Category Archives: Video game addiction
Earlier this year, the World Health Organisation announced that ‘Gaming Disorder’ (GD) was to be officially been included in the latest (eleventh) edition of the International Classification of Diseases (ICD-11). The announcement received worldwide media coverage alongside many debates as to whether its inclusion was justified based on the scientific evidence. The extensive media coverage raised many questions but also appeared to give rise to a number of myths. In this blog, I address these myths in the British context but some of these myths also have resonance outside the UK.
Myth 1 – Gaming Disorder equates to gaming addiction. Almost all of the worldwide press coverage for GD in June 2018 was equated with gaming addiction. However, the World Health Organization (WHO) does not describe GD as an addiction and the WHO criteria for GD do not include criteria that I believe are core to being genuine addictions (such as tolerance and withdrawal symptoms). Confusingly, the criteria for Internet Gaming Disorder (IGD) in the latest (fifth) edition of the Diagnostic Manual of Mental Disorders (DSM-5) does include all my core criteria of addiction. However, to be diagnosed with IGD, an individual does not necessarily have to endorse all the core addiction criteria. In short, all genuine gaming addicts are likely to be diagnosed as having GD and/or IGD but not all those with GD and/or IGD are necessarily gaming addicts.
Myth 2 – Gaming has many benefits so should not be classed as a disorder as it will create a ‘moral panic’: Predictably, the videogame industry has not welcomed the WHO’s decision to include GD in the ICD-11 and issued a statement to say gaming has many personal benefits and that GD will create moral panic and ‘abuse of diagnosis’. None of us in the field dispute the fact that gaming has many benefits but many other activities such as work, sex, and exercise can be disordered and addictive for a small minority, and is not a good basis for denying the existence of GD. The videogame industry also claims the empirical basis for GD is highly contested but then ironically uses non-empirical claims (i.e., that the introduction of GD will cause a moral panic and lead to diagnostic abuse by practitioners) as a core argument for why GD should not exist.
Myth 3 – Gaming Disorder is associated with other comorbidities so is not a separate disorder. In coverage concerning GD, those denying the existence of GD sometimes resort to the argument that problematic gaming is typically comorbid with other mental health conditions (e.g., depression, anxiety disorders, etc.) and therefore should not be classed as a separate disorder. However, such an argument is not applied (for instance) to those with alcohol use disorder or gambling disorder which are known to be associated with other comorbidities. In fact, we recently published some case studies in the International Journal of Mental Health and Addiction highlighting those attending treatment for GD included individuals both with and without underlying comorbidities. Consequently, diagnosis of disorders should be based on the external symptomatic behavior and consequences, not on the underlying causes and etiology.
Myth 4 – Gaming Disorder can now be treated for free by the National Health Service: Unlike many other countries, the UK has a National Health Service (NHS) whose treatment services can be accessed free of charge. A number of British newspapers reported that inclusion of GD in the ICD-11 meant that those with GD can now get free treatment. However, this claim is untenable and is unlikely to happen. All health trusts in the UK have a finite budget and allocate resources to those conditions considered a priority. Treating individuals with GD will rarely (if ever) be given priority over treatment for cancer, heart disease, schizophrenia, depression, etc. In countries where private health insurance is the norm, GD is likely to be a condition excluded for treatment on such policies even though it is now in the ICD-11.
Myth 5 – The inclusion of Gaming Disorder as a mental disorder will lead to ‘millions’ of children being stigmatized for their videogame playing: This myth has been propagated by a group of scholars (mainly researchers working in the media studies field) but is completely unsubstantiated. The number of children who would ever be officially be diagnosed as having GD is extremely low and – as noted above – millions of children play videogames for enjoyment without any problems or stigma.
(Please note: This article is based on an editorial that I first published earlier this year: Griffiths, M.D. (2018). Five myths about gaming disorder. Social Health and Behavior Journal, 1, 2-3)
Dr Mark Griffiths, Distinguished Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Aarseth, E., Bean, A. M., Boonen, H., Colder Carras, M., Coulson, M., Das, D., … & Haagsma, M. C. (2017). Scholars’ open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal. Journal of Behavioral Addictions, 6(3), 267-270.
Gentile, D.A., Bailey, K., Bavelier, D., Funk Brockmeyer, J., … & Young, K. (2017). The state of the science about Internet Gaming Disorder as defined by DSM-5: Implications and perspectives, Pediatrics, 140, S81-S85. doi: 10.1542/peds.2016-1758H
Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Griffiths, M.D. (2017). Behavioural addiction and substance addiction should be defined by their similarities not their dissimilarities. Addiction, 112, 1718-1720.
Griffiths, M.D. (2018). Conceptual issues concerning internet addiction and internet gaming disorder. International Journal of Mental Health and Addiction, 16, 233-239.
Griffiths, M.D., Kuss, D.J., Lopez-Fernandez, O., & Pontes, H.M. (2017). Problematic gaming exists and is an example of disordered gaming. Journal of Behavioral Addictions, 6, 296-301.
European Games Developer Foundation. Statement on WHO ICD-11 list and the inclusion of gaming. 2018 June 15. Available from: http://www.egdf.eu/wp-content/uploads/2018/06/Industry-Statement-on-18-June-WHO-ICD-11.pdf
Király, O., Griffiths, M.D. & Demetrovics Z. (2015). Internet gaming disorder and the DSM-5: Conceptualization, debates, and controversies, Current Addiction Reports, 2, 254–262.
Király, O., Griffiths, M.D., King, D., Lee, H-K., Lee, S-Y., Bányai, F., Zsila, A. Demetrovics, Z. (2018). An overview of policy responses to problematic videogame use. Journal of Behavioral Addictions, 7, 503-517.
Kuss, D.J., Griffiths, M.D. & Pontes, H.M. (2017). Chaos and confusion in DSM-5 diagnosis of Internet Gaming Disorder: Issues, concerns, and recommendations for clarity in the field. Journal of Behavioral Addictions, 6, 103-109.
Kuss, D.J., Pontes, H.M. & Griffiths, M.D. (2018). Neurobiological correlates in Internet Gaming Disorder: A systematic review. Frontiers in Psychiatry, 9, 166. doi: 10.3389/fpsyt.2018.00166
Griffiths, M.D., Van Rooij, A., Kardefelt-Winther, D., Starcevic, V., Király, O…Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing Internet Gaming Disorder: A critical commentary on Petry et al (2014). Addiction, 111, 167-175.
Rumpf, H. J., Achab, S., Billieux, J., Bowden-Jones, H., Carragher, N., Demetrovics, Z., … & Saunders, J. B. (2018). Including gaming disorder in the ICD-11: The need to do so from a clinical and public health perspective: Commentary on: A weak scientific basis for gaming disorder: Let us err on the side of caution (van Rooij et al., 2018). Journal of Behavioral Addictions, 7(3), 556-561.
Torres-Rodriguez, A., Griffiths, M.D., Carbonell, X. Farriols-Hernando, N. & Torres-Jimenez, E. (2018). Internet gaming disorder treatment: A case study evaluation of four adolescent problematic gamers. International Journal of Mental Health and Addiction, https://doi.org/10.1007/s11469-017-9845-9.
As a teenager I was fascinated with LSD purely as a consequence of my love of The Beatles and its alleged association with songs such as ‘Lucy in the Sky with Diamonds‘ (I say ‘alleged’ because all Beatle fanatics know that this song got its’ title from a drawing by John Lennon’s son Julian and that lyrically the song was inspired by the writings of Lewis Carroll, the creator of Alice in Wonderland [AIW], a book which gave its’ name to AIW Syndrome that I examined in a couple of previous blogs).
When I first started teaching my ‘Addictive Behaviours’ module back in 1990, almost all my lectures concentrated on drug addictions (as opposed to behavioural addictions which now take centre stage in my teaching), and it was my session on hallucinogenic drugs (also known as psychedelic drugs) that was always the most fun to teach and the topic that students appeared to be most engaged in. Like many of my students, I have always been interested in altered states of consciousness both in my own research into addiction and the topic more generally.
The reason why I mention all these things as that I did a media interview on the hallucinogenic effects of virtual reality products. The interview was based on comments by Microsoft researcher Mar Gonzalez Franco, who said that virtual reality will soon replace the need for hallucinogenic drugs. More specifically, she was quoted as saying:
“By 2027 we will have ubiquitous virtual reality systems that will provide such rich multi-sensorial experiences that will be capable of producing hallucinations which blend or alter perceived reality. Using this technology, humans will retrain, recalibrate and improve their perceptual systems…In contrast to current virtual reality systems that only stimulate visual and auditory senses, in the future the experience will expand to other sensory modalities including tactile with haptic devices“.
Claims that VR products have the potential to induce hallucinogenic experiences have already started appearing in the media. A recent story in the Daily Mail reported that there was already a VR app (SelfSound) that claimed it can reproduce the effects of hallucinogenic drugs and “plays on the neurological phenomena known as synaesthesia” and that a “program is used to promote mediation through creating abstract reality [and] plays face-melting music with synesthetic DMT-style visualizations uniquely generated in response to [a person’s] voice”. (DMT is an abbreviation for dimethyltryptamine, a powerful hallucinogenic drug).
Over the last seven years, I have published a series of studies with Dr. Angelica Ortiz de Gotari (some of them listed in the ‘Further reading’ section below) showing that hallucinations are common among video gamers in our working examining Game Transfer Phenomena (GTP). Therefore, it’s no surprise that VR games can do the same thing. We have reported that visual and auditory hallucinations are commonly experiences by regular videogame players.
For instance, one of our studies published in the International Journal of Human-Computer Interaction found that some video gamers experience altered visual perceptions after playing (e.g., distorted versions of real world surroundings). Others saw video game images and misinterpreted real life objects after they had stopped playing. Gamers reported seeing video game menus popping up in front their eyes when they were in a conversation, or saw coloured images and ‘heads up’ displays when driving on the motorway. Our study analysed 656 experiences from 483 gamers collected in 54 online video game forums. Visual illusions can easily trick the brain, and staring at visual stimuli can cause ‘after-images’ or ‘ghost images’ among videogame players. We found that GTP were triggered by associations between video game experiences, and objects and activities in real life contexts. Our findings also raised questions about the effects of the exposure to specific visual effects used in video games.
We also reported that in some playing experiences, video game images appeared without awareness and control of the gamers, and in some cases, the images were uncomfortable, especially when gamers could not sleep or concentrate on something else. These experiences also resulted in irrational thoughts such as gamers questioning their own mental health, getting embarrassed or performing impulsive behaviours in social contexts. However, other gamers clearly thought that these experiences were fun and some even tried to induce them.
Visual experiences identified in GTP show us the interplay of physiological, perceptual and cognitive mechanisms and the potential of learning with video games even without awareness. It also invites us to reflect about the effects of prolonged exposure to synthetic stimuli and the challenges that the human mind affront due to the technological advances that are still to come. However, because we collected our data for most of our published studies from online video game forums, the psychological profile of the gamers in our studies are unknown. However, different gamers reported similar experiences in the same games. This highlights the relevance of the video games’ structural characteristics but gamers’ habits also appear to be crucial. Some gamers may be more susceptible than others to experience GTP. The effects of these experiences appear to be short-lived, but some gamers experience them recurrently. It goes without saying (but I’ll say it anyway) that more research is needed to understand the cognitive and psychological implications of GTP. Most of these GTP experiences are viewed positively but a small minority of players find them detrimental.
Whether such hallucinations – either in typical videogames or VR videogames – can be induced on demand is debatable. Very few players in our own research said they were able to induce hallucinations. At present, we simply don’t know what the long-term effects of VR gaming will be and that goes for VR-induced gaming hallucinations too. It may be the case that VR induced hallucinogenic states will be ‘safer’ than ones induced by psychedelic drugs as there is no ingestion of a psychoactive substance, but that’s just speculation on my part.
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Cawley, C. (2016). Virtual Reality could make you hallucinate; Don’t freak out. Tech Co, December 15. Located at: http://tech.co/virtual-reality-hallucinate-dont-freak-2016-12
Hamill, J. (2016). Windows of perception: Microsoft says virtual reality will soon have same mind-bending effects as LSD. The Sun, December 7. Located at: https://www.thesun.co.uk/news/2347705/microsoft-says-virtual-reality-will-soon-have-same-mind-bending-effects-as-lsd/
Liberatore, S. (2016). That’s trippy! Watch the VR app that claims to be able to reproduce the effects of a hallucinogenic drug. Daily Mail, May 4, Located at: http://www.dailymail.co.uk/sciencetech/article-3572184/That-s-trippy-Watch-VR-app-claims-able-reproduce-effects-hallucinogenic-drug.html
Ortiz de Gortari, A.B. & Griffiths, M.D. (2012). An introduction to Game Transfer Phenomena in video game playing. In J. Gackenbach (Ed.), Video Game Play and Consciousness (pp.223-250). Hauppauge, NY: Nova Science.
Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Altered visual perception in Game Transfer Phenomena: An empirical self-report study. International Journal of Human-Computer Interaction, 30, 95-105.
Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. International Journal of Cyber Behavior, Psychology and Learning, 4(1), 59-75.
Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Automatic mental processes, automatic actions and behaviours in Game Transfer Phenomena: An empirical self-report study using online forum data. International Journal of Mental Health and Addiction, 12, 432-452.
Ortiz de Gortari, A.B. & Griffiths, M.D. (2015). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. In: Gamification: Concepts, Methodologies, Tools, and Applications (pp.1329-1345). Pennsylvania: IGI Global.
Ortiz de Gortari, A.B. & Griffiths, M.D. (2016). Prevalence and characteristics of Game Transfer Phenomena: A descriptive survey study. International Journal of Human-Computer Interaction, 32, 470-480.
Ortiz de Gortari, A.B., Pontes, H.M. & Griffiths, M.D. (2015). The Game Transfer Phenomena Scale: An instrument for investigating the non-volitional effects of video game playing. Cyberpsychology, Behavior and Social Networking, 18, 588-594.
Rothman, P. (2014). Virtual Reality and Drugs – Yes, you should get high before using VR. H Plus Magazine, July 31. Located at: http://hplusmagazine.com/2014/07/31/virtual-reality-and-drugs-yes-you-should-get-high-before-using-vr/
Last month, the World Health Organisation (WHO) announced that it was planning to include ‘Gaming Disorder’ (GD) in the latest edition of the International Classification of Diseases. This followed the American Psychiatric Association’s decision to include ‘Internet Gaming Disorder’ in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders in 2013. According to the WHO, an individual with GD is a person who lets playing video games “take precedence over other life interests and daily activities,” resulting in “negative consequences” such as “significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”
I have been researching videogame addiction for nearly 30 years, and during that time I have received many letters, emails, and telephone calls from parents wanting advice concerning videogames. Typical examples include ‘Is my child playing too much?’, ‘Will playing videogames spoil my pupils’ education?’, ‘Are videogames bad for children’s health? and ‘How do I know if a child is spending too long playing videogames?’ To answer these and other questions in a simple and helpful way, I have written this article as a way of disseminating this information quickly and easily.
To begin with parents should begin by finding out what videogames their children are actually playing! Parents might find that some of them contain material that they would prefer them not to be having exposure to. If they have objections to the content of the games they should facilitate discussion with children about this, and if appropriate, have a few rules. A few aims with children should be:
- To help them choose suitable games which are still fun
- To talk with them about the content of the games so that they understand the difference between make-believe and reality
- To discourage solitary game playing
- To guard against obsessive playing
- To follow recommendations on the possible risks outlined by videogame manufacturers
- To ensure that they have plenty of other activities to pursue in their free time besides the playing of videogames
Parents need to remember that in the right context videogames can be educational (helping children to think and learn more quickly), can help raise a child’s self-esteem, and can increase the speed of their reaction times. Parents can also use videogames as a starting point for other activities like painting, drawing, acting or storytelling. All of these things will help a child at school. It needs to be remembered that videogame playing is just one of many activities that a child can do alongside sporting activities, school clubs, reading and watching the television. These can all contribute to a balanced recreational diet.
The most asked question a parent wants answering is ‘How much videogame playing is too much? To help answer this question I devised the following checklist. It is designed to check if a child’s videogame playing is getting out of hand. Ask these simple questions. Does your child:
- Play videogames every day?
- Often play videogames for long periods (e.g., 3 to 6 hours at a time)?
- Play videogames for excitement or ‘buzz’ or as a way of forgetting about other things in their life?
- Get restless, irritable, and moody if they can’t play videogames?
- Sacrifice social and sporting activities to play videogames?
- Play videogames instead of doing their homework?
- Try to cut down the amount of videogame playing but can’t?
If the answer is ‘yes’ to more than four of these questions, then your child may be playing too much. But what can you do if your child is playing videogames too much?
- First of all, check the content of the games. Try and give children games that are educational rather than the violent ones. Parents usually have control over what their child watches on television – videogames should not be any different.
- Secondly, try to encourage video game playing in groups rather than as a solitary activity. This will lead to children talking and working together.
- Thirdly, set time limits on children’s playing time. Tell them that they can play for a couple of hours after they have done their homework or their chores – not before.
- Fourthly, parents should always get their children to follow the recommendations by the videogame manufacturers (e.g., sit at least two feet from the screen, play in a well-lit room, never have the screen at maximum brightness, and never play videogames when feeling tired).
I have spent many years examining both the possible dangers and the potential benefits of videogame playing. Evidence suggests that in the right context videogames can have positive health and educational benefits to a large range of different sub-groups. What is also clear from the case studies displaying the more negative consequences of playing is that they all involved children who were excessive users of videogames. From prevalence studies in this area, there is little evidence of serious acute adverse effects on health from moderate play. In fact, in some of my studies, I found that moderate videogame players were more likely to have friends, do homework, and engage in sporting activities, than those who played no videogames at all.
For excessive videogame players, adverse effects are likely to be relatively minor, and temporary, resolving spontaneously with decreased frequency of play, or to affect only a small subgroup of players. Excessive players are the most at-risk from developing health problems although more research is needed. If care is taken in the design, and if they are put into the right context, videogames have the potential to be used as training aids in classrooms and therapeutic settings, and to provide skills in psychomotor coordination, and in simulations of real life events (e.g., training recruits for the armed forces).
Every week I receive emails from parents claiming that their sons are addicted to playing online games or that their daughters are addicted to social media. When I ask them why they think this is the case, they almost all reply “because they spend most of their leisure time in front of a screen.” This is simply a case of parents pathologising their children’s behaviour because they think what they are doing is “a waste of time.” I always ask parents the same three things in relation to their child’s screen use. Does it affect their schoolwork? Does it affect their physical education? Does it affect their peer development and interaction? Usually parents say that none of these things are affected so if that is the case, there is little to worry about when it comes to screen time. Parents also have to bear in mind that this is how today’s children live their lives. Parents need to realise that excessive screen time doesn’t always have negative consequences and that the content and context of their child’s screen use is more important than the amount of screen time.
(N.B. This article is an extended version of an article that was originally published by Parent Zone)
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Griffiths, M.D. (2003). Videogames: Advice for teachers and parents. Education and Health, 21, 48-49.
Griffiths, M.D. (2009). Online computer gaming: Advice for parents and teachers. Education and Health, 27, 3-6.
Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.
Griffiths, M.D., Kuss, D.J. & Pontes, H. (2016). A brief overview of Internet Gaming Disorder and its treatment. Australian Clinical Psychologist, 2(1), 20108.
Griffiths, M.D. & Meredith, A. (2009). Videogame addiction and treatment. Journal of Contemporary Psychotherapy, 39(4), 47-53.
King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2012). Clinical interventions for technology-based problems: Excessive Internet and video game use. Journal of Cognitive Psychotherapy: An International Quarterly, 26, 43-56.
King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.
Király, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.61-95). New York: Elsevier.
Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22.
Kuss, D.J. & Griffiths, M.D. (2012). Internet gaming addiction: A systematic review. International Journal of Mental Health and Addiction, 10, 278-296.
About a year ago, my colleagues and I published what we believe is the very first study of the helping role that video gaming can play in the lives of transgender individuals. Before I get to that, it’s probably worth noting that there have been studies of how gamers and fans play with sexuality, gender, and the video game Minecraft on YouTube as well as papers discussing whether the gaming industry should cater for marginalized groups and develop games for groups where there is little representation within games (e.g., gay and transgendered characters). For instance, there is now a short autobiographical game by Auntie Pixellante called Dys4ia. This is a WarioWare-style game, played only with the arrow keys, chronicling the experiences of a trans woman rectifying her own gender dysphoria. Such videogames raise interesting questions about how those individuals with gender dysphoria utilize gaming as part of their identity.
In a previous blog I briefly looked at gender swapping in online video games including some of my own research. For instance, in 2003 I published a paper in the journal CyberPsychology and Behavior using secondary poll data from online gaming forums. The paper reported that of 10,350 players at the Everlore fan site, 15% had swapped the gender of their main in-game playing character. We also reported a similar finding among 8,694 players at the Allakhazam fan site with 15.5% reporting that they had gender swapped their main in-game character (and more specifically, 14.5% males and 1% were females who had changed the gender of their lead character). In a 2004 follow-up survey among 540 Everquest gamers (again in the journal CyberPsychology and Behavior) my colleagues and I reported that 60% had swapped their online in-game characters. The prevalence of gender swapping was probably much higher in this study because the question related to the gender swapping of any online game character not just their main playing character.
In a small exploratory study I published in 2008 with Dr. Zaheer Hussain in the International Journal of Mental Health and Addiction, we examined why people engaged in gender swapping in a self-selecting sample of 119 online gamers (mean age of 28.5 years). We reported that 57% of gamers had engaged in gender swapping (any character not just their main character), and that males adopting an online female persona believed there were a number of positive social attributes to becoming female characters in male-oriented gaming environments. The study also reported that significantly more females than males had gender swapped their character – mainly to prevent unsolicited male approaches on their female characters. Some females appeared to gender swap purely out of interest to see what would happen in the game (as a personal experiment), while others claimed that they were treated more favourably by male gamers when they played as a male character. Others reported that gender swapping enabled them to play around with aspects of their identity that would not be possible to explore in real life. Other reasons for gender swapping were that (i) female characters had better in-game statistics, (ii) some specific tools were only available with female characters, (iii) the class of character was sometimes only available in one gender, (iv) they played for fun, and/or (v) they did it to so something that they would not normally do in the game (i.e., they did it for a change in their usual playing behaviour).
Outside of online gaming, a 2002 paper by Hegland and Nelson in the International Journal of Sexuality and Gender Studies noted that the Internet more generally can be used as a tool for expressing gender identity because it allows identities to cross cultural boundaries instantly and without regard for real physical space. They examined 30 cross-dressing websites and argued that for most cross-dressers that visited such websites, the online forum was their primary medium of expression. The users of the website used the Internet to nurture the ability to create a feminine identity, and helped them to pass as a woman in the offline public world. More generally, cross-dressers used the Internet to participate in the larger cultural dialogue of gender.
For an adult to meet current criteria for a diagnosis of transsexualism, the World Health Organisation’s International Classification of Diseases (ICD) reports they must express the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the desired sex through surgery and cross-sex hormones. This transsexual identity must have been present persistently for a minimum of two years and not be a symptom of another mental disorder or a chromosomal abnormality. The latest (fifth) edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association uses the term gender dysphoria to describe people who are uncomfortable and/or distressed regarding their assigned gender, their physical sex characteristics and/or their associated social roles. Depending upon the intensity of this distress, some individuals may wish to transition from one point on a notional gender scale to another. The most common direction is from a man to a woman (individuals known as trans women), or from a woman to a man (individuals known as trans men). The distress intrinsic to gender dysphoria may be focused around anatomy, physiology, and/or being perceived and treated as someone of a gender with which the person does not identify. However, these diagnostic labels do not apply to all trans individuals for a multitude of reasons because some people will not identify themselves as a man or as a woman
The World Health Organisation working group has recommended that the latest ICD replace the term Transsexualism with Gender Incongruence) and remove it from the mental and behavioural disorders chapter. Gender incongruence denotes the incongruence between a person’s gender identity and their assigned sex and/or congenital primary and secondary sex characteristics. The terminology in this field has changed over the years and the terms ‘transgender’ and ‘trans’ have been used in the literature as umbrella terms to cover a wide variety of atypical gender experiences and expressions which may lead to permanent change of social gender role but does not necessarily involve treatment with cross-sex hormones or surgical intervention. A recent study has reported an prevalence for transsexualism of 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men, which is primarily based on studies looking at individuals attending clinical services. (However, it should be noted that recent population studies have reported a significantly higher prevalence rate of atypical gender experiences and expressions).
The study we published in the journal Aloma originated from initial observations made by Dr. Jon Arcelus that a number of gender dysphoric clients presenting at the national (UK) gender dysphoria clinic admitted that they gender-swapped while playing online games. After I met with Dr. Arcelus I suggested he revisit his case files and and to write them up as case studies (as no study in the gaming field has ever examined online gaming among those with gender dysphoria). The main objectives of our study were to use exemplar case studies to highlight that gaming – in some circumstances – appears to be a functional way of dealing with gender identity issues, and that gender swapping in gaming may help such individuals to come to terms with their gender dysphoria.
Our paper featured four case studies who attended an assessment at the National Centre for Gender Dysphoria in Nottingham. All four individuals described in our paper were given pseudonyms and the content of their histories were anonymised (and included ‘Mary’ a 26-year old natal male who fully transitioned to the female social role six months prior to our study; ‘Mark’ a 20-year old natal female who first attended for an assessment in the female role; ‘Paul’ a 31-year old natal male who would like to be female, but still living full-time as a male; and ‘Harry’ a 23-year old natal male who presented for an assessment as a male). If you want to read about each case in detail, the paper can be downloaded for free from here).
The four case studies outlined in our paper are only a selected sample of the number of cases attending a national clinic for people with gender dysphoria. However, they were in no way unusual to the other clients that have sought help at the Centre. However, these individual accounts were specifically selected to demonstrate the different ways that video gaming may help people with gender dysphoria come to terms with their gender identity. For example, gaming can be used among trans people as a psychological tool to increase one’s awareness of gender identity and/or as part of the self. Gaming may therefore be a useful way to express one’s experienced gender identity in a safe, non-threatening, non-alienating, non-stigmatizing, and non-critical environment. This appears to mirror other the findings of other studies outside of the online gaming environment.
Articles published in the mass media have reported that online games such as World of Warcraft provide a creative space that allows gamers that might be questioning aspects of their identity to explore their lives as different individuals. Some have even gone as far as to argue that this could help gamers transform their ‘offline’ identity, as is the case with some trans gamers. This was also demonstrated in the case studies described in our study. Other authors have asserted that the online medium offers an infinite space for development and resistance to traditional gender roles, and that online interaction enables a transgression of the dichotomous categories of male and female, constructing trans (or even genderless) social identities and relationships. However, although such anonymous online communities may provide trans individuals with the power to subvert their physical sex.
Our case studies also demonstrated the different functions of gaming in trans people (e.g., the function of “testing out” their gender feelings). For instance, using gaming to ‘come out’ to other people, by initially coming out in the online community, which is perceived as a safe environment, and then gradually coming out in real life. Gaming, as for many non-trans individuals, can derive psychological benefits and a sense of escapism. This is even more relevant among trans people as it may be the only time that they feel they can be themselves, allowing them to feel happy, relaxed, and achieving a sense of completeness. This could develop into a powerful coping skill substituting unhealthy behaviours, such as self-harming behaviour. This is particularly important in this population as research shows a strong association between being trans and mental health problems, particularly depression and self-harm as a way to manage one’s trans feelings. This is not surprising as the discomfort and distress about assigned gender and body dissatisfaction may lead to a sense of hopelessness, which can bring low mood, self-injury and even suicide.
Although gaming appears (at least initially) to be a positive and beneficial activity for many trans people, there is also the risk that staying in the game becomes too much of a secure and safe environment. This can create a vicious circle where the trans person does not wish to move out of the secure online world, and back into reality. Spending an increasing amount of time in online gaming carries the risk of developing a gaming dependence or addiction. This may not only affect one’s personal relationships, work and/or study, but may also impair real life social gender role transition, as in many cases, the individual is expected to socially transition before they can be considered for treatment.
Obviously our paper only included four participants and may be perceived by some researchers as ‘anecdotal’ because the data were not collected for this specific study but were retrospectively collated. However, our findings showed that for a trans individual, the online gaming environment was perceived as “safe” but further research is needed to establish what the distinctive elements of online gaming are that help to raise gender awareness (or not as the case may be). With the rates of gender dysphoria attending clinical services increasing significantly, future research should investigate (i) the rates and severity of gaming among this population as well as its function, and (ii) the rates of gender dysphoria among game addiction as coming out may help their addiction. The game industry may also want to consider how they can use games as a way of helping trans people being more accepted within society by developing game industry may want to co-observe how their games can prepare and assist individuals to socially transition. Online games also provide a safe environment that provides people access to a platform where individuals can discuss and experiment with gender identity.
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
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