Abstract
Introduction
Problematic pornography use (PPU) affects some individuals, causing distress and impaired functioning, and while psychotherapy is considered a first-line intervention, its efficacy remains understudied and unknown to many therapists. This review aimed to comprehensively synthesize the available evidence on psychotherapy for PPU and related problems (i.e., craving).
Methods
For this meta-analytic systematic review, we conducted a systematic literature search, followed by study selection, coding, and data extraction. We then meta-analyzed the resulting studies using a random-effects model with subgroup analyses, meta-regressions, and risk of bias assessments.
Results
20 studies with 2,021 participants met the inclusion criteria. Most studies included cognitive behavioral therapy and acceptance and commitment therapy interventions. Participants receiving psychotherapy improved significantly more than controls on PPU, frequency/duration of pornography use, and sexual compulsivity, with large effect sizes, that were small for craving. Within-subject effects were also large and stable at follow-up. In addition, single-case designs meta-analyses showed clinically significant reductions in PPU, craving, and frequency/duration. We identified moderate effects for related depression symptoms. Most subgroup and meta-regression analyses adjusting for treatment and sample characteristics were not significant.
Discussion
These results supports the efficacy of cognitive behavioral therapy and acceptance and commitment therapy in treating PPU and related problems. This has relevant implications for clinical practice (e.g., treating these problems with evidence-based interventions). However, these findings are limited by methodological issues, including the high risk of bias identified. To address these limitations, future research should use more rigorous methods (e.g., randomized controlled trials) and include more diverse groups.
Meta-analysis of the efficacy of psychological interventions for problematic pornography use
Most adults and adolescents report that they use pornography and that it is not associated with distress or negative consequences for the majority of them (Bőthe, Tóth-Király, et al., 2021). On the other hand, 6%–11% of men, 0.6%–3% of women, and around 4% of genre-diverse individuals (Bőthe et al., 2023; Bőthe, Nagy, et al., 2024; Grubbs, Kraus, & Perry, 2019a), and 14% and 10% of adolescent boys and girls respectively (Bőthe, Vaillancourt-Morel, Dion, Štulhofer, & Bergeron, 2021; Vigna-Taglianti et al., 2017) report having problems associated with it. Problematic pornography use (PPU) is characterized by a persistent pattern of poorly controlled pornography consumption that causes significant distress and impairs daily functioning (World Health Organization, 2022). PPU is considered one of the most prevalent presentations of compulsive sexual behavior disorder (CSBD) (Grubbs et al., 2024), as defined in the latest revision of the World Health Organization's International Classification of Diseases (ICD-11) (2022). PPU is associated with important areas of impairment, including sexual function (Bőthe, Tóth-Király, et al., 2021; Jacobs et al., 2021), withdrawal-like symptoms such as craving and tolerance (Bőthe, Lonza, Štulhofer, & Demetrovics, 2020; Lewczuk et al., 2022) and internalizing symptoms (Camilleri, Perry, & Sammut, 2021). There is even some evidence of a risk of developing sexually coercive behaviors associated with PPU (Marshall, Miller, & Bouffard, 2021), such as intimate partner violence (Brem et al., 2021) or higher levels of suicidal ideation (McGraw et al., 2024). This meta-analytic systematic review aimed to synthesize the evidence to date on the efficacy of psychotherapy for the treatment of PPU.
Several models have been proposed to describe its etiology, with the Moral Incongruence Model being arguably the most prominent one (Grubbs et al., 2019b). The main proposition of this model is that individuals may experience problems with pornography use not only because of behavioral dysregulation, but also because they have strong moral or sexual values against its use. Among other factors, higher levels of religiosity were associated with greater perceived problems (Grubbs et al., 2019b; Seyedzadeh Dalooyi, Aghamohammadian Sharbaaf, Abdekhodaei, & Ghanaei Chamanabad, 2023). Another relevant theoretical model is the Interaction of Person-Affect-Cognition-Execution (I-PACE) model (Brand et al., 2019), which proposes that PPU may develop as a result of interactions between predisposing variables, affective and cognitive responses elicited by specific stimuli, and impaired inhibitory control. There is empirical support for this model, with studies finding strong evidence for the use of pornography for emotional regulation as one of the main risk factors (Bőthe, Vaillancourt-Morel, et al., 2024; Cardoso, Ramos, Brito, & Almeida, 2022; Wizła & Lewczuk, 2024). This suggests that one of the primary functions of pornography use may be emotional regulation, which negatively reinforces this behavior (Lew-Starowicz, Lewczuk, Nowakowska, Kraus, & Gola, 2020). In addition, predisposing biological and social factors (e.g., ventral striatum activity, unemployment, loneliness) may also increase the risk of developing PPU (Baranowski, Vogl, & Stark, 2019; Cardoso et al., 2022; Seyedzadeh Dalooyi et al., 2023). High frequency of pornography use, intensity of craving, and sexual shame may also be additional psychological predictors of developing PPU (Ben Brahim, Courtois, Vera Cruz, & Khazaal, 2024; Bőthe, Vaillancourt-Morel, et al., 2024; Chen et al., 2022). Given the complex interplay of psychological, biological, and social factors that contribute to PPU and its associated impairments, it is essential to explore effective intervention strategies to address this issue.
Treatment of problematic pornography use
Despite its growing importance, most psychotherapists report not having enough information about PPU (Markert et al., 2023), and they do not feel competent to treat the condition (Short, Wetterneck, Bistricky, Shutter, & Chase, 2016). The latter study, after interviewing 186 clinicians, found that only 35% of them reported that treatment was somewhat successful and only 9.3% felt that it was very successful, with cognitive behavioral therapy (CBT) being the preferred intervention. In fact, several recent reviews have found that there is preliminary evidence primarily for second and third-wave CBT approaches of treatment (Antons et al., 2022; Roza et al., 2024). Second-wave CBT interventions are premised on the idea that cognitions underlie emotions and that these ultimately lead to behaviors (Hardy, Ruchty, Hull, & Hyde, 2010). Thus, CBT-based interventions for PPU often focus on challenging and modifying dysfunctional beliefs to reduce emotional dysregulation and learning new ways to manage these emotions with more adaptive behaviors. The third wave of CBT is represented primarily by acceptance and commitment therapy (ACT) and mindfulness. ACT aims to increase psychological flexibility so that individuals can align their behavior with their values regardless of their internal experiences (Crosby & Twohig, 2016). For instance, reducing the effects of many inner experiences, such as anxiety, in manifest behavior, in this case, the urge to view pornography. Unlike classical CBT, ACT focuses on developing psychological flexibility through its six core processes, rather than simply reducing symptoms (Hayes & Hofmann, 2021). Furthermore, the rationale for using mindfulness in the treatment of this condition is that this intervention is primarily aimed at increasing awareness of triggers for PPU behaviors and increasing tolerance of internal aversive experiences (Holas, Draps, Kowalewska, Lewczuk, & Gola, 2021).
At the same time, several pharmacological approaches have been proposed for the treatment of PPU, mainly opioid antagonists and various antidepressants (Mestre-Bach & Potenza, 2024; Turner et al., 2022). Nevertheless, according to this recent review, the evidence supporting their efficacy comes only from single-case designs (SCDs). Therefore, pharmacotherapy should be used as an adjunct to psychotherapy, which is still considered the first line of intervention. However, there is a significant risk of bias in the studies examining the efficacy of pharmacological and psychological interventions (Roza et al., 2024). Moreover, one the most recent systematic review with a quantitative synthesis of the efficacy of psychotherapy for PPU (Antons et al., 2022), was conducted with studies published up to December 2021, excluding SCDs and the most recent literature, and not focusing exclusively on participants with PPU (i.e., other CSBD problems were included in the analyses). Similarly, other recent reviews focus on a broader population with CSBD problems (Borgogna, Garos, Meyer, Trussell, & Kraus, 2022) or mixed psychotherapeutic and pharmacological interventions (Roza et al., 2024).
The present study
Thus, the present meta-analytic systematic review aimed to provide a comprehensive quantitative synthesis of the current evidence on the efficacy of psychotherapy for PPU and other related problems (e.g., craving, frequency/duration of pornography use, internalizing symptoms, and overall quality of life), including all available designs (e.g., randomized controlled trials, uncontrolled group studies, SCDs). In addition to being the first meta-analysis to summarize the evidence for psychological interventions for PPU, compared to previous reviews, we took a more comprehensive approach, including evidence from all study designs (e.g., RCTs, uncontrolled trials, SCDs) and updated the evidence with more recent studies in this growing field. A secondary objective was to examine how clinically relevant characteristics of the sample or intervention may affect treatment outcomes.
Method
To maximize clarity and transparency, this review adheres to the PRISMA guidelines for meta-analyses (Page et al., 2021) and has been pre-registered in PROSPERO (CRD42024539364). The PRISMA checklist is available at Supplementary Table A.1. The results of the selection and coding process (with the full codebook) and the fully extracted dataset can be consulted online here. This study received no funding from any public, commercial, or non-profit source.
Eligibility criteria
Using a PICOS approach, the following eligibility criteria were established:
Population: Studies with both adolescents (aged 10+ years old) and adults; males, females, and gender-diverse individuals; with PPU, with or without a DSM/ICD diagnosis were included.
Intervention: Studies in which at least one of the experimental groups received some form of psychotherapy, combined with or without medication, were included.
Comparison: For RCTs, studies with both active (e.g., other interventions, support groups) and inactive (e.g., waitlist) control groups were included.
Outcomes: RCTs and uncontrolled group studies had to include a quantitative measure of PPU or a topographic measure of pornography use (e.g., hours of pornography viewing). Single-case designs had to include a quantitative measure of PPU, or pornography use behavior with at least three pre-intervention and three post-intervention measures.
Study designs: Randomized controlled trials (RCTs), uncontrolled group studies, and SCDs were included. We decided to include this broad approach in order to provide a comprehensive review. To avoid potential bias due to the mix of different study designs, data analyses were performed separately.
Additional criteria: Peer-reviewed articles published in scientific journals were preferred, but doctoral theses were also included. Articles had to be written in either English or Spanish, as these were the languages understood by the first and second authors.
Information sources and search strategy
MedLine (via PubMed), PsycInfo, and Scopus databases were searched using the following search terms in the titles, abstracts, and keywords (only in English): problematic porn* OR problematic pornography use OR problematic porn use OR problem porn* OR compulsive porn* OR porn addiction OR pornography addiction. No date restriction was used in the search.
In anticipation of a small number of potentially eligible studies, only population- and outcome-related search terms were used to maximize results. Studies included in previous narrative reviews were also screened. In addition, the reference lists of identified relevant studies were searched and a forward search approach was also used. The last search was conducted on July 8, 2024.
Study selection process
The first author made an initial screening based on the title and abstract. Then the first and second authors independently made the final selection based on the full-text reading. The agreement between the two researchers was excellent (κ = 0.88). Disagreements were resolved by consensus.
Data collection and data items
The first and second authors independently coded the following variables from the included studies:
Study design: RCT, uncontrolled group study, or SCD.
Sample characteristics: Diagnosis (axis I, axis II, compulsive sexual behavior disorder or no diagnosis); mean sample age; percentage of males (based on sex assigned at birth); and percentage of religious participants.
Intervention characteristics: Type of intervention (Second Wave CBT, Third Wave CBT, or other); number of sessions; who delivered the intervention (self-delivered, therapist-delivered, or combined); intervention delivery (online, face-to-face, or combined); and intervention format (individual, group, or combined).
Comparison (for RCTs): Inactive or active control group.
The first author extracted the mean and standard deviation of the outcome variables for each group study and each observation for SCDs, as these are the data needed for effect size (ES) calculations. The second author checked 50% of the data by random selection and found no inaccuracies.
Assessment of risk of bias
First, the overall risk of bias in each study was assessed using different tools: the Cochrane Risk of Bias Tool 2 (Sterne et al., 2019) for RCTs, ROBINS-I for uncontrolled group studies (Sterne et al., 2016), and the SCD RoB tool for SCDs (Reichow, Barton, & Maggin, 2018). In addition, publication bias was assessed by visual inspection of funnel plots, Egger's test (Egger, Smith, Schneider, & Minder, 1997), and the trim-an-fill method (Duval & Tweedie, 2000).
Data analysis
The pre-post change in the quantitative measure of PPU or a topographic measure of pornography use (e.g., hours of pornography viewing) was considered the primary outcome variable. Craving and sexual compulsivity, internalizing symptoms (depression and anxiety), and overall quality of life were included as secondary variables.
To conduct the meta-analysis, the ES was first estimated for each study. For RCTs, the between-group ES was estimated based on previous recommendations (Morris, 2008). This between-group ES was calculated as the difference in average pretest-posttest (and follow-up, if available) changes between the experimental and control groups, divided by the pooled pretest standard deviations of both groups. The ES for the within-subject uncontrolled effect was defined as the average pretest-posttreatment change divided by the pretest standard deviation (Morris, 2000). Both the uncontrolled and controlled ESs were multiplied by a small sample factor correction. The variance was square-rooted to calculate the standard error. As studies did not report Pearson correlation coefficients, they were imputed using r = 0.7, as recommended by Rosenthal (Rosenthal, 1991). For the interpretation of the ES, the usual benchmarks suggested by Cohen of 0.2 for small, 0.5 for moderate, and 0.8 for large were adopted (Cohen, 1988). To estimate the ES of SCDs, the log response ratio (LRR) was calculated according to Pustejovsky (2018). This ES measure was chosen because it shows less procedural sensitivity than others (Pustejovsky, 2019). As ES estimation requires at least three observations for each phase, SCDs with fewer than three observations (Gola & Potenza, 2016; Hervías-Ortega, Romero López-Alberca, & Marchena Consejero, 2020; Minarcik, 2016; Pluhar, Jhe, Tsappis, Bickham, & Rich, 2020; Sniewski, Krägeloh, Farvid, & Carter, 2022) had values imputed using the last observation carried forward method. Sensitivity analyses excluding studies with imputed data were calculated to assess the effect of the imputation. I2 was calculated for each outcome as a measure of heterogeneity between studies.
Additional analyses
Subgroup analyses using Q-tests (for categorical variables), and meta-regression (for continuous variables) were calculated to assess potential sources of heterogeneity. Sample diagnosis, intervention type, intervention delivery and format, and comparison group were included as categorical variables. Sample mean age, percentage of males, number of sessions, and percentage of religious participants were included as continuous variables.
Statistical significance was set at p = 0.05. Calculation of SCDs ES analyses was performed using the SingleCaseES package (Pustejovsky, Chen, & Swan, 2022) for R v4.4.1 (R Core Team, 2023). Meta-analysis, publication bias, and subgroup analyses were performed in IBM SPSS v28.0 (IBM Corp., 2021). Meta-regressions were calculated in Comprehensive Meta-Analysis v4.0 (Borenstein, Hedges, Higgins, & Rohtsein, 2022).
Results
Figure 1 shows the results of the literature search and selection process, and Table 1 summarizes the main characteristics of the included studies. Prisma flow diagram is shown in Fig. 2. A total of 20 studies finally met the inclusion criteria. Their full references are listed in Supplementary Material B. They included 2,021 participants at baseline, of whom 79% (n = 1,588) were included in the post-treatment analysis. The mean age of the included participants was 31.29 years, and 84% of them were men. No gender-diverse individuals were included in the studies. The vast majority of studies included an undiagnosed sample (85%), while 10% included a sample diagnosed with CSBD. Although only five studies reported the percentage of religious participants, an average of 42% of participants reported some religious affiliation or practice. Of the included studies, 40% had an SCD design, 35% were uncontrolled group studies, and 25% were RCTs. One of these RCTs also reported separate data for each participant (Seyedzadeh Dalooyi et al., 2023), and was therefore also considered a SCD. Most studies used a third wave (45%) and second wave (40%) CBT intervention. ACT was the most common third wave intervention. The average length of the interventions was 10 sessions. Most interventions were delivered by a therapist (60%), in a face-to-face (60%) and individual (75%) format. One of the studies did not have sufficient data for ES calculations, so the corresponding author was contacted (Orzack, Voluse, Wolf, & Hennen, 2006). As no response was received, this study was excluded from the analysis. Only 40% of the included studies were funded by at least one institution/grant agency (Bőthe, Baumgartner, Schaub, Demetrovics, & Orosz, 2021; Gola & Potenza, 2016; Hardy et al., 2010; Hatch et al., 2023; Holas et al., 2021; Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015; Minarcik, 2016; Twohig & Crosby, 2010).
Main characteristics of the included studies
| Study (first author, year of publication) | Design | Publi-cation | Baseline participants (n) | Sample characteristics | Intervention characteristics | Control group | ||||||||||
| Treated | Controls | Diagnosis | Mean age | Males | Religious | Heterosexual | Country | Type | Length (sessions/weeks) | Applied by | Delivery | Format | ||||
| Bőthe (2021) | RCT | Journal | 123 | 141 | No diagnosis | 33.2 | 96% | N/A | 73.5% | United States, England, Canada, Hungary, India and Others | CBT | 6 | Self-applied | Online | Individual | Wait list |
| Crosby (2016) | RCT | Journal | 14 | 14 | No diagnosis | 29.3 | 100% | 96.4% | N/A | United States | ACT | 12 | Therapist | Face-to-face | Individual | Wait list |
| Dalooyi (2023) | RCT/SCD | Journal | 6 | 3 | No diagnosis | 20.77 | 100% | N/A | N/A | Iran | ACT + Transcranial direct stimulation | 7 | Therapist | Face-to-face | Individual | Transcranial stimulation alone |
| Gola (2016) | SCD | Journal | 3 | – | No diagnosis | 30.3 | 100% | N/A | 100% | Poland | CBT + Paroxetine | N/A | Therapist | Face-to-face | Individual | – |
| Hardy (2010) | Uncontrolled trial | Journal | 138 | – | No diagnosis | 37.97 | 97% | 95.0% | N/A | United States | CBT | 10 | Self-applied | Online | Individual | – |
| Hatch (2023) | Uncontrolled trial | Journal | 628 | – | No diagnosis | 34.03 | N/A | N/A | N/A | United States | Integrative Behavioral Couple Therapy | N/A | Combined | Online | Combined | – |
| Hervías-Ortega (2020) | SCD | Journal | 1 | – | No diagnosis | 19 | 100% | N/A | Spain | CBT | 13 | Therapist | Face-to-face | Individual | – | |
| Holas et al. (2021) | Uncontrolled trial | Journal | 13 | – | CSBD | 32.69 | 100% | N/A | N/A | Poland | Mindfulness | 8 | Therapist | Face-to-face | Group | – |
| Kellett (2017) | SCD | Journal | 1 | – | No diagnosis | 41 | 100% | N/A | N/A | United Kingdom | Cognitive Analytic Therapy | 13 | Therapist | Face-to-face | Individual | – |
| Kraus (2015) | SCD | Journal | 1 | – | No diagnosis | 30 | 100% | N/A | N/A | United States | CBT + Naltrexone | N/A | Therapist | Face-to-face | Individual | – |
| Levin (2017) | Uncontrolled trial | Journal | 19 | – | No diagnosis | 23.10 | 90% | 84% | N/A | United States | ACT self-help book | 8 weeks | Self-applied | N/A | N/A | – |
| Minarcik (2016) | SCD | Thesis | 12 | – | No diagnosis | 28.87 | 100% | 73.0% | 100% | United States | CBT | 12 | Therapist | Face-to-face | Individual | – |
| Orzack (2006) | Uncontrolled trial | Journal | 35 | – | Paraphilia/Impulse control | 44.5 | 100% | N/A | N/A | United States | CBT + Motivational interviewing | 16 | Therapist | Face-to-face | Group | – |
| Pareek (2023) | Uncontrolled trial | Journal | 8 | – | No diagnosis | N/A | 100% | N/A | N/A | India | Mindfulness | 14 | Self-applied | N/A | Individual | – |
| Pluhar (2020) | SCD | Journal | 1 | – | No diagnosis | 15 | 100% | N/A | N/A | United States | DBT | 14 | Therapist | Face-to-face | Individual | – |
| Rodda (2023) | Uncontrolled trial | Journal | 25 | – | No diagnosis | 37.6 | 96% | N/A | N/A | New Zealand | Behavior change techniques | N/A | Combined | Online | Individual | – |
| Scanavino (2023) | RCT | Journal | 93 | 42 | CSBD | 37.1 | 100% | N/A | 54.1% | Brazil | STPGP-RPGT | 8–16 | Therapist | Face-to-face | Individual | Pharmacotherapy |
| Sniewski (2022) | SCD | Journal | 12 | – | No diagnosis | 32.5 | 100% | N/A | 100% | New Zealand | Mindfulness | N/A | Self-applied | N/A | Individual | – |
| Todorovic (2024) | RCT | Journal | 946 | No diagnosis | 27.15 | 74% | 32.5% | 73.7% | Netherlands | CBT target mechanisms | 1 | Self-applied | Online | Individual | Active control (Distraction) | |
| Twohig (2010) | SCD | Journal | 6 | – | No diagnosis | 26.5 | 100% | N/A | 83.3% | United States | ACT | 8 | Therapist | Face-to-face | Individual | – |
Note: N/A = Not available; SCD = Single-case design; RCT = Randomized controlled trial; CSBD = Compulsive sexual behavior disorder; CBT = Cognitive behavioral therapy; ACT = Acceptance and commitment therapy; DBT = Dialectical behavior therapy; STPGP-RPGT = Short-term psychodynamic group therapy followed by relapse prevention group.
Risk of bias assessment results
For all study designs, the lack of blinding of outcome assessors was rated high or some concerns because all outcomes were self-reported. Therefore, the overall risk of bias was rated high or some concerns for all studies. The risk of bias in RCTs was lower for the assessment of bias due to missing outcome data and the selection of outcome domains reported. For uncontrolled group studies, the risk of bias was lower, especially for potential bias in the classification of interventions, deviations from the intended interventions, and selection of the reported outcome domains. For SCDs, the overall risk of bias was high, mainly due to the lack of blinding of participants/staff, inadequate description of the experimental condition, and insufficient information on the inclusion criteria.
Regarding publication bias, the Egger test was significant only for between-group craving. It was not significant for the remaining outcomes. Trim-and-fill imputed two studies for within-subject sexual compulsivity at follow-up and quality of life at posttreatment, but the ES remained significant and large for sexual compulsivity (SMD = 0.85, 95% CI [0.58 to 1.12]) and moderate for quality of life (SMD = 0.50, 95% CI [0.25 to 0.75]). Trim-and-fill also imputed studies for each SCD outcome. Specifically, one study was imputed for PPU (LRR = 0.31, 95% CI [0.25 to 0.37]) and craving (LRR = 0.34, 95% CI [0.27 to 0.40]), and seven for frequency/duration (LRR = 0.77, 95% CI [0.45 to 1.09]). The effect remained significant in all cases. Following the recommendation of Higgins and Green (2011), only funnel plots with more than 10 studies were examined. For SCD frequency/duration of pornography use, a small amount of asymmetry can be observed in the right part of the graph (see Supplementary Fig. C.1). Overall, therefore, these results suggest that the results are robust to evidence of risk of publication bias, as in the majority of cases there is no evidence, and in those where there is, the ES remains significant.
Meta-analyses results
First, the participants who received psychotherapy improved significantly more than controls on PPU, frequency/duration of pornography use, and sexual compulsivity, with large ES estimates and low heterogeneity (see Table 2). Although those receiving psychotherapy experienced less craving than controls, the ES estimates for this outcome were small, with high heterogeneity. The within-subject effect for these outcomes was also large, with moderate to large heterogeneity. In addition, the within-subject effect of psychotherapy for frequency/duration of pornography use was moderate to large, with high heterogeneity. The large within-subject ES was maintained at follow-up for frequency/duration of pornography use and sexual compulsivity, with less heterogeneity. With regard to associated internalizing problems, the effect was moderate for depression symptoms, with low heterogeneity, and not significant for anxiety. Finally, although the within-subject effect was null at posttreatment, the results suggest a significant and moderate effect at follow-up, with low heterogeneity.
Standardized mean differences (SMD), 95% confidence intervals, heterogeneity analyses (I2), and risk of bias for between-groups, within-subject and single-case designs outcomes
| Variable | Assessment | Between-groups outcomes | Within-subject outcomes | Single-case designs outcomes | ||||||||||||
| k | n | SMD | 95% CI | I2 | k | n | SMD | 95% CI | I2 | n | LRR | LRR 95% CI | LRR % change | I2 | ||
| Problematic pornography use | Posttreatment | 3 | 98 | 1.05 | 0.59/1.50 | 0% | 7 | 98 | 0.93 | 0.66/1.20 | 33% | 6 | 0.32 | 0.26–/0.39 | −27.59% | 0% |
| Frequency/duration of pornography use | Posttreatment | 2 | 113 | 1.07 | 0.59/1.55 | 34% | 10 | 871 | 0.94 | 0.56/1.3 | 90% | 35 | 1.04 | 0.76–/1.33 | −64.04% | 89% |
| Follow-up | – | – | – | – | – | 3 | 50 | 1.07 | 0.75/1.40 | 0% | – | – | – | – | – | |
| Craving | Posttreatment | 5 | 797 | 0.31 | 0.05/0.57 | 88% | 7 | 553 | 1.18 | 0.97/1.40 | 74% | 7 | 0.35 | 0.29–/0.42 | −32.18% | 0% |
| Sexual compulsivity | Posttreatment | 3 | 204 | 1.02 | 0.74/1.30 | 22% | 4 | 119 | 0.97 | 0.70/1.25 | 42% | – | – | – | – | – |
| Follow-up | – | – | – | – | – | 3 | 118 | 1.03 | 0.79/1.26 | 30% | – | – | – | – | – | |
| Anxiety | Posttreatment | – | – | – | – | – | 2 | 20 | 0.30 | −0.39/0.98 | 62% | – | – | – | – | – |
| Depression | Posttreatment | – | – | – | – | – | 2 | 20 | 0.48 | 0.08/0.88 | 0% | – | – | – | – | – |
| Quality of life | Posttreatment | – | – | – | – | – | 3 | 31 | 0.51 | −0.01/1.04 | 52% | – | – | – | – | – |
| Follow-up | – | – | – | – | – | 3 | 42 | 0.60 | 0.31/0.88 | 0% | – | – | – | – | – | |
Note. SMD = standardized mean differences; CI = confidence intervals; k = number of studies; n = number of participants; LRR = log response ratio.
In the SCD study estimates, improvements were more pronounced for frequency/duration of pornography use, with a 64% reduction after intervention, followed by craving (32%) and PPU (28%). Heterogeneity was high for frequency/duration and low for the other variables.
Subgroup analyses, meta-regression, and sensitivity analysis results
Subgroup analyses results
First, it should be noted that these analyses should be interpreted with caution due to the small sample size of many of the subgroups. All significant subgroup analyses are shown in Supplementary Table C.2. For within-subject PPU, the combination of therapist and self-administered delivery (Q = 8.02, p = 0.02) and online delivery (Q = 5.67, p = 0.02) were significantly more effective. CBT was significantly more effective for between-group craving (Q = 15.34, p < 0.01), but less effective for within-subject craving (Q = 10.50, p = 0.01). The remaining subgroup analyses were not significant.
Meta-regression results
None of the four selected predictor variables (percentage of males, mean age of participants, number of sessions, and percentage of religious participants) significantly predicted treatment outcomes (see Supplementary Table C.3).
Sensitivity analyses: studies with imputed data sensitivity analyses
After removing studies with imputed baseline observations, the ES estimates remained significant for SCD frequency/duration of pornography use (LRR = 1.28, 95% CI [0.92 – 1.64]). No observations were imputed for the other two SCD outcomes (PPU and craving).
Discussion
The aim of this meta-analysis was to quantitatively synthesize the available evidence on psychotherapy for PPU, taking into account the externalizing and internalizing problems associated with it. Using a comprehensive approach, the review included all available study designs (i.e., SCD, RCT, and uncontrolled designs). In addition, it sought to assess how different methodological and clinical characteristics may affect treatment outcomes. The results suggest that currently available psychotherapy-based interventions may reduce PPU and related features (e.g., craving). However, the studies reviewed had several sample-related and methodological limitations (e.g., focus on predominantly male populations, as discussed by Kowalewska, Bothe, & Kraus, 2024).
A significant increase in the number of studies and participants was observed compared to previous reviews conducted very recently (Antons et al., 2022; Borgogna et al., 2022; Roza et al., 2024). As expected, most studies used CBT-based interventions, consistent with other related problems such as addictive behaviors or impulse control disorders (Öst et al., 2022; Zamboni et al., 2021). Although most studies in the review still included samples from the United States (Crosby & Twohig, 2016; Hardy et al., 2010; Hatch et al., 2023; Kraus et al., 2015; Levin, Heninger, Pierce, & Twohig, 2017; Minarcik, 2016; Pluhar et al., 2020; Twohig & Crosby, 2010), other regions of the world were also represented, including South America (Scanavino et al., 2023), the Middle East (Seyedzadeh Dalooyi et al., 2023), Asia (Pareek, Jain, & Gupta, 2023), Europe (Gola & Potenza, 2016; Hervías-Ortega et al., 2020; Holas et al., 2021; Kellett, Simmonds-Buckley, & Totterdell, 2017; Todorovic, Huisman, & Ostafin, 2024), and Oceania (Rodda & Luoto, 2023; Sniewski et al., 2022). This is beginning to address the need to evaluate interventions for sexual problems in more diverse populations (Klein, Savaş, & Conley, 2022). Nevertheless, as usual, the African continent is underrepresented. In terms of study design, in line with the findings of previous reviews (Antons et al., 2022), the majority of studies still presented a SCD design or an uncontrolled pre-post group study. While more controlled studies are clearly needed, SCD can also contribute to scientifically valid inferences about treatment effects (Kazdin, 2019). However, there is a clear need for more RCT studies of PPU treatment, preferably with a blinded design. Perhaps one of the main reasons for the relative lack of more rigorous study designs is the underfunding of studies in this area, with only two-fifths of studies receiving any funding. National agencies and other research institutions should therefore invest more in this important issue, as it is becoming a growing problem in modern societies.
In terms of participant gender, although recent studies have found that some women also present with PPU (Bőthe et al., 2023), the vast majority of participants were still men (84%), and no gender-diverse participants were included in the sample. In conclusion, although the literature on psychotherapy for PPU has expanded in both scope and participant diversity, further research is needed to address the continuing gaps in study design, geographic representation, and inclusion of women and gender-diverse individuals (Kowalewska et al., 2024).
The results of the meta-analysis suggest that psychotherapy may be broadly effective in treating problems associated with PPU. However, it is important to note that all of the included studies had a high or moderate risk of bias. This treatment, consisting mainly of CBT and ACT interventions, appears to reduce PPU symptoms (including craving), the duration or frequency of pornography use, and sexual compulsivity. Improvements were observed both in comparison to controls and in within-subject change from pre- to post-treatment, which may support the robustness of the results. Treatment efficacy also remained stable at follow-up. Reductions in PPU symptoms, craving, and time/duration of pornography viewing were also clinically relevant in SCD outcomes. Although this is the first review of the efficacy of psychotherapy for PPU using a meta-analytic approach, these findings support those of previous systematic reviews (e.g., Antons et al., 2022; Borgogna et al., 2022; Roza et al., 2024). Moreover, while only one study examined it (Scanavino et al., 2023), the results suggest that psychotherapy may work better than medication alone, which warrants further investigation. The efficacy of CBT could be explained by better management of maladaptive cognitions related to PPU (e.g., low self-efficacy, negative self-evaluation) and the development of adaptive strategies for emotion regulation (Hardy et al., 2010). Similarly, this CBT effect could also be explained by the Moral Incongruence Model (Grubbs, Perry, Wilt, & Reid, 2019) as well, through the restructuring of beliefs related to potential incongruencies between participants' moral values and beliefs and their behaviors.
The positive effect of ACT on PPU may be due to an increase in psychological flexibility following the intervention (Crosby & Twohig, 2016). This is the main process of change variable proposed by ACT (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Recent literature suggests that PPU may function as an experiential avoidance behavior (Ortega-Otero, Montesinos, & Charrabe, 2023; Testa, Villena-Moya, & Chiclana-Actis, 2024), the opposite of psychological flexibility. The rationale for ACT for PPU is that rigid and controlling responses to urges may exacerbate problem behaviors, and ACT aims to change the way individuals respond to these urges (Crosby & Twohig, 2016). These proposed mechanisms of change for CBT interventions would provide additional support for PPU models, such as the I-PACE model (Brand et al., 2019), that focus on inhibitory control issues. Overall, these findings highlight the clinical potential of CBT and ACT to effectively treat PPU by targeting the underlying cognitive, emotional, and behavioral mechanisms, providing a robust and comprehensive treatment approach.
The meta-analyses also showed within-subject improvements in associated internalizing symptoms (anxiety and depression) and quality of life. This could be explained by a direct effect of the intervention, as the literature has generally shown CBT and ACT to be effective in treating anxiety and depression symptoms and improving quality of life (Bhattacharya, Goicoechea, Heshmati, Carpenter, & Hofmann, 2023; Ciharova et al., 2021; Fordham et al., 2021; Gloster, Walder, Levin, Twohig, & Karekla, 2020). Alternatively, these improvements may be secondary effects to PPU-related symptoms. In any case, these preliminary findings suggest the clinical utility of ACT and CBT for individuals with PPU who also struggle with emotional problems or impaired quality of life. This is important because recent literature has shown a significant relationship between PPU and internalizing symptoms (Grant Weinandy, Lee, Hoagland, Grubbs, & Bőthe, 2023). Therefore, clinicians should consider these interventions as part of a comprehensive treatment approach. However, these findings need to be confirmed in controlled trials, preferably with a randomized allocation.
With respect to the subgroup and meta-regression analyses, many of the examined outcomes had a relatively low heterogeneity index. This may explain why most of the subgroup analyses were not significant and could be interpreted as these variables not having a significant effect on treatment outcome. Regarding the type of therapy, no differences were observed between ACT and CBT. This is consistent with previous literature on interventions for other problems, where ACT and CBT equally improved internalizing and externalizing outcomes (Gloster et al., 2020). Some studies have argued that this may be due to shared mechanisms of change in these interventions (Harley, 2015). However, an unexpected finding is that there were no differences between those formally diagnosed with CSBD and those without a diagnosis. We might expect that those formally diagnosed would be more impaired and therefore have more room for improvement. A possible explanation for these findings is that while many of the studies did not formally diagnose the sample, they used restrictive inclusion criteria, such as requiring higher PPU scores or meeting informal criteria for PPU, resulting in a sample of individuals with more PPU problems.
Another clinically relevant finding was that treatment outcome did not appear to be affected by delivery format, as no significant differences were observed between online versus face-to-face, self-administered versus therapist-administered, or individual versus group interventions. These findings could be interpreted as preliminary evidence for the flexibility of CBT and ACT treatment options, which could make therapy more accessible and tailored to individual preferences or circumstances without compromising its effectiveness. This is of paramount importance, as many individuals experience shame about their PPU behaviors (Sniewski & Farvid, 2020), which could be a barrier to accessing face-to-face therapist-delivered interventions (Dhuffar & Griffiths, 2016; Kraus, Martino, & Potenza, 2016). Finally, none of the four continuous variables (percentage of males, mean age of participants, and number of sessions) significantly predicted treatment outcome. Again, this could be interpreted as preliminary evidence for the flexibility of CBT and ACT interventions for PPU. Of particular note were the results of the meta-regressions that used the percentage of religious participants as a predictor. According to the Moral Incongruence Model (Grubbs et al., 2019), we might expect that a higher percentage of religious participants would predict better treatment outcomes, as they might have more moral incongruence. In contrast, we found no significant associations between the percentage of religious participants in the sample and treatment outcomes.
Limitations and future research
This meta-analytic review had several limitations. First, most of the studies were considered to have a high or unclear risk of bias. This is largely due to the self-reported nature of the outcomes. This raises concerns about potential biases, such as social desirability bias or recall bias, which could undermine the validity of our findings. On the other hand, it has been argued that there is limited evidence in psychotherapy research that self-report measures overestimate treatment effects (Munder & Barth, 2018). Nevertheless, future research should also include more objective measures of pornography viewing, such as computer monitoring programs, to more objectively evaluate the results. Second, the results may be biased because only five studies were controlled, and two of them had inactive control conditions. However, the between-group and within-subject effect sizes were comparable, and no significant differences were observed between the active and inactive comparisons. Therefore, more randomized controlled trials should be conducted in future research to further investigate treatment outcomes. Third, another potential source of bias arose from the fact that several studies used a combined intervention of medication and psychotherapy effects. Several of them did not implement procedures to isolate the effect of each intervention (e.g., comparing multiple groups). This may have introduced some confounding variables of treatment effects that were not controlled for. Future studies should implement procedures to assess the treatment effects of each component. Fourth, another important limitation is that the sample consisted mainly of males, although there is evidence of a significant group of females who have problems with pornography use (Bőthe et al., 2023). As discussed above, future studies should include a more gender-balanced and include women and gender-diverse individuals (Kowalewska et al., 2024). Fifth, a large proportion of the sample of included studies came from large Internet-delivered studies, leaving other interventions underrepresented. On the other hand, subgroup analysis showed that there were no significant differences between face-to-face and online interventions. Sixth, data had to be imputed in some SCDs to calculate ESs, but sensitivity analyses showed no difference between studies with and without imputed data, supporting the robustness of the findings. Seventh, subgroup analyses may be limited by small sample sizes in some subgroups and should be interpreted with caution. Eighth, the vast majority of studies were conducted in Western countries, which may limit the generalizability of the results to other regions. It is imperative to conduct studies in non-Western countries in the future. Ninth, most studies did not report participants' sexual orientation, and those that did reported a relatively low percentage of gay/bisexual participants. This may limit the generalizability of findings to sexually diverse individuals and should be addressed in future research. Finally, another factor limiting the depth of our understanding of the mechanism of change is that the role of process variables (e.g., process variables in the ACT model, changes in dysfunctional beliefs in CBT) was not examined. As recent approaches such as process-based therapy suggest (Hofmann & Hayes, 2019), it is not enough to assess how effective an intervention is, but it is necessary to understand how it works so that interventions can be more targeted and effective. Thus, future studies are needed to better understand the processes underlying changes in PPU due to different therapeutic approaches.
Conclusions
This meta-analysis provides insight into the efficacy of psychotherapy, particularly CBT and ACT, in treating PPU and related problems. Specifically, the results suggest that they can effectively reduce issues associated with PPU, as measured in a variety of ways. They also improved related internalizing symptoms and participants' quality of life. These results are consistent across different study designs, with sustained effects observed several months after the intervention. This underscores their potential as an effective and comprehensive treatment approach for individuals struggling with PPU. However, while these findings are encouraging, they are not without several important limitations that highlight areas for future research. This research should aim to address these limitations by conducting more rigorous and diverse studies that include underrepresented populations and using objective outcome measures. In addition, understanding the mechanisms of change of the interventions will be critical to developing more targeted and effective treatments. In conclusion, while significant progress has been made in understanding the efficacy of CBT and ACT for PPU, much remains to be done. By continuing to refine and expand our research efforts, we can better equip clinicians with the tools necessary to provide effective, evidence-based care to those struggling with PPU.
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Beata Bőthe was supported by the FRQSC – Research Support for New Academics (NP) Program. Carlos López-Pinar and Javier Esparza-Reig did not receive any funding for this research.
Authors' contribution
The study was designed by Carlos López-Pinar, who also wrote the protocol, conducted literature searches, extracted study data, performed the statistical analysis, and wrote the first draft of the manuscript. The final study selection and evaluation of risk of bias were performed by Carlos López-Pinar and Javier Esparza-Reig. The manuscript was revised and edited by Carlos López-Pinar, Javier Esparza-Reig and Beata Bőthe. All authors have contributed to and approved the final manuscript.
Conflict of interest
Beata Bothe serves as an associate editor of the Journal of Behavioral Addictions. The other authors declare no conflict of interest.
Supplementary material
Supplementary data to this article can be found online at https://doi.org/10.1556/2006.2025.00018.
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