Physiological, Psychosocial and Substance Abuse Effects of Pornography Addiction: A Narrative Review

Internet pornography provides explicit content in various forms and can progress from habit to addiction. The consumption of online porn has risen due to the general use of current technology. The main reasons people consume it are sexual arousal and sexual enhancement. We planned this review study to identify the reasons for online pornography utilization, the mechanisms involved in its addiction, and its physiological, emotional, behavioral, social, and substance abuse effects. After a detailed literature search using PubMed Central and Google Scholar, four case studies and nine original articles from 2000 to 2022 were included. The main findings of the literature demonstrated that watching porn was most frequently done out of boredom, for sexual gratification, and to pick up new fashion and behavior ideas from these movies. In all facets of the users' lives, negative consequences were seen. Due to the explosion of new technologies, online pornography has risen to an alarming level, which has very injurious effects on societies and individuals. Therefore, it is high time to get rid of this addiction to protect our lives from its harmful effects.


Introduction And Background
Technological advancement in the 21st century has paved the way for new research in the field of addictive disorders, including highly recognized substance addictions and behavioral addictions. These addictions encompass frequent cravings, lack of control, and neglecting duties despite being aware of their mortifying effects on personality and psychological well-being. Pornography consumption, excessive masturbation, and cybersex come under hyper-sexual disorder, a behavioral disorder [1]. Despite the lack of reliable scientific information, being poorly understood and understudied, assessment of this disorder has been a vital task [1,2]. The prevalence rates range from three to six percent, and its affiliation with shame and extreme distress warrants a thorough examination. Technology and especially the internet, has broken ground and tempted people, encouraging their behavior to develop hyper-sexual addictions like online pornography consumption for self-gratification [1].
There has been a significant increase in the consumption of sexually explicit material, even in places where it is illegal, over the years [2,3]. Porn sites getting more visitors than Amazon, Twitter and Netflix combined shows how alarming this situation is. The increase in online pornography consumption can be appreciated because, in 2019, the world's top porn site's traffic jumped to one billion visitors per month, placing it among the world's top internet sites [2]. Today, 46-74% of men and 16-41% of women watch porn [3]. Various factors have been considered in the striking increase in watching online pornography. Since the outbreak of COVID- 19, there has been a significant increase in internet surfing, online shopping, and of course, online pornography due to lockdown and social restrictions [2]. Boredom and loneliness due to these restrictions are essential factors in this regard [2,3]. Considering 'porn' and 'depression' are the most searched topics online during the pandemic, emphasize the vital connection between the former and the latter [2] Not only has pornography been consumed to temporarily lower stress from being lonely and isolated, but also information seeking, sexual arousal, and enhancement prove to be driving forces towards greater porn consumption [3]. People watch pornographic content to elate their moods and evade routine stressors, but unknowingly pornography itself is a significant stressor. Neurobiological explanations suggest that pornography has dramatically reduced overall sexual activity among couples [2]. A sharp increase in the prevalence of erectile dysfunction (ED) and low sexual desire was observed in men under 40. In a study conducted in 1999, ED and low sexual desire rate was 5%, respectively. By 2011, ED rates have increased to 14-28% in European men between 18-40 years [4]. The following research paper has been formulated to explain the increase in pornography statistics and its impact on physiological, social, and emotional aspects

Data Extraction
Four reviewers read the full articles independently and extracted the data considering the following variables: title, abstract, methods, and main results. The data were then verified for completeness and accuracy and were harvested into a Microsoft Office Word-generated pro forma.

Study Selection
As a result of the keyword terms in the databases, a total of 300 articles were obtained. For this review, researchers used a literature search strategy outlined in Table 1

Results
Most of the studies were conducted between 2017 and 2022. The most common journals used for these studies were "Archives of Sexual Behavior" and "Frontiers in Psychology". Most studies were conducted in the United States of America (USA) and Spain. The most common study type was prospective (  The most common objective in these studies was to identify the reason for pornography consumption and its effects on specific aspects of one's life. The most common method used in these studies was a questionnaire-based survey or interviews. Mostly inclusion criteria were selecting random individuals from either universities or schools. Most studies did not have exclusion criteria ( Table 3).

TABLE 3: Summary of Original Articles -Methodology
Most of the studies had a sample size of less than 1000. Most studies preferred observing the adult population's behavior and patterns, and the chi-square test was frequently utilized for statistical analysis.
Key results of these studies showed that the common reasons to watch pornography were boredom, seeking sexual pleasure, and learning new trends and behavior used in such films. It was also noticed that watching such content had tremendous effects on all aspects of their lives, mainly detrimental. No specific clinical diagnoses were made in these studies ( Our findings corroborate that sexual media matters for many young adolescents and more so for boys compared to girls.

TABLE 4: Summary of Original Articles -Materials
Most of the studies describe mixed effects of pornography on the adult population. These include physiological effects on sexual variety and orgasm; emotional effects, i.e., satisfaction; social effects, i.e., stigma in friends' circle associated with not watching pornography and less commonly, pornographyinduced drug effects ( Table 5).

TABLE 5: Summary of Original Articles -Factors Studied
The majority of the studies revealed the common physiological effects of pornography include risky sexual behaviors, the development of sexual trajectories, and the use of it with a partner to do different sexual acts and to achieve orgasm. Moreover, common emotional effects described in most studies are to relieve boredom, escape negative thoughts, obtain pleasure and sexual gratification, and enhance sexual performance along with the sexual drive. Additionally, most studies showed that common social effects comprise bonding with male friends, spending more time on websites, difficulty stopping watching pornography sites, and not having sex in a while. Though pornography-induced drug abuse is less common than other effects, these are more serious and include the use of substances to do sexual acts that are out of the norm or to reflect these situations ( websites, and unsuccessfully trying to spend less time on the websites. The first factor was identified as "interoceptive," reflecting items related to circumstances that primarily involve the individuals themselves and stemming from internal feelings. These included being alone, lonely, bored, and aroused. The second factor, identified as "impotent," reflected the increased likelihood of pornography use associated with the absence of possibilities to engage in sexual intercourse, specifically, not having sex in a while (no sex) and not finding someone to engage in sexual intercourse with (no one to sex).

TABLE 6: Summary of Original Articles -Description of Studied Factors
Most case reports deal with pornographic addiction and its relation with different entities and were conducted during the year 2014-19 in Indian Subcontinent and published in various journals ( Table 7).

TABLE 7: Summary of Case Reports -Article Details
The majority of the case reports describing pornographic addiction were conducted in males aged 20-40 years and described the common signs of addiction as being low self-esteem, depression, shyness, and lack of appetite. The most common symptoms were losing interest in sex and spending an average of 5 hours watching pornography daily ( Table 8).

Gender Age Symptoms Signs
Adnan et al. [14] Male years Disinterest in sex Relative preoccupation with pornography for the past 3 years. Low mode Depressed look (HAM-D) score: 9 Daniel et al. [15] Male 22 years The intense sexual urge to view an unsuspecting female's exposed buttock. Low self-esteem, Shyness Avinash et al.

TABLE 8: Summary of Case Reports -Clinical Presentation
Half the studies conclude that porn does have physiological effects on the human body, while the other half negates this notion. All the studies describe the emotional effects of porn on the body, and most of the studies indicate that there is no porn-induced drug abuse in humans. Most studies conclude that porn affects the social life of humans ( Table 9).

TABLE 9: Summary of Case Reports -Factors Studied
Most studies described the physiological effects of porn, such as low mood, depression, decreased selfesteem, decreased appetite, etc. The emotional effects of porn includes: getting irritable when disturbed while watching porn, not being able to quit it even for a day, and watching women undress in real life to fulfill their desires. The social effects of porn include social awkwardness, inability to concentrate at work, decreased family interaction, and increased cybercrimes such as cyberstalking and pedophilia (

TABLE 10: Summary of Case Reports -Description of Studied Factors
The most effective therapies for pornographic addiction are Cognitive Behavioral Therapy (CBT), psychoeducation, counseling, distraction techniques, and pharmacological therapy such as fluoxetine or desvenlafaxine (Table 11).

Study by Therapies
Adnan et al. [14] Cognitive

Neuroscience of Pornography Addiction and Compulsive Sexual Behavior
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward or relief by substance use and other behaviors [18]. Online pornography corresponds to the use of the internet to engage in various gratifying sexual affairs [1]. Internet addiction comprises a heterogeneous spectrum of Internet activities with a potential illness value, such as gaming, shopping, gambling, or social networking [18].
Today, it has been considered that mostly the male population between 20-40 years of age is actively involved in pornography consumption, and factors such as knowledge and curiosity lead a person to this addictive behavior. This factor is comparable to the emotional factors because of the stigma of sexual talk in our society. In contrast, other studies reported that sexual arousal and sexual enhancement were the predominant motivations for pornography consumption among the self-reported reasons. Aside from sexual arousal and enhancement, coping and boredom are linked with greater use of pornography as well [3].
Hypersexual behavior is generally referred to as Compulsive Sexual Behavior (CSB). However, more recent definitions of CSB usually refer to multiple sexual behaviors that can be compulsive: the most commonly reported being masturbation, followed by compulsive use of pornography, promiscuity, compulsive cruising, and multiple relationships (22-76%) [4]. Anxiety disorders, mood disorders, substance use disorders, and sexual dysfunction have all been linked to hypersexual behavior. Pornography is merely one of the acknowledged accessories for hypersexual conduct, which is the subject of the majority of research investigations [1].
Porn users had greater electroencephalography (EEG) readings and less desire for masturbation porn, which is reflected in the difference in erection quality. It is well established that viewing pornography increases brain activity among regular users, particularly in the ventral striatum, which is crucial for anticipating rewards. These changes might cause the inability to restrain one's urges to engage in sexual activities. [1].

Physiological Effects of Pornography Addiction
Premature ejaculation, erectile dysfunction, libido, and arousal dysfunction are the most often reported sexual dysfunctions in the general population. Some unique studies associate chronic masturbation, delayed ejaculation, higher anxiety levels, and sexual dysfunction with increased consumption of pornographic content. In a sample of European heterosexual men who had complained of a problem with decreased libido, Carvalheira et al. examined the association between masturbation and the usage of pornography and sexual desire. It was shown that more than half of the study participants who had noticed a substantial drop in libido over the previous six months of the evaluation had used pornographic materials at least once a week. [19] A study in 2015 on high school students discovered a correlation between frequent porn consumption and poor sexual desire [4].

Psychosocial Effects of Pornography Addiction
Most of the studies also described the psychological effects of porn, such as low mood, depression, decreased self-esteem, decreased appetite, etc. There are higher incidence rates of general anxiety, psychological distress, and decreased emotional bonding with family members among Individuals with pornographic addiction [1,3,20]. Most of the studies have shown that porn addiction is one of the types of substance addiction. Our study highlights that common reasons to watch porn were boredom, new trends and behaviors, and seeking sexual pleasure, similar to the results of other articles as participants used pornography to have sexual gratification as a part of masturbation as pornography consumption is an important tool for mood management and stress relief. Common emotional effects described in other studies that are linked with greater consumption of pornography involve emotional coping with social isolation, loneliness, and stress, to escape negative thoughts, to enhance sexual performance along with the sexual drive [3].
Pornography addiction is related to significant psychological and socio-functional impairment [20]. Longterm use of online pornography leads to direct and proportional consequences of engaging in maladaptive behavior. Pornography use has been associated with sexual dissatisfaction, which leads to having more sexual partners and engaging in paid sex. This is noted in relationships which are usually onesided. [1] Another reason for the increase porn consumption may be that people use sex as a survival mechanism for dealing with depressive symptoms, loneliness, and even fear of death. During this time, coronavirus-themed porn might be viewed as an eroticization of fear [3]. Frequent viewers of sexually explicit material had a more liberal or positive attitude towards it and believed that using it could create a more stimulating sex life [20].
Pornography provides temporary relief from negative thoughts like anxiety and stress. With the easy availability of the internet and the emergence of computer technologies, pornography has become an essential economic venture [3,19]. Still, most studies conclude that porn affects the social life of humans. These include social effects, i.e., stigma in friends circle associated with not watching pornography. Most studies showed that common social effects comprise bonding with male friends, spending more time on websites, and difficulty in controlling oneself from watching pornography sites. The social effects of porn include social awkwardness, not being able to concentrate at work, decreased family interaction, and increased cyber crimes such as cyber stalking and pedophilia.

Substance Abuse Effects of Pornography Addiction
Alcohol consumption and being under the influence of addictive drugs alter the sexual behavior of humans. Pornographic consumption stimulates the brain's reward system as those in drug addicts, reflecting the relationship between drug addiction and pornographic addiction [20]. A study found that 9.80% of the drug addicts studied had pornographic addiction as well [1]. However, past studies have not shown a definite link to whether pornographic addiction increases drug abuse. The changes found in the brain of substance abusers have been compared to the changes in pornographic addiction, including; sensitization, desensitization, hypo-frontality, and Dysfunctional stress systems as evidenced by magnetic resonance imaging (MRI) and electroencephalography (EEG) [1]. More research is needed to establish a link between drug abuse in pornographic addiction and vice versa.
We analyze that there needs to be agreement on how detrimental it is to consume pornographic material. In this age of technology and the internet, it is imperative to address the sexual, psychological, and behavioral issues brought on by minors' easy access to online pornographic content and anonymity. Pornography should not be prohibited when used in moderation for amusement during free time or by couples to increase their sexual satisfaction. However, excessive use that causes avoidance, emotional issues, anxiety, and depression should be addressed. It is essential to identify and address the fundamental causes of pornography addiction, which frequently include boredom, loneliness, strained relationships, despair, etc. It is advisable to see therapists who view this as an issue. Physical activity is incorporated into daily living to reduce consumption and dramatically benefits a person's healthy relationships. The typical time spent watching porn decreases with a healthy routine, early bedtime, and limited late-night viewing.

Conclusions
Internet addiction includes various online behaviors that may have medical implications. Concurrently, the development of new technology has increased problematic addictive behavior, particularly addiction to online pornography. The most often reported sexual dysfunctions in the general population are premature ejaculation, erectile dysfunction, and desire and arousal dysfunction. The reward system's functioning, as well as the brain connections that control erection and sexual desire, may change as a result of regular exposure to porn, which may cause a delay in ejaculation. Hypersexual behavior has been associated with anxiety problems, mood disorders, substance use disorders, and sexual dysfunction. Low mood, melancholy, lower self-esteem, and decreased appetite are some of the physiological impacts of porn. Injurious psychological and emotional repercussions from excessive pornography viewing include anxiety, melancholy, and other clinical manifestations like sexual dysfunction and psychosexual dissatisfaction. Online pornography use for an extended period has direct and proportional adverse effects on behavior.
Appendices 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.