article screening, the full-text versions of all articles that were included from the first stage were reviewed in detail. Findings from eligible articles were organized by theme: nosology (n = 20, as discussed in the “Introduction”), epidemiology (n = 26), neurobiology (n = 18), or clinical (n = 39) considerations. Previous reviews (n = 13) were also examined for relevant studies. Within each section, we highlighted key issues relevant to the addictive potential of POPU, such as parallels with established forms of substance use disorders. We also appraised the strengths and limitations of the overall state of evidence in the field. As there are several terms used to describe CSBD and POPU across the literature, the following terms have been collapsed into a working definition of POPU used by the present review: pornography addiction, sex addiction, self-reported pornography addiction, or compulsive use of visual sexual stimuli. The present review was not pre-registered; thus, the results should be considered exploratory.


To date, several studies have explored varied epidemiological aspects of POPU. However, isolated prevalence estimates of POPU are scarce and highly heterogeneous, with extant studies usually measuring the prevalence or incidence of POPU in the context of other sexual disorders, such as CSBD, HD, or sexual addiction.


Prevalence of pornography use in general population samples varies substantially by country. Among Australian adults, past-year pornography use was reported by 76% of males and 41% of females, while only 4% and 1% of men and women respectively reported pornography addiction.30 Among German adults, the degree of pornography consumption was greater among men.31 Among Greek high school students, the prevalence of internet pornography use was approximately 20%, and an association was seen between pornography use and social maladjustment.32 Among university students, POPU prevalence estimates range from 0.7%,33 16%,34 60%,35 and 80%.34 The most common medium being streaming video, and a median age of first exposure of 14 years.34 In adult samples from New Zealand, nearly 1.2% of females and 4.4% of males who viewed pornographic films stated that they were addicted to pornography.30 In an anonymous internet survey, only 1% of pornography consumers had concerns regarding their use, while 17% met criteria for problematic sexual compulsivity.36 Among Canadians, internet pornography use was reported more frequently among males, and greater frequency of pornography consumption was associated with earlier age of exposure, being single, and greater severity of POPU, which was in turn associated with poorer functioning and greater substance use disorder comorbidity.37 Among college age males, between 20% and 60% who used internet pornography found it to be problematic.35 The prevalence of different forms of “sexual addiction” is variable, with some reports citing a range of 3-6% in the general U.S. population.16 However, higher rates of sex addiction are observed among males relative to females, with personality factors and gender accounting for nearly 20% of the variance.38 A recent U.S. study found that 10.3% of adult males and 7.0% of adult females reported experiencing distress associated with difficulty controlling sexual urges, feelings, and behaviours.39 In New Zealand, only 3.8% and 1.7% of males and females reported self-perceived sex addiction.40 A study of Spanish college students found that the prevalence of risky cybersex use was 8.6%.33


Avoidant styles of coping, frequency of pornography use, and the distress connected with incongruence between one's sexual behavior and internalized norms, attitudes and beliefs positively were found to contribute to self-perceived sexual addiction as well as problematic pornography use.41 A 2010 meta-analysis of observational studies found a positive association between pornography use—particularly sexually violent pornography—and attitudes supporting violence against women.42 Among a small sample of Swedish male adult students, frequent users of pornography had a more positive attitude towards pornography, as well as greater urbanicity, comorbid alcohol use, and were more likely involved in sex trade.43 There is also an inverse relationship between mindfulness and hypersexuality independent of emotional regulation, impulsivity, and stress proneness, which suggest that mindfulness may be a meaningful component of therapy for sexual addiction.44 Other perspectives and frameworks for understanding POPU involve deficient self-regulation and social needs, which may perpetuate habitual online pornography consumption and negative life consequences in some individuals.45

Risk Factors

Later-onset and longer-duration of sex addiction are associated with greater severity of sex addiction.46 There is also accumulating evidence suggesting a relationship between POPU and internet addiction among adolescents.47 There may also be an increased risk of POPU among those with a childhood history of trauma.48,49 For example, among gay and bisexual men with a history of childhood sexual abuse, the prevalence of CSBD was 27%.50 Among Brazilian adults in outpatient treatment for substance use disorders, approximately one third of participants with a history of childhood abuse met criteria for a sexual addiction.51 Among Brazilian adults receiving inpatient treatment for substance use disorders, the degree of CSBD was associated with trauma, criminal justice system involvement and substance use disorder severity.52 While there is an association between POPU and concomitant pornography use, this association does not predict the degree of pornography consumption over time.53 Instead, higher self-reports of POPU are observed amongst those who endorse a stronger sense of moral distress around pornography use—rather than on the amount of daily pornography use.54,55 Using anonymous surveys, those using online dating applications score higher on sexual addiction screening tests and higher social anxiety scores.56


Neuropsychological Features

While neurobiological evidence alone cannot substantiate the claim that CSBD or POPU constitutes an addiction, there is evidence of shared neuropsychological features between POPU and established substance-related and addictive disorders.9 For example, individuals with CSBD and gambling disorder share certain psychopathological and personality traits, such as impulsivity; however, there are some diagnostic-specific characteristics that differentiate between these two clinical groups, such as lower novelty-seeking, harm avoidance, and persistence scores among those with CSBD.28 Accordingly, sexual compulsivity scale scores mediate the relationship between pornography viewing and negative outcomes.25 Cognitive and metacognitive processes are also involved in the activation and escalation of sexual desires and cravings, which has the potential to influence negative affect that may drive continued pornography use.57 To that end, processing of pornographic images appears to worsen working memory performance.58 Positive and ambivalent affective states are associated with relatively high levels of subjective sexual arousal and desire, while negative affect is generally a poor predictor of subjective sexual arousal in response to erotic stimuli.59 In other studies have demonstrate that hypersexuality may represent a “high-desire” state, rather than simply a disordered state.60 As well, self-reports of “being addicted” to pornography are also supportive of consideration of POPU as an addiction.

Neurophysiological Features

Similar to substance use disorders and gambling disorder, the neural and behavioural mechanisms associated with the anticipatory processing of cues specifically predicting erotic rewards may also relate importantly to clinically-relevant features of CSBD and POPU.61 Along those lines, there is increasing evidence to support the classification of CSBD as an addiction from the perspective of neuronal receptors, related neuroplasticity, and the so-called “supranormal stimulus” afforded by internet pornography.62 The reward deficiency syndrome, specifically aberrations in the dopaminergic system and the dopamine D2 receptor, are implicated in multiple drug-seeking behaviours, as well as behavioural compulsions, which could extend to POPU.63 To that end, pornography consumption can also stimulate pleasant feelings for the individual while engaged in the activity, such as joy and happiness.59,64 Exposure to pornography appears to stimulate similar reward centres as observed in other forms of addiction,65 while sexual cues may themselves be perceived as a reward.66 Several studies have cited shared patterns of neuroplasticity between sexual addiction and established addictive disorders.62 For example, exposure and subsequent abstinence from sexual behaviours induced a similar pattern of dendritic arborization within the nucleus accumbens as observed with repeated exposure to psychostimulants, substantiating evidence for shared alterations mesolimbic system changes and patterns of reinforcement.67 Deficits in the hypothalamic-pituitary-adrenal axis (HPAA) has been observed in males with CSBD, where affected persons had greater levels of adrenocorticotropic hormone levels.68 The transcription factor ΔFosB plays a critical role in the reinforcement of sexual behavior and experience-induced facilitation of sexual motivation and performance.69 Sexual experience increases ΔFosB levels in several limbic brain regions, including the nucleus accumbens, medial prefrontal cortex, ventral tegmental area and caudate putamen.69 In turn, overexpression of ΔFosB in the nucleus accumbens promotes aspects of sexual behavior.69

Neuroimaging Correlates

Neuroimaging studies have shown that ventral striatum activity is correlated with watching preferred pornography,70 which may play a crucial role in the anticipation of reward.71 Additional neuroimaging data indicates increased ventral striatum activity with the anticipation of erotic stimuli in the context of compulsive sexual behaviours.72 Individuals with HD demonstrate altered activation in the prefrontal cortex and subcortical brain regions in fMRI studies.73 There is also evidence of diminished executive control and impaired functionality in the right dorsolateral prefrontal cortex and inferior parietal cortex,74 as well as structural deficits and resting-state functional impairments in the left superior temporal gyrus.75 Individuals with CSBD show reduced ability to inhibit responses that might be related to lower inferior frontal gyrus activation and pre-supplementary motor area connectivity during response inhibition, which suggests poor response inhibition may be a neurobiological underpinning.76 Neural differences in the processing of sexual-cue reactivity were identified in CSB subjects in regions previously implicated in drug-cue reactivity studies.77 There is also some evidence of dissociation between desire or wanting and liking, which is consistent with theories of incentive motivation underlying CSBD as seen in substance use disorders.77 Individuals with CSBD have greater desire but similar liking scores in response to the sexually explicit videos on fMRI, and demonstrate greater activation of the dorsal anterior cingulate, ventral striatum and amygdala.78


Functional Impairment

Mirroring excessive substance use, the use of excessive pornography has a negative impact on several domains of functioning, impairment and distress.35,79 Pornography use also appears to negatively contribute to adolescent well-being, with one study finding an association between pornography use and symptoms of depression, anxiety, and self-esteem.80 Adolescents who consumed more pornography content at baseline were more likely to initiate sexual behaviours the following year,81 which has important social and health implications, like sexually transmitted diseases and unplanned pregnancies.82,83 In addition to harms to the individual using pornography problematically, there can also be negative impacts on others.79,84–90 In a qualitative study examining personal letters, researchers found negative perceptions in the relationship with one's partner, the view of the character of one's partner, and the view of one's desirability and worth.84 Relatedly, two other qualitative studies have illustrated the negative impacts of POPU on partners, including patterns of distress86 and attachment breakdown.90


Research points to POPU contributing to poor mental health.15,80,91,92 As pornography viewing increases, so do levels of anxiety, stress and depression.85,93 Furthermore, frequent users of pornography reported consuming significantly more alcohol and a variety of drugs as compared to a control group.43 Data also indicate a significant association between the use of pornography and social maladjustment, abnormal conduct issues and poor social functioning.32,93 Perceived excessive pornography use by a partner appears to reduce the overall wellbeing of romantic relationships, particularly with more frequent and covert pornography use, and appears to be mediated by a lack of relationship commitment.89 Greater pornography use is associated with increased symptoms of depression, but only in participants who disapproved of their use.80 The association between greater frequency of pornography usage and higher levels of psychological distress appears to be largely mediated by self-reported pornography addiction.91,92 To that end, sexual arousal and craving in response to pornography are also related to the severity of self-reported pornography addiction among males34,94,95 as well as females.96 While paraphilias are often thought to be more prevalent among persons with CSBD or POPU, a recent survey of university students found no association between the context of sexual fantasies and the presence of a sexual dysfunction.97 Similarly, among individuals with substance use disorders, there was no association between paraphilias and sexual addiction.98 Among adult outpatients with obsessive-compulsive disorder, the lifetime prevalence of CSBD was 5.6% and was significantly higher in males than females.4 Among adult females, CSBD rates appear to be associated with greater scores on compulsivity, anxiety, depression, and impulsivity scales.99 Finally, while there is limited evidence to support an association between pornography use and erective dysfunction or delayed ejaculation, there is some evidence to support a relationship between pornography use and decreased sexual satisfaction.34

Screening Instruments

In recent years, research on sexual addiction has proliferated, and screening instruments have increasingly been developed to diagnose or quantify sexual addiction disorders.16 Several psychometric instruments have been recently developed with the intention of assessing POPU as a diagnostic construct.100 These include the Pornography Consumption Effects Scale,101 the Hypersexual Behaviour Consequences Scale,102 the Problematic Pornography Consumption Scale,103,104 the Hypersexual Disorder Screening Inventory,105 the Internet Sex Screening Test,106 the Compulsive Pornography Consumption Scale,107 and the Problematic Pornography Use Scale (PPUS), which shows high internal consistency, convergent validity, and construct validity for POPU.108 High PPUS scores were positively correlated with measures of psychopathology, low self-esteem and poor attachment.108 Although PPUS scores were also correlated with other behavioural addictions, POPU was uniquely distinguished from features of behavioural addictions relating to gambling and Internet use.108

Pharmacological Treatments

Given some similarities between CSBD, POPU and addictive disorders, interventions effective for established substance use disorders may hold promise for CSBD and POPU.78 As with other behavioral addictions, the appropriate treatment of sexual addiction should combine pharmacological and psychological approaches and should address psychiatric and somatic comorbidities.16 In several reports, compulsive sexual behaviours were treated successfully with naltrexone monotherapy or as an adjunctive treatment.109–112 Gola and colleagues investigated the efficacy of the selective serotonin reuptake inhibitor paroxetine in combination with cognitive-behavioural therapy in the treatment of POPU.113 While paroxetine appeared to be initially effective in reducing pornography use and anxiety, this appeared to be related to new compulsive sexual behaviours that developed after 3 months of treatment.113 Hence, the authors concluded that paroxetine may hold promise for short-term reduction of POPU and related anxiety, but new potentially distressing sexual behaviours may emerge.113

Non-pharmacological Strategies

Several psychotherapies have been proposed as treatments for POPU.114,115 These include cognitive-behavioural therapy,116 couples therapy,117 group therapy,118 group therapies,16 and mindfulness-based therapies.119 Mindfulness-based strategies have shown particular promise in the treatment of CSBD among adults in residential substance use disorder treatment.120–122


While the lack of empirical evidence for a true “sexual addiction” precludes its inclusion as a diagnostic category in the DSM-5, the lack of diagnostic status may have paradoxically impeded research into its neurobiology and epidemiology. Consequently, a primary issue of the field is the extreme heterogeneity in the subject of our review that results from the lack of clear and consistent criteria for labeling these disorders. Another key limitation was that the review, while intending to focus on POPU, had to include studies that also considered related constructs, like sex addiction and hypersexual disorder, as there is some overlap between these conditions. While the neurobiological studies cited have helped substantiate the physiological basis for considering POPU as an addictive disorder, almost all have been cross-sectional in nature; as such, there are few randomized controlled trials. Due to the potential issue of reverse causality, it is challenging to deduce whether other underlying psychological or biological mechanisms are responsible for how those with POPU respond to pornography (and vice versa).


Available findings suggest that there are several features of CSBD and POPU that are consistent with characteristics of addiction, and that interventions helpful in targeting behavioural and substance addictions warrant consideration for adaptation and use in supporting individuals with CSBD and POPU. Future empirical studies will enhance the understanding of CSBD and POPU, as well as their relationship with established forms of addiction—and with impulse control disorders—to help understand which classification schemes are most evidence-based. While the majority of studies have involved predominantly heterosexual male samples, future work should be more inclusive of individuals from other sexual and gender demographics. As this is an important area warranting further study, additional studies will help move the field forward.


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