Don’t blame the game: Parents, videogame content, and age ratings

Back in March 2015, BBC News reported that parents of children in 16 Cheshire county schools had been sent a letter saying that head teachers would report them to the authorities if they allowed their children to play videogames that are rated for adults (i.e., games that have an ‘18’ rating). The teachers claimed that popular games like Grand Theft Auto and Call of Duty are too violent to be played by those under the age of 18 years. They also stated that such games increased sexualised behaviour and left children vulnerable to sexual grooming. The schools also threatened to report parents who let their children play such games because it was a form of parental neglect. The author of the letter, Mary Hennessy Jones, was quoted as saying that:

“We are trying to help parents to keep their children as safe as possible in this digital era. It is so easy for children to end up in the wrong place and parents find it helpful to have some very clear guidelines”.

I’m sure the letter to parents was written with the best of intentions but as a parent of three ‘screenagers’ and someone that has spent almost three decades researching the effects of video games on human behaviour, this appears to be a very heavy-handed way to deal with the issue. Although it is illegal for any retailer to sell ‘18’ rated games to minors, it is not illegal for children to play such games, or illegal for parents to allow their children to play such games. Many parents need to be educated about the positives and negatives of playing video games but reporting them to the “authorities” is not the right way forward.

Back in the early 1990s I was probably the only academic in the UK carrying out scientific research on children’s video game playing. In fact, I was proud of my role in getting age ratings onto all video games in the first place, and for writing the text for educational information leaflets for parents (outlining the effects of excessive playing of such games) sponsored by the National Council for Educational Technology. There are many positive benefits of playing video games (something that I wrote about in a previous article for The Conversation).

I know from first-hand experience that children often play games that are age-inappropriate. Two years ago, my (then) 13-year old son said he was the only boy in his class that did not play or own the Call of Duty video game. This is also borne out by research evidence. One study that I was involved in found that almost two-thirds of children aged 11- to 13-years of age (63%) had played an 18+ video game. Unsurprisingly, boys (76%) were more likely than girls (49%) to have played an 18+ video game. Children were also asked about how often they played 18+ video games. Of the two-thirds who had played them, 8% reported playing them “all the time”, 22% reported playing them “most of the time”, 50% reported playing them “sometimes”, 18% reported playing them “hardly ever”. Again, boys were more likely than girls to play 18+ video games more frequently. Children were asked how they got access to 18+ plus video games. The majority had the games bought for them by family or friends (58%), played them at a friend’s house (35%), swapped them with friends (27%), or bought games themselves (5%). This research certainly appears to suggest that parents and siblings are complicit in the playing of age-inappropriate games.

There is a growing amount of scientific literature that has examined the content of video games designed for adults. For instance, a study led by Dr. Kimberley Thompson and published in the Archives of Pediatric and Adolescent Medicine attempted to quantify the depiction of violence, blood, sexual themes, profanity, substances, and gambling in adult (18+) video games and to assess whether the actual game content matched the content descriptor on the packaging. Although content descriptors for violence and blood provided a good indication of content in the 36 games examined, the authors concluded that 81% of the games studied (n=29) lacked content descriptors of other adult content. Other studies carried out by the same research team have found that adult content can be found in lots of games aimed at young children and teenagers.

Another study led by Dr. David Walsh published in Minerva Pediatrica tested the validity of media rating systems (including video games). Results showed that when the entertainment industry rated a product as inappropriate for children, parents also agreed that it was inappropriate. However, parents disagreed with many industry ratings that were designated as containing material as suitable for children. The products rated as appropriate for adolescents by the industry were of the greatest concern to parents.

The issue of children and adolescents playing 18+ games is no different from the debates about children and adolescents watching 18+ films. However, based on anecdotal evidence appears that parents are more likely to adhere to age ratings on films than they are on video games. This is one area that both media researchers and media educators need to inform parents to be more socially responsible in how they monitor their children’s leisure activity. A school sending out a threatening letter to parents is unlikely to change parental behaviour. Education and informed debate is likely to have a much greater effect in protecting our children from the potential harms of video game playing.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

 Further reading

Anderson, C.A., Gentile, D.A., & Dill, K.E. (2012). Prosocial, antisocial and other effects of recreational video games. In D.G. Singer, & J.L. Singer (Eds), Handbook of Children and the Media, Second Edition, (pp. 249-272). Thousand Oaks, CA: Sage.

Anderson, C. A., Shibuya, A., Ihori, N., Swing, E. L., Bushman, B.J., Sakamoto, A., Rothstein, H.R., & Saleem, M. (2010). Violent video game effects on aggression, empathy, and prosocial behavior in eastern and western countries: a meta-analytic review. Psychological Bulletin, 136, 151-173.

Bartlett, C. P., Anderson, C.A. & Swing, E.L. (2009). Video game effects confirmed, suspected and speculative: A review of the evidence. Simulation and Gaming, 40, 377-403.

Ferguson, C. J. (2007). Evidence for publication bias in video game violence effects literature: A meta analytic review. Aggression and Violent Behavior, 12, 470-482.

Ferguson, C. J. (2013). Violent video games and the supreme court: Lessons for the scientific community in the wake of Brown v. Entertainment Merchants Association. American Psychologists, 68, 57-74.

Ferguson, C. J., San Miguel, S. & Hartley, T. (2009).  Multivariate analysis of youth violence and aggression: The influence of family, peers, depression and media violence. Journal of Paediatrics, 155, 904-908.

Gentile, D. A. & Stone, W. (2005). Violent video game effects in children and adolescents: A review of the literature. Minerva Pediatrics, 57, 337-358.

Griffiths, M.D. (1998). Video games and aggression: A review of the literature. Aggression and Violent Behavior, 4, 203-212.

Griffiths, M.D. (2000). Video game violence and aggression: Comments on ‘Video game playing and its relations with aggressive and prosocial behaviour’ by O. Weigman and E.G.M. van Schie. British Journal of Social Psychology, 39, 147-149.

Griffiths, M.D. (2010). Age ratings on video games: Are the effective? Education and Health, 28, 65-67.

Griffiths, M.D. & McLean, L. (in press). Content effects: Online and offline games. In P. Roessler (Ed.), International Encyclopedia of Media Effects. Chichester: Wiley.

Grüsser, S.M., Thalemann, R. & Griffiths, M.D. (2007). Excessive computer game playing: Evidence for addiction and aggression?  CyberPsychology and Behavior, 10, 290-292.

Ivory, J.D., Colwell, J., Elson, M., Ferguson, C.J., Griffiths, M.D., Markey, P.M., Savage, J. & Williams, K.D. (2015). Manufacturing consensus in a divided field and blurring the line between the aggression concept and violent crime. Psychology of Popular Media Culture, 4, 222–229.

McLean, L. & Griffiths, M.D. (2013). The psychological effects of videogames on young people. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 31(1), 119-133.

McLean, L. & Griffiths, M.D. (2013). Violent video games and attitudes towards victims of crime: An empirical study among youth. International Journal of Cyber Behavior, Psychology and Learning, 2(3), 1-16.

Mehroof, M. & Griffiths, M.D. (2010). Online gaming addiction: The role of sensation seeking, self-control, neuroticism, aggression, state anxiety and trait anxiety. Cyberpsychology, Behavior, and Social Networking, 13, 313-316.

The words and the we’s: When is a new addiction scale not a new addiction scale?

“The words you use should be your own/Don’t plagiarize or take on loans/There’s always someone, somewhere/With a big nose, who knows” (Lyrics written by Morrissey from ‘Cemetry Gates’ (sic) by The Smiths)

Over the last few decades, research into ‘shopping addiction’ and ‘compulsive buying’ has greatly increased. In 2015, I along with my colleagues, developed and subsequently published (in the journal Frontiers in Psychology) a new scale to assess shopping addiction – the 7-item Bergen Shopping Addiction Scale (BSAS) which I wrote about in one of my previous blogs.

We noted in our Frontiers in Psychology paper that two scales had already been developed in the 2000s (i.e., one by Dr. George Christo and colleagues in 2003, and one by Dr. Nancy Ridgway and colleagues in 2008 – see ‘Further reading’ below), but that neither of these two instruments approached problematic shopping behaviour as an addiction in terms of core addiction criteria that are often used in the behavioural addiction field including salience, mood modification, tolerance, withdrawal, conflict, relapse, and problems. We also made the point that new Internet-related technologies have now greatly facilitated the emergence of problematic shopping behaviour because of factors such as accessibility, affordability, anonymity, convenience, and disinhibition, and that there was a need for a psychometrically robust instrument that assessed problematic shopping across all platforms (i.e., both online and offline). We concluded that the BSAS has good psychometrics, structure, content, convergent validity, and discriminative validity, and that researchers should consider using it in epidemiological studies and treatment settings concerning shopping addiction.

More recently, Srikant Amrut Manchiraju, Sadachar and Jessica Ridgway developed something they called the Compulsive Online Shopping Scale (COSS) in the International Journal of Mental Health and Addiction (IJMHA). Given that we had just developed a new shopping addiction scale that covered shopping across all media, we were interested to read about the new scale. The scale was a 28-item scale and was based on the 28 items included in the first step of BSAS development (i.e., initial 28-item pool). As the authors noted:

“First, to measure compulsive online shopping, we adopted the Bergen Shopping Addiction Scale (BSAS; Andreassen, 2015). The BSAS developed by Andreassen et al. (2015), was adapted for this study because it meets the addiction criteria (e.g., salience, mood modification, etc.) established in the DSM-5. In total, 28 items from the BSAS were modified to reflect compulsive online shopping. For example, the original item – ‘Shopping/buying is the most important thing in my life’ was modified as ‘Online shopping/buying is the most important thing in my life’… It is important to note that we are proposing a new behavioral addiction scale, specifically compulsive online shopping … In conclusion, the scale developed in this study demonstrated strong psychometric, structure, convergent, and discriminant validity, which is consistent with Andreassen et al.’s (2015) findings”.

Apart from the addition of the word ‘online’ to every item, all initial 28 items of the BSAS were used identically in the COSS. Therefore, I sought the opinion of several research colleagues about the ‘new’ scale. Nearly all were very surprised that an almost identical scale had been published. Some even questioned whether such wholescale use might constitute plagiarism (particularly as none of the developers of the COSS sought permission to adapt our scale).

According to the plagiarism.org website, several forms of plagiarism have been described including: “Copying so many words or ideas from a source that it makes up the majority of your work, whether you give credit or not” (p.1). Given the word-for-word reproduction of the 28 item–pool, an argument could be made that the COSS plagiarizes the BSAS, even though the authors acknowledge the source of their scale items. According to Katrina Korb’s 2012 article on adopting or adapting psychometric instruments:

“Adapting an instrument requires more substantial changes than adopting an instrument. In this situation, the researcher follows the general design of another instrument but adds items, removes items, and/or substantially changes the content of each item. Because adapting an instrument is similar to developing a new instrument, it is important that a researcher understands the key principles of developing an instrument…When adapting an instrument, the researcher should report the same information in the Instruments section as when adopting the instrument, but should also include what changes were made to the instrument and why” (p.1).

Dr. Manchiraju and his colleagues didn’t add or remove any of the original seven items, and did not substantially change the content of any of the 28 items on which the BSAS was based. They simply added the word ‘online’ to each existing item. Given that the BSAS was specifically developed to take into account the different ways in which people now shop and to include both online and offline shopping, there doesn’t seem to be a good rationale for developing an online version of the BSAS. Even if there was a good rationale, the scale could have made reference to the Bergen Shopping Addiction Scale in the name of the ‘new’ instrument. In a 2005 book chapter ‘Selected Ethical Issues Relevant to Test Adaptations’ by Dr. Thomas Oakland (2005), he noted the following in relation to plagiarism and psychometric test development:

“Psychologists do not present portions of another’s work or data as their own, even if the other work or data source is cited … Plagiarism occurs commonly in test adaptation work (Oakland & Hu, 1991), especially when a test is adapted without the approval of its authors and publisher. Those who adapt a test by utilizing items from other tests without the approval of authors and publishers are likely to be violating ethical standards. This practice should not be condoned. Furthermore, this practice may violate laws in those countries that provide copyright protection to intellectual property. In terms of scale development, a measure that has the same original items with only one word added to each item (which only adds information on the context but does not change the meaning of the item) does not really constitute a new scale. They would find it really hard to demonstrate discriminant validity between the two measures”.

Again, according to Oakland’s description of plagiarism specifically in relation to the development of psychometric tests (rather than plagiarism more generally), the COSS appears to have plagiarized the BSAS particularly as Oakland makes specific reference to the adding of one word to each item (“In terms of scale development, a measure that has the same original items with only one word added to each item … does not really constitute a new scale”).

Still, it is important to point that I have no reason to think that this use of the BSAS was carried out maliciously. Indeed, it may well be that the only wrongdoing was lack of familiarity with the conventions of psychometric scale development. It may be that the authors took one line in our original Frontiers in Psychology paper too literally (“the BSAS may be freely used by researchers in their future studies in this field”). However, the purpose of this sentence was to give fellow researchers permission to use the validated scale in their own studies and to avoid the inconvenience of having to request permission to use the BSAS and then waiting for an answer. Another important aspect here is that the BSAS (which may be freely used) consists of seven items only, not 28. The seven BSAS items were extracted from an initial item pool in accordance with our intent to create a brief shopping addiction scale. Consequently, there exists only one version of BSAS, the 7-item version. Here, Dr. Manchiraju and his colleagues seem to have misinterpreted this when referring to a 28-item BSAS.

(Please note: This blog is adapted using material from the following paper: Griffiths, M.D., Andreassen, C.S., Pallesen, S., Bilder, R.M., Torsheim, T. Aboujaoude, E.N. (2016). When is a new scale not a new scale? The case of the Bergen Shopping Addiction Scale and the Compulsive Online Shopping Scale. International Journal of Mental Health and Addiction, 14, 1107-1110).

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Aboujaoude, E. (2014). Compulsive buying disorder: a review and update. Current Pharmaceutical Design, 20, 4021–4025.

Andreassen, C. S., Griffiths, M. D., Pallesen, S., Bilder, R. M., Torsheim, T., & Aboujaoude, E. (2015). The Bergen Shopping Addiction Scale: reliability and validity of a brief screening test. Frontiers in Psychology, 6, 1374. doi: 10.3389/fpsyg.2015.01374

Christo, G., Jones, S., Haylett, S., Stephenson, G., Lefever, R. M., & Lefever, R. (2003). The shorter PROMIS questionnaire: further validation of a tool for simultaneous assessment of multiple addictive behaviors. Addictive Behaviors, 28, 225–248.

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D., Andreassen, C.S., Pallesen, S., Bilder, R.M., Torsheim, T. Aboujaoude, E.N. (2016). When is a new scale not a new scale? The case of the Bergen Shopping Addiction Scale and the Compulsive Online Shopping Scale. International Journal of Mental Health and Addiction, 14, 1107-1110.

Korb, K. (2012). Adopting or adapting an instrument. Retrieved September 12, 2016, from: http://korbedpsych.com/R09aAdopt.html

Manchiraju, S., Sadachar, A., & Ridgway, J. L. (2016). The Compulsive Online Shopping Scale (COSS): Development and Validation Using Panel Data. International Journal of Mental Health and Addiction, 1-15. doi: 10.1007/s11469-016-9662-6.

Maraz, A., Eisinger, A., Hende, Urbán, R., Paksi, B., Kun, B., Kökönyei, G., Griffiths, M.D. & Demetrovics, Z. (2015). Measuring compulsive buying behaviour: Psychometric validity of three different scales and prevalence in the general population and in shopping centres. Psychiatry Research, 225, 326–334.

Maraz, A., Griffiths, M. D., & Demetrovics, Z. (2016). The prevalence of compulsive buying in non-clinical populations: A systematic review and meta-analysis. Addiction, 111, 408-419.

Oakland, T. (2005). Selected ethical issues relevant to test adaptations. In Hambleton, R., Spielberger, C. & Meranda, P. (Eds.). Adapting educational and psychological tests for cross-cultural assessment (pp. 65-92). Mahwah, NY: Erlbaum Press.

Oakland, T., & Hu, S. (1991). Professionals who administer tests with children and youth: An international survey. Journal of Psychoeducational Assessment, 9(2), 108-120.

Plagiarism.org (2016). What is plagiarism? Retrieved September 12, 2016, from: http://www.plagiarism.org/plagiarism-101/what-is-plagiarism

Ridgway, N., Kukar-Kinney, M., & Monroe, K. (2008). An expanded conceptualization and a new measure of compulsive buying. Journal of Consumer Research, 35, 622–639.

Weinstein, A., Maraz, A., Griffiths, M.D., Lejoyeux, M. & Demetrovics, Z. (2016). Shopping addiction and compulsive buying: Features and characteristics of addiction. In V. Preedy (Ed.), The Neuropathology Of Drug Addictions And Substance Misuse (Vol. 3). (pp. 993-1008). London: Academic Press.

To pee or not to pee? Another look at paraphilic behaviours

Strange, bizarre and unusual human sexual behaviour is a topic that fascinates many people (including myself of course). Last week I got a fair bit of international media coverage being interviewed about the allegations that Donald Trump hired women to perform ‘golden showers’ in front of him (i.e., watching someone urinate for sexual pleasure, typically referred to as urophilia). I was interviewed by the Daily Mirror (and many stories used my quotes in this particular story for other stories elsewhere). I was also commissioned to write an article on the topic for the International Business Times (and on which this blog is primarily based). The IBT wanted me to write an article on whether having a liking for strange and/or bizarre sexual preferences makes that individual more generally deviant.

Although the general public may view many of these behaviours as sexual perversions, those of us that study these behaviours prefer to call them paraphilias (from the Greek “beyond usual or typical love”). Regular readers of my blog will know I’ve written hundreds of articles on this topic. For those of you who have no idea what parahilias really are, they are uncommon types of sexual expression that may appear bizarre and/or socially unacceptable, and represent the extreme end of the sexual continuum. They are typically accompanied by intense sexual arousal to unconventional or non-sexual stimuli. Most adults are aware of paraphilic behaviour where individuals derive sexual pleasure and arousal from sex with children (paedophilia), the giving and/or receiving of pain (sadomasochism), dressing in the clothes of the opposite sex (transvestism), sex with animals (zoophilia), and sex with dead people (necrophilia).

However, there are literally hundreds of paraphilias that are not so well known or researched including sexual arousal from amputees (acrotomophilia), the desire to be an amputee (apotemnophilia), flatulence (eproctophilia), rubbing one’s genitals against another person without their consent (frotteurism), urine (urophilia), faeces (coprophilia), pretending to be a baby (infantilism), tight spaces (claustrophilia), restricted oxygen supply (hypoxyphilia), trees (dendrophilia), vomit (emetophilia), enemas (klismaphilia), sleep (somnophilia), statues (agalmatophilia), and food (sitophilia). [I’ve covered all of these (and more) in my blog so just click on the hyperlinks of you want to know more about the ones I’ve mentioned in this paragraph].

It is thought that paraphilias are rare and affect only a very small percentage of adults. It has been difficult for researchers to estimate the proportion of the population that experience unusual sexual behaviours because much of the scientific literature is based on case studies. However, there is general agreement among the psychiatric community that almost all paraphilias are male dominated (with at least 90% of all those affected being men).

One of the most asked questions in this field is the extent to which engaging in unusual sex acts is deviant? Psychologists and psychiatrists differentiate between paraphilias and paraphilic disorders. Most individuals with paraphilic interests are normal people with absolutely no mental health issues whatsoever. I personally believe that there is nothing wrong with any paraphilic act involving non-normative sex between two or more consenting adults. Those with paraphilic disorders are individuals where their sexual preferences cause the person distress or whose sexual behaviour results in personal harm, or risk of harm, to others. In short, unusual sexual behaviour by itself does not necessarily justify or require treatment.

The element of coercion is another key distinguishing characteristic of paraphilias. Some paraphilias (e.g., sadism, masochism, fetishism, hypoxyphilia, urophilia, coprophilia, klismaphilia) are engaged in alone, or include consensual adults who participate in, observe, or tolerate the particular paraphilic behaviour. These atypical non-coercive behaviours are considered by many psychiatrists to be relatively benign or harmless because there is no violation of anyone’s rights. Atypical coercive paraphilic behaviours are considered much more serious and almost always require treatment (e.g., paedophilia, exhibitionism [exposing one’s genitals to another person without their consent], frotteurism, necrophilia, zoophilia).

For me, informed consent between two or more adults is also critical and is where I draw the line between acceptable and unacceptable. This is why I would class sexual acts with children, animals, and dead people as morally and legally unacceptable. However, I would also class consensual sexual acts between adults that involve criminal activity as unacceptable. For instance, Armin Meiwes, the so-called ‘Rotenburg Cannibal’ gained worldwide notoriety for killing and eating a fellow German male victim (Bernd Jürgen Brande). Brande’s ultimate sexual desire was to be eaten (known as vorarephilia). Here was a case of a highly unusual sexual behaviour where there were two consenting adults but involved the killing of one human being by another.

Because paraphilias typically offer pleasure, many individuals affected do not seek psychological or psychiatric treatment as they live happily with their sexual preference. In short, there is little scientific evidence that unusual sexual behaviour makes you more deviant generally.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Abel, G. G., Becker, J. V., Cunningham-Rathner, J., Mittelman, M., & Rouleau, J. L. (1988). Multiple paraphilic diagnoses among sex offenders. Bulletin of the American Academy of Psychiatry and the Law, 16, 153-168.

Buhrich, N. (1983). The association of erotic piercing with homosexuality, sadomasochism, bondage, fetishism, and tattoos. Archives of Sexual Behavior, 12, 167-171.

Collacott, R.A. & Cooper, S.A. (1995). Urine fetish in a man with learning disabilities. Journal of Intellectual Disability Research, 39, 145-147.

Couture, L.A. (2000). Forced retention of bodily waste: The most overlooked form of child maltreatment. Located at: http://www.nospank.net/couture2.htm

Denson, R. (1982). Undinism: The fetishizaton of urine. Canadian Journal of Psychiatry, 27, 336–338.

Greenhill, R. & Griffiths, M.D. (2015). Compassion, dominance/submission, and curled lips: A thematic analysis of dacryphilic experience. International Journal of Sexual Health, 27, 337-350.

Greenhill, R. & Griffiths, M.D. (2016). Sexual interest as performance, intellect and pathological dilemma: A critical discursive case study of dacryphilia. Psychology and Sexuality, 7, 265-278.

Griffiths, M.D. (2013). Eproctophilia in a young adult male: A case study. Archives of Sexual Behavior, 42, 1383-1386.

Griffiths, M.D. (2012). The use of online methodologies in studying paraphilias: A review. Journal of Behavioral Addictions, 1, 143-150.

Griffiths, M.D. (2013). Bizarre sex. New Turn Magazine, 3, 49-51.

Massion-verniory, L. & Dumont, E. (1958). Four cases of undinism. Acta Neurol Psychiatr Belg. 58, 446-59.

Money, J. (1980). Love and Love Sickness: The Science of Sex, Gender Difference and Pair-bonding, John Hopkins University Press.

Mundinger-Klow, G. (2009). The Golden Fetish: Case Histories in the Wild World of Watersports. Paris: Olympia Press.

Skinner, L. J., & Becker, J. V. (1985). Sexual dysfunctions and deviations. In M. Hersen & S. M. Turner (Eds.), Diagnostic interviewing (pp. 211–239). New York: Plenum Press.

Spengler, A. (1977). Manifest sadomasochism of males: Results of an empirical study. Archives of Sexual Behavior, 6, 441–456.

Come undone: The strange case of the ‘ejaculate fetishist’

In a previous blog I briefly examined semen fetishes and the acts of ‘bukkake’ (most commonly seen in hard core pornographic films where a group of men all simultaneously ejaculate over a women or man), and ‘gokkun’ (where a man or woman consumes the semen of one or more men from a drinking receptacle, e.g., cups, glasses, beakers, etc.). In that article I noted that while there is a fair amount of (non-academic) literature about bukkake, references to semen fetishes appear to be rare with nothing published in academic journals.

However, since writing that article, a case study of a 39-year old man with an ‘ejaculate fetish’ was published in the Journal of Psychiatry by three Turkish medics (Dr. Safak Taktak, Dr. Mustafa Karakus and Dr. Salih Murat Eke) –  ‘The Man Whose Fetish Object is Ejaculate: A Case Report’. (In fact, Dr. Taktak has published a number of interesting case studies of paraphilic behaviour including shoe fetishism and paraphilias more generally [see ‘Further reading’ below]). Following a crime of molestation, the man had been arrested by Turkish police. (In fact, it turned out the man had already spent 10 years in prison for armed robbery when he was in his twenties and was released from jail when he was 31 years old).

The judicial authorities demanded that the man had to undergo a psychiatric assessment because one of his behaviours was the buying of ejaculate from young men that he would then smear on his genitals for sexual satisfaction. The act of smearing semen on his body had begun in prison when he would smear semen on bodily wounds and provided (presumably therapeutic) relief (as the prison did not provide medicine or cream for bodily injuries). The paper also claimed that the act of taking semen from each other and applying it to wounds and sores was commonplace in the prison he was at. Following his release from prison, he continued the habit and “became obsessed with it and he bought semen from different people on a monthly basis and spread it on the genital area”. Fifteen days prior to his psychiatric assessment, he was accused of molesting a 16-year old adolescent while trying to buy semen from him. The adolescent was reported as saying:

“A man held my arm and said that he had a job for me and he would give money if I do that job. I told him if I can do, I would do. He said he would be there [an hour and a half] later, and told me to find him. After he came, he told me that he buys human sperm, and asked me if I give him sperm, which surprised me a lot. Then he took three or four plastic bags out of the pocket of his jacket full of white things. He said these bags are the sperms that he bought from three or four kids. In exchange of sperm, he gave things like money, stereos and televisions”.

The adolescent’s father found out what had happened to his son and caught the man who had wanted his son’s semen. The man told the father that he wanted the semen to alleviate itchiness. During the psychiatric examination by the authors, the man was described as having mildly depressive emotions, natural psychomotor activity, sufficient cognitive function, and no delusions and/or hallucinations. He also had a history of alcohol and marijuana abuse (but since leaving prison he had stopped abusing these substances). Using the Minnesota Multiphasic Personality Inventory (MMPI) the authors said he had inconsistent behaviour, difficulty in controlling his impulses, was angry and short tempered, displayed antisocial behaviour, was sexually deviant, had obsessive sexual thoughts, was socially isolated, and had a negative self-perception. They also wrote that his psychological profile suggested an antisocial or schizoid personality disorder.

The paper also noted that his father has also been in prison on a number of occasions, and that his mother and her relatives looked after him and his younger brother, and that they had “a hard life” while growing up. From the age of 11-12 years old, he started masturbating regularly (sometimes a few times a day). During early adolescence he began engaging in frotteurism (rubbing his genitals up against other people) particularly on bus journeys. Now, as a man, he claimed he could not masturbate without the use of other people’s semen. He began buying other individuals’ semen when he got out of prison (“from 30 young men in exchanges for money”) and always carried semen with him wherever he went.

The authors noted that unlike most other fetishes, the sexualisation of semen as a fetish did not occur until he was in prison (i.e., adulthood rather than childhood or adolescence). I’m not sure why (based on the evidence in the paper) but they also speculated that the man’s semen fetish was used to “overcome low self-esteem and a sense of failure” and that the fetish behaviour “occurred from a trauma caused by the bad attitude of [his] parents at an early age, and [that] such negative experiences contributed to the emergence of fetish behavior”. The paper also claimed that: “He discovered the fetish object to deal with the anger for the negative events he faced when he was in prison for ten years for armed robbery. Impulse control is likely to be impaired because of the adverse conditions created by the prison”.

They also described the man’s semen fetish as a “mental illness” (in fact, the paper seemed to imply that all fetishes are mental illnesses which is clearly not the case as most non-normative sex is non-problematic for those engaging in such behaviour). However, by diagnosing the man has having a mental illness, it meant that he was not mentally competent enough to stand trial. The paper concluded that:

“In our case, the number of [victims] is few, but [our patient is] respectively harmless to the victims and not dangerous. He cannot control his urges and behaviors. For [these] kind of cases, generally, diminished criminal responsibility is decided but for this case, it was decided that he has no criminal responsibility”.

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

BBC News (2010). Israel jails man for ‘holy semen’ sex abuse. April 26. Located at: http://news.bbc.co.uk/1/hi/world/middle_east/8644637.stm

Kuro5hin (2002). A modern craving. August 5. Located at: http://www.kuro5hin.org/story/2002/8/5/71044/01543

Taktak, S., Karakus, M., & Eke, S. M. (2015). The man whose fetish object is ejaculate: A case report. Journal of Psychiatry, 18(3), 276.

Taktak, S., Karakus, M., Kaplan, A., & Eke, S.M. (2015) Shoe fetishism and kleptomania comorbidity: A case report. European Journal of Pharmaceutical and Medical Research, 2, 14-19.

Taktak, S., Yılmaz, E., Karamustafalıoglu, O., & Unsal, A. (2016). Characteristics of paraphilics in Turkey: A retrospective study – 20 years. International Journal of Law and Psychiatry, in press.

Wikipedia (2012). Bukkake. Located at: http://en.wikipedia.org/wiki/Bukkake

Wikipedia (2012). Gokkun. Located at: http://en.wikipedia.org/wiki/Gokkun

Ga(y)ming studies: The importance of sexuality in video gaming

Back in May 2014, hundreds of news outlets reported on Nintendo’s decision not to allow gamers to play as gay characters and form same-sex relationships in the life-simulation game Tomodachi Life. Understandably, there was disquiet and outrage from a number of quarters despite Nintendo’s statement that “Tomodachi Life was intended to be a whimsical and quirky game [and] not trying to provide social commentary”. Their statement at the time appeared to fan the flames rather than silence the critics.

I have been researching video game play for almost three decades and I’ve always found issues surrounding character formation, sexuality, and gender in gaming of great psychological interest. In one of our studies we found that a majority of gamers (57%) had gender-swapped their game character with female gamers (68%) being more likely to gender swap than male gamers (54%). We argued that gender swapping enabled gamers to play around and experiment with various aspects of their in-game character that are not so easy to do in real life. For others it was just fun to see if they felt any different playing a different gendered character. What makes our findings interesting is that in most instances, the gamers had the opportunity to choose the gender of their character and to develop other aspects of their character before they began to play. Choosing to gender swap may have had an effect on the gamers’ styles of play and interaction with other gamers. Whatever the reasons, it was clear from our research that the development of gamers’ online characters and avatars was important to them.

One of the reasons for the importance of online gaming identities may be because it subverts traditional parasocial interaction (PI). PI is a concept used by psychologists that has traditionally described one-sided, parasocial interpersonal relationships in situations where one individual knows a great deal about someone else, but where the other person knows little about the other (the most common being the relationship between celebrities and their fans).

A study led by Nicholas Bowman (and published in a 2012 issue of the journal Cyberpsychology, Behavior and Social Networking [CPBSN]) argued that the playing of video games challenges this concept “as the distance between game players and characters is greatly reduced, if not completely removed, in virtual environments.” The study claimed that online gaming encourages the “psychological merging of a player’s and a character’s mind” and is critical in the development of character attachment. In this context, the sexuality of a character for a player may be of fundamental psychological importance.

This appears to be confirmed in a paper by Melissa Lewis and colleagues (also published in CPBSN) who developed a scale to assess ‘character attachment’ (“the connection felt by a video game player toward a video game character”). They found that character attachment had a significant relationship with self-esteem, addiction, game enjoyment, and time spent playing games.

American researcher Dr. Adrienne Shaw has carried out a number of studies into lesbian, gay, bisexual, and transgender (LGBT) representation in video games from a cultural production perspective. She was one of the first academics in the gaming studies field to note that there was a relative lack of LGBT representation in video games. Other areas of the entertainment media (e.g., music, film, and television) appear to have much greater LGBT representation than in video games so it does beg the question of why the gaming industry appears to be behind in this respect. I recall writing a paper back in 1993 (in The Psychologist) where I argued that most video games at the time were designed by males for other males. This arguably alienated female gamers but eventually led to developers introducing strong female characters into video games (the most notable being Lara Croft in Tomb Raider). Maybe the appearance of LGBT characters and role models within games will increase over time but I’m not holding my breath.

In a more recent paper in a 2012 paper in the journal New Media and Society, Dr. Shaw claimed that the demand for minority representation in video games “often focuses on proving that members of marginalized groups are gamers” and that the gaming industry should focus on appealing to such players via targeted content. However, she argues that an individual’s identity as a gamer will intersect with “other identities like gender, race, and sexuality.” She then goes on to say that the negative connotations about being an online gamer may lead to such marginalized groups not wanting to engage in gaming. She concluded that “those invested in diversity in video games must focus their attention on the construction of the medium, and not the construction of the audience…[This] is necessary to develop arguments for representation in games that do not rely on marking groups as specific kinds of gaming markets via identifiers like gender, race, and sexuality.”

Nintendo’s decision not to allow gay relationships to form within Tomodachi Life was ill-judged, ill-informed, and outdated. Games in which identity content can be generated by its users needs to reflect the world in which the gamers’ live. In short, there should be no compromise when it comes to allowing gamers to choose their sexuality within the game.

(N.B. A version of this article first appeared in The Conversation)

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bowman, N. D., Schultheiss, D., & Schumann, C. (2012). “I’m attached, and I’m a good guy/gal!”: how character attachment influences pro-and anti-social motivations to play massively multiplayer online role-playing games. Cyberpsychology, Behavior, and Social Networking, 15(3), 169-174

Griffiths, M.D. (1993). Are computer games bad for children? The Psychologist: Bulletin of the British Psychological Society, 6, 401-407.

Griffiths, M.D., Arcelus, J. & Bouman, W.P. (2016). Video gaming and gender dysphoria: Some case study evidence. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 34(2), 59-66.

Hussain, Z., & Griffiths, M. D. (2008). Gender swapping and socializing in cyberspace: An exploratory study. CyberPsychology and Behavior, 11(1), 47-53.

Lewis, A. & Griffiths, M.D. (2011). Confronting gender representation: A qualitative study of the experiences and motivations of female casual-gamers. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 28, 245-272.

Lewis, M. L., Weber, R., & Bowman, N. D. (2008). “They may be pixels, but they’re MY pixels:” Developing a metric of character attachment in role-playing video games. CyberPsychology and Behavior, 11(4), 515-518.

McLean, L. & Griffiths, M.D. (2013). Female gamers: A thematic analysis of their gaming experience. International Journal of Games-Based Learning, 3(3), 54-71.

Shaw, A. (2009). Putting the gay in games cultural production and GLBT content in video games. Games and Culture, 4(3), 228-253.

Shaw, A. (2012). Do you identify as a gamer? Gender, race, sexuality, and gamer identity. New Media and Society, 14(1), 28-44.

Shaw, A. (2015). Gaming at the edge: Sexuality and gender at the margins of gamer culture. Minnesota: University of Minnesota Press.

Stars in their eyes: Another look at Celebrity Worship Syndrome

Last week I did a number of media interviews about Celebrity Worship Syndrome (CWS) including the Metro newspaper (‘From Beyonce to Elvis, here’s the ugly truth about why we worship celebrities’) and the International Business Times (‘Crazy about Kylie Jenner? Professor of Behavioural Addiction explains celebrity obsession’). I also wrote an article for the Huffington Post. The ‘hook’ for all these stories was the DVD release of the film Kill The King (also known by the title Shangri La Suite) which tells the story of two 20-year old damaged lovers – Jack and Karen (played by Luke Grimes and Emily Browning) – who head to Los Angeles to kill rock ‘n’ roll legend Elvis Presley in the summer of 1974. While Jack’s obsession with Elvis is somewhat extreme, over the last two decades there has been an increasing amount of research into CWS.

CWS has been described as an obsessive–addictive disorder where an individual becomes overly involved and interested (in short, completely obsessed) with the details of the personal life of a celebrity. Any person who is ‘in the public eye’ can be the object of a person’s obsession (e.g., authors, politicians, journalists), but research and criminal prosecutions suggest they are more likely to be someone from the world of television, film and/or pop music. Research suggests that CWS exists and that according to Dr. John Maltby and his colleagues (see ‘Further reading’ below) there are three independent dimensions of celebrity worship. These are on a continuum and named (i) entertainment-social, (ii) intense-personal, and (iii) borderline pathological.

• The entertainment-social dimension relates to attitudes where individuals are attracted to a celebrity because of their perceived ability to entertain and to become a social focus of conversation with likeminded others.
• The intense-personal dimension relates to individuals that have intensive and compulsive feelings about a celebrity.
• The borderline-pathological dimension relates to individuals who display uncontrollable behaviours and fantasies relating to a celebrity.

Among adults, their research has shown that there is a correlation between the pathological aspects of CWS and poor mental health such as high anxiety, more depression, high stress levels, increased illness, and poorer body image. Among teenage females there is a relationship between intense-personal celebrity worship and body image (basically, teenage girls who identify with celebrities have much poorer body image compared to other groups). In addition, most celebrity-obsessed individuals often suffer high levels of dissociation and fantasy-proneness. Maltby’s research suggests about 1% of his participants have obsessional tendencies towards celebrities.

Research has also shown that worshipping celebrities can have both positive and negative consequences. People who worship celebrities for entertainment and social reasons have been found to be more optimistic, outgoing, and happy. Those who worship celebrities for personal reasons have been found to be more obsessive, more depressed, more anxious, more solitary, more impulsive, more anti-social and more troublesome. My own thoughts on CWS and celebrity culture are provided below and are from the interviews I did with the Metro and the International Business Times (IBT).

IBT: In a world filled with Kardashians, social media and vast consumerism, why do you think people are more obsessed with celebrities than ever?

MG: The first thing I would say is that most people are not obsessed with celebrities but there are probably a lot more people who are obsessed compared to a couple of decades ago (although this is speculation on my part as no research has ever examined the prevalence of celebrity obsession among a nationally representative sample). One study did estimate about 1% of their sample being obsessed with celebrities but there is no comparative study prior to that. However, I do think that the numbers of people who have celebrity obsessions has increased over the last 20 years and much of this is most likely due to the rise of celebrities using social media (and the fact that celebrities can now interact – if they want – hour by hour with their fan base) and the increase in general media coverage surrounding celebrity and celebrity lives (including a large increase in reality TV starring celebrities and an increase in the number of celebrity gossip magazines). These types of media and social media can give rise to what we psychologists call parasocial relationships. With respect to celebrities, parasocial relationships are one-sided relationships, where fans express interest, time, money, and/or emotion in and/or on the celebrity (while the celebrity is totally unaware of the fan in any singular or specific sense).

IBT: Do you know what happens in the mind when we form an obsession or infatuation with some things? 

MG: Celebrity infatuations are nothing to particularly worry about because they tend to be intense but relatively short-lived admiration for the person. Celebrity obsessions can be of a lot more concern. At their simplest level, a celebrity obsession is when someone constantly thinks about a particular celebrity in a way that most people would describe as abnormal. This can be to the point where the obsession conflicts with most other things in the individual’s life including job or education, other relationships, and other hobbies. A person’s whole life can revolve around the celebrity and such individuals can end up spending way beyond their disposable income by buying their merchandise (CDs, DVDs, books, perfumes, clothing lines, etc.) and/or seeing them live on stage (singing, acting, etc.). There is no single explanation as to why someone might develop a celebrity obsession but many appear to start with a sexual attraction to the celebrity in question and have fantasies of what they would do if they met the object of their desire. Research has shown that there is a correlation between the pathological aspects of celebrity worship and poor mental health such as high anxiety, more depression, high stress levels, increased illness, and poorer body image. Among teenage females there is a relationship between intense-personal celebrity worship and body image (basically, teenage girls who identify with celebrities have much poorer body image compared to other groups). In addition, most celebrity-obsessed individuals often suffer high levels of dissociation and fantasy-proneness.

IBT: What does it have to take about a ‘celebrity’ for people to become obsessed?

MG: At a micro-level, any person who is ‘in the public eye’ can be the object of a person’s obsession (e.g., authors, politicians, journalists), but research and criminal prosecutions suggest they are more likely to be someone from the world of television, film and/or pop music. This is most likely because such celebrities tend to be more popular and have bigger followings in the public eye in media and on social media. At a micro-level, we are all individuals it could be something very idiosyncratic but given that the little research carried out tends to report that celebrity worshippers are sexually attracted to their celebrity of choice, then being good looking (at least in the eyes of the beholder) appears to be a common denominator.

IBT: How do you think today’s modern obsession with celebrity influenced and resounded throughout Kill the King?

MG: One of Jack’s reasons for being sent to a rehab centre – in addition to a drug addiction problem – is because of his “increasingly abnormal obsession” with Elvis Presley. While Jack’s obsession with Elvis is somewhat extreme and arguably a type of ‘Celebrity Worship Syndrome’, his character doesn’t seem to overlap too much with modern day celebrity worshippers. Jack’s character is more akin to celebrity stalkers or celebrity assassins (like John Lennon’s killer Mark Chapman) than the archetypal young female totally obsessed and besotted with their favourite pop star or actor. Given that Kill The King was set in 1974 and celebrity obsession (and Celebrity Worship Syndrome) is a more modern day phenomenon, I wouldn’t have expected that much overlap anyway.

Metro: Should we be worried about this kind of social media ‘bond’, seeing as icons like John Lennon were assassinated by fans who became obsessed with them?

MG: The chances of those things happening are few and far between. If someone is absolutely hooked on the idea of killing a celebrity, they’ll go and do it. I don’t think it’s to do with the rise of the mass media or anything like that. Most research says fandom is actually good for people. It gives them a hobby. Fans talk to other fans. It brings us together, and it can be life-affirming. I’m a massive, massive David Bowie fan. I’m a record collector, too and I’m probably more on the obsessive side than most people. But I don’t think I’m a worse person for that.

Metro: So what’s the difference between you and someone who spends thousands and thousands of pounds on plastic surgery to look more like their idol?

MG: Those are the real extreme cases. The good news is that recent research has shown that less than one per cent of people are really unhealthily obsessed with stars. And of those people, most are not going to do things that have negative effects on their life. In my opinion, the difference between a healthy enthusiasm and an unhealthy obsession is that enthusiasm adds to life, and addictions or obsessions take away from it. For most people, even those who have a compulsive element to their fandom like myself, it doesn’t have a negative effect on their quality of life. It’s probably better to buy records and memorabilia than designer handbags. Sometimes it’s not just about money, it’s about the time you spend as well. For one person, an obsession can be fine, and for another it can be very problematic. If a fan works in Tesco and they’re following their hero around the country, watching them night after night on tour and buying merchandise, they just don’t have the disposable income to do it. I could do that, thanks to my salary, but I can’t afford the time.

Metro: Is there a link between someone’s social background and their preference for celebrity culture?

MG: I don’t know the scientific link there, but I wouldn’t be surprised if the lower the socio-economic class you’re in the more likely you are to be involved and like celebrity culture. ‘Gogglebox’ stars, for instance. The middle class, well-to-do people like current affairs, news and politics and those who are less well-off are probably more interested in EastEnders and things like that.

Metro: Are there any psychological issues that lead to celebrity worship?

MG: Those with celebrity worship syndrome tend to have worse mental health. They’re more likely to be anxious, depressed, to have high stress levels, increased bouts of illness and a poor body image. But it’s a case of the chicken or the egg, because these people might self-medicate through these parasocial relationships with celebs they’ll never even meet. 

Metro: What are the effects of celebrity culture? Particularly for young people?

MG: We know that young people are not as engaged with politics. They just don’t trust politicians, and it’s linked to the rise of social media. Celebrities have more pull, and followers, than [British Prime Minister] Theresa May or [leader of the Labour Party] Jeremy Corbyn will ever have. I’m not in a position to say whether people should be more interested in X or Y. Certain things in life make people feel good. As humans we seek out things that get us high, aroused, excited –  or we seek out things which tranquilise and numb us. Celebrities tend to give us a thrill. 

Metro: Are celebrities vulnerable themselves?

MG: I certainly wouldn’t like to be in a position where cameras are waiting outside my house. Stardom can bring positive things, but also a lot of unexpected negatives too. We have to remember at the end of the day that celebrities are just human beings, with all the same emotional foibles and weaknesses we have – and sometimes they’re magnified times a hundred because of the pressure and stress of the spotlight. And the internet, too. It’s no wonder some of them fall prey to serious addictions. 

Metro: People like Amy Winehouse? She’s the most recent example I can think of.

MG: Before she died, Amy Winehouse had got to that stage where she was very famous, and she was earning a lot of money. And that meant she was surrounded by sycophants and ‘yes’ people. Those kinds of people say things they think you want to hear, and they’re not necessarily looking out for you. Amy was surrounded by people thinking about their own wages and careers. No, it’s not a surprise when these things happen, and people could see it coming. Like with Kurt Cobain’s death. Amy didn’t get the help she needed. We can say that in hindsight.’

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

BBC News (2003). Worshipping celebrities ‘brings success. August 13. Located at: http://news.bbc.co.uk/1/hi/health/3147343.stm

Chapman, J. (2003). Do you worship the celebs? Located at: http://www.dailymail.co.uk/tvshowbiz/article-176598/Do-worship-celebs.html

Griffiths, M.D. (2016). Does ‘Celebrity Worship Syndrome’ really exist? Huffington Post, November 18. Located at: http://www.huffingtonpost.co.uk/dr-mark-griffiths/does-celebrity-worship-sy_b_13012170.html

McCutcheon, L.E., Lange, R., & Houran, J. (2002). Conceptualization and measurement of celebrity worship. British Journal of Psychology, 93, 67-87.

Maltby, J., Houran, M.A., & McCutcheon, L.E. (2003). A Clinical Interpretation of Attitudes and Behaviors Associated with Celebrity Worship. Journal of Nervous and Mental Disease, 191, 25-29.

Maltby, J., Houran, J., Ashe, D., & McCutcheon, L.E. (2001). The self-reported psychological well-being of celebrity worshippers. North American Journal of Psychology, 3, 441-452.

Maltby, J., Day, L., McCutcheon, L.E., Gillett, R., Houran, J., & Ashe, D. (2004). Celebrity Worship using an adaptational-continuum model of personality and coping. British Journal of Psychology. 95, 411-428.

Maltby, J., Giles, D., Barber, L. & McCutcheon, L.E. (2005). Intense-personal Celebrity Worship and Body Image: Evidence of a link among female adolescents. British Journal of Health Psychology, 10, 17-32.

Maltby, J., Day, L., McCutcheon, L.E,. Gilett, R., Houran, J. & Ashe, D.D. (2004), ‘Personality and Coping: A Context for Examining Celebrity Worship and Mental Health. British Journal of Psychology, 95, 411-428.

Maltby, J., Day, L., McCutcheon, L.E., Houran, J. & Ashe, D. (2006). Extreme celebrity worship, fantasy proneness and dissociation: Developing the measurement and understanding of celebrity worship within a clinical personality context. Personality and Individual Differences, 40, 273-283.

Wikipedia (2012). Celebrity Worship Syndrome. Located at: http://en.wikipedia.org/wiki/Celebrity_Worship_Syndrome

More cock tales: A brief look at genital drug injection

The idea for this blog was initiated when I read a snippet in The Fortean Times about a 34-year old man from New York who injected cocaine into his penis and ended up with gangrene and further medical complications. It turns out that this report was based on a letter published in a 1988 issue of the Journal of the American Medical Association by Drs. John Mahler, Samuel Perry and Bruce Sutton (and subsequently reported in a June 1988 issue of the New York Times).

The man in question came in for medical treatment following three days of priapism (i.e., prolonged and painful penile erection) and paraphimosis (i.e., foreskin in uncircumcised males can no longer be pulled over the tip of the penis). To enhance his sexual performance, he had administered cocaine directly into his urethra. After three days, both the priapism and the paraphimosis “spontaneously resolved”. However, the blood that had caused the priapism then leaked to other areas of his body over the next 12 hours (including his feet, hands, genitals, chest, and back). To stop the spread of gangrene, the medics had to partially amputate both of his legs (above the knee), and nine of his fingers. Following this, his penis also developed gangrene and fell off by itself while he was taking a bath. The exact reason for the spread of gangrene was unknown but sexologists (such as Professor John Money) speculated that it may have been because of impure cocaine being used.

When I started to search for medical literature on the topic of injecting drugs directly into male genitalia I was surprised to find quite a few papers on the topic (but unsurprisingly all case study reports given the rarity of such behaviour). One of the earliest I located was one from 1986 in the Journal of Urology by Dr. W. Somers and Dr. F. Lowe. They reported the cases of four heroin abusers with localized gangrene of the genitalia, although only one of these had actually injected heroin directly into his genitalia, in this case his scrotum and perineum (the area between the anus and the scrotum). This latter case developed more severe gangrene and was described as a “more lethal entity” than the gangrene in the other three heroin users’ genitalia.

Later, in a 1999 issue of the American Journal of Forensic Medicine and Pathology, Dr. Charles Winek and his colleagues reported the rare case of a fatality due to a male injecting heroin directly into his penis. The cause of death was determined to be due to heroin and ethanol intoxication. More recently, in a 2005 issue of the Medical Journal of the Iranian Red Crescent, Dr. Z. Ahmadinezhad and his colleagues reported a case of heroin-associated priapism. In their paper, they reported the case of a 32-year old man who was admitted to hospital following pain and swelling after injecting heroin into his penis two weeks earlier. Unfortunately, the person left the hospital following initial consultation and never came back so the outcome of the treatment provided is unknown.

In a 2011 issue of the Internet Journal of Surgery, Dr. I. Malek and colleagues reported the case of a 35-year old long-term intra-venous drug user who injected citric acid laced with heroin into the dorsal vein of his penis. This caused worsening pain and his penis developed gangrene. Over the (non-operative) treatment period, the man’s pain became worse and he had trouble urinating (so he was catheterised). Eventually, the treatment with antibiotics led to a good recovery at three-month follow-up.

Another unusual case was reported by Dr. Francois Brecheteau and his colleagues in a 2013 issue of the Journal of Sexual Medicine. They reported the successful treatment of a 26-year old male drug addict who had injected the opiate drug buprenorphine directly into the dorsal vein of his penis. After unsuccessful antibiotic treatment on its own, they then used a number of simultaneous treatments including heparin, anti-platelet drugs, antibiotics, and hyperbaric oxygen therapy, the man made a successful recovery.

Returning to cocaine rather than opiates, a case report by Dr. V. B. Mouraviev and his colleagues in a 2002 issue of the Scandinavian Journal of Urology and Nephrology reported the case of a 31-year-old Canadian man who had injected cocaine directly into his penis. He turned up at the emergency having endured penile pain for 22 hours following the injection. Twelve hours after injecting the cocaine, the man noticed swelling and bruising starting to appear on the right side of his penis where he had made the injection. As a consequence, his penis developed gangrene (“localized death and decomposition of body tissue, resulting from obstructed circulation or bacterial infection”) most probably from bacterial infection via the injection. He had to undergo reconstructive skin graft surgery and was given antibiotics. In this particular case, the treatment was successful. Other similar reports of medical complications (usually gangrene) following the injection of cocaine into the penis have since appeared in a number of papers including a 2013 paper by Dr. Fahd Khan and colleagues in the Journal of Sexual Medicine.

Cocaine and heroin aren’t the only recreational drugs to have been injected into male genitalia. A paper in a 2014 issue of Urology Case Reports by Dr. Cindy Garcia and her colleagues reported the case of a 45-year-old male intravenous drug user who developed an abscess after he injected amphetamine into his penis. The man chose a penile vein after being unable to find any other suitable peripheral vein. He was treated with intravenous antibiotics and had to have his abscess drained via a penile incision. Within a month he had been all but successfully treated. In their paper (which also included a review of the literature on penile abscesses), they concluded that:

“Penile abscesses are an uncommon condition. There are multiple aetiologies of penile abscesses, including penile injection, penile trauma, and disseminated infection. Penile abscesses might also occur in the absence of an underlying cause. The treatment of penile abscesses should depend on the extent of infection and the cause of the abscess. Most cases of penile abscess necessitate surgical debridement [removal of dead or infected tissue]”.

Similarly, in a 2015 issue of Case Reports in Urology, Dr. Thomas W. Gaither and his colleagues reported two cases of men who had injected metamphetamine into their penis. The first case was a 47-year-old gay man who had a history of “methamphetamine use, prior penile abscesses, urethral foreign body insertions, HIV, hepatitis C, and diabetes mellitus”. He attended the hospital emergency department suffering from severe penile pain and scrotal swelling having injected methamphetamine into the shaft of his penis a few days before. On the same day that he went to the emergency department he was immediately taken into the operating room where an incision was made in his penis, and the abscess was drained of its “purulent foul-smelling fluid” and washed out with saline solution. The second case was a 33-year-old heterosexual male with no previous medical history (apart from a history of depression) turned up at the hospital emergency department with acute penile pain, a day after he had injected methamphetamine directly into his penis. Again, he was immediately taken to the operating room where his penile abscess was drained after an incision. Neither of the cases involved any penile gangrene and both men were also given antibiotics to treat the infected area. In both cases, the authors speculated that the abscesses formed as a result of direct contamination from repeated penile injections.

Finally, Dr. Lucas Prado and his colleagues reported a case study in a 2012 issue of the Journal of Andrology of a 31-year-old man who was admitted to the emergency department after he had injected 10ml of methadone into his penis in an attempt to commit suicide (the first case of penile methadone injection). The man had a 15-year history of drug abuse over the past year and had attempted a drug-related suicide three times. This particular suicide attempt led to acute liver and renal failure as well as erectile dysfunction. Although the man survived, ten months after the suicide attempt, the man still had complete erectile dysfunction.

Although I didn’t do a systematic review of all the literature, it is clear that the injection of recreational drugs directly into male genitalia appears to be relatively rare although all the literature I located was based on those who end up seeking treatment for when things go horribly wrong. There could of course be many hundreds or thousands of people out there that have engaged in such practices but don’t end up in a hospital emergency ward. However, I certainly wouldn’t recommend such a practice to anyone.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ahmadinezhad, Z., Jabbari, B.H., Saberi, H., Khaledi, F., & Safavi, F. (2005). Heroin associated priapism. Medical Journal of the Iranian Red Crescent, 7(3), 67-68.

Brecheteau, F., Grison, P., Abraham, P., Lebdai, S., Kemgang, S., Souday, V., … & Bigot, P. (2013). Successful medical treatment of glans ischemia after voluntary buprenorphine injection. Journal of Sexual Medicine, 10(11), 2866-2870.

Cunningham, D.L., & Persky, L. (1989). Penile ecthyma gangrenosum: Complication of drug addiction. Urology, 34(2), 109-110.

Gaither, T.W., Osterberg, E.C., Awad, M. A., & Breyer, B.N. (2015). Surgical intervention for penile methamphetamine injections. Case Reports in Urology, 467683, doi.org/10.1155/2015/467683

Garcia, C., Winter, M., Chalasani, V., & Dean, T. (2014). Penile abscess: a case report and review of literature. Urology Case Reports, 2(1), 17-19.

Khan, F., Mukhtar, S., Anjum, F., Tripathi, B., Sriprasad, S., Dickinson, I. K., & Madaan, S. (2013). Fournier’s gangrene associated with intradermal injection of cocaine. Journal of Sexual Medicine, 10(4), 1184-1186.

Malek, I., Parmar, C., McCabe, J., & Irwin, P. (2011). Successful non-operative management of penile wet gangrene following self-injection of heroin in dorsal vein of penis. Internet Journal of Surgery, 11(1), 1-3.

Mireku-Boateng, A.O., & Tasie, B. (2001). Priapism associated with intracavernosal injection of cocaine. Urologia Internationalis, 67(1), 109-110.

Mouraviev, V. B., Pautler, S. E., & Hayman, W. P. (2002). Fournier’s gangrene following penile self-injection with cocaine. Scandinavian Journal of Urology and Nephrology, 36(4), 317-318.

Munarriz, R., Hwang, J., Goldstein, I., Traish, A.M., & Kim, N.N. (2003). Cocaine and ephedrine-induced priapism: case reports and investigation of potential adrenergic mechanisms. Urology, 62(1), 187-192.

Prado, L. G., Huber, J., Huber, C. G., Mogler, C., Ehrenheim, J., Nyarangi‐Dix, J., … & Hohenfellner, M. (2012). Penile methadone injection in suicidal intent: Life‐threatening and fatal for erectile function. Journal of Andrology, 33(5), 801-804.

Singh, V., Sinha, R. J., & Sankhwar, S. N. (2011). Penile gangrene: A devastating and lethal entity. Saudi Journal of Kidney Diseases and Transplantation, 22(2), 359.

Somers, W.J., & Lowe, F.C. (1986). Localized gangrene of the scrotum and penis: A complication of heroin injection into the femoral vessels. Journal of Urology, 136, 111-113.

Winek, C. L., Wahba, W. W., & Rozin, L. (1999). Heroin fatality due to penile injection. American Journal of Forensic Medicine and Pathology, 20(1), 90-92.

Specific limb: A brief look at ‘restless legs syndrome’

Those that know me well often comment that I have a general inability to sit still and that I am a ‘fidget’. (This is not necessarily a bad thing and in fact there are some positives to fidgeting that I outlined in a previous blog on bad behaviours that are sometimes good for you). There is certainly some truth to the observation that I fidget but sometimes the fidgeting is out of my control. Every few weeks my right lower leg appears to take on a life of its own and I will get strange (uncomfortable) sensations (such as tingling, itching, and aching, and occasionally cramp-like feelings) that force me to move my right leg and foot around. It only happens when I am in a resting and relaxing state and usually lasts about 30 minutes (but can occasionally last much longer). On occasions it disrupts my work and sleep but I find that just getting up and moving around is sometimes enough to alleviate the uncomfortable feelings.

A few years ago I Googled my ‘symptoms’ and was surprised to find that I am not the only person who appears to experience such effects and that there is a whole medical literature on what has been termed ‘restless legs syndrome’ although in my case it would be in a singular rather than plural form). I’ve had the condition for about 15 years now and it may be related to some of the medication I take for an unrelated chronic degenerative health condition that I have. According to the Wikipedia entry on restless legs syndrome (RLS):

“The first known medical description of RLS was by Sir Thomas Willis in 1672. Willis emphasized the sleep disruption and limb movements experienced by people with RLS…The term ‘fidgets in the legs’ has also been used as early as the early nineteenth century. Subsequently, other descriptions of RLS were published, including those by Francois Boissier de Sauvages (1763), Magnus Huss (1849), Theodur Wittmaack (1861), George Miller Beard (1880), Georges Gilles de la Tourette (1898), Hermann Oppenheim (1923) and Frederick Gerard Allison (1943). However, it was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom (1907–1977) provided a detailed and comprehensive report of this condition in his doctoral thesis, Restless legs: clinical study of hitherto overlooked disease. Ekbom coined the term “restless legs” and continued work on this disorder throughout his career. He described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy. Ekbom’s work was largely ignored until it was rediscovered by Arthur S. Walters and Wayne A. Hening in the 1980s. Subsequent landmark publications include 1995 and 2003 papers, which revised and updated the diagnostic criteria”.

As well as being referred to as RLS, it is sometimes referred to as Willis-Ekbom Disease or Willis-Ekbom Syndrome. Since being ‘rediscovered’ in the 1980s, there have been a lot of scientific papers published on the phenomenon although many of these are medical case studies (I don’t think my own experiences are extreme enough or strong enough to appear in any medical textbook. The Wikipedia entry on RLS provides a good summary of what is known medically and empirically:

“Restless legs syndrome (RLS) is a disorder that causes a strong urge to move one’s legs. There is often an unpleasant feeling in the legs that improves somewhat with moving them. Occasionally the arms may also be affected. The feelings generally happen when at rest and therefore can make it hard to sleep. Due to the disturbance in sleep, people with RLS may have daytime sleepiness, low energy, irritability, and a depressed mood. Additionally, many have limb twitching during sleep. Risk factors for RLS include low iron levels, kidney failure, Parkinson’s disease, diabetes, rheumatoid arthritis, and pregnancy. A number of medications may also trigger the disorder including antidepressants, antipsychotics, antihistamines, and calcium channel blockers. There are two main types. One is early onset RLS which starts before age 45 [years], runs in families and worsens over time. The other is late onset RLS which begins after age 45 [years], starts suddenly, and does not worsen. Diagnosis is generally based on a person’s symptoms after ruling out other potential causes… Females are more commonly affected than males and it becomes more common with age…Some doctors express the view that the incidence of restless leg syndrome is exaggerated by manufacturers of drugs used to treat it. Others believe it is an under-recognized and undertreated disorder…An association has been observed between attention deficit hyperactivity disorder (ADHD) and RLS or periodic limb movement disorder. Both conditions appear to have links to dysfunctions related to the neurotransmitter dopamine, and common medications for both conditions among other systems, affect dopamine levels in the brain”.

According to a review by Dr. Richard Allen and Dr. Christopher Earley in the Journal of Clinical Neurophysiology, RLS affects 2.5-15% of the US population. In another review on sleep disorder in the journal American Family Physician, Dr. Kannan Ramar and Dr. Eric Olson reported that RLS is typically characterized by four essential features: These are:

“(1) the intense urge to move the legs, usually accompanied or caused by uncomfortable sensations (e.g., “creepy crawly,” aching) in the legs; (2) symptoms that begin or worsen during periods of rest or inactivity; (3) symptoms that are partially or totally relieved by movements such as walking or stretching; and (4) symptoms that are worse or only occur in the evening or at night”.

Various online articles and papers report a variety of potential treatments based on the notion that RLS might be caused by a dopamine imbalance in the body. Some medics advise a regular sleep routine (such as that advised for those with insomnia), and cutting out the drinking of alcohol and the smoking of cigarettes. Pharmacological treatments include the use of drugs that are also used in the treatment of Parkinson’s disease such as L-DOPA and pramipexole, and the use of magnesium sulphate therapy (as reported in a 2006 paper in the Journal of Clinical Sleep Medicine – magnesium is known to be a natural muscle relaxant). In a 2011 issue of the journal Sleep Medicine, In an online article about RLS, Dr Michael Platt, author of the 2014 book Adrenalin Dominance, claims that RLS sufferers can be treated using a progesterone cream:

“Excess adrenalin during the night can cause restless leg syndrome. People often have associated symptoms also resulting from elevated adrenalin, such as teeth grinding, the need to urinate, and tossing and turning, and they often awaken in the morning with low back pain. Characteristically, RLS patients have an excess of adrenaline, may toss and turn all night, be quick to anger, might be workaholics, will usually have fibromyalgia (aches and pains – low back, side of the hips, and grind their teeth), they might drink too much, and will be hypoglycemic (sleepy between 3-4 p.m. or when in a car), and so on. There is an associated over-production of insulin and an under-production of progesterone…[By using a progesterone cream] I have had 100% success with eliminating RLS by getting hormones into balance, often within the first week. Patients feel more relaxed, they can sleep at night, rage disappears, and they can focus more easily”.

Dr. Luis Marin and his colleagues reported a different treatment for RLS altogether. They reported the case of a 41-year-old male RLS sufferer who after being on medication for RLS discovered his own solution – having sex. Following sex, the man reported that all RLS symptoms would disappear. Marin and colleagues speculated that the release of dopamine following orgasm might alleviate RLS symptoms. This appears to be a reasonable speculation given the findings of research published in the Journal of Neuroscience by Dr. Gert Holstege and his colleagues who examined brain activation at the point of ejaculation. In their paper they reported the similarity between ejaculation and using heroin in terms of brain activation:

“We used positron emission tomography to measure increases in regional cerebral blood flow during ejaculation compared with sexual stimulation in heterosexual male volunteers. Manual penile stimulation was performed by the volunteer’s female partner. Primary activation was found in the mesodiencephalic transition zone, including the ventral tegmental area, which is involved in a wide variety of rewarding behaviors. Parallels are drawn between ejaculation and heroin rush”.

It could well be that the increase in dopamine following ejaculation acts in a similar way to the medications that are given to RLS sufferers. Of all the treatments for RLS that I have read about, I think I know which one I would prefer!

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Allen, R.P., & Earley, C.J. (2001). Restless legs syndrome: A review of clinical and pathophysiologic features. Journal of Clinical Neurophysiology, 18(2), 128-147.

Bartell S1, Zallek S. Intravenous magnesium sulfate may relieve restless legs syndrome in pregnancy. Journal of Clinical Sleep Medicine, 15, 187-188.

Chaudhuri, K.R., Appiah-Kubi, L.S., & Trenkwalder, C. (2001). Restless legs syndrome. Journal of Neurology, Neurosurgery & Psychiatry, 71(2), 143-146.

Ekbom, K., & Ulfberg, J. (2009). Restless legs syndrome. Journal of Internal Medicine, 266(5), 419-431.

Holstege, G., Georgiadis, J. R., Paans, A. M., Meiners, L. C., van der Graaf, F. H., & Reinders, A. S. (2003). Brain activation during human male ejaculation. Journal of Neuroscience, 23(27), 9185-9193

Leschziner, G., & Gringras, P. (2012). Restless legs syndrome. British Medical Journal, 344, e3056.

Marin, L.F., Felicio, A.C., & Prado, G.F. (2011). Sexual intercourse and masturbation: Potential relief factors for restless legs syndrome? Sleep Medicine, 12(4), 422.

Ondo, W. G. (2009). Restless legs syndrome. Neurologic Clinics, 27(3), 779-799.

Ramar, K; Olson, EJ (Aug 15, 2013). Management of common sleep disorders. American Family Physician, 88, 231–238.

Satija, P., & Ondo, W. G. (2008). Restless legs syndrome. CNS Drugs, 22(6), 497-518.

Stitches brew: A brief look at self-harm lip sewing

In previous blogs I have examined both self-harming behaviour (such as cutting off one’s own genitals, removing one’s own eye, removing one’s own ear, self-asphyxial risk taking in adolescence, and religious self-flagellation) and extreme body modification. One area where these two areas intersect is lip sewing. According to the Wikipedia entry on lip sewing:

“Lip sewing or mouth sewing, the operation of stitching together human lips, is a form of body modification. It may be carried out for aesthetic or religious reasons; as a play piercing practice; or as a form of protest. Sutures are often used to stitch the lips together, though sometimes piercings are made with needle blades or cannulas and monofilament is threaded through the holes. There is usually a fair amount of swelling, but permanent scarring is rare. Lip sewing may be done for aesthetic reasons, or to aid meditation by helping the mind to focus by removing the temptation to speak. BMEzine, an online magazine for body modification culture, published an article about a 23-year-old film student Inza, whose quest for body modifications was very varied. She spoke about her experiences with lip sewing as a form of play piercing”.

My reason for writing this blog was prompted by a case study published by Dr. Safak Taktak and his colleagues in the journal Health Care Current Reviews. (I ought to add that I have read a number of papers by Taktak and his colleagues as they have reported some interesting other interesting case studies including those on shoe fetishism, semen fetishism, and fetishes more generally – see ‘Further reading’ below). In this particular paper, they reported the case of a male prisoner who had continually sewed his lips together. Although they were aware of cases of sewing lips together as a form of protest, they claimed that there had never been any case reported in the medical literature.

The case report involved a male 37-year old Turkish (imprisoned) farmer, father of two children, with only basic education. After sewing his lips together, the man was brought into the hospital by the police, along with a handwritten note that read: “My jinns imposed speech ban to me and they made me sew my lips unwillingly. Otherwise, they threaten me with my children. I want to meet a psychiatrist urgently”. (Jinns I later learned are – in Arabian and Muslim mythology – intelligent spirits of lower rank than the angels, able to appear in human and animal forms and are able to possess humans). Not only were his lips sown together with black thread but he had also sewn both of his ears to the side of his head (these are also photographed in the paper and you can download the report free from here). This was actually the fourth time the man had sewed his lips together (but the first that he had sewn his ears). Each time, the doctors took out the stitches and dressed the wounds. The authors examined previous documentation about the man and reported that the man had been in prison for four years after injuring someone (no details were provided) and had been diagnosed with both anxiety disorder and anti-social personality disorder. On a prison ward comprising ten other prisoners, he had attempted suicide when trying to hang himself (in fact, you can clearly see the marks on his neck in the paper’s photographs). The authors reported that:

[The man] had blunted affect. He wasn’t able to stay in the [prison] ward because of the directive voices in his head. He declared he needed to stay in the ward alone. He heard all the words as swearing and he was punished by some people as well as some entities. He also said that some jinns in the form of animals threatened him not to speak and listen to anyone; otherwise they were going to kill his kids. He wanted to protect his children [and] he stitched his lips not to speak anyone and stitched his ears not to hear anyone. In his family history, he stated that his uncle committed suicide by hanging himself and saying ‘the birds are calling me’; his father was schizophrenia-diagnosed”.

The authors then reported:

“The patient stated that he sewed his lips with any colour of thread he could find. He had approximately fifteen pinholes on his upper and lower lips. He tended to suicide with directive auditory and visual hallucination (sic) and reference paranoid delirium. As he was imprisoned, he wasn’t able to use drugs. The patient who was thought to have a psychotic disorder was injected [with] 10 mg haloperidol intramuscularly and he was sent to a safe psychiatry hospital”.

As I have noted in my previous blogs on self-harming behaviour (and as noted in this particular paper), there are many different definitions of what constitutes self-destructive behaviour. This particular case was said to be suited to the psychotic behaviours characterised by Dr. Armando Favazza’s three self-destructive behaviours (i.e., compulsive, typical, and psychotic) outlined in his 1992 paper ‘Repetitive self-mutilation’ (published in the journal Psychiatry Annals). In their discussion of the case, the authors noted:

“The cases like sewing one’s own lips which we observe as a different type of destructing oneself in our case are mostly regarded as intercultural expression of feelings. The ones, who sew their lips in order to protest something, show their reactions by blocking the nutrition intake organ to the ones who want to continue their superiority. It can be expected in psychotic cases that the patients or his beloved ones might be harmed, damaged or affected emotionally. Thus, the patient who is furious and anxious might react by [attempting] violence as a reaction to these repetitive threats. Auditory hallucinations giving orders can cause the aggressive behaviours to start…In our psychotic case, this kind of behaviour is a way to prevent the voices coming from his inner world, not to answer them and hence making passive defending to world which he does not want to interact. By this means, he may harmonise with the secret natural powers which affect him and he may protect himself his children…[also] there can be a relief through sewing lips and ears or strangulation against the oppression created by the person not being able to adapt the prison…It should not be forgotten that the prison is a stressful environment and stressful living [increases] the disposition to psychopathologic behaviour that the living difficulties in prisons can affect the way of thinking and the capacity of coping and it may cause different psychiatric incidences”.

As noted at the start of this article, lip sewing is typically attributed to religious reasons, reasons of protest or aesthetic reasons. In this particular case, none of these reasons was apparent (and therefore notable – in the medical and psychiatric literature at the very least). The addition of sewing his ears appears to be even more rare, and thus warrants further research.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Favazza, A.R. (1992). Repetitive self-mutilation. Psychiatric Annals, 22(2), 60-63.

Taktak, S., Ersoy, S., Ünsal, A., & Yetkiner, M. (2014). The man who sewed his mouth and ears: A case report. Health Care Current Reviews, 2(121), 2.

Taktak, S., Karakus, M., & Eke, S. M. (2015). The man whose fetish object is ejaculate: A case report. Journal of Psychiatry, 18(276), 2.

Taktak, S., Karakuş, M., Kaplan, A., & Eke, S. M. (2015). Shoe fetishism and kleptomania comorbidity: A case report. European Journal of Pharmaceutical and Medical Research, 2, 14-19.

Taktak, S., Yılmaz, E., Karamustafalıoglu, O., & Ünsal, A. (2016). Characteristics of paraphilics in Turkey: A retrospective study – 20years. International Journal of Law and Psychiatry, in press.

Wikipedia (2016). Lip sewing. Located at: https://en.wikipedia.org/wiki/Lip_sewing

Higher and higher: Can psychoactive substance use enhance creativity?

In a previous blog I examined whether celebrities are more prone to addictions. In that article I argued that many high profile celebrities have the financial means to afford a drug habit like cocaine or heroin. For many in the entertainment business such as being the lead singer in a famous rock band, taking drugs may also be viewed as one of the defining behaviours of the stereotypical ‘rock ‘n’ roll’ lifestyle. In short, it’s almost expected. There is also another way of looking at the relationship between celebrities and drugs and this is in relation to creativity, particularly as to whether the use of drugs can inspire creative writing or music. For instance, did drugs like cannabis and LSD help The Beatles create some of the best music ever such as Revolver? Did the Beach Boys’ Brian Wilson’s use of drugs play a major role in why the album Pet Sounds is often voted the best album of all time? Did the use of opium by Edgar Allen Poe create great fiction? Did William S. Burroughs’ use of heroin enhance his novel writing?

To investigate the question of whether drug use enhances creativity, I and my research colleagues Fruzsina Iszáj and Zsolt Demetrovics have just published a review paper in the International Journal of Mental Health and Addiction examining this issue. We carried out a systematic review of the psychological literature and reviewed any study that provided empirical data on the relationship between psychoactive substance use and creativity/artistic creative process that had been published in English in peer-reviewed journals or scientific books. Following a rigorous filtering process, we were surprised to find only 19 studies that had empirically examined the relationship between drug use and creativity (14 empirical studies and five case studies).

Six of the 19 studies (four empirical papers and two case reports) were published during the 1960s and 1970s. However, following the peak of psychedelia, only three papers (all of them empirical) were published in the following 20 years. Since 2003, a further 10 studies were published (seven empirical papers and three case studies). The majority of the studies (58%) were published in the USA. This dominance is especially true for the early studies in which six of the seven empirical papers and both case studies that were published before mid-1990s were written by US researchers. However, over the past 14 years, this has changed. The seven empirical papers published post-2000 were shared between six different countries (USA, UK, Italy, Wales, Hungary, Austria), and the three case studies came from three countries (USA, UK, Germany).

Seven empirical papers and two case studies dealt with the relationship between various psychoactive substances and artistic creation/creativity. Among the studies that examined a specific substance, six (three empirical papers and three case studies) focused on the effects of either LSD or psilocybin. One empirical study focused on cannabis, and one concerned ayahuasca.

With the exception of one study where the sample focused on adolescents, all the studies comprised adults. More non-clinical samples (15 studies, including case studies) were found than clinical ones (four studies). Three different methodological approaches were identified. Among the empirical studies, seven used questionnaires comprising psychological assessment measures such as the Torrance Test of Creative Thinking (TTCT).

According to the types of psychoactive substance effect on creativity, we identified three groups. These were studies that examined the effect of psychedelic substances (n=5), the effect of cannabis (n=1), and those that did not make a distinction between substances used because of the diverse substances used by participants in the samples (n=7). In one study, the substances studied were not explicitly identified.

The most notable observation of our review was that the findings of these studies show only limited convergence. The main reason for this is likely to be found in the extreme heterogeneity concerning the objectives, methodology, samples, applied measures, and psychoactive substances examined among the small number of studies. Consequently, it is hard to draw a clear conclusion about the effect of psychoactive substance use on creativity based on the reviewed material.

Despite the limited agreement, most of the studies confirmed some sort of association between creativity and psychoactive substance use, but the nature of this relationship was not clearly established. The frequently discussed view that the use of psychoactive substances leads to enhanced creativity was by no means confirmed. What the review of relevant studies suggests is that: (i) substance use is more characteristic in those with higher creativity than in other populations, and (ii) it is probable that this association is based on the inter-relationship of these two phenomena. At the same time, it is probable that there is no evidence of a direct contribution of psychoactive substances to enhanced creativity of artists.

It is more likely that substances act indirectly by enhancing experiences and sensitivity, and loosening conscious processes that might have an influence on the creative process. This means the artist will not be more creative but the quality of the artistic product will be altered due to substance use. On the other hand, it appears that psychoactive substances may have another role concerning artists, namely that they stabilize and/or compensate a more unstable functioning.

Beyond the artistic product, we also noted that (iii) specific functions associated with creativity appear to be modified and enhanced in the case of ordinary individuals due to psychoactive substance use. However, it needs to be emphasized that these studies examined specific functions while creativity is a complex process. In light of these studies, it is clear that psychoactive substances might contribute to a change of aesthetic experience, or enhanced creative problem solving. One study (a case study of the cartoonist Robert Crumb) showed that LSD changed his cartoon illustrating style. Similarly, a case study of Brian Wilson argued that the modification of musical style was connected to substance use. However, these changes in themselves will not result in creative production (although they may contribute to the change of production style or to the modification of certain aspects of pieces of arts). What was also shown is that (iv) in certain cases, substances may strengthen already existing personality traits.

In connection with the findings reviewed, one should not overlook that studies focused on two basically different areas of creative processes. Some studies examined the actual effects of a psychoactive substance or substances in a controlled setting, while others examined the association between creativity and chronic substance users. These two facets differ fundamentally. While the former might explain the acute changes in specific functions, the latter may highlight the role of chronic substance use and artistic production.

It should also be noted that the studies we reviewed differed not only regarding their objectives and methodology, but also showed great heterogeneity in quality. Basic methodological problems were identified in many of these studies (small sample sizes, unrepresentative samples, reliance on self-report and/or non-standardized assessment methods, speculative research questions, etc.). Furthermore, the total number of empirical studies was very few. At the same time, the topic is highly relevant both in order to understand the high level of substance use in artists and in order to clarify the validity of the association present in public opinion. However, it is important that future studies put specific emphasis on adequate methodology and clear research questions.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Belli, S. (2009). A psychobiographical analysis of Brian Douglas Wilson: Creativity, drugs, and models of schizophrenic and affective disorders. Personality and Individual Differences, 46, 809-819.

Dobkin de Rios, M. & Janiger, O. (2003). LSD, spirituality, and the creative process. Rochester, VT: Park Street Press.

Edwards, J. (1993). Creative abilities of adolescent substance abusers. Journal of Group         Psychotherapy, Psychodrama & Sociometry, 46, 52-60.

Fink, A., Slamar-Halbedl, M., Unterrainer, H.F. & Weiss, E.M. (2012). Creativity: Genius, madness, or a combination of both? Psychology of Aesthetics, Creativity, and the Arts, 6(1), 11–18.

Forgeard, M.J.C. & Elstein, J.G. (2014). Advancing the clinical science of creativity. Frontiers in Psychology, 5, 613.

Frecska, E., Móré Cs. E., Vargha, A. & Luna, L.E. (2012). Enhancement of creative expression and entoptic phenomena as after-effects of repeated ayahuasca ceremonies. Journal of Psychoactive Drugs, 44, 191-199

Holm-Hadulla, R.M. & Bertolino, A. (2014). Creativity, alcohol and drug abuse: The pop icon Jim Morrison. Psychopathology, 47,167-73

Iszáj, F. & Demetrovics, Z. (2011). Balancing between sensitization and repression: The role of opium in the life and art of Edgar Allan Poe and Samuel Taylor Coleridge. Substance Use and Misuse, 46, 1613-1618

Iszaj, F., Griffiths, M.D. & Demetrovics, Z. (2016). Creativity and psychoactive substance use: A systematic review. International Journal of Mental Health and Addiction. doi: 10.1007/s11469-016-9709-8

Jones, M.T. (2007). The creativity of crumb: Research on the effects of psychedelic drugs on the comic art of Robert Crumb. Journal of Psychoactive Drugs, 39, 283-291.

Jones, K.A., Blagrove, M. & Parrott, A.C. (2009). Cannabis and ecstasy/ MDMA: Empirical measures of creativity in recreational users. Journal of Psychoactive Drugs. 41(4), 323-329

Kerr, B. & Shaffer, J. & Chambers, C., & Hallowell, K. (1991). Substance use of creatively talented adults. Journal of Creative Behavior, 25(2), 145-153.

Knafo, D. (2008). The senses grow skilled in their craving: Thoughts on creativity and addiction. Psychoanalytic Review, 95, 571-595.

Lowe, G. (1995). Judgements of substance use and creativity in ’ordinary’ people’s everyday lifestyles. Psychological Reports. 76, 1147-1154.

Oleynick, V.C., Thrash, T. M., LeFew, M. C., Moldovan, E. G. & Kieffaber, P. D. (2014). The scientific study of inspiration in the creative process: challenges and opportunities. Frontiers in Human Neuroscience, 8, 436.

Plucker, J.A., McNeely, A. & Morgan, C. (2009). Controlled substance-related beliefs and use: Relationships to undergraduates’ creative personality traits. Journal of Creative Behavior, 43(2), 94-101

Preti, A. & Vellante, M. (2007). Creativity and psychopathology. Higher rates of psychosis proneness and nonright-handedness among creative artists compared to same age and gender peers. Journal of Nervous and Mental Disease, 195(10), 837-845.

Schafer, G. & Feilding, A. & Morgan, C. J. A. & Agathangelou, M. & Freeman, T. P. &      Curran, H.V. (2012). Investigating the interaction between schizotypy, divergent thinking and cannabis use. Consciousness and Cognition, 21, 292–298

Thrash, T.M., Maruskin, L.A., Cassidy, S. E., Fryer, J.W. & Ryan, R.M. (2010). Mediating between the muse and the masses: inspiration and the actualization of creative ideas. Journal of Personality and Social Psychology, 98, 469–487.