Effects of a 7-Day Pornography Abstinence Period on Withdrawal-Related Symptoms in Regular Pornography Users

Effects of a 7-Day Pornography Abstinence Period on Withdrawal-Related Symptoms in Regular Pornography Users: A Randomized Controlled Study. David P. Fernandez, Daria J. Kuss, Lucy V. Justice, Elaine F. Fernandez & Mark D. Griffiths. Archives of Sexual Behavior, Jan 18 2023. https://link.springer.com/article/10.1007/s10508-022-02519-w

Abstract: Little is known about whether withdrawal-like symptoms manifest when regular pornography users attempt to abstain from pornography. The present study used a randomized controlled design to examine whether (1) negative abstinence effects that may be potentially reflective of withdrawal-related symptoms manifest when a non-clinical sample of regular pornography users attempt to abstain from pornography for a 7-day period and (2) these negative abstinence effects would only manifest (or manifest more strongly) for those with higher levels of problematic pornography use (PPU). A total of 176 undergraduate students (64.2% female) who were regular pornography users (defined as having used pornography ≥ three times a week in the past 4 weeks) were randomly assigned to an abstinence group (instructed to attempt abstinence from pornography for 7 days, n = 86) or a control group (free to watch pornography as usual, n = 90). Participants completed measures of craving, positive and negative affect, and withdrawal symptoms at baseline and each night of the 7-day period. Contrary to the confirmatory hypotheses, there were no significant main effects of group (abstinence vs. control) or group × PPU interaction effects on any of the outcome measures, controlling for baseline scores. These findings indicate that no evidence of withdrawal-related symptoms was found for abstaining participants, and this was not dependent on level of PPU. However, exploratory analyses showed a significant three-way interaction (group × PPU × past 4-week frequency of pornography use [FPU]) on craving, where an abstinence effect on craving was found at high levels of PPU only once past 4-week FPU reached the threshold of daily use. While these exploratory findings should be interpreted with caution, they suggest that abstinence effects could potentially manifest when there is a combination of high PPU and high FPU—a hypothesis that warrants investigation in future prospective abstinence studies.

Discussion

The present study used a randomized controlled design to examine whether (1) negative abstinence effects potentially reflective of withdrawal-related symptoms manifest when regular pornography users (defined in the present study as having used pornography ≥ three times a week in the past four weeks) try to abstain from pornography for a 7-day period and (2) these negative abstinence effects only manifest (or manifest more strongly) for those with higher levels of PPU.

Confirmatory Analyses

The results showed that both confirmatory hypotheses (H₁ and H₂) were not supported. Contrary to the first hypothesis, there were no significant main effects of group (abstinence vs. control) on craving, negative affect, positive affect or withdrawal symptoms during the experimental period, controlling for baseline scores. This indicates that when assessed prospectively in comparison with a non-abstaining control group, no evidence of withdrawal-related symptoms was found for the abstaining participants in this sample. This finding is in contrast to previous cross-sectional research relying on retrospective self-report that found 72.2% of pornography users who had at least one past pornography abstinence attempt recalled experiencing at least one withdrawal-like symptom upon cessation (Dwulit & Rzymski, 2019).

The second hypothesis that negative abstinence effects during the experimental period would only manifest (or manifest more strongly) for those with higher levels of PPU was also not supported, as there were no significant group × PPU interaction effects on all outcome measures. Nonetheless, it is important to interpret this finding in light of the fact that because this was a non-clinical sample of regular pornography users, the range of scores on the PPCS was relatively low [M = 54.72, SD = 18.60, with only 15.3% of the sample having PPCS scores that met or exceeded the suggested clinical cutoff of ≥ 76 in Bőthe et al. (2018)]. This finding does not rule out the possibility that in a sample with higher levels of PPU, moderating effects of PPU might be observed.

An unexpected finding was that both negative affect and withdrawal symptoms decreased over the experimental period for both abstinence and control groups. This decrease appeared to be indicative of the “downward drift” phenomenon (see Gilbert et al., 2019, p. 538), which is the tendency for participants to report progressively fewer negative affect-related symptoms when tested repeatedly, regardless of assignment to treatment or control. This phenomenon has been observed in studies of abstinence from cigarette smoking (Gilbert et al., 2002) and gaming (Evans et al., 2018) and also non-abstinence-related studies (e.g., Sharpe & Gilbert, 1998). While multiple explanations have been proposed for the phenomenon (Arrindell, 2001; Sharpe & Gilbert, 1998), one plausible explanation is that repeated testing (in the present study, the daily surveys) acts as an intervention that facilitates self-monitoring of negative affect and possibly coping mechanisms to deal with the negative affect. This finding further underscores the importance of including a non-abstaining control group in future prospective abstinence studies, as decreases in negative affective symptoms over time by abstaining participants could easily be misattributed to abstinence.

Exploratory Analyses

Importantly, exploratory analyses provided partial support for the possibility that the null findings observed in the confirmatory analyses could have been the result of not accounting for the moderating effects of a third variable (i.e., past 4-week FPU). The majority of the sample (61.4%) reported past 4-week FPU on the lower end of the spectrum (i.e., three or four times a week), in large part contributed to by the large proportion of female participants in the sample (64.2%) most of whom also reported past 4-week FPU of three or four times a week (77.0%). Consistent with past research (Chen et al., 2018; Grubbs et al., 2019c; Weinstein et al., 2015), female participants in this sample had lower baseline rates of FPU, PPU and craving than male participants. Therefore, the possibility that abstinence effects might only manifest at higher levels of FPU was examined in exploratory models with past 4-week FPU added as a moderator and gender controlled for as a covariate.

A significant three-way group × PPU × past 4-week FPU interaction on craving was found, but past 4-week FPU did not play a significant moderating role in the negative affect, positive affect and withdrawal symptoms models. At high levels of PPU (+ 1 SD), the control group had higher craving scores than the abstinence group over the experimental period when past 4-week FPU was “three times a week,” but inversely the abstinence group had higher craving scores than the control group over the experimental period when past 4-week FPU was “once a day” or “more than once a day.” Notably, this indicates that there was an abstinence effect on craving when PPU was high, but only once past 4-week FPU reached the threshold of daily use. It is noteworthy that this effect was found even though high PPU at + 1 SD (i.e., M = 72.82) in this sample did not reach the clinical cutoff of ≥ 76 specified in Bőthe et al. (2018). This finding is similar to a previous cross-sectional survey of undergraduates in Canada that found an increase in addiction-related symptomatology once FPU reached the threshold of daily use (Harper & Hodgins, 2016). It is uncertain as to why the abstinence group reported significantly lower craving than the control group at high levels of PPU and past 4-week FPU of ‘three times a week,’ but one speculative explanation could be that abstaining participants below a specific threshold of FPU (i.e., three times a week) due to lower habit strength (Sirriani & Vishwanath, 2016) had enough self-regulation such that they were able to successfully implement strategies to regulate their experience of craving (e.g., prevent its occurrence or reduce its intensity whenever it did emerge) to help them achieve the abstinence goal.

There are two possible interpretations of the abstinence effect on craving under high PPU and high FPU conditions that are not necessarily mutually exclusive. First, if negative abstinence effects are interpreted within an addiction framework as withdrawal-related symptoms, then craving could potentially be a withdrawal symptom in PPU. High FPU on its own (without high PPU) may be indicative of preoccupation with pornography that may not be associated with negative life consequences (Bőthe et al., 2020a, 2020b), but the fact that craving manifested for those with daily or more FPU only when PPU was high reinforces the idea that abstinence-induced craving could be reflective of a dependency on pornography and potentially a withdrawal symptom (if a pornography withdrawal syndrome exists). This interpretation would be consistent with a finding from a recent systematic review that craving was the most common abstinence effect across multiple potential behavioral addictions (Fernandez et al., 2020). Second, craving could also have been a manifestation of sexual desire and/or arousal during the experimental period. Because higher baseline rates of FPU could have to some extent been reflective of higher sexual drive (Leonhardt et al., 2021), the fact that craving only manifested for those with high PPU when FPU was daily or more supports the sexual desire explanation. If participants’ primary sexual outlet was masturbating to pornography, then urges to use pornography could be a natural manifestation of sexual desire and/or arousal throughout the deprivation period (Castro-Calvo et al., 2022). The fact that an abstinence effect was found for craving and not the other outcome variables (i.e., positive affect, negative affect and withdrawal symptoms) further lends support to this non-pathological interpretation, because affect-related disturbances would arguably be expected to also be present if an actual withdrawal syndrome exists. At the same time, the lack of abstinence effects on these other outcome variables needs to be interpreted with caution because given the limited statistical power in the sample to detect three-way interaction effects, similar but smaller effects may not have been detected for these variables. Overall, all findings in these exploratory analyses should be interpreted with caution because of their post hoc exploratory nature and limited statistical power to detect effects of interest. While these exploratory findings are noteworthy, they should be regarded as hypothesis-generating for future studies.

Implications

In sum, the findings of the present study have two main implications for understanding the potential manifestation of withdrawal-related symptoms during pornography abstinence. First, confirmatory analyses showed that there was no evidence of negative abstinence effects (i.e., withdrawal-related symptoms) among a sample of pornography users who were using pornography at least three times a week, and this was not dependent on level of PPU (but with the caveat that the sample had relatively low levels of PPU). These null findings are important to emphasize as they provide preliminary evidence that the average regular pornography user who uses pornography somewhat regularly (i.e., a few times a week) generally does not experience withdrawal-like symptoms while trying to abstain from pornography for a 7-day period.

Second, exploratory findings raise the possibility that negative abstinence effects might manifest only when both baseline FPU and PPU are high—a hypothesis that needs to be tested in future prospective studies. Exploratory analyses found that craving was an abstinence effect when PPU was high, but only once past 4-week FPU was at least daily or more. This tentatively suggests that craving could potentially be a PPU withdrawal symptom if a pornography withdrawal syndrome exists, but future adequately powered studies need to verify this finding a priori and rule out alternative theoretical explanations (e.g., craving being solely a manifestation of sexual arousal). While craving was the only significant abstinence effect under these conditions, it cannot be ruled out that adequately powered studies might find other abstinence effects.

Overall, it is crucial that the findings of the present study be considered in terms of its specific sample characteristics (i.e., non-clinical, majority female sample of undergraduates from a sexually conservative country, most of whom were using pornography 3–4 times a week [61.4%], had PPCS scores below the clinical cutoff of 76 [84.7%] and had no intrinsic desire to quit their pornography use [89.8%]). These findings may not generalize to clinical samples, non-clinical samples with higher FPU or PPU, predominantly male samples, samples from more sexually liberal countries or samples composed solely of pornography users intrinsically motivated to quit their pornography use. Future studies using similar prospective designs and diverse samples with varying gender ratios and levels of FPU, PPU and intrinsic motivation to abstain from pornography use are needed to replicate and extend these findings.

It is also important to consider when interpreting the present study’s findings that the study period (February–March 2021) was during the third wave of the COVID-19 pandemic in Malaysia, when movement control and social distancing measures were enforced throughout the country (Rampal & Liew, 2021; Zamri et al., 2021). This could have potentially influenced the present study’s findings in two ways. First, participants’ self-reported affective states during the study period could potentially have been impacted by elevated psychological distress levels brought about by the pandemic (Marzo et al., 2021; Necho et al., 2021). Second, participants’ sexual lives could have also been affected by the pandemic. Frequency of partnered sex among participants may have decreased due to reduced access to potential sexual partners (Herbenick et al., 2022). While some longitudinal data have shown that as a general trend, FPU and PPU did not increase over time during the pandemic, this might not necessarily have been the case for all pornography users (Grubbs et al., 2022; Koós et al., 2022). For example, there has been evidence of retrospective self-reports, particularly among male participants, of increased FPU and frequency of masturbation during the pandemic when compared to pre-pandemic frequencies (Gleason et al., 2021; Sallie et al., 2021). It is plausible that some participants in the present study may have developed an increased reliance on masturbating to pornography as a sexual outlet in the absence of opportunities for partnered sex during stay-at-home orders, which could have made abstaining from pornography more challenging than usual. In sum, it is important to take into account that the present study’s findings may not necessarily generalize to a post-pandemic setting.

Limitations and Directions for Future Research

The present study has several limitations that need to be highlighted. First, because the study’s aim was to investigate abstinence effects irrespective of gender, there were no gender restrictions in the inclusion criteria, resulting in a sample that was close to two-thirds (64.2%) female. Compared to females, males tend to use pornography more for sexual pleasure (Bőthe et al., 2021a; Grubbs et al., 2019c) and have a stronger sex drive in general (Baumeister et al., 2001). As such, males may be more reliant on pornography as a sexual outlet than females. Therefore, it may be reasonable to speculate that males could have greater difficulty in abstaining from pornography than females even if they have similar rates of baseline FPU. However, because females had lower past 4-week FPU than males in the present sample, exploratory analyses with gender as moderator were not run because they would have been difficult to disentangle from exploratory analyses with past 4-week FPU as moderator. Future studies could consider restricting inclusion criteria to just male participants to examine whether abstinence effects manifest in a male-only sample or run adequately powered studies with both genders included (but with narrower inclusion criteria for baseline FPU [e.g., ≥ six times a week]) to investigate potential varying abstinence effects by gender, if any. Differing contexts of pornography use across genders (e.g., women in relationships are more likely than men to use pornography primarily or only with their partner; Carroll et al., 2017) could also be accounted for as a potential moderator of effects in future studies.

Second, nearly half (45.4%) of participants in the abstinence group reported using pornography at least once during the experimental period, which could have led to a mitigation in the frequency and/or intensity of any withdrawal-related symptoms experienced for these participants. While excluding participants who lapse from analyses may introduce bias because these participants are likely to experience the greatest amount of withdrawal in the first place (Hughes, 2007b; Piasecki et al., 2003a, 2003b; Shiffman et al., 2004), it is important to keep in mind that withdrawal-related symptom scores of the abstinence group as a whole may have been influenced by the considerable proportion of participants who did lapse in the present study.

Third, because the focus of the present study was to examine effects of abstinence from pornography specifically, participants in the abstinence group were allowed to masturbate without pornography or engage in non-pornography-related sexual activity. An advantage of allowing non-pornography-related sexual outlets is that potential manifestations of withdrawal-like symptoms can be more clearly attributed to a dependency on pornography use instead of dependency on masturbation or sexual activity (e.g., if withdrawal-like symptoms persist even after masturbating without pornography). However, a drawback of this is that it may not resemble many real-world abstinence attempts, given that many individuals with PPU may decide to abstain from pornography and masturbation or abstain from sexual activity altogether as a short-term recovery strategy (Fernandez et al., 2021). Future studies could consider modifying abstinence instructions so that they also include masturbation or sexual activity altogether.

Fourth, while the experimental design used in the present study contributed to rigorous internal validity due to randomization and use of a control group, experimental designs are inherently limited in the extent to which the studies’ results are generalizable to the wider population (because of the use of a relatively small, homogenous sample) and applicable to real-world situations (because of the emphasis on controlled conditions that prioritize internal validity over ecological validity). Importantly, abstinence in the present study may not be representative of real-world abstinence attempts because participants knew that abstinence would only last for a temporary 7-day period, they could lapse without consequence, and they could terminate their participation at any moment. Non-experimental longitudinal studies of intrinsic abstinence attempts are needed to supplement data provided by studies that experimentally manipulate abstinence.

Fifth, because it is plausible that a pornography withdrawal syndrome, akin to the withdrawal syndromes of some substances (cf. Hughes et al., 1994), might only begin or worsen after a significant period of abstinence (e.g., one or two weeks), the fairly brief duration of the present study (i.e., 7 days) meant that any potential withdrawal symptoms that might have emerged beyond an initial 7-day period could not be captured. Future studies could consider increasing the duration of the abstinence period to investigate this possibility.

Sixth, the outcome measures used to assess potential pornography withdrawal-related symptoms in the present study were a limitation because they were modified from existing scales constructed to assess alcohol craving (Flannery et al., 1999), smoking withdrawal symptoms (Welsch et al., 1999) and general affect (Thompson, 2007). Measures of pornography-specific withdrawal-related symptoms need to be developed and validated for use in future abstinence studies.

Seventh, despite having a significantly shorter recall period compared to a single end-of-week assessment, end-of-day surveys still rely on retrospection and as such remain susceptible to some recall bias (Newman & Stone, 2019). Research comparing aggregated momentary affect ratings throughout the day to retrospective end-of-day affect ratings demonstrates that end-of-day ratings of negative affect tend to be slightly biased toward peak and recent affect (Neubauer et al., 2020). Future studies can use ecological momentary assessment (EMA) instead of daily surveys for greater sensitivity to fluctuations of affect throughout the day.

Eighth, because the baseline measures for all outcome variables had a bigger recall period (past 7 days) compared to the daily measures (past day), changes in daily scores relative to baseline could not be examined. Incorporating a pre-intervention period where baseline data are also collected using the same daily surveys would allow for standardization of measures and examination of changes from baseline.

Finally, the present study did not account for the type or genre of pornography that participants typically used. It is possible that specific types of pornography (e.g., non-mainstream content; Hald et al., 2018) or greater variability of pornography content consumed (Lewczuk et al., 2021) may be associated with increased difficulty in abstaining from pornography use and can be accounted for in future abstinence studies.