Modulation of late positive potentials by sexual images in problem users and controls inconsistent with "porn addiction"

'They're Much Too young': The Entanglement of Porn, Pleasure and Age in Sex Education

Most debates around the place of porn in the classroom focus on abstaining from porn through sex education. Any inclusion of pleasure often entails lengthy consideration of discourses of pornification and sexualization more broadly. In this study, I aimed to elicit young people's and teachers' views, concerns and suggestions about the place of porn, and pleasure more broadly, in sex education. I present a thematic content analysis of small friendship group interviews with 106 young people aged 12-16, who self-identified as boys or girls, and semi-structured interviews with six teachers in New Zealand. I argue that by politicizing age, we continue to view young people as an at risk population. In doing so, we miss the nuance of young people's engagements with porn and pleasure, which denies scope to understand the role of porn in young people's lives. This is a missed opportunity to interrogate and understand porn as a resource through which young people construct and express their sexual subjectivities and social roles.

Increased sensitivity for negative emotional images in individuals with problematic pornography use

Background

Despite the frequent comorbidity of affective and addictive disorders, the significance of affective dysregulation in problematic pornography use (PPU) is commonly disregarded. The objective of this study is to investigate whether individuals with PPU demonstrate increased sensitivity to negative emotional stimuli in comparison to healthy controls (HCs).

Methods

Electrophysiological responses were captured via event-related potentials (ERPs) from 27 individuals with PPU and 29 HCs. They completed an oddball task involving the presentation of deviant stimuli in the form of highly negative (HN), moderately negative (MN), and neutral images, with a standard stimulus being a neutral kettle image. To evaluate participants' subjective feelings of valence and arousal, the Self-Assessment Manikin (SAM) was employed.

Results

Regarding subjective evaluations, individuals with PPU indicated diminished valence ratings for HN images as opposed to HCs. Concerning electrophysiological assessments, those with PPU manifested elevated N2 amplitudes in response to both HN and MN images when contrasted against neutral images. Additionally, PPU participants displayed an intensified P3 response to HN images in contrast to MN images, a distinction not evident within the HCs.

Discussion

These outcomes suggest that individuals with PPU exhibited heightened reactivity toward negative stimuli. This increased sensitivity to negative cues could potentially play a role in the propensity of PPU individuals to resort to pornography as a coping mechanism for managing stress regulation.

Neuroelectric Correlates of Human Sexuality: A Review and Meta-Analysis

Many reviews on sexual arousal in humans focus on different brain imaging methods and behavioral observations. Although neurotransmission in the brain is mainly performed through electrochemical signals, there are no systematic reviews of the electrophysiological correlates of sexual arousal. We performed a systematic search on this subject and reviewed 255 studies including various electrophysiological methods. Our results show how neuroelectric signals have been used to investigate genital somatotopy as well as basic genital physiology during sexual arousal and how cortical electric signals have been recorded during orgasm. Moreover, experiments on the interactions of cognition and sexual arousal in healthy subjects and in individuals with abnormal sexual preferences were analyzed as well as case studies on sexual disturbances associated with diseases of the nervous system. In addition, 25 studies focusing on brain potentials during the interaction of cognition and sexual arousal were eligible for meta-analysis. The results showed significant effect sizes for specific brain potentials during sexual stimulation (P3: Cohen's d = 1.82, N = 300, LPP: Cohen's d = 2.30, N = 510) with high heterogeneity between the combined studies. Taken together, our review shows how neuroelectric methods can consistently differentiate sexual arousal from other emotional states.

The Cancer of Cancel Culture: Spreading "Correct" Scientific Ideologies Across North American Academia

The spread of "cancel culture" related to sex and gender controversies in North America is examined as part of a larger movement to politicize sex research findings and certain sex and gender narratives as "correct" and "incorrect" from a so-called social justice standpoint. This binary is then used by academic administrators and empowered individuals or self-interest groups to reward or punish scholars for their viewpoints. The cases described by Meyer-Bahlburg, Lowrey, and Hooven are concrete examples of a growing "sexual McCarthyism" where empirical results are challenged by offended social justice "warriors" and embellished on social media into ad hominem attacks, to the point that it can damage-or even cancel-the careers of productive sexual scientists. This occurs largely out of fear on the part of academic administrators and lawyers charged with protecting the university from "brand damage" that might occur if the offending scholar is not dealt with. Sexual scientists are being vilified for research on sex differences, sex/gender assignment and subsequent causes for transitioning and/or de-transitioning, research that shows few or no untoward social or psychological effects of viewing pornography, research that debunks the notion of porn or sex "addiction," research showing the efficacy of medications to treat sexual desire disorders in women, research on "minor attracted persons" and even animal research that dares to show homologies to human sexual behavior. The silencing of empirical evidence and alternative viewpoints is contrary to the intellectual mission of universities and destructive to academic and political freedoms.

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

OBJECTIVES

The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD.

METHODS

An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD.

CONCLUSIONS

An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.

No significant effect of frequent online sexual behaviour on Pavlovian-to-instrumental transfer (PIT): Implications for compulsive sexual behaviour disorder

Reward based learning is broadly acknowledged to underpin the development and maintenance of addictive behaviour although the mechanism in sexual compulsivity is less understood. Using a Pavlovian-to-Instrumental Transfer (PIT) task we tested whether the motivational aspect of conditioned Pavlovian conditioned stimulus invigorated instrumental responding in relation to specific compatible monetary rewards. Performance on the task was analysed between two groups of males based on Low (N = 38) and High (N = 41) self-report online sexual behaviour (OSB). Psychometric tests including sexual compulsivity scale and behavioural activation/behavioural inhibition (BIS/BAS) were also administered to determine the relationship between OSB and general reward sensitivity. We show clear evidence of acquisition in the Pavlovian and instrumental conditioning phases. Specific transfer effect was greater in the High-OSB group although the difference compared to the Low-OSB group was non-significant. OSB negatively correlated with both BIS and BAS indicative of introversion and low reward sensitivity. OSB positively correlated with sexual compulsivity although it is unclear whether individuals in the High-OSB group considered their behaviour either excessive or problematic. These findings contribute to the ongoing debate regarding the nature of problematic OSB. Fundamental differences in motivational characteristics and mechanism contributing to compulsive behaviour in relation to high-OSB might indicate incompatibility with behavioural addiction models. PIT was not enhanced in high-OSB by appetitive conditioning, although problematic OSB could stem from failure to inhibit actions. Further research should investigate whether aversive conditioning differentially affects responding in high-OSB individuals, potentially explaining perseverant behaviour despite negative consequences.

Automaticity of Early Sexual Attention: An Event-Related Potential Study

A promising line of research on forensic assessment of paraphilic sexual interest focuses on behavioral measures of visual attention using sexual stimuli as distractors. The present study combined event-related potentials (ERPs) with behavioral measures to investigate whether detection of a hidden sexual preference can be improved with ERPs. Normal variants of sexual orientation were used for a proof-of-concept investigation. Accordingly, 40 heterosexual and 40 gay men participated in the study. Within each group, half of the participants were instructed to hide their sexual orientation. The results showed that a match between sexual orientation and stimulus delays responses and influences ERP before motor responses. Late ERP components showed higher potential in differentiating hidden sexual preferences than motor responses, thereby showing how ERPs can be used in combination with reaction time measures to potentially facilitate the detection of hidden sexual preferences.

The Association between the Quantity and Severity of Pornography Use: A Meta-analysis

Although the quantity of pornography use (QPU, i.e., frequency/time spent on pornography use) has been positively associated with the severity of pornography use (i.e., problematic pornography use, PPU), the magnitudes of relationships have varied across studies. This meta-analysis aimed to assess the overall relationships and identify potential moderating variables to explain the variation in these associations between QPU and PPU. We performed a literature search for all published and unpublished studies from 1995 to 2020 in major online scientific databases up until December 2020. Sixty-one studies were identified with 82 independent samples involving 74,880 participants. Results indicated that there was a positive, moderate relationship between QPU and PPU (r = 0.34, p < .001). The strength of relationship significantly varied across measures of PPU based on different theoretical frameworks, indicators of QPU, and sexual cultural contexts (conservative vs. permissive sexual values). Frequency was a more robust quantitative indicator of PPU than time spent on pornography use. In conservative countries, QPU showed more robust association with self-perceived PPU. Future studies are encouraged to select the measurement of PPU according to research aims and use multi-item measures with demonstrated content validity to assess pornography use. Cross-cultural (conservative/permissive) comparisons also warrant further research.

Electrophysiological Evidence of Enhanced Processing of Novel Pornographic Images in Individuals With Tendencies Toward Problematic Internet Pornography Use

Novelty seeking is regarded as a core feature in substance use disorders. However, few studies thus far have investigated this feature in problematic Internet pornography use (PIPU). The main aim of the present study was to examine group differences in electrophysiological activity associated with novelty processing in participants with high tendencies toward PIPU vs. low tendencies using event-related potentials (ERPs). Twenty-seven participants with high tendencies toward PIPU and 25 with low tendencies toward PIPU completed a modified three-stimulus oddball task while electroencephalogram (EEG) was recorded. Participants were instructed to detect neutral target stimuli from distracting stimuli. The distracting stimuli contained a familiar sexual stimulus and a set of novel sexual stimuli. The novel-familiar difference waves were calculated to identify specific group difference in novelty effect. While both groups demonstrated a sustained novelty effect in the late positive potential (LPP) within the 500–800 ms time windows, the novelty effect was greater in the high tendencies toward PIPU group than in the low tendencies toward PIPU group. This result suggests that individuals with high tendencies toward PIPU allocate more attentional resources for novelty processing. Enhanced brain responding to novel sexual stimuli may facilitate pornographic consumption and play an essential role in the development and maintenance of PIPU.

Increase in the Prevalence of Online Pornography Use: Objective Data Analysis from the Period Between 2004 and 2016 in Poland

Despite the considerable amount of attention presently devoted to the high accessibility of online pornography, very little formal analyses have been carried out to show how the advent and proliferation of Internet technology has changed the prevalence of pornography use in populations. We conducted a preliminary analysis based on objective website traffic data, representing the changes in the number of (1) Internet users generally and (2) online pornography users specifically, between 2004 and 2016 in Poland. We observed a clear increase in the estimated number of people using online pornography in the analyzed period. The estimated number of general population members viewing pornography on the Internet increased over three times (310%) between October 2004 and October 2016-starting from an estimated 2.76 million in the first period to 8.54 million in the last. At the same time, we did not observe a clear increase in the percentage of Internet users who viewed online pornography in the same time period. Additionally, pornography viewership on the Internet was almost 2 times more prevalent among male (47%) than female Internet users (27%), and most popular in the 18-27 age group. Since our analysis is based on objective data, it does not share the limitations inherent in self-reports. However, our approach also has several important limitations (e.g., the analysis does not include online activity generated on mobile devices and under a private browsing mode); thus, the results should be interpreted with caution.

Approach-Avoidance pattern of attentional bias in individuals with high tendencies toward problematic Internet pornography use

Attentional bias plays a vital role in the occurrence and development of addictive behaviors. However, little is known about attentional processes in problematic Internet pornography use (PIPU), and previous studies have reported mixed results. The current study examined the components of attentional processing to sexual stimuli using an exogenous cueing task designed to differentiate between attentional engagement and disengagement. Two different stimulus presentation times (100 and 500 ms) were used to present the pornographic and neutral images to differentiate the early and late stages of attentional bias. Individuals with high (n = 40) and low (n = 40) PIPU tendencies were compared. The results demonstrated that individuals with high tendencies toward PIPU showed enhanced attentional engagement with pornographic stimuli in the early stage of attentional processing (100 ms), followed by attentional avoidance in the late stages of attentional processing (500 ms). Moreover, the severity of PIPU symptoms was positively correlated with attentional engagement scores in the short picture-time trials (100 ms) and weakly negatively correlated with attentional disengagement scores in the long picture-time trials (500 ms). This approach-avoidance pattern of attentional biases is in line with a recent theoretical model that emphasizes that appetitive and aversive motivational processes jointly determine attentional bias.

Electrophysiological evidence of enhanced early attentional bias toward sexual images in individuals with tendencies toward cybersex addiction

BACKGROUND AND AIMS

Attentional bias is a key factor in addictive behavior maintenance. However, whether attentional bias has a similar effect on cybersex addiction is unclear. We investigated differences in the attentional processing of sexually explicit images between individuals with high tendencies toward cybersex addiction (TCA) versus low tendencies using behavioral and electrophysiological indices.

METHODS

Twenty-eight individuals with high TCA and 29 with low TCA performed an addiction Stroop task comprising sexual and neutral images in colored frames. Participants were asked to respond to the frame color and not the image contents, and behavioral and event-related potentials were recorded.

RESULTS

Behaviorally, an addiction Stroop interference effect was found in the high TCA group, as shown by the longer reaction times to judge the frame colors of sexual images. Electrophysiologically, a P200 (150-220 ms) enhancement was present in response to sexual images compared with neutral ones, which was absent in the low TCA group. The event-related potential correlates with the addiction Stroop interference effect, indicating that the attentional bias underlying the addiction Stroop interference operates at an automatic level. A general, sexually related bias was found in the late positive potential (300-700 ms) amplitude, although between-group differences were insignificant.

DISCUSSION AND CONCLUSIONS

These findings indicate that sexual stimuli grab the attentional resources of individuals with high TCA at early automatic stages of attentional processing. Increased cue reactivity to sexual stimuli may contribute to pornographic consumption and play a crucial role in sustaining problematic excessive use of online pornography.

The emotion-elicited late positive potential is stable across five testing sessions

Many studies have examined associations between neural and behavioral markers of attention to emotion and individual differences in affective functioning. However, the majority of these studies are cross-sectional, and examine associations between brain, behavior, and individual differences at one or two time-points, limiting our understanding of the extent to which these neural responses reflect trait-like patterns of attention. The present study used the Emotional Interrupt paradigm, and examined the stability and trajectory of behavioral (i.e., reaction time to targets following task-irrelevant appetitive, neutral, and aversive images), and neural responses to images (i.e., the late positive potential or LPP), across five sessions separated by one week in 86 individuals. Additionally, we examined the extent to which the LPP and behavioral measures were sensitive to naturally occurring daily fluctuations in positive and negative affect. Results indicate that, though the magnitude of the conditional LPP waveforms decreased over time, the degree of emotional modulation (i.e., differentiation of emotional from neutral) did not; in fact, differentiation of appetitive from neutral increased over time. Behavioral responses were similarly stable across sessions. Additionally, we largely did not observe significant effects of state positive and negative affect on the LPP or behavior over time. Finally, the LPP elicited by appetitive images significantly predicted reaction time to targets following these images. These data suggest that neural and behavioral markers of attention to motivationally salient cues may be trait-like in nature, and may be helpful in future studies seeking to identify markers of vulnerability for diverse forms of psychopathology.

The Impact of Negative Mood on Event-Related Potentials When Viewing Pornographic Pictures

Background: Negative affective states may increase the risk for problematic pornography use. Underlying neurophysiological mechanisms are, however, not completely understood. Previous research suggests that the participants' emotional state may affect neural processing of sexual stimuli. The aim of this study was to investigate neural correlates of negative affect-induced alterations in sexual cue reactivity in healthy men. The moderating effects of habitual porn consumption, trait sexual motivation, and symptoms of cybersex addiction were also considered. Method: Sixty-four healthy men engaged in a sexual cue reactivity task (passive viewing of explicit sexual pictures and neutral pictures depicting scenes of social interaction) during negative (n = 32) vs. neutral affect (n = 32), induced via tailored feedback on a performance task. Self-reported sexual arousal and event-related brain potentials indicated cue reactivity and motivated attention. Symptoms of cybersex addiction and trait sexual motivation were assessed with the help of the short Internet Addiction Test, adapted to online sexual activities, and the Trait Sexual Motivation Questionnaire. Results: Negative feedback increased negative affect after the performance task. While sexual pictures compared to neutral pictures elicited significantly larger P300 and late positive potential (LPP) amplitudes, there was no general effect of negative feedback on sexual stimuli-related P300 and LPP amplitudes. In the negative feedback group, men with higher solitary sexual motivation levels showed higher P300/LPP difference amplitudes for sexual stimuli compared to men with lower levels of solitary sexual motivation. The opposite effect was found in the group with neutral feedback. There was no link to other aspects of trait sexual motivation and symptoms of cybersex addiction. Conclusions: Results suggest that higher levels of solitary sexual motivation may enhance motivated attention toward sexual stimuli among men receiving negative performance feedback. Other characteristics of sexual behaviors and traits provided no exploratory value. Future studies extending onto men suffering from compulsive sexual behavior disorder will have to closer look at the neurophysiological bases of why and when some men develop an addictive pornography consumption.

Sexual addiction 25 years on: A systematic and methodological review of empirical literature and an agenda for future research

In 1998, Gold and Heffner authored a landmark review in Clinical Psychology Review on the topic of sexual addiction that concluded that sexual addiction, though increasingly popular in mental health settings, was largely based on speculation, with virtually no empirical basis. In the more than two decades since that review, empirical research around compulsive sexual behaviors (which subsumes prior research about sexual addiction) has flourished, ultimately culminating in the inclusion of a novel diagnosis of Compulsive Sexual Behavior Disorder in the eleventh edition of the World Health Organization's International Classification of Diseases. The present work details a systematic review of empirical research published between January 1st, 1995 and August 1st, 2020 related to compulsive sexual behaviors, with a specific focus on evaluating the methodologies of that literature. This review yielded 371 papers detailing 415 individual studies. In general, the present review finds that, although research related to compulsive sexual behaviors has proliferated, much of this work is characterized by simplistic methodological designs, a lack of theoretical integration, and an absence of quality measurement. Moreover, the present review finds a virtual absence of high-quality treatment-related research published within this time frame. Implications of these findings for both clinical practice and future research are discussed.

Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM)

BACKGROUND

A number of studies have found that hypersexuality is associated with a high propensity for sexual excitation. In comparison, less is known about the relationship between hypersexuality and sexual arousal at the state level. Also, previous research has revealed a relationship between hypersexuality and negative mood. However, the possibility that sexual response might not be as negatively impacted by negative mood in hypersexual individuals has, as yet, not been tested.

AIM

The purpose of this study was to investigate sexual responsivity and the effects of negative mood on sexual arousal in hypersexual men who have sex with men (MSM).

METHODS

A total of 211 MSM were assigned to a hypersexuality (N = 81) or a control (N = 130) group using an interview patterned with a semi-structured Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders format. Participants filled out questionnaires and were shown neutral, sexual, and anxiety- and sadness-inducing films.

OUTCOMES

Changes in penile circumference and self-reported sexual arousal were the primary outcomes analyzed in this study.

RESULTS

Controlling for age and HIV status, no differences were found in genital response between hypersexual and non-hypersexual men. Also, the 2 groups did not differ in subjective sexual arousal. Moreover, no effects of negative mood were found. Time series clustering analyses revealed 3 groups-low responders and slow and fast high responders. Sexual excitation, but not sexual compulsivity or pornography use, predicted cluster membership.

CLINICAL TRANSLATION

Hypersexual MSM may benefit more from an exploration of motivational and behavioral, as compared to psychophysiological, mechanisms underlying possible links between (negative) mood and sexual behavior.

STRENGTHS & LIMITATIONS

Strengths of the study include its sample size, making it one of the larger psychophysiological sex studies; the use of clinical interviews for group assignment; the inclusion of genital response measures; and the application of time series clustering to examine differences among participants. Limitations include possible sample heterogeneity and the reliance on researcher-selected stimuli.

CONCLUSION

Given the lack of any effects of negative mood on sexual response in hypersexual MSM, future studies could explore in more depth possible motivational and behavioral effects, including, for example, the impact of negative mood on the tendency to seek out sex as a form of distraction or for validation or emotional support. Janssen E, Prause N, Romine RS, et al. Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM). J Sex Med 2020;17:1751-1760.

Do Varying Levels of Exposure to Pornography and Violence Have an Effect on Non-Conscious Emotion in Men?

As we are often inundated with images of violence and pornography in modern times with the aid of mobile devices and unrestricted online access and content, the non-conscious effect of such exposure is an area of concern. To date, many clinicians and researchers in behavioral sciences rely on conscious responses from their clients to determine affective content. In doing so, they overlook the effect the non-conscious has on an individual's emotions. The present study aimed to examine variations in conscious and non-conscious responses to emotion-inducing images following varying amounts of exposure to violent and pornographic images. Eighteen participants who self-reported as being low pornography users were presented with emotion-inducing images after no exposure (Session 1), after one round of exposure to 50 pornographic and 50 violent images (Session 2) and after a further nine rounds of exposure to 50 pornographic and 50 violent images (Session 3). Sessions were temporally separated by at least 2 days while startle reflex modulation (SRM) and scalp-recorded event-related potentials (ERPs) were used to determine non-conscious emotion-related responses to pre-evaluated emotion pictures. Explicit valence and arousal ratings were assessed for each of those emotion pictures to determine conscious emotion effects potentially changing as a function of increasing controlled exposure to pornographic and violent visual material. Conscious explicit ratings and SRM amplitudes revealed no significant difference between the sessions. However, frontal ERP analysis revealed significant changes between processing of "violent" and "unpleasant" images at later ERP time windows, further supporting the growing body of research which shows that relying on self-report data does not result in a full understanding of emotional responses.

Effects of Pornography Use and Demographic Parameters on Sexual Response during Masturbation and Partnered Sex in Women

The effect of pornography on sexual response is understudied, particularly among women. A multinational, community-based sample of 2433 women at least 18 years of age completed a 42-item, opt-in questionnaire collecting information on demographic and sexual history characteristics, use of pornography during masturbation, frequency of pornography use, and sexual response parameters. Pornography use and average frequency were compared across demographic variables. We also examined how pornography frequency predicted differences in self-reported arousal difficulty; orgasmic difficulty, latency, and pleasure; and the percent of sexual activities ending in orgasm during both masturbation and partnered sex. On average, women using pornography were younger, and reported more interest in sex. Pornography frequency differed significantly by menopausal status, sexual orientation, anxiety/depression status, number of sexual partners, and origin of data collection. During masturbation, more frequent pornography use predicted lower arousal difficulty and orgasmic difficulty, greater pleasure, and a higher percentage of masturbatory events leading to orgasm. Frequency of pornography use predicted only lower arousal difficulty and longer orgasmic latencies during partnered sex, having no effect on the other outcome variables. Pornography use frequency did not predict overall relationship satisfaction or sexual relationship satisfaction. Overall, more frequent pornography use was generally associated with more favorable sexual response outcomes during masturbation, while not affecting most partnered sex parameters. Several demographic and relationship covariates appear to more consistently and strongly predict orgasmic problems during partnered sexual activity than pornography use.

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

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.

Online Porn Addiction: What We Know and What We Don't-A Systematic Review

In the last few years, there has been a wave of articles related to behavioral addictions; some of them have a focus on online pornography addiction. However, despite all efforts, we are still unable to profile when engaging in this behavior becomes pathological. Common problems include: sample bias, the search for diagnostic instrumentals, opposing approximations to the matter, and the fact that this entity may be encompassed inside a greater pathology (i.e., sex addiction) that may present itself with very diverse symptomatology. Behavioral addictions form a largely unexplored field of study, and usually exhibit a problematic consumption model: loss of control, impairment, and risky use. Hypersexual disorder fits this model and may be composed of several sexual behaviors, like problematic use of online pornography (POPU). Online pornography use is on the rise, with a potential for addiction considering the "triple A" influence (accessibility, affordability, anonymity). This problematic use might have adverse effects in sexual development and sexual functioning, especially among the young population. We aim to gather existing knowledge on problematic online pornography use as a pathological entity. Here we try to summarize what we know about this entity and outline some areas worthy of further research.

Cue-reactivity in behavioral addictions: A meta-analysis and methodological considerations

Background and aims Recent research has applied cue-reactivity paradigms to behavioral addictions. The aim of the current meta-analysis is to systematically analyze the effects of learning-based cue-reactivity in behavioral addictions. Methods The current meta-analysis includes 18 studies (29 data sets, 510 participants) that have used a cue-reactivity paradigm in persons with gambling (eight studies), gaming (nine studies), or buying (one study) disorders. We compared subjective, peripheral physiological, electroencephal, and neural responses toward addiction-relevant cues in patients versus control participants and toward addiction-relevant cues versus control cues in patients. Results Persons with behavioral addictions showed higher cue-reactivity toward addiction-relevant cues compared with control participants: subjective cue-reactivity (d = 0.84, p = .01) and peripheral physiological and electroencephal measures of cue-reactivity (d = 0.61, p < .01). Increased neural activation was found in the caudate nucleus, inferior frontal gyrus, median cingulate cortex, subgenual cingulate, and precentral gyrus. Persons with gambling, gaming, or buying disorders also showed higher cue-reactivity toward addiction-relevant cues compared with control cues: subjective cue-reactivity (d = 0.39, p = .11) and peripheral physiological and electroencephal measures of cue-reactivity (d = 0.47, p = .05). Increased neural activation was found in the caudate nucleus, inferior frontal gyrus, angular gyrus, inferior network, and precuneus. Discussion and conclusions Cue-reactivity not only exists in substance-use disorders but also in gambling, gaming, and buying disorders. Future research should differentiate between cue-reactivity in addictive behaviors and cue-reactivity in functional excessive behaviors such as passions, hobbies, or professions.

Brain Imaging of Human Sexual Response: Recent Developments and Future Directions

PURPOSE OF REVIEW

The purpose of this study is to provide a comprehensive summary of the latest developments in the experimental brain study of human sexuality, focusing on brain connectivity during the sexual response.

RECENT FINDINGS

Stable patterns of brain activation have been established for different phases of the sexual response, especially with regard to the wanting phase, and changes in these patterns can be linked to sexual response variations, including sexual dysfunctions. From this solid basis, connectivity studies of the human sexual response have begun to add a deeper understanding of the brain network function and structure involved.

SUMMARY

The study of "sexual" brain connectivity is still very young. Yet, by approaching the brain as a connected organ, the essence of brain function is captured much more accurately, increasing the likelihood of finding useful biomarkers and targets for intervention in sexual dysfunction.

Emotional Picture Perception: Repetition Effects in Free-Viewing and during an Explicit Categorization Task

Several studies have found that, despite a decrease in the overall amplitude of the late positive potential (LPP) with repeated presentation of the same picture, emotional stimuli continue to elicit a larger LPP than neutral ones. These findings seem to support the hypothesis that the affective modulation of the LPP reflects a mandatory process and does not rely on stimulus novelty. However, in these studies participants were asked to merely look at the pictures, without carrying out any additional task (free-viewing), making picture emotionality the most salient aspect of the stimulus, despite its repetition. The current study aimed to examine the impact of an explicit categorization task on the emotional processing of repeated pictures. To this purpose, ERPs to novel and repeated pictures were measured during free-viewing as well as during an explicit categorization task, where the emotional content of the pictures was task-irrelevant. The within-subject comparison between the free-viewing and task context revealed that the overall LPP habituated more rapidly in the free-viewing condition, but, more importantly, the LPP affective modulation was unaffected by task requirements during both novel and repeated presentations. These results suggest that the affective modulation of the LPP reflects an automatic engagement of cortico-limbic motivational systems, which continues to take place regardless of stimulus novelty and task context.

Should compulsive sexual behavior be considered an addiction?

AIMS

To review the evidence base for classifying compulsive sexual behavior (CSB) as a non-substance or 'behavioral' addiction.

METHODS

Data from multiple domains (e.g. epidemiological, phenomenological, clinical, biological) are reviewed and considered with respect to data from substance and gambling addictions.

RESULTS

Overlapping features exist between CSB and substance use disorders. Common neurotransmitter systems may contribute to CSB and substance use disorders, and recent neuroimaging studies highlight similarities relating to craving and attentional biases. Similar pharmacological and psychotherapeutic treatments may be applicable to CSB and substance addictions, although considerable gaps in knowledge currently exist.

CONCLUSIONS

Despite the growing body of research linking compulsive sexual behavior (CSB) to substance addictions, significant gaps in understanding continue to complicate classification of CSB as an addiction.

Compulsive sexual behavior: Prefrontal and limbic volume and interactions

BACKGROUND

Compulsive sexual behaviors (CSB) are relatively common and associated with significant personal and social dysfunction. The underlying neurobiology is still poorly understood. The present study examines brain volumes and resting state functional connectivity in CSB compared with matched healthy volunteers (HV).

METHODS

Structural MRI (MPRAGE) data were collected in 92 subjects (23 CSB males and 69 age-matched male HV) and analyzed using voxel-based morphometry. Resting state functional MRI data using multi-echo planar sequence and independent components analysis (ME-ICA) were collected in 68 subjects (23 CSB subjects and 45 age-matched HV).

RESULTS

CSB subjects showed greater left amygdala gray matter volumes (small volume corrected, Bonferroni adjusted P < 0.01) and reduced resting state functional connectivity between the left amygdala seed and bilateral dorsolateral prefrontal cortex (whole brain, cluster corrected FWE P < 0.05) compared with HV.

CONCLUSIONS

CSB is associated with elevated volumes in limbic regions relevant to motivational salience and emotion processing, and impaired functional connectivity between prefrontal control regulatory and limbic regions. Future studies should aim to assess longitudinal measures to investigate whether these findings are risk factors that predate the onset of the behaviors or are consequences of the behaviors. Hum Brain Mapp 38:1182-1190, 2017. © 2016 Wiley Periodicals, Inc.

Visual Sexual Stimuli-Cue or Reward? A Perspective for Interpreting Brain Imaging Findings on Human Sexual Behaviors

There is an increasing number of neuroimaging studies using visual sexual stimuli (VSS), especially within the emerging field of research on compulsive sexual behaviors (CSB). A central question in this field is whether behaviors such as excessive pornography consumption share common brain mechanisms with widely studied substance and behavioral addictions. Depending on how VSS are conceptualized, different predictions can be formulated within the frameworks of Reinforcement Learning or Incentive Salience Theory, where a crucial distinction is made between conditioned and unconditioned stimuli (related to reward anticipation vs. reward consumption, respectively). Surveying 40 recent human neuroimaging studies we show existing ambiguity about the conceptualization of VSS. Therefore, we feel that it is important to address the question of whether VSS should be considered as conditioned stimuli (cue) or unconditioned stimuli (reward). Here we present our own perspective, which is that in most laboratory settings VSS play a role of reward, as evidenced by: (1) experience of pleasure while watching VSS, possibly accompanied by genital reaction; (2) reward-related brain activity correlated with these pleasurable feelings in response to VSS; (3) a willingness to exert effort to view VSS similarly as for other rewarding stimuli such as money; and (4) conditioning for cues predictive of VSS. We hope that this perspective article will initiate a scientific discussion on this important and overlooked topic and increase attention for appropriate interpretations of results of human neuroimaging studies using VSS.

Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports

Traditional factors that once explained men's sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brain's motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography's unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use. In the interim, a simple diagnostic protocol for assessing patients with porn-induced sexual dysfunction is put forth.

What Matters: Quantity or Quality of Pornography Use? Psychological and Behavioral Factors of Seeking Treatment for Problematic Pornography Use

INTRODUCTION

Pornography has become popular with Internet technology. For most people, pornography use (PU) is entertainment; for some, it can result in seeking treatment for out-of-control behavior. Previous studies have suggested that PU can influence sexual behaviors, but the direct relation between frequency of PU and treatment-seeking behaviors has not been examined.

AIMS

To investigate whether individuals seeking treatment as a consequence of their problematic PU do so because of their quantity of pornography consumption or because of more complex psychological and behavioral factors related to PU, such as the severity of negative symptoms associated with PU and/or subjective feeling of loss of control over one's behavior.

METHODS

A survey study was conducted of 569 heterosexual Caucasian men 18 to 68 years old, including 132 seeking treatment for problematic PU (referred by psychotherapists after their initial visit).

MAIN OUTCOMES MEASURES

The main outcome measures were self-reported PU, its negative symptoms, and actual treatment-seeking behavior.

RESULTS

We tested models explaining sources of seeking treatment for problematic PU with negative symptoms associated with PU and additional factors (eg, onset and number of years of PU, religiosity, age, dyadic sexual activity, and relationship status). Seeking treatment was significantly, yet weakly, correlated solely with the frequency of PU (r = 0.21, P < .05) and this relation was significantly mediated by negative symptoms associated with PU (strong, nearly full mediation effect size; k(2) = 0.266). The relation between PU and negative symptoms was significant and mediated by self-reported subjective religiosity (weak, partial mediation; k(2) = 0.066) in those not seeking treatment. Onset of PU and age appeared to be insignificant. Our model was fairly fitted (comparative fit index = 0.989; root mean square error of approximation = 0.06; standardized root mean square residual = 0.035) and explained 43% of the variance in treatment-seeking behavior (1% was explained by frequency of PU and 42% was explained by negative symptoms associated with PU).

CONCLUSION

Negative symptoms associated with PU more strongly predict seeking treatment than mere quantity of pornography consumption. Thus, treatment of problematic PU should address qualitative factors, rather than merely mitigating the frequency of the behavior, because frequency of PU might not be a core issue for all patients. Future diagnostic criteria for problematic PU should consider the complexity of this issue.

Hypersexuality Addiction and Withdrawal: Phenomenology, Neurogenetics and Epigenetics

Hypersexuality has been defined as abnormally increased sexual activity. Epidemiological and clinical studies have shown that this non-paraphilic condition consists of "excessive" sexual behaviors and disorders accompanied by personal distress and social and medical morbidity. It is a very controversial and political topic in terms of how best to categorize it as similar or not similar to addictive behaviors including substance abuse. Hypersexual disorder is conceptualized as a non-paraphilic sexual desire disorder with impulsivity. Pathophysiological perspectives include dysregulation of sexual arousal and desire, sexual impulsivity, and sexual compulsivity. The nucleus accumbens, situated within the ventral striatum, mediates the reinforcing effects of drugs of abuse, such as cocaine, alcohol, nicotine, and food as well as music. Indeed, it is believed that this structure mandates behaviors elicited by incentive stimuli. These behaviors include natural rewards like feeding, drinking, sexual behavior, and exploratory locomotion. An essential rule of positive reinforcement is that motor responses will increase in magnitude and vigor if followed by a rewarding event. Here, we are hypothesizing that there is a common mechanism of action (MOA) for the powerful effects drugs, music, food, and sex have on human motivation. The human drive for the three necessary motivational behaviors "hunger, thirst, and sex" may all have common molecular genetic antecedents that, if impaired, lead to aberrant behaviors. We hypothesize that based on a plethora of scientific support hypersexual activity is indeed like drugs, food, and music that activate brain mesolimbic reward circuitry. Moreover, dopaminergic gene and possibly other candidate neurotransmitter-related gene polymorphisms affect both hedonic and anhedonic behavioral outcomes. There is little known about both the genetics and epigenetics of hypersexuality in the current literature. However, we anticipate that future studies based on assessments with clinical instruments combined with genotyping of sex addicts will provide evidence for specific clustering of sexual typologies with polymorphic associations. There have been some studies using electrophysiological techniques that do not support the view that hypersexuality is indeed similar to substance abuse and other behavioral addictions. The authors are also encouraging both clinical and academic scientists to embark on research using neuroimaging tools to examine natural dopaminergic agonistic agents targeting specific gene polymorphisms to "normalize" hypersexual behavior.

Neuroscience of Internet Pornography Addiction: A Review and Update

Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction in at least some individuals. Regarding Internet addiction, neuroscientific research supports the assumption that underlying neural processes are similar to substance addiction. The American Psychiatric Association (APA) has recognized one such Internet related behavior, Internet gaming, as a potential addictive disorder warranting further study, in the 2013 revision of their Diagnostic and Statistical Manual. Other Internet related behaviors, e.g., Internet pornography use, were not covered. Within this review, we give a summary of the concepts proposed underlying addiction and give an overview about neuroscientific studies on Internet addiction and Internet gaming disorder. Moreover, we reviewed available neuroscientific literature on Internet pornography addiction and connect the results to the addiction model. The review leads to the conclusion that Internet pornography addiction fits into the addiction framework and shares similar basic mechanisms with substance addiction. Together with studies on Internet addiction and Internet Gaming Disorder we see strong evidence for considering addictive Internet behaviors as behavioral addiction. Future research needs to address whether or not there are specific differences between substance and behavioral addiction.