Journal of Sex & Marital Therapy

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Sexual Desire and Subjective Distress among

Pornography Consumers

Brian A. Droubay , Kevin Shafer & Robert P. Butters

To cite this article: Brian A. Droubay , Kevin Shafer & Robert P. Butters (2020): Sexual Desire
and Subjective Distress among Pornography Consumers, Journal of Sex & Marital Therapy, DOI:
10.1080/0092623X.2020.1822483

To link to this article: https://doi.org/10.1080/0092623X.2020.1822483

Published online: 25 Sep 2020.

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JOURNAL OF SEX & MARITAL THERAPY
https://doi.org/10.1080/0092623X.2020.1822483

Sexual Desire and Subjective Distress among

Pornography Consumers
Brian A. Droubaya , Kevin Shaferb , and Robert P. Buttersc
a
Department of Social Work, University of Mississippi, Oxford, MS, USA; bDepartment of Sociology, Brigham
Young University, Provo, UT, USA; cCollege of Social Work, University of Utah, Salt Lake City, UT, USA

ABSTRACT
Clients are increasingly seeking professional help related to pornography
viewing in the digital age. Given distress is a key reason clients seek help,
the purpose of this study was to identify variables associated with it.
Drawing from recent literature, we examined the roles of solitary sexual
desire, moral incongruence, feelings of dysregulation, and shame-prone-
ness in predicting subjective distress among consumers. Surveys were
administered through Amazon Mechanical Turk to US adults (n ¼ 559).
Structural equation models supported moderated mediation, where the
positive relationship between sexual desire and subjective distress was
fully mediated by feelings of dysregulation, and the relationship between
sexual desire and feelings of dysregulation was moderated by moral incon-
gruence. Moral incongruence was the largest direct predictor of subjective
distress, while shame-proneness was not significantly associated with it.
This study points to targets for intervention research, reinforces findings
that values play an integral role in how individuals interpret their viewing
and whether they feel distressed, and suggests that values may impact
how individuals interpret their sexual desire. Implications for practitioners
are discussed, including the need for person-in-environment assessment
and more holistic care than has traditionally been proposed in the sex
addiction field.

Problematic pornography use

Given the expansion of the Internet and easy access to sexually explicit materials, the impacts of
pornography viewing have received increased examination in recent years. Researchers have
increasingly been debating pornography’s effects and whether it is addictive (Duffy et al., 2016;
Voros, 2009), and clients have increasingly been seeking professional help for pornography-
related distress (Grubbs, Stauner, Exline, Pargament, & Lindberg, 2015; Kalman, 2008; Mitchell
et al., 2005; Mitchell & Wells, 2007). Despite a large cadre of providers advertising specialty in
sex addiction treatment, there are few controlled studies on therapeutic interventions for these
issues (Miles et al., 2016). Disagreements over the etiology and operationalization of problematic
pornography use (PPU) have stymied intervention research (Duffy et al., 2016; Reid, 2013).

Nomenclature and operationalization

Researchers have debated what to call PPU, its definition, and how to classify it nosologically, if
at all, which has made formulating treatment difficult. While PPU has occasionally been

CONTACT Brian A. Droubay bdroubay@olemiss.edu Department of Social Work, University of Mississippi, P.O. Box 1848,
MS 38677-1848, USA.
ß 2020 Taylor & Francis Group, LLC
2 B. A. DROUBAY ET AL.

presented as a subtype of problematic Internet behavior (Mitchell et al., 2005; Shapira et al.,
2003), it is most commonly considered a subtype of sex addiction or hypersexuality.
Hypersexuality refers to an “excessive preoccupation with sexual fantasies, urges, and behavior
that individuals struggle to control” (Walton, Cantor, Bhullar, & Lykins, 2017a, p. 2232).
Hypersexual behaviors are typically considered nonparaphilic—meaning they conform to local
laws and customs—and include acts such as masturbation, sexual activities between consenting
adults, cyber and telephone sex, visiting strip clubs, and viewing pornography (Kafka, 2010).
Among these, pornography viewing is the most common hypersexual behavior (Reid et al., 2012).
Hypersexual disorder, with a pornography specifier, was advocated for inclusion in the DSM-5
(Kafka, 2010) but was met with resistance from several researchers (Halpern, 2011; Moser, 2011;
Wakefield, 2012) and excluded for lack of evidence (Prause, 2017). This discussion has recently
received renewed attention, with compulsive sexual behaviour disorder being included in the forth-
coming ICD-11 (Kraus et al., 2018; World Health Organization, 2018); PPU will presumably be
encompassed under this umbrella.
Several terms have been used to describe PPU, including pornography addiction, pornography
dependence, excessive viewing, compulsive viewing, and self-perceived addiction (Duffy et al.,
2016). While many frameworks have been put forward, the most commonly employed for dysre-
gulated sexual behaviors include compulsive, impulsive, and addictive models (Bancroft &
Vukadinovic, 2004; Gold & Heffner, 1998; Stein, 2008; Walton, Cantor, Bhullar, et al., 2017). The
distinction between these three, however, is often ambiguous. Though they connote differing etio-
logical mechanisms, the terms are often used interchangeably both colloquially and in the
research literature. For example, the forthcoming ICD-11 diagnosis, compulsive sexual behaviour
disorder, is categorized in the impulse control disorder family (World Health Organization, 2018).
PPU is also defined differently across empirical studies. Crosby and Twohig (2016) define it as
the “inability to control the use of pornography, the experience of negative cognitions or emo-
tions regarding pornography use, and the resulting negative effects on quality of life or general
functioning” (p. 355). Other researchers have attempted to identify a threshold of frequency or
duration that constitutes problematic use. Cooper et al. (1999), for instance, identified 11 or more
hours per week of seeking “sexual pursuits” online as the point where individuals “show signs of
psychological distress and admit that their behavior interferes with some area(s) of their lives”
(p. 161).

Prevalence
Pornography viewing is common. Nationally representative data suggest between 54–69% of men
and 27–40% of women aged 18–39 view pornography in a given year in the US; approximately
33–46% of men and 8–16% of women endorse viewing pornography in a given week (Grubbs,
Kraus, et al., 2019; Regnerus et al., 2016). In 2009–2010, pornography accounted for roughly 13%
of all web searches (Ogas & Gaddam, 2011).
Estimates on the prevalence of PPU vary widely depending on sampling methodology, as well
as measurement of the construct. An oft cited but unsubstantiated estimation of hypersexuality
(or sex addiction, the nomenclature depending on the author) is between 3 and 6% of the popu-
lation (Carnes, 1991; Kuzma & Black, 2008; Walton, Cantor, Bhullar, et al., 2017). In an epi-
demiological study of young adults, Odlaug et al. (2013) estimated the prevalence of compulsive
sexual behaviors to be 2%.
Studies estimating prevalence specific to PPU are rarer. The best estimate at this point comes
from a study conducted by Grubbs, Kraus, et al. (2019), where among a nationally representative
sample of US adult Internet users, 11% of men and 3% of women indicated some level of agree-
ment with the statement, “I am addicted to pornography” (p. 91). This shows at the very least
that many individuals perceive their pornography use as dysregulated.
 JOURNAL OF SEX & MARITAL THERAPY 3

Key correlates of PPU

Subjective distress
Despite ongoing uncertainty about how to best operationalize PPU—and spirited debates as to
whether pornography viewing is harmful or addictive—it is apparent many individuals feel genu-
inely distressed about their viewing and report negative consequences (Walton, Cantor, Bhullar,
et al., 2017). These feelings of subjective distress are important to understand, as distress is a key
reason individuals seek professional help (Gola et al., 2016) and clinically significant distress is a
requirement for practitioners to make diagnoses across disorders (American Psychiatric
Association, 2013).

Sexual desire
Several authors have expressed concern about pathologizing sexual behaviors (Halpern, 2011; Ley
et al., 2014; Reay et al., 2013; Williams, 2017). An alternative explanation is that high-frequency
sexual behavior, including pornography use, represents one end on a continuum of normative
sexuality, rather than a pathological category (Bancroft & Vukadinovic, 2004). Unsurprisingly,
high-frequency sexual behaviors are associated with high sexual desire. Steele et al. (2013), for
instance, found that high sexual desire, rather than hypersexuality, predicted neurophysiological
responses to sexually explicit images. Moholy et al. (2015) likewise found that “higher levels of
desire for sex with a partner,” rather than hypersexuality, predicted difficulties in downregulating
sexual arousal (p. 1505).
The differentiation between sexual desire and hypersexuality can be somewhat convoluted.
Generally, while sexual desire refers to level of desire for sexual activity, hypersexuality incorpo-
rates persons subjectively feeling their behaviors are dysregulated, negative consequences associ-
ated with related behavior, and persons utilizing sex to cope with negative affect (Reid et al.,
2011; Walton et al., 2016). Importantly, hypersexuality is not synonymous with high-frequency
sexual behaviors. Walton, Cantor, Bhullar, et al. (2017) explain, “Some non-hypersexual persons
exhibit high levels of sexual behavior similar to the levels of sexual behavior reported by hyper-
sexual persons, but about which non-hypersexual persons are not clinically distressed” (p. 2235).
In sum, sexual desire appears to play an important role in arousal, response to arousal, and
subsequent frequency of sexual behaviors. Whether a person feels distressed by high-frequency
sexual behavior, however, appears related to subjective interpretation of it.

Moral incongruence and feelings of dysregulation

Several researchers, recognizing that personal values may impact pornography consumers’ feelings
about and propensity to pathologize their use (Grubbs & Perry, 2019), have defined PPU in terms
of self-labeling and subjective distress rather than attempting to establish universal criteria.
Several authors refer to “self-perceived” pornography addiction (Duffy et al., 2016; Grubbs,
Exline, et al., 2015). Grubbs, Stauner, et al. (2015) explain, “In contrast to prior foci on the
addictive nature of pornography or the compulsive use of pornography, perceived addiction
focuses on the propensity of the individual to interpret use of pornography in a pathological
manner” (p. 1056).
Moral values play an integral role in how pornography viewing is experienced by individuals.
For persons who have personal or religious convictions against pornography, the intrapersonal
and relational costs of consumption are higher (Perry, 2016). Consumers who morally disapprove
of pornography viewing are more likely to pathologize their use and feel it is dysregulated
(Grubbs, Exline, et al., 2015), which in turn predicts psychological distress (Grubbs, Stauner,
et al., 2015). Moreover, pornography consumption is more likely to have deleterious effects on
relationship and sexual satisfaction in religious households (Perry, 2016; Perry & Whitehead,
4 B. A. DROUBAY ET AL.

2019). Importantly, moral incongruence—defined as perceiving one’s behaviors are misaligned

with one’s values (Grubbs & Perry, 2019)—may play a role in fostering distress, including shame
(Perry & Whitehead, 2019; Volk et al., 2016).

Shame-proneness
Shame may play a key role in the development and maintenance of PPU. Shame in this context
is defined as a global, negative self-critique, evident in the belief that engagement in an objection-
able behavior indicates a defective self (Lewis, 1971; Petrican et al., 2015). While shame is associ-
ated with problematic sexual behaviors, it is also negatively associated with motivation to change
and proactive change behaviors (Gilliland et al., 2011; Tangney et al., 2014). Further, shame is
predictive of increased sexual excitability in persons with dysregulated sexual tendencies (Petrican
et al., 2015). In sum, shame may be both an important priming emotion in the development of
PPU and perpetuate related behavior by stymieing change. Persons who have a dispositional
proneness to shame (i.e., who are shame-prone) may be especially vulnerable to feelings of shame
and other forms of distress associated with pornography viewing.

Hypotheses
This study is motivated by practitioners’ ethical obligation to provide culturally-sensitive and evi-
dence-based care. As noted, there is a dearth of research on interventions for clients presenting
with distress related to pornography use (Miles et al., 2016). Our hope was to identify targets for
intervention research.
A key first step is to better understand the relationship between the variables outlined above.
We were particularly interested in the relationship between sexual desire and subjective distress.
The above literature suggests that how consumers interpret their viewing—whether they perceive
it to be dysregulated—impacts whether they feel distressed (Grubbs, Stauner, et al., 2015), and
consumers’ moral values about pornography are strongly associated with how they interpret their
viewing (Grubbs, Exline, et al., 2015). Extending this, it seems probable that individuals with
higher sexual desire, who may have more difficulty downregulating sexual arousal (Moholy et al.,
2015), may interpret their viewing as dysregulated and feel distressed by it, particularly if they
have moral qualms with pornography. Finally, persons who have a dispositional proneness to
shame may be especially susceptible to distress.
To test this, we developed a structural model. Our hypotheses were as follows:
H1. Higher sexual desire, moral incongruence, feelings of dysregulation, and shame-proneness will be
associated with greater feelings of subjective distress about pornography viewing

H2. The relationship between sexual desire and subjective distress will be mediated by feelings of
dysregulation

H3. Higher sexual desire will be associated with greater feelings of dysregulation

H4. The relationship between sexual desire and feelings of dysregulation will be moderated by moral
incongruence

H5. The direct effect between sexual desire and subjective distress will also be moderated by moral
incongruence

Regarding H2, we further explored the following question (EQ1): If the relationship between
sexual desire and subjective distress is mediated by feelings of dysregulation, will it be fully or
partially mediated?
 JOURNAL OF SEX & MARITAL THERAPY 5

Methods
Participants and procedure
We administered surveys through Amazon’s Mechanical Turk (MTurk). MTurk is a crowdsourc-
ing platform where individuals volunteer to complete a multitude of online tasks, including sur-
veys, for a small fee. While MTurk does not produce a truly representative sample, its users are
quite diverse across demographics such as gender, age, and income (Ross et al., 2009). MTurk
samples are significantly more diverse than traditional college samples (Buhrmester et al., 2016),
and participants closely resemble the Internet-using population in the US (Ross et al., 2009).
MTurk has shown promise in behavioral addiction research (Schluter et al., 2018) and has suc-
cessfully been utilized to gather data specific to distress related to pornography viewing (Grubbs,
Stauner, et al., 2015).

Inclusion/exclusion criteria
Eligible participants were English-speaking US adults registered with MTurk who reported having
viewed pornography in the past month. A total of 139 respondents reported no pornography con-
sumption and were excluded. While the term pornography was not explicitly defined—in part
because this study centers on persons’ subjective experiences with it—participants were informed
that all questions were referring to solo viewing (in the absence of a partner). Further, partici-
pants were asked not to participate if their viewing includes illegal pornography, such as child
pornography.
Participation was restricted to persons with an MTurk approval rating of 95% or greater,
which suggests they have successfully completed that percentage of tasks (Buhrmester et al., 2016;
Schluter et al., 2018) or are new to MTurk. To weed out surveys where participants were not
reading through items, several attention check questions were included. Persons who answered
inaccurately on more than one of these questions were excluded from the analysis (n ¼ 13).
Duplicate IP addresses were screened to prevent participants from completing the survey multiple
times (Kim & Hodgins, 2017; Schluter et al., 2018).
While multiple authors have extolled the quality of MTurk data (Buhrmester et al., 2016;
Shapiro et al., 2013), beginning in summer 2018, several researchers voiced concerns about the
possible deterioration of data quality, which stemmed from increasing numbers of participants
using virtual private servers (VPS) to hide their personal IP addresses and circumvent MTurk’s
screening tools. Many of these individuals appear to reside outside the US and employ VPS to
access surveys restricted to persons residing therein (Dennis et al., 2020; Kennedy et al., 2020).
Given this, we screened for VPS users via two proxy detection products—IP Hub (https://iphub.
info/) and Proxycheck (https://proxycheck.io/)—that flag IP addresses originating from commer-
cial server farms and non-US IP addresses. We utilized a free app developed for researchers by
Waggoner et al. (2018, 2019) that streamlines the use of these two products for data auditing. IP
Hub and Proxycheck showed a high level of agreement (97%) in screening IP addresses; those
that were flagged by both were considered VPS users, and their data were further scrutinized.
VPS participants (n ¼ 162) produced lower quality data in the current study. Twenty-eight per-
cent of VPS participants compared to 9% of non-VPS participants missed at least one attention
check item. Independent-samples t-tests indicate VPS participants answered significantly differ-
ently (p < 0.05) than non-VPS participants on several key variables. Most importantly, VPS par-
ticipants produced substantially lower internal consistency scores than non-VPS participants on
several previously well-validated scales included in the survey. Taken these findings together, VPS
participants were excluded from the analysis.
6 B. A. DROUBAY ET AL.

Sample size
A number of recommendations have been made for calculating sample size for structural models,
though no one approach has been universally accepted (Kyriazos, 2018). When maximum likeli-
hood estimation is used, one common approach is to determine the number of participants
needed from number of model parameters (the N:q rule; Jackson, 2003; Kline, 2016). Several
authors have recommended a minimum ratio of 10:1 (Kyriazos, 2018), while Kline (2016) recom-
mends an even more conservative 20:1 ratio (see also Jackson, 2003). The latter was used as a
general guide for this study. Given this, we aimed to recruit approximately 560–600 participants.
After excluding VPS users and participants who missed more than one attention check item, our
final sample size was 559.

Measures
Subjective distress
The primary outcome, subjective distress associated with pornography use, was assessed via the
emotional distress subscale of the Cyber Pornography Use Inventory-9 (CPUI-9; Grubbs, Volk,
et al., 2015). The CPUI-9 consists of 9 Likert-like items (1 ¼ not at all, 7 ¼ extremely) assessing to
what degree participants perceive they are addicted to Internet pornography. The emotional dis-
tress subscale consists of three items that assess negative affect associated with pornography view-
ing: e.g., “I feel depressed after viewing pornography online” (Grubbs, Volk, et al., 2015, p. 91).
Because we were interested in distress associated with all forms of pornography viewing, the
word online was omitted. This subscale exhibited strong internal consistency in the current sam-
ple (a ¼ 0.90).

Sexual desire
Sexual desire was measured via a subscale of the Sexual Desire Inventory-2 (SDI-2; Spector et al.,
1996). The SDI-2 is a widely used 14-item scale thought to tap into solitary sexual desire (e.g.,
masturbation) and dyadic sexual desire (e.g., intercourse; Spector et al., 1996). Given this study’s
focus on solo pornography viewing, the former subscale, which consists of four items, was uti-
lized. Example items include, “Compared to other people of your age and sex, how would you
rate your desire to behave sexually by yourself” (0 ¼ much less desire, 8 ¼ much more desire;
Spector et al., 1996, p. 188). The SDI-2 has exhibited good psychometric properties across sam-
ples (e.g., Mark et al., 2018; Moyano et al., 2017; Spector et al., 1996) and been used in prior
studies investigating PPU and hypersexuality (Moholy et al., 2015; Steele et al., 2013; Winters
et al., 2010). Internal consistency of the subscale in the current sample was excellent (a ¼ 0.86).

Feelings of dysregulation
Feelings of dysregulation associated with pornography use was assessed via the compulsivity sub-
scale of the CPUI-9 (Grubbs, Volk, et al., 2015), which consists of three Likert-like items (1 ¼ not
at all, 7 ¼ extremely). Example items include, “I feel unable to stop my use of online
pornography” (Grubbs, Volk, et al., 2015, p. 106). As above, the items were slightly modified to
exclude the words online and Internet. This subscale exhibited strong internal consistency in the
current study (a ¼ 0.92).

Moral incongruence
Moral incongruence was assessed via an adapted version of a scale developed by Grubbs, Exline,
et al. (2015) consisting of four Likert-like items (1 ¼ not at all, 7 ¼ extremely) assessing partici-
pants’ moral beliefs about pornography consumption. Example items include, “Viewing
 JOURNAL OF SEX & MARITAL THERAPY 7

pornography online troubles my conscience” (p. 128). Questions were slightly modified in three
ways: (1) The word online was excluded across items. (2) Following the lead of Volk et al. (2016),
we adjusted the wording of two questions that specifically reference religion, so they apply to all
respondents (religious and nonreligious). For example, the item, “Viewing pornography online
violates my religious beliefs,” (Grubbs, Exline, et al., 2015, p. 128) instead read, “Viewing pornog-
raphy violates my personal values” (Volk et al., 2016, p. 250). And (3) two questions were person-
alized with the adjective my to better portray moral incongruence, rather than mere moral
disapproval. For example, the item, “I believe that viewing pornography online is morally wrong,”
was adjusted to read, “My pornography viewing is morally wrong.” Internal consistency was
excellent in the current sample (a ¼ 0.96).

Shame-proneness
Shame-proneness was assessed via the Shame-Negative-Self-Evaluation (NSE) subscale of the
Guilt and Shame Proneness Scale (GASP; Cohen et al., 2011). The full GASP contains 16 scen-
ario-based items that assess individuals’ propensity to feel guilt and shame. The NSE consists of
four items that assess individuals’ propensity to negatively self-label (1 ¼ very unlikely, 7 ¼ very
likely). Example items include: “You rip an article out of a journal in the library and take it with
you. Your teacher discovers what you did and tells the librarian and your entire class. What is
the likelihood that this would make you feel like a bad person?” (Cohen et al., 2011, p. 966). The
GASP has shown utility across diverse samples and topics of study (Poless et al., 2018; Rebega,
2017; Straub et al., 2018; Wang et al., 2016). Internal consistency in the current sample was
good (a ¼ 0.78).

Analytic procedure
All data were transferred from Qualtrics and cleaned in IBM SPSS Statistics 25. Only two values
(from one participant) were missing in the entire dataset. These missing values were addressed
using full information maximum likelihood procedures. Structural equation modeling was con-
ducted using the Lavaan package (Rosseel, 2012) in R (R Core Team, 2008). Feelings of dysregu-
lation, shame-proneness, and subjective distress were entered into the model as latent variables,
with individual scale items acting as observed indicators . The scales for solitary sexual desire and
moral incongruence were each summed and entered into the model as observed variables, both
(1) because of their high alpha coefficients (a  0.86), which in conjunction with the few number
of items on each scale suggests minimal measurement error (Tavakol & Dennick, 2011), and (2)
because of the computational complexity of producing interaction terms among latent variables
(Muth
en & Asparouhov, 2015).
For the measurement model, we utilized maximum likelihood (ML) estimation. Model fit was
assessed via four common fit indices: Chi-square goodness of fit (v2), the comparative fit index
(CFI), root mean square error of approximation (RMSEA), and standard root mean square
residual (SRMR). Chi-square goodness of fit is a test of absolute fit. A nonsignificant result indi-
cates adequate model fit; however, the test is prone to reject even mild misfit in large samples
(Henry et al., 2015). CFI values range from 0 to 1, with values close to 1 indicating good fit; Hu
and Bentler (1999) suggest values at or above 0.95. RMSEA values less than 0.05 suggest good fit,
while values under 0.08 suggest adequate fit and values over 0.08 suggest poor fit (Browne &
Cudeck, 1993). SRMR is another index of absolute fit, with values under 0.08 suggesting adequate
fit and values under 0.05 suggesting good fit (Hu & Bentler, 1995). Given each of these indices
have their own limitations, we considered them jointly, rather than rejecting the model solely
because one index suggests inadequate fit (Henry et al., 2015). Prior to testing the full model, we
tested the measurement models of each of the latent variables.
8 B. A. DROUBAY ET AL.

Given the interaction terms in the model, solitary sexual desire and moral incongruence were
grand mean centered both to minimize nonessential multicollinearity and to aid with interpret-
ability of lower order terms (Iacobucci et al., 2016). Bootstrapping (n ¼ 5000) was utilized to test
the indirect effect (of solitary sexual desire on subjective distress through feelings of dysregula-
tion), as well as to address some nonnormality and heteroscedasticity in the data.
To test EQ1 (full versus partial mediation), we constructed a second, more parsimonious
model excluding the direct effect between solitary sexual desire and subjective distress . To com-
pare the two models directly, we examined the Akaike Information Criterion (AIC) and Bayesian
Information Criterion (BIC), which can be used to compare fit across models; smaller values rep-
resent better fit. We then conducted a nested comparison of the two models via the Chi-square
difference of fit test. It was presumed that should this second model either show better fit
(according to AIC or BIC) or should the Chi-square differences of fit test be nonsignificant, this
would suggest retaining of the full mediation model (Henry et al., 2015).

Results
Sample characteristics
Participants ranged in age from 18 to 77, with an average of 34. Regarding race/ethnicity, 66% of
participants identified as White, 11% as Asian, 10% as Black, 9% as Hispanic or Latino, and fewer
than 1% identified as American Indian or Pacific Islander. A plurality of participants identified as
single (45%), having never been married, with 35% identifying as currently married, 14% report-
ing being in a domestic partnership, and 4% identifying as divorced. Overall, the sample was
quite educated, with 50% of respondents reporting they had earned a bachelor’s degree or higher.
The majority of respondents identified as male (55%). Regarding sexual orientation, 78% identi-
fied as heterosexual, 17% as bisexual, 4% as gay or lesbian, and 2% as “other” (e.g., pansexual).
The sample leaned liberal politically (M ¼ 3.36, where 1 ¼ very conservative and 5 ¼ very liberal).
Regarding religious affiliation, 20% identified as Catholic and 16% Protestant, while religious
“nones” (consisting of atheists, agnostics, and individuals who said they were religiously unaffili-
ated) made up 50% of the sample. Non-Christian faiths (e.g., Jewish, Muslim, Buddhist, Hindu)
made up about 8% of the sample total.

Descriptive statistics and model fit

Descriptive statistics for the model variables, as well as factor loadings for the measurement mod-
els, are displayed in Table 1. All items loaded strongly onto their hypothesized constructs. On the
aggregate, participants reported low levels of moral incongruence (M ¼ 9.49, range ¼ 4–28), feel-
ings of dysregulation (M ¼ 7.14, range ¼ 3–21), and subjective distress (M ¼ 6.78, range ¼ 3–21);
moderate levels of solitary sexual desire (M ¼ 21.33, range ¼ 4–35); and moderate-to-high levels
of shame-proneness (M ¼ 21.53, range 4–28).
Taken together, fit indices for the partial mediation model suggest good fit overall: v2(57,
n ¼ 559) ¼ 151.74, p < 0.001; CFI ¼ 0.98; RMSEA ¼ 0.06 [90% CI 0.04, 0.07]; SRMR ¼ 0.03.
The Chi square value suggests the model suffers from some misfit, though (as mentioned above)
it is prone to Type I errors in large samples and so should be interpreted with caution here. The
RMSEA value suggests adequate to good fit, while the CFI and SRMR values indicate excellent
fit. The full mediation model produced similar results—v2(59, n ¼ 559) ¼ 154.00, p < 0.001; CFI
¼ 0.98; RMSEA ¼ 0.05 [90% CI 0.04, 0.06]; SRMR ¼ 0.03—with the RMSEA value improving
very slightly, likely because of the model’s improved parsimony (Browne & Cudeck, 1993).
 JOURNAL OF SEX & MARITAL THERAPY 9

Table 1. Range, mean, SD, and factor loadings/SEs of model variables (n ¼ 559).
Latent constructs and manifest variables Range Mean SD Est. SE
Subjective distress
CPUI-7 1–7 2.63 1.91 1.00 0.000
CPUI-8 1–7 2.19 1.73 1.04 0.037
CPUI-9 1–7 1.93 1.65 0.94 0.045
Shame-proneness
GASP-3 1–7 5.42 1.72 1.00 0.000
GASP-6 1–7 5.63 1.52 0.96 0.090
GASP-10 1–7 5.17 1.70 0.93 0.080
GASP-13 1–7 5.31 1.65 0.95 0.095
Feelings of dysregulation
CPUI-1 1–7 2.38 1.76 1.00 0.000
CPUI-2 1–7 2.47 1.84 1.03 0.038
CPUI-3 1–7 2.29 1.78 0.99 0.040
Moral incongruence 4–28 9.49 7.12
Solitary sexual desire 4–35 21.31 6.92
Note. Factor loadings set to 1.00 are marker variables. Factor loadings are unstandardized. All were statistically significant
(p < 0.001). Moral incongruence and solitary sexual desire were entered into the model as manifest variables. Their items
were summed beforehand for a total score.

Figure 1. Partial mediation model with standardized coefficients.

Note: CFI ¼ 0.98, RMSEA ¼ 0.06 [90% CI 0.04, 0.07], SRMR ¼ 0.03. Dysregulation R2 ¼ 0.38. Distress R2 ¼ 0.77. p < 0.05,
p < 0.01, p < 0.001.

Path analysis
Path analysis results for the partial mediation model can be viewed in both Figure 1 and Table 2;
results for the full mediation model can be viewed in Figure 2. As can be seen, path coefficients
across the two models were nearly equivalent.
10 B. A. DROUBAY ET AL.

Table 2. Unstandardized and standardized coefficients for the partial mediation model.
Endogenous
(M) Feelings of dysregulation (Y) Subjective distress
Exogenous b [95% CI] SE b p b [95% CI] SE b p
(X) Solitary sexual desire 0.074 0.009 0.325 <0.001 0.005 0.007 0.021 0.484
[0.058, 0.091] [0.018, 0.009]
(M) Feelings of dysregulation 0.356 0.055 0.349 <0.001
[0.251, 0.467]
Shame-proneness 0.071 0.041 0.052 0.086
[0.008, 0.153]
Moral incongruence 0.109 0.009 0.492 <0.001 0.146 0.013 0.643 <0.001
[0.091, 0.128] [0.119, 0.171]
(W) Solitary sexual desire x 0.004 0.001 0.149 <0.001 0.001 0.001 0.031 0.718
Moral incongruence [0.002, 0.007] [0.001, 0.004]
R ¼ 0.384
2
R ¼ 0.767
2

Note: X ¼ primary predictor, M ¼ mediator, Y ¼ outcome variable, W ¼ interaction term. 95% CI ¼ Bias corrected and acceler-
ated bootstrapped confidence interval. Total effect ¼ 0.022, 95% CI [0.010, 0.035], p ¼ 0.001. Indirect effect ¼ 0.026, 95% CI
[0.018, 0.035], p < 0.001. Index of moderated mediation ¼ 0.002, 95% CI [0.001, 0.003], p ¼ 0.001.

Figure 2. Full mediation model with standardized coefficients.

Note: CFI ¼ 0.98, RMSEA ¼ 0.05 [90% CI 0.04, 0.06], SRMR ¼ 0.03. Dysregulation R2 ¼ 0.38. Distress R2 ¼ 0.77. p < 0.05,
p < 0.01, p < 0.001.

Feelings of dysregulation
Congruent with H3 and H4, higher solitary sexual desire was significantly associated with feelings
of dysregulation (b ¼ 0.074, p < 0.001), and this relationship was moderated by moral incongru-
ence (b ¼ 0.004, p < 0.001). In standardized terms, a one standard deviation increase in solitary
sexual desire was associated with a 0.325 standard deviation increase in feelings of dysregulation
 JOURNAL OF SEX & MARITAL THERAPY 11

Figure 3. Simple slopes equations of the regression of feelings of dysregulation on solitary sexual desire at various levels of
moral incongruence.
Note: Values for solitary sexual desire and feelings of dysregulation are standardized. Minimum ¼ lowest score of moral incongru-
ence possible. Maximum ¼ highest score possible. þ1 SD ¼ one standard deviation above mean of moral incongruence. þ2
SD ¼ two standard deviations above mean. All slopes are significant (p < 0.001).

at the mean of moral incongruence. Solitary sexual desire, moral incongruence, and their inter-
action term explained 38.4% of the variance in feelings of dysregulation in total.
To better conceptualize the relationship between solitary sexual desire and feelings of dysregu-
lation, we produced simple slopes equations at varying levels of moral incongruence. The rela-
tionship between solitary sexual desire and feelings of dysregulation remained significant
(p < 0.001) at all levels of moral incongruence, suggesting a robust relationship between the two.
The magnitude of this relationship, however, substantially increased at higher levels of moral
incongruence. For example, the standardized coefficient (b) at the minimum of moral incongru-
ence was 0.218, while it was 0.685 at the maximum. Visualization of the simple slopes equations
can be seen in Figure 3.

Subjective distress
H1 was partially supported; as hypothesized, moral incongruence (b ¼ .146, p < 0.001) and feel-
ings of dysregulation (b ¼ 0.356, p < 0.001) were significantly associated with subjective distress
related to pornography use, and these effects were very large, with one standard deviation
increases in moral incongruence and feelings of dysregulation predicting 0.643 and 0.349 standard
deviation increases in subjective distress, respectively. Shame-proneness, however, was not signifi-
cantly associated with subjective distress related to pornography use (b ¼ 0.071, p ¼ 0.086), con-
trary to our hypothesis.
Further supporting H1, the total effect between solitary sexual desire and subjective distress—
that is, the relationship between the two in the absence of the mediator (feelings of dysregula-
tion)—was significant (b ¼ 0.022, p ¼ 0.001). Once feelings of dysregulation was entered into the
model, however, the relationship between the two not only became insignificant but even changed
12 B. A. DROUBAY ET AL.

directions (b ¼ 0.005, p ¼ 484); this lends support for H2 (that feelings of dysregulation would
mediate the relationship between the two; Baron & Kenny, 1986).
This hypothesis was further supported by a significant indirect effect—calculated as the prod-
uct of paths a1 and b in Figure 1—evidenced by a bootstrapped confidence interval that does not
cross zero (point estimate ¼ 0.026, 95% BCa CI [0.018, 0.035]; Berndt et al., 2013; Hayes, 2009;
Preacher & Hayes, 2008). While various indices of effect size have been suggested for indirect
effects, the completely standardized indirect effect is preferable given it is less biased than propor-
tion and ratio effect sizes (Miocevi
c et al., 2017) and can be utilized to evaluate effects across
studies with varying units of measurement (Cheung, 2009; Preacher & Kelly, 2011). The com-
pletely standardized indirect effect was 0.113 (p < 0.001). Taking into account the interaction
term (path a3 in Figure 1), this suggests that subjective distress will increase 0.113 standard devia-
tions for every one standard deviation increase in solitary sexual desire, through feelings of dysre-
gulation, at the mean of moral incongruence.
To evaluate whether the magnitude of the indirect effect significantly differed at varying levels
of the moderator, we examined the index of moderated mediation (calculated as the product of
paths a3 and b in Figure 1; Hayes, 2015); this value suggested that the magnitude of the indirect
effect does indeed systematically vary based on level of moral incongruence (point estimate ¼
0.002, 95% CI [0.001, 0.003]). To better conceptualize this, we calculated the indirect effect at the
minimum and maximum values of moral incongruence. The indirect effect remained significant
(p < 0.001) at all levels of moral incongruence, suggesting the effect of solitary sexual desire on
subjective distress through feelings of dysregulation is robust regardless. The magnitude of this
relationship, however, substantially increased with higher levels of moral incongruence. For
example, the completely standardized indirect effect was 0.076 at the minimum of moral incon-
gruence and 0.238 at the maximum.

Model comparison
Regarding EQ1, as noted prior, the direct effect (path c’ in Figure 1) not only became insignifi-
cant but also changed directionality with moral incongruence in the model, suggesting full medi-
ation. AIC and BIC values further suggested better fit for the full mediation model (31764.11 and
31919.85, respectively) over the partial mediation model (31765. 85 and 31930.25). Finally, the
nested comparison of the two models suggested that the direct effect parameter was unnecessary:
Dv2 ¼ 2.26, Ddf ¼ 2, p ¼ 0.324. These findings combined, in conjunction with the slightly
improved RMSEA value, suggest keeping the more parsimonious, full mediation model (seen in
Figure 2).
Related to this, moral incongruence was not found to moderate the direct effect (c0 ) between
solitary sexual desire and subjective distress (p ¼ 0.718), as hypothesized (H5); this hypothesis,
however, was largely moot given the full mediation model was supported. Overall, the partial
mediation model explained 76.7% of the variance in participants’ subjective distress related to
pornography use, while the full mediation model explained 76.5%.

Discussion
The purpose of this research was to better understand persons’ feelings of distress related to their
pornography consumption, in hopes of identifying targets to better help clients with related con-
cerns. While recent studies have pointed to the roles of sexual desire, moral incongruence, feel-
ings of dysregulation, and shame-proneness in PPU (e.g., Gilliland et al., 2011; Grubbs, Perry,
et al., 2019; Steele et al., 2013), these have heretofore been separate threads of literature. Given
this, we tested structural equation models incorporating them. Taken together, these variables
 JOURNAL OF SEX & MARITAL THERAPY 13

explained a large portion of the variance in participants’ reports of subjective distress: R2

¼ 0.767.

Commentary on results
Results suggest solitary sexual desire is positively associated with persons feeling their pornog-
raphy viewing is dysregulated, and this relationship is moderated by moral incongruence. For
persons with moral qualms related to pornography viewing, having a higher desire to view it may
feel dysregulated in and of itself; for these individuals, merely possessing higher solitary sexual
desire may be interpreted as pathological because they are repeatedly having impulses to engage
in behavior that they believe is immoral.
While frequency of viewing may be associated with feelings of dysregulation, we chose not to
include it in the model primarily because including additional variables would have necessitated a
greater sample size. Further, frequency of viewing may, at least partially, be seen as a behavioral
byproduct of solitary sexual desire. A post hoc regression analysis, however, revealed that even
after frequency of pornography viewing was included as a control, the relationship between sexual
desire and feelings of dysregulation—as well as the moral incongruence interaction term—stayed
significant (p < 0.001). This suggests that overly simplistic metrics like frequency of use are inad-
equate for explaining perceived dysregulation.
Results further suggest that the relationship between solitary sexual desire and subjective dis-
tress is fully mediated by feelings of dysregulation. This suggests that the association between sex-
ual desire and subjective distress is fully dependent on participants’ interpretation of their
viewing. And, as noted above, whether they perceive it to be dysregulated is heavily influenced by
moral incongruence. In sum, these findings add to the literature pointing to moral incongruence
as key to understanding individuals’ feelings of dysregulation and subjective distress associated
with pornography use (Grubbs et al., 2019).
Contrary to H1, shame-proneness was not significantly associated with subjective distress. This
does not suggest that shame itself is unrelated to subjective distress, however. Shame might be
considered a facet of subjective distress. Indeed, one of the items used to assess subjective distress
was, “I feel ashamed after viewing pornography” (Grubbs, Volk, et al., 2015, p. 91). Rather, this
suggests that persons with a dispositional proneness to experiencing shame may not be at signifi-
cantly greater risk to feel distressed. This result, however, may be a reflection of the way we chose
to assess shame-proneness. Given we used the NSE subscale of the GASP, this suggests persons
who have a higher propensity to negatively self-evaluate may not be significantly more likely to
endorse distress. Other facets of shame-proneness, however, warrant further investigation. For
example, post hoc analyses revealed that another subscale of the GASP, shame-withdraw (which
assesses the propensity for individuals to want to hide following transgressions; Cohen et al.,
2011), was substantially more strongly associated with subjective distress (r ¼ 0.369) than was
negative self-evaluation (r ¼ 0.044).

Limitations
This study’s design had several limitations. First, while MTurk participants more closely resemble
the US adult population than college samples (Buhrmester et al., 2016; Ross et al., 2009), this was
not a representative sample; thus, generalizability of findings is uncertain. Second, although struc-
tural models presume directionalities of relationships—and while the hypothesized models show
good fit—no inferences about causality can be made given the cross-sectional nature of the data.
In this vein, some of the relationships represented in the models may be more complicated than
were hypothesized or testing allowed for. For example, the presented models presume that all
14 B. A. DROUBAY ET AL.

relationships are recursive; it is possible, however, that the relationship between sexual desire and
subjective distress, for instance, is bidirectional, or nonrecursive.
Third, this study was reliant on participants’ self-report. Given that sexuality is a sensitive
topic, social desirability bias could have affected responses. Fourth, while we utilized measures
that show sound psychometric properties, they are inherently limited in their scope. For instance,
the emotional distress subscale of the CPUI-9, which was used to assess the outcome variable,
inquires about consumers’ feelings following pornography viewing (Grubbs, Volk, et al., 2015). It
is possible some individuals feel other types of distressing emotions (e.g., anxiety) not captured in
this subscale’s questions. Further, these questions fail to assess how enduring these feelings might
be. (A person might feel momentarily distressed following pornography viewing, but how impact-
ful are those feelings? Do they last?)
Fifth, this study lacks nuance pertaining to how different types of viewing experiences may
impact subjective distress. Pornography was purposefully not defined for participants. Different
mediums of viewing or types of content, however, may affect individuals’ feelings about their
consumption, and this likely intersects with values as well. Willoughby and Busby (2016), for
example, found that religiosity impacts whether persons perceive ambiguous media content to be
pornographic or not. It is possible, then, that persons with strong values against pornography
may become distressed even by viewing content that others would not even categorize as porno-
graphic. Finally, these models are certainly not comprehensive in their inclusion of relevant varia-
bles to explaining subjective distress. Other potential explanatory variables, such as frequency of
viewing or neuroticism (Walton, Cantor, & Lykins, 2017), were excluded simply because of the
difficulties of testing an overly complex model.

Directions for future research

Methodological rigor
While this study addresses an important gap in the literature, more research is needed to better
understand the phenomenon of PPU. This area of study lacks longitudinal data, as well as data
that are not solely derived from self-report (Duffy et al., 2016; Prause, 2017; Walton, Cantor,
Bhullar, et al., 2017). Tracking consumers’ distress over time would be particularly beneficial in
confirming directionality of the relationships between variables more authoritatively. Also, while
participant self-report is essential in this area, methodological triangulation should be utilized
where possible. Qualitative research might further provide rich information about how individuals
conceptualize their pornography use.

More nuance needed

Further research is needed to provide a more nuanced understanding of the relationship between
predictors in the model and subjective distress. As noted, post hoc analyses revealed that the
shame-withdraw component of shame-proneness is more strongly related to subjective distress
than negative self-evaluation. This warrants further investigation, particularly because of shame’s
role in exacerbating PPU (Gilliland et al., 2011; Petrican et al., 2015). Sexual desire also warrants
further investigation. We chose to focus on solitary sexual desire because solo pornography view-
ing is a solitary sexual behavior; however, dyadic sexual desire may be equally predictive of sub-
jective distress. Given pornography viewing is often an alternative to dyadic sexual activity when
a partner is unavailable or unwilling, this warrants further investigation. In relationships where
partners have disparate levels of sexual desire, individuals with higher desire could conceivably
feel like their levels of desire are dysregulated, particularly if it leads them to engage in behavior
that they find morally objectionable to fulfill their unmet sexual urges.
 JOURNAL OF SEX & MARITAL THERAPY 15

Intervention research
Finally, this study highlights potential targets for intervention research. Sexual desire, moral
incongruence, and feelings of dysregulation accounted for a large portion of the variance in sub-
jective distress associated with pornography use. Addressing these variables has the potential to
decrease client distress. As noted earlier, while many practitioners purport to specialize in the
treatment of PPU and sex addiction more broadly, there is very little intervention research in this
area (Miles et al., 2016).

Implications for practice

This research contributes to the literature suggesting how individuals interpret and are impacted
by their pornography viewing is profoundly influenced by personal values. Given this, taking a
person-in-environment, biopsychosocial perspective may be especially important to help clients
who report distress.

Practitioner messaging and reflexivity

Results from the present study suggest feelings of dysregulation are significantly associated with
subjective distress related to pornography use. This echoes longitudinal findings suggesting self-
perceived addiction to pornography is predictive of psychological distress (Grubbs, Stauner, et al.,
2015). Given this, practitioners need to be cognizant of how their messaging affects clients and
deliberate with their choice of words. Practitioners contribute to the authoritative discourse that
shapes how their clients perceive and are affected by these issues (Foucault, 1990). Loosely using
terms like addiction could potentially increase client distress and cause harm.
One key to accomplishing this is ongoing reflexivity. Practitioners certainly are not exempt
from having their values impact their perspectives on these issues. In a recent study, highly reli-
gious therapist-in-training students were significantly more likely to rate pornography both as
addictive and as a serious public health issue than their nonreligious peers (Droubay & Butters,
2020). Educators can help by emphasizing reflexivity in the classroom and encouraging dialogue
about these sensitive topics.

Assessment of client views on sexuality

Given the salience of values in informing clients’ perceptions of their viewing, practitioners need
to engage in assessment with clients rather than taking self-reported sex or pornography addic-
tion at face value (Kraus et al., 2018). Clients’ distress should obviously not be discounted; how-
ever, practitioners’ diagnostic conceptualizations and treatment decisions should be grounded in
best available evidence and determined based on client best interest, rather than automatically
reinforcing fad diagnoses.
The present findings suggest moral incongruence may affect how individuals interpret their
sexual desire, with persons higher in sexual desire and moral incongruence more likely to per-
ceive their pornography viewing as dysregulated. Given this, an assessment of how clients per-
ceive sexuality—what healthy sexuality means, how they perceive their own sexual urges—may be
a productive starting place. For clients with high sexual desire coming from sexually conservative
backgrounds, an exploration of how they manage this and what this means in the context of their
relationships and social roles may help explain their distress and decision to seek professional
help (Winters et al., 2010). Assessing these issues will not only provide clarification to practi-
tioners (about why clients are seeking help) but may also nudge clients to begin reflecting on
their perceptions of sexuality and where those perceptions come from.
16 B. A. DROUBAY ET AL.

Addressing moral incongruence

The large impact of moral incongruence raises the question: How is this best addressed in prac-
tice? Given practitioners’ mandate to respect clients coming from diverse backgrounds, as well as
their obligation to honor clients’ right to self-determination, across fields (e.g., American
Psychological Association, 2017; National Association of Social Workers, 2017), it is an ethical
nonstarter to suggest to clients that they should not feel morally incongruent about pornography
viewing. Rather, meeting clients where they are and taking a nonjudgmental approach may
prove helpful.
For instance, a key component of Acceptance and Commitment Therapy is values clarification
work, wherein clients reflect upon and identify their own values (Crosby & Twohig, 2016; Hayes
et al., 1999). While this may not resolve the moral incongruence persons feel about their pornog-
raphy viewing, it may help them better understand what their own values are (which may overlap
with or be apart from how their partner, family-of-origin, religious congregation, etc. perceive
these issues). This is a form of consciousness raising, which is a common change process across
psychotherapy (Prochaska & Norcross, 2018). This added insight into how moral incongruence
contributes to their perceptions of pornography viewing may allow clients to not reflexively path-
ologize their use or label themselves addicts, which may, in turn, lead to decreased distress. As
Prochaska and Norcross (2018) state, “Values clarification can help [clients] decide which values
provide the best context [for making choices], rather than be controlled by their cultural context
that requires they fill a rigid role” (p. 273).

Client-informed treatment
In conclusion, practitioners can take a client-informed approach to treatment—one in which care
is taken not to over-pathologize clients and therapeutic goals are flexibly determined after assess-
ment and consciousness-raising activities, rather than aiming to quell pornography viewing from
the outset in every case. Remaining cognizant of their own biases, practitioners can provide more
holistic care than has traditionally been proposed in the sex addiction field, adapting to the needs
of clients coming from diverse backgrounds and helping to alleviate client distress related to
pornography use.

Compliance with ethical standards

The authors affirm this manuscript has not been submitted to more than one journal for simultaneous
consideration.

Acknowledgments
This manuscript was derived from portions of the lead author’s dissertation research. The authors thank Christina
Gringeri, Charlie Hoy-Ellis, Brad Lundahl, and Mary Jane Taylor for their earlier feedback on this project.

Disclosure statement
The authors declare they have no conflicts of interest.

Ethical approval
Ethical approval was granted by the University of Utah Institutional Review Board (ref. #00120625).
 JOURNAL OF SEX & MARITAL THERAPY 17

Author Note
Robert P. Butters is now Clinical Director at LifeMatters Counseling & Health Center in Salt Lake City, UT.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID
Brian A. Droubay http://orcid.org/0000-0002-9850-2011
Kevin Shafer http://orcid.org/0000-0003-2511-244X

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