Darryl Mead & Mary Sharpe (2019): Pornography and sexuality research papers at the 5th International Conference on Behavioral Addictions, Sexual Addiction & Compulsivity, Mar 2019. DOI: 10.1080/10720162.2019.1578312
ABSTRACT: The 5th International Conference on Behavioral Addictions was held in Cologne, Germany, April 23-25, 2018. It featured one of the largest concentrations of papers on pornography and sexual research presented in a single venue to date. Several key themes emerged from the conference. The theoretical basis for developing pornography and sexuality studies as components within the behavioral addiction research landscape is beginning to mature. Core components are the I-PACE theory and the development, validation, and employment in field studies of a steadily growing set of assessment tools including the Problematic Pornography Use Scale, the Brief Pornography Screener, and the Hypersexual Behavior Inventory. The field also benefitted from a keynote speech and a formal pro/con debate. The other principal debate was around the imminent release of ICD-11 by the World Health Organization and the way that Compulsive Sexual Behavior Disorder (CSBD) would be handled. There was a selection of papers looking at the debate from a variety of theoretical and practical points of view. Fieldwork from Poland suggested that well over 80% of people seeking treatment for CSBD had a problem with pornography use, rather than issues from acting out with real sexual partners.
Introduction
The overall message for pornography research from the three days of the 5th International Conference on Behavioral Addictions (ICBA, 2018) was one of positive advances in scientific understanding. Compared to the 4th Conference, 14 months earlier, there were greater aspirations in the scope of the research, significant progress in increasing the sample sizes in many studies, and improvements in sample quality. Underpinning all of these was the success of the Interaction of Person-Affect-Cognition-Execution (I-PACE) theory in providing a unifying framework. I-PACE not only starred in the sexuality papers, but also was referred to in several keynotes and featured in the work presented in several parallel research fields. It has become a common starting point for many behavioral addiction researchers, irrespective of their field of interest.
For sexuality and pornography researchers, the critical background factor was the imminent release of the 11th revision of the International Classification of Diseases (ICD-11) by the World Health Organization. There were a number of papers attempting to predict what it would contain. In some cases, the authors hoped to directly influence what was to be included and how it would be framed or limited. ICD-11 was released on June 18, 2018. It introduced 6C72, Compulsive Sexual Behavior Disorder (CSBD), within the category of Impulse Control Disorders. This differed from what some researchers proposed at ICBA 2018. They indicated that it might best be placed in the realm of addictions, within the category of Disorders Due to Addictive Behaviors, along with 6C50 Gambling Disorder and 6C51 Gaming Disorder. It is anticipated that there will be plenty of scope at upcoming ICBA meetings to develop the arguments to shape future updates of the ICD. All abstracts for the 5th Conference have been published in a supplement to the Journal of Behavioral Addictions (Demetrovics 2018). The 6th International Conference on Behavioral Addictions was announced by the International Society for the Study of Behavioral Addictions for June 17-19, 2019 in Yokohama, Japan.
Keynote lecture
The keynote lecture by Germany’s eminent researcher and clinician Rudolf Stark on “Pathological Pornography Use—What We Know and What We Still Need to Know” was the first time pornography research had been given such a prominent place at the International Conference on Behavioral Addictions.
This keynote was in three parts. First, it considered pornography consumption as a social phenomenon on the Internet, noting the rising prevalence of use, particularly by men. Stark explored the neurobiological correlates of watching pornography as well as experiments covering distractibility and learning. Pornographic stimuli may activate reward systems and capture attention. The anticipation of sexual stimuli may activate reward systems in similar fashions as does anticipation of drugs, although these have not been directly compared.
The second part considered the potential to place problematic pornography use within the Beta draft of ICD-11 under 6C5Y, “Other Specified Disorders Due to Addictive Behaviors.” Two open questions were identified. First, within diagnostic criteria, are withdrawal and tolerance key features of pathological pornography use? Second, are different compulsive sexual behaviors, such as excessive impairing promiscuous dating behavior and pathological pornography use, different or do they constitute the same disorder?
The Keynote concluded by considering the current knowledge of the etiology of problematic pornography use. Stark made reference to the I-PACE model for problematic pornography use, covering data from experimental perspectives of cue reactivity, personality analysis, and co-occurring disorders. He then referred to his own work using the Trait Sexual Motivation Questionnaire (Stark et al, 2015) to consider if there may be subtypes of individuals with problematic porn use. He identified a Gratification group driven mainly by positive reinforcement, that is seeking pleasure, and a Compensation group where the reinforcement was negative, to avoid pain or other negative affect. He reported that around half of a clinical sample was in one group and half in the other.
Stark concluded by suggesting more work is needed to examine the natural course of problematic pornography use where non-problematic pornography use transitions into problematic use. He concluded by suggesting that the case for pornography use disorder in the ICD is strengthened by its foundation in the stimulation of systems relating to the processing of natural rewards. As to why a clinical diagnosis was not yet accepted, at the time of the conference, he suggested that it may be due to individual, socio-cultural, and political reasons.
Pro/Con debate on behavioral addictions
A welcome addition to ICBA 2018 was the introduction of a debate on the fundamental nature of behavioral addiction. The bonus for students of sexual behavioral addiction studies was that both speakers are recognized researchers in the pornography field, so they drew heavily on sexualitybased issues in framing their arguments.
Pro: “Behavioral Addictions: From Over-Pathologizing to Real Clinical Phenomenon” Aviv M. Weinstein, Israel
The arguments identified by Weinstein in favor of considering behavioral
addictions as a real clinical phenomenon were as follows:
Pathological gambling (PG), Internet gaming disorder (IGD), compulsive
sexual behavior (CSB), and compulsive buying (CB) all fit better into the
behavioral model of addiction than in an obsessive-compulsive model. He
argued that the neural mechanisms underlying the four conditions are
similar to those of drug addictions. These conditions and behaviors involve
changes in reward processing, inhibitory mechanisms, impulsivity, and
impaired control.
For example, he reported that video game playing was associated with
dopamine release similar in magnitude to that of drugs of abuse. He stated
that lower dopamine transporter levels and dopamine receptor D2 occupancy
in the striatum suggested poor sensitivity of dopamine
reward mechanisms.
He reported that high rates of co-morbidity between behavioral addictions
and other psychiatric disorders are evident including with respect to
depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), obsessive-
compulsive disorder (OCD), and personality disorders. He stated that
treating co-morbid conditions may not solve addiction problems.
Con: “Conceptualizing Behavioral Addictions without Pathologizing Common Behaviors.” Joel Billieux, Luxembourg
Joel Billieux began with a working hypothesis that “According to the criteria generally used to identify behavioral addictions, it is likely that the elevated involvement of any type of activity can be considered as a psychiatric disorder…”
The aim of this working hypothesis was to clarify possible confusion between “real” disorders and healthy passions and/or dysfunctional coping strategies. In this way, clinicians could avoid imposing inappropriate treatments, and the conference could contribute to the continuing credibility and relevance of (behavioral) addiction research.
After considering the literature generated for a range of potential “fringe” behaviors as test candidates for addiction, which might alternatively be seen as everyday behaviors and leisure activities, such as dancing, studying, taking selfies, fishing, and binge watching, the analysis considered the unhelpful power of the confirmatory approach.
Billieux’s talk ended with three recommendations. First, there is a need to shift from a confirmatory and symptom-based approach to a theoretically grounded and process-based approach, for example, the I-PACE model of problematic Internet use (Brand et al, 2016). Second, there is a need to improve the diagnostic approach of behavioral addiction with stronger clinical relevance and construct validity, with particular reference to the World Health Organization initiative to develop new screening tools (Carragher et al, 2018). Lastly, there is need to acknowledge the differences between high involvement (passion) versus dysfunctional involvement (addiction).
Presentations
Session: Hypersexual disorder: Relationships with transdiagnostic measures and clinically relevant behaviors Chair: Shane W. Kraus
“The Impulsive and Compulsive Aspects of Problematic Pornography Use and Hypersexuality”
Zsolt Demetrovics, Hungary with B. B}othe, I. T oth-Kir aly, and G. Orosz
This study used a Hungarian online sample that provided a useable dataset of 13,778 individuals, 30.1% female. It concluded that impulsivity and compulsivity did not contribute as importantly and directly to problematic pornography use as previously hypothesized, and that impulsivity may have a more prominent role in hypersexuality. This research has now been published as B}othe et al. (2018a) and interested readers are directed to the full paper.
“Sexting among Military Veterans: Prevalence and Correlates with Psychopathology, Suicidal Ideation, Impulsivity, Hypersexuality, and Sexually Transmitted Infections Steven D. Shirk, USA, with J. L. Turban, M. N. Potenza, R. A. Hoff, and S. W. Kraus
This study surveyed 283 male and female veterans via email, recording data across nine mental health, substance use, psychological, and sexual behavior instruments. Within the sample, 68.9% had sent sexually explicit texts, photos, or videos. Sexting rates in the sample were comparable with rates in civilian populations, with men having higher rates. Sexting rates were higher among individuals with less education and employment. Individuals reporting more religious service attendance were less likely to engage in sexting. Sending sexts was significantly linked to measures of depression, impulsivity, sensation seeking, and a lack of perseverance. Individuals who had sexted as compared to those who did not had more lifetime sexual partners and more symptoms of hypersexuality, but there were no group differences in reported sexually transmitted infections.
“Investigating the Psychometric Properties of the Hypersexual Behavior Inventory Using a Large-Scale, Nonclinical Sample across Gender and Sexual Orientation” Beata Bothe, Hungary, with R. Bartok, I. Toth-Kiraly, M. D Griffiths, Z. Demetrovics, and G. Orosz
This study was based on a substantial data set of over 18,000 individuals gathered in Hungary through the January 2017 online survey by Demetrovics et al., referenced above. The sample was one third women and about 6% non-heterosexual. The mean age was 33.6 years, standard deviation (SD) 11.1 years and range 18–76 years. The study measured coping, control, and consequences using the Hypersexual Behavior Inventory (HBI) and employed sexuality-related questions. The focus was on hypersexuality rather than pornography consumption. It concluded that the HBI has initial diagnostic value, but to secure a diagnosis, the patients would also need to undergo a formal clinical interview using defined criteria. Efforts to determine valid threshold values for the HBI were complicated by the presence of possible false positives. The group with the highest risk of developing hypersexual disorder may have been non-heterosexual males, with non-heterosexual females also apparently at high risk. Individuals with hypersexuality had lower levels of mindfulness, self-compassion and selfforgiveness. This research has now been published as Bothe et al. (2018b).
“Hypersexuality and Pornography Consumption in U.S. Military Veterans with Comorbid Pathological Gambling Disorder”
Joshua B. Grubbs, USA, with H. Chapman, L. Milner, and R. C. Reid
This study of 329 U.S. military veterans receiving inpatient treatment for gambling disorder (80% men, mean age 53 years, SD 11.5 years) reported on the prevalence of compulsive sexual behavior disorder (CSBD) in the group. Analysis suggested that gambling disorder was associated with greater levels of CSBD, although less than suggested by prior studies. Veterans with both gambling and sexual behavior problems exhibited greater distress and lower quality of life, as well as a greater severity of gambling-related difficulties.
“Psychological Correlates of Coping with Stressful Life Events among Hypersexual Patients in an Outpatient Setting” Rory C. Reid, USA
The study focused on the types of coping strategies and treatments used with hypersexual patients. The HBI is available in seven languages, including English and Spanish. A short form of the HBI with 8 items may be published soon, employing 5-point scales. Reid reported that in the clinical group he studied, shame, withdrawal, and turning to sex as a way of coping were related to hypersexuality. Patients were given training to reduce shame through self-compassion based on a model developed by Kristen Neff. In the setting of stressful experiences, hypersexuality was positively correlated with stress proneness and tendencies to adopt avoidant strategies and negatively correlated with assertive strategies. The strongest correlation appeared to exist with the tendency to distract oneself in response to a stressful event. Data in this study support the idea of hypersexual patients turning to sex as a way of distracting themselves from stressful events.
Session: The Diversity of Addictive Behaviors Chair: Koby Cohen “On the Relationship between Obsessive-Compulsive Symptoms, Depression, Anxiety and Sexual Addiction among Adults Who Use the Internet to Find Sexual Partners” Koby Cohen, Israel, with G. Levi, K. Cohen, and A. M. Weinstein
This small-scale Israeli study included 145 males of mean age 32.79 years (range 20–65) and 32 females, mean age 30.18 (20–63). The participants were recruited online via social network sites for finding sexual partners. It concluded that the largest contribution to sexual addiction was the presence of obsessive-compulsive symptoms, rather than depression or anxiety.
“Obsessive-Compulsive Disorder in Hypersexual Patients” Magdalena Smas-Myszczyszyn, Poland, with M. Lew-Starowicz
This Polish study considered levels of obsessiveness and compulsiveness
in three patient groups—compulsive masturbators, people who were engaging
in poorly controlled sexual relationships with multiple partners, and a
group doing both activities. The study interviewed 108 patients meeting the
criteria for hypersexual disorder and took measures using the Yale-Brown
Obsessive-Compulsive Scale, the Obsessive-Compulsive Inventory–Revised,
and the State-Trait Anxiety Inventory.
The authors found that the nature of obsessions and compulsions presented
by hypersexual patients is varied and includes non-sexual aspects.
Significant differences were found relating to the intensity of the obsessivecompulsive
symptoms and the level of anxiety between the three groups.
The group of compulsively masturbating patients had a higher level of anxiety
and a greater severity of obsessive-compulsive features than the two
other groups.
The basis for impaired control in the compulsive masturbation group
may relate to high levels of anxiety. Compulsive masturbation may be
obsessive-compulsive in nature, and this relationship should be considered
in planning therapy.
Session: Compulsive Sexual Behavior: Characteristics and Diagnostic Considerations
Chair: Marc N. Potenza
“Findings from the Polish Compulsive Sexual Behavior Disorder Field Trial”
Mateusz Gola, Poland, with E. Kowalewska, M. Wordecha, M. Lew-Starowicz, S. W.
Kraus, and M. N. Potenza
This study examined in a large Polish sample the proposed definition of
Compulsive Sexual Behavior Disorder (6C72) in the draft of ICD-11. In
particular, among those seeking treatment for CSB, the criteria proposed
for ICD-11 CSBD were examined, as were relationships with constructs
such as sex addiction and hypersexual disorder. Screening tests were also
examined, as were characteristics of people seeking treatment for CSB.
Recruitment of test subjects through Polish media resulted in 1,812 treatment
seekers, with 93% being male, 86% reporting problems with pornography,
87% reporting problems with masturbation, 18% having concerns
relating to casual sex, and 12% having concerns relating to paid sexual
activities. The sample had a mean age of 35.69 years (SD¼9.78).
In the sample, 50% to 72% of people interested in treatment for CSB
met criteria proposed for ICD-11 for CSBD. The most common problematic
behaviors included pornography viewing and masturbation. Screening
tools such as the Hypersexual Behavior Inventory, the Sexual Addiction
Screening Test, and the Brief Pornography Screener (BPS) appeared to
perform well. When compared to the group who failed to meet the criteria
for CSBD diagnosis under ICD-11, the individuals meeting the criteria
experienced more primary and secondary negative impacts on their life,
especially in the areas related to relationships.
“The Relationship between Compulsive Sexual Behavior and Sexual Performance and Attitudes among Males and Females” Ewelina Kowalewska, Poland, with K. Sro slak and M. Gola
Following a detailed introduction on the Multidimensional Sexuality Questionnaire (MSQ; Snell et al, 1993), the team described two studies. The first study examined relationships between dimensions on the MSQ and CSB symptoms in a general Polish population. The respondents were 200 males (mean age 25.78 years, SD¼5.75 years, 66.5% heterosexual) and 43 females (26.05 years, SD¼6.88 years, 79.5% heterosexual). The study used Polish versions of the MSQ, the Sexual Addiction Screening Test (SAST-PL) and the Brief Pornography Screener. In the case of women, problematic pornography use was correlated positively with anxiety about sexual aspects of one’s life, the tendency to be aware of the public impression that one’s sexuality makes on others, and the fear of engaging in sexual relations with another individual. Among males, all three of these aspects were strongly and significantly related to scores on the SAST-PL. Individual scores obtained on the SAST-PL for both genders were also strongly related to feelings of depression stemming from sexual behaviors. CSB features (as assessed with SAST) were negatively related to levels of sexual satisfaction in both males and females.
In the second study, the researchers compared the general population to a group of patients seeking treatment for CSB. The male sample from Study 1 and a separate sample of 7 men meeting the criteria of hypersexual disorder (Kafka, 2010) who were seeking treatment for CSB were studied. Instruments employed included the MSQ, SAST (revised), and the BPS. There were significant differences between the clinical group and the males from Study 1 on scores of sexual anxiety, sexual assertiveness, and sexual monitoring and SAST-R scores. There were significant negative correlations between BPS scores and sexual esteem and sexual satisfaction, and significant positive correlations between BPS scores and sexual anxiety and sexual depression.
“Reward Learning in Men with Compulsive Sexual Behavior” Valerie Voon, UK
Taking Kuhn and Gallinat (2014) as a starting point for distinguishing between problematic and non-problematic levels of pornography use, Voon characterized the problematic users as men with CSB. She used the models for the proposed DSM-5 criteria for Hypersexual Behavior Disorder from Kafka (2010) and Reid et al. (2012), as well as the Carnes (2001) model of sexual addiction. This led her to posit a conceptual model which considered the potential overlaps between four factors: behavioral addiction, excessive desire, impulse control disorders, and obsessive-compulsive-spectrum disorder. At this point, the question was asked, “Do addiction theories apply to CSB?” The examination came from experimental perspectives of incentive motivation, the relationship of impulsivity to compulsivity, and the role of negative reinforcement. To explore the question, Voon discussed a selection of cue-reactivity studies, including recent work by Gola et al. on wanting and liking. She then considered how conditioning or novelty-seeking may relate to attentional bias, particularly with respect to habituation. Men with CSB were more likely to prefer novel sexual cues than men without CSB. The CSB group also demonstrated a preference for cues conditioned to sexual and monetary outcomes. Men with CSB were also more likely to demonstrate greater habituation in dorsal cingulate activation to repeated sexual, versus monetary, stimuli. The degree of the habituation correlated with their preference for sexual novelty. Functional connectivity patterns in the dorsal cingulate to the ventral striatum and hippocampus relating to sexual cue outcomes differed over time for the CSB and non-CSB groups, with greater connectivity in later trials by the CSB group (Banca et al., 2016).
“Assessing Problematic Pornography Use in a Nationally Representative Sample ofU.S. Adults” Joshua B. Grubbs, USA, with S. Perry and S. W. Kraus
This study considered four potential predictors of self-reported pornography related problems in a nationally representative sample of 2,000 people. The predictors were pornography use, religious beliefs, moral disapproval and male gender. Test subjects were representative by age, gender, income, race, and U.S. Census Region. Within the sample, 1,061 (67% male) had used pornography in the past year. The tools used included the Cyber Pornography Use Inventory (CPUI-3), single item addiction, BPS, a single item Moral Disapproval of Pornography Use, pornography use by frequency and hours, religiousness (three items), and a DSM-5 measure. A substantial percentage (15.5%) of people reported some problems with pornography use based on a BPS score greater than 4. Overall, 6% of the population identified with the statement, “I am addicted to internet pornography.”
Cross-sectionally, self-reported pornography problems were positively associated with moral disproval, religiousness, pornography use, and the frequency of pornography use. They were associated with male gender but not age.
“A Rose by Any Other Name? Classification Issues Surrounding Compulsive Sexual Behavior for ICD-11” Marc N. Potenza, USA
This presentation summarized developments in the field of CSBD during
the past year and then outlined some issues requiring additional research.
It began with a recent history of CSBD in the context of DSM-5 and the
development of ICD-11. It noted that the Impulse Control Disorder
Workgroup had been the group most actively considering CSB for inclusion
in ICD-11. There has been significant discussion in the literature, particularly
in Kraus et al. (2018) that appeared in World Psychiatry, as to
whether it should be listed as an impulse control or addictive disorder.
Other key contributions included letters in Lancet Psychiatry from Potenza
et al. (2017) and Prause et al. (2017).
Potenza noted that data collection, particularly field testing, was ongoing
to see how the proposed definitions for ICD-11 diagnoses operate (e.g., in
clinical settings). The ICD-11 Beta test site has produced feedback which
led to the removal of the narrower term of “sex addiction.” The presentation
concluded with the suggestion that the inclusion of CSBD in the ICD
would support public health, prevention, program, policy, and treatments
relating to the disorder. It is expected that precise diagnostic criteria will be
developed through an ongoing process supported by additional data.
Session: Hypersexual Behavior in Different Contexts Chair: Yasser Khazaal
“Understanding and Predicting Profiles of Compulsive Sexual Behavior among Adolescents”
Yaniv Efrati, Israel, with M. Gola
This two-part study aimed to provide data on CSB features among adolescents
and hoped to propose a typology of CSB sub-types in this age
group. The first study of 1,182 Israeli school students (42.3% boys, mean
age 16.68 years, SD¼1.54 years) worked with the new Individual-based
Compulsive Sexual Behavior (I-CSB) tool (Efrati & Mikulincer, 2018).
Latent profile analysis was used to examine differences between groups
across four factors: unwanted consequences, negative affect, poor control,
and affect regulation. The study generated characteristic profiles for individuals
with no CSB (low), fantasizing CSB (medium), and CSB (high)
scores. The authors noted that the I-CSB scale showed that individuals
with high sexual desire, but also high fear of performance, generally
escaped to sexual fantasies rather than engaging in explicit sexual behaviors
with other people.
In the second study, participants were 618 Israeli adolescents (341 boys,
mean age 16.69 years, SD¼1.16 years). Instruments/assessments included/
measured the I-CSB, frequency of pornography use, off-line sexual
behaviors, sex-related online activities, Big Five inventory, revised UCLA
Loneliness Scale, and the Levenson feelings of control and attachment styles
through the Experiences in Close Relationships scale. The results were considered
with respect to the same characteristic profiles as in Study 1: no
CSB (low), fantasizing CSB (medium) and CSB (high) scores. Study 2
found that the majority of participants engaged in sexual activity, with
approximately 10% presenting a high level of CSB. Adolescents in the high
CSB group differed in their personality features (higher neuroticism and
lower agreeableness) from adolescents in the non-CSB and fantasizing
groups. The findings suggest possible risk factors of CSB development and
provide some hints for early prevention.
Adolescents with high levels of CSB symptoms may be characterized by
an external locus of control, anxious attachment, greater loneliness, higher
frequency of pornography use, and more sex-related online activities. The
CSB and CSB fantasizing groups were comprised of more boys than the
non-CSB group. In addition, more adolescents in the CSB group had offline
sexual experiences than the fantasizing CSB group, which in turn had
more than the non-CSB group.
“Implicit Associations in Hypersexual Disorder”
Jannis Engel, Germany, with M. Veit, C. Sinke, J. Kneer, C. Laier, U. Hartmann, T.
Hillemacher, and T. H. C. Kru€ger
In Germany, a group of 50 male, heterosexual participants (mean age
36.51 years, SD¼11.47 years) with Hypersexual Disorder (Kafka 2010) were
compared to 40 healthy volunteers (37.92 years, SD¼12.33 years) across a
selection of questionnaires, clinical interviews, neuropsychological tests, and
fMRI. Weekly pornography viewing by the two groups was respectively
87.53 minutes (SD¼125.50) and 18.93 minutes (SD¼19.2). A modified
version of the Implicit Association Test (Snagowski et al, 2015) was
employed. The responses of the hypersexual disorder group were distinct
from those of the healthy volunteers when plotting the Hypersexual
Behavior Inventory-19 scale against the Implicit Association Test. The
researchers concluded that the men classified as having hypersexual behavior
disorder had stronger implicit associations towards pornographic content
than did the healthy volunteers. The results indicate similarities to
findings from research on substance and behavioral addictions.
“Online Sexual Activities (OSAs) in Spain: Similarities and Differences across the Lifespan”
Jesus Castro-Calvo, Spain, with R. Ballester-Arnal, D. Gil-Llario, C. Gimenez-Garcia, & J. Billieux
Aims of this study were to compare the online sexual activities of people
of various ages and to compare the prevalence of problematic use of the
Internet for sexual purposes by different age groups. They recruited 1,000
participants, 200 in each age group of under 18 years, 18–25 years, 26–40,
41–60, and 61 or older. All groups had 50% males and females. Assessment
was on an ad hoc scale assessing online sexual activities and the Internet
Sex Screening Test (ISST).
Overall, nearly all age groups used the Internet for sexual purposes, with
prevalence rates exceeding those from previous national studies in Spain.
Differences between men and women were more evident among people
over 40 years old, and in women, the use of the Internet for sexual purposes
was infrequent in individuals over 40 years of age. There was a progressive
reduction of gender-related differences among younger
respondents.
In both males and females, non-arousal and solitary arousal activities
were most frequent in individuals aged between 18 and 25 years. Partnered
arousal activities were more prevalent in individuals aged between 26 and
40 years old. Age is an important variable in considering potential risks of
problematic Internet use for sexual purposes, particularly in males. The
highest prevalence of participants seemingly at risk of developing symptoms
of problematic Internet sexual use was in the group between 26 and
40 years old. In this group 33% were at risk. Overall, educational and
hedonic motives related to OSAs may lose importance with age, whereas
social motives may be more relevant later in life. However, factors related
to generational impacts as opposed to age per se cannot be excluded.
“Gambling Motives Questionnaire Adapted to Cybersex”
Yasser Khazaal, Switzerland, with E. Franc and S. Rothen
This Swiss project reported on the conversion of the Gambling Motives
Questionnaire, an established tool, into an instrument for investigating the
motives for the use of cybersex. The study also sought to validate the new
tool. The Cybersex Motives Questionnaire adapted a 17-question set from
gambling research into three motivation subscales.
The modification included the removal of several gambling questions
and the inclusion of several new potential cybersex motivations. The result
was a 17-item questionnaire which allows assessment on three sub-scales:
enhancement, coping, and social.
The validity of the new tool was examined for the principal component
analysis using an online sample of 191 adults who used cybersex and for
the confirmatory factor analysis using an online sample of 204 adults.
External validity was judged against the Sexual Desire Inventory. The selfselected
test sample population had a median age of 32 years, was 54.4%
male, with a breakdown of relationship status of 29.4% single, 45.4% in a
relationship, and 24.4% married. The sample reported as 81.3% heterosexual,
13.8% homosexual, and 4.9% bisexual. The researchers concluded that
the motivation factors, enhancement, social and coping were in line with
existing mainstream work in this field.
“Communicating the Science of Cybersex Addiction to Wider Audiences”
Darryl K. Mead, UK, with M. Sharpe
Research suggests that there is considerable potential for internet pornography
consumption to lead to addiction-related brain changes. How can
the emerging science of problematic pornography use be made accessible to
professionals and the wider public in effective ways?
After a brief review of the origins of The Reward Foundation, Mead and
Sharpe looked at the efficacy of some of the public communication initiatives
with which they have experimented in the past three years. Their
efforts fell into two main strands. First, they have concentrated on sharing
their knowledge of the behavioral-addiction-based pornography research
with healthcare professionals such as family doctors and sex therapists. In
2017, their one-day training workshop on the impact of Internet pornography
on mental and physical health was accredited by the Royal College
of General Practitioners in London for Continuing Professional
Development credits. Delivery of this training helps bridge the knowledge
gap between the behavioral addiction research community and the practitioners
who can apply that knowledge in a healthcare context. The authors
also published a summary of the cybersex papers presented at the 4th
ICBA Conference in a peer-reviewed journal for the sexual therapy community
to enhance their understanding of the neuroscience (Mead &
Sharpe, 2017).
Second, The Reward Foundation delivers lessons in secondary schools,
where it also trains teachers and engages with parents. Since 2017, The
Reward Foundation has developed lesson plans for use by a school’s own
teachers to help them unpack different aspects of problematic pornography
use in the classroom context. To date, this work has concentrated on the
government school sector and is now being extended experimentally into
faith-based schools. Religious educators are very cautious about encouraging
any discussion of the influence of pornography. However, using an evidence-
based behavioral addiction model makes access easier. Delivered
sensitively, the science of cybersex addiction can be acceptable to faithbased
communities, where its messages are seen as complementary, not
contradictory, to teachings in religions such as Catholicism and Islam.
Session: Problematic Pornography Use: Assessing Characteristics in a Rapidly Changing
Environment Chair: Joshua B. Grubbs
“Gender Considerations in the Correlates of Problematic Pornography Use”
Gretchen R. Blycker, USA, with S. W. Kraus, B. Bothe, A. Zsila, I. Toth-Kiraly, G.
Orosz, Z. Demetrovics, and M. N. Potenza
Health concerns linked to pornography viewing have been underresearched
within populations of women. The presentation began with an
assessment of the literature. It then utilized a large online sample to understand
how pornography viewing relates to hypersexuality, impulsivity,
childhood sexual abuse, and other factors.
Data from 24,372 pornography viewers (7,486 female) were gathered
through a large Hungarian news portal. Assessment tools included the
Problematic Pornography Consumption Scale (PPCS), the Hypersexual
Behavior Inventory, the Hypersexual Behavior Consequences Scale, the
Sexual Abuse History Questionnaire, the UCLA Loneliness Scale and the
ADHD Self Report Scale. Impulsivity was assessed using the UPPS-P scale.
As hypothesized, more men (97%) than women (78%) reported past year
pornography use. Men also reported greater hypersexuality, more hypersexuality-
related consequences, and more problematic pornography use than
women. Surprisingly, men also reported more childhood and adolescent
sexual abuse than women.
Women were more likely than men to score higher on ADHD measures
and impulsivity, including all except the Sensation-Seeking subscale. The
findings suggest that women who view pornography may be particularly
impulsive and may experience attentional difficulties. Additionally, 6.2% of
men and 4.7% of women recorded behaviors above the threshold for
Problematic Pornography Use.
The correlations between the PPCS and measures of impulsivity, hypersexuality,
loneliness, and ADHD were similar in men and women, suggesting
that common pathways may be operating across gender groups. The
particularly strong correlations in men between PPCS scores and hypersexuality
and its consequences is consistent with existing research and suggests
interventions for hypersexuality in men may need to consider targeting
pornography viewing.
“Binge Pornography Use and Masturbation as a Key Characteristic of Males Seeking Treatment for Compulsive Sexual Behaviors”
Małgorzata I. Wordecha, Poland with M. Wilk, E. Kowalewska, M. Skorko, A.
Łapi nski, and M. Gola
The study reported on nine men who had been referred by sexual health
centers for treatment of CSB. The group was a mix of heterosexual and
homosexual men with a mean age of 31.7 years (SD¼4.85). There was no
control group.
This study considered binge pornography use and masturbation with
respect to self-perceived factors hypothesized to be driving the behavior.
The factors were compared via ten weeks of daily diary data and a onehour
structured clinical interview. Diary records included measures of
sexual arousal, anxiety, stress, mood, and features of CSB, including time
spent viewing pornography and numbers of sessions of masturbation and
intercourse.
The researchers noted that there is a lack of scientific evidence to show
if bingeing is a standard characteristic of CSB. The study defined a binge
as watching pornographic content (and/or masturbating) for a few hours,
or repeating the activity many times during a day. Seven subjects had experienced
binges, ranging from duration of half-an-hour to half-a-day, up to
several times per day, and with frequency ranging from daily to several in
the ten weeks or only one day in their life. In the clinical interview, the
triggers reported were mainly stress and problems in personal life, fear of
failure, anger, loneliness, and rejection.
For processing the diary data, the criteria for bingeing were set at more
than two masturbations per day and a single pornography session lasting
more than one hour. Overall, the researchers reported that binge pornography
use may allow men to feel excitement and pleasure, while “turning
off” thinking and emotions. After the binge, all subjects reportedly experienced
negative emotions and thoughts about themselves. Four possible
explanations were put forward for binges: a stress-reducing mechanism,
increasing reactivity with stronger urges, habituation, and as a delay of climax
(“edging”). This paper has now been published by Wordecha
et al. (2018).
“Delay Discounting and Craving in the Context of Internet-Pornography-Use Disorder”
Stephanie Antons, Germany, with M. Brand
Antons and Brand focused on specific aspects of the I-PACE Model to
consider delay discounting. Delay discounting involves selecting smaller,
more immediate rewards over larger, later rewards. It is considered a form
of impulsivity and of the tendency to have difficulties in delaying gratification.
The researchers studied this aspect of impulsivity component through
the lens of craving in the affective and cognitive responses involved in
Internet-pornography-use disorder. They asked if craving has a mediating
or moderating effect on the link between delay discounting and the symptom
severity of Internet-pornography-use disorder. The sample was comprised
of 145 heterosexual males who use Internet pornography (average
age¼29.92 years).
Participants performed a delay-discounting task. Baseline craving and
symptom severity of Internet-pornography-use disorder were assessed using
questionnaires. While baseline craving was correlated with symptom severity
of Internet-pornography-use disorder on a bivariate level, delay discounting
and symptom severity of Internet-pornography-use disorder
were not.
The moderated regression analysis shows that participants who preferentially
selected immediate rewards rather than delayed rewards and who
showed higher baseline craving also had higher symptom severity of
Internet-pornography-use disorder. This finding suggests that decisionmaking
styles, in conjunction with affective factors such as baseline craving,
explain symptom severity of Internet-pornography-use disorder. Results
were also discussed in the context of potential neural mechanisms.
“Individual Delay-Discounting Rate in a Patient with Hypersexual Disorder”
Magdalena Smas-Myszczyszyn, Poland, with M. Lew-Starowicz
This sample of 108 patients with hypersexual disorder was given the
Monetary Choice questionnaire that assessed delay discounting. They also
completed the Polish version of the Sexual Addiction Screening Test. The
sexological sample was comprised of 66 individuals with compulsive masturbation,
along with 22 individuals who were compulsively “acting out”
sexually with partners and 20 who were compulsive in both categories.
Small amounts of money were discounted, preferred, more than large
amounts by all test groups. Patients in the group who were compulsive in
both masturbation and in pursuing sex with many partners were the most
impulsive. Learning the ability to defer gratification may represent an
important therapeutic goal for this group. Previous experiments confirm
that rewards are more strongly discounted than penalties (Thaler 1991),
suggesting that approaches that place more emphasis on the potential benefits
of the cessation of uncontrolled sexual behaviors, rather than on the
consequences of continuation, could have therapeutic effectiveness.
“Sociodemographic Changes in Pornography Use Between 2002 And 2016: A Study of a Representative Sample of the Polish Population”
Karol Lewczuk, Poland, with M. Gola
In the United States, the General Social Survey has been asking a single
question “Have you seen an X-Rated movie in the last year?” in every decade
since the 1960s. Currently 40% of men and 20% of women answer
“yes.” However, many studies from gaming, gambling, and Facebook use
show a large gap between declared use and a higher level of actual use.
Obtaining new longitudinal, population-level data on pornography use is
rare. This Polish study collaborated with an Internet provider, Gemius,
who could provide technical access and historical data. Participants were
invited to participate in a panel survey through pop-ups on popular websites.
After giving informed consent, basic information about participants’
Internet browsing activities were gathered in an anonymized way using
cookies. The cookies revealed if individuals had visited pornographic websites.
Separately, the team analyzed data from samples of 10,000 plus users
in the month of October every two years from 2004 to 2016. A person was
rated as a pornography user if they visited a pornographic website during
the month—a yes/no variable.
Researchers observed a steady increase in the population using pornography,
from 8% in October 2004 to 25% in October 2016. This growth paralleled
the overall growth of the number of Internet users in the population
during the same period. There is a moderate increase in the proportion of
Internet users using pornography, most notably for males. Gender, age,
and to a small degree the size of the place of residence, seem to influence
the probability of having viewed pornography on the Internet. Age and
gender explained 8% of the variance of online pornography viewing. The
limitations of the study include that data were not gathered if incognito
mode was used for browsing and it was based only on fixed line computers
(no mobiles). The figures were also scaled up to the population level, rather
than being based on raw data. The study does not provide information
regarding the quantity, frequency or type of pornography use.
“Clinical Characteristics of Compulsive Pornography Users: A Military Sample”
Shane W. Kraus, USA, with R. A. Hoff, M. Gola, E. Kowalewska, and M. N. Potenza
In the first part of this presentation, and in reaction to the growing
range of tools to measure problematic pornography use, this team set out
to develop and validate a shorter instrument, the Brief Pornography
Screener (BPS). It is a 5-item screener used to assess compulsive/problematic
use of pornographers in healthcare settings. It is scored each factor
either “never” (0), “sometimes” (1), and “frequently” (2), producing a
cumulative range of scores from 0 to 10. Work with U.S. (n¼223) and
Polish (n¼703) samples indicated excellent reliability and recommended a
cutoff score of 4, above which the subjects are likely to have problematic
pornography viewing issues. A score of 4 has a sensitivity of 80.4% and a
specificity of 80.3%.
The second study evaluated the clinical characteristics of participants
who scored positive on the BPS. The sample was 283 U.S. post-9/11 military
veterans was assessed with tools including sociodemographics, PRIMEMD,
AUDADIS-IV, Insomnia Severity Index, PTSD Symptom Checklist,
BPS, PPUS, HBI, UPPS-P, and the Difficulties in Emotional
Regulation Scale.
In the sample, 27.3% scored on or above the cutoff for the BPS. Over
92% of the veterans in the sample were male and more than a third of
individuals screening positive viewed pornography daily.
Emotional dysregulation was higher among problematic users than
among non-users. It is possible that problematic use may occur within the
context of emotional states related to stress or depression. Positive and
negative urgency forms of impulsivity were higher among individuals with
problematic pornography use. The findings resonate with prior work in
substance use and hypersexuality suggesting that problematic use can occur
in the context of stress or strong emotional states.
Depression was elevated among individuals with problematic pornography
use. Problematic pornography use was also associated with craving
for pornography.
Other presentations on pornography and sexuality
There were five other presentations that we were not able to observe. Readers are directed to the published abstracts for an indication of their content and conclusions (Demetrovics 2018). The session Cue-Reactivity and Craving in Off-Line and Online Behavioral Disorders included two relevant papers:
“Hypersexual Behaviors and Craving Reactions to Pornographic Pictures are Related
to Symptoms of an Internet-Pornography-Use Disorder”
Jaroslaw Pekal, Germany, with M. Brand
“The Influence of Stress on the Processing of Visual Sexual Stimuli in Men”
Jana Strahler, Germany, with O. Kruse and R. Stark
Research presented in the session Binge Behaviors: Conceptualization and Underlying Psychological Processes included:
“Approach and Avoidance Tendencies in Hypersexual Disorder”
Maria Veit, Germany, with J. Engel, C. Sinke, J. Kneer, C. Laier, S. Antons, U. Hartmann, T. Hillemacher, and T. H. C. Kru€ger
“Surveying Self-Identified Sex Addicts Supplies Evidence That Symptoms of Hypersexual Behavior and Internet-Pornography-Use Disorder are Associated with Common, but also Different Personality Characteristics”
Christian Laier, Germany, with J. Engel, M. Veit, S. Antons, M. Brand, and T. H.
C. Kru€ger
Within the Minitalk strand there was a paper titled:
“Excessive Internet Use for Sexual Purposes in Late Life: An Explorative Study of Risk Factors” Anna Sevcıkova, Czech Republic, with L. Blinka and K. Skarupova
...............................................
Discussion
This conference explored many different aspects of current research into the use of pornography by individuals and populations. Importantly, the conference keynote by Rudolf Stark concluded by suggesting that the case for pornography use disorder in the ICD-11 was strengthened by its foundation in the processing of natural rewards. Less than two months later, the new diagnosis of CSBD was ratified by the WHO secretariat for inclusion in ICD-11 (World Health Organization, 2018).
There were also advances in the collective scale and ambition of the reported research. In the past, small sample sizes and variable sample quality have limited some studies in the pornography research field. At the 2018 ICBA, the emergence of some larger samples suggested a growing strength in the field. While heterosexual men still dominate the research reports as test subjects in terms of sheer number, three of the studies reported on samples involving thousands of women and several more involved hundreds of women. Key were studies in Hungary, Poland, and the United States. The major Spanish study controlled its subject sample by both gender and age, but this was at the cost of only having 100 people of each gender and age group. Sexual minorities also appeared in a few studies at levels which support the drawing of statistically valid conclusions.
Several studies focusing on smaller numbers of subjects were able to work
more intensively, administering a wider selection of investigatory tools.
Sexually focused behavioral research is becoming well established with a
wider range of societies around the world now being investigated by
national or multinational research groups. A positive trend is the resulting
translation and validation of research tools into more languages. For
example, the Hypersexual Behavior Inventory has been translated and is
available in seven languages, and several other instruments originally developed
in English now come in Hungarian, Polish, and German versions.
Efforts to make assessment and diagnostic instruments shorter are also
coming to fruition. The Brief Pornography Screener now seems fit for
adoption by frontline practitioners as a tool for initial assessment of individuals
within the context of a short face-to-face consultation.
Work linked to the WHO CSB field trial found that significant numbers
of individuals who use pornography felt they were addicted to pornography
(6% in United States). Within the treatment-seeking Polish group, 86%
self-reported problems with pornography and 87% with masturbation, with
about half of both groups meeting clinical criteria for entering treatment.
In the online Hungarian study, 6.2% of the men and 4.7% of the women
recorded behaviors above the threshold for problematic pornography use.
These studies of self-selected groups begin to give a picture of the extent to
which issues relating to pornography use are appearing in pornographyconsuming
populations.
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