Exposing the Big White Elephant - Pornography and Mental Health

Dr. David J. Koehn Psychologist Fort Myers, Florida

Dr. David Koehn is a psychologist practicing in Fort Myers, FL. Dr. Koehn specializes in the treatment of mental health problems and helps people to cope with their mental illnesses. As a psychologist, Dr. Koehn evaluates and treats patients through a variety of methods, most typically being psychotherapy or talk therapy.... more

Exposing the Big White Elephant - Pornography and Mental Health


Dr. David J. Koehn


Taken from several sources on the internet, here is a treatise on the subject of pornography.  Over the years, I have run into teenagers, couples, adults, and the elderly that have had excessive appetites for pornography, all that have gotten them in trouble, either psychologically, emotionally, socially, and/or legally

When I began counseling in the mid-1970s, hardcore pornography was difficult to obtain. But in recent decades, new electronic technologies, such as cable television, computers, and iPhones, have transformed it into a product that's available to anyone---anytime, anywhere, and often cheap or free. It's become a substantial part of our economy, boasting annual revenues of over $13 billion in the United States and $100 billion worldwide.
The revolution in accessibility has led to record consumption. According to statistics on the Internet Filter Review site, 40 million Americans visit internet porn sites at least once a month. Some porn users visit sites for only a few minutes at a time. Others visit porn sites daily, spending more than 15 hours per week. One-third of all downloads each month and one-quarter of all online searches each day are for porn. According to a recent Nielsen Online survey, a record-breaking 25 percent of employees in the United States are accessing porn at work, despite the risks involved.
Not surprisingly, concerns about the effect of porn on individuals and relationships are also on the rise. According to a survey in Men's Health, more than 70 percent of the men surveyed said they've looked at more porn since the advent of the Internet, and one in two expressed concern about their use of it. The American Academy of Matrimonial Lawyers and the British Nielsen NetRatings organization have identified it as a major cause of divorce and relationship difficulties. No wonder sexual addiction experts, such as Patrick Carnes, have begun calling pornography addiction "our newest and most challenging mental health problem."
Changes in how people access and use pornography have taken the therapeutic community by surprise. The explosion in porn use has happened so fast that many therapists have been caught unprepared; they may not yet comprehend the extent of the problems porn can cause, or how deeply its use can harm individuals and their intimate partners. Despite the increase in the number of people suffering from anxiety, depression, sexual problems, relationship distress, and other serious consequences of habitual porn use, few therapists feel comfortable and confident addressing porn-related concerns.
How We Feel about Porn
Pornography draws strong responses---from the public at large and within the therapeutic community. Many of us have such strong feelings about pornography that we automatically label, condemn, or reject anyone who sees it differently. If we're critical of porn, we might judge people who like it as "excessively permissive," "exploitive," "addicted to sex," or "misogynistic." If we're supportive of porn, we may see those who don't share our view as "sexually uptight," "religiously conservative," "radically feminist," or "against free speech." Unlike other common mental health concerns, such as depression or substance abuse, we have no reasonably coherent and agreed-upon clinical perspective for what constitutes a "porn problem" or how to approach it.
A Drug
Pornography seems to have a drug-like effect on the body and mind. Despite being ingested through the eyes and ears instead of the mouth or bloodstream, porn stimulates the reward and pleasure centers in the brain, instantly and dramatically, increasing the production of dopamine, a neurotransmitter associated with both sexual arousal and drug highs. In addition, using porn for sexual stimulation has been shown to increase the production of other "feel-good" chemicals, such as adrenaline, endorphins, testosterone, and serotonin; with a sexual climax, it releases powerful hormones related to falling in love and bonding, such as oxytocin and vasopressin.
My insight into pornography's drug-like effects helped me bring more compassion to the issues porn users faced. Not only were their partners in distress: anyone trying to quit using porn faced his or her own difficult emotional and physiological struggles. Patients were to supplement their individual and couples counseling work by attending 12-step sexual addiction recovery programs, such as Sex Addicts Anonymous, Sexaholics Anonymous, and Recovering Couples Anonymous, or porn recovery groups of their choosing. Intimate partners are encouraged to attend Codependents of Sex Addicts meetings and to check out supportive websites, such as www.pornaddicthubby.com. With an extensive background in drug and alcohol counseling, I know that support groups can be critical to successful recovery, helping overcome social isolation and shame, building accountability supports, and sharing triumphs.
A Threat to Public Health
To beat the drum against pornography appears relevant and has evidenced-based research to support why it is unhealthy. From my own experience, I've concluded that pornography is moving from an individual and couples problem to a public health problem, capable of deeply harming the emotional, sexual, and relationship well-being of millions of men, women, and children.

The only way to prevent the spread of porn-related problems is for people to be informed and to get help early, and for society to be alert to the problems. There is a great need for parents, teachers, employers, clergy, healthcare workers, law enforcers, and therapists to start addressing pornography problems with the same kind of shame-free directness with which we've learned to tackle other public health concerns, such as cigarette smoking, alcohol consumption, domestic violence, and drug abuse.
As a therapist, perhaps our most important role is in providing patients with a safe place to discuss and examine their concerns. It's best to analyze porn-related situations on a case-by-case basis, taking into consideration a patient's values, sexual experience, sexual orientation, and relationship status. As mental health professionals we're most helpful when we resist our tendencies to automatically condemn or advocate porn. Our effectiveness depends on our ability to join patients in regularly evaluating porn's impact on their lives. While remaining aware that porn use isn't a problem for everyone, given its unprecedented power and accessibility, it can become a problem for anyone.

Pornography can be a factor in mental health issues
While this may come off as shocking to some, consuming porn can take you to a whole different world—not only physically, but mentally.  As humans, we are biologically wired for connection and real-life connections with real people. Watching porn does the complete opposite—removing the consumer from their real-life world—leading to disconnection and driving a wedge between the consumer and their other relationships. Social isolation starts small, but it’s possible that it can lead to and fuel various forms of addiction and fuel existing depression.  In other words, research has indicated that having a frequent, isolating porn habit can increase a consumer’s vulnerability to mental health issues like depression and anxiety.

Does porn trigger depression or vice versa?
Some patients expressed how porn affected their mental health and depressive state. For many, porn “was a drug” that they couldn’t escape from. It took them many tries to quit and it not only gave them a false and short-lived sense of pleasure, but it triggered real feelings of depression, disconnection, and shame. In their words, porn made them feel less human. So, what happened when they tried to give porn up for good? They noticed their depression noticeably lessened and happiness, joy, and connection started to take place. Life became more enjoyable and they felt more connected to the people around them. Now, we’re not saying that their depression was solely caused by porn, only that using porn as an escape did not help their mental state.

In all honesty, anytime anyone spends a lot of time with the usual pornography consumption cycle, it can often turn into a depressing, demeaning, self-loathing, and lonely kind of experience. Not only for the person watching porn, but it even affects the relationships and the ones you care about.  Studies have found that when people engage in an ongoing pattern of “self-concealment,” which is when they do things they’re not proud of and keep them a secret, it can not only hurt their relationships and leave them feeling lonely, but can also make them more vulnerable to mental health issues. 

Could it be true that porn triggers depression or is it the other way around? The answer isn’t clear. What we do know is this: the more people feel bad about themselves, the more they seek comfort wherever they can get it. If they’re already caught up with a secret porn habit, they will likely turn to more porn.  It’s difficult to say what exactly comes first, the porn problem or the depression itself, but in this particular scenario, it goes together.

Several peer-reviewed studies have found a link between pornography consumption and mental health outcomes like depression,4 anxiety,5 loneliness,6 lower life satisfaction,7 poorer self-esteem, and overall mental health.8 These studies have found that these links are particularly strong when pornography is consumed to try to escape negative emotions, and also when pornography consumption becomes heavy and compulsive.9 According to another study performed in the United States, researchers found a significant bi-directional association between pornography and loneliness, prompting them to conclude: “Results revealed that the association between loneliness and viewing pornography was positive and significant those who viewed pornography were more likely to experience loneliness, and those who were experiencing loneliness were more likely to view pornography. These findings are consistent with research linking pornography use to negative affect. 

Although it’s fairly common for consumers to use porn as an escape mechanism or self-soothing technique, research indicates that those who consumed pornography to avoid uncomfortable emotions had some of the lowest reports of emotional and mental well-being.11 Another study examined the relationship between the frequency of online pornography consumption and mental health problems, particularly in the context of “experiential avoidance” or trying to avoid negative emotions. The study found that frequent pornography consumption was significantly related to greater depression, anxiety, and stress as well as poorer social functioning.12

Similarities between porn struggles and mental health issues

Did you know that watching a lot of porn can trigger similar symptoms as a mental health disorder?  Struggling with mental health issues and struggling with porn have more similarities than you’d think. Let’s take a look into a few similarities, side effects, and symptoms associated with both mental health issues and an obsession with or addiction to porn:

Throughout my years in the mental health profession, I have seen numerous misdiagnoses, at least a few of which were based primarily on a person’s sexual behavior, in particular the use of pornography. Typically in such cases, someone is using pornography and their loved ones or their therapist disapproves, so that person is slapped with an inaccurate diagnosis and pushed into therapy that won’t help them (and might even harm them by increasing their sexual and social shame, as we see with so-called gay conversion therapy). In other situations, I have seen people whose porn use was highly problematic to themselves and others be told that they should just become more comfortable with their sexuality.

Typically, the thinking behind these various misdiagnoses seems to be, “There must be something wrong with you. Otherwise, why would you be looking at porn, or that porn, or that much porn,” or, “There must be something wrong with you for being uncomfortable with your porn viewing. If you just embrace it, everything will be fine.” In both cases, rather than digging in and performing a full bio-psycho-social and sexual assessment, well-meaning but under-informed clinicians go with what they know – unresolved traumadepressionpersonality disorders, compulsivity, or whatever else they feel comfortable treating.

The good news is that sometimes these diagnoses are spot-on in terms of identifying the patient’s primary problem. Just as often, however, those diagnoses uncover and treat a secondary disorder or even something that’s not a disorder at all. Mostly this occurs because clinicians are not trained to appropriately explore sexual behaviors and identify them for what they are. They just don’t understand that something like porn use, even heavy porn use, could be a symptom of a psychological disorder without being a disorder itself. Nor do they understand that psychological disorders like depression, anxiety, and the like can manifest as symptoms of compulsive sexual behavior.

The use of pornography – even the heavy, seemingly compulsive use of pornography – can indicate (be symptomatic of) any number of psychological disorders. If and when those disorders are accurately diagnosed and treated, the individual’s struggles with pornography (and any other compulsive or impulsive sexual behaviors) will typically clear up. Let’s say an individual’s underlying issue is depression and he or she is self-medicating (numbing out) by compulsively using pornography. When the individual’s depression is effectively treated, his or her compulsive porn use will likely abate. Another example is an individual in the manic stage of Bipolar Disorder who feels driven, obsessive, and compulsive with sexual thoughts and behaviors. This person may end up viewing hours and hours of pornography, hooking up with strangers, and engaging in all sorts of other sexual behaviors. Once this person is properly medicated, however, the compulsive sexual behaviors will abate.

For a reverse example, let’s consider an individual whose true issue is compulsivity with pornography, though his lack of control over pornography is creating depression. In such a case, a therapist may misinterpret the client’s porn use as symptomatic of depression (rather than vice versa), and then aggressively treat the depression – assuming that when the depression clears, so will the client’s struggles with pornography. Unfortunately, because the client’s true underlying issue (compulsive porn use) is not being addressed, the symptom (depression) is likely to continue.

It is vital when sexual issues arise as a possible disorder or symptom requiring treatment that the client’s true situation is accurately assessed, acknowledged, and addressed. If, as in the first two examples above, compulsive sexuality is symptomatic of another disorder, that other disorder is primary and must be the initial focus of treatment. If, however, as in the third example, sexual compulsivity is driving the client’s depression, anxiety, and the like, then treatment should focus on stepping away from compulsive sexual behaviors.

As a best practice, before making any diagnosis directly related to an individual’s sex-porn behaviors, such as Compulsive Sexual Behavior Disorder (CSBD) as defined by the World Health Organization in the ICD-11, clinicians should first rule out other mental health issues that may exacerbate or be exacerbated by porn use, or that may symptomatically manifest through porn use. Such disorders include (but are not limited to):

At the end of the day, therapists must recognize and understand that compulsive and impulsive sexual behaviors can arise related to any number of psychological conditions. Clinicians must also recognize and understand that the reverse may be true, meaning any number of psychological issues can arise related to compulsive and impulsive sexual behaviors. Thus, it is incumbent on the therapist to fully assess the client, including sexual issues – where they started, how they manifest, and why they manifest – before assigning a diagnosis and proceeding with treatment.

If all of this sounds a little bit confusing, that’s because it is. Especially for lay people and clinicians who are not adequately trained to assess and diagnose sexual symptoms and sexual disorders. Most clinicians are not – many states require special certification to practice. Therapists who are unsure of a diagnosis for a particular client because sexual issues, such as porn use, are part of the scenario should either make a referral to or seek outside guidance from a specialist in sexual issues. Without that, the client may be underserved.