The effectiveness of intervention with cognitive behavioral therapy on pornography: A systematic review protocol of randomized clinical trial studies

Abstract Background The increasing rate of problematic pornography use (PPU) among the general population has risen. There are limited data on the efficacy of Cognitive Behavioral Therapy (CBT) on online pornographic addiction; therefore, this study aimed at investigating the issue. Methods SCOPUS, PubMed, PubPsych, WOS (Web of Science), Cochrane Central Register of Controlled Trials, Google Scholar, Scientific Information Database (SID) & Iranmedex, and other databases (for gray literature) (eg, conference papers, key journals) will be systematically reviewed. Preliminary search strategies were started on March 2, 2019, and will be updated in April 2021. Eligibility criteria were having PPU, with designs of interest including randomized trials with three or more months of follow‐up with CBT intervention. Two authors will independently conduct data extraction and quality assessment. A modified Verhagen checklist for clinical trial studies will be used for quality assessment. Pooled measures of association will be computed using random‐effects model meta‐analyses. Between‐study heterogeneity will be assessed using the I2 statistic and the Cochrane χ2 statistic. Minor study effects will be evaluated for meta‐analyses with sufficient studies using funnel plots and Egger's test. If a meta‐analysis is appropriate, quantitative data will be pooled using the comprehensive meta‐analysis software. Discussion The evidence obtained in this meta‐analysis will help to determine whether CBT can decrease PPU severity, anxiety, depression, and compulsive sexual behavior. In addition, due to the comprehensive view on CBT effects on PPU patients, which was not clarified before, we can expect that the results of this study will benefit psychiatrists.


| BACKGROUND
The increasing rate of pornography use among the general population has caused mental health professionals to be deeply concerned about the increased number of patients presenting the symptoms of sexual addictions and sexual compulsivity. Studies have revealed that watching pornography is related to many negative consequences, such as failure in the relationship and sexual satisfaction, impairment of academic and professional functioning, subjective distress, perceived addiction, and sexual compulsivity. [1][2][3] Due to accessibility to the Internet worldwide and feasible access to pornographic websites, the number of people affected by online pornography is rapidly increasing. In this case, it is reported that the number of people using adult pornographic videos has been doubled from 1992 to 2006. 4 In addition, the youth are the most sensitive group of society in this rapidly increasing wave of pornography use. The majority of college students (males and females) watched pornographic videos at least one time in their lifetime (approximately 90%), and almost half of them (40%) reported watching pornography weekly. 5 As a result, the increasing prevalence of online pornography use among adolescents (mostly male) revived social worries regarding the possible effects of pornography use on sexual aggressiveness. 6 The growing rate of psychological addiction and compulsive pornography use as a prevalent complication could be accompanied by considerable psychological distress forms, such as depression, anxiety, perceived stress, and anger. 7 Based on the DSM-5 criteria classification, problematic pornographic use (PPU) is characterized by excessive sexual behaviors, diminished self-control over sexual engagement, use of sex for escaping from or avoiding negative emotions, and functional impairment and distress. 8 Furthermore, other features that are not included in DSM-5 and are related to addictive pornography use are (a) frequent, excessive, or compulsive behavioral engagement; (b) an appetitive urge before engaging in the behavior to reach/maintain a positive emotional state or to escape from/avoid a negative emotional state; (c) diminished self-control over behavioral engagement; and (d) continued attention despite adverse consequences, which, in turn, leads to significant personal distress and functional impairment. 9 The prevalence of PPU in 2019 was reported 1% to 6% in the adult population. 10 However, there is no particular treatment for this issue, and treatment strategies targeting sexual addiction are vast.
They could be included in medications, behavior therapies, 12-step approaches, and solution-focused therapy. 11 Cognitive-behavioral therapy (CBT) is typical and might be the most effective technique for such patients addicted to pornography. The CBT has demonstrated generally good tolerability, acceptability, and efficacy for other conditions like migraines in children. 12 Furthermore, CBT as a comprehensive treatment and an isolated method was reported to be effective for compulsive sexual behaviors. Therefore, it might not be surprising that CBT is the chosen intervention for 81% of addiction counselors. 13 The CBT method mainly has focused on maladaptive thinking patterns and the associated beliefs and behaviors supporting those patterns. 14 CBT addresses distorted thinking, and by using disregarded or ignored empirical evidence in the patient's life, it reframes those thoughts. The reframing becomes an affirmation for patients challenging those aspects of a belief system that might be irrational. 15 Previous reports on the efficacy of this method on sex-addicted patients combined with motivational interviewing, several open studies and case reports have reported significant reductions in sexual behaviors, such as frequency of sexual partners and amount of time spent online during working hours. [16][17][18] The isolated use of the CBT method in an open study revealed that by using this method, the overall depression, anxiety, and sexually compulsive behaviors of patients were reduced. 18

| Research aims
This study aims at investigating the impact of cognitive-behavioral therapy on pornography.

| METHODS AND ANALYSIS
The preliminary search strategy will be based on Population/Intervention/ Comparison/Outcomes/Study Design (PICOS), PRISMA-P checklist, 19,20 and the acronym with this review question: Does Cognitive Behavioral com/) will be used to store all the references and comprehensive searches. It should be noted that all keywords in each database (such as MeSH terms, PsycINFO Thesaurus, and mesh browser) will be identified with their synonyms. The search terms were combined using the Boolean operators "AND" and "OR." 21 (Table 1).
Study selection will be based on the PICOS 22 search strategy shown in Table 2. Only RCT studies investigated the effect of CBT on pornography use in both sexes; all ages and ethnicities will be included in the study. Observational studies, N RCT, and qualitative studies will be excluded.

| Methodological appraisal
Critical appraisal for assessing each paper's methodological quality will be performed using a modified Verhagen checklist. 23 The Verhagen checklist consists of eight items as follows: (a) method of randomization and allocation concealment, (b) similarity of prognostic indicators at baseline, (c) considering eligibility criteria, (d) blinding of assessors, (e) providers (f) participants, (g) considering point estimates for outcome measures, and (h) intention-to-treat analysis. The score of each item will be 1 and 0 for "Yes" and "No/do not know" answers, respectively. Papers scored at least 5 (out of 8) will be included in the systematic review. 23 Two independent reviewers (M.B. and A.L.) will assess the methodological quality of eligible trials. Any discrepancies between raters will be discussed until a consensus is reached.

| Data synthesis and meta-analysis
Two independent reviewers (A.L. and M.B.) will insert the extracted data from each study into an Excel sheet. If a meta-analysis is appropriate, quantitative data will be pooled using the comprehensive meta-analysis software STATA version 13.0. Analysis of subgroups or subsets will be conducted if the subgroup analysis (eg, age, disease status, ethnicity, socioeconomic status, presence, or absence of comorbidities) was satisfying.