Sex

Do Sex-Porn and Mental Health Issues Interact?

If so, how?

Posted Jul 20, 2020

In my 25 plus years in the mental health profession, I have seen numerous misdiagnoses, at least a few of which were based primarily on a person’s sexual behavior, in particular the use of pornography. Typically in such cases, someone is using pornography and their loved ones or their therapist disapproves, so that person is slapped with an inaccurate diagnosis and pushed into therapy that won’t help them (and might even harm them by increasing their sexual and social shame, as we see with so-called gay conversion therapy). In other situations, I have seen people whose porn use was highly problematic to themselves and others be told that they should just become more comfortable with their sexuality.

Typically, the thinking behind these various misdiagnoses seems to be, “There must be something wrong with you. Otherwise, why would you be looking at porn, or that porn, or that much porn,” or, “There must be something wrong with you for being uncomfortable with your porn viewing. If you just embrace it, everything will be fine.” In both cases, rather than digging in and performing a full bio-psycho-social and sexual assessment, well-meaning but underinformed clinicians go with what they know – unresolved trauma, depression, personality disorders, compulsivity, or whatever else they feel comfortable treating.

The good news is that sometimes these diagnoses are spot-on in terms of identifying the client’s primary problem. Just as often, however, those diagnoses uncover and treat a secondary disorder or even something that’s not a disorder at all. Mostly this occurs because clinicians are not trained to appropriately explore sexual behaviors and identify them for what they are. They just don’t understand that something like porn use, even heavy porn use, could be a symptom of a psychological disorder without being a disorder itself. Nor do they understand that psychological disorders like depression, anxiety, and the like can manifest as symptoms of compulsive sexual behavior.

In the first scenario, the use of pornography – even the heavy, seemingly compulsive use of pornography – can indicate (be symptomatic of) any number of psychological disorders. If and when those disorders are accurately diagnosed and treated, the individual’s struggles with pornography (and any other compulsive or impulsive sexual behaviors) will typically clear up. Let’s say an individual’s underlying issue is depression and he or she is self-medicating (numbing out) by compulsively using pornography. When the individual’s depression is effectively treated, his or her compulsive porn use will likely abate. Another example is an individual in the manic stage of Bipolar Disorder who feels driven, obsessive, and compulsive with sexual thoughts and behaviors. This person may end up viewing hours and hours of pornography, hooking up with strangers, and engaging in all sorts of other sexual behaviors. Once this person is properly medicated, however, the compulsive sexual behaviors will abate.

For a reverse example, let’s consider an individual whose true issue is compulsivity with pornography, though his lack of control over pornography is creating depression. In such a case, a therapist may misinterpret the client’s porn use as symptomatic of depression (rather than vice versa), and then aggressively treat the depression – assuming that when the depression clears, so will the client’s struggles with pornography. Unfortunately, because the client’s true underlying issue (compulsive porn use) is not being addressed, the symptom (depression) is likely to continue.

It is vital when sexual issues arise as a possible disorder or symptom requiring treatment that the client’s true situation is accurately assessed, acknowledged, and addressed. If, as in the first two examples above, compulsive sexuality is symptomatic of another disorder, that other disorder is primary and must be the initial focus of treatment. If, however, as in the third example, sexual compulsivity is driving the client’s depression, anxiety, and the like, then treatment should focus on stepping away from compulsive sexual behaviors.

As a best practice, before making any diagnosis directly related to an individual’s sex-porn behaviors, such as Compulsive Sexual Behavior Disorder (CSBD) as defined by the World Health Organization in the ICD-11, clinicians should first rule out other mental health issues that may exacerbate or be exacerbated by porn use, or that may symptomatically manifest through porn use. Such disorders include (but are not limited to):

At the end of the day, therapists must recognize and understand that compulsive and impulsive sexual behaviors can arise related to any number of psychological conditions. Clinicians must also recognize and understand that the reverse may be true, meaning any number of psychological issues can arise related to compulsive and impulsive sexual behaviors. Thus, it is incumbent on the therapist to fully assess the client, including sexual issues – where they started, how they manifest, and why they manifest – before assigning a diagnosis and proceeding with treatment.

If all of this sounds a little bit confusing, that’s because it is. Especially for laypeople and clinicians who are not adequately trained to assess and diagnose sexual symptoms and sexual disorders. And most clinicians are not. Therapists who are unsure of a diagnosis for a particular client because sexual issues, such as porn use, are part of the scenario should either make a referral to or seek outside guidance from a specialist in sexual issues. Without that, the client may be underserved.