Introduction

Pornography consumption has increased over the past two decades during expansion of the internet [1, 2]. Online pornography is easily available, accessible, affordable, and often perceived to be anonymous, and these factors that may contribute to early exposure to pornography [3].

Concerns have emerged regarding how pornography may impact adolescents’ attitudes and behaviors [4]. An important aspect to consider is that pornography has become an informal source of sex education for adolescents, especially in the relative absence of other sources [5]. Other reasons why adolescents may search for pornography include curiosity, sexual arousal, masturbation, entertainment, and to keep up with their peers [4, 6, 7]. However, adolescents are at an important stage of development regarding self-identities, sexual arousal templates, and brain structure and function [8]. Negative consequences of early exposure to pornography have been suggested, although varying views have been reported. Pornography use in adolescents has been related to various dimensions of sexual practices, permissive sexual attitudes, instrumental attitudes toward sex, and gender-related stereotyped thinking [9]. Other authors have described an association between pornography use and feeling unsure about one’s sexual self and body image [10, 11].

Bearing these considerations in mind, a first level of intervention may involve prevention-oriented approaches, such as programs for pornography education or pornography literacy. A second level of intervention may include treatment-oriented approaches to reduce problematic pornography use (PPU), which involves use of pornography that produces significant distress or impairment to the individual at personal, relational, social, educational, or occupational levels [12].

The purpose of the present narrative review was to examine the literature on the prevention and intervention programs focused on pornography use and PPU in adolescents. The literature search was conducted on PubMed, Google Scholar, and PsychINFO. Case studies and those articles unrelated to the objectives of the review were excluded.

Findings are presented and critically discussed, highlighting the current issues and future directions for therapeutic approaches at initial and subsequent levels of intervention that may be tailored to adolescents.

Pornography Education for Adolescents

Internet pornography is often readily available to adolescents, with limited enforcement of age verification permitting them to access it as a source of informal sexual education [13, 14]. Families represent a potential source of information about sexuality and pornography. However, parents do not always feel prepared or comfortable discussing sexuality generally or pornography specifically with their children [15]. Moreover, they may lack knowledge about the nature of pornography and its potential effects [16]. Prohibition of pornography access to minors using filtering software or personal identification systems appears relevant but suboptimal since adolescents often find ways of bypassing such control systems [17, 18].

A better way to prevent possible consequences of pornography exposure in minors may involve empowering them with appropriate resources regarding how to consider pornographic material, such as a critical understating of the nature of pornography [18]. Such an approach has been termed pornography education, also called pornography literacy, which could be provided by schools or other nonschool institutions as part of age-appropriate curricula [5, 19]. However, sex education in schools often does not include pornography literacy curriculum, although there are some proposed programs. Pornography literacy derives from critical media literacy, which is an educational approach to helping young people to develop critical thinking and skepticism toward media messages and to understand misrepresentations of reality often present in media. Media-literacy interventions have been shown to promote healthier choices among adolescents [20, 21] and, when adopted in sexual-health-education programs, shown to reduce sexually risky behaviors (e.g. unprotected sex) and increase sexual-health-related knowledge [22–24].

Qualitative research has investigated core contents and elements that could be relevant for pornography-literacy programs (see Table 1). Some of these studies were conducted among young adults (ranging from 18 to 29 years old) using thematic analyses of pornography-related discussions [25, 26]. Others have included samples of participants from 14 to 29 years old [27, 28]. One such study tested the usability of a health-education website covering pornography and sexting [27]. Thematic analysis of the interviews of people having used the website suggested the relevance of the website and provided information on elements that could be improved (see Table 1 for details). Another study including vulnerable adolescents and young adults used a participatory action method to codesign a digital tool for pornography literacy [28]. Vulnerability was defined as including at least one of the following: receiving a fragmented school education, having limited education regarding sex or sexuality, being from nonmajority cultural and/or linguistic backgrounds, or undergoing family breakdowns.

Table 1 Qualitative studies of pornography-education programs
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Overall, results deriving from qualitative research highlighted some relevant topics to address in programs such as reducing shame associated with pornography use, discussing sexual consent, comparing pornography with real sex, discussing physical safety and sexual consent, exploring concerns about body-image comparisons, and considering pornography as a gateway to risk behaviors [25, 26, 28]. Furthermore, some important elements to consider when designing online tools for adolescents included using age-appropriate content and language, reducing text, increasing audiovisual aspects, giving credibility to resources, and proposing real stories [27].

Notwithstanding, quantitative research providing evidence for the efficacy of pornography education programs is limited (see Table 2). A first study was conducted on a large sample of adolescents and young adults, involving a longitudinal evaluation of their exposure to sexually explicit internet material (SEIM), sexual objectification of women, and self-perceived learning about SEIM in their sexual-education programs at school [29]. Results showed that the more the youth had learned about SEIM at school, the less strong relationships existed between the frequency of SEIM exposure and sexist attitudes. This was the first evidence of the potential positive effects of introducing information about pornography (e.g., learning about SEIM) into sex-education school programs.

Table 2 Quantitative studies evaluating the efficacy of pornography-education programs
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The second quantitative study specifically explored the efficacy of a five-session pornography-literacy program in adolescents [30]. Core concepts of the program included the history of SEIM, pornography and norms related to gender and sex, the unreal representation of sex in pornography, the potential harms of pornography exposure, the nonconsensual dissemination of pornography/sexual imagery, and healthy sexual relationships. From pre- to postsurvey, there were significant increases in pornography-related knowledge and changes in some pornography-related attitudes (e.g., more likely to agree that pornography promotes unhealthy expectations of male and female sexuality). Likewise, changes in some of the pornography-related behavioral intentions were detected (e.g., more likely to agree to ask for advice if they needed help with too much pornography use). However, no direct changes were observed in adolescents’ behaviors related to pornography (e.g., feeling fine about watching pornography).

Finally, the third quantitative study evaluated the feasibility and efficacy of pornography literacy training for school staff to provide them with skills to talk about pornography with adolescents [31]. The short training consisted of one class of 4 h covering issues related to new sexual environments, teens’ online sexual experiences, gender-related roles, and sexual violence in school environments. Posttraining there was increased knowledge about online pornography and perceived self-efficacy in discussing pornography and sexual harassment with students. In addition, decreased scores on the Scale for the Assessment of Sexual Standards Among Youth [32] suggested changes in the beliefs about gender-related sexual roles among youth.

The existing pornography-education programs should be considered a starting point to conduct evidence-based research on adolescents. However, the limited number of studies makes it difficult to establish the quality and feasibility of pornography education, which may represent a first stage of intervention to reduce the risk of PPU in adulthood.

From Prevention to Intervention: PPU in Adolescents

High frequency of pornography viewing in adolescence may be associated with its problematic use [33, 34]. PPU may be considered one form of a compulsive sexual behavior disorder (CSBD) as described in the 11th edition of the International Classification of Diseases [ICD-11; 35]. PPU and other forms of CSBD are typically characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors, leading to clinically significant distress or impairment in social and occupational functioning and other adverse consequences [35, 36]. CSBD, including PPU, has been proposed as a nonsubstance or behavioral addiction, although its classification and symptomatology remain debated [37–41].

Early identification of problems related to sexuality and pornography use in adolescents is important and often challenging. Initial attempts to define CSBD among adolescents have been based on adult criteria [42, 43]. Subsequent empirical studies have suggested that CSBD in adolescents is associated with some factors, such as sex/gender, religiosity, temperament, anxious attachment orientations, external locus of control, greater loneliness, higher frequency of pornography use, and more sex-related online activities [44, 45]. Regarding PPU, the adaptation and validation of self-reported measures have been conducted among adolescents [46, 47]. However, PPU and CSBD remain underexamined in adolescents.

Studies evaluating psychological treatments for PPU and CSBD have been conducted in adults [48•, 49••]. Cognitive behavioral therapy (CBT) has empirical support [50–54, 55••, 56], as do mindfulness-based approaches [57–59]. Regarding adolescents, therapies involving family members have been proposed as potentially useful in the treatment of PPU [12]. However, it is worth noting that there is a lack of studies evaluating treatments for PPU or CSBD in adolescents, possibly due to potential legal (e.g., regarding informed consent) and clinical barriers (e.g., limited self-awareness).

Evidence from studies in adolescents with behavioral addictions (e.g., internet gaming disorder) suggests that CBT, family therapy, or a combination of both may be particularly promising [60, 61]. In addition to traditional forms of psychotherapy, online interventions (i.e., web- or app-based) appear promising in the prevention and treatment of behavioral and substance addictions among adults and adolescents [62•, 63•]. Regarding web-based interventions for PPU, “Hands-off” is a six-week program based on principles of CBT, mindfulness, and motivational interviewing [54] that has shown promising results in a two-arm randomized controlled trial (RCT) in adults [55••, 64]. Given the current gap in the literature on the treatment of adolescents with PPU, future studies are needed to evaluate treatment programs tailored to this population.

Future Directions in Preventing and Treating PPU in Adolescents

Despite the existing programs on pornography education for adolescents, much work remains to be done, taking into account the following aspects. First, there appears consensus that content of pornography education should be age-appropriate and delivered in a safe, inclusive, and supportive environment [65•]. It is recommended to integrate elements of sex and relationship education by discussing topics related to physical safety and health intimacy, under a perspective that is sensitive to gender and different sexual orientations. Other core topics of pornography education include the unrealistic representation of sex in pornography compared to real life, body-image considerations in pornography, and sexual, often gender-based or race-based violence [25–27, 66].

Participatory teaching and learning perspectives may be helpful. One challenge is to adopt methods to educate young people about pornography without directly exposing them to sexually explicit material. To this end, alternative methods have been proposed, such as using games that generate debates or discussions [67, 68]. Some research has suggested that young people should be informed about risks associated with viewing pornography [69]. It is possible that the best approach to prevention should include psychoeducation regarding pornography and its potential effects as a part of pornography-literacy programs. Evidence from the efficacy of psychoeducational approaches derives from other prevention programs for risk behaviors in adolescents [70]. Thus, introducing and evaluating the efficacy of psychoeducation as part of pornography-education programs represent a future avenue for research on prevention.

Finally, pornography education should be provided by appropriately trained personnel, since certain risks may arise when talking to young people about pornography (e.g., lack of confidence and knowledge, incitement to viewing). Therefore, another important step toward prevention is to assess the feasibility and effectiveness of training programs on pornography education targeting school staff or clinical staff.

Regarding treatments for PPU, there is a current gap in the literature on adolescents. More research is needed to develop or adapt and evaluate interventions such that they are tailored to young people.

Early identification of PPU among youth is one important first challenge. It is recommended in future research to use validated instruments for assessing PPU that have been adapted for adolescents [46, 47].

There is preliminary evidence for the effectiveness of CBT and mindfulness-based therapies for reducing PPU in adults [52, 55••, 57]. It is likely that feasible options for treatment of adolescents may involve adaptations and validation of these protocols. Moreover, several advantages could be derived from using online-based interventions in adolescents with PPU. First, it may reduce barriers to treatment, such as feelings of shame or stigmatization related to pornography use that could be particularly present among youth. Second, flexibility of and potentially free access to these programs could help facilitate a wider diffusion of interventions and data collection across countries. As a final methodological consideration, longitudinal studies including a control group, and possibly RCT, are strongly recommended.

Conclusions

The present narrative review is aimed at analyzing interventions to prevent and treat PPU in adolescents and to discuss the current state of the art and the future directions in this field. Regarding prevention, a variety of pornography-education programs have been proposed even though there appear only three published quantitative studies on pornography education [29–31]. Findings from these studies have indicated that learning about pornography at school may be related to less sexist attitudes over time [29] and that providing a specific pornography-literacy curriculum may help increase knowledge and promote changes in attitudes and behavioral intentions related to pornography [30]. Furthermore, delivering a short training on pornography education to school staff has been shown to improve teachers’ knowledge and confidence in addressing pornography-related problems [31].

Concerning psychological treatment for PPU and CSBD, promising results of CBT and mindfulness-based therapies derive from studies in adults. However, the lack of studies involving adolescents with PPU precludes an assessment of the effectiveness of these approaches in young people, as has been shown for other behavioral addictions [60, 61].

In conclusion, prevention research to reduce potential negative consequences of pornography use in adolescents is in early stages. Likewise, adolescent-oriented treatment studies are needed to provide empirical support for interventions designed to help adolescents with PPU. In this sense, online treatments are potentially attractive to young people and may be considered good candidates for future research.