When Does Pornography Use Become Problematic?

The concept of sex addiction is a hot topic among laypersons and professionals alike, including a lively discussion here on Psychology Today. Some view the recent rise of online pornography and sex chat sites as well as apps for finding casual sex partners to all be symptoms of an insidious disease of epic proportions that must be eradicated. Meanwhile, others see the use of these technologies as well within the normal range of human sexual expression.

Discussions about sex addiction also involve considerations of morality in a way that debates on other psychological disorders do not. Sexual attitudes have become far more liberal over the course of the last century. However, there are sizable portions of the population who still see sexual behaviors as essentially immoral in all but a few highly circumscribed situations.

In the professional world, the debate about sex addiction is quite heated, with positions clearly delineated by individual views on the morality of “extraordinary” sexual behaviors. As the American Psychiatriatric Association drew up plans for the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there was much discussion on whether to include hypersexuality as a disorder. Although it didn’t make the final cut, it still hasn’t stopped some clinicians from diagnosing certain sexual behaviors they disapprove of as disorders.

Recently, the World Health Organization (WHO) has included a new category of disorder in the eleventh edition of its International Classification of Diseases (ICD-11). This is compulsive sexual behavior disorder, or CSBD. According to Bowling Green State University psychologist Joshua Grubbs and his colleagues, the decision was praised by many and condemned by many others, generating more commentary than any other novel diagnosis ever has.

In the ICD-11, compulsive sexual behavior disorder covers a wide range of activities. These include engaging in casual sex with multiple partners, frequenting prostitutes, and using phone-sex or online sex-chat services. However, as Grubbs and colleagues point out, all of these practices entail significant social and financial costs, and relatively few clients seeking therapy for a sex addiction report these as problematic for them. Instead, the vast majority of individuals seeking help report problematic viewing of pornography accompanied by compulsive masturbation.

Despite the inclusion of compulsive sexual behavior disorder in the ICD-11, the text provides clinicians with limited support in making a diagnosis. Specifically, the ICD-11 indicates that distress over sex acts based on moral judgments isn’t sufficient to diagnose CSBD. That is to say, if you believe masturbating to porn is sinful yet you do it anyway and feel guilty afterward, that itself is not CSBD.

And yet, Grubbs and colleagues maintain, if moral distress is excluded, there’s little else to base a diagnosis of compulsive sexual behavior disorder on. Instead, the researchers argue that self-reports of sex or porn addiction may largely stem from the cognitive dissonance that individuals experience when their porn viewing and masturbation habits conflict with their moral and religious beliefs. To test this hypothesis, they conducted a large-scale survey of more than 3,600 individuals, with samples drawn from both college students and the general population.

The participants responded to questions assessing four categories:

• Problematic pornography use. Participants indicated the degree to which they agreed with statements such as “I believe I am addicted to internet pornography.”
• Moral disapproval of pornography. Items included “I believe that viewing pornography is morally wrong.”
• Pornography use. Participants reported the frequency of porn viewing, ranging from “never” to “once a day or more.”
• Religiousness. Items included “I consider myself religious.”

The results were as the researchers expected. Specifically, frequency of pornography use in itself didn’t correlate with the self-perception of it being problematic. That only occurred when the individual also morally disapproved of pornography and was highly religious. In other words, those with liberal moral views didn’t see their porn use as problematic, even when they viewed it quite often. Furthermore, some respondents who were religious and morally disapproved of porn didn’t use it much, if at all. Yet religious individuals who did use porn often felt their behavior was problematic.

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Grubbs and colleagues maintain that therapists need to discuss views on religion and morality with their clients who self-report sex addiction issues. Specifically, clinicians need to help them reconcile their religious beliefs with their natural sexual inclinations. In some cases, this may mean giving up porn in order to stay true to the teachings of their church. But in other cases, people will learn to be more flexible in their moral reasoning while coming to accept their sexuality as natural and not perverted.

Therapists also need to reflect on their own moral and religious attitudes, particularly how these play into their interactions with their clients. For instance, Grubbs and colleagues cite earlier research showing that religious therapists are more likely to view pornography use as problematic compared with their non-religious colleagues. At the very least, therapists should be upfront with their clients about the ways in which their personal beliefs define their approach to therapy.

Other research shows how therapists’ moral attitudes can also lead to biased diagnoses. For instance, one study found that therapists were more likely to diagnose clients as having a sex addiction when those clients were heterosexual than when they were homosexual.

It’s not unusual for people to experience cognitive dissonance as their natural sexual urges conflict with their religious upbringing. However, the problem isn’t necessarily in the sexual acts themselves but may really be in the subsequent guilt, and in such cases, resolving this mismatch between beliefs and behaviors should be the focus of therapy.

I should also add that there certainly are cases of people engaging in compulsive sexual behaviors that do negatively impact the work, social, health, and family aspects of their lives. But such cases of hypersexuality are most likely to be symptoms of other mental illnesses, in which case it’s the underlying disorder giving rise to these behaviors that needs to be treated.

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