Changes in sexual thoughts and behaviors in a clinical sample of child sexual abuse material users under the COVID-19 pandemic

Abstract

In this article, we describe a qualitative study in which we examined perceived effects of the COVID-19 pandemic on help-seeking individuals who access child sexual abuse material (CSAM, legally referred to as child pornography). The study recruited 18 participants who were part of the internet based Prevent It Cognitive Behavior Therapy (CBT) clinical trial, which aims to reduce CSAM use and child exploitation, and were willing to answer questions during a semi-structured interview about the perceived impact of the pandemic restrictions on their lives, including their sexual thoughts and behaviors. Key themes that were identified from the participants’ answers included changes in day-to-day life, mental health, sexual thoughts, behaviors or urges, responses and coping strategies used to deal with sexual urges, changes on the forums, positive changes, and how they could best be assisted with coping in this situation. Our qualitative analysis also suggested that the pandemic affected urges to use CSAM, therefore potentially increasing the risk of online sexual offending. These results support that there is a need to investigate this potential negative side effect of quarantines or lockdowns before future pandemics.

LAY SUMMARY

Users of child sexual abuse material were interviewed about changes in their daily lives as well as sexual thoughts and behaviors during the COVID-19 restrictions. The changes found, such as in general mental health and sexual urges, can increase the risk for sexual offending and are therefore important to consider regarding possible future lockdowns.

Keywords:

• Child abuse
• pedophilia
• COVID-19
• sexual behavior
• cognitive behavior therapy

Introduction

Many people experienced an increase in time spent at home due to restrictions during the COVID-19 pandemic, particularly during the first year, such as directives to work from home when possible, virtual schooling, and the closing of many restaurants and retail shops (Centers for Disease Control and Prevention, 2021; United Kingdom Parliament, 2021; World Health Organization, 2020). As a result, both adults and children spent more time online for work, school, and socialization. Many experts expressed concerns that these restrictions would lead to more opportunity for online sexual exploitation against children (Alfonso, 2020; End Child Prostitution and Trafficking (ECPAT) International, 2020; The European Union Agency for Law Enforcement Cooperation (EUROPOL), 2020a; Khazan & Fetters, 2020; Turban, 2020; United Nations International Children’s Emergency Fund (UNICEF), 2020). In addition, the United Kingdom police, as well as other law enforcement and child protection agencies, reported notable increases in concerning online behavior, specifically on forums where child sexual abuse material (CSAM) is spread (Fitzpatrick, 2020; National Crime Agency, 2020). Recorded data from the United Kingdom was published showing a 17% increase in police reported online sex crimes, including crimes involving child sexual abuse material (CSAM) and grooming behaviors, within the first six months of the lockdown (National Society for the Prevention of Cruelty to Children, 2021). Additionally, there were reports from The European Union Agency for Law Enforcement Cooperation (EUROPOL) (2020b) in which a sharp increase in concerning online activity following the first wave of the COVID-19 pandemic was seen. Information on this concerning online activity was gathered by looking at changes in the volume of users attempting to access CSAM online (through both clearnet and darknet forums), as well as changes in the number of posts on these forums, the volume of police reports about child sexual abuse or exploitation, and the number of referrals from the National Center for Missing and Exploited Children.

The Prevent It team at Karolinska Institutet also noticed changes in the darknet forums where users of CSAM are recruited. These changes occurred in the months following the start of pandemic restrictions and included an increase in the number of active chatters, an increase in aggressive messages (toward other CSAM users and Prevent It recruiting staff), and an increase in instructive messages detailing how to gain more access to children in light of the pandemic (McMahan et al., 2020).

One potential explanation for any increases in online child sexual exploitation include increased opportunity, because potential perpetrators and victims were online more frequently (Bhatia et al., 2020; United Nations International Children’s Emergency Fund (UNICEF), 2020). Another is that there would be less reporting as a result of fewer contacts with teachers or other trusted adults, reduced access to health care services, and workplace restrictions on child protection authorities. A third possibility is that, as a result of the pandemic and the restrictions, many people suffered from stress, other negative mental health effects, worries about illness, and economic impacts. These mental health effects might increase risk of perpetration or victimization (Fancourt et al., 2021; O’Connor et al, 2021). Because of the growing concern about increased risk of child exploitation and abuse, the Prevent It research team investigated perceived changes in both risk and protective factors during the pandemic for participants in the Prevent It online therapy program.

The motivation-facilitation model

Risk of child sexual exploitation perpetration is neither randomly nor uniformly distributed. Some individuals are at a relatively greater risk of child sexual exploitation and abuse. The Motivation-Facilitation Model (MFM) (Seto, 2019) has been proposed to organize risk factors for the onset or maintenance of sexual offending involving children. According to this model, three primary motivations to commit sexual offenses involving children are (1) paraphilias, particularly pedophilia or hebephilia, involving sexual attraction to prepubescent or pubescent children, respectively; (2) excessive sexual preoccupation (sometimes referred to as hypersexuality); and (3) intense mating effort, reflected in atypical effort towards novel and multiple sexual partners. Whether someone acts on these primary motivations depends on the presence or absence of facilitation factors, which can be organized into trait, state, or situational factors. Trait factors include personality traits such as impulsivity or callousness, state factors include negative mood or intoxication, and situational factors include access to potential victims (or, in the case of CSAM offending, access to CSAM online). There is ample evidence that these motivation and facilitation factors are relevant in understanding sexual offending (Hanson & Bussière, 1998; Hanson & Morton-Bourgon, 2005; Whitaker et al., 2008). Pandemic restrictions, and their subsequent effects on time at home and online, mood, and stress could particularly affect state and situational factors, thereby increasing the risk of child sexual exploitation as some individuals will view pornography or engage in other sexual behavior in order to cope with negative feelings (Cortoni & Marshall, 2001).

The Motivation-Facilitation Model is silent on the potential role of protective factors, which can be defined as factors that buffer the individual against effects of risk factors. Protective factors are not simply the absence of risk factors. Research on protective factors is less well developed than research on protective factors, but several candidates have been identified. Possibly the strongest evidence of protective effects in criminology is for positive social ties (to family, friends, co-workers, and the community) (Laub et al., 2006). These positive social effects can buffer the individual against the influence of antisocial peer influences.

It has been suggested that the MFM could also be applied to CSAM offenders (Seto, 2019). There are potential differences in facilitation factors for CSAM offenders as they have been shown to have lower antisocial traits and criminal history when compared to contact offenders (Babchishin et al., 2015). CSAM offenders’ motivation to engage in sexual behavior involving children is suggested to be due to their pedophilic or hebephilic sexual interests, however CSAM offenders’ high self-control or low facilitation factors create a low likelihood of committing contact offenses. Even though these factors are barriers for CSAM offenders to commit contact offenses, they do not inhibit acting on their motivations by committing CSAM offenses online. CSAM offenders have more access to the internet but less access to children when compared to contact offenders, which is consistent with routine activity theories (Babchishin et al., 2015; Seto, 2019) and is a further concern with regards to the COVID-19 pandemic restrictions resulting in increased time online for both adults and children.

Another framework that has been used to give a broader context is the Routine Activities Theory (RAT), which posits that there are three elements for a crime to occur. These factors include a motivated offender, a suitable or available target, and the absence of a capable guardian (Cohen & Felson, 1979). As previously described, the situational and environmental factors during the pandemic increased the number of potential motivated offenders as well as the number of suitable and available targets. There was a potential change in the number of capable guardians due to the limited in-person interactions with external individuals. This could mean a reduction in non-related guardians and an increase in time with related guardians at home. Both the MFM and the RAT models suggest that pandemic restrictions may increase risk for CSAM.

Prevent it

Interventions have tried to prevent CSA by reducing the strength of motivation and/or reducing facilitation factors (or increasing protective factors) (Seto, 2019). Prevent It is an anonymous internet-based cognitive behavioral therapy (CBT) given in English, which tries to reduce facilitation by reaching individuals who are already using CSAM and teaching them how to manage their sexual urges (motivation), risk situations, and increase their coping and other skills (facilitation) (https://www.iterapi.se/sites/preventit/register). Prevent It has been tested in a blinded, controlled randomized clinical trial design of 160 participants and was shown to be effective in decreasing the consumption of CSAM (Lätth et al., 2022). In Sweden, where the Prevent It research group operates from, it is illegal to produce, possess, view and/or distribute documented sexual abuse against children (those under the age of 18) and termed “child pornography crime.” It is classified as a crime against public order according to chapter 16 of the Swedish Penal Code (Brottsbalken (SFS 1962:700, n.d.)).

Prevent It participants were randomized into either a CBT or Placebo group, with the difference being the removal of active CBT components such as behavioral activation exercises. Both treatment arms contain weekly module content, assignments, and weekly individual therapist feedback over eight weeks. The feedback for the CBT group was active and change-focused by identifying and encouraging behavioral change, while participants in the Placebo group received more passive feedback that only focused on reflecting and validating the participants’ answers. The CBT group in our study received internet-based cognitive-behavioral therapy modules, which were designed to help reduce their use of child sexual abuse material (CSAM). These modules involved teaching the participants various cognitive and behavioral strategies to help them manage their CSAM use and reduce the risk of engaging in online sexual offending. In contrast, the placebo group received a basic internet-based program, which provided them with information about the harmful effects of CSAM use and the importance of seeking professional help. The service providers for both groups were trained mental health professionals with experience in working with individuals who use CSAM.

Given a hypothetical scenario in which a participant expresses a desire to use CSAM, a CBT therapist might use cognitive-behavioral strategies such as thought stopping, distraction, or relaxation techniques to help the participant manage their urge to use CSAM. The placebo provider might instead provide the participant with information on the harmful effects of CSAM use and encourage them to seek professional help if needed.

The target group for Prevent It was individuals who were actively using CSAM and wanted to stop. Participants needed to be over 18 years, have accessed CSAM in the week prior to the study’s intake interview, have about one hour a week over eight weeks to dedicate to treatment, and be able to read and write in English. The recruitment for Prevent It went on from April 16, 2019, to September 20, 2021 which means that there was ongoing recruitment during lockdowns in different parts of the world.

Recruitment for Prevent It occurs over specific forums on onion sites, sometimes called the darknet, where CSAM content has been known to be discussed and shared. These onion sites apply onion services’ protocol for extra security, with the tradeoff that the users, in order to access them, need a specialized web browser such as Tor. Onion sites maintain a high degree of anonymity by obscuring the source and destination of the user, hence making it difficult to connect an identity with one’s online activity. On the one hand, this allows individuals to speak freely and have more control over their privacy; however, this also makes it easier to engage in illegal activity, such as downloading and sharing CSAM, without one’s identity being discovered by law enforcement. The Prevent It treatment is also offered through an onion site to increase participant comfort given their concerns about privacy or the potential of being identified as engaging in illegal behavior. The anonymity gives individuals an opportunity to seek care and be more open and truthful than they might be with an in-person therapist.

Present study

Due to pandemic responses having a large impact on daily life, the noticed changes on the forums, and the unique access we have to this specific target group, we were interested in how the sexual thoughts, feelings, and behaviors of individuals who are involved in an online CBT intervention to reduce their use of CSAM may have changed during the pandemic. To achieve this, a qualitative semi-structured interview study was conducted by inviting the clinical population included in Prevent It to give us more insight into the changes they perceived during the pandemic. This patient group and process are described below.

Method

Participants

A total of 18 male participants who were already enrolled in the Prevent It program were recruited to participate in the present study. Two thirds (67%) of these participants had already completed participation in Prevent It before the interview and the other one third (33%) were at least halfway through the program. Interviews were semi-structured, with researchers asking follow up questions to predetermined questions, and were held from June 2020 to April 2021. All participants started the Prevent It program after April 2020, meaning that they started working to decrease their use of CSAM after the pandemic had already begun. Of the 18 participants, 9 were in the Prevent It CBT group and 9 were in the placebo group. It was by chance that the group was evenly divided between CBT and placebo patients. All participants who were either done or at the end of their programs were asked if they would like to take part of this sub study and all who said yes and participated were included. Table 1 gives an overview of the participants’ self-reported descriptive information including approximate age and which continent they currently lived on at the time of the interview. Regarding age, 11% were in the 18–20 age range, 39% were in the 21–25 age range, 22% were in the 26–30 age range, 6% in the 31–35 range, 11% in the 36–40 range, and 11% in the 51–55 range. 50% lived in Europe, 11% in Asia, 11% in South America, and 28% in North America. No further demographic information was available because no other demographic questions were asked, to protect participant anonymity.

Table 1. Participant demographic information.

Participant	Age	Continent
1	18–20	Europe
2	18–20	South America
3	21–25	Asia
4	21–25	Europe
5	21–25	South America
6	21–25	North America
7	21–25	Asia
8	21–25	Europe
9	21–25	Europe
10	26–30	Europe
11	26–30	North America
12	26–30	North America
13	26–30	Europe
14	31–35	North America
15	36–40	Europe
16	36–40	Europe
17	51–55	Europe
18	51–55	North America

The project description of the Prevent It application that was approved by the Swedish Ethics Appeal Review Board (Reference No.: Dnr Ö 1-2019) includes approval to interview the participants about their sexual and psychological health, use of CSAM, risk factors for committing sexual crimes against children, and social situation over the chat function on the Iterapi platform. The questions asked in this qualitative study were assessed to be covered in this description.

Interview protocol

The interview protocol was designed by the research team to get a broad picture of the participants’ lives during the pandemic and how it affected them (see Appendix). The questions asked how the pandemic impacted participants’ day to day life, their sexual thoughts or behaviors, their sexual urges or use of CSAM, availability of CSAM material on darknet forums, what they felt would have helped them cope with their sexual thoughts and behaviors during pandemic, and their mood and mental health. These interview questions were created in order to detect changes in established risk factors for CSAM use (Seto, 2019) and aimed to target facilitation factors, specifically state or situational factors that could have an effect on risk. State factors we focused on included mood, mental health, and day to day activities. Situational factors included interactions with children and the presence of others. At the end of the interview, the participants were given the opportunity to discuss any other experiences related to COVID-19 pandemic. The first, second, and third authors conducted the interviews. The first three interviews were conducted collaboratively to make sure there was consistency in interview technique and responses to participants. Because of the semi-structured interview style, there were no noticeable issues with the consistency between interviewers. The interviews were also conducted over a chat forum, which allowed for more time to think for both the researcher and the participant, with no inconsistencies in demeanor. If there were any questions about a particular answer, the other researchers were accessible over the phone. After each interview, a transcript of the conversation was sent to the first author with password encryption.

Procedure

Participants in Prevent It who were finished with the program, or close to finishing, were asked if they would like to participate in a 45-minute interview which would ask specific questions about how the pandemic affected their well-being, and more specifically, how it affected their daily life, sexual thoughts or fantasies, and online behavior. All communication, including recruitment and the interviews, were done on the Prevent It internet platform (https://www.iterapi.se/sites/preventit/register). Of the 50 Prevent It participants who were asked if they would like to participate, 18 replied that they were interested. A consent form was sent which included consent to being quoted, and once consent was given, an interview time was set and the interview was held over the secure Prevent It chat server. Advantages of holding the interviews over text include documenting answers exactly how they were written by the participants, allowing the participants time to pause and think about their answers, as well as anonymity to encourage openness about stigmatized thoughts and behaviors. Some disadvantages to this method could be a decreased rapport, the inability to see facial expressions and body language, and a possible decrease in spontaneous excerpts in response to the interview questions. Additionally, chat-based, video, or telephone qualitative interviews have been shown to be reliable and valid alternatives to in person interviews (Saarijärvi & Bratt, 2021). The interviews were conducted from June 2020 to April 2021.

Data analysis

The interview transcripts were analyzed through qualitative inductive content analysis (Sandelowski, 2000). In inductive content analysis, the meaning units and categories are linked to the data themselves rather than a preconceived coding manual. In this way, the analysis is flexible, and allows researchers to make modifications as data provides information. Information from Sandelowski (2000) was used to guide the coding process, which is described in detail here.

In the first phase of the analysis, active reading of the interview transcripts was done to become familiar with the data, and to take note of any initial emerging patterns, potential meaning units, or points of interest. Meaning units can be best described as terms or phrases that identify an element in the data that can assist in organizing the data into groups. Phase two of the analysis involved combing through each transcript and developing meaning units for specific elements of interest. This was done by taking note of any changes the participants described. Phase three involved collapsing the meaning units into comprehensive categories. Due to the interview being about changes during the pandemic, many of these meaning units fell into categories related to different changes, for example, related to their work or about their anxiety. Phase four involved collapsing these categories into overarching themes. Phases one through three were completed by the first author and sent to the second author for review and discussion. Because of the wide range of answers that we received, and due to the questions directly related to behavioral and mental health changes, the created themes became linked to the questions. The initial analysis was done inductively, without predetermined meaning units or categories. This means that while the themes became linked to the questions, the meaning units were not necessarily taken only from the related question. For example, many participants expressed feelings of depression or anxiety under several different points in the interview, not just in response to the question about possible changes to mental health. These responses were all grouped under the theme “Changes in Mental Health.” Phase five involved refining the themes to ensure that they were distinctive from all other themes. Lastly, in phase six, the themes were formally defined and the data within were described.

Due to the subjective nature of the coding process, criteria such as internal validity and reliability cannot be established in content analysis. Instead, qualitative researchers have recommended the use of credibility, transferability, and confirmability as criteria for judging the quality and impact of this kind of research (Korstjens & Moser, 2018). Credibility, similar to internal validity, involves ensuring that the qualitative findings are the correct interpretation of the views expressed by the participants. There are several strategies that can strengthen credibility, and in the present article this included prolonged engagement, where participants were asked follow-up questions to clarify their answers, and to give examples in order to get richer data. An example of this is if in response to the question “Have you noticed any changes in your sexual thoughts, urges and behaviors since the beginning of the pandemic restrictions? If so, in what way, and why?” a participant replied “Yes, there were changes” they would be prompted again with validation and examples of possible changes in order to fully investigate the participants’ perceived changes. Persistent observation was also used when creating the meaning units and categories. This required reading and analyzing the data, as well as revising the concepts and meaning units, as described above. Transferability, as with external validity, refers to the ability of the researcher to generalize the findings to other contexts. This was achieved by giving a detailed account of the descriptive data, including the context, procedure, and responses from participants in this study. In this way the results from this qualitative analysis can be considered when thinking about similar groups and situations. In this case, the group is very specific: help seeking participants who were in treatment for CSAM use reflecting about pandemic restrictions. Finally, confirmability (i.e. objectivity) is the degree to which the findings may be confirmed by others. Confirmability was obtained by openly sharing themes, meaning units, and a raw data set within the research team as well as openly discussing research steps and development. Everyone working with the study discussed the research steps and helped develop the interview guide. Participant answers were discussed as a group, and the way in which the meaning units were combined into categories and themes was openly discussed and agreed upon.

Results

The answers to the interview questions were grouped by the question and their response into the following themes: Changes to Day-to-Day Life; Changes in Mental Health; Changes to Sexual Thoughts, Behaviors or Urges; Responses and Coping used to deal with Urges; Forum Changes; Positive Changes; Needed to Cope. In this section we discuss the major categories and findings, focusing on those related to potential risk and protective factors. Table 2 provides a full description of all themes and accompanying meaning units.

Table 2. Themes and accompanied codes.

Theme	Category	Responses	Number of participants
Day-to-Day Life	Work related changes	Working from home	6
		Working with restrictions	2
		Difficulty finding work	2
		Difficulties with organization, scheduling, and daily structure	2
		Increased procrastination	1
		Increased work stress	1
		Decreased work stress	1
	Social related changes	Decreased social activities	12
		Decreased recreational activities	5
		Increased time talking to online friends	1
		Working on social skills/relationships	1
		Increased time on social media	1
	Changes at home	Increased unstructured free time	9
		Change of living situation	2
	Health/lifestyle changes	Decreased meals	1
		Less eating out	1
		More cooking	1
		Decreased alcohol consumption	1
		Increased exercise	1
		Decreased exercise	1
		Poor sleep; difficulties with sleep	4
		Better sleep	1
Mental Health	Anxiety/Depression	Increased anxiety and worry	4
		Anxiety specifically about Covid	1
		Feeling unsatisfied and unsettled	1
		Difficulty concentrating	1
		Increased frustration	1
		Feeling uneasy around others	1
		Feeling easily irritated	2
		Depressed “sour” mood	1
		Increased depression	4
		Decreased motivation	1
		Feelings of despair	1
		Feeling hopeless and unsatisfied	1
		Feeling trapped	2
		Feeling isolated	1
		Worry about seeing children face to face	1
		Suicidal thoughts	2
		Feeling lonely	6
		Increased negativity	1
		Negative mental health	1
		Improved mental health	1
		Mood changes	1
		Mixed emotions about CSAM urges	1
Sexual thoughts, behaviors, and urges	Legal pornography	Increased use of legal pornography	3
		Decreased use of legal pornography	1
	CSAM related	Increased fantasies	1
		Increased urges	4
		Increased frequency of CSAM use	7
		Triggers: increased time, increased boredom, more time on social media	3
		Reduced urge to access CSAM	1
		Difficulty to abstain from CSAM	2
		Increased thoughts about minors	2
		CSAM escalated from 2d/3d depicted images to containing real children	1
		Increased violence of material	1
		Increased desire for violent conversations with others on the darknet	1
		Increased collection of CSAM	1
	Compulsivity	Decreased compulsive behavior	1
		Increased compulsive behavior	1
	Masturbation	Increased masturbation	5
Responses/coping strategies for urges	Activities	Keeping busy (working, spending time with family and friends, chats or calls)	3
		Playing video games	4
		Journaling	1
		Reading	2
		Going outside	1
		Watching a movie	1
		Exercise	1
		Sleeping	1
		Self-care	1
		Other hobbies	1
		Reflect on Prevent It exercises	1
		Mindfulness exercises	1
		Identifying risky situations	1
	Substance use	Increased alcohol use	2
		Increased drug use	1
		Increased use of marijuana	1
	Creating Barriers	Deleted the TOR browser	1
		Deleted all accounts on CSAM forums	1
		Deleted all CSAM from the computer	1
		Taking medicine that reduces libido	1
	Reaching out	Speaking to a therapist	3
		Signing up for Prevent It	2
		Peer support groups	2
		Connecting with friends	2
	Acting on urges	Watching legal pornography instead	5
		Masturbating without pornography	1
		Watching 2D/3D rendered CSAM	3
		Watching CSAM	4
	Other	Carrying on despite it being difficult	1
		Trying to reduce porn use	1
		Trying to stop using CSAM	1
		Hitting themselves	1
Forum changes	Activity	Increase in activity	2
		Increase in users	2
		Perceived ease to find CSAM	1
		Brief decrease in users on the forums	1
		Possibly more shut down forums	1
	Content	Increased violent tone	1
		Increase in CSAM uploads	2
	Users	Possible change in material restriction	1
		Increased time to create more CSAM	2
		Increased stress and boredom	1
		Increased use of CSAM to cope	1
Positive Changes	Time	Increase in time for themselves	1
		Increase in family time	1
		Increased time for personal issues	2
		Less guilt about time use	1
		Increased time for hobbies	1
		Increased time for future planning	1
		Increased time at home; time to rest	1
		Time to work on sexual thoughts/behaviors	1
	Health	Increased exercise	2
		Improved health	1
		Improved diet	1
		Decreased stress	1
		Reduced external stressors	1
		Increased mental health awareness	1
	Reflections on other people	Felt that others were more friendly	1
		Felt that others were more helpful	1
		Improved relationships	1
		Perception that one doesn’t need to deal with difficult people anymore	1
		Less crowded	1
Needed to cope	Support	Therapy	6
		Support of partner	1
		Support of friend	3
		A way to manage stress	1
		Get rid of the guilt from CSAM use	1
	Activities	Distractions; less access to CSAM	1
		Social activities	3
		A job to stay more productive	1
		Lifestyle changes (meditation, exercise, relationship with a partner, increased sexual activity)	2
		Avoid boredom; find hobbies/activities	2
		Getting away from the computer	1

Changes to day-to-day life

When it comes to day-to-day life, many participants found themselves working from home with limited social and recreational activities, and an increase of unstructured free time, which some found led to more time online. The categories for this theme included work and social related changes, changes at home, and health/lifestyle changes. Some participants tried to use this time to be productive, such as Participant 2 who reported that they were using their time to form social relationships and improve social skills, stating “My social habits were never good, and since last year it’s been worse, as this year I’m trying to think more about myself, I have started to desire social relationships, and to want to get better with social skills.” There were other health/lifestyle changes indicated by a couple of participants, such as changes in the amounts of exercise, sleep, and eating out they did during the times of COVID-19 restrictions.

Mental health

Mental health was an area where many participants experienced changes. The categories for this theme included anxiety and depression symptoms. These mental health changes included increased anxiety and depression, worry, feelings of dissatisfaction and unsettledness, difficulty concentrating, increased frustration, feeling uneasy around others, and feeling easily irritated. Participant 11 stated, “I find [the pandemic] brought me back to a time where I would stay at home and not do anything, which made me highly depressed.” There were also reports from participants feeling despair, hopelessness, dissatisfaction, isolation and trapped. Participant 13 expressed worry about seeing children face to face after the pandemic, stating that “an interesting factor is that I haven’t seen kids face to face as much in person because of the pandemic. And that is a trigger for sexual thoughts that I may have to get used to again as things go back to normal.” Another common change that six participants discussed was feeling lonely. Participant 8 stated that because “all of my social contacts were [away] … it was hard and I had more time and situation-based triggers which had a negative impact on my sexual behavior.”

Two participants brought up suicidal thoughts during these interviews related to the pandemic and the restrictions. In these cases, where participants mentioned any thoughts of self-harm, the interviewers consulted with the Prevent It supervisor (last author) and these participants were followed up with after the interview.

Changes in sexual thoughts, behaviors, or urges

There were many concerning changes in sexual thoughts, behaviors, or urges expressed by many of the participants. This theme was grouped into the following categories: Legal pornography use; CSAM related; Compulsivity; Changes in masturbation.

When asked about legal pornography use, three participants stated that their urge to use, and their overall use, of legal pornography had increased. When asked about their use of child sexual abuse material (CSAM) during the pandemic, six of the eighteen participants answered that their use of CSAM had increased, and three of them said that this was due to having more time, being bored more often, or spending more time on social media, which led to seeing more triggers for CSAM use. One possible explanation for this increase was stated by Participant 9 as “I do notice that it has been more difficult for me to stay disciplined. That is, it was harder to not think about these things, because I was at home more often and had less distractions.” Along those same lines, Participant 15 wrote that “Considering I am all alone the entire day, I have noticed a stronger temptation to go online to look for sexual material. Even during what would normally be working hours. And the ease of access has made a feedback loop, making me fantasize outside those moments more as well.”

Four participants wrote that their sexual urges had increased, including increased fantasies, increased thoughts about minors, feeling a loss of control about CSAM use, feelings of compulsion to use CSAM, and having increased difficulty abstaining from using CSAM. Participant 11 stated that their sexual behavior changed quite a lot due to the lockdowns, writing “the more depressed I felt, the more violent and deeper the content [I used] … depending on my ‘mood’ for the day I’d pursue different forms of porn but in all likelihood I would see what aroused me and follow that train. So this progressed from 2D and 3D depictions of CSAM to real depictions.”

Responses and coping strategies used to deal with urges

When asked about how they were coping with changes to their sexual urges, thoughts, and behaviors, we received a variety of answers which were divided into the following categories: Activities; Substance use; Creating barriers; Reaching out; Acting on urges; Other.

A common coping strategy was finding hobbies or activities to keep busy or productive. Examples of this could be playing video games, journaling, or exercising. Another common strategy among the participants was the act of reaching out to talk about their struggles with having an attraction to children or their use of CSAM. Some found it helpful to put barriers in place in order to make it more difficult to access CSAM and give into their urges; these barriers included deleting the Tor browser they used to access onion sites from their computer, deleting all accounts from CSAM spreading forums, and deleting any CSAM on their computer.

Another coping strategy that was used by three participants was the use of substances, as they reported increasing alcohol use, increased use of marijuana, and an increased unspecified drug use. Several participants also stated that to cope with increased urges over the last year, they ended up acting on them. Five of the eighteen participants reported being able to watch legal pornography instead of resorting to the use of CSAM, three participants stated they watched 2D/3D rendered images of CSAM instead of images containing real children, and four said they would give into their urges and watch CSAM featuring real children.

Changes to the forums

Participants were also asked about the forums that spread CSAM online. The following categories were created from this theme: Activity; Content; Users. When it came to the activity on the forums, we received a variety of responses including that there was increased activity and amount of users. Participant 14 wrote, “there are many many more users and the amount of users have been uploading 100% more child pornography, it has gotten a lot easier to find and I see more trolling in chatrooms of people seeking new children to photograph.” Two different participants discussed specific content changes. One stated that there was an increased violent tone (examples given were fantasies of rape, torture, killing). Participant 15 stated that “I have noticed a rise of material of a specific type, namely young girls (from early teenagers to very young girls) being tricked into exposing themselves on webcam applications.”

Some participants also gave their impressions of the users on the forums. One participant noticed that people on the forums seemed to be happy about the lockdown because there was more time alone with children to create new CSAM content to upload. Participant 5 got the impression that “some people like me who live with children and are in the houses are more likely to abuse… and these children have no ‘escape routes’, like school, or their friends.” Another participant stated that the users seemed more stressed and bored. When looking at the discussions the users were having on the forums, Participant 3 noticed “a growing sentiment of using child pornography as a way to relieve themselves of sexual urge without ‘actually hurting a child’.”

Perceived positive changes

There were several categories of positive changes that the participants pointed out. These included: Time; Health; Reflections On Other People. There were several who stated that they positively experienced having more time for themselves, family, to focus on personal issues, to improve sexual thoughts and behaviors, and for hobbies. There were also some improved health changes, and two participants stated that they felt less stress and had fewer external stressors due to the pandemic.

Several participants commented on their own perceptions of other people during the pandemic. One participant said that something they found positive from the pandemic was an increased awareness for mental health. There were also comments that others were more friendly during this time, that people were more willing to help each other, that relationships had improved, that you did not have to deal with as many difficult people, and that it was less crowded. One participant expressed that they felt that this time was a way for others to relate to his own feelings of isolation, which he experienced as positive.

What can help the participants to cope?

There were two main categories of answers for question five “Is there anything you feel would help you cope with your sexual thoughts or urges involving children during this pandemic?” These included Support and Activities.

Six of the participants said that therapy would be important to be able to cope, another said the support of a partner, and three said talking to a friend. Other answers included wanting some way to manage stress and wanting to get rid of the guilt from using CSAM in the past. Activities that participants discussed were wanting more social or free time activities, getting away from the computer, and lifestyle changes such as meditation, exercise, or a relationship with a partner.

Discussion

Key themes from the qualitative analysis include perceived changes to day-to-day life, mental health, sexual thoughts, behaviors or urges, as well as changes on the forums, positive changes, coping strategies used to deal with urges during the pandemic, and lastly, how participants could best be assisted with coping in this situation. Reviewing the wide range of responses we received within these themes, we see that while the perceived effects of the pandemic were varying, there were also many similarities in the participants’ descriptions. The biggest similarities were seen in the day-to-day life changes. Due to the pandemic restrictions, many started working from home, with decreased social and recreational activities, and increases in stress and other mood changes. Both the Motivation-Facilitation Model and Routine Activities Theory would predict this could lead to changes in CSAM use during this time period.

Consistent with the Motivation-Facilitation Model and Routine Activities Theory, changes in situational factors caused by the pandemic restrictions were associated with changes in sexual thoughts, feelings, and behavior. This included the urge to use CSAM, using CSAM, or engaging in coping behaviors such as alcohol or drug use. The increased use of coping strategies such as use of alcohol and drugs can also be a cause for concern as it can lead to lowered inhibition and thus state facilitation effects which increase risk. These results are consistent with recent longitudinal research showing an initial increase in mainstream pornography use in the general population, followed by a return to baseline and then decline (Grubbs et al., 2022). Lehmiller et al. (2021) reported, however, retrospective evidence of a decline in sexual behavior (reported by approximately half their sample) but an increase in diversity of sexual behavior for a minority (approximately 1 in 5 respondents).

These similarities also included greater concerns about mental health amongst the participants, many of whom indicated increased symptoms of depression, anxiety, and loneliness, combined with increased unstructured time at home due to the pandemic restrictions (Fancourt et al., 2021; O’Connor et al., 2021). This connection between fewer activities, or sedentary behavior, leading to anxiety (Allen et al., 2019) and depression (Zhai et al., 2015) is well documented. The initial studies of mental health changes during the start of the COVID-19 pandemic also indicated increased stress, anxiety, and depression (Talevi et al., 2020; Wang et al., 2020) as well as increased distress during the first lockdown that evened out over time (Fancourt et al., 2021; O’Connor et al, 2021). It is therefore unsurprising that participants in this study also experienced these mental health effects during the pandemic, and that these mental health effects may have affected their risk of CSAM offending.

Unlike Grubbs et al. (2022), we did not know about patterns of pornography use before compared to after the start of the restrictions. However, the Prevent It team had already reported seeing changes on online CSAM sharing forums, such as increases in activity and violent language, and this was also confirmed by participants who still were accessing these sites (McMahan et al., 2020). We also did not have information about other sexual behavior, such as sexual contacts with children, like Lehmiller et al. (2021).

Many of the participants discussed what could help them cope with these increased urges, which was a combination of support and activities. Access to therapy was the main suggestion by participants, which would also reinforce many of the other suggested areas (increasing support, making lifestyle changes, finding, and scheduling free time activities). Looking at this more broadly we see a situation where some individuals were more bored, depressed, had more unstructured time and were coping by spending more time online and increasing substance use. This is potentially concerning when it comes to a group that has urges to use CSAM or a history of using CSAM, especially when resources and support for this behavior are lacking. Our findings reflect distress and increased urges to online offend in a large portion of the participants who would like to receive help. This could mean that the lockdown period is a potential risk escalation for certain individuals. Because of this there is a need to actively explore preventative interventions for this and other vulnerable groups when it comes to possible future quarantine and lockdown periods. There was also a large need for mental health and wellbeing support shown when it comes to future quarantine and lockdowns, as this could have an impact on risk factors for CSAM use.

These results have implications for clinical practice because it highlights recommendations about general lifestyle factors that may also need to be addressed to reduce CSAM offending. These general lifestyle factors include time spent online, use of leisure time, positive social supports, and healthy ways of coping with stress or negative mood, such as exercise or other structured activities, and socializing. Another clinical implication of the findings is that this patient category, individuals with urge to use CSAM, should be given extra attention by their therapists during potential risk situations such as lockdowns.

Limitations

A sampling limitation of this study is that we interviewed participants who were registered in the Prevent It trial, which is a group of help seeking individuals. There could be differences between help-seeking and non-help seeking persons who currently use or have in the past used CSAM which could influence their responses to the interview questions. Because these participants had just participated in either the Prevent It CBT or a placebo treatment program, the way of reflecting on their mental health and behaviors could be different than if they had not just received treatment. For example, access to therapy was a common suggestion for what was needed to cope with increased sexual urges among participants, this may be a less common suggestion among those who were not involved in treatment or interested in seeking help.

Even amongst the Prevent It participants, our interview participants likely differed in meaningful ways, because they were a minority (18 out of 50) of the participants who were approached. For example, compared to those who declined, these individuals may have been more comfortable talking about themselves over chat, felt more positively about Prevent It because they found it beneficial, or had stronger opinions about the COVID-19 pandemic.

In addition to having participated in Prevent It, participants in this study may have differed in meaningful ways from other CSAM users. For example, many participants indicated they were able to work from home, something that was not possible for many workers in hospitality, manufacturing, and other sectors that require an in-person presence. The COVID experiences of workers who could not work-from-home might be quite different, where initially there was no work at all, leading to financial and other stresses, and then there was an expectation of working under potentially stressful conditions, including risk of COVID infection.

Another limiting factor is that we don’t know the exact locations of our participants due to the study being anonymous. Countries responded differently to the pandemic, with varying reaction times and degrees of restrictions. This could have been one of the reasons for the variety of answers we collected in this study, as respondents living in jurisdictions where there were relatively few restrictions, such as in Stockholm, Sweden, would presumably report fewer changes than those in jurisdictions where there were heavy restrictions and a high impact of COVID, such as New York City, United States of America.

This study was based on self-reported information from the participants, so participants could have chosen not to be open about certain aspects of their sexual behavior. For example, they could have estimated fewer changes in order to appear like they are doing better after the Prevent It program than they actually were. Additionally, an analysis based on the treatment group could have been done to see if there were any differences in the way participants in the CBT or placebo group answered.

The interview protocol was created to give open ended questions about changes to sexual behavior, thoughts, and feelings. However, because the resulting themes were closely tied to the questions asked, the wanted flexibility may not have been achieved. In order to reach new or unexpected findings more general questions could have been asked at the start.

Lastly, we are unable to draw conclusions about causality. It is a retrospective, cross-sectional survey which means that we also could not examine changes over time. Participants reported on whether they experienced changes or not, but we don’t have information on the magnitude of these changes, if they changed over time (e.g. an initial increase in pornography use in the first few months following the first pandemic lockdowns but then a return to baseline) or were still ongoing. The answers received were also given based on open questions without examples of possible answers, so it can be the case that multiple participants would have agreed with additional answers but that they were unable to think of them during the interview.

Future directions

Though being online was seen as potentially increasing risk because of potential access to CSAM or visiting forums that facilitate CSAM use, a recent survey study suggested that some online forums can be sources of emotional and informational support, where individuals concerned about using CSAM might find positive peer interactions (Roche et al., 2022). Further research on both positive and negative effects of being online, and being involved in online forums in particular, would shed light on the net effects of being online more and how that might interact with individual characteristics and other factors.

Future research may also be able to look at potential differential effects of pandemic restrictions. Though there were worries as well as some data suggesting increases in online sexual offending, including CSAM use, because of work-from-home, virtual schooling, and the shutdown of restaurants and retail spaces, the same pandemic restrictions might have had a net effect of decreasing contact extrafamilial child sexual abuse because unrelated adults and children mingled less, while increasing contact intrafamilial child sexual abuse because related adults and children spent more time together.

Another avenue for future research would look at protective factors as well as risk factors. In particular, positive social support has been identified as a promising protective factor, where both offline and online influences could conceivably neutralize some of the effects of risk factors (de Vries Robbé et al., 2015).

Conclusion

Our qualitative data reflects that the help-seeking CSAM viewers in this study experienced that restrictions could have affected their urges to consume CSAM, increasing them and increasing the risk of online offending. The perceived impact and effects of the restrictions varied among participants, some experienced improvements while others had negative experiences. Due to our findings reflecting distress and increased urges to online offend in a large portion of the participants, there is a need to explore preventative interventions for this and other vulnerable groups when it comes to possible future quarantine and lockdowns, including children at risk of being exploited. Prevent It, as well as other treatment manuals currently being tested, will need to take the potential effects of the pandemic restrictions into account when analyzing the results of treatment on the patients due to the large strain on mental health, especially in the beginning months of the lockdown.

Availability of data and material (data transparency)

Data and material not available on request due to ethics approval.

Code availability (software application or custom code)

No software used.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was funded by World Childhood Foundation.

Employment through Psychiatry South, Region Stockholm.

Appendix

Interview questions

1. “How has the pandemic affected your day to day life?”

2. “Have you noticed any changes in your sexual thoughts, urges and behaviors since the beginning of the pandemic restrictions? If so, in what way, and why?” Follow up question: “Have you found there to be a change in your: use of legal pornography; masturbation; engagement in sexual activity with a partner; other sexual behaviors?” If yes, “What have you done in response to your sexual thoughts, urges, and behaviors during this pandemic?”

3. “Can you tell me if your use of, or urges to access CSAM have changed compared to prior to the pandemic restrictions? If so, in what way and why?” If yes, “What have you done in response to your sexual urges involving CSAM during this pandemic?”

4. “If you still access darknet or clearnet forums/chats with other users who have a sexual interest in children, have you noticed any changes in these forums (for example, in the tone of interactions, activity in the forums, availability of new material, etc.)?”

5. “Is there anything you feel would help you cope with your sexual thoughts or urges involving children during this pandemic?”

6. “Earlier you mentioned the pandemic affected you in X ways. To get more information about this, could you tell me how the pandemic has affected, for example, your employment/studies, your current housing situation, your social habits, or the structure of your day?” Once they were asked this question, if participants only answered with either positive or negative changes the following question was used, “Have you noticed any [positive/negative] changes in your day to day life resulting from the pandemic?”

7. “Have the pandemic restrictions affected your mood/mental health (positively/negatively)? If so, how?” Follow up question, “If you experienced any negative changes, how did you cope with these?”

8. “Are there other changes that you have experienced related to COVID-19 that you would like to talk about?”