Treatments for Problematic Pornography Use

Source: Kris K / Pixabay

While most people who view pornography report neutral to positive experiences, some people report struggles with their viewing of erotic videos, particularly online. Historically, most people who identified as having sexual disorders were heterosexual men engaging in extramarital sex.

However, the rise of internet pornography has shifted this, with pornography-related problems now making up a majority of the people diagnosed with compulsive sexual behavior disorder—predominantly in Europe, where this diagnosis was adopted under the International Classification of Diseases 11th Revision (ICD-11). Porn addiction is not recognized in the U.S.

Most people who identify as struggling with pornography may get better on their own, without treatment, according to longitudinal research in Canada. But, for those individuals who seek out clinical treatment for their pornography use, what treatments are effective?

Who Struggles with Pornography?

First, it's important to recognize that people may self-identify as having problems related to their pornography use for many different reasons, not all of which have to do with the pornography itself. Moral incongruence and sexual shame contribute significantly to this feeling, as people report struggling with their use of pornography.

One large study found that the average self-identified porn addict viewed porn only around 10 times a year, so this isn't clearly about frequency of use. Instead, pornography appears to be often a stand-in for sexual desires or interests that a person wishes they didn't have.

A recent study found that in sexual minorities, internalized homophobia, lack of social support, and substance abuse problems predicted problems with pornography. Depression and anxiety are frequently reported symptoms in persons who struggle with pornography, and it appears that many of these persons use pornography viewing as a means to cope with these negative feelings.

Finally, personality features such as narcissism play a significant role in self-reported problems with pornography and may reflect efforts to externalize responsibility and blame for one's sexual desires and behaviors.

All of these issues, and more, must be taken into consideration when exploring treatment strategies for persons with self-reported struggles with pornography. Each individual treatment must be tailored to the person's needs. It's not so simple as to just say, "Stop using pornography," given that this would be almost meaningless to that person who watches pornography fewer than once a month.

Indeed, some suggest that reducing the frequency of use may not be a primary treatment goal. One study found positive increases in mental well-being and decreased depression without affecting the frequency of pornography viewing at all.

What Treatments Exist?

Roza et al. published a thorough systematic review of treatment approaches for problematic pornography use. A systematic review is a modern approach to large-scale research reviews, with a design and methodology to minimize bias.

So, review authors may not simply exclude research they disagree with, and we can trust that a systematic review is a more objective analysis of a broad area. Roza et al. included in their review 28 publications that described research analysis of treatments for problem pornography use and excluded articles that were merely observational, didn't evaluate outcomes, didn't include original data, and were solely based on qualitative information.

In psychological treatments for pornography problems, acceptance and commitment therapy (ACT) was the most widely studied intervention, with multiple studies investigating whether ACT was effective. Mindfulness skills and meditation have also been studied, though cognitive behavioral therapy (CBT) strategies were more commonly applied and investigated for pornography problems.

Very few studies utilized family and couples' therapy strategies, though Roza et al. note that this modality may be valuable to explore further, given that problems with pornography may often occur in relationships and relate to desire discrepancies. These psychological interventions often incorporated elements of motivational interviewing and were provided in both individual and group therapy formats, as well as some novel self-directed computerized models.

Surprisingly, medications are often described as treatment interventions for pornography problems, including opioid antagonists such as Naltrexone (used to decrease cravings for substances). Antidepressant medications have also been prescribed and investigated.

In some cases, the sexual side effects of some medications, including decreased libido and anorgasmia, may be intentionally used for potential treatment effects. However, it's important to note that all such pharmacological interventions are "off label," as such uses are not Food and Drug Administration (FDA)-approved, nor has sufficient research been done to demonstrate safety. Another recent review recommended that such medications should not be used outside research trials.

Pornography Essential Reads

Do Accessibility and Anonymity Lead to Problematic Porn Use?

14 Ways That Porn Can Threaten a Relationship

One study addressed transcranial electromagnetic stimulation, a novel intervention shown in the past to increase or decrease libido potentially.

Source: Image by Ri Butov from Pixabay

What Works for Treating Pornography Problems?

Roza et al. note that before evaluating whether the treatments work, we must consider whether such treatments may harm. Unfortunately, of the 28 studies included, 21 (75%) did not include information about the tolerability or side effects of the treatments. In several studies, high dropout rates were observed, as participants found the treatment materials boring, redundant, and unhelpful or reported that side effects were interfering.

But was the research revealing of what treatments worked? Unfortunately, Roza et al. caution that the available research data is generally of such poor quality that drawing effective conclusions is likely premature. The researchers applied the grading of recommendations assessment, development and evaluation (GRADE) approach to evaluate the quality of the available research to determine effectiveness.

Only the studies on ACT rose to a "low" grade. All other treatment interventions, medication, CBT, mindfulness, etc., ranked at a "very low" quality level. Significant levels of bias were noted in many of the studies, indicating further need for caution in basing interpretation on them.

It's worth noting that this systematic evaluation included no studies of the 12-step treatment models, residential treatments, or the online "Reboot" or "NoFap" self-help models. These programs weren't deliberately excluded; it's just that no published studies of them met the inclusion criteria.

So, anyone who asserts these models work is, unfortunately, purely based on anecdotal evidence, where the quality of the evidence cannot even be evaluated.

Where positive results from treatment interventions were noted, the results were often associated with decreases in psychiatric symptoms such as depression and anxiety or increased tolerance for internal distress, and not clearly from changes to pornography viewing. Indeed, they note that "attempts to suppress thoughts and impulses actively may not be helpful." Opioid antagonists, used to decrease feelings of craving for pornography, appear promising, but still with great need for future research.

Finally, Roza et al. point out that because the studies often used varying definitions of problematic pornography use, it is impossible to identify whether these treatment models are effective with varying presentations. For instance, where problems with pornography emerge from moral incongruence and sexual shame, opioid antagonists may have limited usefulness.

These results suggest that you are likely best off seeking treatment that evaluates you as a whole person, assessing and treating symptoms such as depression, anxiety, and moral incongruence, and increasing your tolerance for feelings of distress.