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Archives of Sexual Behavior

, Volume 48, Issue 2, pp 397–415 | Cite as

Pornography Problems Due to Moral Incongruence: An Integrative Model with a Systematic Review and Meta-Analysis

  • Joshua B. GrubbsEmail author
  • Samuel L. Perry
  • Joshua A. Wilt
  • Rory C. Reid
Target Article

Abstract

The notion of problematic pornography use remains contentious in both academic and popular literature. Although the mental health community at large is divided as to the addictive versus non-addictive nature of Internet pornography, substantial numbers of individuals report “feeling” as if their use of Internet pornography is problematic. The present work seeks to construct a model related to problematic pornography use that is clearly derived from empirical literature and that provides directions to be tested in future research. The focus of the present work is on those perceptions as they relate to the overarching experience of moral incongruence in pornography use, which is generally thought of as the experience of having one’s behaviors be inconsistent with one’s beliefs. To this end, we put forth a model of pornography problems due to moral incongruence. Within this model, we describe how pornography-related problems—particularly feelings of addiction to pornography—may be, in many cases, better construed as functions of discrepancies—moral incongruence—between pornography-related beliefs and pornography-related behaviors. A systematic review of literature and meta-analysis is conducted in order to evaluate support for this model, and the implications of this model for research and clinical practice are discussed.

Keywords

Pornography Addiction Morality Compulsive sexual behavior Religion ICD-11 DSM-5 

Introduction

The use of Internet pornography (hereafter IP) is highly contentious both in academic (Hilton Jr., 2013; Hilton Jr. & Watts, 2011; Ley, Prause, & Finn, 2014; Prause, 2017; Prause, Steele, Staley, Sabatinelli, & Hajcak, 2015; Voros, 2009) and in popular (Foubert, 2016; Ley, 2012, 2016; Luscombe, 2016; Struthers, 2009; Wilson, 2014) circles. Some have claimed that pornography is an inherently addictive form of media that inevitably promotes compulsivity and dysregulation (Hilton Jr., 2013; Struthers, 2009; Wilson, 2014), while others have argued that there is no evidence for these assertions (Ley, 2012; Prause, 2017). These controversies are further complicated by recent works which have highlighted varying issues around the appropriate understanding and classification of compulsive sexual behaviors (Humphreys, 2018; Kraus et al., 2018; Kraus, Voon, & Potenza, 2016b; Potenza, Gola, Voon, Kor, & Kraus, 2017; Reid, 2016) and by the proposed diagnosis of compulsive sexual disorder (under consideration for the ICD-11), which specifically notes that impairment around seemingly compulsive sexual behaviors may be due to other causes such as moral judgments (Kraus et al., 2018).

Despite these debates, there is clear consensus that pornography use may be problematic at times (Duffy, Dawson, & das Nair, 2016; Gola et al., 2016b; Harkness, Mullan, & Blaszczynski, 2015; Short, Black, Smith, Wetterneck, & Wells, 2012; Twohig, Crosby, & Cox, 2009), that some individuals report severe, life-altering consequences as a result of their patterns of use (Gola & Potenza, 2016; Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015; Twohig et al., 2009), and that some people self-identify as being addicted to IP (Cavaglion, 2008). In response to this discrepancy, we have sought to construct and evaluate a new model that may assist in interpreting pornography addiction literature, with a specific focus on how moral incongruence—broadly, the experience of engaging in activities that violate one’s deeply held moral values—may lead to self-perceived problems stemming from pornography use. In support of this model, we have conducted a historical review of literature salient to pornography addiction, as well as a systematic review and meta-analysis specifically testing the tenets of our model. We begin below by first considering the historical context of pornography addiction in academic literature.

History of Problematic Pornography Use

Psychological literature has considered problematic pornography for several decades, with case reports of pornography addiction and similar disorders appearing as early as the 1980s (Brod, 1988; Robison, 1982; Schneider & Schneider, 1990), and a US Attorney General’s report on the supposed harms of pornography emerging around the same time (United States Attorney General’s Commission, 1986). However, with the advent of the Internet in the mid-1990s, research related to pornography use proliferated quickly, and the dangers of IP were decried in both popular (Ullman, 1998) and academic (Cooper, 1998) literature. This negative attention was common enough that, by the early 2000s, commentaries (Barak, Fisher, Belfry, & Lashambe, 1999; Fisher & Barak, 2001; Stern & Handel, 2001) had emerged urging psychology and related fields to take a more neutral, investigative stance toward IP, rather than embracing the seemingly anti-pornography zeitgeist of the time.

Much early work on the potential dangers of IP relied primarily on the work of Cooper and others (Cooper, 1998; Cooper, Putnam, Planchon, & Boies, 1999; Delmonico & Carnes, 1999) who proposed the “Triple-A Engine” as a possible explanatory model for why the Internet might often lead to a pornography problem. Specifically, IP (unlike conventional venues for pornography, such as an adult bookstore) provided Accessibility, Affordability, and Anonymity when viewing online sexual materials, in a way that no previous sexual media had done. These characteristics of IP ostensibly led to a greater frequency in viewing sexual material online, and a greater potential for addictive use for some individuals (Cooper, Delmonico, & Burg, 2000). Although theoretically intuitive in its alliterative appeal, the Triple-A Engine was not without critics. Shortly after being proposed, various limitations were noted (Barak & Fisher, 2001, 2002), and the only empirical study attempting to test the model (Byers, Menzies, & O’Grady, 2004) found it was unsupported by available data. Even so, this model is still uncritically cited in even very recent research (Ahmad et al., 2015; Giordano & Cashwell, 2017; Kühn & Gallinat, 2014; Lykke & Cohen, 2015) and is still often touted in popular media as evidence for the inherently addictive nature of IP (Salzman, 2017).

Moving beyond Cooper’s early work, Young (2008) proposed a five-stage model of online sexual addiction, in which users progressed from (1) discovering online sexual materials (i.e., pornography) to then (2) experimenting with such materials, followed by (3) escalating the use of IP until (4) reaching state of addiction and fixation, ultimately (5) culminating in feelings of deep hopelessness. Although supported by case reports and examples, much like Cooper’s Triple-A engine, Young’s model was primarily theoretical in nature, with little (if any) empirical effort being made to test its tenets in larger-scale, quantitative inquiries.

More recently, problematic pornography use emerged as a potentially important form of hypersexual behavior (Kafka, 2010). Specifically, in field trials for the development of the DSM-5, the most commonly reported problem associated with the tentative hypersexual disorder diagnosis was problematic pornography use (Reid et al., 2012). Although the diagnosis of hypersexual disorder was highly controversial (Halpern, 2011; Moser, 2011; Reid & Kafka, 2014) and ultimately left out of the final version of the manual (Kafka, 2014), the prevalence of pornography-related problems in the field trial for the diagnosis speaks to its persistent presence within mental and sexual health fields more broadly.

At present, the diagnosis of compulsive sexual behavior disorder is under consideration for inclusion in the ICD-11 (Kraus et al., 2018). This diagnosis would likely subsume the notion of pornography addiction or compulsive pornography use, though it is much broader—including a wide range of sexual behaviors. However, at present, this diagnosis has yet to be formally included in the ICD-11. Furthermore, this diagnosis includes specific exclusions for certain types of distress related to sexual behaviors (e.g., moral judgments or disapproval), which is particularly relevant to the present work, as we will examine later.

Current State of Affairs

Ultimately, despite the aforementioned theories and lines of research, the mental health community has been slow to recognize pornography addiction or problematic pornography use as a clinical disorder (Duffy et al., 2016; Sniewski, Farvid, & Carter, 2018). Even so, a plethora of popular books (Foubert, 2016; Fradd, 2017; Struthers, 2009; Wilson, 2014), self-help guides (Brandenburg, 2015; Park, 2014), Internet communities (“NoFap.com,” 2017; “Reboot Nation,” 2017), and even web-filtering software program (“Covenant Eyes,” 2017; “Net Nanny,” 2017; “X3Watch,” 2017) have appeared over the past two decades, all claiming to address some aspect of the purported epidemic of pornography addiction. There are also seemingly countless stories on a variety of self-help websites (“Fight the New Drug,” 2017; “Your Brain On Porn,” 2017), detailing individuals’ reported struggles with pornography addiction.

In line with popular attention to the topic, numerous studies conducted over the past several years have noted that many individuals report feeling addicted to IP. Prior works have studied self-help communities for self-identified IP addicts, noting that they have active and engaged memberships, filled with people who believe themselves to be addicted to pornography (Cavaglion, 2008); a number of papers have highlighted that individuals often report feeling out of control (Grubbs, Sessoms, Wheeler, & Volk, 2010; Stein, Black, Shapira, & Spitzer, 2001) or compulsive (Cooper et al., 2000; Kraus, Rosenberg, Martino, Nich, & Potenza, 2017) in their use of pornography; and mental health providers often report encountering IP addiction in their clients (Kalman, 2008; Kraus, Martino, & Potenza, 2016a; Mitchell, Becker-Blease, & Finkelhor, 2005; Short, Wetterneck, Bistricky, Shutter, & Chase, 2016). In short, there is considerable evidence that a number of people report having an addiction to or problems with pornography that the mental health community does not currently recognize at large.

Toward an Integrative Model

Given the data reviewed above, questions remain about why a large number of individuals self-identify as addicted to or experiencing problems related to pornography use, particularly given the lack of scientific consensus on the topic and the absence of any objective criteria for such a purported addiction. Conceivably, the general public may have more insight into the nature of pornography use than the scientific community; or, perhaps, the scientific community is simply slow to recognize what the public already knows. However, we would argue that there may be a more nuanced explanation. Specifically, we posit that there is evidence of multiple pathways by which someone might find the use of pornography to be problematic.

The central argument of the present work is that problems related to pornography use may arise from two distinct, but possibly related, pathways. This model is illustrated in Fig. 1. In the first pathway, pornography-related problems and distress can be seen as the by-product of dysregulated pornography use itself. Compulsive or extreme use of pornography is well documented in various studies, and, despite the controversies in the field on whether or not pornography addiction is a “real” disorder, it is abundantly clear that some individuals do experience dysregulation in their use of pornography (e.g., Gola & Potenza, 2016; Kraus et al., 2015). It stands to reason that, should an individual actually be experiencing such dysregulation, self-perceived problems around pornography use would be a natural result. Similarly, even in the absence of such self-insights, we would expect such dysregulation to be associated with distress itself, allowing for a potentially direct pathway from dysregulated use to distress. This contention flows from other literature on out-of-control behavior patterns noting that behaviors may be impairing or distressing, regardless of self-insights into the problematic behavior. More to the point, an individual might deny or be unaware of the links between their behaviors and their distress, even when such links are apparent from careful assessment.
Fig. 1

Summary of proposed pathways by which pornography use may be experienced as problematic. Bold pathway to the right of the figure represents the proposed model of pornography problems due to moral incongruence

This first pathway is not the primary interest of the present model, as numerous prior models have provided insights into how dysregulation around sexual behavior may lead to addictive or compulsive behaviors patterns and distress (for example, the “Sexhavior Cycle,” Walton, Cantor, Bhullar, & Lykins, 2017) or how Internet behaviors may become dysregulated (for example, the I-PACE model; Brand, Young, Laier, Wölfling, & Potenza, 2016). However, we are particularly interested in proposing and evaluating a model of pornography problems due to moral incongruence, which we have highlighted in the second pathway in Fig. 1. In this model, we posit that moral disapproval of pornography use among pornography users is likely to lead to the experience of moral incongruence, which, in turn, leads to perceived problems associated with pornography use. Ultimately, both incongruence itself (in that feeling as if one’s values and behaviors are out of alignment can be distressing; Perry, 2017) and perceived problems arising from moral incongruence may lead to the experience of psychological distress.

There is considerable evidence that many people maintain strong moral—often religiously based1—prohibitions to the use of pornography, while still using pornography (Perry, 2018; Whitehead & Perry, 2018). More simply, many people experience moral incongruence between their beliefs about pornography and their pornography-related behaviors (Grubbs & Perry, 2018). In prior works on problematic pornography use (e.g., Grubbs, Exline, Pargament, Hook, & Carlisle, 2015a), the links between self-perceived pornography-related problems and moral incongruence were readily apparent. Whereas historically (Grubbs et al., 2015a; Grubbs, Stauner, Exline, Pargament, & Lindberg, 2015c), we conceptualized some forms of problematic use of pornography as problems of perceived addiction (rather than actual pornography addiction per se), our current contention is that the more parsimonious explanation for these phenomena are problems of moral incongruence (Grubbs & Perry, 2018). More simply, as we review below, perceived addiction (as it has been considered in prior literature) is often likely functioning as a proxy for more general views of pornography use as problematic due to feelings of moral incongruence. As such, we are proposing a shift away from the language of “perceived addiction,” instead focusing on pornography problems due to moral incongruence.

As the scientific community is still divided on the correct conceptualization of problematic pornography use, we do not assume the present model will resolve this debate. However, it is reasonable to conclude that, for many individuals—particularly in population- or community-based studies (as opposed to clinical samples of treatment-seeking individuals)—feelings of addiction, dysregulation, or disruption may be better understood as a function of distress (e.g., shame, feeling discouraged, depressed, anxious) about incongruence between sexual behavior and moral beliefs, rather than actual dysregulation or addiction to pornography. As such, rather than focusing on objective behaviors that may or may not indicate behavioral dysregulation, our focus herein will be on the experience of pornography-related problems arising from moral incongruence (hereafter PPMI,   pornography problems due to moral incongruence).

Importantly, we intend this model not only as a guidepost for future research, but also as a means of enhancing clinical care in mental health settings. As evidenced by the specific exclusion of self-perceived problems with compulsive sexual behaviors due to moral judgments from the proposed ICD-11 diagnosis of compulsive sexual behavior disorder (Kraus et al., 2018), this is a phenomenon that is clinically relevant and likely to be of importance when seeking to accurately diagnose and treat individuals reporting problems with compulsive sexuality. Regardless of whether an individual actually experiences excessive pornography use (e.g., addiction) or PPMI, we acknowledge both clinical presentations can be associated with emotional pain, psychological suffering, and significant interpersonal consequences. It is for this reason we advance our model of PPMI as an alternative conceptualization to help illuminate what the focus of clinical attention should be. By delineating the difference between objective behavioral dysregulation and PPMI, we hope to help guide clinicians in deciding between therapy that strives for behavioral modification of excessive levels of pornography use or, instead, strives for resolution of internal conflict related to moral incongruence while avoiding reinforcing perceptions that the pornography use itself is pathological or addictive.

Review of Evidence in Support of the PPMI Model

In evaluating the evidence for or against our proposed model of PPMI, the first and most relevant considerations are those factors that might contribute to the development and maintenance of such self-perceptions. Below, we review prior literature examining these factors. Should our model be accurate, we would expect to find that religiousness would directly predict moral incongruence about pornography use. We would further expect to find that self-perceptions of problems associated with pornography use would often be predicted better by moral incongruence or religiousness (which may serve as a proxy for moral disapproval of pornography use, thereby implying moral incongruence) than by pornography use itself.

To test our proposed model, we conducted a systematic review and meta-analysis of published works examining aspects of the primary links associated with PPMI using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher, Liberati, Tetzlaff, & Altman, 2009). Specifically, we examined literature related to our contentions that (1) religiousness predicts greater moral incongruence in pornography users, (2) that pornography use is related to self-perceived problems, (3) that religiousness is associated with self-perceived problems associated with pornography use, and that (4) moral incongruence is the strongest predictor of self-perceived problems associated with pornography use.

Records were identified via searches on Academic Search Complete, Academic Search Premier, MEDLINE, Psychology and Behavioral Sciences Collection, PsycINFO, SocINDEX, CINAHL, and PubMed. All searches included the initial term, “pornography,” as well as either “problem*” or “addiction” and “religio*” or “moral*” (e.g., a total search phrase may look like: “pornography + addiction + religio*” or “pornography + problem* + moral*”). We additionally identified potentially relevant articles via review of references in related papers. The details of these searches are described via the flowchart in Fig. 2. We reviewed any manuscripts that directly addressed pathway 2 of Fig. 1. That is, we only reviewed manuscripts that specifically assessed relationships between pornography problems2 and either religiousness or moral incongruence. Below, we summarize the findings of our systematic review in narrative form and conclude with a meta-analysis of key effects (e.g., links between religiousness and moral incongruence, links between pornography use and perceived problems, links between religion and perceived problems, and links between moral incongruence and perceived problems).
Fig. 2

PRISMA flow diagram demonstrating the article selection process for the included systematic review and meta-analysis testing our proposed model of pornography problems due to moral incongruence

Religion and Moral Incongruence

According to our model, religiousness should be a consistent contributor to moral incongruence around pornography use. For many individuals, religious beliefs and teachings may lead them to ardently oppose the use of pornography, in any form or amount (Lambe, 2004; Lykke & Cohen, 2015; MacInnis & Hodson, 2016; Thomas, 2013, 2016). Religious individuals also tend to report substantially less use of pornography (Hardy, Steelman, Coyne, & Ridge, 2013; Perry, 2015; Perry & Hayward, 2017; Rasmussen & Bierman, 2016; Wright, 2013; Wright, Bae, & Funk, 2013). Even so, religious people still use pornography with some frequency (Grubbs et al., 2015a; Nelson, Padilla-Walker, & Carroll, 2010; Patterson & Price, 2012), with some analyses finding more pornography purchases (Edelman, 2009) or Google searches for porn (MacInnis & Hodson, 2015; Whitehead & Perry, 2018) in religious locales than in non-religious locales. By nature then, this pornography use among those who disapprove of such use implies moral incongruence, which is a contention supported by published literature as reviewed below.

Review of Evidence

A number of studies empirically confirm our proposed link between religiousness and moral incongruence around pornography use. For example, in a study of adults in the U.S. (N = 252, 50% women, Mage = 36.8, SD = 12.7), among pornography users, religiousness (measured as the aggregate of religious identity and religious importance) was positively associated (r = .39) with feelings of moral incongruence (as indicated by ratings of feelings of guilt after use) over pornography use (MacInnis & Hodson, 2016).

Moving further, in two samples of undergraduates who acknowledged pornography use in the past six months (Study 1, N = 331, 68.8% men; Mage = 19.5, SD = 1.9; Study 2, N = 97, 51% men; Mage = 19.5, SD = 1.3), religiousness was quite strongly associated (Study 1, r = .57; Study 2, r = .57; Grubbs et al., 2015a) with reported moral incongruence (measured as moral disapproval of pornography among pornography users). In the same work (Grubbs et al., 2015a, Study 3), among adults who acknowledged pornography use in the past month (N = 208; 65% men; Mage = 31.8, SD = 10.6), the association between religiousness and moral incongruence was very strong (r = .68). In a more recent analysis (Grubbs, Wilt, Exline, Pargament, & Kraus, 2018b) of pornography consumers (undergraduates, N = 1507, 65% men, Mage = 19.3, SD = 2.2; and adults, N = 782; 49% men, Mage = 32.6, SD = 10.3), comparable effect sizes were again found (undergraduates, r = .58; adults, r = .68), with religiousness being strongly associated with moral incongruence. Finally, in another sample of Internet-using adults in the U.S. (N = 358, 52.2% men; Mage = 34.1, SD = 10.6; Volk, Thomas, Sosin, Jacob, & Moen, 2016), religiousness (measured as religious commitment via the Religious Commitment Inventory) was substantively associated with greater moral incongruence around pornography use (moral disapproval of pornography by pornography users; r = .49). Collectively, these findings point toward a robust association between religiousness and moral incongruence regarding pornography use.

Pornography Use and Perceived Problems

If the present model is correct in contending that many individuals experience pornography-related problems due to moral incongruence, rather than due to use itself, we would expect to find only a small-to-moderate relationship between frequency or quantity of pornography use and perceived problems. Whereas using some pornography is likely a prerequisite for PPMI (there must be some morally incongruent behavior), the quantity or frequency of use should not be the primary predictor associated with use. As such, we should expect to find a relationship between use of pornography and perceived problems, but these findings should be small in magnitude, particularly when compared to links between moral incongruence and perceived problems. Such an expectation is largely confirmed by existing literature.

Review of Evidence

The presence of a consistent but small link between pornography use and perceived problems is apparent in a wide variety of samples and measurement methods. For example, in two samples of undergraduates who acknowledged pornography use in the past six months (Study 1, N = 331, 68.8% men; Mage = 19.5, SD = 1.9; Study 2, N = 97, 51% men; Mage = 19.5, SD = 1.3), perception of having a problem with pornography and actual use were again positively, but only moderately, correlated (i.e., Study 1, r = .30; Study 2, r = .35; Grubbs et al., 2015a). In the same work (Grubbs et al., 2015a, Study 3), among adults who acknowledged pornography use in the past month (N = 208; 65% men; Mage = 31.8, SD = 10.6), the correlation between having a perceived problem (measured by the CPUI-9) and daily pornography use was again significant, but small in magnitude (r = .19). In a more recent analysis (Grubbs et al., 2018b) of pornography consumers (undergraduates, N = 1507, 65% men, Mage = 19.3, SD = 2.2; and adults, N = 782; 49% men, Mage = 32.6, SD = 10.3), comparable effect sizes were again found (Study 1, r = .18; Study 2, r = .22), with average daily use of pornography being only weakly correlated with experiencing perceived problems related to pornography (for secondary analyses of these same samples, see also: Grubbs, Exline, Pargament, Volk, & Lindberg, 2017a; Wilt, Cooper, Grubbs, Exline, & Pargament, 2016).

These findings have been replicated in other research groups as well. In a sample of Internet-using adults in the U.S. (N = 686, 51% men, Mage = 28.54, SD = 7.85), pornography use frequency (7-point ordinal scale: about once a year or lessdaily) was again positively, but weakly (r = .18), correlated with perceptions of pornography-related problems (measured by a modified version of the Kalichman Sexual Compulsivity Scale; Leonhardt et al., 2018). Furthermore, in another sample of Internet-using adults in the U.S. (N = 358, 52.2% men; Mage = 34.1, SD = 10.6; Volk et al., 2016), pornography use in the past six months (5-point ordinal scale, 0 timesmore than 10 times) was again positively correlated (r = .20) with feeling dysregulated in one’s use of pornography (as measured by the CPUI-9).

Moving beyond the U.S., there are similar results. In a large sample of Swedish adults (N = 1913; 65% women; Mage = 28.4, SD = 10.9), Internet sexual problems (e.g., “I feel that I have become addicted to the Internet for love- and sexual purposes.”) were significantly predicted by frequency of IP use, even when other relevant variables (e.g., gender, frequency of masturbation, past history of pornography-related negative experiences) were held constant (via multiple regression; however, the individual effect in this relationship was not provided). In a sample of men from the community and men seeking treatment for problematic pornography use (N = 428, Mage = 28.7, SD = 6.4; Gola, Lewczuk, & Skorko, 2016a), pornography use (average use in minutes per week) was again positively correlated (r = .41) with perceptions of pornography-related problems, compulsivity, and disruption. Additionally, in a sample of women (N = 719) in Poland (Lewczuk, Szmyd, Skorko, & Gola, 2017), associations between pornography use and perceived problems associated with such use (as measured by the SAST-R) were notably larger (r = .45). In both of these examples, however, it is important to note that samples included individuals seeking treatment for their self-perceived problematic pornography use and those that were not seeking treatment, which may account for these notably larger associations between use and perceptions of pornography-related problems.

Finally, in a sample of young adult men in Malaysia (N = 76, Mage = 22.3, SD = 3.4; 100% men), correlations between pornography use (measured by frequency of use over previous 14 days) and feeling addicted or dysregulated in one’s use (measured by CPUI-9) were again positive and moderate in size (r = .32, Fernandez, Tee, & Fernandez, 2017). Collectively, these cross-sectional results across studies suggest that pornography use is uniquely and importantly related to the experience of believing one is addicted, though it seems that the effect of quantity or frequency of pornography use on the perception one is experiencing problems is consistently only small to moderate in size. This conclusion is also supported by limited longitudinal work.

In a 1-year follow-up to a previously described study of both undergraduates and web-using adults (one-year follow-up: students, N = 146; adults, N = 211), average daily use of pornography at baseline (measured as average daily use in hours) was not significantly related to feelings of dysregulation or self-perceptions of problematic use (measured by the CPUI-9) or any of its sub-facets a year later (Grubbs et al., 2018b). There were no significant links between baseline pornography use and feelings of dysregulation or compulsivity over time, whether or not pornography use was examined alone or in conjunction with other plausible predictors. Similarly, in a two-week, longitudinal follow-up to a previously described sample (Fernandez et al., 2017; N = 76), there were positive links between baseline pornography use and self-perceptions of problematic use (as measured by the CPUI-9) over a two-week period (r = .34), though these associations were reduced to insignificance when the role of baseline perceptions of problematic use (among other variables) was held constant statistically (b = .03, p < .32). Such findings are consistent with our model; namely, whereas there are clear links between current use of pornography and the perception that one is experiencing pornography-related problems, the amount of pornography use itself may not be the most salient causal or driving factor in such perceptions.

Religion and Perceived Problems

Moving beyond pornography use itself, should our model of PPMI be accurate, we would expect to find religiousness to be a consistent predictor of perceived problems associated with pornography use. Early theoretical works posited that religious men often report experiencing any amount of pornography use as pathological processes indicative of addiction (Kwee, Dominguez, & Ferrell, 2007). In such populations, it seems that failure to abstain from any pornography use may be interpreted as evidence of dysregulation and compulsivity, despite the objectively small amount of use (Kwee et al., 2007). Additionally, religiousness is often a motivation for seeking therapy among pornography users (Lewczuk et al., 2017; Ross, Månsson, & Daneback, 2012; Twohig et al., 2009; Winters, Christoff, & Gorzalka, 2010). Furthermore, narrative analyses of religious periodicals have demonstrated that part of the popular culture’s attention to pornography addiction seems to have primarily arisen from conservative religious communities in response to the growing popularity of pornography (Thomas, 2013, 2016). Given these strict mores around pornography use, it is very possible that religious users of pornography might be experiencing profound moral difficulty with their own behaviors. More succinctly, it is plausible that some religious individuals consuming pornography may self-identify as experiencing pornography-related problems because they have failed to completely abstain from any viewing of sexual content. Below, we examine this link in our model via our systematic review.

Review of Evidence

A number of studies demonstrate links between religiousness and perceived problems associated with pornography use. For example, comparisons between students at a private, non-religious university (N = 145; Mage = NA; 65% men) and students at a private, religiously affiliated university (N = 127; Mage = NA; 80% men) found that students at the religiously affiliated university consistently reported much higher rates of feeling compulsive in (Cohen’s d = .570) and distressed by their use of pornography, despite lower rates of use (Sessoms, 2011). Similarly, analyses (Levert, 2007) of Christian versus non-Christian men who consumed pornography (N = 416; Mage = 38.5) found a disproportionate number of religious men (30.6%) reported feeling compulsive in their pornography use compared to much smaller proportions of non-religious men (14.7%; χ2 = 15.01, p < .001). More recently, among adult pornography users (N = 713; 52% men; Mage = 30.2, SD = 9.9), religious belief (belief in the existence of a god) was a consistent predictor of perceived pornography-related problems (as measured by the CPUI-9; r = .24), demonstrating that non-believers consistently reported lower levels of pornography-related problems (Bradley, Grubbs, Uzdavines, Exline, & Pargament, 2016).

Moving further, in very early empirical work on this topic (N = 125; 100% men; Mage = 20.67 SD = 4.51), religiousness (aggregation of religious involvement, personal importance of religiousness, and religious social engagement and support) demonstrated positive associations with greater perceived problems associated with pornography use (measured by the Cyberporn Compulsivity Scale), although these associations were small (r = .20, Abell et al., 2006). Since this initial work, these links between religiousness and perceptions of addiction have been confirmed repeatedly in a variety of studies.

In a qualitative study of undergraduate men (N = 84, Mage = 22, SD = not reported), there were notable associations between pornography use and feelings of religious concerns (Twohig et al., 2009). Specifically, in this sample, 66% of young adult men who viewed pornography reported concerns about that behavior being inconsistent with their religious beliefs. In a previously reviewed sample of Swedish adults (Ross et al., 2012), Internet sexual problems were significantly predicted by personal religiousness (e.g., “How religious are you?”), even when gender, frequency of masturbation, pornography use, and prior negative experiences with online sexual behaviors were all held constant. Even so, the individual effect of religiousness on such problems was not reported.

Across three previously described samples (Grubbs et al., 2015a), religiousness (aggregate of religious participation and religious belief salience) was consistently positively and substantially related to perceived problems related to pornography (as measured by the CPUI-9; Sample 1, N = 331, r = .25; Sample 2, N = 97, r = .35; Sample 3, N = 208, r = .48). Similarly, more recent samples (Grubbs et al., 2018b) of both undergraduates (Sample 1, N = 1507) and adults (Sample 2, N = 782) have again found significant and substantial associations between religiousness (aggregate of religious participation and religious belief salience) and a belief one is addicted to pornography (as measured by the CPUI-9; Sample 1, r = .48, Sample 2, r = .36).

Such findings have also been replicated in independent research groups, with results from a previously described sample (Leonhardt et al., 2018) demonstrating clear positive correlations (N = 686; r = .29) between religiousness (dichotomous variable, low vs. high religiousness) and perception of addiction (measured by a modified version of the Kalichman Sexual Compulsivity Scale). Similarly, in results from another previously described sample of adult web-users (Volk et al., 2016), religiousness and problems associated with use (measured by the CPUI-9) were again positively correlated (N = 358; r = .19). Moving outside of the U.S., results from a previously described (Gola et al., 2016a) sample of Polish men found positive associations (N = 476; r = .40) between religiousness (four-point ordinal, “Do you consider yourself a religious person?”; definitely nodefinitely yes) and perceived problems associated with pornography use (measured by the SAST-R). Similarly, in a previously described sample of Polish women (N = 719), the association between subjective religiousness and problems associated with pornography use was also positive (r = .25; Lewczuk et al., 2017).

Importantly, limited research also seems to demonstrate that these associations persist over time. Longitudinal analyses over a one-year time span in a previously described study (Grubbs et al., 2018b) involving samples of both undergraduates and adults found significant positive associations between baseline religiousness and pornography-related problems one year later (Sample 1, N = .146; r = .43, Sample 2, N = 211, r = .39). When baseline beliefs about addiction were controlled statistically (via regression) the relationships between baseline religiousness and reported pornography-related problems one year later were reduced to non-significance. Even so, the presence of even a raw correlation over such a time period suggests that religiousness is a factor in understanding the etiology and maintenance of feeling one has a pornography problem or addiction.

Religion and Hypersexuality More Broadly

In our systematic review of the literature, we additionally identified five studies that examined problematic hypersexuality more broadly, rather than pornography-related problems specifically. As the contents of these articles were divergent from the present focus, they were not included in our meta-analyses, but their contents may warrant brief consideration. Specifically, in a sample of Croatian adults (Carvalho, Štulhofer, Vieira, & Jurin, 2015), self-identifying as having hypersexual tendencies was associated with greater self-reported religiousness, and in a sample of Croatian men (Štulhofer, Jurin, & Briken, 2016), extremely high scores on a self-report measure of hypersexuality were associated with greater religiousness. Similarly, in at least two studies of undergraduates in the U.S. (Griffin et al., 2016; Hook et al., 2015), greater reported hypersexuality has shown relationships with greater reported religiousness as well.

These relationships in community samples differ slightly from clinical samples. Among clients receiving treatment for hypersexual behavior more broadly (i.e., not limited to compulsive pornography use), religiousness was unrelated to self-reported frequency of sexual thoughts, urges, and behaviors as measured by the Hypersexual Behavior Inventory (HBI, Reid, Carpenter, & Hook, 2016). In short, in a sample of individuals for whom behaviors were demonstrated to be excessive and compulsive—people for whom sexual behaviors were truly addictive (in a functional sense of the word)—religiousness was not predictive of symptoms. Such a finding suggests that religiousness is not a key factor in predicting truly dysregulated behavior, despite its notable relationship with perceptions of dysregulation or problems associated with pornography use in community samples.

Moral Incongruence and Perceived Problems

Moving beyond pornography use itself and religiousness as a proxy for the experience of moral incongruence, the central thesis of our model is that moral incongruence around pornography use is the primary driving factor in the experience of perceived problematic pornography use or pornography addiction for some people. As the logic for this link has been described extensively above, we will not exhaustively review this link again. Below, we examine the evidence relevant to this central thesis of our model.

Review of Evidence

There is indeed quite a bit of evidence suggesting that perceptions of pornography-related problems are very well predicted by moral incongruence. For example, in three previously described samples (Grubbs et al., 2015a) of undergraduates and adults, the correlations between moral incongruence (measured as moral disapproval of pornography use among pornography users) and the report of pornography problems are very strong (Study 1, N = 331, r = .57; Study 2, N = 97, r = .57; Study 3, N = 208, r = .68). These findings have persisted in more recent works on the topic (Grubbs et al., 2018b), using the same measurement techniques and finding highly comparable results (Study 1, N = 1507, r = .58; Study 2, N = 782, r = .68). Furthermore, these findings have been replicated by separate research groups (Volk et al., 2016; N = 358, r = .48) and in separate cultures (e.g., Malaysia, Fernandez et al., 2017; N = 76, r = .41).

The associations between moral incongruence and a report that one is experiencing pornography-related problems also appear to persist over time, with two longitudinal studies documenting clear associations between moral incongruence at baseline and future ratings of such problems. Primarily, in two longitudinal samples (Grubbs et al., 2018b) involving both undergraduate and adult pornography users, baseline ratings of moral incongruence were significantly associated with reports of compulsivity, distress, and disruption due to pornography one year later (undergraduates, r = .46; adults, r = .61). These associations persisted in regression analyses, with moral incongruence predicting pornography-related problems over time, even when baseline levels of pornography use, religiousness, gender, and dispositional characteristics (i.e., personality traits such as self-control) were held constant.

Similarly, in a previously described longitudinal study of male pornography users in Malaysia (Fernandez et al., 2017), baseline levels of moral incongruence were positively associated with perceived problems associated with pornography use (i.e., compulsivity, distress, and disruption as measured by the CPUI-9) over a two-week time period (r = .48). Importantly, in regression analyses, baseline levels of moral incongruence predicted unique variance in perceived problems over time, even when baseline levels of such perceptions were also included in analyses, suggesting again that moral incongruence very strongly predicts perceptions of being addicted to pornography and that it likely contributes to the development and maintenance of these beliefs over time.

Finally, in the three studies (Grubbs et al., 2015a, 2018b; Volk et al., 2016) that specifically examined both religiousness and moral incongruence as predictors of pornography-related problems, moral incongruence was consistently the primary factor in predicting a perception of being addicted to pornography. More simply, in regression and mediation analyses across six reported samples in three studies, the relationship between religion and a perception of being addicted to pornography was largely accounted for by the mediating effect of moral incongruence. Religiousness consistently predicted moral incongruence which, in turn, consistently predicted a perception of being addicted to pornography, suggesting the possibility of a sequential effect of these variables. Collectively, these results support our position that moral incongruence may be the most important factor to consider when an individual self-identifies as having problems related to their use of pornography, particularly in studies involving non-clinical samples.

Summary and Meta-Analyses

In sum, across a number of reviewed studies assessing perceived problems, a few clear associates and predictors have emerged. Primarily, there is considerable evidence to indicate that religiousness is associated with greater experience of moral incongruence and with greater report of problems related to pornography use. There is also evidence to indicate a moderate association between pornography use itself and perceived problems associated with such use. Finally, there is compelling evidence to suggest that there are very strong associations between moral incongruence regarding pornography use and self-perceived problems associated with pornography use.

To test these associations empirically, we subjected the above effects to a meta-analysis. For the purpose of this meta-analysis, as summarized in our PRISMA flowchart in Fig. 2, we only included quantitative analyses of relevant effects (correlations or group differences such as t-tests or χ2). To establish the aggregate observed effect in published literature to date, where appropriate (i.e., more than five reported effects in the literature emerging from different research groups), meta-analytic effect sizes across studies were computed. These results are summarized in Table 1. When the reported correlations from the previously reviewed studies are subjected to a meta-analysis, a strong association (where r = .10, r = .30, and r = .50 are equivalent to small, medium, and large effect sizes, respectively; Cohen, 1992) is found between religiousness and moral incongruence among pornography users (k = 7; Fisher’s rz = .64, 95% CI [.518, .773]; aggregate r = .56; Total N = 3464; Rosenthal’s Failsafe N = 3560). When the reported effects between pornography use and perceived problems with pornography are subjected to aggregate analysis, a positive and moderately sized effect is found (k = 10; Fisher’s rz = .28, 95% CI [.211, .361]; aggregate r = .27; Total N = 5192; Rosenthal’s Failsafe N = 1258). For religiousness and reported pornography problems, aggregated reported effect sizes, the average association was moderate to strong in magnitude (k = 13; aggregate Fisher’s rz = .31, 95% CI [.243, .378]; aggregate r = .30; Total N = 6642; Rosenthal’s Failsafe N = 2847). Finally, across reported effects between moral incongruence and reported pornography problems, the meta-analytic effect size is quite substantial (k = 7; aggregate Fisher’s rz = .66, 95% CI [.570, 769]; aggregate r = .58; Total N = 3408; Rosenthal’s Failsafe N = 3158), suggesting a considerable degree of overlap between moral incongruence regarding pornography use and the belief or perception that one is experiencing pornography-related problems. These associations are summarized in Fig. 3.
Table 1

Summary of studies included in meta-analysis

Study

Sample characteristics

Reported effect sizes

R & MI

R & PP

PU & PP

MI & PP

Abell et al. (2006)

US adults (N = 125; 100% men)

n/a

r = .20

n/a

n/a

Bradley et al. (2016)

US adults (N = 713; 52% men)

n/a

r = .24

n/a

n/a

Fernandez et al. (2017)

Malaysian undergraduates (N = 76; 100% men)

n/a

n/a

r = .32

r = .41

Gola et al. (2016a)

Polish adults (N = 428; 100% men)

n/a

r = .40

r = .41

n/a

Grubbs et al. (2015a); Study 1

US undergraduates (N = 331; 69% men)

r = .59

r = .25

r = .30

r = .57

Study 2

US undergraduates at religious university (N = 97; 51% men)

r = .49

r = .35

r = .35

r = .57

Study 3

US adults (N = 209; 65% men)

r = .57

r = .48

r = .19

r = .68

Grubbs et al. (2018b); Study 1

US undergraduates (N = 1507; 65% men)

r = .73

r = .48

r = .18

r = .58

Study 2

US adults (N = 782; 49% men)

r = .61

r = .36

r = .22

r = .68

Leonhardt et al. (2018)

US adults (N = 686; 51% men)

n/a

r = .30

r = .18

n/a

Levert (2007)

US adults (N = 416; 100% men)

n/a

χ2 = 15.01 (r = .19)

n/a

n/a

Lewczuk et al. (2017)

Polish adults (N = 719; 100% women)

n/a

r = .25

r = .45

n/a

MacInnis and Hodson (2016)

US adults (N = 181; gender n/a)

r = .41

n/a

n/a

n/a

Sessoms (2011)

US undergraduates at religious (n = 145, 65% men) and secular (n = 127, 80% men) universities.

n/a

Cohen’s d = .570 (r = .27)

n/a

n/a

Volk et al. (2016)

US adults (N = 358; 52% men)

r = .50

r = .19

r = .20

r = .49

Meta-analytic effect

 

k = 7, N = 3464, Ag. rz = .65 (.52, .77)

k = 13, N = 6642, Ag. rz = .31 (.24, .38)

k = 10, N = 5192, Ag. rz = .29 (.21, .36)

k = 7, N = 3408, Ag. rz = .67 (.57, .77)

R religiousness, MI moral incongruence, PU pornography use, PP pornography-related problems

Fig. 3

Model of pornography problems due to moral incongruence with meta-analytic effects. Effects represent Fisher’s aggregate Z. Associations are drawn directionally (i.e., religiousness leading to moral incongruence) to demonstrate the proposed model

From these findings, a few key conclusions can be drawn. First, religiousness is a clear and substantial predictor of moral incongruence around pornography use. Although this is an intuitive finding, it is also directly supported by our review of literature. Moving further, moral incongruence around pornography use is consistently the best predictor of the belief one is experiencing pornography-related problems or dysregulation, and comparisons of aggregate effects reveal that it is consistently a much better predictor than pornography use itself (Fisher’s z = 17.55, p < .001). Importantly, current literature suggests that these associations are not just evidenced cross-sectionally, but also over time. This provides meaningful and direct support for our contention that many individuals experiencing pornography-related problems are actually dealing with PPMI. Additionally, we would contend that self-perceived problems with pornography do seem to have real associations with actual pornography use, though these associations tend to be smaller in nature (relative to the associations with moral incongruence) and predominantly cross-sectional. This is not what we would expect if someone had a undeniable pattern of behavior reflecting addictive pornography use. Instead, as was articulated earlier, it seems that having some pornography use is a requisite condition for experiencing PPMI, but the quantity or frequency of that use plays only a minor role. In sum, for a large number of people, perceptions of addiction to or problems associated with pornography seem to be largely driven by moral incongruence, which is consistent with our model of PPMI.

Outcomes Associated With Pornography Problems Due to Moral Incongruence

Perhaps the most important test of the utility of PPMI as a construct (or the utility of our model as a whole) is its role in predicting various relevant outcomes, such as future use of pornography, personal distress, and relational functioning. Below, we seek to review how PPMI relates to each domain.

Pornography-Related Problems and Pornography Use Over Time

If one were to assume that perceptions of problems represent a valid and accurate self-assessment of true dysregulation (as opposed to a distress response arising from moral incongruence), then one might also expect that such perceptions would also predict more use of pornography over time. However, this does not seem to be the case in the limited works that have examined this topic empirically. Very recent works on the role of perceived problems in predicting pornography use over time have found that such perceptions do not predict reported use of pornography over a one-month or a 1-year time span in either undergraduates or adults (Grubbs, Wilt, Exline, & Pargament, 2018a). Notably, this lack of prediction is found for both average daily use one month and 1 year post-baseline and for reported use at all (i.e., acknowledging using any pornography within the specified timeframe). Similarly, in a previously described two-week, longitudinal study of Malaysian men (Fernandez et al., 2017), perceptions of problematic use (measured by the CPUI-9) did not significantly predict failed abstinence attempts related to pornography. Collectively, such findings indicate that individuals’ self-perceptions of problems or loss of control may not be reliable or robust predictors of pornography use. However, such findings are consistent with the present model of PPMI, which would suggest that the experience of pornography problems is more associated with moral incongruence and associated distress than with use itself.

PPMI and Distress

Despite the unclear relationship between PPMI and pornography use, there is still considerable evidence that PPMI may be an important predictor of salient psychosocial outcomes. A body of research now suggests that PPMI are broadly related to a wide range of psychological distress indicators that extend beyond feelings of addiction alone. For example, cross-sectionally, PPMI are associated with anxiety and depression (Grubbs et al., 2015c, 2015d), problematic Internet use and gaming (Bőthe, Tóth-Király, & Orosz, 2014; Morelli, Bianchi, Baiocco, Pezzuti, & Chirumbolo, 2017), problematic alcohol use (Morelli et al., 2017), and overall reports of diminished sexual well-being (Vaillancourt-Morel et al., 2017). PPMI are also associated with greater experiences of relational stress (Leonhardt et al., 2018) and greater levels of sexual dissatisfaction (Blais-Lecours, Vaillancourt-Morel, Sabourin, & Godbout, 2016). Additionally, PPMI also seem to be associated with distress in religious and spiritual functioning, with PPMI predicting religious and spiritual struggles and difficulties (Grubbs et al., 2017a; Wilt et al., 2016).

Many of these findings also appear to exist over time, as longitudinal analyses have found that PPMI predicts depression, anxiety, anger, and perceived stress over a 1-year period, even when baseline levels of such distress and other salient variables (e.g., pornography use, trait neuroticism) are controlled statistically (Grubbs et al., 2015c). Similar results are also evident with religious and spiritual struggles, in that baseline levels of PPMI predict unique variance in religious and spiritual difficulties over a one-year time period, even when baseline levels of such struggles and difficulties are held constant (Grubbs et al., 2017a). Collectively, these findings suggest the possibility PPMI may undermine overall well-being, though more research is needed before definitive conclusions can be made.

Finally, there is also recent evidence indicating that moral incongruence around pornography use (as opposed to pornography problems arising from moral incongruence) is problematic for overall mental health. In a nationally representative, longitudinal panel study (Perry, 2017), pornography use was associated with increased depressive symptoms over time (six years), but only in men who also disapproved of that use. More simply, men who used pornography while disapproving of it morally (i.e., moral incongruence) were more likely to experience increases in depression over a six-year period than other users of pornography who did not experience such incongruence. Such findings are consistent with the greater body of research demonstrating that religious individuals who use pornography (implying moral incongruence) often experience greater levels of distress such as lower levels of subjective happiness (Patterson & Price, 2012), diminished quality or well-being in family relationships (Doran & Price, 2014; Perry, 2016; Perry & Snawder, 2017; Thomas, Alper, & Gleason, 2017), and lower levels of sexual satisfaction (Perry & Whitehead, 2018). Collectively, such findings suggest that moral incongruence may represent a threat to well-being, beyond the effects that PPMI themselves may have (Grubbs & Perry, 2018).

Summary and Implications

Throughout the present work, we have conducted an integrative review of literature on problematic pornography use in support of a novel model for understanding self-perceived problems associated with pornography use. Consistent with the proposed ICD-11 diagnosis of CSBD (and its exclusion of distress related to moral judgments), the primary contentions of this work are that there is likely a distinction between PPMI and actual compulsivity or dysregulated behavior patterns and that PPMI are still meaningful sources of distress and clinical concern. Below, we consider the implications of this model, point toward future directions for research, and consider the limitations of our work.

Implications for Future Research

One of the most direct implications of the present research is the relevance of focusing on moral incongruence and perceptions about pornography addiction when studying problematic pornography use, in addition to attempting to measure objective behavioral dysregulation or disruption. Many psychological constructs (perceived stress, Cohen, Kamarck, & Mermelstein 1994; e.g., perceived social support, Zimet, Dahlem, Zimet, & Farley, 1988) differentiate between the objective measurement of the phenomena and a person’s evaluations or personal perceptions of those phenomena. In some regards, it appears that IP use and perceived problems associated with that use may also need to be discussed in these terms. Whereas there is likely still some value in measuring objective dysregulation (e.g., time spent using pornography, consequences of pornography use), there is also value in specifically measuring the individual’s personal perceptions of pornography use that may arise from moral incongruence. This conclusion is bolstered by previously referenced works that have repeatedly noted that pornography use frequency and average pornography use are not reliable predictors of seeking treatment for self-perceived problems with pornography, while feelings of dysregulation and disruption are (Gola et al., 2016a; Kraus et al., 2016a). Regardless of time spent viewing pornography, it is likely that self-perceived problems, such as the belief one has a pornography addiction, are key to accurately understanding the true impact that pornography use has on health and well-being and therefore a key focus of continued research.

Finally, it is yet unclear the numbers of people that might be experiencing PPMI (e.g., pathway 2 of our model) rather than true dysregulation (e.g., pathway 1). Some prior work (Vaillancourt-Morel et al., 2017) has found that roughly 13% of pornography users report great distress over their use, without signs of compulsivity, as opposed to roughly 12% of users who report both distress and compulsivity. However, such prior work was not representative in nature and did not specifically examine clinical or treatment-seeking groups. As such, there is a clear need for research into the epidemiological basis for both potential pathways to problems.

Clinical Implications

Moving beyond research implications of the present work, we also believe that this model has particular value in clinical and applied domains. The present model and review of associated data suggest that immediately focusing attention only on actual pornography use, without also assessing perceptions about that use and moral incongruence related to that use, would likely be overly narrow in many cases. In asserting this position, we recognize advocates for an addiction model of pornography problems might argue moral incongruence is simply an associated feature of pornography addiction. However, we believe the data favor viewing some cases of pornography-related problems as a manifestation of feeling distressed due to internal conflicts arising from moral incongruence and discrepancies between values, beliefs, and behavior involving pornography use.

Importantly, the present work contends that pornography use may become problematic for individuals based on personal perception that arise from feelings of moral incongruence, rather than simply as a function of behavioral dysregulation alone or “addictive pornography use.” In short, we posit that PPMI are real problems with real psychosocial consequences, but that the etiology of those problems is distinct from a true addiction. In clinical settings, being able to differentiate between these etiological variants is likely important. A client presenting for psychological or psychiatric help with self-perceived problems with pornography is likely experiencing profound and life-altering distress as an associate of his or her use, even if such distress is not a function of behavior directly. In some cases, there may be clear patterns of excessive disruption and dysregulation, but for many, we believe self-identification as a pornography addict may be a function of distress related to moral incongruence. For these individuals, reductions in shame and distress may be helpful, alongside efforts to enhance value-congruent behavior patterns and resolution of internal conflicts related to morals. Indeed, such work may focus on the very moral judgments an individual makes about pornography and how these influence their reactions when discrepancies arise in their belief systems.

Regardless of etiology, there continue to be burgeoning efforts on effective treatment modalities for problematic sexuality, including problematic pornography use (for reviews, see: Grubbs, Hook, Griffin, & Davis, 2015b; Sniewski et al., 2018). In this vein, Acceptance and Commitment Therapy techniques seem to be emerging as a leading modality for addressing concerns about problematic pornography use (Crosby & Twohig, 2016; Sniewski et al., 2018; Twohig & Crosby, 2010). These techniques are effective at addressing negative self-image or self-conceptions generally (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), and with reducing shame and self-stigma associated with addictive behavior patterns such as substance use (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008; Luoma, Kohlenberg, Hayes, & Fletcher, 2012). Given this modality’s focus on both behavioral change (i.e., value-consistent living) and reductions in self-stigma and internal dissonance, it is likely that Acceptance and Commitment Therapy approaches will continue to demonstrate efficacy in treating self-perceived problematic pornography use across the spectrum. Similarly, approaches incorporating mindfulness may allow patients to sit non-judgmentally with moral incongruence without giving special status to such experiences that can result in exaggerated appraisals of behavior (e.g., “I’m a pornography addict!”).

What About Pathway Three?

Throughout, we have framed our model of PPMI as a distinct pathway that is separate from pathway 1 in Fig. 1. More to the point, we have framed pornography-related problems due to dysregulation and PPMI as distinct. However, we would note that it is at least plausible that individuals might be experiencing both objective dysregulation, with its associated problems, and PPMI simultaneously. That is, there is no reason to assume that objective dysregulation precludes moral incongruence or that moral incongruence precludes objective dysregulation. Moreover, one could contend that pornography use despite moral incongruence is a form of dysregulation, which may also combine pathways. Engaging in a behavior that one finds distressing at a moral level could indicate problems of self-regulation, indicating a different sort of compulsivity or addiction. At present, there is not a great deal of empirical data available in extant literature that would test such variations of a combined pathway. To our knowledge, there are, at present, no current studies specifically examining how moral incongruence might be manifested in clinical settings among individuals experiencing objective dysregulation. As such, while we acknowledge that this is a likely pathway of concern, we encourage more research in this domain before making definitive speculations about the nature of such a combination of symptoms.

Limitations and Future Directions

Despite the reviewed evidence for our proposed model of PPMI, there are notable limitations and critiques of our model, as well as clear needs for future research.

Research Biases

The present model is partially constrained by some of the limitations of pornography research in general. Specifically, as has been noted elsewhere (Campbell & Kohut, 2017; Kohut, Fisher, & Campbell, 2017; Montgomery-Graham, Kohut, Fisher, & Campbell, 2015), pornography research has often been negative or problem-focused in nature. More specifically, much of the current body of research related to pornography has specifically been interested in problems or dysfunctions associated with such use. As such, the existing body of research related to pornography use has not often considered the possibility that pornography use may have positive effects. However, given that the present model seeks to provide an alternative explanation for some of these reported negative impacts of pornography, we would contend that our model of PPMI may actually help to mitigate this bias. More succinctly, the present model would indicate that much of this literature documenting negative effects of pornography use may actually be documenting negative effects of moral incongruence. In any case, there is a clear need for continued research exploring the possibility that pornography use may have neutral or positive effects (e.g., Kohut et al., 2017).

Cultural Limitations

Although PPMI has been studied outside the U.S. (e.g., Malaysia: Fernandez et al., 2017; Hungary: Bőthe et al., 2014), via investigations of perceptions of addiction to pornography, the body of evidence on which the current model is built is largely taken from W.E.I.R.D. samples (Western, Educated, Industrialized, Rich, and Democratic cultures, Henrich, Heine, & Norenzayan, 2010). Additionally, given Western contexts, the primary religious affiliation reported in prior works on this topic has been Christianity. Some limited work in this area (e.g., Fernandez et al., 2017, with a plurality of Buddhists) found results that are consistent with the current model, with moral incongruence being clearly related to greater experience of self-perceived pornography-related problems both cross-sectionally and over time. Furthermore, results in non-religious samples are generally consistent with our premise that religiousness seems to drive moral incongruence around pornography use (e.g., Bradley et al., 2016). However, to date, there has not been research published examining the tenets of the present model in other religious contexts. As such, there is a need for more cross-cultural work in this field to determine whether these constructs are salient outside of Western, predominantly Christian contexts. As such, there is a need for more cross-cultural work in this field to determine whether these constructs are salient outside of Western, predominantly Christian contexts. Furthermore, we acknowledge that religion alone may not be the only source of moral incongruence regarding pornography use. Personal values, such as certain feminist ideologies, might create moral incongruence around pornography use. As such, there is a need for future research that examines alternate morality and value systems that extend beyond religion alone.

Clinical Applications

Finally, how well this model extends to clinical samples is yet unclear. In two samples of Polish adults, which included treatment seekers for problematic pornography use, religiousness was related to pornography-related problems (Gola et al., 2016a; Lewczuk et al., 2017); however, in a sample of adults seeking treatment for compulsive sexuality more broadly, religiousness was unrelated to such problems (Reid et al., 2016). Collectively, these findings suggest a need for more research on our proposed model of PPMI in clinical samples.

Conclusion

IP use has been, and will likely continue to be, an immensely common and controversial behavior. Building on previously published empirical research, we have demonstrated that many individuals report problems associated with IP use (i.e., addiction), despite ongoing controversies in the field related to this topic. In response to these ongoing controversies, we have proposed a model of perceived problems associated with IP use, whereby self-perceptions of disruption, dysregulation, and distress may be seen as often arising from moral incongruence between individuals’ moral beliefs about pornography and their actual behaviors. This distress likely poses a real threat to psychosocial well-being, but is etiologically distinct from true patterns of dysregulation and compulsivity. Moral incongruence likely represents an alternate pathway by which pornography use may become problematic—a pathway that does not rely on notions of dependence or true dysregulation. In sum, pornography-related problems due to moral incongruence seem to be a real and salient phenomenon in the scientific study of pornography use and the clinical treatment of those who report such problems.

Footnotes

  1. 1.

    A diverse array of terms may refer to religiousness. For example, terms such as religiosity, religiousness, spiritual, and spirituality are all often encountered in psychological literature, with each potentially referring to different constructs (Hill et al., 2000; Oman, 2013; Pargament, 1999). Indeed, the psychology of religion and spirituality is actually an entire subfield of psychology more broadly, one that is concerned with the nuances of religion and spirituality (Hill et al., 2000; Hill & Pargament, 2003; Pargament, 1999). As such, in some domains of psychological literature, there are incredibly detailed and nuanced discussions of the precise definitions of religion or spirituality (for a review, see Hill & Pargament, 2003). Even with such nuances, such careful considerations of how religiousness is defined are not often found in academic considerations of pornography use or related problems. Given these factors, the studies reviewed herein most often conceptualize religiousness as some combination of the following: religious belief salience (i.e., how important religious belief is), religious participation (i.e., engagement in religious activities), religious affiliation (i.e., faith or denominational identity), or belief in god.

  2. 2.

    As previously explained, early work in this area focused on perceived problems associated with use (rather than objective measures of problematic pornography use more broadly), often using the Cyber-Pornography Use Inventory (Grubbs et al., 2010) and its later adaptation the Cyber-Pornography Use Inventory-9 (CPUI-9; Grubbs, Volk, Exline, & Pargament, 2015d). The CPUI-9 was the first instrument to specifically articulate a primary objective measuring perceived (as opposed to actual) problems associated with pornography use. However, as has been repeatedly highlighted in various studies, whereas the CPUI-9 may be the only inventory to explicitly state an intention of measuring perceptions of pornography-related problems, the vast majority of problematic pornography use inventories rely on self-reported perceptions of loss of control, disruption, and inability to self-regulate (for reviews, see: Grubbs et al., 2017b; Hook, Hook, Davis, Worthington Jr., & Penberthy, 2010; Womack, Hook, Ramos, Davis, & Penberthy, 2013). In this sense, then, to the extent that any measure of problematic pornography use relies primarily on self-reported feelings of compulsivity, disruption, dysregulation, preoccupation, or loss of control, that measure is assessing perceptions of problems associated with pornography use. In this vein, below we review studies that have made use of the CPUI-9, the Sexual Addiction Screening Test–Revised (Carnes, Green, & Carnes, 2010), a pornography-specific version of the Kalichman Sexual Compulsivity Scale (Kalichman & Rompa, 1995; Leonhardt, Willoughby, & Young-Petersen, 2018), and the Cyberporn Compulsivity Scale (Abell, Steenbergh, & Boivin, 2006).

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychologyBowling Green State UniversityBowling GreenUSA
  2. 2.Department of SociologyUniversity of OklahomaNormanUSA
  3. 3.Department of Psychological SciencesCase Western Reserve UniversityClevelandUSA
  4. 4.Department of Psychiatry and Biobehavioral SciencesUniversity of CaliforniaLos AngelesUSA

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