Introduction

Over the past decades, with the popularization of high-speed internet, the consumption of pornographic material has become a highly prevalent activity across the globe (de Alarcón et al., 2019; Hald et al., 2013). The rise of new technologies such as the smartphone, the advancements in the industry associated with the production of pornography, and the free and anonymous access to a massive and distinct quantity of sexually explicit material (which can easily be done without leaving one’s own room), are some of the factors that may explain the increase in the prevalence of this phenomenon (de Alarcón et al., 2019; Wood, 2011). Even though pornography viewing is generally more common in males, significant proportions of women have had regular contact with this type of content (Kowalewska et al., 2020). For instance, according to a large and nationally representative Australian study, 84% of men and 54% of women had ever seen pornographic material, with 76% of men and 41% of women describing that they have consumed this type of content in the past year (Rissel et al., 2017). In addition, data from another nationally representative survey from the US described that 94% of men and 87% of women reported lifetime pornography use, with the mean age of first exposure to pornography being 13.8 years for males (Herbenick et al., 2020).

Considering the widespread use of pornographic material, researchers and clinicians started investigating potential psychological and sexual negative outcomes associated with this type of behavior. According to the available evidence, not all pornography regular users report physical and mental health problems, and there is still controversy if high frequency pornography use is always problematic (Bőthe et al., 2020b; de Alarcón et al., 2019). Nonetheless, a significant proportion of these regular pornography users report several potential consequences associated with the behavior. For instance, according to a large cross-sectional online survey from Poland (n = 6463 students), self-perceived addiction was reported in 15.5% of current pornography users, and approximately 25% of these participants described decreased sexual satisfaction (Dwulit & Rzymski, 2019). Other potential consequences may take the form of mental health problems such as depression, anxiety, and suicidality; sexual difficulties, including premature ejaculation, erectile dysfunction, and reduced libido; other addiction-like symptoms, such as cravings, compulsive behavior, and withdrawal symptoms (de Alarcón et al., 2019; Fernandez et al., 2021).

Considering this context, comes into relevance the concept of problematic pornography use (PPU), which is still in construction and surrounded by controversy. On the one hand, some researchers consider it to be a behavioral addiction (Brand et al., 2019; de Alarcón et al., 2019; Potenza et al., 2018), with some preliminary evidence for the existence of tolerance and withdrawal-like symptoms (usually considered components of the addiction model) in individuals with PPU (Griffiths, 2005; Lewczuk et al., 2022).

In terms of official diagnostic categories, recently the World Health Organization (WHO) included compulsive sexual behavior disorder (CSBD) in the International Classification of Diseases 11th Revision (ICD-11) (World Health Organization, 2022). CSBD can be described as a persistent pattern that lasts for at least six months, marked by “failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it,” which is also associated with significant impairment or distress (World Health Organization, 2022). According to the ICD-11, CSBD may be expressed through different behaviors, including pornography use and masturbation. In addition, distress exclusively associated with negative moral views towards sexual urges, impulses or behaviors is not enough to make a diagnosis of CSBD (World Health Organization, 2022). Even though some researchers in the field consider that CSBD is a behavioral addiction, it was classified in the ICD-11 as an impulse control disorder (Rumpf & Montag, 2022).

Nevertheless, the concept of CSBD may not comprehend all individuals with PPU. For instance, a recent survey from Poland, based on a nationally representative sample of adults (n = 1541 participants), described the prevalence of PPU (defined by the “Brief Pornography Screen” [Kraus et al., 2020]) as 22.84%, while the prevalence of CSBD was 4.67% (according to the “CSBD-19” scale [Bőthe et al., 2020a]) (Lewczuk et al., 2022).

On the other hand, according to some researchers on the topic, in several cases, PPU may be associated with moral incongruence, in which the perception that a given individual has about his own use of pornography as being problematic may arise in the incongruence between his own beliefs and the pornography-associated behavior, which ultimately may lead to the significant distress experienced by the individual (Grubbs et al., 2019). For instance, there is empirical evidence describing that moral incongruence and religiosity are independently associated to self-perceived addiction to pornography, and that the interaction between frequency of pornography use and moral disapproval is a significant predictor of self-reported feelings of addiction to porn (Grubbs et al., 2022; Lewczuk et al., 2021). In addition, some researchers suggest that the moral disapproval of pornography use may amplify feelings of addiction and compulsivity in relation to the behavior, with moral disapproval moderating the association between the behavior and self-perceived addiction in such a way that higher levels of moral disapproval may lead to higher self-perceived addiction at a given frequency of the behavior (Grubbs, 2021; Grubbs et al., 2022). Interestingly, moral incongruence was also significantly associated with self-perceived addiction to other problematic behaviors, such as gaming, gambling, internet and social media use, which may suggest that moral incongruence plays an important role in other addictive behaviors as well (Grubbs, 2021; Grubbs et al., 2022; Lewczuk et al., 2021).

Regardless of controversies concerning the diagnosis, patients with PPU have already been the target of several potential treatment interventions. Some of the investigated strategies include pharmacological treatments (such as naltrexone and antidepressants), cognitive behavioral therapy (CBT), self-help and online tools, among others (Bőthe et al., 2021; Gola & Potenza, 2016; Lotfi et al., 2021; Sharma et al., 2022). Importantly, several individuals who self-identify as having PPU (on internet forums focused on this issue) advocate or encourage abstinence from pornography and sexually stimulant materials as the only way to reverse adverse consequences associated with this potentially addictive behavior (Fernandez et al., 2021). Moreover, there is evidence that these individuals also aim to abstain from masturbation in many cases. As reported in a previous investigation, while 100% of the participants of a qualitative study, based on abstinence journals from an online porn abstinence forum (n = 104 abstinence journals), intended to abstain from pornography, approximately 86% aimed to abstain from pornography and masturbation (Fernandez et al., 2021). These individuals often report several benefits associated with pornography abstinence, that are not restricted to sexual function, but also influence other domains in social life and mental health (Fernandez et al., 2020, 2021).

Previous studies reviewed treatment interventions for CSBD and PPU. For instance, one of these studies reviewed behavioral interventions for CSBD, including nine clinical trials after searching for eligible references on Google Scholar (Borgogna et al., 2022). Another study (Sniewski et al., 2018), performed a literature review of treatment strategies for PPU, focusing on self-perceived problematic pornography use, searching for studies published in English between 2000 and 2017. Another paper reviewed interventions for compulsive sexual behaviors (Efrati & Gola, 2018). Furthermore, the World Federation of Societies of Biological Psychiatry published a guideline, reviewing the English-language literature on pharmacological treatments for CSBD by searching potentially eligible studies in Pubmed and Google Scholar (Turner et al., 2022). Even though these studies presented important and significant contributions to the field of PPU and CSBD, they were not systematic reviews in nature.

A prior systematic review aimed to investigate the evidence regarding the use of acceptance and commitment therapy (ACT) for PPU (Ghazanfarpour et al., 2020). This study presents important limitations in terms of lacking a comprehensive search of the literature on the topic, identifying only 5 records in database searches (Ghazanfarpour et al., 2020). Another study systematically reviewed strategies of treatment for online sex addiction (including studies published between 1995 and 2014), describing a few studies that treated individuals with PPU (Dhuffar & Griffiths, 2015). Lastly, during the development of our study, another systematic review focused on a similar topic was published; this study reviewed treatments of CSBD and PPU searching (in PubMed, Scopus, Web of Science, and PsycInfo) potentially eligible peer-reviewed studies published between 2000 and 2021, also assessing the quality of the evidence with the use of the CONSORT criteria (Antons et al., 2022). Studies were included in this systematic review if they were written in German or English, were published in peer-reviewed journals, and in terms of methodology were at least case series, case–control, pre-post intervention, or correlation studies with measures of change in outcomes of interest (Antons et al., 2022). Antons et al. included 24 studies (only 13 were about PPU), with the majority of these studies describing psychotherapeutic interventions (mainly interventions applying components of CBT). In this sense, even though there may be some overlap between the review by Antons et al. (2022) and ours, our study presented a more comprehensive search focused on PPU, also including studies (without restrictions in language and time of publication) that were case reports and unpublished manuscripts (for instance thesis dissertations). In addition, we updated our searches in electronic databases up to April 2023, in order to give an updated account of the literature on the topic. Tolerability and side-effect measures of the included studies were extracted as well. Lastly, we also reported the quality of the evidence for each type of distinct intervention using the GRADE approach (Balshem et al., 2011).

Therefore, the main aim of this investigation was to systematically review treatment interventions for individuals with PPU, evaluating the quality of the evidence, the efficacy of the intervention, and the description of other outcomes related to each treatment approach. We adopted a more broad definition of PPU (described in detail in the methods section) given the controversies surrounding its diagnosis, the reason why we also reported the PPU definition for each included study. Our secondary aim was to summarize the literature on the potential side effects and tolerability measures associated with each reported intervention.

Method

Search Strategy and Selection Criteria

In this systematic review, references were identified through searches of electronic databases (PubMed/MEDLINE, Embase, PsycINFO, Web of Science), from inception up to April 1, 2023, searches of reference lists of included studies, and the consulting of experts in the field. PubMed/MEDLINE search terms were (“problematic pornography use” OR “problematic pornography” OR “problematic porn*” OR “porn addiction” OR “pornography addiction” OR “porn*” OR “pornography consumption”) AND ("Drug Therapy"[Mesh] OR "Psychotherapy"[Mesh] OR "Therapeutics"[Mesh] OR “treatment” OR “prescription” OR “drug” OR “pharmac*” OR “medicine” OR “pill*” OR “medication” OR “pharmacotherapy” OR “therapy” OR “intervention” OR “trial” OR “psychotherapy” OR “psychological treatment” OR “therapeutic*”), with the use of equivalent search terms for the other databases (Supplementary File 1).

After duplicates removal, titles and abstracts were screened independently by a pair of investigators (THR, LTN), with this procedure being performed in Rayyan, an online tool for systematic reviews (Ouzzani et al., 2016). Full-texts of potentially eligible studies were retrieved and screened independently by the same pair of investigators (THR, LTN). Disagreements in each of these stages were solved in consensus, with a third investigator (AOS) solving potential conflicts between the pair.

Inclusion criteria were the following: (1) studies describing treatment interventions for patients with problematic pornography use (PPU). Given the controversies in the diagnosis of PPU, we adopted a more broad definition of the phenomenon (PPU could be diagnosed by the clinician, for instance as pornography addiction or a similar concept; be based on the assessment of specific scales for measuring the construct, or be based on specific criteria defined in the study), also including studies that investigated self-perceived PPU. Individuals diagnosed with CSBD or hypersexual disorder with PPU were also included as long as it was possible to extract data concerning problematic pornography use; (2) intervention studies or case reports/case series; (3) peer reviewed papers, conference abstracts, and unpublished research manuscripts were eligible for inclusion. Studies were excluded if they met any of the following criteria: (1) articles that did not report original data; (2) observational studies; (3) studies which did not describe the outcomes of the intervention; (4) qualitative studies focused on the experience of patients with problematic pornography use under treatment; (5) studies describing the treatment of child pornography users; (6) studies in which it was not possible to extract data concerning the treatment of patients with problematic pornography use. Language was not an exclusion criteria.

The manuscript was reported according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Page et al., 2021). The protocol of the study was registered at PROSPERO in August 2022 (CRD42022356353). Considering that this is a systematic review, it was not necessary to seek approval from a local research ethics board.

Data Extraction and Synthesis

Three investigators (THR, LTN, and AOS) extracted data from each included study to a standardized spreadsheet (each investigator extracted data concerning a third of the total included studies and checked the extraction performed by another investigator).

The extracted variables were the following: (1) identification: name of the first author, year of publication; (2) demographics: sex, age, marital status, sexual orientation; (3) study characteristics: study design, sample size, country of the study, presence of a control group (when applicable); (4) PPU variables: frequency of pornography use, time spent viewing pornography, length of illness, definition of PPU, adverse outcomes associated with PPU; (5) intervention: type of intervention, characteristics of the intervention (frequency, dosing), tolerability, side effects, outcomes associated with the intervention, length of follow-up; (6) comorbidity: presence and type of psychiatric comorbidity, presence and type of medical comorbidity.

Study quality and risk of bias were assessed by the same investigators that performed data extraction (THR, LTN and AOS), with the use of the Joanna Briggs Institute’s (JBI) checklists (Aromataris & Munn, 2020; Munn et al., 2020), with the use of a different JBI checklist for each type of study design. Studies were not excluded based on the quality assessment. For randomized clinical trials, we also used the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) (Sterne et al., 2019), while for quasi-experimental studies we additionally used the Risk Of Bias In Non-Randomized Studies—of Interventions (ROBINS-I) (Sterne et al., 2016). Lastly, even though we initially did not specify this procedure in our study protocol, we also assessed the quality of the evidence for each type of distinct intervention using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach (Balshem et al., 2011). Considering that we did not perform meta-analysis, we adapted the GRADE approach for the context of a systematic review with a narrative summary of the evidence as recommended by (Murad et al., 2017).

The data extracted from the included studies were described and synthesized narratively.

Results

The process of study selection is described in detail in Fig. 1. We identified a total of 8936 references in database searches. 28 studies were included in our systematic review, corresponding to a total of 500 participants. Table 1 and Supplementary Table 1 describe the characteristics of the included studies.

Fig. 1
figure 1

Study selection flowchart.

*Kraus and Sweeney (2019) reported two different case reports, each one describing a different intervention for problematic pornography use; therefore, this paper was split into two different study units

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Table 1 Characteristics of the included studies (k = 28)
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The majority of the included studies were cases reports (n = 16) (Bostwick & Bucci, 2008; Capurso, 2017; Cuppone et al., 2021; Darshan et al., 2014; Ford et al., 2012; Kraus & Sweeney, 2019; Kraus et al., 2015; Ortega et al., 2020; Şenormanci et al., 2014; Sharma et al., 2022; Shorrock, 2012; Skryabin et al., 2021; Wernik, 2012; Wéry et al., 2019; Yazdi et al., 2020). It is important to highlight that the paper by Kraus and Sweeney (2019) was split into two different study units (a and b), because it described two different case reports that met inclusion criteria for our review (out of 3 cases described in the manuscript), with each one of these two cases describing a distinct intervention for PPU. One study was a case series (Gola & Potenza, 2016); 7 were quasi-experimental investigations (Holas et al., 2020; Kellett et al., 2017; Levin et al., 2017; Minarcik, 2016; Rodda & Luoto, 2023; Sniewski et al., 2022; Twohig & Crosby, 2010), of which one was extracted from a dissertation (Minarcik, 2016). It is important to highlight that even though the sample size of the quasi-experimental study by Kellett et al. (2017) was N = 1, it is a single-case experimental study and even though these studies may apply a sample size of one they should not be classified as case reports (Krasny-Pacini & Evans, 2018). Four other studies were RCTs (Bőthe et al., 2021; Crosby & Twohig, 2016; Lew-Starowicz et al., 2022; Wainberg et al., 2006). Country of origin for each study can be seen in Table 1.

Methodological and Evidence Quality

According to the RoB2, high risk of bias was found for all included RCTs (Bőthe et al., 2021; Crosby & Twohig, 2016; Lew-Starowicz et al., 2022; Wainberg et al., 2006). As for the ROBINS-I quality assessment tool for non-randomized intervention studies, critical risk of bias was found for four quasi-experimental studies (Kellett et al., 2017; Minarcik, 2016; Sniewski et al., 2022; Twohig & Crosby, 2010), and serious risk of bias was found for the other 3 quasi-experimental investigations (Holas et al., 2020; Levin et al., 2017; Rodda & Luoto, 2023). Information about individual studies’ methodology appraisal according to the JBI checklists can be seen in the supplementary material (Supplementary Tables 2–5), with Table 2 summarizing the number of items met by each included study.

Table 2 Individual studies’ methodology appraisal according to the JBI checklists
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The quality of the evidence for each specific intervention according to the GRADE approach can be seen in Table 3, with all interventions receiving a “very low” rating, with the exception of ACT, which received a “low” grade.

Table 3 GRADE approach for assessing the quality of the evidence for the treatment of problematic pornography use and pornography use-related outcomes (which can be seen in detail in Table 1) by each intervention
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Treatment Approaches for Problematic Pornography Use

Pharmacological Treatments

An opioid antagonist, Naltrexone, was investigated in the treatment of PPU comorbid with tobacco use disorder (Capurso, 2017). The patient's average daily use of pornography decreased from 1.65 h to 16 min, and daily use of cigarettes from 30 to 10 at the first 2 weeks of follow-up, with naltrexone 50 mg/day. Due to complaints of anhedonia, the patient discontinued treatment and symptoms regressed to baseline. After restarting treatment at a 25 mg daily dose, daily use of porn decreased to 1.25 h but smoking did not change. As anhedonia persisted with a reduced dose, treatment was discontinued (Capurso, 2017). Another case report described the use of Naltrexone 50 mg/day, in association with sertraline 100 mg/day (that was mainly used for the treatment of psychiatric comorbidity), for PPU; the patient presented sustained remission (at least 3 years) of PPU with the treatment (Bostwick & Bucci, 2008).

A double-blind placebo controlled RCT investigated the efficacy and tolerability of Paroxetine and Naltrexone in the treatment of CSBD in 73 heterossexual males for 20 weeks (Lew-Starowicz et al., 2022). In assessments based on clinical interviews patients treated with paroxetine or naltrexone (in comparison with placebo) were more likely to present cessation of any problematic sexual behavior for more than 30 days at week 8 of treatment (p = 0.029, Cramer’s V = 0.34), to present reduced frequency of sexual binges at week 20 of treatment (p = 0.031, Cramer’s V = 0.34), and to present reduced frequency of problematic sexual behaviors at weeks 8 (p = 0.016, Cramer’s V = 0.31) and 20 of treatment (p = 0.017, Cramer’s V = 0.37). Ecological momentary assessment of cravings for pornography use and sexual encounters indicated a significant decrease for both in the paroxetine condition at the end of treatment in comparison with baseline. Nevertheless, according to results based on data from specific questionnaires of CSBD symptoms (Table 1 in detail) and self-reported measures of pornography consumption (duration and frequency) Naltrexone and Paroxetine were not statistically superior to placebo (Lew-Starowicz et al., 2022).

An RCT investigated the effect of a flexible dose of citalopram (20–60 mg/day) versus placebo in the treatment of compulsive sexual behaviors in men who have sex with men for 12 weeks (n = 28) (Wainberg et al., 2006). In both treatment arms, participants presented improvements in several variables associated with compulsive sexual behaviors; nevertheless, most of these differences were non-significant in the comparisons between the citalopram and placebo groups, including the reduction in hours per week spent using the internet for sexual purposes. The citalopram group presented significantly higher reductions only in frequency of masturbation (p < 0.01), sexual drive/desire (p < 0.05), and time spent watching pornography per week (p < 0.05). In addition, it is essential to highlight that in the study, according to a secondary analysis, sexual side effects mediated treatment effects on frequency of masturbation and pornography use (Wainberg et al., 2006).

Another opioid antagonist, Nalmefene, was investigated in the treatment of PPU (Yazdi et al., 2020). In this case, the patient presented significant improvement in cravings and days using porn, with a worsening in both variables upon discontinuing the medication during follow-up. After restarting Nalmefene, the patient presented remission of PPU (also illustrated in the CSB-Y-BOCS, which displayed 0 points for compulsions and obsessions) and sustained abstinence over few years until his passing for a non-disclosed reason not connected to PPU (Yazdi et al., 2020).

Psychological Treatments

Acceptance and Commitment Therapy (ACT) was an intervention widely investigated for the treatment of PPU. For instance, a quasi-experimental investigation with 6 males studied the effects of an ACT protocol for internet pornography viewing applied in eight 1.5 h weekly sessions (Twohig & Crosby, 2010). According to the results of the study, on average there was a reduction in daily time watching pornography from 1 h (baseline) to 0.15 h post treatment (85% reduction), and 0.17 h at the 3-month follow-up (83% reduction). 5 out of the 6 participants presented marked reductions in daily pornography consumption post treatment, according to the study. Nevertheless, statistical significance of findings was not reported (Twohig & Crosby, 2010).

An RCT with 28 male participants also investigated an ACT protocol for PPU for 12 weeks, in comparison with a waitlist control condition (Crosby & Twohig, 2016). According to the results of the study, in pretreatment to posttreatment analyses there were significant reductions in the ACT group that were not seen in the control condition in the following variables: hours per week viewing pornography (p = 0.001, d = 1.8; 93% decrease relative to baseline), sexual compulsivity (p = 0.001, d = 1.28), and in worries about negative consequences of sexual behavior (p = 0.004, d = 1.43) (Crosby & Twohig, 2016).

Another quasi-experimental study assessed a 8-week ACT self-help program based on the book “Get Out of Your Mind and Into Your Life” in 19 participants with self-perceived PPU (Levin et al., 2017). Even though the intervention described interesting results, with significant improvements in PPU measures (weekly time spent watching pornography, compulsive pornography viewing according to the Cyber-Pornography Use Inventory, and negative outcomes of pornography consumption according to the Cognitive and Behavioral Outcomes of Sexual Behavior Scale; p < 0.001, Cohen’s d effect sizes ranging between 1.72 and 2.48), there was an issue in terms of adherence to the intervention. Only 11 participants completed the post intervention assessments (58%); and considering participants who completed the post intervention and follow-up assessments, participants read 52% of the book on average, 45% read at least half of the book, and 45% of them described that the book was too long or redundant (Levin et al., 2017).

Mindfulness and meditation-based interventions were also investigated in studies aiming to treat individuals with PPU. A quasi-experimental study, which employed a single-case experimental design in 12 heterosexual males (11 participants completed the intervention), investigated the effect of twice daily 15-min guided meditation sessions (via audio recordings) in the treatment of self-perceived problematic pornography use (Sniewski et al., 2022). According to the results of the study, only two participants presented results that suggested the intervention as statistically effective (according to TAU-U scores) for the reduction of the duration of pornography viewing, and 7 out of 11 participants presented significant reductions (according to reliable change index scores) in the Problematic Pornography Consumption Scale (Sniewski et al., 2022).

Another quasi-experimental study investigated the effects of Mindfulness-based relapse prevention for the treatment of 13 participants with hypersexual disorder (Holas et al., 2020). This intervention was delivered during eight weeks, by two certified professionals, consisting of 2-h weekly sessions (composed by guided meditation, psychoeducation, exercises, inquiry and discussion), and between session practices to do at home. According to the results of the study, participants reported a significant reduction of week’s time spent watching pornography (p = 0.028, n = 6, r effect size of − 0.64), and a non-significant reduction in the Brief Pornography Screener scores (p = 0.075, n = 10) (Holas et al., 2020).

A quasi-experimental study from the USA, applying a nonconcurrent multiple-baseline design, investigated a 12-week CBT protocol for PPU in 12 males (Minarcik, 2016). According to the results of the study, all participants reported reductions in pornography use, with an average reduction of 32.86 min per week, representing a 94% reduction in overall pornography use from baseline to post-treatment. In addition, 6 participants (50%) presented reliable decreases (Reliable Change Index) in hypersexual behavior measures, 6 participants (50%) presented reliable decreases in sexually compulsive behaviors, and 6 participants (50%) demonstrated reliable reductions in self-reported cravings for pornography (Minarcik, 2016). A case report from Spain (Ortega et al., 2020) described a 19-year-old male who went through 13 CBT sessions due to PPU. The treatment resulted in marked improvement in time spent using pornography (decrease of weekly porn consumption from approximately 24 h at baseline to around 3 h at the follow-up session), academic functioning and other mental health symptoms (Table 1 for details) (Ortega et al., 2020).

An RCT with 264 participants from several countries assessed an online self-help intervention (n = 123; based on motivational interviewing, CBT, mindfulness and social psychological interventions) in comparison with a waitlist control condition (n = 141) for 6 weeks (Bőthe et al., 2021). The drop-out rate was significantly higher in the intervention arm (p < 0.001), with only 11% of the intervention group completing the 6-week follow-up, while 55% of the control group completed this follow-up. After the intervention, the treatment arm presented significant improvement in several PPU variables, in comparison with the control group: lower levels of PPU according to the PPCS (p < 0.001, d = 1.32); lower pornography frequency use (p < 0.001, d = 1.65); lower self-perceived pornography addiction (p = 0.01, d = 0.85); lower pornography craving (p = 0.02, d = 0.40); higher pornography avoidance self-efficacy (p = 0.001, d = 0.87). Time spent consuming pornography (minutes) in each session, and moral incongruence did not change significantly (Bőthe et al., 2021).

A quasi experimental study from Australia and New Zealand (Rodda & Luoto, 2023) investigated a brief internet-delivered intervention with the application of behavior change techniques (in line with the self-determination theory) in 25 participants. The intervention aimed to increase skills, autonomy, and competence in the self-regulation of impulses to use pornography (Rodda & Luoto, 2023). According to the results of the study (based on completers only analysis, n = 14), there were significant reductions in frequency of viewing pornography (p = 0.002; d = 1.04), days spent viewing pornography (p = 0.008; d = 0.83), and frequency of maladaptive behaviors associated with pornography use (p < 0.001; d = 1.36). Nevertheless, there was a non-significant reduction in hours spent viewing pornography (p = 0.101; d = 0.47) (Rodda & Luoto, 2023).

An investigation from Israel (n = 1) assessed the efficacy of a Non-blaming Chance and Action Approach (Wernik, 2012). The treatment consisted of a pack of cards with random assignments for the patient to read before sleep time; these cards would give instructions on how to act the next day, including instructions on how to consume pornography. After the intervention, the patient presented marked improvement in several domains, not only remission in PPU (Table 1 for details) (Wernik, 2012).

A study from the UK (Kellett et al., 2017) using a single-case experimental design (N = 1, in a 231-day time series), described the treatment of a 41-year-old married man with hypersexual disorder with 16-sessions of cognitive analytic therapy. After the treatment, the patient presented abstinence from porn use (p < 0.001, partial eta squared = 0.39), significant reduction in daily masturbation frequency (p < 0.001, partial eta squared = 0.57), significant and clinically meaningful reduction in the Sexual Compulsivity Scale (p < 0.01, reliable change index = 3.02), as well as significant improvements in measures of self-esteem, sexual obsessions, and other psychiatric symptoms (Kellett et al., 2017).

Some studies applied mixed psychological approaches. For instance, a case report from Belgium (Wéry et al., 2019), described partial improvement (measures not specified) in a male with PPU in his thirties, after 3 years of an eclectic-integrative psychotherapy approach combining components of cognitive, behavioral, and psychodynamic therapy. Another case report from the UK (Shorrock, 2012), described a heterossexual male, in his mid-30 s, who presented marked (but not specified) improvement in PPU after receiving four years of a person-centered mixed psychotherapy (individual and group therapy) using a pluralist approach (combining elements of CBT and psychodynamic psychotherapy).

Family-based interventions and treatment approaches for couples were also investigated as potential options for PPU. One of the cases reported in Kraus and Sweeney (2019) described the treatment of a married man in his 40s, who presented PPU due to moral incongruence and difficulties in his sexual relationship with his wife. After couples therapy and individual psychotherapy (approaches not described), the patient presented decreases in pornography consumption (measures not specified), which were attributed to improvements in his relationship with his wife and the resuming of sexual activity with her (Kraus & Sweeney, 2019). Another example is a report from the United States (Ford et al., 2012) that described a couple married for 10 years, in which the husband presented PPU. After structural family therapy, the husband presented abstinence from porn and the couple reported increased relationship satisfaction (details of the outcomes not specified) (Ford et al., 2012).

Combined Interventions

Several cases reported the combination of naltrexone and CBT. For instance, a case report from India (Sharma et al., 2022) described a 26-year-old male who presented a partial response in the PPU treatment after 6 weeks of individual CBT. After the addition of naltrexone (25 mg daily dose) he reported marked improvement (no urges for pornography and masturbation + pornography abstinence), with benefits also reported in mood and occupational functioning (Sharma et al., 2022). Naltrexone was also used in combination with CBT for the treatment of PPU in a case report from the US (Kraus et al., 2015). At the 10th week of treatment the patient’s baseline use of pornography decreased by 70% with only CBT, but sexual urges to masturbate to porn persisted. Naltrexone 50 mg/day was then initiated, and within 9 weeks of treatment with Naltrexone, sexual urges (p < 0.0001, Cohen’s d = 1.25) and frequency of pornography consumption (p < 0.01, odds ratio = 0.25) significantly decreased (Kraus et al., 2015). Similarly, one of the cases reported in Kraus and Sweeney, 2019a (Kraus & Sweeney, 2019) described clinical improvement (measures not reported) in a married male patient with PPU (who met the diagnostic definition of CSBD according to the ICD-11), with the use of a combination of Naltrexone 50 mg/day and individual CBT. Lastly, a case report from Turkey described sustained abstinence in a 30-year-old male treated for PPU with CBT combined with Fluvoxamine (300 mg/day) and Naltrexone (50 mg/day) (Şenormanci et al., 2014).

Paroxetine 20 mg/day was used in combination with CBT for the treatment of PPU in 3 heterossexual males (Gola & Potenza, 2016). Frequency of pornography consumption decreased but not to a statistically significant level in the participants. According to the study, within 12–14 weeks of Paroxetine use, new sexual behaviors were reported, with two patients describing having sex with prostitutes and one patient reporting an extra-marital affair (as described in the study, patients were not in mania/hypomania). It is not clear if these emergent sexual behaviors were side effects associated with paroxetine use or if they were associated with therapeutic effects of the medication. For instance, one of the patients considered these emergent sex behaviors as a positive outcome (reporting that previously he suffered with anxiety and other difficulties in pursuing intimate relationships with women), while the other two described that even though they were morally conflicted to pursue extra-marital relationships, they were interested in having novel sexual experiences (both reported to have had sexual relationships only with their partners). In addition, Paroxetine was soon discontinued after the emergence of these sexual behaviors, but two patients reported the maintenance of these behaviors (Gola & Potenza, 2016).

A case report from India described the treatment of a male with PPU and dhat syndrome, which consists in a cultural related preoccupation about seminal loss (Darshan et al., 2014). The treatment consisted of a combined strategy with Desvenlafaxine 100 mg/daily and CBT for 9 months. At the end of follow-up, compulsion/urges to watch pornography were approximately zero (with marked, but not specified, reductions in porn use) and the patient experienced improvements in other domains, including self-esteem and in sexual life (Darshan et al., 2014). Another case report described the use of CBT and Fluoxetine 40 mg/daily in the treatment of PPU in a 26-year-old homosexual male, with partial improvement in PPU (non-specified) that was also associated with improvements in comorbid depression and anxiety symptoms (Skryabin et al., 2021).

Other Interventions

A case report from Italy presented another intervention for individuals with PPU: a high frequency rTMS protocol targeting the l-DLPFC (Cuppone et al., 2021). Even though the patient presented remission of cravings (0 on a visual analog scale of cravings), pornography abstinence, improvements in porn-related intrusive thoughts, as well as in mood and anxiety symptoms (with maintenance of improvements at a 1-year follow up assessment), there were two potential confounding factors that should be highlighted. For instance, the patient was treated for social anxiety symptoms with Propranolol 60 mg/day, which presented improvements in anxiety and mood symptoms, but also improvements in porn-related cravings; additionally, the patient was also receiving individual psychological counseling during the intervention period.

Tolerability and Side Effects

18 studies did not report on tolerability or side-effects of the applied interventions (Bostwick & Bucci, 2008; Crosby & Twohig, 2016; Darshan et al., 2014; Ford et al., 2012; Holas et al., 2020; Kellett et al., 2017; Kraus et al., 2015; Kraus & Sweeney, 2019; Minarcik, 2016; Ortega et al., 2020; Rodda & Luoto, 2023; Şenormanci et al., 2014; Sharma et al., 2022; Shorrock, 2012; Skryabin et al., 2021; Twohig & Crosby, 2010; Wéry et al., 2019).

Three case reports did not report side effects concerning the investigated intervention. One of these studies investigated the use of nalmefene (Yazdi et al., 2020), another case report investigated a specific psychotherapeutic approach (Non-blaming Chance and Action Approach) (Wernik, 2012); while the third case report described no side effects with the use of propranolol, rTMS and psychological counseling (Cuppone et al., 2021).

In a case series that investigated CBT + paroxetine 20 mg/daily, the three patients reported reduction in libido and delayed ejaculation during the first 2–4 weeks of treatment with paroxetine; within 10 weeks from the start of paroxetine, the patients were no longer complaining about these side-effects (Gola & Potenza, 2016). Another patient from a case report described anhedonia even when using 25 mg/day of naltrexone (Capurso, 2017).

In the RCT investigating citalopram versus placebo for the treatment of compulsive sexual behaviors in men who have sex with men (n = 28), the citalopram group reported delayed ejaculation more often (p < 0.05). In addition, two participants dropped-out from the citalopram arm (at week 4), but neither reported sexual side effects (Wainberg et al., 2006).

In the study that investigated meditation as an intervention for self-perceived PPU, 3 out of the 11 participants that completed the intervention reported that they considered the meditations unpleasant (Sniewski et al., 2022).

In the quasi-experimental study investigating an ACT self-help intervention based on the book “Get Out of Your Mind and Into Your Life”, considering participants who completed the intervention and follow-up assessments (n = 11), participants read 52% of the book on average, and 45% read at least half of the book. The most common reasons for not reading the entire book were: not having enough time (55%) and lack of interest (27%). In addition, 45% of these participants reported that the book was too long and/or redundant (Levin et al., 2017).

In the RCT (n = 264) that investigated an online self-help intervention based on motivational interviewing, CBT, mindfulness and social psychological interventions, the drop-out rate was significantly higher in the intervention arm (p < 0.001), with only 11% of the intervention group completing the 6-week follow-up, while 55% of the control group completed this follow-up. Authors also described that there was a decrease in the completion of modules of the intervention over the weeks (Bőthe et al., 2021). According to the authors, dropouts described significantly higher measures of pornography craving at baseline than participants who completed the intervention, and in general participants evaluated all modules of the intervention positively (Bőthe et al., 2021).

In the RCT (n = 73) that investigated the tolerability and efficacy of paroxetine and naltrexone in the treatment of CSBD, 5 participants discontinued treatment due to adverse effects (2 in the paroxetine group, 3 in the naltrexone). The most persistent and bothersome side effects were: sedation (29.2% with paroxetine, 37.5% with naltrexone, and 0% with placebo), weight gain (16.7% with paroxetine, 4.2% with naltrexone, and 12% with placebo), erectile dysfunction (12.5% paroxetine, 0% naltrexone, and 8% placebo), apathy (8.3% paroxetine, 8.3% naltrexone, and 0% placebo), and orgasmic dysfunction (2.8% paroxetine, 0% naltrexone, and 0% placebo). No serious medication-related side effects occurred during the trial (Lew-Starowicz et al., 2022).

Discussion

Our main aim was to systematically review treatment interventions for individuals with PPU, evaluating the quality of the evidence, the efficacy of the interventions, and the description of other outcomes related to each treatment approach. According to our results (k = 28, n = 500), most individual studies present important limitations in terms of quality assessment and risk of bias; in addition, according to the GRADE approach, all interventions, with the exception of ACT (which received a “low” grade), were rated as presenting “very low” quality of the evidence. The majority of the studies reported psychological treatments, including ACT, CBT, mindfulness, meditation, couple interventions, other psychotherapeutic strategies, as well as mixed psychological approaches. Pharmacological treatments included naltrexone, nalmefene, selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs); while one study investigated a protocol that included rTMS. Several studies reported the use of a combination of psychological and pharmacological strategies. The majority of the included studies did not report on side effects or tolerability of the investigated treatment approaches, with self-help and online psychological interventions presenting important issues concerning treatment adherence.

One of the most important findings of this systematic review concerns the significant limitations that the scientific literature presents in the topic of treatment approaches for individuals with PPU. These limitations could be seen in the individual studies, which were assessed by the JBI critical appraisal tools and the Cochrane risk of bias tools, with high risk of bias being found for all included RCTs according to the RoB2, and quasi-experimental investigations presenting serious or critical risk of bias according to the ROBINS-I. Moreover, only ACT received a “low” rating according to the GRADE approach, while all the other investigated interventions received a “very low” rate. Therefore, even though several studies presented interesting results, which will be discussed in the next paragraphs, it is essential to consider these limitations when interpreting these results and assessing the potential clinical usefulness of the reviewed treatment approaches.

Psychological interventions, either alone or in combination with pharmacological treatments, were the most investigated treatment approaches. Among these psychological interventions, the most commonly reported for the treatment of PPU were second and third wave CBT therapies, with some studies applying mixed psychological approaches that used to some extent CBT-based interventions. CBT is a well-established and recommended treatment that has a large support from empirical research for the treatment of substance use disorders and behavioral addictions, targeting maladaptive processes that contribute to these conditions; CBT not only treats addiction related symptoms, but also presents efficacy in the treatment of other mental health symptoms that may be present in these patients (Chang et al., 2022; King et al., 2017; Morin et al., 2014; Stevens et al., 2019; Zamboni et al., 2021; Zhang et al., 2022). Similarly, it may represent a viable and promising psychological approach for the treatment of PPU, with the application of similar concepts likely benefiting these patients. As for third wave CBT therapies, ACT and mindfulness strategies were investigated in several included studies, presenting promising results for the treatment of PPU. The manner an individual interacts with pornography-related urges was previously shown to affect not only frequency of pornography consumption, but also the distress associated with the behavior (Crosby & Twohig, 2016; Twohig et al., 2009). Therefore, attempts to actively suppress thoughts and impulses related to pornography may not be helpful for several patients seeking treatment for porn-related problems. In this sense, treatment interventions based on the acceptance and open experience of unpleasant internal states may be interesting options for these individuals (Crosby & Twohig, 2016; Powers et al., 2009).

Even though the addition of a partner in the treatment of PPU was a strategy rarely used in the studies included in our review, it may represent an interesting approach for the treatment of individuals with PPU, mainly considering the potential impact that PPU has on romantic relationships and partnered sexual activity (Bennett-Brown & Wright, 2022). Nevertheless, it is essential to highlight that there is evidence describing that the negative association between pornography use and relationship or sexual satisfaction was significant for men but not for women (Bennett-Brown & Wright, 2022; Wright et al., 2017), with a previous study reporting that wives who viewed pornography more frequently reported higher marital quality in comparison with wives who did not consume pornography or who consumed it less frequently (Perry, 2017). Future studies may investigate this additional strategy with more robust studies in order to see if it represents an interesting option for individuals, mainly males, with PPU.

One of the most frequently used pharmacological options in our review was Naltrexone, which was used alone or in combination with psychological interventions. Naltrexone is a mu-opioid antagonist, that also blocks other opioid receptors, first synthesized in the 1960s, and approved by the FDA for the treatment of alcohol use disorder and opioid dependence (Aboujaoude & Salame, 2016; Mouaffak et al., 2017; Singh & Saadabadi, 2022). Due to its effects in reducing cravings, euphoria and pleasurable experience associated with addiction, naltrexone is also currently used in clinical practice for the treatment of several other addictive disorders and related conditions, with evidence supporting the efficacy and safety of the medication for conditions such as stimulant use disorder, nicotine dependence, gambling, kleptomania, and trichotillomania (Aboujaoude & Salame, 2016; Lam et al., 2019; Mouaffak et al., 2017). According to the results of our study, Naltrexone may represent a promising option for the treatment of PPU as well, being associated with significant improvement in several studies, deserving to be explored in further RCTs about the topic. Likewise, Nalmefene, another opioid antagonist, was investigated in only one case report, with remission of PPU being described as an outcome of the intervention (Yazdi et al., 2020).

Other pharmacological options explored in the treatment of PPU include SSRIs and SNRIs. Impulsivity and compulsivity, which may be associated with hipersexuality and the pathophysiology of PPU, have also been associated with serotonergic neurotransmission imbalances, potentially representing a target of pharmacological treatment for impulse control disorders (Bőthe et al., 2019; Gola & Potenza, 2016; Robbins & Crockett, 2010; Tahir et al., 2022). Nevertheless, in several cases included in our review, the use of these pharmacological options were associated with improvements in comorbid psychiatric symptoms such as depression and anxiety, or with sexual side effects, which ultimately may have mediated or influenced the improvements seen in PPU or porn-related outcomes (Bostwick & Bucci, 2008; Darshan et al., 2014; Gola & Potenza, 2016; Şenormanci et al., 2014; Skryabin et al., 2021; Wainberg et al., 2006). Taking it into consideration, future studies should investigate the potential mediating effect that these variables present on the treatment of PPU. Regardless of the mechanism of treatment, there is evidence in the literature suggesting that the treatment of comorbid psychiatric conditions in combination with the co-occurring addictive disorder is superior to the treatment of each condition separately (Kelly & Daley, 2013; Torrens et al., 2012).

As for the use of rTMS for the treatment of PPU, the only study which investigated this treatment approach remains inconclusive (Cuppone et al., 2021). Even though the patient presented marked improvement in several domains, including pornography-related outcomes (remission of cravings and pornography abstinence), there were potential confounding factors that should be considered when interpreting their findings (the patient received psychological counseling and was treated for social anxiety symptoms with Propranolol 60 mg/day, with descriptions of marked reduction in measures of cravings for pornography after the start of Propranolol) (Cuppone et al., 2021). Therefore, further investigations on this potential intervention may address these limitations in order to assess the efficacy of this strategy for the treatment of individuals with PPU.

As highlighted in the introduction, there is an important debate about the understanding and diagnostic definition of PPU. This controversy can be seen in our systematic review as well, in which the definition of PPU in the individual included studies ranged from clinical assessment (without an explicitly described definition of PPU in several cases) and criteria defined by the investigators of a given study, to the meeting of diagnostic criteria of CSBD (World Health Organization, 2022) or hypersexual disorder (Kafka, 2010). In this sense, the understanding and definition of PPU may have played an important role in the intervention investigated and the potential success of a given treatment approach. Some patients may present PPU features that resemble solely the definition of CSBD, with a compulsive/addictive clinical presentation and difficulties in controlling the behavior; while others may exhibit PPU due to moral incongruence, or due to a mixed clinical presentation with characteristics of both pathways (CSBD and moral incongruence) (Grubbs et al., 2019; Kraus & Sweeney, 2019). Patients seeking help for problems with pornography may actually present distinct conditions, with the differential diagnosis potentially representing an essential step before the choice of the treatment approach (Kraus & Sweeney, 2019). For instance, those who present features of a compulsive/addictive porn use may benefit from pharmacological options such as naltrexone, while patients who have significant distress due to moral incongruence may benefit more from psychotherapeutic approaches that target this distress and the associated internal conflict (Grubbs et al., 2019; Kraus & Sweeney, 2019). Nevertheless, considering the relevance of the still ongoing debate about the diagnostic framework of PPU, future intervention studies may explore further the importance of the definition of the condition for the choice and success of a given treatment.

The majority of the included studies did not report on tolerability or side-effects. Among those which described side-effects, mostly were combined treatments (including pharmacological options) or pharmacological interventions, with the most detailed account on side-effects being given in the RCT by (Lew-Starowicz et al., 2022), which reported that no serious medication-related side effects occurred during the trial, even though 5 participants discontinued treatment due to adverse effects (2 in the paroxetine group, 3 in the naltrexone group). Importantly, sexual side-effects were reported in studies investigating paroxetine and citalopram (Gola & Potenza, 2016; Lew-Starowicz et al., 2022; Wainberg et al., 2006).

In addition, it is essential to highlight issues in treatment adherence in studies that investigated self-help and online interventions. In the quasi-experimental study investigating an ACT self-help intervention based on the book “Get Out of Your Mind and Into Your Life”, considering participants who completed the intervention and follow-up assessments, they read 52% of the book on average, and 45% read at least half of the book. The most common reasons for not reading the entire book were not having enough time and lack of interest; with several participants reporting that the book was too long and/or redundant (Levin et al., 2017). In the RCT (n = 264) that investigated an online self-help intervention based on motivational interviewing, CBT, mindfulness and social psychological interventions, the drop-out rate was significantly higher in the intervention arm (p < 0.001), with only 11% of the intervention group completing the 6-week follow-up, while 55% of the control group completed this follow-up. Authors also described that there was a decrease in the completion of modules of the intervention over the weeks (Bőthe et al., 2021). Another quasi-experimental study investigated a brief internet-delivered intervention, reporting that only 14 out of 25 participants completed post-treatment assessment (Rodda & Luoto, 2023). Even though these treatment adherence issues may reflect intrinsic limitations of each specific study, it could be also understood in the context of low adherence rates reported in other psychological online and self-help interventions (Beatty & Binnion, 2016; Cuijpers et al., 2019).

Limitations of the Review

Even though this investigation presents many merits, including a comprehensive search of potentially eligible references, the use of different tools for quality assessment, and a very detailed procedure of data extraction, it is essential to acknowledge the limitations of our study. Most of the studies included in our review are case reports, and the majority of the individual studies present significant risk of bias and overall low quality. In addition, several studies did not specify (with the reporting of specific quantitative measures or with appropriate statistical methods) the supposed improvements reported in their manuscripts. The definition of PPU was considerably different among studies, which may also compromise a general interpretation of findings, with all interventions being graded as low or very low according to the GRADE approach. Moreover, the results of this systematic review are based on a low number of participants (n = 500), with most studies being based on cis and heterossexual males, which may limit the generalizability of the results of this study. All these aspects compromise the possibility of reaching more definitive conclusions about the recommendation of interventions and treatments for patients with PPU, and represent rather limitations of the field than limitations that arise from our systematic review.

Conclusion

In conclusion, this study systematically reviewed treatment strategies for individuals with PPU. According to the included studies, potential treatment interventions for these patients range from either psychological or pharmacological interventions alone, to combined approaches. In addition, given the complexity of the condition, controversial diagnostic criteria and issues regarding the understanding of PPU yet to be addressed, several different psychotherapeutic techniques and pharmacological treatments may be beneficial, depending on the characteristics of the patient. Nevertheless, the review also highlighted the limitations in the field, with most individual investigations presenting significant biases and overall low quality, and all interventions receiving a low or very low rate according to the GRADE approach. Future investigations may use the results of this review as a guide for the development of more robust studies that may be able to give more definitive conclusions about treatment strategies for PPU. In addition, the role of religious affiliation and moral incongruence should be better investigated in future studies of treatment strategies for PPU.