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Archives of Sexual Behavior

, Volume 48, Issue 2, pp 461–468 | Cite as

Response to Commentaries

  • Joshua B. GrubbsEmail author
  • Samuel Perry
  • Joshua A. Wilt
  • Rory C. Reid
Commentary

With the inclusion of Compulsive Sexual Behavior Disorder (CSBD) in the forthcoming ICD-11, research into the compulsive or addictive use of sexual media will likely greatly expand in coming years. Similarly, behavioral science debates about the best way to conceptualize pornography use—particularly problematic pornography use—are likely to continue for the foreseeable future. In tandem with these trends, there is also an increasing need for nuanced discussions of these topics that enhance taxonomical, diagnostic, and etiological understandings of such problematic sexual behavior. In service of this goal, we described a model by which pornography use might lead to problems in users’ lives, even in the absence of dysregulation, compulsivity, or addiction (Grubbs, Perry, Wilt, & Reid, 2018a).

In our Target Article, we posited a model of pornography problems due to moral incongruence (PPMI) wherein some users experience problems related to their pornography use that arise due to a misalignment between moral values and actual behavior. As theorists have speculated for over half a century (Bem, 1967; Festinger, 1962) and as addictions researchers have noted for several decades (Hettema, Steele, & Miller, 2005; Miller & Rollnick, 1991), the relationships between behaviors and self-perceptions of those behaviors are often misaligned. In that same tradition, we set forth a model that accounts for the documented tendency of a substantive percentage of pornography users to describe moral disapproval of their own behaviors. Simply put, many users of pornography—particularly in the U.S.—find that behavior to be morally problematic (Grubbs, Kraus, & Perry, 2019b).

Building on the fact that many users of pornography morally disapprove of their own use habits, we constructed our model of PPMI. Across a number of studies, we found support for this model. Religiousness is consistently related to moral disapproval of pornography use. Self-reported feelings of addiction to pornography are consistently linked to feelings of moral incongruence. And, in non-clinical populations, meta-analytic results strongly support the notion that moral incongruence is the strongest correlate of self-reported problems associated with pornography use. In sum, moral incongruence, which appears to often (but not always) be a by-product of conservative religious ideals, is clearly a key component of self-reported problematic pornography use.

Across all commentaries and feedback (both praise and critique), we are grateful for the evaluations and careful considerations provided. The opportunity to have one’s work critiqued and debated in such a public and rigorous forum is an honor and privilege. Across all commentaries, we noted both commendations and insightful critiques. Chiefly, most responses commended the nature of the review and the utility of the model for some specific cases. Moreover, at least two commentaries directly applied the model to either case studies in problematic pornography use (Kraus & Sweeney, 2018) or empirical analyses of hypersexuality more generally (Walton, 2018). Importantly, in both of these cases, the model was well supported by available data. Rather than expand further on the commendations received, however, it is our aim to specifically summarize and address the critiques raised and future directions posited.

Ultimately, we believe that the two most substantive critiques fall into one of two primary categories. Chiefly, a number of critiques noted that the model was quite narrow in its scope, focus, and implications (Fisher, Montgomery-Graham, & Kohut, 2018; Vaillancourt-Morel & Bergeron, 2018; Willoughby, 2018), while others noted that the work may inappropriately distinguish between pathways to problematic use (Brand, Antons, Wegmann, & Potenza, 2018; Wright, 2018). Below, we consider these critiques broadly.

Narrowness of the Model

Several of the commentaries noted that the PPMI model, in its original form, was rather narrow, both in focus and in implications (Fisher et al., 2018; Vaillancourt-Morel & Bergeron, 2018; Willoughby, 2018; Wright, 2018). Indeed, we enthusiastically endorse this assessment of the model. That is, the model we articulated focused almost entirely on intrapersonal difficulties arising from the intersection of conservative sexual ideals and personal interpretations of pornography use. Undoubtedly, as commenters noted, there are likely other sources of incongruence that extend beyond conservative or religious sexual ideals (Vaillancourt-Morel & Bergeron, 2018; Wright, 2018). Moreover, a focus on problematic use only (as opposed to non-problematic use or even positive effects of use) is inherently limited (Fisher et al., 2018; Vaillancourt-Morel & Bergeron, 2018). Finally, an exclusively intrapersonal focus inherently misses many of the potential effects, impacts, and associates of pornography use in interpersonal contexts (Vaillancourt-Morel & Bergeron, 2018; Willoughby, 2018).

Ultimately, we agree with all of the above critiques. Pornography is often used in interpersonal contexts, with interpersonal effects (Perry, 2017; Perry & Davis, 2017; Perry & Schleifer, 2018; Perry & Snawder, 2017; Wright & Tokunaga, 2018; Wright, Tokunaga, Kraus, & Klann, 2017). Moving further, the morally charged nature of sexuality (though often religiously based; Droubay, Butters, & Shafer, 2018) extends beyond religiously based scruples and client-held individual differences. More to the point, there are indeed likely many different sources of sexual morality, beliefs about sexual behaviors, and self-judgments associated with sexual behaviors, and these diverse themes are just as likely to influence us as researchers and clinicians as they are to influence the subjects of our research or the patients within our practices. Similarly, pornography use does indeed seem to have a wide range of effects that extend beyond problematic practices alone (Montgomery-Graham, Kohut, Fisher, & Campbell, 2015), and the PPMI model does not address such use at all.

Such limitations are clear deficits of the PPMI model in its original form. However, we would contend that such deficits are likely a part of any theoretical structure or model that is in its nascent stages. Although we do believe the model (as articulated) is coherent and well grounded in empirical literature, the true test of the utility of the work is for future research to determine. As such, we expect adaptations, revisions, modifications, and extensions of the model to occur in future works. Indeed, as noted in one of the commentaries (Fisher et al., 2018), recent empirical work in Croatia suggests that the model may not wholly generalize outside the U.S. (Kohut & Stulhofer, 2018). Future work will need to more carefully consider whether or not our model of PPMI might extend beyond the context of the U.S., whether other sources of incongruence bear the same influence in predicting problematic outcomes as does religiously based incongruence, and whether or not incongruence extends to interpersonal contexts.

What About Emotional Distress?

We also note that one of the commentaries mentioned potential confounds associated with the measurement of PPMI (Brand et al., 2018; Willoughby, 2018). More simply, a large number of the studies reviewed and included in our meta-analyses did rely on research using the Cyber Pornography Use Inventory-9 (CPUI-9). With this commentary, there now exist two articles critiquing the utility of the CPUI-9 as a general measure of pornography addiction (see also Fernandez, Tee, & Fernandez, 2017). Across all of these critiques, the central point of contention is consistent: The argument is presented that the CPUI-9, as a measure of pornography-related problems, is confounded by the Emotional Distress subscale of the instrument. To address this critique, more context on the development of the CPUI-9 is needed.

The CPUI-9 (Grubbs, Volk, Exline, & Pargament, 2015c) was developed in 2013 as a shorter revision of the longer Cyber Pornography Use Inventory (Grubbs, Sessoms, Wheeler, & Volk, 2010), which was, in turn, developed as a pornography-specific version of the Internet Sex Screening Test (Delmonico & Miller, 2003). As developed, the CPUI-9 was meant to capture cognitive (Perceived Compulsivity subscale), behavioral (Access Efforts subscale), and emotional (Emotional Distress subscale) aspects of self-reported pornography addiction. Given that no diagnosis subsuming problematic sexual behavior existed at that time, it was branded as a measure of perceived addiction to online sexual media. That is, it was developed as a measure of individual’s self-perceived problems with pornography use that was independent of any formal diagnosis.

As previously mentioned, a very small amount of academic literature (e.g., Brand et al., 2018; Fernandez et al., 2017) and some non-academic, non-peer-reviewed online commentaries have critiqued this structure of the measure, stating that including the Emotional Distress subscale of the CPUI-9 is unfounded. More to the point, these critiques suggest that the links between moral incongruence and self-reported pornography problems (as measured by the CPUI-9) are due simply to emotional distress. In defense of this contention, Fernandez et al. (2017) noted that, when the emotional aspects of self-reported problems are controlled for statistically (i.e., the Emotional Distress subscale of the CPUI-9), the link between moral disapproval of pornography and cognitive aspects of self-reported problems (e.g., Perceived Compulsivity subscale of the CPUI-9) is reduced to statistical nonsignificance. That is, when emotional distress is partialled out, links between moral incongruence and compulsivity are diminished.

Although such a finding is interesting, we do not think it accurate to characterize it as evidence that moral incongruence is only related to emotional distress. Primarily, this finding is not novel in general nor was it unknown to us. In a previously described large sample (N = 1070) of undergraduates from three universities across the U.S., Wilt, Cooper, Grubbs, Exline, and Pargament (2016) found virtually identical results, specifically noting that the associations between moral disapproval and perceived compulsivity seem to be diminished when emotional distress and various other emotional, cognitive, and individual difference variables are controlled for statistically. However, as is the case with Fernandez et al.’s (2017) findings, this is likely due to the large correlations between the Emotional Distress subscale and the Perceived Compulsivity subscale (r = .51, Fernandez et al., 2017; r = .50, Wilt et al., 2016). Indeed, the scale was designed to have high covariance between subscales, as it is thought that behaviors, emotions, and beliefs/cognitions would all be related to the experience of addiction. As such, controlling for one subscale when predicting another is also somewhat inconsistent with the specific theoretical underpinnings of the scale.

We would also note (and have stated elsewhere, Grubbs, Grant, & Engelman, 2019a) that the conceptual meaning of the residualized Perceived Compulsivity subscale after statistically partialling out Emotional Distress subscale is altogether unclear. More to the point, by partialling out the influence of emotional distress, the remaining component of perceived compulsivity is simply a measure of a perceived loss of control that the individual does not find concerning or distressing. Statistically controlling for emotional distress due to pornography use (which is what is implied by Fernandez et al.’s analysis) removes one of the key diagnostic features of any mental disorder: subjective distress. Such a construct (the non-distressing part of dysregulation) has little theoretical meaning and practically no real-world application.

Additionally, we note that several prior publications that have been criticized in non-peer-reviewed forums actually did address concerns about emotional distress quite substantively. For example, in the original publication on moral incongruence (Grubbs, Exline, Pargament, Hook, & Carlisle, 2015a), in which self-reported problems with pornography use were specifically linked to moral incongruence, these links were tested with the Emotional Distress subscale of the CPUI-9 removed from analysis. Rather than controlling for emotional distress and partialling out its influence (which is problematic for the above-discussed reasons), this foundational work simply omitted it. Even so, this work demonstrated direct links between moral disapproval and the cognitive and behavioral components of self-reported problems.

In more recent works linking perceived addiction and moral incongruence (Grubbs, Wilt, Exline, Pargament, & Kraus, 2018b), all three subscales of the CPUI-9 were examined separately, eliminating possible confounds between subscales. That is, each scale was included independently, both cross-sectionally and over time, eliminating possible confounds. More to the point, claims that prior literature was confounded by the Emotional Distress subscale of the CPUI-9 are ignoring the fact that most prior analyses controlled for such a confound.

We also note that, in latent variable analyses of self-reported pornography-related problems (Grubbs, Stauner, Exline, Pargament, & Lindberg, 2015b), the Emotional Distress subscale of the CPUI-9 was consistently found to have the lowest loadings on the latent variable Perceived Addiction, relative to cognitive (i.e., Perceived Compulsivity subscale) and behavioral (i.e., Access Effort subscale) perceptions. Finally, within this same sample, the links between self-reported problems and relevant outcomes (e.g., psychological distress) persisted even when trait neuroticism was held constant, indicating that the links between self-reported problems and distress are not simply the function of a propensity to negative affect, as one would expect if self-reported problems were simply a function of emotional distress.

In addition to the above reasons justifying the use of the CPUI-9 and the careful attention paid by prior articles to avoid confounds, we would note that a number of the studies that were cited in our original Target Article did not use the CPUI-9 at all, thereby circumventing this critique. Specifically, samples in both the U.S. (Abell, Steenbergh, & Boivin, 2006; Leonhardt, Willoughby, & Young-Petersen, 2018; Levert, 2007) and Poland (Gola, Lewczuk, & Skorko, 2016; Lewczuk, Szmyd, Skorko, & Gola, 2017) used alternative measures of problems related to pornography use. As such, it would be unfounded to dismiss all conclusions of the prior work as being driven by the CPUI-9.

In addition to the number of studies in our original study that did not rely on the CPUI-9, we also note that, in the time since the original Target Article was submitted, additional studies have been published on this topic. Specifically, several manuscripts have been published either in whole (Kohut & Stulhofer, 2018; Walton, 2018) or as preprints of in-press manuscripts (Grubbs et al., 2019a, 2019b) reiterating links between religiousness and/or moral incongruence and self-reported pornography-related problems, without the inclusion of the CPUI-9. Most notably, in a nationally representative sample of pornography using adults in the U.S., moral incongruence about pornography use remains a powerful predictor (outside of male gender) of agreement with the statement “I am addicted to pornography” (Grubbs et al., 2019b). This finding was underscored in three samples of adult men in the U.S. using an alternative measure of problematic pornography use that did not rely on emotional distress at all (Grubbs & Gola, 2019). Moreover, across four samples of Internet-using adults in the U.S. (Grubbs et al., 2019a), moral incongruence regarding pornography use consistently emerged as a predictor of affirmative agreement (e.g., responding “true”) to the statement: “I believe I am addicted to internet pornography.”

Collectively, for the above reasons, we believe that, while skepticism regarding the CPUI-9 deserves consideration, both academic and popular criticisms of PPMI as being confounded by emotional distress are wholly unfounded. Emotional distress is likely part of pornography-related problems, and past literature using the CPUI-9 has done an excellent job controlling for any confounds in the measurement of pornography-related problems. When these facts are considered alongside the bodies of literature that did not use the CPUI-9, we believe that it is safe to conclude that this specific critique—despite its apparent popularity in non-peer-reviewed critiques of our work—does not invalidate any part of our model. Even so, in order to more rigorously test our model of PPMI, we elected to revise our meta-analysis with these concerns in mind.

Revised Meta-Analytic Totals

Building on the aforementioned critiques, we revised the original meta-analyses in the following ways. Specifically, we added recent works that assessed self-reported problematic use of pornography and either religiousness or moral incongruence (Grubbs et al., 2019a, 2019b; Kohut & Stulhofer, 2018; Rissel et al., 2017). Additionally, in accordance with the above-noted criticism about potential confounds resulting from the use of the CPUI-9 as a primary measure of pornography-related problems, we have only included correlations between the Perceived Compulsivity subscale of the CPUI-9. This resulted in updates to effect sizes from five separate samples (Studies 1–3; Grubbs et al., 2015a; Samples 1 and 2; Grubbs et al., 2018b). We also deleted the effects from one previous study from an independent laboratory that relied on the CPUI-9 total score (Volk, Thomas, Sosin, Jacob, & Moen, 2016). More simply, in response to the critique that our results were partially confounded by the Emotional Distress subscale of the CPUI-9, we wholly removed that subscale from the meta-analysis. Despite the fact that, as we reviewed above, including the emotional distress in conceptualizations of problematic pornography use is likely prudent and reasonable, we opted to test our model using an extremely conservative test.

Even with this extremely conservative reanalysis, the same pattern of findings reported in our original analysis persisted, with one notable exception. The direct association between religiousness and self-reported problems did decrease (k = 20, aggregate rz = .23, 95% CI [.184, .279]), becoming smaller than the association between use and self-reported problems (k = 19, ag. rz = .34, 95% CI [.275, .398]). However, although the association between moral incongruence and self-reported problems also decreased (k = 14, ag. rz = .46, 95% CI [.363, .557]), it remained the strongest associate of self-reported problems in the meta-analysis. Moreover, the association between religiousness and moral incongruence remained largely unchanged (k = 12, ag. rz = .61 [.523, .688]).

From this revised meta-analysis, a few conclusions can be drawn. Primarily, despite critiques of measures and mentions of possible confounds, even extremely conservative tests of our model revealed the same pattern of findings with regard to moral incongruence and self-reported problematic use of pornography. Such a finding is rather strong support for the notion that moral incongruence is, likely, the primary associate of self-reported problems of pornography use. We can also conclude that wholly removing emotional distress from the analysis did marginally reduce the association between self-reported pornography-related problems and moral incongruence, though this reduction was rather small. Finally, consistent with our original work, links between religiousness and moral incongruence were also extremely strong, suggesting that, for many people, moral incongruence is entwined with religiously based scruples around sexuality. In sum, the notion of PPMI is well supported by the data.

We also note that at least one commentary (Willoughby, 2018) speculated that the role of moral incongruence in predicting pornography-related problems was likely relatively uncommon, if not altogether rare. In response to this finding, we would like to direct attention to recent work specifically seeking to assess the scope of such a problem. Specifically, recent U.S. nationally representative estimates (N = 2075; Grubbs et al., 2019b) found that 22% of people with a lifetime history of pornography use report some moral incongruence regarding their use of pornography. This distribution of responses is summarized in Table 1. That is, among pornography users, 22% indicated that they found pornography use morally wrong. Among recent users (e.g., those who have used within the past year), 18% reported incongruence, and among those that acknowledge at least monthly use of pornography, 20% reported incongruence. Among those self-indicating some agreement with the statement “I am addicted to internet pornography,” there was high convergence with agreement to the statement “I believe pornography use is morally wrong” (χ2 [36] = 728.01, p < .001). That is, among 141 participants who indicated some agreement with feelings of addiction to pornography, 65% (n = 89) reported some level of moral incongruence. Examined differently, those same data reveal that, among people with a lifetime history of viewing pornography, 28% of those who agreed with the statement “I believe that pornography use is morally wrong” reported some feelings of addiction to pornography. However, among those who disagreed with the statement that pornography use is morally wrong, only 4% reported some feelings of addiction to pornography. As such, we would contend that not only is moral incongruence related to pornography use common in nationally representative samples, but it is particularly common among individuals who believe they are experiencing dysregulation and compulsivity.
Table 1

Distributions of responses to feelings of moral disapproval of pornography use and feelings of addiction to pornography use among lifetime users of pornography in a U.S. nationally representative sample

 

“I am addicted to internet pornography”

“I believe that pornography use is morally wrong”

Strongly disagree

Disagree

Somewhat disagree

Neither agree nor disagree

Somewhat agree

Agree

Strongly agree

Strongly disagree

374

48

19

15

7

5

10

Disagree

129

97

11

11

5

1

2

Somewhat disagree

59

24

24

17

6

1

0

Neither agree nor disagree

124

23

17

98

9

3

2

Somewhat agree

63

13

6

10

15

6

1

Agree

32

13

2

2

8

19

2

Strongly agree

73

5

3

9

3

11

24

For full details regarding this sample, see Grubbs et al. (2019b)

Incongruence in a Unipathway Approach

Despite the previously reviewed affirmative evidence for our model of PPMI, however, we also acknowledge—as several commentaries aptly pointed out—that moral incongruence does not necessarily imply a separate pathway to problems (Brand et al., 2018; Wright, 2018). That is, although we mentioned the possibility of a unipathway experience in our Target Article (Pathway 3, a combined experience of incongruence and dysregulation), we did not fully consider the likelihood of this pathway. Below, we seek to address this shortcoming on our part.

Central to our model of PPMI was the notion that pornography-related problems are likely, in some cases, to flow almost exclusively from feelings of moral incongruence. In support of this, we noted the growing literature demonstrating strong links between moral incongruence (or proxies for moral incongruence, such as religiousness) and self-reported problems. However, it is also quite possible that moral incongruence might arise from dysregulation as well. Indeed, as a number of commentaries pointed out—via case studies (Kraus & Sweeney, 2018), analyses of hypersexual patients (Walton, 2018), and as theoretical reviews (Brand et al., 2018; Wright, 2018)—it is quite likely that incongruence can often be a feature of problematic behavior itself. Indeed, the original conceptualization of the Hypersexual Behavior Inventory-19 (Reid, Garos, & Carpenter, 2011) included several questions about engaging in behaviors that violated one’s values or beliefs. Moreover, several early descriptions of compulsive sexual behavior disorders also noted that individuals often feel morally conflicted, ashamed, or guilty regarding their sexual behaviors (Gold & Heffner, 1998; Reed, 1994; Schneider, 1994).

From these prior works, we posit that two reasonable conclusions can be drawn. Primarily, it is distinctly possible that the continuation of a behavior, even in the presence of incongruence, is a type of dysregulation. To continue to do something—even infrequently—that violates one’s values, beliefs, or morals is undoubtedly a failure of self-regulation. Such lapses in self-regulation likely reflect an inability to perpetually and unfailingly manage one’s impulses. However, we would similarly contend that such lapses do not equal or even imply addiction or compulsivity. That is, infrequent lapses in self-control in other domains would hardly be considered an addiction (e.g., the person who drinks to the point of intoxication once every few months, and feels profoundly guilty about it; the person who eats unhealthy food once a month, and then feels shame over their behavior). As such, even if infrequent use of pornography among those that disapprove of any use is a type of dysregulation, addiction paradigms are likely not the best means of describing such problems.

Additionally, we do concede that individuals may certainly experience incongruence as a by-product of dysregulation. It is hardly radical or revolutionary to suggest that addictive behavior patterns in various domains would produce incongruence. Many alcoholics, tobacco users, and drug users experience moral self-judgments in the form of self-stigma (Evans-Polce, Castaldelli-Maia, Schomerus, & Evans-Lacko, 2015; Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008; Schomerus et al., 2011). Additionally, many individuals with problematic gambling patterns or gambling disorder describe moral disapproval of gambling behavior (Hing, Nuske, Gainsbury, & Russell, 2016; Kolla, Mansukhani, Barraza, & Bostwick, 2010). Arguably, 12-step programs for addiction recovery rely on moral disapproval of addictive behaviors (Dodes & Dodes, 2014), and feelings of incongruence between behaviors and values are a foundational aspect of motivational interviewing techniques (Hettema et al., 2005; Miller & Rollnick, 1991, 2012) and other substance abuse treatment regimens. As such—as some commentaries noted (Brand et al., 2018; Kraus & Sweeney, 2018)—the presence of incongruence is likely to occur in cases of true dysregulation. More simply, the presence of moral incongruence does not imply the absence of dysregulation.

Having acknowledged the above points, we do not believe that either obviates the possibility of individuals experiencing problems primarily due to incongruence. Indeed, the diagnostic criteria for CSBD clearly articulate that distress over sexual behaviors due to moral or religious beliefs—both of which imply the presence of moral incongruence—does not meet criteria for the disorder (Kraus et al., 2018). That is, there is evidence from prior works (Cantor et al., 2013; Sutton, Stratton, Pytyck, Kolla, & Cantor, 2015) and presented in some of the commentaries (Brand et al., 2018; Kraus & Sweeney, 2018) that some individuals who present for treatment of problematic sexual behaviors, such as pornography use, are likely to do so due to distress arising from moral incongruence. To dispute or ignore this would be to ignore a clear potential confound in the accurate classification, categorization, and treatment of compulsive sexuality more broadly. Indeed, our model highlights the need to explore and resolve internal conflict that may give rise to incongruence among those seeking help for problematic pornography use.

Conclusions

In the context of novel diagnoses for compulsive or problematic sexuality, diagnostic precision, etiological clarity, and taxonomical accuracy should be of utmost concern for current and future research. These goals are best accomplished by establishing coherent frameworks by which existing and future research may be organized, evaluated, critiqued, replicated, and built upon. Our model of PPMI represents an initial attempt at such an organizational structure that is useful for understanding a specific category of pornography use (problematic use) and the specific etiological pathways that might lead to that use.

In considering our original model of PPMI alongside the commentaries presented, it is evident that our work is limited in some regards, though likely quite useful in others. Building on the current model, recent research suggests that moral incongruence is clearly quite common among pornography users, with recent U.S. nationally representative statistics (Grubbs et al., 2019b) demonstrating that up to 20% of regular users express some moral disapproval of pornography use in general and 65% of individuals reporting feelings of addiction express some disapproval of pornography use. As such, it is reasonable to conclude that moral incongruence is a key component of properly understanding, classifying, and treating problems associated with pornography use.

Ultimately, it is our hope that the present model will aid in the classification and treatment of problematic sexual behavior patterns, particularly problematic pornography use. With the inclusion of the CSBD diagnosis in the ICD-11, researchers who study compulsive sexual behavior and clinicians who treat compulsive sexual behaviors have been afforded a long-awaited opportunity to test and confirm their arguments for the necessity of such a diagnosis. However, given the many controversies surrounding sexual behaviors, such an opportunity must be met with rigor and critical analyses. Rather than present an argument against CSBD, it is our intention and belief that our model of PPMI adds needed nuance to ensure the accurate use of the CSBD diagnosis. Pornography use specifically and sexual behaviors in general are regularly the topic of moral judgments and pontification in the public sphere (Montgomery-Graham et al., 2015). This morally charged nature of the topic necessitates a careful understanding of the roles that cultural morality might play in the experience and expression of problematic pornography use and sexual behavior (Perry, 2018). As the diagnostic criteria for CSBD clearly note (Kraus et al., 2018), religious and moral concerns about sexual behavior are necessary considerations when evaluating patients’ self-reports of problems associated with sexual behavior. Our model of PPMI supplies a framework by which such problems (i.e., morally/religiously based distress related to sexual behavior) may be understood.

Finally, the original development of PPMI does not account for the numerous ways in which pornography use (both problematic and non-problematic use) may be best understood outside of addiction/compulsivity/hypersexuality frameworks. The present work was largely built from an addiction science framework, though it likely has utility in sexual science more broadly. Future work that expands the model to account for other sources of incongruence (Vaillancourt-Morel & Bergeron, 2018; Wright, 2018), for the role of researcher- and clinician-based feelings of incongruence or judgment (Fisher et al., 2018), and for intrapersonal effects of pornography use (Vaillancourt-Morel & Bergeron, 2018; Willoughby, 2018) is needed.

Notes

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

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 California Los AngelesLos AngelesUSA

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