Internet pornography use (IPU) is a sexual behavior [1
], corresponding to the use of internet to engage in various gratifying sexual activities also known as online pornography use or cybersex [2
]. It comprises a variety of online sexual activities (OSAs), including watching pornography, online pornography exchange, engaging in sex chats, using sex webcams, searching for sexual partners, or engaging in sexual role playing, among which stands the watching pornography, which is the most popular activity [5
]. According to the past findings, engaging in IPU sometimes derives various negative consequences, such as financial, legal, occupational, and relationship trouble or personal problems [6
]. Feelings of loss of control and persistent use despite these adverse outcomes constitute compulsive cybersex or problematic IPU. To date, no consensus exists regarding the conceptualization and diagnosis of problematic IPU. For instance, numerous terms have been used to describe the phenomenon (e.g., internet sex addiction [7
], problematic online sexual activities [9
], cybersex addiction [10
], and problematic internet pornography use [6
]). Although these concepts are slightly different, they all comprise three crucial components: the medium (the internet), the content (sexual behavior), and the problematic use (the compulsive behavior). Regardless of the debate, it is now acknowledged that excessive involvement in IPU or cybersex may become dysfunctional and associated with addiction symptoms (e.g., loss of control, compulsive use). Considering these inconsistent terms sharing crucial components, problematic IPU may be regarded as a subtypes of problematic internet use from a classification perspective, which may help advance clinical and research efforts into its prevalence and impact.
Nevertheless, evidence regarding the problematic IPU is inconsistent, due to the heterogeneity of assessment tool. The fundamental reason is that the definition and diagnostic criteria of problematic IPU is still unclear. In order to address these conceptual ambiguities, researchers have developed several scales that measure different aspects of pornography use [11
]. Some briefer scales are more convenient to administer, but they underscore the self-perceived addiction (e.g., Cyber-Pornography Use Inventory-9). Some of these scales have been designed to assess the motivations underlying pornography use among hypersexual men (e.g., Pornography Consumption Inventory) [12
]. Some scales fail to capture the different aspects of problematic IPU and focus solely on specific dimensions (e.g., the Pornography Craving Questionnaire, PCQ). Additionally, some globally accessible websites host the Cybersex Addiction Test, Sexaholics Anonymity Test, Sex Addicts Anonymous, and Sexual Addiction Screening Test, which assess difficulties in exercising self-control, its negative consequences, and the social problems that are associated with sexual activities. Furthermore, assessing IPU, using measures of sexual addiction, entails a few challenges. Specifically, these assessments may not be able to capture the characteristics of the activities (e.g., chat-based cybersex, sexual video games that cannot be played offline) and symptoms (e.g., separation from reality due to immersion in the virtual world that are unique to IPU. To address this gap in the literature and conduct further research in this domain, assessments with strong psychometric properties are much needed [5
Several scales of problematic IPU are available to researchers and clinicians. Indeed, a recent meta-analysis identified 22 psychometric instruments that assess problematic pornography use [11
]. Otherwise, most of the studies that have been conducted during the past decade had used self-developed items and a few of these measures have been subsequently revalidated [4
]. Therefore, it is difficult to compare the results of different studies because there is a lack of concordance in the assessments that have been used. In order to select suitable tools for comparison from the existing scales, a systematic review was conducted. The following terms and their derivatives were used in multiple combinations: (Cybersex* OR internet porn* OR hypersex*) AND (addict* OR compulsiv* OR problem*) AND (assessment OR scale OR instrument OR measure*), to identify relevant studies in order to address the questions related to assessment and available screening questionnaires. The selection criteria of the literature search were limited to articles focusing specifically on cybersex and/or internet pornography consumption and dysfunctional cybersex, and also describe the development and adaptation of self-reported psychometric instruments that assesses at least one aspect of problematic pornography use. Finally, we found a total of 27 instruments on assess the problematic IPU (cybersex). Through the systematic review process conducted, we decided to retain three scales that were developed to measure problematic pornography use, even if not all of the three scales were specifically designed to measure internet pornography, as a large majority of participants used online pornography, and the developers of these scales suggested that they could be used to measure problematic IPU [14
], additionally we replaced “pornography” into “internet pornography” in the Chinese version. We selected these three scales for the following reasons: (1) they include fewer items and are thus easily administered measures, (2) all of them cover the core characteristics of IPU, such as loss control, (3) they are grounded in addiction components such as impaired control, conflict, salience [11
], (4) they are applicable within the Chinese culture [16
], and (5) they display strong test-retest (i.e., two weeks) reliability; consequently, these three previously validated scales were identified for further examination. First, the Short Internet Addiction Test Adapted to OSAs (s-IAT-sex), which has demonstrated satisfactory psychometric properties [9
]. However, this scale has been validated only among men [5
], and a large number of studies have shown that there are substantial gender differences in IPU [18
]. Second, the Problematic Pornography Use Scale (PPUS) [15
], which has been validated using a large sample; unfortunately, however, a valid cutoff score has not been specified for this measure. Third, the Problematic Pornography Consumption Scale (PPCS); this scale is founded upon the theoretical framework of Griffiths’s components model of addiction [22
]. All three scales include strong internal consistency and a valid factorial structure, which has been supported by the results of confirmatory factor analysis (CFA) [9
]. Nevertheless, it is difficult to compare the findings of studies that have used these scales because they entail different factor structures. Therefore, it is necessary to select reliable indicators and methods, and identify the most accurate instrument.
In order to effectively compare different scales, a unifying and reliable standard should first be established. The Brief Pornography Screener (BPS), which is a screening tool that measures loss of self-control, overuse of problematic pornography use, may be useful in identifying individuals who are at risk for problematic pornography use or can serve as a proxy measure [23
]. Kraus et al., who developed the BPS, have proposed that the diagnostic criteria for compulsive sexual behavior (CSB) should be included in the new International Classification of Diseases (ICD-11) [24
], and this proposal has been accepted. According to the upcoming ICD-11’s diagnostic criteria for impulse control disorder [25
], patterns of failure to control intense sexual impulses or urges and the resultant repetitive sexual behaviors are considered to be the characteristic features of the disorder. The BPS considers compulsive pornography to be the core component of problematic pornography use. Moreover, the BPS has been used with different samples, and it has demonstrated satisfactory psychometric properties among American and Polish pornography users [26
]. Many past studies have used the BPS to identify pornography addicts. Furthermore, it has also been used to ascertain the severity of problematic pornography use among men who seek pharmacologic or psychological treatment as a result of their loss of control over their sexual behaviors [27
]. Therefore, in this study, the BPS scores were used as the reference standard against which the sensitivity and specificity of the three aforementioned scales were ascertained.
Several recent reviews have focused specifically on the conceptualization and assessment of problematic pornography use [4
]. Some reviews have briefly summarized and commented on the included instruments [5
], whereas others have evaluated their ability to assess the core components of problematic pornography use [11
]. However, no past study has compared the different scales and identified the most accurate measure of problematic pornography use using a same standard or indicator. Measures of problematic IPU are heterogeneous, and each scale focuses on a different aspect of problematic IPU. Furthermore, because these scales have not been extensively validated, it is difficult to compare the findings of the studies that have used them. In addition, the sensitivity of the different scales that assess problematic IPU have not been adequately compared. Therefore, in the present study, a QUAN→QUAL mixed-methods design was conducted, including (1) using quantitative methods to identify a scale with a higher sensitivity index from three selected scales (PPCS, PPUS, s-IAT-sex) for assessing problematic IPU. Moreover, the duration of usage, frequency of engagement in OSAs, sexual compulsivity, and pornography cravings were used to examine the criterion validity of the assessments. Subsequently, (2) qualitative interviews were conducted with volunteers and therapists who have serviced the individuals in trouble of problematic IPU to further examine the appropriateness of the “more accurate” scale from the service providers’ perspectives, whereby the qualitative part helps to evaluate and interpret the results obtained from the main quantitative study.
4. General Discussion
Problematic IPU is still a controversial issue; notably, it appears that no real consensus exists regarding the conceptualization and screening tool of problematic IPU. Several scales are available; thus, the assessment of problematic IPU is inconsistent, indicating that findings in this area are not readily comparable. The present study aimed to selected a more sensitive scale to screen problematic IPU, because higher sensitivity implies lower rate of missed diagnosis (i.e., problematic users who have been incorrectly screened as nonproblematic users). Basing on a systematic literature review, three scales were retained. Considering that research with mixed methods combining quantitative and qualitative analyses can enrich and improve our understanding of complicated phenomena [38
], a quantitative method was used to identify a “more accurate” analysis from the three retained scales. Results of CFA showed that all three scales have good applicability in the wide range of adult groups (age in this case ranged from 18 to 45 years) in three highly homogeneous samples; compared to the other two scales, the PPCS demonstrated greater sensitivity and comparative specificity among samples drawn from the general population (results of the QUAN). Considering that the expression of questionnaire survey is brief and closed, and that the interview can understand the participants’ undefined views more deeply and comprehensively, subsequently, results of QUAL showed that symptoms of problematic IPU proposed by the servers (volunteers and therapists) can be grouped into the six dimensions of PPCS and most of the servers supported the six-factor structure of PPCS.
Among the three scales, the PPCS score was most robustly related to the duration of usage, frequency of engagement in OSAs, and pornography cravings. Problematic IPU can appear under the umbrella of hypersexuality similarly to frequent engaging in various forms of cybersex, intense craving for pornography, and compulsive sexual behaviors [40
], insofar that the robust relationship not only demonstrated a higher criterion validity, but also implied that co-screening instruments (i.e., pornography craving, frequency and duration of use, compulsive use) are expected to work as auxiliary screening indicators. Recent studies have revealed that for some people, pornographic use gave rise to their feeling of discord and shame contributing to their conflict of actual sexual materials consumption and their belief; in turn, these feelings of distress and shame may drive a morbid self-perception that they are addicted, but this may not be a real behavioral disorder [41
]. In order to avoid misjudgment due to the self-perceived problematic use, it is more advisable to combine other supporting scales, and the combination diagnosis indexes of the diversity were selected to screen the prevalence of problematic IPU. In this study, with the higher correlation of PPCS with frequency of OSAs, the PCQ showed that combined with other indicators, it can better screen out problematic use and is more likely to avoid the misjudgment caused by subjective self-perceived addiction.
The more robust psychometric properties and higher recognition accuracy of the PPCS may be attributable to the fact that it has been developed in accordance with Griffiths’s six-component structural theory of addiction (i.e., in contrast to the PPUS and s-IAT-sex). The PPCS has a very strong theoretical framework, and it assesses more components of addiction [11
]. In particular, tolerance and withdrawal are the important dimensions of problematic IPU that are not assessed by the PPUS and s-IAT-sex; PPCS is the only instrument that explicitly assesses the “tolerance” component [11
]. According to the “two-phased” internet pornography addiction model, in which the first step is characterized by an excessive use to internet pornography, and the second functions as a marker by repeated failures to break free from excessive use, despite negative consequences [43
]. Items related to information about salience, carving, and tolerance reflect the engagement in internet pornography, corresponding to the first step, whereas items related to withdrawal, relapse, and conflict measure addiction more, corresponding to the second step. Obviously, components of PPCS includes both engagement in pornography and addiction of IPU, which has an intact theoretical framework of addiction.
The PPCS appears to be a more valid instrument for assessing problematic pornography use, has potential application in detecting prevalence concerning problematic IPU or cybersex addiction, and may be useful in assessing treatment outcomes. Our findings indicate that individuals who score high on the PPCS also report frequent engaging in various forms of online sexual activities, intense craving for pornography, and compulsive sexual behaviors. Thus, it appears important for clinicians to be aware of problematic pornography use and its related associations such as pornography craving, compulsive use. Moreover, it is important to note that the scale PPCS is recommended as a screening instruments to identify problematic users in the public and assess the prevalence rather than a diagnostic tool; future studies should further research its validity and cutoff in clinical sample; we also encourage individuals to visit a clinical therapist after being identified with problematic IPU by the use of PPCS.
This study has several limitations. First, data were collected using self-report measures; therefore, the reliability of the results depends on the respondents’ honesty and accuracy of their comprehension of the scale items. Second, the study sample was recruited through an online survey company; therefore, the participants of this study may have been more educated and affluent than the average Chinese person. Furthermore, the study participants primarily lived in the capital/provincial capital, cities, and towns. Third, because the sample consisted of only a small number of non-heterosexual subjects, it was not possible to examine whether the factor structure and meaning of the contents of the PPCS differed across individuals with different sexual orientations.