Just Because a Client Says He’s Porn Addicted…

As digital technologies become more ubiquitous and porn usage becomes more prevalent, clinicians, especially Certified Sex Addiction Therapists (CSATs), have seen a corresponding increase in the number (and variety) of people seeking help with porn-related problems.

Importantly, there are multiple and often very different populations seeking such assistance. For instance, some clients seek treatment because they are compulsive/addicted, while others seek treatment because they feel shame (cultural, religious, or interpersonal) about their porn use. Still others seek help for porn use that is symptomatic of underlying mental health issues like Bipolar Disorder, OCD, and Depression – an issue I have written about previously at this link.

Unfortunately, all of these populations may self-identify as compulsive/addicted, even when they’re not.

Needless to say, these differing porn abusing cohorts, while seeking help for the same basic behavior, can have very different treatment needs. This means that addiction treatment (as provided in my Seeking Integrity programs) is appropriate and effective for those who are truly compulsive/addicted, but not appropriate or effective with individuals whose primary issue is shame tied to their use of pornography.

Admittedly, individuals in each of these groups arrive in treatment unhappy about their use of pornography, often to the point where they report severe depression or debilitating anxiety. They are all displeased with their sexual fantasy lives and the way they’re living them out. They also tend to keep secrets and lie about their porn use. But this does not mean they’re all struggling with the same issue. For example, shame-based clients, rather than being compulsive/addicted, may simply be applying a self-diagnosis of compulsivity/addiction as a way of explaining and justifying sexual fantasies and behaviors about which they feel deep emotional discomfort.

Recognizing this, therapists should never automatically accept any porn using client’s self-diagnosis of compulsivity/addiction. To do so would be a disservice to both the client and the psychotherapeutic community. Proper clinical assessment is always required.

Shame-Based Porn Users vs. Addicted Porn Users

There are two primary categories of shame-based porn users. First up is the person whose social, religious, or moralistic belief system vilifies pornography (and, perhaps, sexuality in general). Research tells us that religion, especially strict/conservative/sexually repressive religions, is the primary culprit. For example, one recent, relatively large-scale study found that religious beliefs lead a meaningful percentage of people to believe they are addicted to pornography, even when a proper assessment clearly indicates they’re not.

A typical client of this type is a young man with a strict religious background who looks at porn occasionally, maybe a few times per month for no more than 30 minutes. Though porn use does not directly affect his day-to-day functioning, he feels horrible about the behavior because his church, his family, his friends, and pretty much every other important person in his life says that viewing porn is sinful. Now he believes he is addicted to porn. Otherwise, why would he use it?

The second type of shame-based porn user seeks treatment related to ego-dystonic sexual attractions. A typical client of this sort is a married, supposedly heterosexual man who feels great shame about his use of gay or trans porn, which he looks at occasionally for short periods of time with no direct effects on his day-to-day functioning. However, his self-esteem is damaged because the porn he looks at leaves him feeling like he’s “less than a man.” Now, he’s deeply depressed. In therapy, he may blame his same-sex fantasies and behaviors on porn compulsivity/addiction, likely because he sees that as the lesser of two evils. He seems to think (or wants to believe), “I only look at porn with men and trans-women because I’m an addict. If I wasn’t addicted, I wouldn’t have these desires.”

At this point you may be asking: Is it possible for a shame-based porn user to also be addicted? The answer to that question is yes, absolutely. But only if that person’s behaviors meet the criteria used by CSATs to properly assess for porn compulsivity/addiction. These benchmarks are:

• Preoccupation to the point of obsession with pornography.
• Loss of control over the use of pornography, generally evidenced by multiple failed attempts to quit or cut back.
• Real-world consequences directly related to out of control porn use, including damaged relationships, trouble at work or in school, loss of interest in previously enjoyable hobbies and activities, social isolation, lack of self-care, declining physical and emotional health, sexual dysfunction with real-world partners, financial struggles, legal issues, etc.

The Need for Proper Diagnosis

Neither of the shame-based clients described above meets the criteria for porn compulsivity/addiction, and no therapist should treat them as such. Instead, therapists should try to help these individuals normalize, accept, and integrate their sexual desires and behaviors so they don’t feel so much shame, and to then reconcile their desires and behaviors with their social, religious, and interpersonal ideals. In short, clinicians should try to help these clients find a sexual comfort zone, which might or might not include future porn use. More importantly, if/when such clients attempt to self-label as compulsive/addictive with pornography, therapists should educate them as to the nature of that disorder vs. the issue(s) they are reporting.

In truth, treating either of these non-addicted individuals for porn compulsivity/addiction, using the techniques that have proven effective in that regard, would be counterproductive, inadvertently reinforcing their mistaken belief that their attractions and behaviors are abnormal, sinful, or whatever else it is that they feel shame about. And that, in turn, would almost certainly deepen their presenting symptoms (depression, anxiety, lowered self-esteem, and the like).

At the same time, trying to treat a person who really is compulsive/addicted with porn by helping him feel better about (less shamed by) his or her porn use can be equally damaging, as this approach may be interpreted as encouraging the obsessive, out-of-control activity that’s creating problems in the client’s life. It’s a bit like telling an alcoholic, “Oh, don’t worry about it. Everybody has a cocktail once in a while.” Such an approach willfully ignores the addict’s loss of control and the resultant negative consequences. So, once again, when dealing with clients seeking treatment related to their use of pornography, proper assessment and diagnosis is a must. Without it, clinicians can do more harm than good.

Once upon a time, accessing pornography was difficult, expensive, and potentially embarrassing. And until very recently, nearly all of the porn produced was geared toward heterosexual men. Because of these limitations, compulsive/addictive porn use was a relatively rare concern in the spectrum of sexual problems. And when those issues did occur, they primarily afflicted adult males. Minors had a tough time accessing porn and females were not the target audience, so porn compulsivity/addiction for those groups was highly unlikely.

Not so today.

In today’s world, porn is accessible to and viewed by just about every demographic. And this accessibility explosion happened in what feels like the blink of an eye. One day porn was taboo and hard to find; the next day it was everywhere. First, we got softcore on cable TV. Then we got hardcore on VHS tapes rented from the local video store. Then we got the internet. Now, pretty much anyone who wants to look at porn can do so – anytime, anywhere, free of charge. We’ve got porn sites with an endless supply of images and videos, plus sexting, virtual reality sexual encounters, sexy social media, participatory avatar sex games, and more. Much more. All of which can be easily and anonymously accessed by anyone who’s interested. And it seems that people of all ages, genders, sexual orientations, ethnicities, religions, and cultural backgrounds are indeed interested.

The era when pornography was the sole purview of adult males is long gone. Today, sexual imagery of every ilk imaginable can be easily and instantly accessed. Whatever you’re into, it’s out there and available. All you need to do is find the right online porn site, click a button, and you’re in. You don’t have to flash an ID to prove your age, and you don’t need to provide a credit card because most online porn is now available free of charge.

Younger people in particular are taking advantage of this ever-expanding pornographic wonderland. And at least a few of them are falling through the looking glass into compulsivity/addiction. Boys seem to be especially susceptible to the allure of online porn, with potentially negative consequences down the line.

If you don’t believe me, consider the tribulations of Canadian researcher Simon Lajeunesse. When Lajeunesse tried to conduct research on the effects of porn use on adolescent males, he was unable to do so because he couldn’t find any male adolescents who weren’t already using porn. Lacking a control group of non-porn using boys, there was no way to compare and contrast. Admittedly, Lajeunesse was searching for older adolescents who hadn’t used porn, and we do hope that there are at least a few prepubescent boys who have not yet typed “sex” or “nude” into a search engine, but it’s nonetheless clear that nearly all boys (whether mom and dad know it or not) will get there sooner or later. And usually sooner. In fact, research estimates that the average age of first porn use in boys is now eleven years old.

Please note that I’ve used the word “estimates” when talking about the age of first porn use. In truth, questions about when children start using porn, how often they use it, and the ways in which it impacts them are incredibly difficult to answer. There are countless legal and ethical reasons why researchers cannot directly study pornography use among minors, so the best we can do is to survey them after the fact, as young adults. And since most young people aren’t exactly forthright about their sexual selves, even that research must be deemed at least moderately unreliable.

That said, it is abundantly clear that many young people are viewing porn, and some of them are experiencing negative consequences. Online forums such as RebootNation.org, YourBrainRebalanced.com, and NoFap.com are built for the discussion of porn addiction and porn-induced sexual problems, and collectively they host many thousands of active members who are trying to overcome compulsive/addictive porn use and related consequences. Users routinely post comments like:

• I started watching porn at ten and masturbating soon after, several times a day for the last four years until I decided to quit.
• I have weird fetishes and can’t stay hard during sex.
• I have tons of reasons for wanting to quit: girls, anxiety, depression, and just feeling dead inside.
• What’s worse than the erectile dysfunction is the desensitization to the world. I find it hard to enjoy anything at all.
• I stopped going to swim practice after school to find time to view porn without my folks around. Then I got kicked off the team for missing practices. Now I just go home and watch porn every day. No homework, no hanging out with other kids, just me and the porn.

Based on nothing more than the extensive anecdotal evidence on these and similar sites, it is relatively easy to conclude that a meaningful percentage of adolescent boys and young male adults (we have no idea how many) are currently dealing with a variety of negative consequences related to porn use – relationship issues, trouble in school (or at work), loss of interest in real-world romance, social isolation, sexual dysfunction, anxiety, depression, diminished self-esteem, and more.

Unsurprisingly, the research that exists on adolescent male porn use rather strongly supports the conclusions drawn from postings on the sites mentioned above. In one study of 16-year-old Swedish boys, 96% admitted they were porn users, with 10% saying they looked at porn every day. The boys who used porn daily self-reported higher levels of risky sexual behaviors, relationship problems, truancy, smoking, drinking, and illicit drug use. Furthermore, approximately one-third of the daily users said they sometimes watched more porn than they wanted – a sign that they’ve lost (or are starting to lose) control over their use of porn.

Females are also susceptible to pornography’s allure, though females are generally more likely to become hooked on romance and intense love experiences than on purely sexual activities like hardcore porn. This is indicative of male/female sexuality in general. Whereas males are primarily interested in highly objectified sexual imagery and acts, females typically seek out sexual content with at least a hint of emotional connection (like the book/movie Fifty Shades of Grey). That said, plenty of females also look at the same hardcore stuff that males access.

Recognizing the desire for romance-driven porn for females, porn producers are actively creating stories, imagery, and videos that appeal to this market. But as increasing numbers of girls and women seek “romanticized” porn, they can easily be exposed to and end up viewing the highly sexualized porn that is generated primarily for males.

I will write more extensively about female porn use in a future post to this site. For now, let’s just say that more and more females are viewing porn, and a certain percentage are becoming compulsive/addictive and experiencing negative consequences.

At the end of the day, it is clear to me that porn use in our increasingly digital world can impact any person – male or female or anything in between, regardless of age, race, religion, ethnicity, or any other factor. Because pornography of every ilk imaginable is now freely available to any person, porn compulsivity/addiction is also available to any person.

If you or someone you care about is struggling with compulsive/addictive porn use or other forms of sexual compulsivity/addiction, contact Seeking Integrity or visit the free resources website SexandRelationshipHealing.com.

In a previous post to this site, I discussed how therapists can clinically define and diagnose porn compulsivity/addiction (as a form of Compulsive Sexual Behavior Disorder), and how problematic, compulsive porn use typically manifests in a person’s life. In this post, I am focused on the most common consequences of this type of porn use.

People who struggle with the compulsive use of pornography nearly always find themselves leading stressful, highly compartmentalized lives.  Because they feel so much personal, cultural, religious, and/or moral shame about their porn use, they hide this behavior from family, friends, and everyone else who matters to them. Often, their shame prevents them from seeking help for their problem. And when they do reach out, they tend to ask for help with anxiety, depression, and low self-esteem rather than directly addressing their underlying issue of pornography. Many heavy porn users spend months or even years in therapy without ever discussing (or even being asked about) their secret sexual life.

Of course, shame is hardly the only consequence that people experience related to heavy porn use.

Research tells us that compulsive porn users experience a wide variety of directly and indirectly related problems. For example, a survey of 350 self-identified sex and porn addicts conducted by UK therapist Paula Hall identified the following issues:

Shame                                                                              70.5%
Low Self-Esteem                                                            65.0%
Mental Health Issues                                                   49.8%
Loss of a Relationship                                                   46.5%
Sexual Dysfunction                                                       26.7%
Serious Suicidality                                                         19.4%
Sexually Transmitted Disease                                    19.4%
Other (Non-STD) Physical Health Problems            15.7%
Debt                                                                                 14.7%
Impaired Parenting                                                       14.7%
Legal Actions Against                                                   06.0%
Loss of Employment                                                     04.1%
Press Exposure                                                              00.9%

Regardless of the study and who conducted it, the primary consequences of compulsive porn use tend to boil down to shame, mental health issues, relationship woes, and sexual dysfunction. At the very least, these are the issues that seem to drive heavy porn users into treatment.

Shame and Low Self-Esteem

As stated above, compulsive porn users often feel personal, cultural, religious, and/or moral shame about their behavior. If an individual was raised in a home or a religion or a culture that frowns upon porn use, that person can’t help but feel defective and “less than” for using it. And even individuals who are not externally shamed for using pornography may feel internal shame about it, especially if pornography is their primary or only sexual outlet. In such cases, they may feel lonely and embarrassed about their “failure” to engage sexually in the real world, and, over time, this can eat away them, diminishing their self-esteem in all areas of life.

Mental Health Issues

The link between mental health issues and pornography will be discussed in detail in a future posting to this site. For now, I will simply state that common mental health issues like depression, anxiety, and even suicidality are often linked to compulsive porn use. The cause and effect relationship is not always clear, however. It appears mental health issues can result from compulsive porn use; it also appears that mental health issues can create emotional discomfort and a need to “numb out” through the compulsive use of pornography (or compulsive gambling, alcoholism, drug abuse, binge eating, etc.) Either way, there is an undeniable link between heavy porn use and a variety of mental health issues.

Relationship Woes

Individuals who are in committed, supposedly monogamous relationships may or may not be committing infidelity by using pornography, depending on how the couple has defined monogamy and the boundaries of their relationship. Either way, if porn use escalates to the level of compulsivity, the relationship can’t help but be negatively impacted. When porn use is compulsive, it starts to override everything else that’s important, including intimate connections. When porn is placed ahead of the user’s primary romantic relationship in this way, strife is inevitable.

Sexual Dysfunction

Depending on the research, anywhere from 17 percent to 58 percent of men who struggle with pornography report issues with erectile dysfunction (ED), delayed ejaculation (DE), or inability to reach orgasm (anorgasmia). Often, this is the most disturbing consequence of compulsive porn use, especially among younger male users. And without a doubt, this issue is increasingly common. Stated simply, growing numbers of physically healthy men, including men in their sexual prime, are suffering from sexual dysfunction related to their use of pornography.

And no, this issue is not linked to frequency of masturbation and orgasm (i.e., the need for a sexual refractory period in which males reload, so to speak). In actuality, the problem is tied to the fact that when a male spends the majority (or all) of his sexual life masturbating to online pornography – endless images of visually perfect (whatever that means to the user), constantly changing partners and experiences – he is, over time, likely to find a real-world partner or a simple sexual fantasy less than stimulating. For these individuals, online porn creates an emotional and psychological disconnect that manifests physically as sexual dysfunction.

Even worse, this sexual dysfunction affects not just male porn users but their romantic partners. If a guy can’t get it up, keep it up, or reach orgasm, then his partner’s sexual pleasure and self-esteem are also likely to be diminished. Many heavy porn users find themselves ending an existing relationship with someone they genuinely care about because of the shame they feel when they can’t perform sexually, or their partners end it for them because they don’t feel a healthy sexual and romantic connection and don’t know why.

If you or someone you know is struggling with compulsive or addictive porn use, please visit the free resource website SexandRelationshipHealing.com for assistance and guidance. To receive specialized treatment for porn compulsivity/addiction, contact Seeking Integrity.

Although the American Psychiatric Association has willfully ignored our nation’s ongoing sex and porn addiction/compulsivity epidemic, other organizations, equally if not more prominent, have chosen to recognize the issue and act on it. Most notably, the World Health Organization (WHO) has revised its diagnostic manual, the International Classification of Diseases (ICD-11), to include Compulsive Sexual Behavior Disorder, with a definition that comfortably encompasses both sex and porn addiction and compulsivity. The WHO states:

Compulsive sexual behavior disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behavior; and continued repetitive sexual behavior despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behavior is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet this requirement.

This description meshes nicely with the criteria Certified Sex Addiction Therapists (CSATs) have been using for many years to identify and diagnose sex and porn addiction and compulsivity. The short version of those criteria reads as follows:

1. Preoccupation to the point of obsession with sex/porn.
2. Loss of control over the use of sex/porn, best evidenced by multiple failed attempts to quit or cut back.
3. Directly related negative life consequences – troubled relationships, issues at work or in school, declining physical health, depression, anxiety, diminished self-esteem, social and/or emotional isolation, loss of interest in previously enjoyable hobbies and activities, financial woes, legal problems, etc.

Any person who identifies with the WHO’s definition of Compulsive Sexual Behavior or the typical CSAT criteria related to his or her porn use is probably has a problem related to his or her heavy usage of pornography, regardless of whether we call that problem an addiction or compulsively.

Research suggests that in today’s world most of the people who self-identify as addicted to or compulsive with pornography spend at least 11 or 12 hours per week looking at (and usually masturbating to) porn – most often digital imagery accessed via their computer, laptop, tablet, smartphone or some other Internet-enabled device. Magazines, VHS tapes, DVDs, and other ‘traditional’ forms of pornography are still in use, but the vast majority of heavy porn users prefer the anonymity, affordability, and 24/7 accessibility that digital technologies provide. And this 11 or 12 hours per week number is the low end of the spectrum. Many users spend double or even triple that amount of time with pornography.

Common signs that casual porn use has escalated to a level that is problematic for the user include:

• Continued porn use despite consequences and/or promises made to self or others to stop
• Escalating amounts of time spent on porn use
• Hours, sometimes days, lost to searching for, viewing, and organizing pornography
• Masturbation to the point of abrasions or injury
• Viewing progressively more arousing, intense, or bizarre sexual content
• Lying about, keeping secrets about, and covering up the nature and extent of porn use
• Anger or irritability if asked to stop using porn
• Reduced or even nonexistent interest in real-world sex and intimacy
• Male sexual dysfunction (erectile dysfunction, delayed ejaculation, inability to reach orgasm)
• Deeply rooted feelings of loneliness and/or detachment
• Drug/alcohol abuse in combination with porn use
• Drug/alcohol addiction relapse related to porn use or feelings about porn use
• Increased objectification of strangers, viewing them as body parts rather than people
• Escalation from two-dimensional images to casual/anonymous sexual hookups, paid sex, affairs, etc.

Individuals who are addicted to or compulsive with pornography feel compelled to look at porn. Over time, they organize their lives around pornography. Porn becomes an obsession to the point where important relationships, interests, and responsibilities are partially and sometimes completely ignored. They spend inordinate amounts of time searching for porn, viewing porn, and organizing their porn collection. Very often, feeling shameful or remorseful, they will tell themselves, “This is the last time that I am going to use pornography,” but in a few days or weeks they’re right back at it. Sometimes they delete their entire porn collection and feel great about doing that. But then, when their pink cloud dissipates, as inevitably occurs, they regret the deletion and scramble to reassemble their collection. Many people spin their way through this delete-reassemble cycle over and over and over.

Sadly, individuals who struggle with pornography are often reluctant to seek help because they don’t view their solo sexual behaviors as an underlying source of their unhappiness. And when they do seek assistance, they often seek help with related symptoms – depression, loneliness, and relationship troubles – rather than the porn problem itself. Many are in therapy for extended periods without ever discussing (or even being asked about) pornography and masturbation. Either the subject feels too shameful to talk about, or they just don’t see the correlation between their porn use and the problems they’re having in life. As such, their core problem remains underground and untreated.

If you’ve read this article and you are still unsure about whether you might be addicted to or compulsive with pornography, the following 15-question yes/no quiz (derived from Seeking Integrity’s 25-question Sex and Porn Addiction Self-Assessment) might help.

Porn Addiction/Compulsivity Self-Assessment

1. Do you feel distracted by, obsessed with, or preoccupied with pornography?
2. Do you ever use porn when you don’t want to?
3. After using porn, do you sometimes feel depressed, anxious, or ashamed?
4. Does porn use interfere with you meeting your personal life goals?
5. Do you think that your porn use has impacted your ability to form or maintain a meaningful romantic relationship?
6. Do you get restless, irritable, or discontent when you want to look at porn but can’t?
7. Do you keep secrets about your porn use (like how long you’re online or what you look at)?
8. Has the amount or nature of your porn use escalated over time?
9. Have you experienced negative consequences related to your porn use?
10. Once you start looking at porn, do you find yourself using it for longer periods of time than you initially intended?
11. Do you look forward to events with family/friends being over so you can use porn?
12. Has a friend or loved one ever told you that he or she is worried about or upset by your porn use?
13. Is your involvement with porn greater than your involvement with other people?
14. Do you prefer ‘pixel sex’ to real-world sex?
15. Have you ever promised yourself or others that you would stop using porn, only to return to it within a few days or weeks?

Answering yes to three or more of the questions above suggests that you may indeed be addicted to or compulsive with pornography. If so, you should explore your use of pornography with a certified sex and porn addiction treatment specialist. For information and advice on how to go about this, visit the free resource website SexandRelationshipHealing.com.

Once upon a time, in the pre-internet dark ages, finding and viewing porn was not so easy, especially for young people. Even for adults, using porn was an expensive and potentially humiliating experience. So becoming compulsive with or addicted to pornography was relatively rare.

Not so today.

Porn is accessible to and viewed by just about every demographic. And this happened in what feels like the blink of an eye. One day porn was taboo and hard to find, the next day it was everywhere. In today’s world, pretty much anyone who wants to look at porn can do so, and they can easily find whatever it is that sexually excites them. And eventually some of these individuals are bound to become compulsive or addictive with their use of porn.

For a long time, clinicians treating people with porn-related issues found that all (or at least the vast majority) of these clients had a history of early-life trauma – physical neglect, emotional neglect, physical abuse, sexual abuse, covert incest, etc. This put porn addicts in line with alcoholics, drug addicts, compulsive gamblers, and the like. In fact, there is a large body of research showing that unresolved early-life trauma is a huge risk factor for later-life addiction (of all types).

Recently, however, we have encountered a new and rapidly growing subcategory of individuals struggling with pornography. These are individuals who meet the basic criteria used to identify Compulsive Sexual Behavior Disorder (delineated below) but lack the underlying early-life trauma that typically drives an addiction. So, rather than qualifying as traditional trauma-driven porn addicts, it appears these individuals have developed a ‘conditioned’ compulsivity with pornography.

The criteria for compulsive/addictive porn use are as follows:

1. Preoccupation with pornography to the point of obsession, often resulting in the continual objectification of self and others (both real-world and online).
2. Loss of control over the use of pornography, typically evidenced by multiple failed attempts to quit or cut back.
3. Directly related negative life consequences, such as relationship disconnection, issues at work or in school, social and emotional isolation, depression, anxiety, diminished self-esteem, legal woes, financial struggles, poor self-care, loss of interest in previously enjoyable hobbies and activities, etc.

Both categories of struggling porn users (traditional addicts and conditioned compulsives) meet these criteria. But when we look beneath the surface at causes and conditions that underlie the behavior, the two cohorts are very different.

Traditional Porn Addicts

Traditionally, porn addicts are driven by complex (multi-layered) early-life trauma. These individuals learn, usually during childhood and adolescence, that an effective way to escape the pain of their abusive, traumatic, or neglectful upbringing is to numb out and escape through a pleasure-inducing substance or behavior. Sometimes these individuals discover alcohol and drugs; other times they discover masturbation, pornography, video gaming, gambling, and the like. Whatever the substance or behavior, they use it less for having a good time and more to escape emotional discomfort – stress, anxiety, depression, loneliness, boredom, shame, etc.

Traditional, trauma-driven porn addicts seek to control their emotions by ‘escaping’ into pornography. Porn triggers a neurochemical pleasure response that helps them temporarily avoid whatever in-the-moment unpleasant feelings they’re having. Over time, this numbing effect becomes their go-to coping mechanism, no matter what is happening. Basically, they have a feeling, and they automatically and without conscious thought turn to pornography to escape that feeling.

Nearly always, this addictive call and response is developed early in life, with young people seeking to escape the pain of neglect, abuse, inconsistent parenting, and the like through escapist sexual fantasies that are aided and abetted by porn. In other words, traditional, trauma-driven porn addicts repeatedly and compulsively choose to ‘self-medicate’ their emotional discomfort with pornography.

Conditioned/Compulsive Porn Users

This new and rapidly emerging subcategory of people who struggle with porn differs from what we’ve traditionally seen in two significant ways:

1. Conditioned/Compulsive porn users appear to lack the unresolved early-life trauma that typically drives addictive behaviors.
2. Their sex life almost exclusively revolves around pornography (and porn-like online activity such as sexting, camgirls/boys, and mutual masturbation via webcam).

This group of porn users is preoccupied with porn to the point of obsession, they’ve lost control over their use of porn, and they’re experiencing negative consequences related to their porn use. In other words, they absolutely qualify as porn addicts. They do not, however, present with a trauma-driven need to escape from and numb their emotions, as we see with traditional addicts.

So, why does this group turn to porn over and over despite the problems it causes in their lives? As stated earlier, it appears this digital-age group of porn users is more ‘conditioned’ toward compulsivity than traditionally addicted via trauma. Not that traditional addicts aren’t conditioned toward porn. They are. Just as conditioned porn users typically do have some elements of trauma. Sometimes porn use itself can be traumatic, especially for young people who are inadvertently exposed to pornography, and for individuals whose usage escalates to include rape porn, bestiality, child sexual abuse, and the like.

Clearly, there is crossover between traditional porn addicts and conditioned porn users. Moreover, conditioned porn users, if/when their usage escalates in ways that create trauma, can easily move from one category to the other. But often they do not.

Who Are Conditioned/Compulsive Porn Users?

Generally speaking, conditioned porn users start viewing porn at a young age – often before puberty hits – and then they fail to move beyond this easily accessed sexual outlet. For these individuals, porn (and similar forms of online sexuality) serve as both sex education and sexual fulfillment. In such cases, their emotional and psychological development in terms of sexuality and relationships is stunted – beginning and ending with what they learn from porn. As such, their ability to form and maintain meaningful real-world romantic and sexual attachments does not develop or does not fully develop in the usual ways.

Typically, conditioned porn users continue to use porn without recognizing that they may have a problem until they decide they want to have a real-world relationship and realize they have no idea how to go about that. Other times, they recognize that porn might be a problem for them only when they attempt to be sexual with a real person – often someone they care about and find extremely attractive – and find that they can’t perform. We see this most often with young males who, when they try to be sexual with a real person, experience what clinicians refer to as porn-induced erectile dysfunction (PIED).

Conditioned/compulsive responses to porn typically develop because pornography presents no risk of rejection, no risk of sexual failure, and no risk of committing an embarrassing social faux pas. Plus, with porn there are no strange odors or unexpected physical sensations. All that users get with porn is a constant, easily controllable, and constantly changing barrage of hyper-stimulating sexual intensity.

What’s not to like, right?

Over time, these often very young porn users become conditioned to porn to the point where real-world interactions can’t and don’t match up. So porn becomes their go-to sexual outlet, and they get hooked on ‘pixel sex.’ Eventually, as with any compulsive or addictive behavior, this can be highly problematic.

Does the Category Matter?

Many (perhaps most) of the clinicians who treat porn-related issues are unaware of the difference between traditional porn addiction and conditioned/compulsive porn use. This is partly because the two categories, on the surface, look the same, and partly because clinicians have not yet been taught to look for the subtle differences. Thus, they treat all struggling porn users with the same approach and methodology. In the early stages of recovery, this is not an issue, as the same initial interventions are effective with both cohorts. Longer-term, however, because the underlying etiology is significantly different, treatment should also differentiate.

The differential approaches to treatment will be discussed in a future posting to this site. In the interim, if you or someone you know is struggling with either addictive or conditioned/compulsive porn use, I suggest that you visit SexandRelationshipHealing.com for free resources, and SeekingIntegrity.com for information about fully informed professional treatment.

Death and dying? Yup.

Shock, anxiety, and confusion? Yup.

How could this happen? Yup.

Government late to the problem and lacking solutions? Yup.

Raw fear? Yup.

Hospitals overflowing? Yup.

Uncertainty about who is well and who is not? Yup.

Lack of clarity regarding transmission and lethality? Yup.

As gay men of a certain age, my colleague Dr. David Fawcett and I are having some uncomfortably familiar feelings. Déjà vu, if you will. You see, we’ve already lived through a plague – in this country, in our lifetimes. We’ve seen sickness, overflowing hospitals, and death on a mass scale. And to be honest, we were hoping those experiences would occur only once in our lifetimes. But apparently not. Because here we are again.

There was a time, not so long ago, when nearly everyone we knew was afraid of a potentially deadly disease that they didn’t understand, with symptoms that didn’t manifest immediately, sporadic testing, and no cure. It was a time when none of us know who did and who didn’t have a lethal and easily communicable disease. People were dying – quickly, unpleasantly, far too young. We had no idea how to stop the spread, and our government failed to grasp the enormity of what was happening. So we watched helplessly as countless friends and loved ones grew sick and died.

For most of America, the early-1980s were pretty awesome. Wham, Madonna, Whitney, Prince, and Michael. The mall, bright colors, big hair, and all-night dance parties. Other than the constant fear of nuclear holocaust, life was relatively simple. Until the plague. Which not everyone experienced. Many people died or loved someone who died. But much of our nation never got closer to the epidemic than listening to Dan Rather on the evening news.

For the most part, AIDS was viewed as a “gay virus,” and the majority of the American populace was not at risk. Our current plague started in similar fashion, initially labeled the “Chinese virus” by government officials and others who were eager to distance themselves and to declare themselves and other God-fearing Americans as immune to all things bad or painful or deadly. “Not me. Not us. Nothing to worry about here.”

Then we found out COVID-19 is an equal-opportunity disease.

For people who lived through and remember the unimaginable horrors of the AIDS epidemic, the current pandemic is creating some post-traumatic stress symptoms. We remember crossing names out in our address books until there were hardly any names left. We remember going to memorials three times a week. We remember when we were so wounded, so damaged by all the death and dying that we decided we would no longer go to memorials. We simply had no tears left.

We also remember a sense of us and them. In the 1980s, the White House, the social elite, and much of America embraced expensive tastes, extravagant events, gigantic shoulder pads, and a culture of self-absorption. Our favorite TV show was Dynasty. “Greed is good” was more than a line from a movie; it was a mantra. And I have to ask: Are we much different today, with government geared toward the rich, massive drug-fueled ‘circuit’ parties, $1500 skinny jeans, and Keeping Up With the Kardashians?

In the 1980s, it was the ‘4H Club’ that was dying: Homosexuals, Haitians, Heroin Addicts, and Hemophiliacs. Right-wing politicians and religious leaders used this to foster discrimination and stigma, and as the rationale for ignoring the epidemic and letting the disease run its course with little or no intervention. They actually said hateful things like, “AIDS is a punishment from God,” and, “These people brought this on themselves, so why should we try to help?”

With coronavirus, of course, it’s a little different. It’s the ‘E Club’ that’s sick and dying: Everybody. Our grandparents, parents, siblings, children, friends, and neighbors. It’s not just people on the margins. Rich people are getting this disease. Even rich and famous people are getting this disease. Powerful politicians, too, like UK Prime Minister Boris Johnson, who recently spent several days in an ICU as he battled the disease.

In the 1980s, the names of famous people suffering with and succumbing to the pandemic shocked the public into a growing awareness that a plague was truly afoot. Yet there was still a belief that the virus was a problem of “others” that would never hit home for most. This presents yet another parallel with COVID-19, with the federal government and numerous states still failing to enact shelter in place orders and countless people in states with such orders choosing to ignore them and/or protesting against them.

David and I have witnessed firsthand the effects of a plague. During the AIDS epidemic, we both lived in New York City, and we can still picture young men on the streets in the West Village – blind from cytomegalovirus, skin marred with Kaposi’s Sarcoma, frail beyond words, many experiencing dementia. These beautiful, dying men still haunt our dreams. Today, of course, the afflicted gasp their last breath hidden away in ICUs, under anesthesia and quarantined from loved ones. Only the wailing of ambulance sirens and the presence of refrigerated trucks at the delivery bays of hospitals belie the enormity of the still-growing death toll. But make no mistake, people are dying just as fast, if not faster, than we saw at the height of AIDS.

This virus is less discriminating and more easily transmittable than HIV, yet there is still denial among our leaders and much of the population. Parties at the beach, family gatherings, religious celebrations, and plenty of other events are still taking place – sometimes okayed by the state, sometimes not. And this reckless self-absorption is having deadly consequences, not only for those who are reckless but for their loved ones, their friends, and even total strangers.

Surprisingly to us, there are a lot of people who seem to think that nothing like this has ever happened before. But in reality, this is far from new ground. People are getting sick and we’re struggling to test them. People are dying and we don’t know how to stop that. Our hospitals are overflowing and medical personnel are putting their lives at risk to care for those who are ailing. And our leaders are blaming everyone but themselves for the lack of leadership in a time of extreme national crisis. It’s déjà vu all over again.

Maybe this time we’ll learn something.

A Form of Escape

Today, we live in greater stress than most of us have ever experienced, and many of us are reaching to distractions for comfort and escape –TV, overeating, spending, alcohol, drugs, porn, and the like. But how do we know when something has crossed the line from an occasional coping mechanism into compulsivity, dependency, and addiction? To examine this question, let’s look at a growing 21^st century behavior: the use of pornography.

Both research and clinical experience suggest that individuals who’ve ‘crossed the line’ with their use of pornography typically experience one or more of the following issues.

• Shame
• Social and emotional isolation
• Damage to an existing romantic relationship (usually because porn use is seen as a form of infidelity)
• Sexual dysfunction related to the heavy use of pornography
• Ego-dystonic arousal (latent, unwanted arousal patterns revealed through porn)
• Legal issues (related to the use of illegal pornography)

These issues are relatively similar to what we see with people who are compulsive with eating, spending, drinking, drugging, and the like.

Categories of Porn Users

Not every person who uses pornography struggles. For an analogy, consider alcohol. Almost every person, by the time they reach adulthood, has experimented with alcohol. And the vast majority of those individuals do so without incident. They don’t become alcoholic, they don’t make terrible decisions because they drink too much, they don’t ruin their lives and the lives of people around them because of alcohol. However, a small percentage of the individuals who try alcohol will develop problems related to its use. Pornography is the same in this regard. Not every porn user struggles, but some do.

Consider the following story of two porn users.

Marcus and Jeremy, childhood best friends who are now in their early 20s, discovered online porn when they were 12. At that time, they lived in the same upper-middle-class suburb and attended the same school. They both made good grades, played sports, and were starting to get interested in girls. One day after school, Marcus’s older brother told them how they could access an online porn site. Curious and excited about what they might find, they both decided to look at porn that evening for a few minutes before doing their homework.

Since then, Marcus has occasionally viewed porn for sexual stimulation, but he has not demonstrated any signs of compulsivity or loss of control. Mostly he just logs on once in a while and quickly masturbates. And when he is dating a girl he likes, he doesn’t look at porn at all, preferring to stay focused on the real-world partner in his life.

For Jeremy, however, viewing porn after school and again before bed quickly became a regular pattern. By the time he was 14, he was looking at and masturbating to porn for at least an hour every single day. His grades dropped, he isolated himself from friends and family, he quit playing sports, and he lost interest in the girls at his school. Today, porn is ruining his life. He failed out of college, can’t keep a job, hasn’t dated since high school, is having issues with erectile dysfunction, and hates himself.

So, why was Marcus able to experiment with porn and move forward into a healthy life, when Jeremy was in trouble almost from the start? Surely there is some obvious difference between the two, some tell-tale sign of what drove Jeremy but not Marcus into problems.

Unfortunately, there isn’t. You can’t just look at someone and say that he (or she) is or is not likely to struggle with pornography. On the surface, Marcus and Jeremy were so alike they were practically twins. They lived in the same neighborhood, they took the same classes, they earned the same grades, they played the same sports, and they hung out with the same kids. They even started viewing porn on the same website at the same time in their lives. From every outward appearance, there was no way to know that one boy was predisposed to struggle while the other was not.

If we could see beneath the surface, however, we would likely find some important genetic and environmental differences. I will cover these differences – the specific risk factors for struggles with pornography – in a future post to this site. For now, I simply want to note that there are multiple causes for problematic porn use. In this post, I want to focus on the fact that there are three basic categories of porn users. The three categories are as follows:

1. Casual Users: These are individuals who find pornography fun and sexually stimulating, but ultimately not that important. They use porn occasionally but not compulsively. Often, their use of porn is driven by curiosity and novelty. For instance, they might use porn to learn about sex during adolescence. Casual porn users find porn enjoyable but ultimately not as satisfying as real-world sexuality. As such, their interest in porn is not sustained.
2. At-Risk Users: These are individuals who go through periods of intense engagement with pornography, perhaps, at times, using it as a distraction from emotional discomfort and other life issues. However, their porn use does not reach the point where it creates problems. In fact, they will stop using porn if they start to experience (or even see the possibility) of porn-related problems.
3. Problem Users: These are individuals who use porn compulsively or addictively, regardless of potential or actual consequences. Often, they use porn as a way to emotionally numb out. Typically, they find themselves leading a double-life, keeping their porn use separated from the rest of their life – maintaining secrets, telling lies, and justifying their behavior to make it OK in their own mind. They typically lack empathy for those who are negatively impacted by their isolationist porn use. Sometimes they even blame their ‘need’ to use porn on the attitudes and actions of these other people.

In today’s increasingly digital world, porn is accessible to and viewed by all sorts of people – male and female, adults and kids, gay and straight and everything in between. And this happened in what feels like the blink of an eye. One day porn was taboo and hard to find, the next day it was everywhere, easily and anonymously accessible to any person willing to type the word ‘nude’ into an internet search engine. Pretty much anyone who wants to look at porn can do so – anytime, anywhere, free of charge. And people of all ages, genders, sexual orientations, ethnicities, religions, and cultural backgrounds are doing so. Sometimes this results in problems, other times not.

This article is one part in an extended series of posts I am writing about pornography and its impact on users. Feedback is greatly appreciated, so please comment if you feel the urge to do so.

If you or someone you know is struggling with the use of pornography, free help can be found via SexandRelationshipHealing.com, with professional help available through Seeking Integrity.

The good news is that there is plenty of support for recovering addicts (and those who care for them) that does not require in-person attendance. For instance, my own company, Seeking Integrity, has pioneered the use of video in treatment settings, with our clinicians educating and lecturing on a regular basis from all over the world. And Seeking Integrity’s affiliated website, SexandRelationshipHealing.com, provides a vast array of no-cost online resources for addicts, including webinars, drop-in discussion groups, addiction-focused podcasts, and more.

For recovering addicts who would like to stay home as much as possible as we deal with the current pandemic, recovery does not need to take a back seat. In fact, recovering addicts may be able to ramp up rather than scale down their meeting attendance without ever leaving the house. To this end, I suggest the following resources.

Websites with Free Online Resources

IntheRooms.com offers both hosted specialty meetings and more than 130 online 12-step meetings each week (covering pretty much every addiction).

• Hosted specialty meetings can be found at this link.
• Online 12-step meetings and other online support groups can be found at this link.

SexandRelationshipHealing.com offers webinars and drop-in discussion groups for sex addicts, porn addicts, loved ones of addicts, and recovering addicts in general.

Meetings that all populations, regardless of the addiction, typically find helpful include:

• Sex, Love, and Addiction Q&A, hosted by Dr. Robert Weiss, Mondays 5 p.m. PST
• The Wednesday Morning Webinar Series on Addiction, Relationships, and Recovery, Wednesdays 9:30 a.m. PST
• Addiction and Recovery Webinar with Q&A, hosted by Dr. David Fawcett, Wednesdays 5 p.m. PST

12-Step Recovery Online

Twelve-step programs universally offer a large number of phone and video meetings. Each program has its own schedule that can be found on the program’s website. Programs and links are provided below.

Twelve-Step Groups for Chemical Dependency

• Alcoholics Anonymous
• Cocaine Anonymous
• Crystal Meth Anonymous
• Heroin Anonymous
• Marijuana Anonymous
• Narcotics Anonymous
• Nicotine Anonymous
• Pills Anonymous
• SMART Recovery

Twelve-Step Groups for Sex, Porn, and Love Addiction

• Sex Addicts Anonymous
• Sexual Compulsives Anonymous
• Sex and Love Addicts Anonymous
• Sexaholics Anonymous
• Sex and Porn Addicts Anonymous
• Pornography Addicts Anonymous
• Porn Anonymous
• Recovering Couples Anonymous
• Sexual Recovery Anonymous
• SMART Recovery

Twelve-Step Groups for Other Addictions and Issues

• Clutterers Anonymous
• Debtors Anonymous
• Emotional Health Anonymous
• Emotions Anonymous
• Food Addicts Anonymous
• Food Addicts in Recovery Anonymous
• Gamblers Anonymous
• On-Line Gamers Anonymous
• Overeaters Anonymous
• Recoveries Anonymous
• Spenders Anonymous
• Survivors of Incest Anonymous
• Underearners Anonymous
• Workaholics Anonymous

Twelve-Step Groups for Loved Ones of Addicts

• Adult Children of Alcoholics
• Al-Anon
• COSA
• Families Anonymous
• Recovering Couples Anonymous
• S-Anon

Please Share This Resource List

My sincere hope is that recovering addicts and those who care for them will find this list of resources helpful. To this end, I ask you to please share this list with any and all people – addiction therapists, loved ones of addicts, and addicts themselves – who may find it useful. If you wish to repost this article and list of resources on your own website, please do so.

When people hear the word addiction, their typical first thought involves the use of alcohol or drugs. Many are surprised to learn that behaviors can also be addictive. Even those who work in the mental health field sometimes struggle with the concept of behaviors as potentially addictive. As such, there can be a good deal of confusion when it comes to understanding, identifying, and treating behavioral addictions – including increasingly common issues like porn addiction. However, this is largely unnecessary when one understands the basic neurobiology of addiction.

Stated very simply, addictive substances and addictive behaviors trigger the same neurochemical pleasure response. Over time, some individuals can learn to use this response as a form of emotional escape (as a way to distract themselves from emotional discomfort). Eventually, they can become addicted, meaning they use this neurobiological reaction as their go-to coping mechanism for stress, boredom, loneliness, shame, and anything else they’d prefer to not feel. So the only real difference between substance and behavioral addictions is that substance addicts ingest alcohol, nicotine, or some other drug to create a pleasurable and therefore emotionally escapist neurochemical reaction, while behavioral addicts rely on a fantasy or behavior (like viewing porn).

To further understand the link between substance and behavioral addictions, consider a cocaine addict on payday. After receiving his check, he runs to the bank to exchange it for cash, perhaps skipping out of work early to do so. Then he dashes off to his dealer’s house to spend money that he really ought to set aside for food and rent. As he approaches his dealer’s house, his heart races, he’s sweating, and he is so obsessed and preoccupied with using that he doesn’t even notice the police car parked a block away. He is so completely focused on cocaine that the day-to-day world, with all of its problems and obligations, has temporarily receded. From a neurochemical perspective, this individual is high already. It doesn’t matter that there are no actual drugs in his system because his brain is behaving as if there are. He is experiencing an anticipatory high.

This escapist neurobiological state, no matter how it is induced, is the goal with all addictions. Addictions of all types are about the neurobiological manipulation of feelings and emotions, and this can occur with or without an addictive substance. Porn addicts in particular ‘get high’ based more on anticipation and fantasy than anything else. In fact, porn addicts experience a greater sense of emotional escape while searching for the perfect image or video than they get by masturbating to that image or video. Clinicians and addicts even have a name for this escapist dissociation, referring to it as either the bubble or the trance.

This means that porn addiction is not, as most people might expect, about masturbation and orgasm, even though most porn addicts do masturbate and reach orgasm. Instead, porn addiction is about losing touch with reality for an extended period of time. For porn addicts, masturbating and reaching orgasm actually ends the high and throws them back into the real world, where they must once again face life and its many difficulties – which is what they were trying to avoid and escape in the first place.

Porn is not the only behavioral addiction, of course. Others include:

• Gambling: Gambling addiction, also called gambling disorder and compulsive gambling, is an uncontrollable urge to gamble. Typically, gambling addicts will play whatever game is available, though their preference is fast-paced games like video poker, slots, blackjack, and roulette, where rounds end quickly and there is an immediate opportunity to play again.
• Shopping/Spending: Spending addiction, also called oniomania, compulsive spending, shopping addiction, and compulsive buying disorder, occurs when people shop/spend obsessively despite the damage this does to their finances and their relationships.
• Gaming: Video game addiction is the extreme use of computer and video games. Typically, gaming addicts play for at least two hours daily. Sometimes they play four or five times that amount. They often neglect sleep, personal hygiene, diet, relationships, jobs, exercise, financial obligations, and life in general.
• Love/Romance: Love/romance addiction is the compulsive search for the neurobiological rush of early romance (clinically referred to as limerence). Love addicts sacrifice time, health, money, self-esteem, and more in their pursuit of this escapist high.
• Sex: Sex addiction and porn addiction are similar. The primary difference is that sex addicts tend to search for and engage in real-world sexual activity as well as online sexual activity, while porn addicts engage primarily (sometimes exclusively) with porn.
• Social Media: Social media addiction is the obsessive quest to have the most friends or followers on sites/apps like Facebook, Twitter, and Instagram, to have one’s lovingly constructed posts and tweets responded to in positive ways, and to ‘look good’ through an endless series of narcissistic posts. Social media addicts sometimes choose to bypass real-world relationships, recreation, and social engagement for their online life.

Compulsions vs. Addictions

It may seem from the preceding discussion that almost anything can be addictive – substances and behaviors alike. This is not in fact the case. For a substance or a behavior to be addictive, it needs to trigger the experience of pleasure and emotional escape. Without these elements, a behavior may be compulsive, but it does not qualify as an addiction. For instance, compulsive handwashing, though out of control and possibly creating negative consequences, causes neither pleasure nor emotional escape. As such, it is not an addiction. Instead, this behavior is classified as a form of Obsessive-Compulsive Disorder (OCD).

Sobriety Can Look Different for Behavioral Addictions

With substance addictions, sobriety is easily defined – total abstinence. And for some behavioral addictions, like gambling addiction, it’s the same. However, with other behavioral addictions, sobriety may be more about harm reduction than total abstinence. This is the same basic approach that we see with eating disorders. Individuals with an eating disorder don’t stop eating altogether; they just work to eat in healthy ways. This is the approach with sex addiction, as well, though sex addicts who struggle with pornography will generally aim for total abstinence from porn. And porn addicts certainly shoot for total abstinence. Either way, the goal is to eliminate behaviors that create problems while still engaging in healthy ways in naturally occurring human functions.

Behavioral Addictions Can Be Difficult to Identify

Even though porn addiction and other behavioral addictions are in many respects similar to substance addictions, they can be more difficult to identify. After all, they’re easier to hide, they’re (usually) more socially acceptable, and outside observers (even some therapists) don’t always recognize certain behaviors as potentially addictive. As such, behavioral addicts typically must experience serious directly related consequences before anyone is willing to confront them and help them admit they have a problem.

Occasionally, behavioral addictions are uncovered during treatment for substance addiction, depression, or some other psychiatric condition. For instance, a man trying to get sober from alcohol and drugs may find himself compulsively using pornography as a replacement for drinking and drugging, leading to the realization that, for him, the compulsive use of porn is a cross-addiction. More often, however, individuals with behavioral addictions must ‘hit bottom’ before the addiction is uncovered.

Another major obstacle in the identification and treatment of porn and other behavioral addictions is the fact that most people view these issues as being less serious than ‘real’ addictions (i.e., substance addictions). In actuality, nothing could be further from the truth. Porn addiction and other behavioral addictions create the same types and degrees of havoc as substance addictions – relationship trouble, issues at work or in school, declining physical and/or emotional health, isolation, financial woes, loss of interest in previously enjoyable activities, legal trouble, and more.

For more information about the identification and treatment of porn addiction, visit the free resource website SexandRelationshipHealing.com, or the treatment-focused website SeekingIntegrity.com.

A few days ago, I was in a coffee shop and overheard two sisters discussing their grandfather and his recent sexual behaviors. One said, “I was at the grocery with him yesterday and he was hitting on the cashier, who couldn’t have been more than 18 or 19. And it wasn’t just an old man being cute by flirting with a young girl. He was really hitting on her. I was embarrassed, and so was the girl. But Pop-Pop was clueless.” The other sister responded by saying, “It’s weird, isn’t it? Grandma told me she caught him looking at porn on the internet the other day, and she said it’s not the first time, either. Do you think this might be some weird symptom of his Parkinson’s Disease?”

If you are wondering, Parkinson’s Disease (PD) is a neurodegenerative disorder that affects dopamine producing neurons in the substantia nigra region of the brain. Essentially, dopamine producing cells die off, reducing dopamine levels in the brain. Because dopamine impacts movement (as well as pleasure and various other elements of the central nervous system), people with PD often experience physical tremors, usually starting in one or sometimes both hands. Other symptoms include slow movement, stiffness, and loss of balance.

Sexual dysfunction is another common issue. People with PD often experience a lack of sexual desire, erectile dysfunction, vaginal dryness, and difficulty reaching orgasm. Some of this may be psychological – perhaps related to the depression that often accompanies PD. But physical issues are also in play. For starters, dopamine, the production of which is significantly diminished with PD, is, as noted above, related to our experience of pleasure, potentially resulting in lowered sexual desire. Dopamine is also related to smooth motor function within our bodies, making sexual activity considerably more difficult and potentially less enjoyable.

Oddly, however, some people with PD become hypersexual rather than sexually bereft, as we see with Pop-Pop in the story above. Research tells us that this hypersexual behavior is related not to PD itself, but to medications used to treat it. In particular, therapies involving dopamine agonist drugs tend to be the culprit. (More on this later.)

So here we are with a (usually middle-aged or older) person suffering from PD, and that individual starts to behave sexually like a drunken teenager. Or a sex addict. They make inappropriate statements and advances, they spend all kinds of money in strip clubs and with prostitutes, they view porn for hours on end, and they masturbate to the point of physical injury. And these are people who were not in any way hypersexual prior to receiving certain PD meds. This means that they are not sex or porn addicts and should not be treated as such.

And it’s not just hypersexuality that PD patients experience. PD meds can induce a wide variety of impulsive and compulsive behaviors, such as pathological gambling, compulsive eating, and compulsive spending (Vilas, Pont-Sunyer & Tolosa, 2012). Research suggests that impulsive/compulsive behaviors of this sort are triggered in 1 out of 7 PD patients (Weiss & Marsh, 2012). Research also tells us that hypersexuality and other impulse control issues in PD patients can lead to significant financial loss and psychosocial morbidity for both patients and families (Vilas, Pont-Sunyer & Tolosa, 2012; Weiss & Marsh, 2012).

As stated above, the most common cause for this appears to be dopaminergic therapies that involve dopamine agonists. Dopamine agonists are drugs that activate dopamine receptors. They do not cause the production of dopamine, nor do they replace dopamine in the brain. They simply activate dopamine receptors, and the receptors then send signals throughout the brain as if they’ve just received a hit of dopamine.

Weiss and Marsh (2012) have also found that impulse control issues in PD patients tend to resolve if the dopamine agonist is withdrawn and PD symptoms are managed solely with the amino acid known as levodopa (more commonly referred to as L-Dopa). So it’s becoming more and more clear that dopamine agonists are the cause of hypersexuality, compulsive gambling, and other impulse control issues in PD patients. Unfortunately, the pathopsychological basis for this is, as yet, unknown, so short of removing the dopamine agonist drug (which often is working well with the PD symptoms), we are unable to mitigate the impulsivity/compulsivity side effects.

NOTE: The similarities we see between medication-induced hypersexuality in PD patients and sex addicts (and in fact all addicts) suggests there may be neurobiological commonalities that could help us better understand both PD and addiction, potentially developing more effective treatment methodologies for both (Politis et al, 2013). Of particular importance here is the concept of incentive salience, where the ‘wanting’ of the stimulus is more important than the actual reward from the stimulus. This factor arises with both PD (Berridge, 2007; Berridge, 2012) and sexual addiction (Mechelmans et al, 2014; Voon et al, 2014).

At this point, we do not know why some PD patients become hypersexual or otherwise impulsive or compulsive, while others on the same medications do not. It is possible that a propensity toward these behaviors in some way exists prior to the use of dopamine agonists, but at this point we cannot say for certain one way or the other. And if there are premorbid factors or biomarkers, we have no idea, as of now, what they are. If we did, we could refrain from using dopamine agonists in susceptible patients.

For now, it is important that clinicians who treat and work with PD patients, and also clinicians who treat and work with people who suffer from addiction (especially sex, gambling, and spending addiction) are aware of the potential side effects seen with dopamine agonists. PD clinicians should look for and ask about signs of impulsivity and compulsivity in their patients, and if those signs are spotted, a corresponding action (most likely the withdrawal of dopamine agonist drugs) should be taken. At the same time, addiction specialists should inquire about medications their clients are taking, and if dopamine agonists are part of the mix (for PD or, perhaps more likely, for restless leg syndrome), that should be looked at and addressed.

I do want to be clear here: I am not arguing against the use of dopamine agonists when it appears those drugs will help individuals with PD and similar disorders. I am simply saying that clinicians who work with PD and addiction should be aware of the potential side-effects of dopamine agonist drugs, and should monitor all patients on these drugs closely, knowing that behaviors that look impulsive/compulsive may be more about a medication than an individual’s psychological health.

References

Berridge, K. C. (2007). The debate over dopamine’s role in reward: The case for incentive salience. Psychopharmacology, 191(3), 391-431.

Berridge, K. C. (2012). From prediction error to incentive salience: Mesolimbic computation of reward motivation. European Journal of Neuroscience, 35(7), 1124-1143.

Mechelmans, D. J., Irvine, M., Banca, P., Porter, L., Mitchell, S., Mole, T. B., … & Voon, V. (2014). Enhanced attentional bias towards sexually explicit cues in individuals with and without compulsive sexual behaviours. PloS one, 9(8), e105476.

Politis, M., Loane, C., Wu, K., O’Sullivan, S. S., Woodhead, Z., Kiferle, L., … & Piccini, P. (2013). Neural response to visual sexual cues in dopamine treatment-linked hypersexuality in Parkinson’s disease. Brain, 136(2), 400-411.

Vilas, D., Pont-Sunyer, C., & Tolosa, E. (2012). Impulse control disorders in Parkinson’s Disease. Parkinsonism & related disorders, 18, S80-S84.

Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., … & Irvine, M. (2014). Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PloS one, 9(7), e102419.

Weiss, H. D., & Marsh, L. (2012). Impulse control disorders and compulsive behaviors associated with dopaminergic therapies in Parkinson disease. Neurology: Clinical Practice, 2(4), 267-274.