The Potential Cutaneous Effects of Pornography Addiction: A Narrative Review

Pornography addiction is an area of increasing concern, particularly due to the ubiquitous nature of pornographic material on the Internet. Even so, there is no formal Diagnostic and Statistical Manual of Mental Disorders (DSM-5) inclusion of compulsive pornography use as a behavioral addiction. Although the psychosocial impacts of pornography addiction have been studied, the risk of direct skin injuries and behavioral changes brought about by excessive pornography usage remain to be seen. Adult males constitute the majority of cases of engaging in risky and violent sexual behaviors with an unclear association with pornography consumption. Adult females may be likely to copy pubic hair trimming patterns analogous to those seen in pornographic content, even though attitudes towards labiaplasty are unclear. Finally, adolescents regularly exposed to pornography have been found to replicate sexual activity seen in pornographic material and have earlier sexual activity. In the literature evaluated, an association between pornographic material and direct cutaneous disease remains a major area of further research.

sociobehavioral changes, or skin injuries, are described in Table 1.

High-risk autoerotic maneuvers and genital injuries in males
In rare cases, adult males engaging in excessive masturbation had direct skin manifestations like hemorrhagic bullae, urticaria, or even Fournier's gangrene [8][9][10]. Additionally, males were more likely to engage in risky behaviors like autoerotic asphyxiation, often leading to unintentional death [11,12]. These cases had some form of pornographic materials during the event such as magazines, webpages, and pictures. Overt skin findings include purpura and strangulation marks. Penile strangulation is also an uncommon phenomenon whereby constricting objects (usually metal) are placed around the penile shaft to increase erotic arousal. These cases are usually emergencies and present with overt penile injury including edema and necrosis [13]. There have been only a few overt cases of penile strangulation having pornography as a patient risk factor [13].
For adult males, the increased likelihood of engaging in dangerous autoerotic maneuvers may have underlying biopsychosocial causes [22]. Even though there is similar behavior reported in women, the majority of practitioners are men. Therefore, the tendency to partake in such maneuvers may not solely be attributed to erotic material or pornography addiction. However, engaging in such maneuvers has a high risk of cutaneous injury and even death as evidenced by the numerous case reports of accidental death during autoerotic asphyxiation. In a review of autoerotic deaths in the literature from 1954-2004, it was found that most victims were Caucasian males (390/408 cases), with no evaluation of pornographic materials used [23]. This represents a potential area of future research as only one case report demonstrated accidental death while ostensibly trying to replicate violent pornographic material viewed on the internet [12].
Similarly, in the cases of masturbation-induced urticaria and hemorrhagic bullae with lichen planus, the association with pornographic or erotic materials was not clearly mentioned [8,9]. There may be hesitation to mention this during physician encounters, especially if lesions on the genitalia are already uncomfortable for patients. Providers should consider including pornography consumption as a potential screening question for patients with atypical genital lesions.

Attitudes towards pubic hair trimming or labiaplasty in women after exposure to pornography
More evidence points towards pubic hair trimming among women in an effort to mimic patterns seen in pornographic materials [16,17]. This may reflect a general cultural trend or a tendency to internalize the pubic hair patterns seen in pornography. One major psychological trend that has been studied is the increasing belief that extra hair makes patients feel 'less feminine', thereby leading to extra removal behaviors [24,25]. Additionally, there is a risk of genitourinary laceration during depilation, which is predominantly done by razors [26]. Adult females' tendency to undergo labiaplasty procedures after exposure to pornography is still unclear as there is insufficient evidence in studies analyzed thus far [17]. Schick et al. noted a decreased likelihood to attempt risky sexual behaviors among women who were dissatisfied with their genital appearance, which may be one of the few protective instances against genital injury from perilous sexual maneuvers [15].
In a case series of six women with persistent genital arousal disorder, an association with certain dermatoses existed [14]. This was often accompanied by masturbation to relieve sensations of genital engorgement, often requiring the use of pornographic material. Further, after viewing media including pornography, adult females were more likely to have self-image issues, leading to pubic hair trimming patterns. However, any association between labiaplasty surgeries and masturbation remains unclear [15][16][17].

Risk of early sexual activity and mirroring acts of pornographic performers by children
Notable reports of masturbation-induced genitocutaneous injuries among adolescents focused on males. The first of two notable cases involved a urethrocutaneous fistula from the insertion of magnets into the urethra [18]. These magnets were initially inserted one year prior to the emergency department presentation. The other case involved salicylate toxicity secondary to the use of topical methylsalicylate as a masturbation lubricant [19]. In both cases, the use of pornography was not explicitly stated. Further investigation is needed to determine whether such cases arose due to material viewed by the adolescents.
As Wong et al. demonstrated, an increased likelihood of early sexual activity in adolescents who regularly consumed pornography exists [20]. Although no overt cutaneous manifestations were described, another cross-sectional study by Ng et al. in a Singaporean sexual health clinic found an increased frequency of encounters with sex workers among adolescents aged 16-19 years [21]. Many patients presented with cutaneous manifestations such as genital warts, ulcers, and molluscum.
In adolescents, recurring themes include attempting to recreate what is seen in pornographic materials and engaging in early sexual activity; either with peers or with sex workers [20,21]. These can have overt cutaneous manifestations, such as genital injury or lesions from sexually transmitted diseases. In a cross-sectional study of Swedish high school students, it was found that males with a high level of pornography consumption were statistically more likely to attempt acts seen in pornographic films, which can be problematic if they regularly view violent genres of pornography with risk of genitocutaneous injury [24].

Preemptive Management by Pediatricians
Children and adolescents have been found to be at risk for autoerotic asphyxiation, especially if there is a history of emotional dysregulation and sadomasochistic relationships. Choking games among the young with related cutaneous findings like strangulation marks and neck erythema may be early manifestations of autoerotic asphyxiation, as a subset of these progress to fatality [27]. Pediatricians should therefore be alert to such behavior to interrupt it and prevent further its development.

Potential treatments and therapies
The lack of specific diagnostic criteria is also coupled with a lack of evidence-based management for pornography addiction. In one notable case series, a majority of male patients (17/19; 89%) with compulsive sexual behavior experienced a reduction in symptoms when taking naltrexone, with treatment ranging from 2-27 months. However, these patients were concurrently taking other psychotropic medications during naltrexone initiation [28].
In another case, a patient with obesity and cue-triggered snacking was prescribed topiramate 50 mg daily for weight loss. Coincidentally, he also noticed an improvement in trigger-associated compulsive sexual behaviors such as the consumption of prostitution. Both binge eating and consumption of prostitution reoccurred after the drug was discontinued, and decreased again after reinitiation [29]. Further research into these medications may be a first step into the potential pharmacologic management of pornography addiction and by extension, cutaneous injury.

Risks among pornographic performers
Finally, among pornographic performers themselves, there is a high risk of cutaneous sexual disease transmissions such as herpes simplex and human papillomavirus as these are ubiquitous and not routinely monitored [30]. Instead, most sexually transmitted disease panels for performers are limited to HIV, gonorrhea, chlamydia, and syphilis. Pornographic films featuring unprotected sexual intercourse may encourage viewers to engage in unprotected sex without thought of the associated sexually transmitted infection and pregnancy risks.
Overall, there may not be a clear picture of cutaneous manifestations of pornography addiction ( Figure 2). Certainly, excessive masturbation can lead to genital injury, but the strength of their association still remains to be seen and is an area of further research.

FIGURE 2: Current gap in literature pertaining to the direct link between pornography and cutaneous injuries or effects.
Among studies evaluated, a link between pornography and sex acts like masturbation was studied extensively in adolescents [20,21,24,27]. Additionally, the rare cutaneous sequelae of excessive masturbation like hemorrhagic bullae, Fournier's gangrene, and penile asphyxiation were demonstrated in notable cases [8,10,13]. However, the direct link between pornography and cutaneous effects on genital and extragenital skin was not clearly evaluated in any of the studies included, thereby highlighting a notable gap for further study.

Conclusions
There is no unified psychiatric classification of pornography addiction, which often falls into either internet addiction or hypersexuality disorders. Similarly, there is no consensus on the treatment of behaviors where excessive pornography consumption causes significant impairment in daily functioning. Our review of the literature yielded articles evaluating an association between pornography and masturbation, or masturbation and cutaneous injuries, with an unclear association between pornography and cutaneous pathologies.
Different behavioral patterns occur with cutaneous manifestations, often in the presence of pornography. Adult males are at risk of engaging in sexual behaviors with a risk of injury or death, like autoerotic asphyxiation. Adult females often trim their pubic hair to mirror pornographic performers. Children and adolescents are likely to replicate sexual acts seen in pornographic material, leading to an increased risk of early sexual activity, sex worker solicitation, and sexually transmitted diseases. Further research is needed to evaluate the direct relationship between pornographic addiction and genitocutaneous pathology with or without psychosocial changes. Relationships exist in the link between masturbation and skin injury, although the strength of association remains unclear and overt injury is quite rare. These major gaps in knowledge represent avenues for more thorough research. Using data from the national community-based Australian Twin

Appendices
Registry, we used biometric model fitting to examine the extent to which the genetic liabilities for DG and alcohol use disorder (AUD) were shared, and whether this differed for men and women. The effect of using categorical versus dimensional DG and AUD phenotypes was explored, as was the effect of using diagnoses based on the DSM-IV and the proposed DSM-5 diagnostic criteria.
The genetic correlations between DG and AUD ranged from 0.29 to 0.44. There was a significantly larger genetic correlation between DG and AUD among men than women when using dimensional phenotypes. Overall, about one-half to two-thirds of the association between DG and AUD was due to a shared genetic vulnerability.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.