Behavioral Addictions _ _______________________________________________________________________
addictive sexual behavior may be more common with Inter- net mediation. A Swedish study estimated the prevalence of “Internet sexual problems” was 17.8% in men and 6.7% in women, higher than studies from the pre-Internet era [22]. Addictive sexual behavior is more common in men, with onset usually in late adolescence. It can involve a wide range of sexual behaviors, often including a mixture of paraphilic and nonparaphilic behaviors. Sexual urges and behaviors are often distressing and uncontrollable, triggered by certain mood states, and result in feelings of shame [143; 144]. Comorbidity is common in addictive sexual behavior, includ- ing substance use disorder (64%), affective disorders (14% to 39%), anxiety disorders (50%), and childhood conduct disorder (44%). In the family histories of patients with addic- tive sexual behavior, 40% had substance use disorder in at least one parent and 36% had sexual addiction in at least one parent [145; 146]. Addictive sexual behavior is consistently linked to high-risk sexual behaviors, including multiple partners, unprotected sex, and sex under the influence of drugs or alcohol. The adverse consequences and risks of addictive sexual behavior include HIV/STI infection, unwanted pregnancies, infertility, loss of relationships, social isolation, loss of self-esteem, job loss, legal issues, financial problems, significant personal distress, and impairment in daily functioning [139]. Patients diagnosed with sex addiction differ in common per- sonality characteristics from those diagnosed with gambling disorder. Sex addiction is associated with higher education level and lower novelty-seeking, harm avoidance, persistence, and self-transcendence. Being employed and lower cooperativeness scores also predicted the presence of sex addiction. However, patients with gambling disorder or sex addiction do not differ in comorbid psychopathology [147]. Gender Differences In one of few Internet pornography addiction studies involv- ing women, Internet pornography users rated pornographic images as more arousing and reported greater craving for sex than non-users. Craving, sexual arousal, sensitivity to sexual excitation, problematic sexual behavior, and severity of psy- chological symptoms were predictors of Internet pornography addiction. In contrast, current relationship status, number of sexual contacts, satisfaction with sexual contacts, and use of interactive cybersex were not associated with addiction. The reinforcing nature of sexual arousal, learning mechanisms, and cue reactivity and craving in the development of Internet pornography addiction in women were found consistent with those reported in heterosexual men [148]. In a large community survey, 51% of women and 90% of men reported using Internet pornography. Internet pornography use was associated with sexual dissatisfaction from perceived addiction (perceived compulsivity, effort to access, distress
from pornography use) and sexual function problems (sexual dysfunction, compulsion, avoidance). This pattern held for men and women [149]. Geo-Locating Social Media Growing in popularity and market share, geo-locating social media gives users the ability to find each other for casual sexual encounters (“hook-ups”). Unlike standard online dating apps, location-matching apps typically do not require users to create a profile about themselves; instead, users upload one or more photos. The simplicity of appearance-based selection and proximity accounts for the increasing growth in popularity of location-based dating apps. One of the first such apps, Grindr, was introduced in 2008 specifically for gay and bisexual males, followed by other apps for gay men, lesbians, and heterosexuals (Tinder, Bumble, and others) [141; 150]. INTERNET PORNOGRAPHY ADDICTION Excessive and addictive Internet pornography use by younger men has received little attention outside of behavioral and sexual addiction research, but data suggest this has become a rapidly growing problem with serious consequences that requires fuller discussion. Epidemiology of Adverse Effects High-speed broadband Internet access became widely avail- able in the early 2000s. Until the early to mid-2000s, erectile dysfunction (ED) prevalence in sexually active men younger than 40 years of age was low, consistently 2% to 4%. In con- trast, studies conducted since 2005 show sharply increased prevalence of ED and low sexual desire in men younger than 40 years of age [151]. For example, new ED diagnoses in active- duty servicemen doubled from 2004 to 2013 [152]. In 2014, 53.5% of men 16 to 21 years of age had symptoms of sexual dysfunction, including ED (26%), low sexual desire (24%), and problems with orgasm (11%) [153]. In 2016, a study of persons 16 to 21 years of age followed over two years found persistent problems in boys/men of low sexual satisfaction (47.9%), low desire (46.2%), and ED (45.3%). Over time, sexual problems declined in women but not men [154]. A 2015 study found ED with low desire for partnered sex was common in men (mean age: 36 years) seeking help for Internet pornography use with excessive masturbation [155]. ED in men younger than 40 years of age is typically diagnosed as psychogenic and linked to stress, depression, generalized anxiety, or performance anxiety. Organic ED, diagnosed in 15% to 20% of cases, is linked to neurologic, hormonal, or ana- tomic conditions or drug side effects. ED in older men is more often diagnosed as organic, associated with smoking, alcohol use, diabetes, obesity, hypertension, or cardiovascular disease [156]. None of the known correlative factors of psychogenic ED adequately account for the rapid increase in youthful sexual dysfunction. The historical correlates of organic ED in older men have not changed proportionately, or have decreased, in younger men over the past 20 years [151; 157].
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