Understanding the Addictive Nature of Pornography

Donald L. Hilton, Jr., MD
(Article from CombatingPornography.org)

Donald L. Hilton, Jr. has practiced medicine for 14 years in San Antonio, Texas, specializing in neurological surgery. He has been named to Best Doctors in America. Brother Hilton and his wife, Jana, currently serve as LDS Family Services program coordinators in San Antonio for those who struggle with pornography and sexual addiction and their spouses. They are the parents of five children and have two grandchildren.

Continued viewing of pornography causes pain and frustration not only for those who struggle with this addiction, but also for their loved ones, ecclesiastical leaders, and others. Many wonder why addicts don’t “just stop.” If we consider this problem from a spiritual and behavioral model alone, we may have difficulty understanding both the scope and the tenacity of this addiction. A better understanding of what is happening to not only the spirit of one so afflicted, but also the brain, will help us understand this “why.”

True addiction was once thought to be a pathologic behavior tied to compulsive use of drugs that had the power to change brain chemistry. A distinction was usually made between drug addictions and so called “natural addictions,” such as obesity, compulsive gambling, and unrestrained sexuality. Subsequent research is removing this distinction, and it now appears that all addiction is a derangement in the pleasure control and reward areas of the brain. A simple description of the pleasure systems of the brain may help in understanding this concept and in interpreting what current research is telling us about addiction.

Like a computer, the brain stores memories on a “hard drive.” This part of the brain is called the cerebral cortex, which also generates cognition and thought and initiates motor function. It may be called the “thinking” part of the brain. Under the cortex is a relay station called the thalamus, which is integrated into an area under it termed the brainstem. The thalamus and brainstem, among other important functions, regulate pleasure and pain and reward activities such as eating and sexuality, which are important in the survival of the individual and species.

In the brainstem, a chemical called dopamine is produced in the ventral tegmental area (VTA), which has been found to be important in the brain’s pleasure and reward system. When activated by a pleasurable stimulus, the VTA causes dopamine to be released in an area of the thalamus called the nucleus accumbens. Other chemicals such as the brain’s natural opioids, the endorphins, also stimulate the nucleus accumbens. It may be that dopamine is more important in wanting pleasure, whereas the endorphins are more important in liking pleasure.1 These pathways are important because without them we would not value appropriate pleasures. An area of the cerebral cortex called the frontal lobe helps control the amount and context of the pleasure. It also helps us weigh the benefits and risks of a pleasurable stimulus. For instance, uncontrolled eating may be pleasurable, but it is unhealthy. Unrestrained sexuality may be pleasurable, but it destroys relationships and spiritual power and insight. It is the frontal lobe that tells us to judge these risks and benefits.

When we overuse pleasure centers, the cells that produce dopamine are overworked, and in what may be a defensive reaction, the brain decreases the amount of dopamine available for use and also causes shrinkage in the cells that produce the dopamine and in the frontal control areas. Paradoxically, the pleasure cells in the nucleus accumbens may actually enlarge in the addicted state because they have less dopamine available for pleasure and are seeking to extract every possible molecule. These physical changes in the brain have been called long-term potentiation and long-term depression.3 Thus, in addiction, normal pleasures are not enough to alleviate the craving for dopamine, and this craving in the newly reset pleasure thermostat in the brain is likely key in the desire to relapse. The shrinkage in the frontal control areas also contributes to the compulsivity and impulsivity seen in addiction. Interestingly, as neurosurgeons, we see these same characteristics in frontal lobe shrinkage from traumatic brain injury, and this has been recognized by addiction scientists.4 Sexual addiction obviously involves other neurotransmitters, two of which may be oxytocin and vasopressin. Oxytocin is important in bonding5 and increases trust in humans,6 and vasopressin may be important in sexual bonding, particularly in males. It may be a combination of dopamine-depletion craving and oxytocin-mediated bonding to pornography through masturbatory conditioning8 that contributes to relapse.

While no one now doubts that drug abuse causes the changes we have discussed, in the past some questioned whether natural appetites could produce these changes and thus be termed true addictions, rather than just compulsive, behavioral problems. A series of studies within the last decade has radically changed the way we look at what we now call “natural addictions” with a “common pathway”10 in the mesolimbic dopamine system and whether the addiction comes “from a chemical or an experience.”11 Brain scans show changes in addiction in three ways. First, functional MRI (fMRI) shows changes in metabolism, or how the brain actually works in the addicted verses the unaddicted state. These tests usually require cueing, or administering the stimulus of addiction. Second, structural MRI (sMRI) looks at actual physical shrinkage in key areas of the brain important in pleasure and control. Third, MR spectroscopy, PET, and SPECT scans look at small amounts of chemicals in the brain and can look at dopamine receptors and actually measure the amount of depletion addiction has caused.

Significantly, we now see with each of the above tools the changes in brain chemistry occurring in both drug and natural addictions. We see fMRI changes not only in drug addictions such as cocaine,12 but also in natural addictions such as pathologic gambling.13 Dopamine receptor depletion is seen in drug addiction14 and in the natural addiction of obesity.15

Brain shrinkage has been seen in drug addictions such as cocaine16 and methamphetamine,17 but also in natural addictions such as obesity18 and more recently, sexual addiction.19 Studies are currently underway to examine shrinkage specifically in pornography addiction.

Significantly, some of these changes appear to be reversible with healing and recovery from addiction. Restoration to more normal brain volumes has been seen with recovery in both a drug20 and a natural addiction,21 and improvement of metabolism with abstinence has been seen in methamphetamine addiction.22 

Why is it important to understand that compulsive pornography use is an actual addiction?  By recognizing this, we will treat it with the respect required to overcome an addiction. For instance, no spiritual leader would tell a member who confesses an alcohol addiction to pray and repent without recommending counseling and 12-step support in such programs as the Addiction Recovery Program with LDS Family Services and Alcoholics Anonymous. Similarly, with the proper perspective on sexual addiction, we should also recommend that those afflicted with pornography and other sexual addictions, in addition to proceeding through the steps of repentance, will also seek recovery with therapy and group support.

Whether we serve as a bishop, facilitator, missionary, group leader, family member, or support person, we would do well to remember the words of Paul.23 We are admonished to neither strive nor argue.  He reminds us to be gentle and patient and apt, or ready, to teach. Teaching is to be done with humility and meekness.  Note the powerful relationship in 2 Timothy 2:25-26 between repentance, which God grants, and recovery, which one must seek first on his own, in order to be freed from the snare of addiction and the captivity of being led by the will of the adversary. God grants us repentance and we recover ourselves with His assistance, after “all we can do.”24