Name: ______Date:______

Internet Questions1

Question Response Notes

How many times do you view pornography per week?

Approximately how long is each episode?

How many times do you masturbate per week?

How often do you have sex with your spouse or another person per week?

Have you become less interested in Yes / No partner sex since viewing pornography?

Can you masturbate to climax Yes / No without internet porn?

Do you have problems maintaining Yes / No an erection when having sex with a partner compared to internet pornography?

Have you escalated to pornography Yes / No genres that you find disturbing?

Have you begun to question your Yes/No sexual orientation since you began using internet porn?

1 Adapted from the Sexual Dependency Inventory and Your Brain on Porn

1 Name: ______Date:______

2 Problematic Pornography Consumption Scale

1 = never, 2 = rarely, 3 = occasionally, 4 = sometimes, 5 = often, 6 = very often, 7 = all the time

Questions (reflecting on the past six months) Score

1. I felt that porn is an important part of my life

2. I used porn to restore the tranquility of my feelings

3. I felt porn caused problems in my sexual life

4. I felt that I had to watch more and more porn for satisfaction

5. I unsuccessfully tried to reduce the amount of porn I watch

6. I became stressed when something prevented me from watching porn

7. I thought about how good it would be to watch porn

8. Watching porn got rid of my negative feelings

9. Watching porn prevented me from bringing out the best in me

10. I felt that I needed more and more porn in order to satisfy my needs

11. When I vowed not to watch porn any more, I could only do it for a short period of time

12. I became agitated when I was unable to watch porn

13. I continually planned when to watch porn

14. I released my tension by watching porn

15. I gradually watched more ‘extreme’ porn, because the porn I watched before was less satisfying

16. I resisted watching porn for only a little while before I relapsed

17. I missed porn greatly when I didn't watch it for a while

2 Reference: http://irep.ntu.ac.uk/id/eprint/30387/1/PubSub8168_Griffiths.pdf. 76 points or more indicate possible problematic pornography use

2 Name: ______Date:______

Categories of Pornography

Please select the types of pornography you view regularly:

o Heterosexual o Cartoon (incl. overwatch, o Lesbian , minecraft) o Gay male o Amateur o Anal o Bondage (BDSM) o Non-caucasian: ______o Public sex o Asian o Big breasts o Vintage/70s o Mature o Big penis o Teen (18+) o School girl o Babysitter o Threesome o Female friendly o MILF o o Incest (Mom, Step/Mom) o Creampie o Massage o Forced sex o Virtual reality o Other: o Bestiality o Other:

Top 3 Categories viewed:

1. 2. 3.

Top 3 visited:

1. 2. 3.

3 Name: ______Date:______

Sex Addiction Diagnostic Criteria

1. Have you repeatedly failed to resist sexual impulses to engage in specific sexual behavior? __

2. Have you frequently engaged in those behaviors to a greater extent or over a longer period of time than intended? __

3. Do you have a long-standing desire, or a history of unsuccessful efforts to stop, reduce, or control those behaviors? __

4. Have you spent excessive time in obtaining sex, being sexual, or recovering from sexual experiences? __

5. Do you become obsessed with preparing for sexual activities? __

6. Have you frequently engaged in sexual behavior at times when you were expected to be fulfilling occupational, academic, domestic, or __ social obligations?

7. Have you continued your sexual behavior despite knowing it has caused or exacerbated persistent or recurrent social, financial, __ psychological or physical problems for you?

8. Do you need to increase the intensity, frequency, number or risk of sexual behaviors to achieve the desired effect, or do you experience diminished effect when continuing behaviors at the same level of __ intensity, frequency, number, or risk?

9. Have you given up or limited social, occupational, or recreational activities because of your sexual behavior? __

10. Do you become upset, anxious, restless, or irritable if you are __ unable to engage in sexual behavior?

4 Name: ______Date:______

Sexual Anorexia Diagnostic Criteria

1. Do you recurrently resist or experience aversion to any sexual activity, initiative, or __ behavior? 2. Do you experience persistent aversion to sexual contact even though it is self- __ destructive or harmful to relationships? 3. Do you make extreme efforts to avoid sexual contact or attention, including self- mutilation, distortions of body appearance or apparel, and aversive behavior? 4. Do you have rigid, judgmental attitudes towards your sexuality or the sexuality of __ others? 5. Do you experience extreme shame and self-loathing about sexual experiences, body __ perceptions, and sexual attributes? 6. Does sexual aversion affect your work, hobbies, friends, family and primary __ relationships? 7. Are you preoccupied and obsessed with avoiding sexual contact or with concern __ over the sexual intentions of others? 8. Do you experience despair about sexual adequacy and functioning? __ 9. Do you avoid intimacy and relationships out of fear of sexual contact? __ 10. Do you experience distress, anxiety, restlessness or irritability because of sexual __ contact or potential sexual contact?

5 Name: ______Date:______

Sexual Bingeing and Purging

1. Do you experience relief at the time of sexually acting out, but despair afterward? __ 2. Are there times when all of your sexual interests and behaviors cease? __ 3. Do you have a pattern of sexual bingeing followed by periods of being __ compulsively non-sexual? 4. Are you sexually excessive in some areas while simultaneously being compulsively __ non-sexual in others? 5. Do you take extreme measures, such as self-mutilation, as an attempt to disrupt __ the acting out cycle? 6. Do you have other family members who are sexually addicted? __ 7. Do you have other family members who are sexually anorexic? __ 8. Do you have a significant other who is a sex addict? __ 9. Do you have a significant other who is sexually anorexic? __ 10. Do both you and your significant other have sexual binge-purge patterns? ___

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