Problematic pornography use (PPU) has been extensively studied in terms of its negative implications for various life domains. The empirical literature reveals measured outcomes of interpersonal and intrapersonal dysfunction in participants’ everyday living, supporting its classification as a disorder. The increasing number of complaints around PPU opens the door to the creation of online self-help rebooting communities. This qualitative study aimed to provide a better understanding of this behavior by investigating potential etiological pathways contributing to the onset of PPU, as they were expressed by members of the online NoFap/PornFree self-help communities with self-perceived PPU. The critical narrative analysis reveals a complex web of mutually informing causal connections. The dialectical relationship between situational resources, material conditions, and an embodied spectator gives rise to an online persona with motivations of self-exploration, experimentation, and socializing. A sense of vulnerability rendered the use of pornography as a means of escape and validation. Furthermore, commitment to abstinence, framed by the notions of recovery and relapse, was found to be a major factor for maintaining distress. The study highlighted the need for a thorough understanding of the etiological pathways of PPU for a more effective and targeted intervention. Moving beyond biomedical conceptualizations suggests an intervention whereby PPU is placed in a context of a crisis of meaning. The definition of what actually constitutes pornography is a necessary step preceding any discussion related to pornography. Some of the main contradictory viewpoints have drawn upon liberal and radical feminist epistemologies, or have moral conservative roots McNair, . These aDefining pornography can also be conceptualized more individually, by focusing on the kind of pornographic material designed to stimulate the consumer  has been theoretically characterized by its accessibility, affordability and anonymity Cooper, ; King 1 later adWithin discussions around the expansion of the qualities and capacities of IP, a discourse of dangerousness arising from its consumption emerged. By the end of 1990s, alongside the media, there has been a proliferation of academic and clinical literature investigating the potential effects of IP on the user’s mental wellbeing  addictions  from the subreddits NoFap (see r/NoFap) and Pornfree (see r/pornfree). These forums are available 24 h a day, publicly accessible for reading, while posting is allowed only via registration. Anonymity is preserved by using usernames. These sites seem to share the same philosophy; IPU is considered unhealthy and has severe effects in relational and personal domains. The notion of pornography addiction is clearly manifested in both of these self-help community forums; with recovery as their stated aim, regarded as attainable mostly through abstinence from pornography and/or masturbation. However, it needs to be mentioned that in contrast to the strict guidelines of r/Nofap regarding abstinence from pornography, masturbation, and orgasm (PMO), the subreddit r/pornfree seems to support the abstinence from pornography-induced masturbation without criticizing necessarily the masturbation itself. Given the person-centered approach interwoven in these forums, mutual support is achieved through encouraging answers, motivational tracts, information sharing and consultation for alternative approaches. Based on asynchronous posting in conversation threads, these forums provide vast numbers of shared stories of IPU’s effects on their daily lives as well as around the potential roots of their situation.For this study, participants were 40 registered online forum members (30 from r/Nofap and 10 from r/pornfree respectively) who described themselves as problematic pornography users or pornography addicts. Throughout the manuscript, participants share problems and report difficulties related to both perceived addiction to pornography and perceived pornography induced sexual difficulties (PIED). Out of 40 participants, 26 mention erectile dysfunction (ED) and/or porn-induced ED as their main topic related to self-perceived PPU while 14 of them make complaints about porn addiction without mentioning any sexual difficulties. Despite the fact that sociodemographic details were not easily accessible due to the anonymity provided on the internet, information on age and gender was deduced implicitly from the content of posts . Thus, in this study the majority of participants were males between 21 and 32 years old, heterosexual  with good intellectuality . Some of them could be considered as actively engaged in the forums while others were more occasional users. Moreover, a degree of heterogeneity about their cultural background could be assumed based on expressions like “English is not my first language.”The sample investigated can be seen as representative to the forums as a whole. NoFap’s  survey rIn spite of the fact that online forum communities are widely recognized as a valid method for research  were created. These patterns were grouped, in turn, into themes which were finalized after repeated modifications. Furthermore, the identified stories and canonical narratives were compared across individuals. Differentiations and commonalities were framed using Murray’s narrative lenses. Across the analytical procedure emphasis was placed on the co-construction of the identity and the experience. This level of synthesis led to the creation of a coherent whole. Before the final stage of writing up, a checking process of the internal homogeneity and the external heterogeneity Patton,  of the tIn this section, the prevailing narratives of participants’ are theoretically presented as a three part chronicle. These categories are distinct in their nature but overlap, to a great extent, in terms of their mutually informing causal interactions. Across the chronicle, the three analytical levels are intertwined and work together to provide a coherent and prevailing story. A summary of the potential etiological factors, as constructed from the analytical process, is illustrated in Fig. [Extract 1]: I have been masturbating since I was 11–12. Everything started when a friend gave me some CDs with hardcore content… Since then I have been masturbating every day… When I was 15 I got a limitless internet connection, and that's when all began to turn serious .[Extract 2]: Alone now, out in the world, with my own paycheck to satisfy myself with whatever I wanted. Not concerned about my father catching me, not worried about friends finding my secret stash at school, I could consume as much as I wanted for as long as I wanted .The above extracts exemplify the typical starting point of participants’ personal story regarding IP use. The participants’ accounts provide a chronologically structured ontological narrative where specific space and place relationalities introduce their engagement with IP use as a multifaceted, context-created temporal experience.As it is indicated, the onset of their use began in the early or middle adolescence, an event which is representative across the data set. Within this context, pornography was introduced, in part, by peers in a socialization context. Extract’s 1 positioning regarding the initial phase of IP use illustrates that pornography use is a matter of privacy, open for sharing with a social group. This public narrative implies the participants’ casual use, motivated and framed by the longing for bodily self-exploration. However, participants’ discourses around availability of resources, experimentation and privacy frame the shift from casual pornography engagement to more conditional use. Specifically, the availability of a private space, internet access, and a limited family gaze enhance IP engagement to a great extent. For instance, narrators clearly point out that acquiring a feeling of personal freedom without external limitations was a pivotal moment for its use in a regular basis (Extract 2).Thus, situational resources (private space and free expression) and material conditions (computer existence and internet access), usually associated with and enhanced by a discourse of virginity, is a crucial factor in initiating engagement with pornography. This context-dependent experience seems to facilitate the creation of personal times and spaces of self-enactment. Within this process of sexual interaction between the body and the screen, where the absence of the “third-other” is necessary, the embodied spectator emerges, deriving pleasure from watching and sexualizing the content on their display. These dimensions, together, are involved in shaping and establishing the identity of the regular pornography user. The image of a person self-restrained to their private space, in the presence of a computer, masturbating with several tabs running simultaneously, is commonly described by participants.In this particular phase, participants justify their positioning with pornography turning into a matter of “consumption” by referring to culturally established narratives of the ubiquity of pornography within a perceived hyper-sexualized culture . At the same time, the decisive role of this social phenomenon in the onset of PPU is revealed:[Extract 3]: Every time I see something somewhat sexual, I turn into an autopilot mode and spend lot of time on it. I really have no idea how to stop, even though I'm aware of what's happening .[Extract 4]: In short, when you spot a very hot image, be it on a screen or in real life, it says: “I am what you want.” And your normal answer is: “Yes! Yes! I want you! I want more of this!” At that very moment you’re screwed up (…) you’re getting on a train moving toward one more failure .This process of “pornification”—where pornography is gradually incorporated in everyday life by becoming normalized in public life  and then others from school latched onto that pattern, until I was totally consumed by self-loathing. I decided to rely on fantasy, porn, fapping, and weed instead of real relationships from now on .[Extract 7]: I don’t know how all began. I am pretty sure it actually started when girls started to call me ugly. Afterwards I somehow turned to porn .A prevalent pattern across individuals’ sense-making process is a history of victimization (bullying), especially within their environment of interaction. This victimization takes the form of physical abuse, taunting behavior, and social isolation by peers. In their narrations, many participants  reported complaints about intimidation and fears for their safety when exposed around others. These feelings of insecurity are also perpetuated by a sense of lack of control over the situation, which in turn enhances the narrators’ sense of dangerousness . This prolonged psychological state of vulnerability might consequently lead to problems regarding trust. Thus, it could be asserted that this core sense of security crisis  constitutes one of the dimensions of “being weak.”The participants’ lived experiences of intense and prolonged states of extreme shame and worthlessness lead to an overall desire to hide, suggesting loneliness as a conscious choice to avoid the painful gaze of peers. Here, the notion of loneliness is conceptualized both as self-isolation and lack of emotional intimacy with others within a context of loss of complete control over the situation. Interlinked with these experiences were participants’ accounts of feelings of shame and self-hate, usually accompanied with references of substance misuse .These psychologically discursive repertoires  construct a discourse of distress that needs intervention and a temporary solution—an escape from the perceived “problem.” Pornography consumption is regarded as a comfort zone and presented as a non-intimidating practice. On this basis, it can be argued that under these circumstances, pornography usage can be conceived as a psychological form of dissociation, acting as a defence mechanism against the prolonged violation experienced in adolescence.[Extract 8]: Probably the problem stems from my father being emotionally absent from my life for the biggest part of my adolescence… If it is more an outcome of my childhood and the lack of acceptance from my alcoholic father, what can I do with that insight? .[Extract 9]: The cause is lined to mother and/or father since you were born, who either didn't accept you as you are, always disapproving, controlling the mind forms natural defense/escape pathways to block the pain… this is how addictions form .Consistent with the use of pornography use as a means of escape are narratives derived from the interpersonal environment of the family. Specifically, mentions of a physically and emotionally distant father, a disturbing environment and/or controlling parents, structure a wider pattern of a non-supportive familial environment. As it is illustrated in narrators’ confessions, these patterns have significantly influenced their perception about their self and self-confidence. In that way, the causal interactions involved in the psychological state of “being weak” are enriched with a new dimension. Feelings of being humiliated, betrayed, deceived and abandoned are the prevalent intrapsychic factors that add to the etiological spectrum of pornography use as a means of escape.[Extract 10]: This is how my psychology works. I feel like a failure in social relationships, then I feel like a smashing success in sexual relationships through the medium of porn and frequent, lengthy masturbation .[Extract 11]: I think porn looks to me like a strong representation of myself. That is, it usually makes perfect sense to me that I would be a kind of sex-god. I use virtual reality as a method of seeing what to me seems like true reality .As it can be assumed from these narratives that the feature of “de-individualization”—“a psychological state in which inner restraints are lost when individuals are not seen or paid attention to as individuals” Chiou, , p. 548—[Extract 12]: So actually a couple of months ago I had a chance to have sex with a girl that I liked for some time, and she was fairly good looking. It was 5 in the morning and I was quite drunk, and I have been able to get a half erection after she pleasured me orally. I blamed it on alcohol and tiredness. I felt shitty and embarrassed. She was quite disappointed as well as she really wanted me to (expletive) her (…). It was 80% at first, but as she continued my soldier started to shrink, and finally ended totally lifeless .[Extract 13]: I just broke up with a 25 year old girl who was more experienced than me. She was very attractive and wanted me BAD. I started to notice that I wasn't able to perform regularly (even though I found her attractive) and it got to the point where it was pissing her off and led her to cheat me. I felt depressed and less of a man because I couldn’t satisfy her hunger for me .A dominant narrative that has been observed across participants’ threads is a series of disclosures around the significance of gender performativity highlighting the importance of masculinity reassurance through sexual intercourse. Sexual performance is virtually interconnected with scenarios of interpersonal sexual negotiations and demonstration of masculinity via a successful erection. Through this performative narrative, participants introduce the significance of corporeality in negotiating the longing for gender comfort and consciousness. As a consequence, online users’ narratives of distress stem greatly from their inability to demonstrate sexual prowess, particularly to a desirable and “hungry” woman. This social construct of women as having an unlimited sexual appetite seem to co-construct men as super-powered, always ready to perform successfully. Therefore, participants’ narratives regarding sexual arousal and ability to perform, as well as the meanings attached to them, are structured around prescribed expectations. Thus, these two bodily practices , combined with the pattern of sexual inexperience, engender a feeling of failure.Moreover, the self-perception of sexual inadequacy seems to result in ambivalence around their virility which in turn leads to overwhelming emotions such us deep shame and embarrassment. According to Thomas , p. 131,[Extract 14]: That was a really difficult time for me. I became very depressed for a long period and I consumed more and more porn, in order to prove to myself that I still can have an erection during fapping .[Extract 15]: I started watching more porn, as porn is the only thing that helped me get an erection and I was thinking I will be more in-control with her next time. All went in reverse of course .In the aftermath of this crisis of masculinity, narrators are turning to pornography consumption in a desperate attempt to confirm their physical adequacy. Since its quasi-realness and enhanced interaction facilitates the self-reflection of the user on the screen, the virtualized “authenticity” of documented successful arousals and orgasms aid the participants to feel better about themselves. In this almost personal relationship with the image, participants’ need to verify that they are “real men” is being artificially met, leading to an increased consumption of pornography. However, this etiological relation between a fragile identity and pornography consumption underscores a feedback loop; pornography’s illusionary ailment of sexual difficulties drives individuals into compulsive use.[Extract 16]: Well, I tried to stop a few things after that to increase my potency at large such us doing a lot of exercise, supplements e.g., some testosterone boosters. I even bought some Viagra online. But nothing actually worked (No. 4 225–227).[Extract 17] Since about when I was 19, I have been having obsessive thoughts about my appearance, my height, how I feel I would have no chance with any girl I would be attracted to. In fact PMOAs it has been demonstrated so far, participants’ self-esteem is based on the internalization of both masculine and feminine idealized standards derived from hypersexualized culture, managed through pornography consumption, and enhanced by it. In these extracts, online users seem to draw on conceptualizations of shame as a strong motivator to “fix” themselves and to regain control over hegemonic masculinity.The causal role of these factors could be understood within the social process of self- objectification within which the narrators’ account implies their attempt to restore their lost masculinity. The theory of self-objectification refers to the adoption of an observer’s gaze to evaluate one’s own body  [Emphasis in original].[Extract 19]: Currently, I have no release, just these thoughts of insecurity and helplessness in my mind, telling me no matter how much money I earn, how much time I spend in the gym, how good clothes I wear I will never have an opportunity with an attractive girl. I am easily triggered to this state when walking around in the city and noticing hot girls  .The aforementioned narratives offer a plethora of readings about the required skills needed in order for someone to be able to prove his masculinity both on a self- conscious level and socially. Participants’ narratives are framed by a “discourse of distress” which can be seen as the result of diminished self-worth and their self-conceptualization as socially inferior. Specifically, having a well-paid job, being well-dressed, fit, and in relationship with an “objectively” good-looking woman, corresponds to the socially recognized lifestyle symbols of happiness, desirability, and success. As a consequence, the absence of these social attributes render participants in vulnerable position of feeling inadequate and worthless. However, it is not merely the absence of these skills that affect men’s reputation but also their need for recognition of their personal value by other men.The double meaning attached to the notion of male identity can be recognized within this emerging social interaction of male competitiveness. More specifically, participants seem to be both subject to a self-conscious identity and to others’ control and recognition. Thus, online users’ masculine identity is confirmed on a personal level by a successful sexual performance and socially by leading a specific lifestyle, which imposes finding a female partner. This practice could be interpreted in what Brooks  called tDrawing on phenomenological theory of incorporation . Well but sadly I stumbled about porn addiction and that this may also cause ED after all .From the above-mentioned narrative, it could be supported that online users’ ED is considered the crucial event that raises a series of concerns about pornography being problematic. This was also the starting point of a diagnostic process where the behavior of “comparing and fitting” into available online categories took place. In this context, addiction to pornography started becoming more of a self-identified problem. As Attwood  puts forIn that way, online pornography addiction communities emerged as the real “eye opener” by taking advantage of the position of “talking from lived experience.” Thus, the disease model within these communities was framed as a mutual concept providing a common understanding. However, in line with the view that individuals are active agents of discourse .The past 165 days of recovery have been, although markedly more challenging and painful than any other attempt in my life, equally as transformative. The problem is that transformation can quickly and easily dissolve into the abyss of suicidal despair if the porn addict pathways of the mind are revived .[Extract 22]: I question the improvement in my recovery. I question my future. I worry repeatedly. Every day is tremendously stressful. I continuously have thoughts of porn. It's tough to use the PC without clenching my teeth and banishing a nasty urge .[Extract 23]: And EVERY TIME, I relapse I get anxious and paranoid   [Emphasis in original].Participants’ stories of recovery and relapse are framed by dichotomous thinking. For instance, recovery has been associated with conceptualizations of “beauty, opportunity and richness” while relapse is experienced with overwhelming emotions and a sense of failure. When framed together, it could be argued that recovery symbolizes self-affirmation and faith to a brighter future, while failure to persevere reflects the possible loss of self. Moreover, since individuals are presented as unable to manage their choices within medically-oriented underpinnings, the commitment to recovery requires an ongoing focus on self-control Thomas, . Within [Extract 24]: I am in my 400+ day streak on my first attempt after I choose to proceed into a lifestyle change. The fact that nofap is so rough challenged me. I wanted to succeed magnificently in a thing that so many people find so hard. It was very hard for me as well, but that made it easier. (…) I converted my PMO addiction to nofap addiction. That would be the toxically shame approach of superachiver: you can defeat an addiction by turning addicted to the pride of beating it .Specifically, this bodily intervention of abstinence was also followed by the transformation of the diagnostic identity; from a pornography addict to a nofapper. Abstinence has been regarded as a common goal reflecting a man’s reputation and value; almost monastic in some ways. But, having sexual outlets is integral to our species, meaning that abstinence for those not in sexual relationships is virtually impossible. It could be supported that nofap was transformed into a moral commitment that invests in the “price” of hegemonic masculinity. Within this context of promotion of performance ideals, abstinence was linked with an, “accreditation ceremony” .[Extract 26]: Reading all of those success stories and expecting enormous changes in my life merely because I was quitting porn transformed into a kind of mental masturbation for me. I put too much pressure on myself to reach this goal—and the goal was superficial. I wanted “superpowers,” and I believed that Nofap was this particular thing keeping me from happiness. Now, I have a healthier approach .What is observed for some participants is that there is a “narrative of change.” That is, how the participants’ sense-making process and self- conceptualizations could be transformed as well as how these changes are framed. Thus, at this point, a narrative re-construction emerges Jirek, . SpecifiBy questioning “who are you without this story?” participants essentially challenged the discourse provided on the forums and, by extension, their self-diagnostic labels. Additionally, this narrative re-construction portrays their effort to frame the etiology of their PPU within a complex socio-psychological interaction. Specifically, narrators locate the source of their PPU in a conflict between their personal identity, social norms, and expectations from life.The analysis of narratives of online r/Nofap and r/PornFree reddit users with self-reported PPU revealed multiple etiological connections, informed by a range of intrapersonal, interpersonal and socio-cultural narratives related to the onset of PPU. At first, the interaction between materiality, the embodied spectator, and a perceived hypersexualized culture contributed to the creation of an “online persona,” signifying the beginning of the PPU experience. Furthermore, the narratives of an adverse childhood, inadequate gender performativity, and an unfulfilled lifestyle formed a belief of “being weak” resulting in distress. The causal contradiction between a psychological state of “being weak” and an empowered online persona portrayed the IPU as a means of escape and validation. Finally, dichotomous thinking, linked with the notions of recovery and relapse, rendered abstinence as a valuable intervention in a context of powerlessness.The narrative analysis revealed the crucial contribution of adverse life events to the onset of PPU, highlighting dissociation through pornography as a defense mechanism; partly keeping with the findings of Ybarra and Mitchel , who sugIn addition, previous literature has attempted to showcase the mediating role of religiousness (Grubbs et al., Moreover, it has been observed that moral incongruence emerged as an etiological pathway of distress (Grubbs et al., This study provides valuable insights that could be employed in a clinical and therapeutic domain. The causal complexity between social norms, interpersonal interactions, personal motivations and expectations underlines the need for clinicians to evaluate the etiological variants of PPU beyond biomedical conceptualizations. Specifically, the analysis indicated that the narratives of distress around PPU are possible manifestations of internal conflicts. Since these conflicts stem from a causal interaction between transformations of the self, identity loss, social expectations, and an adverse interpersonal history, clinicians may need to examine the motivations, personal meanings and functions attached to the use of IP. In this study, for instance, the participants’ concerns regarding sexual performance are portrayed as vital for the onset of their self-perceived PPU. This finding questions the current biomedical model where sexual difficulties are not deemed as a main factor contributing to excessive pornography consumption, rather than a symptom of pornography addiction Tylka, . TherefoAdditionally, therapeutic approaches to PPU that usually draw on interventions for sexual addiction, typically involve self-regulation by identifying the environmental triggers that enhance sexual urge, and/or techniques which facilitate self-observation Goodman, . HoweverThe present study, in general, contends that pornography use could, indeed, become problematic with multiple psychological implications. However, PPU seems to arise and be maintained by vicious cycles of causal connections. In particular, the finding highlighting a utilitarian use of pornography demonstrates the different forms of individual use. For instance, motivations of escape and/or validation might indicate one’s overall anxiety in relating with others. Thus, IP may acts as a means for wishes to be fulfilled and experienced as a reality, suggesting a need for affirmation and interaction with others that takes place in a less threatening and more controllable virtual environment Thomas, . These pConcerning treatment modalities, it could be argued that a narrative psychotherapeutic approach could be effective, as it focuses on providing an understanding of the psychological process of meaning-making and its role in individuals’ lives McTighe, . TherefoThe present qualitative study is also subject to particular limitations. First and foremost, the collection of the data through online forums limited the researcher’s capacity for seeking further clarification on lived experiences (Holtz, Kronberger, & Wagner, Additionally, a relatively homogenous sample is evident from the available demographics derived from the participants’ personal narrations. In particular, the fact that the research participants were heterosexual, mostly single men limits the generalizability of the present findings to more diverse populations. Therefore, future research could explore the etiology of PPU in both women and non-heterosexual populations, since social identity status is considered as a crucial factor in how distress is expressed and experienced Tylka, . MoreoveFinally, another limitation in terms of the representativeness of the study’s population is linked with the normative structured self-help communities advocating pornography abstinence. Since the role of addiction is prevalent in the narratives of r/Nofap and r/Pornfree, it could be argued that participants’ choice of events and the way of its narration are largely influenced by these conceptualizations. Hence, the participants of this project could be considered a niche population, highlighting the necessity to investigate the etiology of PPU by exploring narratives collected from non-addiction oriented environments.This study aimed to contribute to the scholarship regarding PPU emphasizing the voices of IP users and moving beyond discourses of “harmful effects.” To our knowledge, this study is one of the first attempts to directly explore the etiological variants of self-perceived PPU of the NoFap/Pornfree population using a detailed qualitative analysis of their lived experiences.The narrative analysis revealed that conceptualizations regarding the etiology go beyond reductionist interpretations of “cause and effect.” The causal efficacy between intrapersonal, interpersonal and contextual aspects forms a complex network of etiological interactions. The participants’ narratives suggest that the onset of PPU was determined from a constant self-negotiation between embodied relationalities and intersectionalities. In particular, the utilitarian use of pornography portrayed a background of relational marginalization and invalidation where intense feelings of a vulnerable real-self emerged. Similarly, individual’s inability to respond to a perceived hypersexualized culture, where gender expectations, self-actualization, and performance have replaced living itself, contributed to self-stigmatization and identity loss. Thus, in a context where the dialectical relationship between materiality and an online persona allows for free sexual expression only in a private space, IPU, apart from temporarily numbing negative feelings, serves, also, as a guise of coherence to a weak and fragile identity. On this basis, abstinence in online communities was connected with hope for a better future self. In this case, hoping implies a desire to regain the “lost hegemonic masculinity.”Finally, this study highlighted the need both for a comprehensive assessment of the etiological spectrum of PPU in clinical settings and for further investigation in a more general population, moving beyond a conceptualization of addiction by incorporating self-perceptions of PPU into the individuals’ meaning-making processes.


A successful self-participation experience empowers patients to adapt to living with hemodialysis. However, few studies regarding the subjective experiences of such patient participation have been conducted. This study’s purpose was to describe hemodialysis patients’ perspectives on integrating hemodialysis into a new life regarding self-participation experience. A qualitative study using the grounded theory method was applied. Thirty-two well-adaptive hemodialysis Taiwanese patients attended in-depth interviews. “Integrating hemodialysis into a new life journey” was identified as the core category guiding the entire self-participation experience of hemodialysis patients. The three antecedent themes were “Sense of worthlessness”, “Life is still worth living”, and “Friendly and joyful atmosphere of the hemodialysis room”. Once the patients went through the three antecedent themes, they gradually began making efforts to participate more fully in their hemodialysis. Within this participation experience, the hemodialysis patients exhibited these four interactive themes: “Overcoming one’s predicament”, “Integrating self-care skills into my life”, “Resuming previous roles and tasks”, and “Adapting to independent living”. Finally, most adaptive patients master the hemodialysis life. Encouraging patients to discover that their life is worth living and providing a friendly and joyful atmosphere in hemodialysis units are the keys to facilitating patients’ self-participation more fully. Each patient is an expert regarding his or her own body, symptoms, and conditions . When paMany recent studies have indicated that CKD requires long-term self-management or individual strategies for coping with stress ,11,12. THowever, previous studies have focused on empowerment ,17,18,19A qualitative study was conducted applying the grounded theory method that enables researchers to study a specific phenomenon or process and uncover new stories based on the collection and analysis of real-world data. The participants were recruited from an outpatient hemodialysis clinic with 126 beds at a medical center in Taiwan using purposive sampling. The sampling criteria for participants were as follows: (a) had already adapted to life as a hemodialysis patient and was leading a normal life; (b) was aged 20 years or older (c) had been undergoing hemodialysis three times a week for at least one year, and (d) they identified themselves as undergoing well-adapted HD, although some interviewed HD patients were very long HD survivors who still have a vivid memory of initial self-participation experiences and were willing to share these experiences. The well-adapted patients were referred by attending physicians or the head nurse.The study protocol was approved by the Institutional Review Board (IRB) of a medical center in northern Taiwan . In order to ensure informed consent and to protect the participants’ anonymity, confidentiality, and interests, the participants were provided with sufficient time to read the consent form. All participants were chosen to be interviewed once during a scheduled dialysis session in a private room at their dialysis centers, in order to save time and reserve energy, without nurses or family in the private room. Prior to beginning the interview, the purpose of the study was explained again, and the included patients provided signed informed consent. The female first researcher was a nephrology nurse practitioner. SLY interviewed each interviewee using an interview guide to conduct face-to-face interviews . All intFor the purpose of preventing presupposition bias and to ensure consistency of the interview content, open questions jointly developed by the three researchers were used in the interviews, during which the interviewees could provide vivid descriptions of their life experiences regarding HD self-participation. Open-ended interview prompts were also utilized to encourage the interviewees to provide in-depth accounts. Prompts and exploratory questions were utilized, and verbatim records were made until theoretical saturation was reached. The content of each interview was converted into an interview record within 48 h after recording. Comparative methods were used consistently to analyze the transcripts.Verbatim transcripts of interviews and field notes were analyzed using the constant comparative method for repeatedly comparing the existed categories and content. Four steps were executed during the coding process: (1) open coding: the researcher repeatedly reviewed each interview transcript to obtain insight into the meaningful phrases and sentences by line-by-line; (2) axial coding: the related subcategories were clustered to generate main themes; (3) selective coding, which integrated the axial coders; and (4) determination of the initial diagram: all subcategories were testified to find out the core category, build up the storyline and develop an initial substantive theory about the self-participation experiences, until category saturation was achieved and no new major themes arose. Four criteria were applied to evaluate the trustworthiness of this study: (a) credibility, (b) transferability, (c) dependability, and (d) confirmability . This waThis study screened and recruited 32 HD patients, including 15 male patients and 17 female patients, with an average age of 61.72 years  and an aInitially, the HD patients often self-reported feeling that they were “worthless” individuals. When affected by these feelings, the patients experienced fear, sadness, and negative feelings arising from their need to rely on others and the discrimination that they faced. However, these patients discovered that “life is still worth living” and recognize the “friendly and joyful atmosphere of the HD room.” Consequently, these two forces would drive them to participate in their treatment more completely and gradually integrate hemodialysis into their new life journeys. Six themes emerged during this process .Self-perceived survival value and a “friendly and pleasant atmosphere in the HD room” initiated patients’ self-participation. Upon learning that they required HD, patients experienced negative feelings arising from their need to depend on others and the discrimination that they would face. In some cases, patients may even discontinue the treatment or become pessimistic. People who felt a “Sense of worthlessness” indicated that they experienced numerous negative feelings because HD patients are subjected to several restrictions in their daily lives and must rely on a machine and the hospital for the remainder of their days. In some cases, patients may even be disparaged by their relatives, friends, and neighbors, or experience a sense of worthlessness due to their disability or the fear that they will become a burden to their family and friends and be incapable of living independently.“The doctor told me that I had to go on hemodialysis, and I refused. I insisted on not going and ran away from the problem. …A man who is told that he needs hemodialysis feels worthless. My wife was always crying…”.(P10)“When I knew that I had to undergo HD, I was in pain and fearful. My girlfriend kept asking about the situation that we couldn’t get married, work, or raise our children. With tears in her eyes, she told me that it was alright because I wouldn’t die immediately. I am able to live a long life while I’m on HD. For the sake of my marriage and children, I decided to do it…”.(P07)“I cried from the pain of the needle insertion. I had to restrict my daily food intake, and I had no freedom. I asked them how they could be happy. This was when I learned about the many types of local anesthetics”.(P11)“Initially, I didn’t know anyone when I started my hemodialysis. I listened to what the others  were talking about and whether they had the same symptoms as I did. I figured that I should follow what they were doing, and it’ll be effective…”.(P05)The HD patients were brave enough to confront the tough situation by relying on their religion or beliefs; they engaged in self-talk to endure the distress caused by HD needle insertions, forced themselves to achieve better results through various methods, and thereby adapted to the discomfort of HD through positive feedback from self-encouragement.“As a devout Christian, I felt that God was punishing me. However, in my prayers, He told me that He has his reasons, and I should accept this ordeal. Every time I had a needle inserted, I thought about God sending his angels to lift away my pain. I attempted the methods of the others (fellow HD patients). I felt myself improving… because these methods were helpful”.(P04)The patients’ integration of self-care skills into their lives occurred during the self-participation experience. Hemodialysis imposes various life restrictions, including those related to electrolyte balance (diet) and fluid management. After four hours of HD, the arm in which the HD needle was inserted will be mostly immobilized and cannot be turned; hence, only one arm is freely movable. Furthermore, the patients must gradually acquire HD skills. Based on these circumstances, the patients needed to learn the following self-care life skills: water restrictions, fatigue management, traveling to the HD center by oneself, self-preparation of a homemade diet to maintain good energy and nutrition, self-relief of discomforts, maintaining AV-Shunt function patency and staying alert for changes in weight and laboratory measurements.“I was unable to restrict my water intake…In summer, I would suck and swallow a lot of ice…and I swallowed more than I spit out. Then, someone taught me how to make iced lemon water, which seemed to help cope with my water restrictions. I would place lemon water in a bottle, freeze it and drink after exercising. It was effective, as I would drink the amount of ice that melted…”.(P24)“They  taught me that I could drink more. I may not drink four hours prior to hemodialysis, but I could drink more during each session and during meals. I thought to myself that I could eat more if I didn’t increase my weight; I could eat less if my blood potassium was not controlled. I ensured that vegetables were cooked. When I drank water during each session, I wouldn’t exceed my restrictions or have low blood pressure. I didn’t feel weak, as I had enough nutrients. Therefore, I would take a bus by myself to the hemodialysis room and arrange a taxi by myself to go home”.(P01)“Blood vessel care is very important. I am afraid of the occlusion of the AV shunt at night, and I don’t even dare to sleep. It would result in me being unable to “wash” my kidneys . I want to use an L-shaped pillow to prevent occlusion. When I wake up, I will touch the blood vessel. If the flow is not strong, I will strengthen my grasping muscles and let the blood flow improve ”.(P15)When an HD patient has integrated HD into his or her daily life, he or she will be able to gradually assume the roles and tasks of a normal person, including holding a job, utilizing social benefits to reduce family burdens, caring for his or her family, and enjoying social activities. As a result, the HD patient will experience a reduction in stress related to post-hemodialysis discomfort and achieve a better physical and mental state.“I love beauty, but my face disappears after hemodialysis. Today, I will wear makeup. I will be beautiful when taking hemodialysis. As long as I look happy, others will feel the same. I look more beautiful”.(P06)“Now, I am able to perform carpentry and sell my own creations. My wife no longer has to endure many hardships... I feel more like a man now that I have more self-worth and a sense of self-accomplishment”.(P08)The patients were required to make independent arrangements to engage in outdoor activities and fun activities, develop their own personal interests and life, bring positive energy into their lives, and help their families or others understand that they were living well.“I would always check with the hemodialysis centre in Tainan located nearest to my hometown before treatment. Traveling locally isn’t a problem for me, and I have been to Japan. I would undergo my hemodialysis sessions before departing”.(P09)“The blood vessel on my arm is unsightly. Since I enjoy making handicrafts, I would buy fabrics and stitch to make armbands that are beautiful and special: other fellow HD patients felt the same way, so I would give armbands to them. I felt happy”.(P20)Regarding happiness, satisfaction, and appreciation, when the HD patients engaged in HD self-participation and adapted to HD through the four interactive themes of behaviors that mutually influenced each other, they began to attain joy and satisfaction in their lives after HD because they now had control, and learned to better appreciate themselves.“I am always able to overcome any difficulty all along..., I am grateful… I just want my family to be healthy and happy, as I am able to take care of myself. I feel happy as I take daily HD … several conversations and the government subsidies are also viewed as remunerations. You can see that we’re pretty well off, too”.(P22)“I was left alone after my parents passed on. I used to be scared of the two needle insertions during each hemodialysis session because I was timid and susceptible to pain. However, now I don’t require anesthesia. I told myself to handle one thing at a time. I now have higher self-esteem since I grew from being fearful and timid to an independent person. I feel blessed and free all the time”.(P19)To the best of our knowledge, this was the first study to explore the Taiwanese hemodialysis self-participation experience using the grounded theory method. This study shows that the antecedent theme of “Worthlessness sense being gradually disintegrated” contains “Perceived survival value” and “Supportive hemodialysis room” and four interactive themes: “Overcoming one’s predicament”, “Integrating self-care skills into my life”, “Resuming roles and tasks”, and “Adapting to independent living”; and finally, consequence theme of “Self-mastering dialysis lives”.Patients may develop a sense of worthlessness or depression-induced thoughts. Depression is a commonly encountered psychological problem among HD patients ,23,24 anPrevious studies showed that adjustment to ESRD was a dynamic and constant process ; HD patiThe introduction of religious or spiritual interventions for chronic HD patients helps trigger positive emotions during stress and influences overall health , including patients’ commitment and adherence to hemodialysis ,33,34. APatients undergoing HD attempt various methods and learn a number of techniques to help them adapt to hemodialysis-related problems in areas such as transportation , diet, fluid intake, exhaustion, blood pressure fluctuations, and cramps. These methods help patients to reduce the obstacles created by HD in their daily lives and the burden on their families, as well as to build their confidence in playing their roles and taking on tasks, obtain positive feedback relating to their efforts, and maintain their social lives. In recent years, many studies have shown that the promotion of problem-centered participation was recommended to lengthen the lifespan and improve the quality of life of HD patients ,35.In the present study, the theme exhibited by the self-participating HD patients emphasized the attainment of results concerning self-awareness, self-efficacy, and self-control. The patients actively participated in individualized learning to acquire the HD skills they needed to utilize social resources, regain control over their lives, and understand how they would be able to achieve and appreciate the outcomes related to self-participation in HD. Throughout this process, the HD patients continued to integrate HD into their new life journeys.The present study found that participants expressed that as they gradually resume their roles and lives, they would regain self-confidence and adapt to an independent life. After hemodialysis, patients needed to rebuild their lifestyles to accommodate the hemodialysis schedule. In many cases, patients would travel back and forth independently from home to the HD center and needed to learn how to deal with their discomforts when they were alone before and after dialysis. Their daily activities were different from those of their peers and friends. Therefore, teaching patients to be alone and help themselves during activities, shopping or entertainment is an important step in self-participation. Because of self-participation in HD life, they would perceive the usefulness of self-care, self-efficacy, and health status in coping, compliance with fluid and food restrictions, sleep disorders, symptom distress, as well as adjustment of anxiety, emotional distress, and dialysis stress ,37. PartWhile HD patients are actively involved in hemodialysis lifestyles, they have the problem-solving ability of symptom management. They are able to find happiness and interests, fulfil their expectations toward life, express a positive perspective on hemodialysis , appreciate when the disease results in benefits , and experience wellness and good family relationships.In this study, the four interactive themes exhibited by the self-participating hemodialysis patients emphasized the attainment of results in relation to self-awareness, self-efficacy, and self-control. The patients actively participated in individualized learning to acquire the hemodialysis skills they needed to utilize social resources, regain control over their lives, and understand how they would be able to achieve and appreciate the final outcome related to self-participation in hemodialysis. Throughout this process, the core category was “integrating hemodialysis into my life journey”.The present study reached data saturation with a sample of 32 HD patients. Since the sample consisted of only well-adapted HD patients from northern Taiwan who had engaged in self-participation, the results obtained for the experiences of these patients are limited regarding the understanding the experiences of self-participation of unadjusted HD patients, which is a limitation of this study. Therefore, future studies may explore the experience of self-participation among unadjusted HD patients. The results from this qualitative study will serve as a reference for the construction of an HD self-participation scale. We believe that incorporating the findings of the present study will help HD patients acquire self-participation HD skills, such that they are able to build new healthy lives for themselves.More complete self-participation in hemodialysis positively influences HD patients, allowing them to acquire skills that help incorporate the restrictions of hemodialysis into their lives. In terms of psychological outlook, the HD patients’ willingness to continue living was main finding of our study. Therefore, this requires that nurses recognize patients with lower-level emotional and psychological needs. Secondly, they must provide their professional knowledge and assistance in order to encourage self-participation and motivation to overcome the various life limitations of hemodialysis. Nurses should encourage patients to express their negative emotions or depressive feelings, which appears to reduce such feelings. Nurses should focus on strengthening patients’ will to live, the joy of life, and the discovery of fun in life to increase their self-confidence and perceptions of self-worth. These measures may allow HD patients to gradually construct their roles and tasks, and to transition to the self-mastery of dialysis in their daily lives.


Identity fusion represents a strongly-held personal identity that significantly overlaps with that of a group, and is the current best explanation as to why individuals become empowered to act with extreme self-sacrifice for a group of non-kin. This is widely seen and documented, yet how identity fusion is promoted by evolution is not well-understood, being seemingly counter to the selfish pursuit of survival. In this paper we extend agent-based modelling to explore how and why identity fusion can establish itself in an unrelated population with no previous shared experiences. Using indirect reciprocity to provide a framework for agent interaction, we enable agents to express their identity fusion towards a group, and observe the effects of potential behaviours that are incentivised by a heightened fusion level. These build on the social psychology literature and involve heightened sensitivity of fused individuals to perceived hypocritical group support from others. We find that simple self-referential judgement and ignorance of perceived hypocrites is sufficient to promote identity fusion and this is easily triggered by a sub-group of the population. Interestingly the self-referential judgement that we impose is an individual-level behaviour with no direct collective benefit shared by the population. The study provides clues, beyond qualitative and observational studies, as to how hypocrisy may have established itself to reinforce the collective benefit of a fused group identity. It also provides an alternative perspective on the controversial proposition of group selection - showing how fluidity between an individual’s reputation and that of a group may function and influence selection as a consequence of identity fusion. In particular, identity fusion2 has made significant progress in characterising the causal mechanisms that lead individuals to act with extremist pro-group actions that appear self-less. Unlike preceding theories on social identity , identity fusion postulates that individuals retain a personal identity that has a porous boundary with a group identity, meaning that the personal and group identity become integrated, rather than a dominant single identity fluctuating . Critically, through identity fusion, individuals do not become depersonalised, and instead, both individual and group identities persist, with characteristics of group identity being evident in the individual’s sense of self. Consequently when identity fusion is strong, behaviours that occur in support of one’s identity are also pro-group. The implications of this mechanism are significant since a group can benefit from the acts of an individual while that individual remains self-focused. This may promote positive survival benefits for a group, but it can also support extremism, through so-called “devoted actors”11, defined as individuals fused with a group, with which they share a sacred value. These individuals become fully aligned with all-consuming group beliefs that motivate extreme behaviour, to the extent that actors disassociate themselves from any consideration of personal risk and costly sacrifice. Furthermore, identity fusion predicts not only extreme self-sacrifice with a group, but also for an ideology, another individual, or even other entities1.The role of strongly-held identities in motivating human behaviour, particularly in respect of groups, has gained widespread interest2, identity fusion has been developed from extensive empirical observations that bring together principles of personal agency12, identity synergy14, the saliency of relational ties15 and irrevocability16, resulting in measures of identity fusion12 that assess the permeability of an individual’s personal and social self, including the development of a verbal scale17. This has enabled wide-ranging insights to be established, helping to explain diverse pro-group behaviours such as loyalty18, altruism19, self-sacrifice20, extreme cooperation21 and nationalism22.Described as a visceral feeling of oneness with the group21. This can be explored through an experimental approach using agent-based modelling, which is a long standing, valuable and potentially underused method in social psychology23. In particular, agent-based modelling has predominantly been used to model the fast evolution of minimal groups , where elegantly simple assumptions on agent-based interaction result in remarkable group-level coordination. However, agent-based modelling has had limited application in exploring strongly-held identities21, which are inherently more complex to model because of the necessary recourse to underlying qualitative theory1. In this paper we present a first approach to exploring how and why might identity fusion establish itself in an unrelated population with no previous shared experiences. The conditions under which self-sacrifice becomes incentivised has received greater attention with existing literature providing useful clues in support of the hypothesis that pro-group sacrifices may be a by-product of one or more basic survival mechanisms2. This builds on inclusive fitness30 as a means for individuals to promote the survival of one’s genes through support for those with whom they are shared, with evidence of correlation between self-sacrificial behaviour and genetic relatedness across a wide range of species35. However inclusive fitness alone is insufficient to explain how such behaviour may become embedded in unrelated individuals. Research on human kin detection36 further indicates that small group interactions may have co-evolved as a proxy for genetic relatedness, for example through perinatal associations, which implicitly support inclusive fitness by promoting the groups in which they evolve.In contrast to these empirical breakthroughs, relatively little attention has addressed the evolutionary origins of strongly-held group identities such as identity fusion2 comment that a form of “shared essence”37 may have emerged where biological behaviours have transferred to the social world, contributing to the visceral feeling that binds an individual to the group, based on observations of natural human tendencies to conceptualise the world based on biological survival mechanisms . These observations point to the important role that evolution has likely played in explaining identity fusion, however the possible mechanisms that are responsible for its promotion are open to further consideration2. In particular, beyond kinship, have particular mechanisms evolved that allow identity fusion to be incentivised and establish itself?However, identity fusion is prevalent beyond this context, in large unrelated groups rather than small tribal groups, where individuals do not a-priori interact . Swann et al46. This is a fundamental form of ‘one-shot’ interaction and across all species only humans fully engage with indirect reciprocity48, which is thought to have established itself through the management and assessment of an agent’s reputation49. As a first model for the evolution of strongly-held identities across a population with no a-priori relationships or shared experiences, we adopt indirect reciprocity for two main reasons. Firstly, it presents an opportunity to extend a simplistic approach to modelling identity, since the widespread convention for indirect reciprocity is to assume that all agents have a unique identity with no component being influenced or shared with others52. Secondly, significant progress has been made based on this assumption, providing a baseline for comparison53. We make progress noting that the composition of an agent’s identity determines how its reputation is derived and subsequently used by others in decision-making for potential one-shot cooperation. This approach is aligned to the particular context of indirect reciprocity where reputation is an important characteristic. However, we note that alternative attributes beyond an agent’s source of reputation could be used to facilitate identity.Agent based modelling requires a framework for interaction between agents, and we explore identity fusion using indirect reciprocityOur agent based model involves six steps as indicated below, based on the parameters presented in Table Identity and reputation. Each agent j expresses the extent of its identity fusion G, where 54 developed for human subjects to express an overlap between their personal identity and a group identity on a pictorial basis through a Venn diagram. The extent that a human subject intersects a circle representing their personal identity with a circle representing the group G’s identity has been shown to strongly correlate with the individual’s level of identity fusion G17. This approach presents a region of j’s personal identity circle that does not overlap with the group G, representing j’s personal identity circle. Through this model, a fused human participant j expresses G, and G’s identity. We adopt this simple conceptual representation, as used to assess human subjects54, as a first proxy for an agent’s reputation. That is, when i views j’s integrated reputation as approximated by:personal reputation that is unique to j and a consequence of its actions, while group reputation which is shared with those having non-zero fusion. When i views j’s reputation j’s identity fusion towards G, irrespective of j’s fusion level, specifically:Step (1) - i is unfused  and j’s standing with respect to the group, ensuring that j’s personal identity remains salient even when j is highly fused. In other words, j’s personal identity is not substituted for the group identity as fusion increases, which is defining characteristic of identity fusion.When viewed in isolation, Eq.  appears mentclass2pt{minimAgent interaction. Pairs of agents, say i and j, are repeatedly selected at random to play the donation game, a generalisation of the mutual aid game83, where agents choose whether or not to donate at cost c to a recipient who gains benefit i decides to donate to j then i incurs a cost c while the recipient j receives a greater benefit b, where i’s donation decision is based on simple self-comparison53 of its reputation j’s reputation i’s donation strategy which is subject to evolution, with  known to dominate and sustain cooperation in the absence of identity fusion53.Step (2) - 27 and can invoke in-group effects71. Here we model this using variable i randomly selects an interaction partner j from its so-called in-group, which is defined as the subset of agents having at least the same level of fusion as i  - Selection and reproduction. After m interactions between agents, the end of a single generation is reached and selection is modelled. Payoff, as a consequence of making and receiving donations gives a basis for fitness (see step (2)), where agents update their future strategy based on copying the action rules and fusion level of another agent with probability proportional to its relative fitness across the population. This roulette wheel approach follows the long standing basis for asexual reproduction95 and represents a form of social learning commonly applied in the evolution of indirect reciprocity97. Payoff and all reputation variables are set to zero in preparation for the next generation to commence.Step (4) - Personal identity remains salient for fused agents. Under identity fusion, it is not to be expected that strongly fused individuals solely derive their identity and reputation from the group’s identity, and personal identity remains highly salient. Because fused individuals see themselves and other group members through an individualising lens, they take into account their personal standing and that of other group members when they consider each other’s positioning. Therefore we assume fused agents undertake further assessment between themselves based on their personal contribution (Step (5) - 82 due to their identity being drawn in part from the group. There are many ways in which awareness of perceived inconsistent behaviour of other group members could present itself to an agent and invoke a response through extended fusion72. Based on the fundamental role of social comparison56 in group processes, which enables group members to navigate and understand their positioning and social context99, we assume a simple  approach, based on detecting inconsistency in others personal behaviour as compared to oneself. This aligns with experiencing vicarious hypocrisy100. It models the potential for a fused agent to experience cognitive dissonance79 due to the perceived hypocritical personal identity77 of agents who are connected through co-dependency on fusion with G.Note that fused agents have a personal incentive to support pro-group behaviour and the group’s competitive advantagei  on a poResponding to hypocrites. Behavioural responses to manage cognitive dissonance can take many potential forms103. Here we apply the most basic response, involving the exclusion of others, or ostracism80. This effectively provides a “cost-less punishment”81 and its positive effects in sustaining cooperation have been well-established106. Ostracism can be applied at the interaction stage (step 2) which we call type-1, or at the reproduction stage (step 4) which we call type-2, or both stages, denoted type-3. Under type-1 ostracism at the interaction step, j does not receive a donation from i, irrespective of i’s action rules. Under type-2 ostracism at the reproduction step, then j becomes excluded as a candidate to replace i in the next generation. These responses correspond to individuals discounting those that are a threat to their own identity due to this being fused with that of the group. To understand the sensitivity of fusion upon ostracism, we also invoke a minimum threshold T (Step (6) - The modelling assumptions in these six steps incorporates possible relevant behaviours that align with drivers from identity fusion  to understand the conditions under which identity fusion  to gain payoff while using the shared group reputation. The average result for the baseline scenario  element of personal reputation, through fusion towards the group.To assess resilience, we consider the effect of errors upon an agent’s interpretation of exclusion in response to hypocrisy [Eq. ], and weThe more execution error 53. Note that these experiments are performed without errors being applied to the action rules, which govern the extent of cooperative behaviour.In contrast to this, perception errors function by injecting noise in the signal on which the decision to perform ostracism is based, rather than using authentic information and failing to execute ostracism. As perception error increases, type-1 and type-2 ostracism result in average cooperation and average fusion behaving in a similar way, diminishing to a plateau in terms of average cooperation. However type-3 ostracism behaves significantly differently, which appears counter-intuitive on first sight. In particular, when perception error is more frequent , we consider a marginal cost for agents potentially instigating ostracism, as compared to those who function without .While ostracism is regarded as a “cost-less punishment”T, we introduce an additional cost T incur a cost of T  incur a cost c for a donation. Figure c, applying Using threshold T where T or beyond, and Beyond 1, an agent centric approach is modelled where the group is a passive entity that holds a reputation but no agency in is own right. Thus agents retain personal empowerment and have the autonomy to change their fusion level, which governs the extent to which an individual’s own identity is drawn from the group. This is represented by the fused agent’s personal embodiment of the group’s reputation. Natural selection is invoked to observe the evolution of agents’ fusion levels, alongside the agents strategy for cooperation, which is based on the social comparison of other agent’s reputation.The results provide insight into how identity fusion is promoted alongside cooperation in support of a group. Consistent with the qualitative development of identity fusionThe saliency of fused agents’ personal identity is reflected through a form of in-group reputation, expressing their contribution towards the group. Vicarious hypocrisy is central to assessing this form of reputation between agents, the sensitivity to which heightens through identity fusion towards the group. This captures inconsistent behaviour from the perspective of a fused agent, concerning support for the group’s reputation given the extent of the agents’ fusion. When fusion is strong, vicarious dissonance indicates a threat to the individual agent, triggering cognitive dissonance and motivating a behavioural response to reconcile this effect - our results indicate that ostracism at both interaction and selection is preferential. Through this mechanism, the group implicitly benefits from the action of fused agents. This is also sustained when there is a modest cost differential associated with the ‘punishment overhead’ . Consequently, fusion provides a coordination mechanism for collective action, where personal incentives drive a benefit that is shared across other fused individuals. A strong incentive for fused individuals to sustain their contribution towards the group is inherent, otherwise agents become vulnerable to being perceived as hypocrites themselves, resulting in ostracism diminishing their payoff and future selection opportunities. This drives the evolution of fusion, with fused agents effectively gaining an advantage from the support of fused others, against shirkers.109, particularly in the context of a group, which is central to the organisation and success of human cooperation. Such punishment represents collective action110, where individuals undertake a potentially costly individual action that benefits the wider group and introduces a second-order free rider problem. However it has remained a longstanding puzzle as to how such collective action arises83, with a variety of alternative mechanisms proposed without consensus. A significant number of proposals align with human psychological capabilities, such as an individual becoming culturally conditioned by social norms113, neural satisfaction from punishing norm violation115, egalitarianism116, morality117 or influence due to negative emotions109. However, the belief system that underpin these dispositions is likely to occur as the consequence of an individual’s identity, including their psychological interdependence with their in-group118. Noting that this can be expressed through identity fusion119, and based on our model that demonstrates how identity fusion can transfer group objectives to the individual, we hypothesise that identity fusion unifies the explanation of how collective action enables the resourcing and coordination of seemingly altruistic punishment.The coordination mechanism for ostracism, invoked through identity fusion towards a group, is particularly noteworthy. From the perspective of human cooperation, altruistic punishment of shirking behaviour in humans has been acknowledged as key in promoting indirect reciprocity120 and its important to consider the consequences of identity fusion not being globally visible. Our results on execution and perception errors provide some initial insights in this direction, indicating that reasonable level of obfuscation can be sustained  while allowing fusion and cooperation to evolve. However this may change considerably when observations are to some degree private, and individual agents may be positioned to make different private observations. Investigation of such a scenario may benefit from using a social network to structure the agents, which also allows hetrogeneous relationships between individuals to come into play.An important point to note however, is that our findings are based on fusion evolving entirely from dyadic encounters rather than from multimodal encounters, which is arguably more realistic. Different dynamics may result under such conditions. Furthermore, perception of in-group violations in our model assume public knowledge. In practice this may well not be the case121 strongly argues that this is an illusion, with no plausible mechanism for a ‘group gene’ facilitating selection. It is argued that this illusion exists as a consequence of the power, influence and manipulation exercised by a group over its members .The evolution of identity fusion through our model also provides a new perspective on group or multi-level selection. This is a longstanding issue of considerable debate, where it is proposed that selection can act on groups as well as their constituent members. Pinker7, provides an explanation as to how group level selection may appear to be a phenomenon in its own right, while actually its the individuals that are fused with the group’s identity that give the basis for selection. Because identity fusion enables individuals to take a degree of the group identity as their own, and the group benefits  are felt by the single individual, the group is providing utility and advantage that can be propagated to individuals in future generations. Our model demonstrates that this requires individuals to increasingly influence the contribution of others towards the group as they become increasingly fused, which is plausible because individuals become more dependent on the group’s reputation under these circumstances. Detecting hypocrisy is therefore individually incentivised, but the benefits spread to the group. In this way, fused individuals can gain an evolutionary advantage, that helps to explain at least partially, why a notion of group-level evolution may appear to present itself as a selection mechanism. This also highlights that hypocrisy, as an instinctive human state, may have been realised as a mechanism to provide advantage to those engaging in identity fusion.However, our model of reputation, based on identity fusion towards a group122. Furthermore, observers tend to be quite sensitive to violations of norms of in-group loyalty123, suggesting that such processes would be even more powerful in highly fused individuals. Thus, an empirical approach could assess the relationship between identity fusion and sensitivity to the behaviour of other individuals towards the group. For example, are highly fused individuals more sensitive to the group-related behaviour of others? Are they more likely to ostracise of otherwise impose costs on group members who fail to act in the group’s interests? Answering these questions via experimental research would be a valuable way to align model predictions with human behaviour. Such experiments would involve observing how participants, expressing a range of fusion levels towards a particular group, respond to the potentially hypocritical actions of others. Existing approaches123 provide useful experimental designs that could be further augmented to consider identity fusion, where data can be collected online or through in-lab participation.Representing our model in a computational form has enabled observation of important dynamics that are sufficient to promote the evolution of identity fusion in digital agents, while also sustaining cooperation. These dynamics embody simple representations of human behaviour and give clues as to their possible ecological importance, indicating new directions for experimental validation in a human context. One such avenue is the role of hypocrisy with respect to group identity, which has not been central in the original conceptualisation of identity fusion but, we argue, represents a novel and straightforward response behaviour that is likely invoked through heightened fusion. As fused individuals are motivated to act in support of the group, it is plausible that they would also expect such behaviour in other group members, with heightened sensitivity to group members who, despite their group membership, do not act in the group’s interests. Such sensitivity to hypocrisy is finely tuned in humans and can be understood, in part, as a form of false signalling124, this has not yet been explicitly linked to identity fusion per se, and would contribute further insights concerning homophily and identity. Finally, the model also highlights opportunities to explore how fused individuals might consider their reputation as contingent on the group’s reputation. Arguments on how groups are used to define one’s social self125 are relevant here, in particular how individuals perceive they are evaluated given the groups to which they belong. These questions would also be readily open to exploration through experimentation or observation.Additionally, we note that how identity fusion affects choices for interaction between individuals is an interesting direction for empirical research that is stimulated by this work. For example, it would be useful to examine whether individual-level fusion increases the tendency to preferentially interact with other in-group members, as optionally considered in our model; while the tendency to prefer in-group partners in general has been previously observed83 assuming a single donor. We extend the social comparison of reputation53 to consider the evolution of identity fusion of agents towards a group G. An agent’s identity fusion is modelled through its composition of reputation (see Reputation Section) and the extent to which it draws on the group’s reputation. Agents are randomly selected to play the donation game. Two components affect how this is conducted - firstly the agent’s action rules (see Action Rules Section), and secondly the agent’s fusion level, which may lead the agent to considering their in-group standing and the potential hypocrisy of the other player . The donor’s reputation is updated (see Assessment Rules Section). After 5000 donation games, which constitutes one generation, natural selection is performed (see Selection and Reproduction Section). This cycle is repeated for 50,000 generations. Initial action rules and fusion levels are randomly assigned and results represent the average of 5 randomly seeded runs. Key variables are summarised in Figure We consider the evolution of indirect reciprocity based on the donation game, a special case of the mutual aid gamei’s fusion level G determines the extent that its reputation i’s integrated reputation is i’s personal reputation, consistent with the Venn diagram overlap approach through which human subjects express the extent of their identity fusion towards a group54. 53. However, whether or not agent i has non-zero fusion towards G affects how i views j’s reputation. When i is not positioned to value the group reputation i views only j’s isolated personal reputation  that don’t invoke a change to i that reduce i  and does not undertake a donation towards j. This may result in a penalty for its personal reputation type-2 ostracism, i excludes j at reproduction (see Reproduction Section). Under type-3 ostracism i invokes both type-1 and type-2 ostracism. type-0 is used to indicate that no ostracism is undertaken.Hypocrite detection is used by agent i plays the donation game. The probability that i plays against a randomly selected member of i’s in-group . When an agent k is selected, its action rule and fusion level is copied and carried forward to create an offspring agent in the new generation. This process is repeated for all agents i in the current generation. For each agent k in the new generation, At the end of each generation we apply clonal reproduction, which is dependent on a single parent being replaced by an agent selected from the current population. This is commonly used in previous studies on the evolution of indirect reciprocityPerception error (


Anti-Asian sentiment is surging because of COVID-19 and there have been incidentsof hate crime. This paper presents a reflection by an Asian social workresearcher on the impact of this surge on herself and other Asians in America.Reflecting on the history of pandemic, racism against Asian Americans, andanti-Chinese sentiment among other Asian group, the paper provides importantpoints for us to ponder as a community of social workers in the topics of racialjustice I don’t want to wear a mask in grocery stores because people look at me allweird. They might be thinking I’m already sick, walking around in the public andspreading the virus, you know?It is OK for White people to wear a mask, or to not wear it…. But as Asians,we must be careful.People look at me like I AM the virus. [By wearing a mask] I am beingprotective [of] my own health and everyone else’s.These are the things I am hearing from my Asian friends and acquittances. BecauseCOVID-19 began in China, Asian American communities have been experiencing an increasedrate of discrimination and racial microaggressions ranging from subtle hints to physicalassaults; even children have been attacked . Inter-minoritydiscrimination has been an element of this surge. I am experiencing intense emotionssuch as confusion, frustration, exhaustion, and most of all, fear: fear of the unknown,fear of the uncertainty, and fear of possible threat to myself and my family. Friends,relatives, and acquaintances reflect my feelings back to me. Asian Americans are scaredand concerned about the virus as much as anyone, and racist attacks add a layer ofstress.People in our society are panicking because of COVID-19 and its economic impacts. Ibelieve that fear from unknowns can transform into other emotions such as anger andhatred. Oftentimes, the hatred is targeted to bigger systems such as governments, media,and other institutions. And people are blaming governments across the world for lack ofpreparedness and making wrong judgements. However, the accumulated and shared hatredsometimes finds easy targets around us, resulting in racist attacks and intimidation.This essay reflects on fear, stigma, and discrimination during the COVID-19 pandemicfrom my perspective as a Korean Canadian social work researcher who studies racialmicroaggressions in the southern part of the United States.th century when smallpox killed more than 90% of the indigenouspopulation of the Americas . The flu pandemic that began in 1918 killedalmost 50 million people worldwide  that the Chinesegovernment and other governments have taken after the outbreak that worsened it havecaused legitimate outrage. However, there is no excuse for directing the resultinganger and hatred to individuals with no real connection to these governments. Yet indoing so those who have committed hate crimes repeat a history in which individualsor groups were punished for or negatively impacted by the relationships betweennations or bigger systems. During the World War II, Japanese Americans werediscriminated against and forced to relocate to internment camps regardless of theircitizenship status . The notI came to Canada from Korea when I was 14 years old and lived there ten years beforecoming to the United States as an international student/scholar eleven years ago. Iam well-aware of the stereotypes and stigma attached to Asians in North America: as“model minorities,” perpetual foreigners, and outsiders a. I havenot wearing a mask, while others were attackedbecause they were wearing a mask. I became afraid of taking even a leisurely walkaround our neighbourhood, fearing a hate crime. When I did take a walk with myfamily, I was hyper-conscious of keeping our distance, seeking to stay well over sixfeet away if possible, fearing that others would assume we might be infectiousbecause we were Asian. We joked about the stigma, “Being Asians is actuallyconvenient. People just walk away from us. We can keep our social distanceeasily.”I heard anecdotes about microaggressions from my Asian friends and learned of serioushate crimes across the states which targeted Asian Americans .Microaggressions are “brief and commonplace daily verbal, behavioural, andenvironmental indignities, whether intentional or unintentional, that communicatehostile, derogatory, or negative racial slights and insults to the target person orgroup” b, and, wThe experts’ view on the pros and cons of wearing masks has varied as the currentpandemic has developed, and in this environment, we feared, as did our friends, thatwearing a mask could make us targets. One school of thought argued that wearing amask does not protect one from infection, and any mask a healthy person, not workingin health care, was wearing represented one fewer mask for health care workers andthe already sick people . The other school of thought was that it is a“common sense” to wear a mask to protect oneself and others, as a nominally healthyperson may be asymptomatic or a pre-symptomatic carrier. It is, however, impossibleto run a randomized clinical trial to shed light on this question. It is simplyunethical and impractical because of time constraints in the current crisis. In theabsence of better information, some people say that it’s better to wear a mask. OnApril 3 the CDC finally began to recommend wearing masks in public . I was eOnce liberated from the dilemma, I realized I had been thinking ill of other Asianswho wore masks before the CDC guidelines changed. I had thought, “Wow, look at allthe Asians wearing masks. Other people will see them as Chinese carrying the virus.”I was being conscious of how other Asians were being perceived by non-Asians out offear that we might experience discrimination because they stoked non-Asians’ angeragainst us. When I saw White, Black or Latinx people in masks and medical gradegloves, I perceived them as cautious and smart. When I saw White people withoutthem, I found myself giving them credit for not being overly panicky and keep beingcalm. In reflecting on these feelings, I could see that I have accumulated theunconsciously shared beliefs that White people are “good” “fair-minded” and“descent” a, 2007b.I never tried to protect myself from discrimination by asserting that I am notChinese, but I understood the impulse. Hate crimes against Asian made non-Chineseeager to assert their differences. Friends joked about wanting a tee-shirt saying,“I am from Korea, NOT from China” or “Made in Vietnam, NOT CHINA” and in factmultiple online sites sell such products . My Asian friends fromvarious ethnic groups—Korean, Taiwanese, and Japanese—expressed hatred towardsChina. When I told a Korean friend that we should not blame the Chinese people foractions their government might have taken, she said, “Government or people, they arethe same!” I found this quite alarming. I wanted to ask, “So, is it okay if Koreangovernment did something wrong and we experience discrimination?” But I understandthat there are cultural explanations for this logic. First, since collectivism, inwhich an individual is often seen as a part of the bigger group that they belong to,is part of most Asian cultures , distingIndeed, the mask question is a hard one for other people of color. I was surprised tolearn that Black men are afraid to wear a mask in public. Surely no one, I reasoned,thought they had a particular propensity for the virus? But I learned that they wereconcerned that a mask might be associated with criminality, in line with persistentstereotyping of Black men as violent and lawless a, 2007b.Learning about how different marginalized groups are experiencing discrimination, ontop of the fearing for virus, was extremely fatiguing. The virus itself is scaryenough. If people cannot wear a mask without added fear, we are living in adystopia.Virtually no one alive today remembers a pandemic as serious as the one we now face.The future of the virus and its impact on mankind is still unknown. It feels surrealand bizarre. I dream of my family using our unused admissions tickets to DisneyWorld or going to a Maroon 5’s concert. When I wake up, I feel sad again. Nobodyknows how we will go back to being “normal” again.This is a surreal time of many tragic events. Already vulnerable families areexperiencing financial crises as they lose their jobs, their childcare, and theirhealth care without preparation or support. Thousands of people are quarantiningwith abusers and death tolls are mounting. In times of uncertainty and fear hatredcan grow. Then the consequences can be devastating. As a social work researcher whostudies racial discrimination, observing the intensified anti-Asian discrimination,from non-Asians and Asians during pandemic fuels my research interests. But as amember of the society and humanity, it is deeply troubling and disheartening.Prominent historian Yuval Harari called on the countries of the world to worktogether to solve the biggest challenge in human history in the Financial Times’article (2020). In today’s world, every society is interconnected closely. Thepandemic has exposed this. We are scared and angry. I desperately want the answers,too. When will a vaccine and cure be available? What caused the emergence of thisdeadly virus? Just like many people, I want someone to take responsibility for thepain that the world is going through. But we cannot allow the fear of unknown totarget the innocent and equally scared. Although it is difficult, we should supportand show compassion to each other in this time.


Azim, Sanjoy Chatterjee, Katie Zhou, Jiwen Wu, Lakshmi Menon‑Singh and Claudio Zamagni, was originally published electronically on the publisher’s internet portal on 19 August 2021 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 27 August 2021 to © The Author(s) 2021 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit


Mahnken, Lena Maier‑Hein and Klaus Maier‑Hein, was originally published Online First without Open Access. After publication in volume 15, issue 7, page 1095–1105 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2021 and this article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The original article has been corrected.Open Access funding enabled and organized by Projekt DEAL.