Today we're going to talk about

pornography addiction in women. So this

is a topic that is chronically

undertalked about, very underststudied,

and I'm absolutely guilty of that as

well. So I got sort of highlighted onto

this when someone on a subreddit posted,

hey, like we never talk about porn

addiction in women. And this is a really

common problem in medicine where when

there is one gender that has a problem

that is really really serious, we tend

to or very common, we tend to ignore

that problem in other genders. So, good

examples of this are like borderline

personality disorder in men is not

talked about or studied nearly as much

as BPD in women. And so, I saw this post

and first of all, thank you very much to

the community for alerting me to this.

And then I looked into the research and

about some studies suggest that up to

20% of men are addicted to pornography

and actually up to 7% of women are

addicted to pornography. And this is

really common where it's like, okay, so

if 20% of men are addicted, like let's

help the men. But actually up to 7% of

women being addicted is really, really

high. So just to give you all a frame of

reference, about 6% of people in the

world are alcoholic. So pornography

addiction in women is actually more

common than alcoholism is across the

globe. So there are a couple of things

that are distinct about pornography

addiction in women compared to men, but

we're going to cover it cover all the

basics today. So, the first thing that

really stood out to me, and fair

warning, I've never actually worked with

a patient who is a woman who has

pornography addiction. Part of where my

bias comes from, but I've worked with

tons of women who have many of the

conditions that we're talking about in

including borderline personality

disorder and compulsive sexual behavior

or sex addiction that I have plenty of

experience with. So first thing that

we're going to talk about is really

interesting fact that if you look at

women who struggle with pornography

addiction or compulsive sexual behavior

of some kind, trauma is a very very very

high coorbidity. I think around 57% of

women who have some kind of sex or

pornography addiction have a diagnosis

of PTSD. That is shockingly high. About

42.9%

of them have a diagnosis of BPD. So this

is a personality disorder that is

heavily related to trauma. BPD or

borderline personality disorder also has

unstable sexual relationships as part of

the diagnostic criteria. So, one of the

key things that I've sort of seen in my

work with women who have sex addiction

is that trauma is a huge huge factor.

So, we're going to sort of start there.

So, what kind of trauma are we talking

about and how does trauma shape

fundamentally our risk for becoming

addicted to sex or pornography? Okay. So

early on when we have certain caregiver

relationships,

these relationships form the

foundational script for our romantic

relationships later in life. Okay? So I

I'm not saying that this is like we're,

you know, this isn't like edible complex

where I'm attracted to my mother or

things like that. What I mean is that

when we consider human intimacy at its

core, right? So like what does intimacy

look like? What does it look like to

feel close and connected to someone?

That fundamental attribute of

connectedness, which is not even sexual,

how does someone who is loving and

caring and someone that I'm close with,

someone that I I love and they love me,

right, on a fundamental level, what does

that look like? So, what we see in

people who are addicted to pornography

or sex is that these relationships early

on are messed up in some way. So, in

some cases, there is frank abuse,

physical abuse, sexual abuse. I think

the fundamental thing is something that

is contradictory. Okay. So what really

traumatizes and messes people up is when

they have caregiver relationships or

early important relationships that are

contradictory in some way. So mom or dad

loves me and physically abuses me. So

that's a contradiction that really

messes up our script for intimacy later

in life. Mom or dad loves me but is

sexually abusive. So that too really

really messes up our understanding of

what a sexual relationship looks like.

Right? This is the way that we're being

conditioned or programmed. But it

doesn't have to be frank sexual or

physical abuse or even emotional abuse.

Sometimes it's neglect where it's like,

okay, we want this person's love, but

we're not able to get it. So we engage

in all kinds of behaviors. We develop an

insecure attachment style. And there's a

lot of work on how insecure attachment

is a heavily, heavily, heavily important

part of pornography addiction. Other

examples of things that are not explicit

abuse are seeing your father engage in

affairs, seeing your mother bring home,

you know, random men because she's a

prostitute. Like, I've seen all this

stuff. It's represented in the

literature. But the key thing to

understand is that at the outset 57%

coorbidity for PTSD is insane in

psychiatry. Generally speaking, the

highest coorbidities that we tend to see

are around like 30 to 40%. And that's

like super super high coorbid

conditions. So the key thing here is

that it seems like early relationship

trauma of some kind heavily heavily

heavily increases your risk for

developing a later pornography

addiction. And the main way that it does

that is by messing up our script of what

intimacy looks like. So as these women

get older, their capacity to engage in

relationships is impaired for many of

them, unfortunately. Okay. So now what

we're going to do is sort of walk you

through sort of the sequence of how a

pornography addiction evolves and we're

going to cover a lot of other types of

science, literature, psychiatry, and see

how everything fits together. Okay. So

early on there's you and then you have

caregiver relationships that are somehow

impaired, right? So the first thing is

that we end up with the idea that love

is contradictory. So like love is like

yeah this person does something really

nice for me but then also puts me in

situations that are really really really

uncomfortable. And so the key thing here

is love is not all good. This is the key

key key thing that really messes people

up. So, as a psychiatrist, I've worked

with a lot of sex workers, people who

are addicted to sex addiction, engage in

unstable sexual relationships. There's

sort of two jobs that I've found working

with them. One is sort of like healing

the trauma and dealing with like the

mental illness, and the second is like

equipping them with the skills to form a

healthy relationship cuz what we want is

that corrective emotional experience.

That stuff isn't necessarily psychiatry.

And I actually put all that stuff

together in Dr. K's guide to love, sex,

and relationships. So check it out if

y'all are interested in that. So when we

sort of think about, you know, a

mother's love or a father's love or a

parent's love, the key thing is it's

like kind of unconditional, right?

That's like the healthiest form of love

where like mom or dad is is there for me

all the time. This can happen with other

caregivers as well. But then instead of

that, what we end up with is love is

good and love is bad. It's actually both

of those things. And this becomes the

script that we will follow later on.

There's a ton of evidence to support

this. Just to give you all a quick kind

of aside. So, good examples of this are

like, you know, when we're abused by our

parents, the likelihood of being abused

by our romantic partner skyrockets. And

that's because we think it is normal in

a loving relationship, even if

intellectually we know that it's not

normal. Other deeper conditioned parts

of ourselves feel comfortable and safe

and understand the script of an abusive

or contradictory loving relationship.

This is what I think is really

interesting. I'm going to just talk

about trauma for a second. So, here's

what's really fascinating to me as a

psychiatrist. See, you can have an

abusive relationship growing up.

Sometimes that results in BPD. Sometimes

that results in substance addiction.

Sometimes it results in sex addiction.

Sometimes it results in a mood disorder

or bipolar disorder. So, what's really

fascinating to me is to understand why a

trauma manifests as a pornography

addiction in some people later in life.

Does that kind of make sense? It's like

the injury can be the same, but the way

that we adapt to that injury depends on

a lot of things. And this is what's

really fascinating. So the first is that

people with pornography addictions have

altered dopamine reward circuitry. Okay?

And we'll we'll understand how this will

this will sort of paint us a picture of

how we end up with pornography

addiction. So basically these people are

like hyper sensitive to dopamineergic

rewards. This predisposes them for

addiction. So the risk of addiction goes

up, right? And if you're someone who's

lucky enough to not have this

polymorphism of the dopamine receptor,

so like your dopamine receptors aren't

particularly sensitive, then I think

that that like, you know, it manifests

potentially as like major depressive

disorder. The trauma will grow into

major depressive disorder instead of

some kind of addiction. This is what's

also really fascinating. There's also

endocrine changes, specifically stress

responsiveness. The stress

responsiveness is blunted. Now what does

that mean? So generally speaking, our

tissues have receptors for stress

hormones. So when our body is under a

condition of stress, it secretes things

like cortisol. And when it secretes

things like cortisol, the rest of our

tissues respond to that stress. But what

we find in people with pornography

addiction is that they have a

dexamethasone

suppression test that is abnormal.

Specifically, it's blunted. Now, what

does this mean? This means that when we

try to shut off your stress system, it

doesn't respond normally. So these

people are also prone to baseline levels

of high stress. The third thing that

we're going to talk about which is

really common is emotional regulation

difficulties. For whatever reason, these

people will have difficulty regulating

their emotions. So when we go back to

this idea of of trauma early on, we know

that insufficient emotional support,

insufficient emotional mirroring is what

results in difficulty with regulating

our emotions later in life. So the way

that this kind of works, okay, just big

picture is when I feel upset as a child,

when my parent comes to me and expresses

an exaggerated emotion. So if I fall

down and I get a boo boo and my mom runs

over and says, "Oh my god, what the baby

got a boo boo?" they are displaying to

me the same emotion that I feel, right?

So like if I feel worried, if I feel

panicked, they're going to run over to

me panicked. So I get this thing called

mirroring. And then something really

cool happens is like when my parent runs

over panicked, right? I'm hurt. My

parent runs over panic. They examine me.

They see, okay, it's just a you just

fell. There's a little bit of a scrape.

And then they calm down. And when they

calm down, I calm down. My favorite

example of this is a really cool study I

saw many years ago about how if you have

a parent with an anxiety disorder and

you have a child with anxiety disorder,

if you just treat the parents anxiety,

the child's anxiety improves

automatically. You don't have to do

anything with the kid. So literally as

children, part of what we do is we

outsource our negative emotions to our

parents to take care of. when our

parents are not around to take care of

them or there's lots of weird emotions

like my mom brings home men and is a

prostitute or sex worker that evokes a

lot of emotions that like it's hard for

my mom to emotionally mirror and then

what happens is people who grow up with

this kind of stuff their brains engage

in dissociative behavior instead okay so

we tend to see an increase in

dissociative behavior and just to

explain this once again right so like

let's say I have a parent who is abusive

in some way how do I recon reconcile

that it's really hard to understand it.

So instead, what my brain does is

actually dissociate. So this is

important to understand. Dissociation is

not the same as regulation. Okay? So

dissociation and regulation are

fundamentally different. Regulation is

when I feel the thing and I calm it

down. So it's like if I'm really upset,

an example of emotional regulation is

like, okay, I know I'm upset. This

person did this wrong. I sort of talk to

myself or I engage in some kind of deep

breathing or I make myself a cup of tea.

The emotions don't disappear. I deal

with them. The mechanism of dissociation

is fundamentally different. What it

actually does is separates communication

from different parts of the brain. So

literally what it does is the emotional

circuits of our brain are active but

what we do is we silence them. They're

still turning on but it's kind of like

we wall them off. It's like we stick

them in the basement. So then the

emotion is still active. We're not

actually calming anything down. We're

simply walling it off. And this comes

across, it's something called

hemispheric lateralization, which if you

all have seen the trauma guide and stuff

like that, you know some of this

neuroscience. But this is really

important to understand. You know, it's

like if I have music playing and I just

stick the speaker in the basement, it's

still playing. That's very different

from turning down the volume or getting

the music to stop. So people engage in

uh they have emotional regulation

difficulties. This is really common.

Okay. So then this is sort of the setup

for pornography addiction. And then a

couple of really interesting things

happen. So now you're a person with

resistance to stress lowering. We have

emotional regulation issues. We've got

dopamine sensitivity. And then we also

have messed up patterns of intimacy. So

this is the backdrop. Okay, these are

the risk factors. We haven't developed a

pornography addiction yet. Then comes

the catastrophic step which is early

exposure to porn. Now this is where

things are a bit different for women. So

first thing is that if you look at male

pornography addicts, female pornography

addicts, there's good evidence that all

of them are expo not all but a high

majority of them are exposed to

pornographic or erotic because now we're

talking women and fanfiction and smut

and you know 50 shades of gray lemon

scale. We're going to get to all of it,

okay? Cuz women are different. But

they're exposed to some kind of sexual

material early on. So we're talking 10

years old, 11 years old. Many of them

are exposed between 10 and 14. Okay? And

so then what happens like something

weird happens. So this is often times

pre-puberty. So uh this there's a great

quote about this about how when you get

exposed to sexual activity before

puberty, let alone after puberty. It's

kind of like you're a ship at sea

without a rudder, right? So like imagine

you're like a 9-year-old and like you've

never seen sex before and you've

interacted with humans for like 9 years.

There's hugs, there's kisses, they're

playing on the playground, there's

picking you up, there's rocking you to

sleep, there's rubbing your boo boo,

there's giving you a bath, right? And

then suddenly like you see these naked

people and they're like inserting body

parts into other body parts and you're

like, "What the hell is this?" Okay, so

you don't know how to make sense of

this. The problem is on a cognitive

level, you don't know how to make sense

of it. You may not even be aroused. But

the really interesting thing about sex

is how powerfully it alters your brain.

So we know for example that pornography

is one of the best ways to regulate your

emotions. We know that pornography and

sex releases dopamine in your brain. We

know that pornography in sex calms you

down. Okay? It reduces your stress

levels. So now we have a catastrophic

event. We'll get to the lemon scale in a

second. So this is sort of the shared

part of of pornography addiction. Okay.

We have a brain that is resistant to

lowering stress. We have a brain that is

dopamine sensitive. We have a brain that

does not know how to regulate its own

emotions. And along comes pornography

and solves all these problems. For a

9-year-old, it is my belief that it's

not even about arousal or masturbation

or orgasm. It's about these elements. So

the effect on the brain still seems to

happen. Then we get to sort of the

female aspect of it, which is that a lot

of women who eventually become addicted

to pornography will start with erotica.

So they'll start with things like

fanfiction. And this is where I

discovered something called the lemon

scale, which is like a citrus scale

depending on how smutty a particular

level of fanfiction is. But this is

really important to understand as well,

which is like, man, I'm saying that all

the time, but I feel like all this is

really important to understand. Okay,

for me maybe it was revolutionary to to

crack this thing and understand my my

female patient so much better. So

remember the key thing here is that with

women as opposed to men, right? Our rate

of BPD is like ridiculous. 42.9% of

people with sex addiction or pornography

addiction have BPD. 57% have trauma. So

what is it that gets traumatized? What

gets traumatized is our fundamental

script of how we interact with intimate

partners. And what we find in erotica,

what we find in fanfiction, what we find

on the lemon scale is appropriate

romantic and intimate interactions,

sexual interactions, right? We see a

script of something that is I don't know

if it's like appropriate or not

appropriate, but what it is is it feels

like it's absolutely romanticized. So it

is portrayed in a way that is good. I

don't even know if it's healthy, right?

So I don't know if like Fifty Shades of

Gray is healthy, but it's portrayed in

like a positive light. So it's like,

okay, this is what it's supposed to look

like. This is what it's supposed to feel

like. This is like this is what intimacy

this is the fantasy of intimacy. So many

people who are addicted to pornography

will gravitate towards this. And we'll

come back to this a little bit later as

well. Okay. So the key thing here is

that we have all of these

predispositions. We're wired in a way

that makes us vulnerable to addiction

plus an exposure of some sort of sexual

material triggers something in the brain

and then creates this kind of like

addictive picture. That's how it forms.

Now what are the features of it? Okay,

sex addiction or pornography addiction

is some part OCD, some part impulsivity,

some part addictive behavior. Okay, now

what do I mean by this? So OCD is

characterized by intrusive thoughts.

Okay. So we can't control what pops into

our head. It is also characterized by

compulsions. So what is a compulsion

necessarily? You know turning the light

on and off. That's not what that is. So

a compulsion is an action. Whatever it

is, it can actually be a mental action.

So you can think something, you can pray

something. It's some kind of response

that lowers the anxiety created by the

intrusive thoughts. So the this cycle is

something pops into my head and it makes

me feel bad. Then I engage in some kind

of behavior that makes the anxiety go

down. This fundamental loop of thought

pops into my head makes me feel bad.

Engage in behavior make thought go away.

That's actually on the OCD spectrum.

Second thing that we see is impulsivity.

So people are not able to control their

behavior once they have the thought to

watch pornography. They they literally

like they can't control it. It's like

some switch flips in their brain and

before they even realize it often times

is on autopilot. It's open on the second

screen. This is where we see

implications for dopamine. We also see

implications for ADHD. And then we have

the standard addictive behaviors. What

does that mean? Addictive behaviors is

tolerance. Right? So as we watch

pornography, as we read erotica, it

doesn't do the job right. We start to

develop a tolerance to it. We need more

of it. Often times we need more extreme

versions of it, right? So this this sort

of basic idea of like dopamineergic uh

so this releases dopamine and then

addictions also. So addictions do two

things. Okay? Addictions make us feel

good and they also make us feel less

bad. It has to do for us to get addicted

to anything. It has to involve both of

these elements. So this is emotional

regulation. Our understanding of

pornography is it's sort of like like if

we were to draw a ven diagram of OCD,

ADHD and addiction like porn addiction

is like in here. And then of course this

is all under the backdrop of trauma. So

this is sort of like how this picture

ends up evolving. These are the features

of it. So then we end up with you in the

present day. Okay. And this is where

we're going to sort of touch on a couple

of other features of pornography. And

this is how we got here. So at this

point, you're addicted to porn. Probably

have a history of some kind of trauma or

neglect, okay? But not necessary, right?

So let's remember it's about 50%.

Impulsive. You have thoughts about it.

Have difficulty controlling it. You're

kind of on autopilot. So now we have to

talk about a couple of other elements to

this. The first is when we have

relationships that don't go well early

in our life, we engage in something

called reenactments. Okay, this is also

something called the repetition

compulsion. So I'll I'll kind of give

you an example. Okay, so this is

something that like Freud talked about,

many of the other psychoanalysts talked

about. They basically noticed a a really

common pattern which is that when

something doesn't go right in life, we

try to fix it over and over and over

again. So classic example is someone

with daddy issues or mommy issues where

daddy or mommy didn't love me enough

growing up and I'm going to spend my

whole life trying to fix that wound. I

want y'all to think about this for a

second. Right? So as human beings we are

wired to fix problems. Like if something

is not working properly like I need to

get it to work properly. Right? So if my

foot hurts I figure out how to get my

foot to stop hurting or how to keep

walking. This is a core survival

element. Other thing about humans is we

are social creatures. So our survival

depends on our social interactions. So

we are especially sensitive to fixing

social failures. I got bullied a lot. I

didn't want to get bullied. I wanted to

become the bully. Right? So we reenact

this in other kinds of ways because

there's one person who's powerful and

there's one person who's powerless. I'm

going to play that script again, but in

this in this version, I'm going to be

the person who's powerful. Okay, this is

why people who are abused become

bullies. Key thing here is that

something in our brain and we can do

whole not even lectures, we can do whole

courses on reenactment and the

repetition compulsion. We try to fix it

later. So if mommy or daddy didn't love

me enough, I will find mentor figures

and try to get them to love me, try to

win their affection, try to win their

approval. I will find romantic partners,

try to win their approval. Okay, this is

just sort of like a fact of human

psychology and how it works. One of the

key ways that we try to fix these wounds

from the past is in our romantic

relationships. So, if I can get like,

and this is just kind I know it's kind

of weird and messed up, but this is just

sort of how it works. So, if I wasn't

loved sufficiently by my parent, if I am

loved sufficiently by somebody else, it

could be a coach, right, who's really

there for me, showed up at my

graduation, walked me down the aisle,

could be a grandparent, could even be a

spouse. We call these in psychiatry

corrective emotional experiences. We

have to get that love somehow. And one

of the key places that we look for it is

in our romantic partners. Because

remember our script of intimacy that

starts with parents ends up with

romantic partners. So then we end up in

the modern world and we are trying to

correct the fun we're trying to get that

fundamental sense of love. So we look

for it in a romantic partner. Now this

is where I think also a lot of that

erotica comes in and the lemon scale

comes in because a lot of the people who

are addicted to pornography will also

engage in other forms of like erotic

media for lack of a better term right so

these are the relationship these are the

fantasy corrections of our traumatic

wounds and I don't know if this explains

why like you know erotica is so um

popular amongst women or what I'm not

really sure about that so another

important part of the erotic

is the emotional safety. Okay? So, we

are drawn to the emotional safety of

erotica. Now, you may say, "But Dr. K,

if you look at those situations, they're

not safe. They're like abusive

at the beginning, right? So, if you look

at Fifty Shades of Gray, like that's not

that's not safe." But what ends up

happening? Oh my god. So, this is an

unsafe situation with a woman who gets

taken advantage of and put in this

compromised situation, and then it all

ends well. Oh [ __ ] It ends up taming

the beast. They end up falling in love

and getting married and like all this

guy. I don't know if they actually do

that. I haven't read this stuff. I

really should. Okay, if you guys have

recommendations, leave them in chat for

me to get started. It's like, oh wow,

like that's the perfect fantasy. Oh,

it's so interesting that this situation

was toxic at the beginning, abusive at

the beginning, and then ended up totally

fine. It ended up with a deep emotional

intimate connection. She understands him

in a way that no one else can, and he's

been tamed by her. And oh my Oh my god.

It's almost like it's the fantasy that

you wanted when you were a kid when your

parents wouldn't love you. It's like, oh

my god, that maps on like so well. Okay,

but we are seeing an astronomic rise in

pornography addiction. Children have

been neglected or abused by their

parents for thousands of years, right?

So, what is it that's different now?

Because some studies show like older

studies on female pornography addiction

shows something like a.7% prevalence

which means you know one out of 100 not

even one out of 100. And so how has this

gone from 7% to 7%. And this is because

we live in an unsafe world. So we live

in a world where you get dickpicks. We

live in a world where you get sexually

harassed. We live in a world where you

get sexually assaulted. Okay this is

crazy. This is the world that we live

in. And what I've seen in in many of my

my patients who have some kind of sex

addiction or sex workers, things like

that, is like they will try to engage in

relationships. They will try to engage

in sexual relationships, romantic

relationships. But when you go on a

date, when you encounter someone, what

happens in your brain? First of all,

what happens to your emotions? Do they

become more regulated or more

disregulated? Is there an increase or

decrease in anxiety when you were going

on a date texting with someone? Right?

So, we see an increase in anxiety. What

happens to your dopamineergic circuitry?

Right? Is this necessarily fun? For some

people, it is. For people who are

promiscuous and have borderline

personality disorder, they can

absolutely get a dopamine spike from

dating, right? That's why they do it.

But for many people, dating is like

terrible. It's like anxious. There is no

dopamine. It's not fun, right? Right? So

the dopamine level is low and it creates

a stressful situation. So what is our

stress responsiveness? And this is

another thing to point out. Stress

responsiveness means our body's capacity

to respond to stress and regulate

stress. Okay? So when cortisol levels

are high, they hit certain receptors and

then our brain is our body is our tissue

is basically like okay cortisol levels

are high. Let's calm down. Because we

try to maintain something called

homeostasis, right? So we keep our

temperature at 98.6. We try to keep our

oxygen saturation at 99%. So we'll

increase our respiratory rate if our

oxygen saturation is low. We'll decrease

our respiratory rate if our oxygen

saturation it's CO2 but anyway we try to

keep things at a middle level. So when

our stress responsiveness is really poor

and we enter into a situation that

increases our stress, we cannot calm

ourselves down. You make the mistake of

going on a date. Now compare this to

pornography, right? And let's remember

there's also the OCD elements of safety

and intrusive thoughts, right? Is this

person going to attack me? Especially if

I have a history of like abuse by

intimate partners. Remember, like I'm

attracted to this person. I want love. I

want a relationship, but it's really

confused. I'm a ship at sea without a

rudder, but this person could be

dangerous. They could hurt me. And this

is sort of like what we think about as

trauma, right? So, all of this stuff is

going on. And then we have pornography.

We have erotica. And what is the

response to our emotions? Anxiety goes

down, dopamine goes up, stress goes

down. Right? So now I sort of end up

getting stuck. I wind up addicted to

pornography. Right? And the reason is

because when I try to fix these things,

my body does not respond in the right

way. My mind does not respond in the

right way. Even though what I need is a

corrective emotional experience, the

path to that corrective emotional

experience is fraught with struggles, is

fraught with danger. And so sometimes

even I'll have patients who like try to

force themselves, right? I need to enter

a relationship. I need to enter a

relationship. So then they end up

ignoring the red flags and then they end

up in abusive relationships. They end up

in neglectful relationships. They end up

in relationships with people with

avoidant attachment who don't text them

back. And then that retraumatizes them.

So in instead you return to safety and

you return to emotional regulation. You

return to that sexual outlet, the sexual

parts of your brain, your desire for sex

being way safer with porn than it is

with people.