Table 2.
Characteristics of included studies and main results
| Study/study site | Sexual behavior/diagnostic procedure | Sample/study design | Main results | Treatment |
| Psychotherapy with focus on cognitive behavioral therapy | ||||
|
Bőthe et al. (2021); Switzerland, Hungary |
PPU; self-identified/willing in participating in an online treatment for PPU | TG: n = 123, dropout: 89%, M
age = 33 ± 11.5, 95.9% male, 74.8% heterosexual, 5.7% homosexual, 13.8% bisexual; CG: Waitlist, n = 141, dropout: 44.7%, M age = 33 ± 9.9, 96.5% male, 72.3% heterosexual, 4.3% homosexual, 21.3% bisexual; RCT; Within-between subject design; Measurements: BL, post |
↓ symptom severity [PPCS] (post-BL: TG < CG); ↓ behavior engagement [freq] (post-BL: TG < CG); ↔ behavior engagement [dur] (post-BL: TG = CG); ↓ craving (post-BL: TG < CG) ↔ moral incongruency (post-BL: TG = CG); ↑ pornography-related self-efficacy (post-BL: TG > CG) |
Web-based self-help tool including six core modules developed to reduce PPU based on motivational interviewing, CBT, mindfulness, and wise social-psychological intervention techniques; individual therapy; 6 weeks; 6 modules + booster module after 1 month; 45–60 min per module; digital therapy. |
|
Crosby and Twohig (2016); United States |
PPU; clinical interview, criteria: (a) engaged in problematic Internet pornography use for more than 6 months, (b) viewing frequency of at least two sessions per week, on average, for the month previous to enrolling in the study, (c) experiencing significant distress and/or functional impairment in his life; and (d) at least one unsuccessful attempt at stopping |
Overall (TG and CG): M
age = 29 ± 11.4, 100% male, sexual orientation: n/a; TG: n = 14; CG: Waitlist with subsequent therapy, n = 13 RCT; Within-between subject design; Measurements: BL, post, 3FU |
↓ symptom severity [SCS] (TG: BL > post, CG: BL = post, overall: BL > post/3FU); ↓ behavior enactment [am] (TG: BL > post; CG: BL = post); ↓ negative outcomes of sex. behavior (TG: BL > post, CG: BL = post, overall: BL > post/3FU); ↔ quality of life (TG: BL = post, CG: BL< post, BL < post) |
Modified ACT manual for PPU aiming to help the client determine effective strategies for responding to urges, to practice using these strategies outside of session, to gradually decrease pornography use and to increase occurrence of high quality-of-life activities; individual-therapy, 12 sessions à 1 h. |
| Hall et al. (2020); United Kingdom | CSBD; current clients, SASAT [no-cut-off criteria] | TG: N = 119, age: n/a, gender: n/a, sexual orientation: n/a; Within subject design, descriptive; Measurements: BL, post, 3FU, 6FU |
Only descriptive results
behavior enactment (BL vs. 3FU vs. 6FU: 82%/4%/11% answered most of the time/often); obsessive sexual thoughts (76%/80% report having fantasies/intrusive thoughts most of the time/often at BL, 7.5%/17% at 4FU, 13/19 at 6FU); psychological distress (change from BL to 3FU of 58% improvement, from Bl to 6FU 60% improvement) |
Psycho-educational program following the precept of ‘growth through knowledge’ and the philosophy of the CHOICE Recovery Model which incorporates principles from CBT, ACT, psychodynamic and relational psychotherapy theory and positive psychology. The program aims at giving clients greater insight into the root causes of their compulsive behavior, practical skills for preventing relapse, positive goals for the future and motivation to change, along with a long-term support network; group-therapy; 6 days. |
| Hallberg et al. (2017); Sweden | CSBD predominantly PPU (90% of participants); Kafka-criteriaa, validated through clinical interview | TG: Final n = 10, M
age = 39 ± 8.1, 100% males, drop out: n = 5, sexual orientation: n/a; Within subject design; Measurements: BL, mid, post, 3FU, 6FU |
Non-parametrical tests
↓ symptom severity [HD:CAS] (BL > mid/post/3FU/6FU); ↓ symptom severity [HDSI] (BL > mid/post/3FU); treatment satisfaction (70% high level of satisfaction) |
CBT program targeting different criteria of CSBD. The seven models include viewing CSBD from cognitive, behavioral, and functional perspectives, stress and time-management techniques, cognitive restructuring and diffusion techniques addressing negative thoughts and beliefs, identification of values, and relapse prevention; group-therapy, 7 weeks, 7 or 10 sessions à 2.5 h. |
| Hallberg et al. (2019); Sweden | CSBD; HDSI, Kafka-criteriaa validated in clinical interview | TG: BL: n = 58, M
age = 40 ± 12, 100% males, sexual orientation: n/a, mid: n = 52, post: n = 47, 3FU: n = 21, 6FU: n = 14; CG: During waitlist period BL: n = 54, M age = 40 ± 11, 100% males, sexual orientation: n/a, mid: n = 52, post: n = 50; Waitlist sample during treatment BL: n = 48, mid: n = 40, post: n = 35, 3FU: n = 22, 6FU: n = 11; RCT; Within-between subject design; Measurements: BL, mid, post, 3FU, 6FU |
↓ symptom severity [HD:CAS] (TG: BL > mid/post; post: TG < CG); ↓ symptom severity [SCS] (mid/post: TG < CG; BL > mid/post < 3FU/6FU); ↓ psychological distress (TG: BL > mid/post/3FU/6FU; mid/post: TG < CG); ↓ depression (TG: BL > mid > post > 3FU/6FU; mid/post: TG < CG); ↔ treatment satisfaction (TG = CG) |
CBT program as described in Hallberg et al. (2017); group-therapy; 7 weeks; 7 sessions à 2.5 h. |
| Hallberg et al. (2020); Sweden | CSBD with/without paraphilia; HDSI cut-off, clinical interview | TG: N = 36, M
age = 39 ± 8.5, 100% males, sexual orientation: n/a; Within subject design; Measurements: BL, mid, post, 3FU |
↓ symptom severity [HBI-19] (BL > mid/post/3FU); ↓ symptom severity [HD:CAS] (BL > post); ↓ symptom severity [SCS] (BL>mid/post/3FU); ↓ psychological distress (BL>mid/post/3FU); ↓ depression (BL>mid/post/3FU); ↔ paraphilic disorders (BL = mid = post = 3FU); Treatment satisfaction (88% high level of satisfaction) |
Internet-based CBT that is based on the CBT program by Hallberg et al. (2017), individual-therapy, 12 weeks, 10 modules, internet-based. |
| Hardy et al. (2010); United States | CSBD with emphasis on PPU and masturbation; self-identified/willing in participating in an online treatment for CSBD/PPU | TG: N = 138, M
age = 38 ± 12.4, 97% males, 91% heterosexual cross-sectional, retrospective evaluation |
Retrospective pre-post comparison
↓ behavior engagement; ↑ perceived recovery; ↓ obsessive sex. thoughts |
CBT program aiming to reduce causes of distress by self-paced, psychoeducation modules, delivered online through text, graphics, video, audio, and interactive exercises; individual self-help; 10 modules; online program. |
| Holas et al. (2020); Poland | PPU; clinical interview, fulfilling 4 of 5 Kafka criteriaa | TG: N = 13, M
age = 33 ± 5.74, 100% male, sexual orientation: n/a; Within subject design; Measurements: BL, post |
↔ symptom severity [BPS] (BL = post); ↓ behavior enactment (pornography use: BL > post); ↓ depression (BL > post); ↔ anxiety (BL = post); ↔ obsessive compulsive disorders (BL = post) |
Mindfulness-based intervention aimed at, among other things, reducing craving and negative affect—i.e. processes that are implicated in the maintenance of problematic sexual behaviors; group-therapy; 8 weeks; 8 sessions à 2 h. |
| Levin et al. (2017); United States | PPU; self-identified, treatment seeking; phone screening | TG: N = 19, M
age
= 23 ± 4.5, 90% male, sexual orientation: n/a, post: n = 11; Within subject design; Measurements: BL, post, 2FU |
↓ symptom severity [CPUI] (BL > post); ↓ behavior enactment [am] (BL > post); ↓ negative outcomes of sex. behavior (BL > post); ↔ quality of life (BL = post = 2FU); ↔ psychological flexibility (BL = post = 2FU) |
ACT self-help program for PPU in which clients work through a self-help book that emphasizes core ACT components and related skills including acceptance, cognitive defusion, mindfulness of the present, self-as-context, values, and committed action; 8 weeks; 15 chapters of self-help book. |
| Orzack et al. (2006); United States | PPU; Internet-related sexual behaviors, diagnosis with paraphilia not otherwise specified, impulse control disorder not otherwise specified | TG: N = 35, M
age = 45 ± 5.74, 100% male, sexual orientation: n/a Within subject design; Measurements: BL, mid, post |
↔ problematic use of computers (BL = Post); ↑ quality of life (BL < post); ↓ depression (BL > post) |
Treatment combined Readiness to Change, CBT, and Motivational Interviewing interventions within a group-therapy setting; 16 weeks; 16 sessions. |
| Sniewski et al. (2020); New Zealand | PPU; self-identified/willing in participating in a self-help treatment for PPU | TG: N = 12; Drop-out: n = 1; M age = 32 ± 8.9; 100% male; 100% heterosexual Within subject design; Measurements: BL, weekly assessment until post |
Only single case analyses
7 of 11 participants showed significant improvement in symptom severity [PPCS]; 2 of 11 participants showed significant improvement in behavior enactment [dur] |
Intervention included guided and unguided meditation sessions that were applied via an online platform; individual self-help intervention; overall 12 weeks; baseline between 2 and 5 weeks; intervention between 10 and 7 weeks; online meditation audio-tapes. |
| Twohig and Crosby (2010); United States | PPU; clinical interview, criteria: (a) viewing pornography more than three times a week on some weeks and (b) the viewing causes difficulty in general life functioning | TG: N = 6, M
age = 27 ± 6.1, 100% male, 83% heterosexual, 16% unsure Case series; Within design; Measurements: BL, post, 3FU |
Only descriptive results
5 of 6 showed reduced behavior enactment [freq] (BL vs. post); increase in quality of life (from BL to post 8%, from BL to 3FU 16.4%); decrease in obsessive compulsive disorder (from BL to post 51%, from BL to 3FU 68%) |
Modified ACT manual for PPU including core components of ACT such as acceptance, values, committed action, defusion, and self as a context; individual-therapy; 8 sessions. |
| Wan et al. (2000); Canada | CSBD (SAST, criteria unclear) | TG: N = 59, M
age = 43, 70% male; sexual orientation: n/a Within subject design; Measurements: post 0.8–43 months |
Only descriptive results
behavior enactment: 29% stayed abstinent/64% relapse |
Sexual dependency program consisting of core addiction treatment components and specialized sexual dependency components. The approach included a 12-steps approach development of knowledge and skills for recovery; group and individual therapy; M duration = 32 days, 2–12 h therapy/psychoeducation and 12-steps approach. |
| Wilson and Fischer (2018); United States | CSBD; criteria for hypersexual behavior [unclear which concrete criteria], individuals in treatment |
CBT subgroup: n = 27; Art therapy subgroup n = 27; overall: M age = 43 ± 10.8; 93% male; sexual orientation: n/a Within-between subject design; Measurements: BL, post, 3FU |
↓ symptom severity [HBI-19] (CBT: BL > post/3FU; art therapy: BL > post/3FU; post/3FU: art therapy = CBT); ↓ shame (CBT: BL > post/3FU; art therapy: BL > post/3FU; post/3FU: art therapy = CBT) |
CBT or art-therapy aiming at reducing shame and CSBD symptoms. Both interventions addressed the same topics including denial, the nature of sex addiction and surrender to the process; group-therapy; 6 weeks. |
| Other psychotherapy approaches | ||||
| Efrati and Gola (2018); Israel | CSBD; self-identified, participants of Sexoholics Anonymous | TG: N = 97, M
age = 30 ± 7.3, 100% male, sexual orientation: n/a Cross-sectional design |
Number of steps is correlated with (-) symptom severity [I-CSB]; (+) self-regulation; (-) psychological distress |
12-step program of Sexaholics Anonymous, group-therapy. |
| Hartman et al. (2012); Canada | CSBD with/without SUD; in treatment, SAST-R [no cut-off criteria] | TG: Subgroup without SUD n = 21, subgroup with SUD n = 36; Overall: M age = 39 ± 8.81, 91.2% males, sexual orientation: n/a Within subject design; Measurements: BL, post, 6FU |
↓ symptom severity [CSBI] (with and without SUD: BL > 6FU); ↑ quality of life (with and without SUD: BL < 6FU); ↓ substance use (with SUD: BL < 6FU) |
Inpatient treatment program that includes 12-steps approach, physical health education and training, psychosocial education, recovery planning; group- and individual therapy. |
| Kjellgren (2018); Sweden | CSBD; SAST [cut-off: core score ≥6]; 27% report main problem with pornography use | TG: N = 28, M
age = 40 ± 11.5, 96% male, 96% heterosexual Within subject design; Measurements: BL, post, 10FU |
↓ symptom severity [SAST] (BL > post); ↓ psychological distress (BL < 10FU); treatment satisfaction (100% positive/very positive) |
Treatment provided by specialized social welfare units without any standardized manual; methods applied were psychodynamic, cognitive-behavioral, or system-based approaches, individual therapy, about 25.6 sessions à 45–60 min. |
| Klontz et al. (2005); United States | CSBD; diagnosis, in treatment | TG: N = 38, M
age = 44 ± 8.9, 73% male, 79% heterosexual Within subject design; Measurements: BL, post, 6FU |
↓ symptom severity [GSBI] (sexual obsession: BL > post/6FU; discordance: BL/post > 6FU); ↓ psychological distress (BL > post > 6FU); ↓ anxiety (BL/post < 6FU); ↓ depression (BL > post); ↓ obsessive-compulsive disorder (BL > post) |
Brief residential, multimodal experiential group therapy treatment program including psychodrama (32 h), psychoeducation (12 h), mindfulness-based technique/meditation (16 h); group-therapy; attending at five 8-day-retreats within 12 months. |
| Pharmacological treatment | ||||
| Coleman et al. (2000); United States | CSBD; DSM-IV criteria for sexual disorder not otherwise specified, in treatment | TG: N = 14, M
age = 45, 100% males, sexual orientation: n/a Retrospective design; Measurements: retrospective evaluation through therapists |
Only descriptive results
self-regulation (55% report good control over obsessive thoughts; 45% report remission of obsessive thoughts) |
Nefazodone (Mdose = 200 mg/day, min-max dose: 50–400 mg/day), treatment duration about 13.4 months, parallel individual and group-CBT. |
| Gola and Potenza (2016); Poland | PPU; treatment seeking with preoccupations/urges, numerous failed quit attempts, and significant distress related to PPU and masturbation |
TG: N = 3, M
age = 30 ± 4.64, 100% male, 100% heterosexual Case study design; Measurements: weekly assessment, 3FU |
Only descriptive results
behavior enactment [am]: short-term reduction; new compulsive sexual behaviors after 3 months; anxiety: significant reductions after ten weeks |
SSRI (paroxetine; dose = 20 mg/day), in addition to CBT. |
| Kafka and Hennen (2000); United States | Paraphilias: DSM-IV criteria, clinical interview; CSBD: Kafka-criteria, clinical interview |
TG: N = 26, Paraphilia: n = 14, CSBD: n = 12, age: n/a, 100% males, 73.1% heterosexual Within subject design; Measurements: BL, post-SSRI, post-SSRI + psychostimulant |
Combined analysis for individuals with paraphilias and CSBD
↓behavior enactment [am] (BL > post-SSRI > post-SSRI + psychostimulant) |
8 weeks; SSRI (fluoxetine 49 mg/day: n = 19, sertraline 110mg/day: n = 3, paroxetine 35 mg/day: n = 2, fluvoxamine 100 mg/day: n = 2) and psychostimulant (methylphenidate SR 40 mg/day: n = 25, dextroamphetamine: n = 1). |
| Raymond et al. (2010); United States | Paraphilic and non-paraphilic CSBD, 58% CSBD, 31% PPU; individuals with diagnosis in treatment, criteria unclear | TG: N = 19, M
age = 4 4.1 ± 9.4, 100% males, 73.3% heterosexual Measurements: Investigation during treatment |
Only descriptive results
89% report reduction in symptom severity [S-SAS] |
Individual or group therapy and medical treatment with naltrexone (first 25–50 mg/day, after 1–2 weeks 100 mg/day). 79% also took SSRI or SNRI (venlafaxin). Treatment duration 2 months–2.3 years. |
| Savard et al. (2020); Sweden | CSBD, 85% with PPU; ICD-11 criteria and 3 of 5 A-criteria and 1 of 2 B-criteria DSM-5 conceptualization for hypersexual disorder | TG: N = 20, M
age = 38.8 ± 10.3, 100% males, 70% heterosexual Within subject design; Measurements: BL, mid, post, 1FU |
↓ symptom severity [HD:CAS] (BL > mid/post/1FU); ↓ symptom severity [HBI-19] (BL > mid/post/1FU); ↓ symptom severity [SCS] (BL > mid/post/1FU) |
4 weeks, naltrexone (25–50 mg/day). |
| Wainberg et al. (2006); United States | CSBD; YBOCS-CSB [no cut-off criteria], CSBD [no cut-off criteria] | TG: n = 13; CG: placebo, n = 15 Overall: M age = 36 ± 8.2, 100% males, 100% homo-/bisexual RCT; Within-between design; Measurements: BL, post |
↔ symptom severity [YBOCS-CSB] (post: TG = CG); ↔ symptom severity [CSBI] (post: TG = CG); ↓ behavior enactment [am] (pornography, masturbation) (post: TG < CG); ↓ sexual desire (post: TG < CG) |
12 weeks, citalopram. |
Note. Primary outcomes are highlighted in bold. a Kafka criteria as defined in Kafka (2010). 1FU/2FU/3FU/6FU/10FU = 1/2/3/6/10 months follow-up assessment, 6wFU = six-week follow-up assessment, ACT = acceptance and commitment therapy, am = amount of time spent on sexual behaviors, BL = baseline assessment, BPS = Brief Pornography Screener (Kraus et al., 2020), CBT = cognitive behavior therapy, CG = control group, CPUI = Cyber-Pornography Use Inventory (Grubbs, Sessoms, Wheeler, & Volk, 2010), CSBD = compulsive sexual behavior disorder, CSBI = Compulsive Sexual Behavior Inventory (Coleman, Miner, Ohlerking, & Raymond, 2001), dur = duration of behavior enactment, freq = frequency of behavior enactments, GSBI = Garos Sexual Behavior Inventory (Garos & Stock, 1998), HBI-19 = Hypersexual Behavior Inventory (Reid, Garos, & Carpenter, 2011), HD:CAS = Hypersexual Disorder: Current Assessment Scale (American Psychiatric Association's DSM-5 workgroup on sexual and gender identity disorders), HDSI = Hypersexual Disorder Screening Inventory (Kafka, 2013), I-CSB = Individual-based CSB (Efrati & Mikulincer, 2018), mid = assessment in the middle of treatment, post = post treatment assessment, PPU = problematic pornography use, PPCS = Problematic Pornography Consumption Scale (Bőthe et al., 2018), RCT = randomized controlled trial, TG = treatment group, SAST = Sexual Addiction Screening Test (Carnes, Green, & Carnes, 2010), SCS = Sexual Compulsivity Scale (Kalichman & Rompa, 1995), S-SAS = Sexual symptom assessment scale (Raymond, Lloyd, Miner, & Kim, 2007), YBOCS-CSB = Yale-Brown Obsessive Compulsive Scale – Compulsive sexual behavior (Wainberg et al., 2006). ↓ statistically significant decrease in outcome, ↑ statistically significant increase in outcome, ↔ no statistically significant change in outcome.