Problematic consumption of online pornography during the COVID-19 pandemic: clinical recommendations

Abstract The coronavirus disease (COVID-19) pandemic is one of the greatest contemporary challenges. Feelings of fear and uncertainty triggered by this pandemic have had noxious effects on people’s mental health. This seems to have increased during quarantine and there is evidence of an intensification of reward-directed behavior. Nevertheless, there are few studies dealing with pornography consumption during this period. The aim of this manuscript is to contextualize this phenomenon during the pandemic and suggest some clinical recommendations on the matter.

scientific evidence indicate that an increase in online pornography use is expected likewise. [9][10][11] With the rise in online pornography consumption, it is likely that there is also an increase in compulsive sexual behaviors and excessive masturbation. 10,11 Data from Pornhub website show an increase of 11.6% in views in comparison to a random day before COVID-19 pandemic. In Brazil, there has been an even greater increase in views (13.1%).
Although, for most people, watching online pornography is adaptive and should not be pathologized, a subgroup of vulnerable individuals is at risk of developing problematic patterns of consumption. 12 Frequent consumption of pornography, especially online, may lead to a range of side effects, such as lower levels of well-being, reduced productivity, and impaired interpersonal relationships, together with increased isolation and narrowing of social repertory, which add to the effects of the pandemic and the "quarantine." 13 In spite of the scarcity of more robust scientific data and the controversy around the subject (sometimes understood as harmless entertainment or benign sexual expression, other times seen as having harmful effects on society), recent studies estimate that pornography may gain new contexts and challenges in some parts of the world during and after the pandemic. 10,13,14 In this sense, the aim of this study is to appraise problematic consumption of online pornography during the COVID- 19 pandemic and suggest clinical recommendations on the matter.

Clinical features
Several behaviors which potentially affect reward circuits in the human brain may lead to loss of control and may contribute to development of other symptoms of dependence in some individuals. 2,15 Regarding internet dependence, neuroscientific research supports the assumption that the underlying neural processes are similar to those of addiction to psychoactive substances. 16 The American Psychiatric Disorders, that one of these internet-related behaviors, online gaming, is a potential disorder which leads to dependence and merits further study. 17 On the other hand, other internet-related behaviors, such as online pornography consumption, were not included. Nonetheless, there is little evidence that considers these behaviors as causes of dependence or addiction. 15,18 In this context, "pornography dependence" is not a formally recognized disorder, mainly because of disagreements among researchers regarding the concept and clinical features and even its existence. 12,15,19,20 However, self-perceived pornography dependence and its perception by health professionals and some researchers, which emerged in the 1970s, has become more relevant since the 1990s as a concept in research as well as in clinical practice. There is an alert on problematic consumption of pornography -its frequency and its possible side effects in legal, psychological (psychological and interrelationship suffering), and health-related aspects of people's lives -since these individuals have been seeking help for dealing with such behaviors. 10,12 In Excessive consumption of pornography may impact users' financial lives, involving them in legal and occupational problems and leading to interpersonal relationship difficulties. 10,12 Another impact that can affect pornography users is sexual frustration related to their real-life sex partner. 22 These users frequently criticize their sex partner's body and pressure them to engage in high performance sexual acts, far removed from "real sex" and mostly fanciful. 22,23 Although some available studies show little association between pornography and erectile dysfunction among young men, 24 other researchers state that the rise in pornography consumption may be the main factor to explain the sharp increase in erectile dysfunction among young people. 25 Another study points out that 60% of men who experienced erectile dysfunction with a real partner did not have the same problem when consuming internet pornography, raising the hypothesis of a complex background linked to the available and easily accessible world of internet sex. 26 Individuals who consume pornography tend to be more susceptible to stress, impairing their ability to meet domestic demands, for example. 27,28 If these subjects are regular users of online pornography and also parents, the impact may be even greater. Social isolation per se generates relevant negative outcomes in mental health, 4 while young people tend to isolate even further into themselves during quarantine and surf the internet by themselves or with virtual friends, which may become an important source of stress due to the large number of hours that they remain connected. 29

Clinical recommendations
In the context of children One very pertinent concern that has been posited by researchers and also by the authors of this document refers to children and teenagers. Our opinion is that they deserve special attention, mainly because this is the period in which an individual's identity develops and consolidates, as well as because it is the transition to adult life. Next, some very illuminating studies will be mentioned, since they may provide some insights into these concerns, especially with regards to young men.
The authors of this study highlight that over the course of the pandemic, children and teenagers seem to be more vulnerable in terms of the availability of Hardcore pornographic content, which is spread around the internet, and some studies seem to corroborate this hypothesis. [30][31][32] First exposure to pornographic content at a premature age is a cause of concern for several different sectors of society nowadays. The importance and relevance of these data seem to be confirmed by several scientific studies. A study conducted with young people aged 15 to 29 years reported that mean age of first exposure to online pornography was at 13 for men and 16 for women. 33 Moreover, 84% of those who had watched online pornography in the 12 months prior to the survey were men and 19% were women, but one curious fact was that women consumed pornography on a weekly or daily basis. 34 Another study showed that 64% of young people aged from 13 to 24 actively sought pornography on a weekly basis. 33 Research shows that children and teenagers are more inclined to problematic consumption of online pornography than adults. 35 The most popular pornographic content website A multi-centered study in Europe involving 4,564 teenagers between 14 and 17 years of age suggested that watching pornography on a weekly basis is associated with a higher probability of sending sexual content (sexting) between peers. 38 In another systematic review and meta-analysis of 14 papers reporting cross-sectional studies, sexting behavior among people between 10 and 24 years of age was strongly associated with premature sexual activities, with alcohol use before the sexual act, and with multiple sex partners. 39 Adolescence is a period in which experimentation with sexuality starts. According to specialists, sex education should begin in puberty and adolescence. 40 Studies have already shown the inefficacy of sex education based on fear and guilt. 41 Nonetheless, recently a new way of experimenting with sexuality through sexting, especially among pre-adolescent and adolescent populations, has come to the attention of parents, educators, psychologists, and the general public. 42 Based on studies which suggest that online pornography consumption by young people is related to sexting, it is very likely that this practice will grow exponentially during the pandemic, since many young people and adults will