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What is Secondary Research? | Definition, Types, & Examples

What is Secondary Research? | Definition, Types, & Examples

Published on January 20, 2023 by Tegan George . Revised on January 12, 2024.

Secondary research is a research method that uses data that was collected by someone else. In other words, whenever you conduct research using data that already exists, you are conducting secondary research. On the other hand, any type of research that you undertake yourself is called primary research .

Secondary research can be qualitative or quantitative in nature. It often uses data gathered from published peer-reviewed papers, meta-analyses, or government or private sector databases and datasets.

When to use secondary research, types of secondary research, examples of secondary research, advantages and disadvantages of secondary research, other interesting articles, frequently asked questions.

Secondary research is a very common research method, used in lieu of collecting your own primary data. It is often used in research designs or as a way to start your research process if you plan to conduct primary research later on.

Since it is often inexpensive or free to access, secondary research is a low-stakes way to determine if further primary research is needed, as gaps in secondary research are a strong indication that primary research is necessary. For this reason, while secondary research can theoretically be exploratory or explanatory in nature, it is usually explanatory: aiming to explain the causes and consequences of a well-defined problem.

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qualitative research secondary data analysis

Secondary research can take many forms, but the most common types are:

Statistical analysis

Literature reviews, case studies, content analysis.

There is ample data available online from a variety of sources, often in the form of datasets. These datasets are often open-source or downloadable at a low cost, and are ideal for conducting statistical analyses such as hypothesis testing or regression analysis .

Credible sources for existing data include:

The government
Government agencies
Non-governmental organizations
Educational institutions
Businesses or consultancies
Libraries or archives
Newspapers, academic journals, or magazines

A literature review is a survey of preexisting scholarly sources on your topic. It provides an overview of current knowledge, allowing you to identify relevant themes, debates, and gaps in the research you analyze. You can later apply these to your own work, or use them as a jumping-off point to conduct primary research of your own.

Structured much like a regular academic paper (with a clear introduction, body, and conclusion), a literature review is a great way to evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

A case study is a detailed study of a specific subject. It is usually qualitative in nature and can focus on a person, group, place, event, organization, or phenomenon. A case study is a great way to utilize existing research to gain concrete, contextual, and in-depth knowledge about your real-world subject.

You can choose to focus on just one complex case, exploring a single subject in great detail, or examine multiple cases if you’d prefer to compare different aspects of your topic. Preexisting interviews , observational studies , or other sources of primary data make for great case studies.

Content analysis is a research method that studies patterns in recorded communication by utilizing existing texts. It can be either quantitative or qualitative in nature, depending on whether you choose to analyze countable or measurable patterns, or more interpretive ones. Content analysis is popular in communication studies, but it is also widely used in historical analysis, anthropology, and psychology to make more semantic qualitative inferences.

Secondary research is a broad research approach that can be pursued any way you’d like. Here are a few examples of different ways you can use secondary research to explore your research topic .

Secondary research is a very common research approach, but has distinct advantages and disadvantages.

Advantages of secondary research

Advantages include:

Secondary data is very easy to source and readily available .
It is also often free or accessible through your educational institution’s library or network, making it much cheaper to conduct than primary research .
As you are relying on research that already exists, conducting secondary research is much less time consuming than primary research. Since your timeline is so much shorter, your research can be ready to publish sooner.
Using data from others allows you to show reproducibility and replicability , bolstering prior research and situating your own work within your field.

Disadvantages of secondary research

Disadvantages include:

Ease of access does not signify credibility . It’s important to be aware that secondary research is not always reliable , and can often be out of date. It’s critical to analyze any data you’re thinking of using prior to getting started, using a method like the CRAAP test .
Secondary research often relies on primary research already conducted. If this original research is biased in any way, those research biases could creep into the secondary results.

Many researchers using the same secondary research to form similar conclusions can also take away from the uniqueness and reliability of your research. Many datasets become “kitchen-sink” models, where too many variables are added in an attempt to draw increasingly niche conclusions from overused data . Data cleansing may be necessary to test the quality of the research.

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If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

Normal distribution
Degrees of freedom
Null hypothesis
Discourse analysis
Control groups
Mixed methods research
Non-probability sampling
Quantitative research
Inclusion and exclusion criteria

Research bias

Rosenthal effect
Implicit bias
Cognitive bias
Selection bias
Negativity bias
Status quo bias

A systematic review is secondary research because it uses existing research. You don’t collect new data yourself.

The research methods you use depend on the type of data you need to answer your research question .

If you want to measure something or test a hypothesis , use quantitative methods . If you want to explore ideas, thoughts and meanings, use qualitative methods .
If you want to analyze a large amount of readily-available data, use secondary data. If you want data specific to your purposes with control over how it is generated, collect primary data.
If you want to establish cause-and-effect relationships between variables , use experimental methods. If you want to understand the characteristics of a research subject, use descriptive methods.

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

Sources in this article

We strongly encourage students to use sources in their work. You can cite our article (APA Style) or take a deep dive into the articles below.

George, T. (2024, January 12). What is Secondary Research? | Definition, Types, & Examples. Scribbr. Retrieved July 30, 2024, from https://www.scribbr.com/methodology/secondary-research/

Largan, C., & Morris, T. M. (2019). Qualitative Secondary Research: A Step-By-Step Guide (1st ed.). SAGE Publications Ltd.

Peloquin, D., DiMaio, M., Bierer, B., & Barnes, M. (2020). Disruptive and avoidable: GDPR challenges to secondary research uses of data. European Journal of Human Genetics , 28 (6), 697–705. https://doi.org/10.1038/s41431-020-0596-x

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Qualitative Secondary Analysis: A Case Exemplar

PMID: 29254902
PMCID: PMC5911239
DOI: 10.1016/j.pedhc.2017.09.007

Qualitative secondary analysis (QSA) is the use of qualitative data that was collected by someone else or was collected to answer a different research question. Secondary analysis of qualitative data provides an opportunity to maximize data utility, particularly with difficult-to-reach patient populations. However, qualitative secondary analysis methods require careful consideration and explicit description to best understand, contextualize, and evaluate the research results. In this article, we describe methodologic considerations using a case exemplar to illustrate challenges specific to qualitative secondary analysis and strategies to overcome them.

Keywords: Critical illness; ICU; qualitative research; secondary analysis.

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Forum: Qualitative Social Research / Forum Qualitative Sozialforschung

Strategies in Teaching Secondary Analysis of Qualitative Data

Louise Corti ESDS Qualidata
Libby Bishop ESDS Qualidata

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Louise corti, esds qualidata, libby bishop, esds qualidata, how to cite.

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Secondary Data Analysis: Ethical Issues and Challenges

Research does not always involve collection of data from the participants. There is huge amount of data that is being collected through the routine management information system and other surveys or research activities. The existing data can be analyzed to generate new hypothesis or answer critical research questions. This saves lots of time, money and other resources. Also data from large sample surveys may be of higher quality and representative of the population. It avoids repetition of research & wastage of resources by detailed exploration of existing research data and also ensures that sensitive topics or hard to reach populations are not over researched ( 1 ). However, there are certain ethical issues pertaining to secondary data analysis which should be taken care of before handling such data.

Secondary data analysis

Secondary analysis refers to the use of existing research data to find answer to a question that was different from the original work ( 2 ). Secondary data can be large scale surveys or data collected as part of personal research. Although there is general agreement about sharing the results of large scale surveys, but little agreement exists about the second. While the fundamental ethical issues related to secondary use of research data remain the same, they have become more pressing with the advent of new technologies. Data sharing, compiling and storage have become much faster and easier. At the same time, there are fresh concerns about data confidentiality and security.

Issues in Secondary data analysis

Concerns about secondary use of data mostly revolve around potential harm to individual subjects and issue of return for consent. Secondary data vary in terms of the amount of identifying information in it. If the data has no identifying information or is completely devoid of such information or is appropriately coded so that the researcher does not have access to the codes, then it does not require a full review by the ethical board. The board just needs to confirm that the data is actually anonymous. However, if the data contains identifying information on participants or information that could be linked to identify participants, a complete review of the proposal will then be made by the board. The researcher will then have to explain why is it unavoidable to have identifying information to answer the research question and must also indicate how participants’ privacy and the confidentiality of the data will be protected. If the above said concerns are satisfactorily addressed, the researcher can then request for a waiver of consent.

If the data is freely available on the Internet, books or other public forum, permission for further use and analysis is implied. However, the ownership of the original data must be acknowledged. If the research is part of another research project and the data is not freely available, except to the original research team, explicit, written permission for the use of the data must be obtained from the research team and included in the application for ethical clearance.

However, there are certain other issues pertaining to the data that is procured for secondary analysis. The data obtained should be adequate, relevant but not excessive. In secondary data analysis, the original data was not collected to answer the present research question. Thus the data should be evaluated for certain criteria such as the methodology of data collection, accuracy, period of data collection, purpose for which it was collected and the content of the data. It shall be kept for no longer than is necessary for that purpose. It must be kept safe from unauthorized access, accidental loss or destruction. Data in the form of hardcopies should be kept in safe locked cabinets whereas softcopies should be kept as encrypted files in computers. It is the responsibility of the researcher conducting the secondary analysis to ensure that further analysis of the data conducted is appropriate. In some cases there is provision for analysis of secondary data in the original consent form with the condition that the secondary study is approved by the ethics review committee. According to the British Sociological Association’s Statement of Ethical Practice (2004) the researchers must inform participants regarding the use of data and obtain consent for the future use of the material as well. However it also says that consent is not a once-and-for-all event, but is subject to renegotiation over time ( 3 ). It appears that there are no guidelines about the specific conditions that require further consent.

Issues in Secondary analysis of Qualitative data

In qualitative research, the culture of data archiving is absent ( 4 ). Also, there is a concern that data archiving exposes subject’s personal views. However, the best practice is to plan anonymisation at the time of initial transcription. Use of pseudonyms or replacements can protect subject’s identity. A log of all replacements, aggregations or removals should be made and stored separately from the anonymised data files. But because of the circumstances, under which qualitative data is produced, their reinterpretation at some later date can be challenging and raises further ethical concerns.

There is a need for formulating specific guidelines regarding re-use of data, data protection and anonymisation and issues of consent in secondary data analysis.

Acknowledgements

The authors declare that there is no conflict of interest.

Fielding NG, Fielding JL (2003). Resistance and adaptation to criminal identity: Using secondary analysis to evaluate classic studies of crime and deviance . Sociology , 34 ( 4 ): 671–689. [ Google Scholar ]
Szabo V, Strang VR (1997). Secondary analysis of qualitative data . Advances in Nursing Science , 20 ( 2 ): 66–74. [ PubMed ] [ Google Scholar ]
Statement of Ethical Practice for the British Sociological Association (2004). The British Sociological Association, Durham . Available at: http://www.york.ac.uk/media/abouttheuniversity/governanceandmanagement/governance/ethicscommittee/hssec/documents/BSA%20statement%20of%20ethical%20practice.pdf (Last accessed 24November2013)
Archiving Qualitative Data: Prospects and Challenges of Data Preservation and Sharing among Australian Qualitative Researchers. Institute for Social Science Research, The University of Queensland, 2009 . Available at: http://www.assda.edu.au/forms/AQuAQualitativeArchiving_DiscussionPaper_FinalNov09.pdf (Last accessed 05September2013)

Qualitative Research : Get data for secondary analysis

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Syracuse Qualitative Data Repository "QDR is a dedicated archive for storing and sharing digital data (and accompanying documentation) generated or collected through qualitative and multi-method research in the social sciences. QDR provides search tools to facilitate the discovery of data, and also serves as a portal to material beyond its own holdings, with links to U.S. and international archives. The repository’s initial emphasis is on political science."
ICPSR The Interuniversity Consortium for Political and Social Research (ICPSR) archive includes quantitative, qualitative, and mixed methods datasets. Using the search engine, select "Qualitative" under "Type of Analysis."
Henry A. Murray Research Archive "The Henry A. Murray Research Archive is Harvard's endowed repository for quantitative and qualitative research data at the Institute for Quantitative Social Science. Our collection comprises over 100 terabytes of data, audio, and video. We provide long-term preservation of all types of data of interest to the research community, including numerical, video, audio, interview notes, and other data."
UK Data Archive The UK Data Archive has quantitative, qualitative, and mixed methods data.
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URL: https://guides.library.stanford.edu/qualitative_research

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Published: 26 July 2024

Improving Clerkship to Enhance Patients’ Quality of care (ICEPACQ): a baseline study

Kennedy Pangholi 1 ,
Enid Kawala Kagoya 2 ,
Allan G Nsubuga 3 ,
Irene Atuhairwe 3 ,
Prossy Nakattudde 3 ,
Brian Agaba 3 ,
Bonaventure Ahaisibwe 3 ,
Esther Ijangolet 3 ,
Eric Otim 3 ,
Paul Waako 4 ,
Julius Wandabwa 5 ,
Milton Musaba 5 ,
Antonina Webombesa 6 ,
Kenneth Mugabe 6 ,
Ashley Nakawuki 7 ,
Richard Mugahi 8 ,
Faith Nyangoma 1 ,
Jesca Atugonza 1 ,
Elizabeth Ajalo 1 ,
Alice Kalenda 1 ,
Ambrose Okibure 1 ,
Andrew Kagwa 1 ,
Ronald Kibuuka 1 ,
Betty Nakawuka 1 ,
Francis Okello 2 &
Proscovia Auma 2

BMC Health Services Research volume 24 , Article number: 852 ( 2024 ) Cite this article

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Proper and complete clerkships for patients have long been shown to contribute to correct diagnosis and improved patient care. All sections for clerkship must be carefully and fully completed to guide the diagnosis and the plan of management; moreover, one section guides the next. Failure to perform a complete clerkship has been shown to lead to misdiagnosis due to its unpleasant outcomes, such as delayed recovery, prolonged inpatient stay, high cost of care and, at worst, death.

The objectives of the study were to determine the gap in clerkship, the impact of incomplete clerkship on the length of hospital stay, to explore the causes of the gap in clerkship of the patients and the strategies which can be used to improve clerkship of the patients admitted to, treated and discharged from the gynecological ward in Mbale RRH.

Methodology

This was a mixed methods study involving the collection of secondary data via the review of patients’ files and the collection of qualitative data via key informant interviews. The files of patients who were admitted from August 2022 to December 2022, treated and discharged were reviewed using a data extraction tool. The descriptive statistics of the data were analyzed using STATA version 15, while the qualitative data were analyzed via deductive thematic analysis using Atlas ti version 9.

Data were collected from 612 patient files. For qualitative data, a total of 8 key informant interviews were conducted. Social history had the most participants with no information provided at all (83.5% not recorded), with biodata and vital sign examination (20% not recorded) having the least number. For the patients’ biodata, at least one parameter was recorded in all the patients, with the greatest gap noted in terms of recording the nearest health facility of the patient (91% not recorded). In the history, the greatest gap was noted in the history of current pregnancy (37.5% not provided at all); however, there was also a large gap in the past gynecological history (71% not recorded at all), past medical history (71% not recorded at all), past surgical history (73% not recorded at all) and family history (80% not recorded at all). The physical examination revealed the greatest gap in the abdominal examination (43%), with substantial gaps in the general examination (38.5% not recorded at all) and vaginal examination (40.5% not recorded at all), and the vital sign examination revealed the least gap. There was no patient who received a complete clerkship. There was a significant association between clerkships and the length of hospital stay. The causes of the gap in clerkships were multifactorial and included those related to the hospital, those related to the health worker, those related to the health care system and those related to the patient. The strategies to improve the clerkship of patients also included measures taken by health care workers, measures taken by hospitals and measures taken by the government.

Conclusion and recommendation

There is a gap in the clerkships of patients at the gynecological ward that is recognized by the stakeholders at the ward, with some components of the clerkship being better recorded than others, and no patients who received a complete clerkship. There was a significant association between clerkships and the length of hospital stay.

The following is the recommended provision of clerkship tools, such as the standardized clerkship guide and equipment for patient examination, continuous education of health workers on clerkships and training them on how to use the available tools, the development of SOPs for patient clerkships, the promotion of clerkship culture and the supervision of health workers.

Peer Review reports

Introduction

A complete clerkship is the core upon which a medical diagnosis is made, and this depends on the patient’s medical history, the signs noticed on physical examination, and the results of laboratory investigations [ 1 ]. These sections of the clerkship should be completed carefully and appropriately to obtain a correct diagnosis; moreover, one part guides the next. A complete gynecological clerkship comprises the patient’s biodata, presenting complaint, history of presenting complaint, review of systems, past gynecological history, past obstetric history, past medical history, past surgical history, family history, social history, physical examination, laboratory investigation, diagnosis and management plan [ 2 , 3 ].

History taking, also known as medical interviews, is a brief personal inquiry and interrogation about bodily complaints by the doctor to the patient in addition to personal and social information about the patient [ 4 ]. It is estimated that 70-90% of a medical diagnosis can be determined by history alone [ 5 , 6 ]. Physical examination, in addition to the patient’s history, is equally important because it helps to discover more objective aspects of the disease [ 7 ]. The investigation of the patient should be guided by the findings that have been obtained on history taking and the physical examination [ 1 ].

Failure to establish a good complete and appropriate clerkship for patients leads to diagnostic uncertainties, which are associated with unfavorable outcomes. Some of the effects of poor clerkship include delayed diagnosis and inappropriate investigations, which lead to unnecessary expenditures on irrelevant tests and drugs and other effects, such as delayed recovery, prolonged inpatient stays, high costs of care and, at worst, death [ 8 , 9 ]. Despite health care workers receiving training in medical school about the relevance of physical examination, this has been poorly practiced and replaced with advanced imaging techniques such as ultrasounds, CT scans, and MRIs, which continue to make health care services unaffordable for most populations in developing countries [ 6 ]. In a study conducted to determine the prevalence and classification of misdiagnosis among hospitalized patients in five general hospitals in central Uganda, 9.2% of inpatients were misdiagnosed, and these were linked to inadequate medical history and examination, as the most common conditions were the most commonly misdiagnosed [ 9 ].

At Mbale RRH, there has been a progressive increase in the number of patients included in the gynecology department, which is expected to have compromised the quality of the clerkships that patients receive at the hospital [ 10 ]. However, there is limited information about the quality and completeness of clerkships for patients admitted to and treated at Mbale RRH. The current study therefore aimed to determine the gap in patient clerkships and the possible causes of these gaps and to suggest strategies for improving clerkships.

Methods and materials

Study design.

This was a baseline study, which was part of a quality improvement project aimed at improving the clerkships of patients admitted and treated at Mbale RRH. This mixed cross-sectional survey employing both quantitative and qualitative techniques was carried out from August 2022 to December 2022. Both techniques were employed to triangulate the results and address the gap in clerkship using quantitative techniques. Then, qualitative methods were used to explain the reasons for the observed discrepancy, and strategies to improve clerkship were suggested.

Study setting

The study was carried out in Mbale RRH, at the gynecologic ward. The hospital is in Mbale Municipal Council, 214 km to the east of the capital city of Kampala. It is the main regional referral hospital in the Elgon zone in eastern Uganda, a geographic area that borders the western part of Kenya. The Mbale RRH serves a catchment population of approximately 5 million people from 16 administrative districts. It is the referral hospital for the districts of Busia, Budaka, Kibuku, Kapchorwa, Bukwo, Butaleja, Manafwa, Mbale, Pallisa, Sironko and Tororo. The hospital is situated at an altitude of 1140 m within a range of 980–1800 m above sea level. Over 70% of inhabitants in this area are of Bantu ethnicity, and the great majority are part of rural agrarian communities. The Mbale RRH is a government-run, not-for-profit and charge-free 470-bed capacity that includes four major medical specialties: Obstetrics and Gynecology, Surgery, Internal Medicine, and Pediatrics and Child Health.

Study population, sample size and sampling strategy

We collected the files of patients who were admitted to the gynecology ward at Mbale RRH from August 2022 to December 2022. All the files were selected for review. We also interviewed health workers involved in patient clerkships at the gynecological ward. For qualitative data, participants were recruited until data saturation was reached.

Data collection

We collected both secondary and primary data. Secondary data were collected by reviewing the patients’ files. We identified research assistants who were trained in the data entry process. The data collection tool on Google Forms was distributed to the gadgets that were given to the assistants to enter the data. The qualitative data collection was performed via key informant interviews of the health workers involved in the clerkship of the patients, and the interviews were performed by the investigators. The selection of the participants was purposive, as we opted for those who clerk patients. After providing informed consent, the interview proceeded, with a voice recorder used to capture the data collected during the interview process and brief key notes made by the interviewer.

Data collection tool

A data abstraction tool was developed and fed into Google Forms, which were used to collect information about patients’ clerkships from patients’ files. The tool was developed by the investigators based on the requirements of a full clerkship, and it acted as a checklist for the parameters of clerkships that were provided or not provided. The validity of this tool was first determined by using it to collect information from ten patients’ files, which were not included in the study, and the tool was adjusted accordingly. The tool for collecting the qualitative information was an interview guide that was developed by the interviewer and was piloted with two health workers. Then, the guide was adjusted before it was used for data collection.

Variable handling

The dependent variable in the current study was the length of hospital stay. This was calculated from the date of admission and the date of discharge. There were two outcomes: “prolonged hospital stay” and “not prolonged”. A prolonged hospital stay was defined as a hospital stay of more than the 75 th percentile, according to a study conducted in Ethiopia [ 9 ]. This duration was more than 5 (five) days in the current study. The independent variables were the components of the clerkship.

Data analysis

Data analysis was performed using STATA version 15. Univariate, bivariate and multivariate analyses were performed. Continuous variables were summarized using measures of central tendency and measures of dispersion, while categorical variables were summarized using frequencies and proportions. Bivariate analysis was performed using chi-square or Fischer’s exact tests, one-way ANOVA and independent t tests, with the level of significance determined by a p value of <= 0.2. Multivariate analysis was performed using logistic regression, and the level of significance was determined by a p value of <=0.05.

Qualitative data were analyzed using Atlas Ti version 9 via deductive thematic analysis. The audio recordings were transcribed, and the transcripts were then imported into Atlas Ti.

Qualitative

The files of a total of 612 patients were reviewed.

The gap in the clerkships of patients

Patient biodata.

As shown in Fig. 1 below, at least one parameter under patient biodata was recorded for all the patients. The largest gap was identified in the recording of the nearest health facility of the patient, where 91% of the patients did not have this recorded, and the smallest gap was in the recording of the name and age, where less than 1% had this not recorded.

The gap in patients’ biodata

Compliance, HPC and ROS

As shown in Fig. 2 below, the largest gap here was in recording the history of presenting complaint, which was not recorded in 32% of the participants. The least gap was in the review of systems, where it was not recorded in only 10% of the patients.

Gap in the presenting of complaints, HPCs and ROS

As shown in Fig. 3 below, the past obstetric history had the greatest gap in recording the gestational age at delivery of each pregnancy (89% not recorded), while the least gap was in recording the number of pregnancies (43% not recorded). In terms of the history of current pregnancy, the greatest gap was in recording whether hematinics were given to the mother (92% not recorded), while the least gap was in recording the date of the first day of the last normal menstrual period (LNMP) (44% not recorded). On other gynecological history, the largest gap was in recording the history of gynecological procedures (88% not recorded), while the least gap was in the history of abortions (73% not recorded). In the past medical history, the largest gap was in terms of history of medication allergies and history of previous admissions (86% not recorded), and the smallest gap was in terms of history of chronic illnesses (72% not recorded). In the past surgical history, the largest gap was in the history of trauma (84% not recorded), while the least gap was in the history of blood transfusion (76% not recorded). In terms of family history, there was a greater gap in the family history of twin pregnancies (86% not recorded) than in the family history of familial illnesses (83% not recorded). In terms of social history, neither alcohol intake nor smoking were recorded for 84% of the patients.

Gap in history

Physical examination

As shown in Fig. 4 below, the least recorded vital sign was oxygen saturation (SPO2), with 76% of the patients’ SPO2 not being recorded, while blood pressure was least recorded (21% not recorded). On the general examination, checking for edema had the greatest gap (63% not recorded), while checking for pallor had the least gap (45% not recorded). On abdominal examination, auscultation had the greatest gap (76% not recorded), while inspection of the abdomen had the least gap (56% not recorded). On vaginal examination, the greatest difference was in examining the vaginal OS (57% not recorded), while the least difference was in checking for vaginal bleeding (47% not recorded).

Gap in physical examination

Investigations, provisional diagnosis and management plan

As shown in Fig. 5 below, the least common investigation was the malaria test (76% not performed), while the most common investigation was the CBC test (41% not performed). Provisional diagnosis was not performed in 20% of the patients. A management plan was not provided for approximately 4-5 of the patients.

Gap in the provisional diagnosis and management plan

Summary of the gap in clerkships

As shown in Fig. 6 below, most participants had a social history with no information provided at all, while biodata and vital sign examinations had the least number of participants with no information provided at all. There was no patient who had a complete clerkship.

Summary of the gaps in clerkships

Days of hospitalization

The days of hospitalization were not normally distributed and were positively skewed, with a median of 3 [ 2 , 5 ] days. The mean days of hospitalization was 6.2 (±11.1). As shown in Fig. 7 below, 20% of the patients had prolonged hospitalization.

Duration of hospitalization

The effect of the clerkship gap on the number of days of hospital stay

As shown in Tables 1 and 2 below, the clerkship components that had a significant association with the days of hospitalization at the bivariate level included vital examination, abdominal examination, history of presenting complaint and treatment plan.

As shown in Table 3 , the only clerkship component that had a significant association with the days of hospitalization at the multivariate level was abdominal examination. People who had partial abdominal examinations were 1.9 times more likely to have prolonged hospital stays than those who had complete abdominal examinations.

Qualitative results

We conducted a total of 8 key informant interviews with the following characteristics as shown in table 4 below.

The qualitative results are summarized in Table 5 below.

The quality of clerkships on wards

It was reported that both the quality and completeness of clerkships on the ward are poor.

“…most are not clerking fully the patients, just put in like biodata three items name, age address, then they go on the present complaint, diagnosis then treatment; patient clerkship is missing out some important information…” (KIISAMW 2)

It was, however, noted that the quality of a clerkship depends on several factors, such as who is clerking, how sick the patient is, the number of patients to be seen that particular day and the number of hours a person clerks.

“…so, the quality of clerkship is dependent on who is clerking but also how sick the patient is…” (KIIMO 3)

Which people usually clerk patients on the ward?

The following people were identified as those who clerking patients, midwives, medical students, junior house officers, medical officers and specialists.

“…everyone clerks patients here; nurses, midwives, doctors, medical students, specialists, everyone as long as you are a health care provider…” (KIIMO 2)

Causes of the gaps in clerkships

These factors were divided into factors related to health workers, hospital-related factors, health system-related factors and patient-related factors.

Hospital-related factors

The absence of clerkship tools such as a standardized clerkship guide and equipment for the examination of patients, such as blood pressure machines, thermometers, and glucometers, among others, were among the reasons for the poor clerkships of the patients.

…of course, there are other things like BP machines, thermometers; sometimes you want to examine a patient, but you don’t have those examining tools…” (KIIMO 1)

The tools that were available were plain, and they play little role in facilitating clerkships. They reported that they end up using small exercise books with no guidance for easy clerkship and with limited space.

“…most of our tools have these questions that are open ended and not so direct, so the person who is not so knowledgeable in looking out for certain things may miss out on certain data…” (KIIOG 1)

The reluctance of some health workers to clerk patients fully was also reported to be because it is the new normal, and everyone follows a bandwagon to collect only limited information from patients because there is no one to follow up or supervise.

“…you know when you go to a place, what you find people doing is what you also end up doing; I think it is because of what people are doing and no one is being held accountable for poor clerkship…” (KIIMO 3)

The absence of specialized doctors in the OPD department forces most patients, even stable patients, to be managed by the OPD to crowd the ward, making complete clerkships for all patients difficult. Poor triaging of the patients was also noted as one of the causes of poor clerkship, as emergency cases are mixed with stable cases.

“…and this gyn ward is supposed to see emergency gynecological cases, but you find even cases which are supposed to be in the gyn clinic are also here; so, it creates large numbers of people who need services…” (KIIMO 1)

Clerkships being performed by the wrong people were also noted. It was emphasized that it is only a medical doctor who can perform good clerkships for patients, and any other cadres who perform clerkships contribute to poor clerkships on the ward.

Health worker-related factors

A poor attitude of health workers was reported, and it was found that many health workers consider complete clerkship to be a practice that is performed by people who do not know what they look for to make a diagnosis.

A lack of knowledge about clerkships is another factor that has been reported. Some health workers were reported to forget some of the components of clerkship; hence, they end up recording only what they remember at the time of clerkship.

A lack of confidence by some health workers and students that creates fear of committing to making a diagnosis and drawing a management plan was reported to hinder some of them from doing a complete clerkship of the patients.

“…a nurse or a student may clerk, but they don’t know the diagnosis; so, they don’t want to commit themselves to a diagnosis…” (KIIMO 2)

Some health workers reported finding the process of taking notes while clerking tedious; hence, they collected only limited information that they could write within a short period of time.

Health system-related factors

Understaffing of the ward was noted to cause a low health worker-to-patient ratio. This overworked the health workers due to the large numbers of patients to be seen.

“…due to the thin human resource for health, many patients have to be seen by the same health worker, and it becomes difficult for one to clerk adequately; they tend to look out for key things majorly…” (KIIOG 1)

It was noted that in the morning or at the start of a shift, the clerkship can be fair, but as the day progresses, the quality of the clerkship decreases due to exhaustion.

“…you can’t clerk the person you are seeing at 5 pm the same way you clerked the person you saw at 9 am…” (KIIMO 3)

The large numbers of patients were also associated with other factors, such as the inefficient referral system, where patients who can be managed in lower health facilities are also referred to Mbale RRH. It was also stated that some patients do not understand the referral system, causing self-referral to the RRH. Other factors that contributed to the poor referral system were limited trust of the patients, drug stockouts, limited skilled number of health workers, and limited laboratory facilities in the lower health facilities.

“…so, everyone comes in from wherever they can, even unnecessary referrals from those lower health facilities make the numbers very high…” (KIIMO 1)

Patient-related factors

It was reported that the nature of some cases does not allow the health worker to collect all the information from such a patient, for example, the emergency cases. However, some responders stated the emergent nature of the cases to be a contributor to the complete clerkship of such a patient, as the person clerking such a case is more likely to call for help, so they must have enough information on the patient. Additionally, they do not want to fill the gap in the care of this critical patient.

“…usually, a more critical patient gets a more elaborate clerkship compared to a more stable one, where we will get something quick…” (KIIMO 3)

The poor health of some patients makes them unable to afford the files and books where clerkship notes are to be taken.

“…a patient has no money, and they have to buy books where to write, then you start writing on ten pages; does it make sense...” (KIIMO 2)

Strategies to improve patients’ clerkships

These were divided into measures to be taken by the health workers, those to be taken by the hospital leadership and those to be taken by the government.

Measures to be taken by health workers.

Holding each other accountable with respect to clerkship quality and completeness was suggested, including providing feedback from fellow health workers and from the records department.

…like everyone I think should just be held accountable for their clerkship and give each other feedback…” (KIIMO 3)

It was also suggested that medical students be mentored by senior doctors on the ward on the clerkship, and they should clerk the patients and present them to the senior doctors for guidance on the diagnosis and the management plan. This approach was believed to save time for senior doctors who may not have obtained time to collect information from patients and to facilitate the learning of students, most importantly ensuring the complete clerkship of patients.

“…students can give us a very good clerkship if supervised well, then we can discuss issues of diagnosis, the investigations to be done and the management…” (KIIMO 1)

Changes in the attitudes of health workers toward clerkships were suggested. This was also encouraged for those who work in laboratories to be able to perform the required investigations to guide diagnosis and management.

“…our lab has the equipment, but they need to change their attitude toward doing the investigations…” (KIIMO 1)

Measures to be taken by hospital leaders

The provision of tools to be used in clerkships was suggested as one of the measures that can be taken. Among the tools that were suggested include the following: a standardized clerkship guide, equipment for examination of the patients, such as blood pressure machines, and thermometers, among others. It was also suggested that a printer machine be used to print the clerkship guide to ensure the sustainability and availability of the tools. An electronic clerkship provision was suggested so that the amount of tedious paperwork could be reduced, especially for those who are comfortable with it.

“…if the stakeholders, especially those who have funds, can help us to make sure that these tools are always available, it is a starting point…” (KIIOG 1)

Continuous education of the clinicians about clerkships was suggested in the CMEs, and routine morning meetings were always held in the ward. Then, it was suggested that clinicians who clerked patients the best way are rewarded to motivate them.

“…for the staff, we can may be continuously talking about it during our Monday morning meetings about how to clerk well and the importance of clerking…” (KIIOG 1)

They also suggested providing a separate conducive room for the examination of patients to ensure the privacy of the patient, as this will ensure more detailed examination of the patients by the clinicians.

It was also suggested that more close supervision of the clerkship be performed and that a culture of good clerkship be developed to make clerkship a norm.

“…as leaders of the ward and of the department, we should not get tired to talk about the importance of clerkship, not only in this hospital but also in the whole country…” (KIIOG 1)

Proper record-keeping was also suggested, for people clerking to be assured that information will not be discarded shortly.

“…because how good is it to make these notes yet we can’t keep them properly...” (KIIMO 2)

It was also suggested that a records assistant be allocated to take notes for the clinicians to reduce their workload.

Coming up with SOPs, for example, putting different check points that ensure that a patient is fully clerked before the next step

“…we can say, before a patient accesses theater or before a mother enters second stage room, they must be fully clerked, and there is a checklist at that point…” (KIIOG 1)

Measures to be taken by the government

Improving the staffing level is strongly suggested to increase the health worker-to-patient ratio. This, they believed would reduce the workload off the health workers and allow them to give more time to the patients.

“…we also need more staffing for the scan because the person who is there is overwhelmed…” (KIIMO 1)

Staff motivation was encouraged through the enhancement of staff salaries and allowances. It was believed that it would be easy for these health workers to be supervised when they are motivated.

“…employ more health workers, pay them well then you can supervise them well…” (KIIMO 1)

Providing refresher courses to clinicians was also suggested so that they could be updated during the clerkship process.

Streamlining the referral system was also suggested through the use of lower health facilities so that some minor cases can be managed in those facilities to reduce the overcrowding of patients in the RRH.

“…we need to also streamline the referral system, the way people come to the RRH; some of these cases can be handled in the lower health facilities; we need to see only patients who have been referred…” (KIIMO 2)

The qualitative results are further summarized in Fig. 8 below.

Scheme of the clerkship of patients, including the causes of the clerkship gap and the strategies to improve the clerkship at Mbale RRH

Discussion of results

This study highlights a gap in the clerkships of patients admitted, treated, and discharged from the gynecological ward, with varying gaps in the different sections. This could be because some sections of the clerkship are considered more important than others. A study performed in Turkey revealed that physicians tended to record more information that aided their diagnostic tasks [ 11 ]. This is also reflected in the qualitative findings where participants expressed that particular information is required to make the diagnosis and not everything must be collected.

Biodata for patients were generally well recorded, and name and age were recorded for almost all the patients. A similar finding was found in the UK, where 100% of the patients had their personal details fully recorded [ 12 ]. Patient information should be carefully and thoroughly recorded because it enables health workers to create good rapport with patients and creates trust [ 13 ]. This information is also required for every interaction with the patient at the ward.

The presenting complaint, history of presenting complaint and the review of systems were fairly recorded, with each of them missing in less than 40% of the patients. The presence of a complaint is crucial in every interaction with the patient to the extent that a diagnosis can rarely be made without knowing the chief complaint [ 14 , 15 ]. This applies to the history of presenting complaint as well [ 16 ]. For the 30% who did not have the presenting complaint recorded, this could mean that even the patient’s primary problem was not given adequate attention.

In the history, the greatest gap was noted in the history of current pregnancy, where many parameters were not recorded in most patients. This is, however, expected since the study was conducted on a gynecological ward, where only a few pregnant women are expected to visit, as they are supposed to go to their antenatal clinics [ 17 ]. However, there was also a large gap in past gynecological history, which is expected to be fully explored in the gynecology ward. A good medical history is key to obtaining a good diagnosis, in addition to a good clinical examination [ 3 , 18 ]. Past obstetric history, past medical history, past surgical history, and family history also had large gaps, yet they are very important in the management of these patients.

The abdominal parameters, especially the pulse rate and blood pressure, were the least frequently recorded during the physical examination, and vital signs were most often recorded. However, there were substantial gaps in the general examination and vaginal examination. The least gap in vital sign examination is close monitoring, which is performed for most patients admitted to the ward due to the nature of the patients, some of whom are emergency patients [ 19 ].

Among the investigations, 29% of patients were not investigated. The least commonly performed investigations were pelvic USS and malaria tests, while complete blood count (CBC) was most commonly performed. Genital infections are among the most common reasons for women’s visits to health care facilities [ 20 ]. Therefore, most women in the gynecological ward are suspected to have genital tract infections, which could account for why CBC is most commonly performed.

The limited number of other investigations, such as pelvic ultrasound scans, underscore the relative contribution of medical history and physical examination to laboratory investigations and imaging studies aimed at making a diagnosis [ 1 ]. However, this would also highlight the system challenges of limited access to quality laboratory services in low- and middle-income countries [ 21 ]. This was also highlighted by one of the key informants who reported that the USS staff is available on some and not all days. This means that on days where the ultrasound department does not work, USS is not performed, even when needed.

We found that 20% of patients experienced prolonged hospitalization. This percentage is lower than the 24% reported in a study conducted in Ethiopia [ 22 ]. However, this study was conducted in a surgical ward. The median length of hospital stay was the same as that in a study conducted in Eastern Sudan among mothers following cesarean delivery [ 23 ]. A prolonged hospital stay has a negative impact not only on patients but also on the hospital [ 24 , 25 ]. Therefore, health systems should aim to reduce the length of hospital stay for patients as much as possible to improve the effectiveness of health services.

At the multivariate level, abdominal examination was significantly associated with length of hospital stay, with patients whose abdominal examination was not complete being more likely to have a prolonged hospital stay. This underscores the importance of good examination in the development of proper management plans that improve the care of patients, hence reducing the number of days of hospital stay [ 5 , 26 ].

There is a gap in the clerkships of patients at the gynecological ward, which is recognized by the stakeholders at the ward. Some components of clerkships were recorded better than others, with the reasoning that clerkships should be targeted. There were no patients who received a complete clerkship. There was a significant association between clerkships and the length of hospital stay. The causes of the gap in clerkships were multifactorial and included those related to the hospital, those related to the health worker, those related to the health care system and those related to the patient. The strategies to improve the clerkship of patients also included measures taken by health care workers, measures taken by hospitals and measures taken by the government.

Recommendations

Clerkship tools, such as the standardized clerkship guide and equipment for patient examination, were provided. The health workers were continuously educated on clerkships and trained on how to use the available tools. The development of SOPs for patient clerkships, the promotion of clerkship culture and the supervision of health workers.

Strengths of the study

A mixed study, therefore, allows for the triangulation of results.

Study limitations

The quantity of quantitative data collected, being secondary, is subject to bias due to documentation errors. We assessed the completeness of clerkship without considering the nature of patient admission. We did not record data on whether it was an emergency or stable case, which could be an important cofounder. However, this study gives a good insight into the status of clerkship in the gynecological ward and can lay foundation for future research into the subject.

Availability of data and materials

The data and materials are available upon request from the corresponding author via the email provided.

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Contributions

P.K came up with the concept and design of the work and coordinated the team to work K.E.K and A.P helped interpretation of the data O.F and O.A helped in the analysis of data N.A.G, A.I, N.P, W.P, W.J, M.M, A.W, M.K, N.F, A.J, A.E, M.R, K.A, K.A, A.B, A.B, I.E, O.E, N.A, K.R, N.B substantially revised the work.

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Correspondence to Kennedy Pangholi .

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The study was conducted according to the Declaration of Helsinki and in line with the principles of Good Clinical Practice and Human Subject Protection. Prior to collecting the data, ethical approval was obtained from the Research Ethics Committee of Mbale RRH, approval number MRRH-2023-300. The confidentiality of the participant information was ensured throughout the research process. Permission was obtained from the hospital administration before the data were collected from the patients’ files, and informed consent was obtained from the participants before the qualitative data were collected. After entry of the data, the devices were returned to the principal investigator at the end of the day, and they were given to the data entrants the next day.

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Pangholi, K., Kagoya, E.K., Nsubuga, A.G. et al. Improving Clerkship to Enhance Patients’ Quality of care (ICEPACQ): a baseline study. BMC Health Serv Res 24 , 852 (2024). https://doi.org/10.1186/s12913-024-11337-w

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Moshe Bensimon ORCID: orcid.org/0000-0002-0008-035X 1 &
Yael Idisis ORCID: orcid.org/0000-0002-7096-0758 1

Amateur Pornography (AP) is a new phenomenon that emerged a few decades ago and is distinctly different from Professional Pornography (PP). Yet, academic literature that focuses on AP hardly exists. This qualitative study focuses on male AP actors’ lived experience, including their motivations, implications and ways of coping with its challenges. Semi-structured interviews with 27 male AP actors revealed five themes: (1) AP as a unique genre that promotes diverse human body appearance, free choice, and profit as its secondary motive; (2) personal background that includes sexual abuse during childhood and unmet childhood emotional needs; (3) moral reasons for involvement in AP , including challenging sexual misperceptions, preventing sexual harmfulness, and promoting education for healthy sexuality and gender equality; (4) implications of involvement in AP , including positive implications such as increased self-esteem and gaining admiration and appreciation, as well as negative implications, such as impaired interpersonal relationships, social stigmatization, harassments and persecutions, and physical and psychological work injuries; and (5) ways of coping with sex work’s particular difficulties , such as the AP actors’ emotional reliance on their romantic partners, developing an artistic perspective, hiding one’s involvement in AP, and adopting a “work persona”. This research suggests that the participants’ involvement in AP was based on free choice and motivated by ideological reasons. Their strategies for coping with the negative implications of their involvement in AP reflect their sense of potency which is contrary to victimhood that is associated with impotency and helplessness.

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Introduction

The academic literature which analyzes Professional Pornography (PP) has examined different aspects of the phenomenon of pornography, including sexual violence among porn actors (Bridges & Anton, 2013 ); the actors’ dealing with sexually transmitted diseases among porn actors (Hurley, 2009 ); the actors’ coping with poor mental health and high prevalence of mental disorders (Griffith et al., 2012 ; Jarke, 2022 ); a comparison between prostitution and porn acting (Bar-Johnson & Weiss, 2015 ); motivations for choosing a porn acting career (Evans-DeCicco & Cowan, 2001 ; Griffith et al., 2013 ); the actors’ sexual behavior and their perceptions of sex (Griffith et al., 2013 ); and examination of the concept of power in the porn industry (Brickell, 2012 ). Amateur Pornography (AP) is a unique niche in the pornographic industry, which has become more accessible and interactive due to the elaboration of the Web 2.0 browser (Parreiras, 2013 ). Significantly, it is marketed as an authentic, individual initiative rather than an industrialized production. AP presents itself as a sort of “do-it-yourself” nonindustrial home movies freely produced and distributed for entertainment purposes by internet users (Hardy, 2008 ). This niched pornography is apparently opposed to PP, which is produced by corporations and is often associated with the exploitation of workers (Macleod, 2021 ).

AP studies usually focus on sociological aspects of the development of this phenomenon, including social, technological, and global changes in commercialized erotic cultures (Ruberg, 2016 ). Additionally, AP studies concentrate on different social attitudes towards PP and AP and the actors’ motivations for working in the pornography business (Evans-DeCicco & Cowan, 2001 ) as well as psychological attributes of porn actors, including their self-esteem, self-image, and self-perception of their quality of life (Griffith et al., 2013 ). Despite the prevalence of AP, however, this phenomenon is highly under-researched. AP is a unique phenomenon that has almost never been investigated as a phenomenon. The rare references to AP in academic research typically regard this phenomenon as anecdotal, whereas PP is extensively analyzed. AP is still misperceived as a “niche” that is not thoroughly analyzed as a growing, influential pornographic industry (Griffiths et al., 2018 ). Hereby, this research aims to explore the lived experience of AP actors and their motivations, challenges and ways of coping with particular physical and emotional difficulties.

Male porn actors

While male filmmakers and producers are at the core of the porn industry (Lucas, 2006 ), its actors are both male and female (Ramirez-Rubio et al., 2022 ). Yet, recent American research reveals significant differences between 105 male actors and 177 female actresses who perform in commercialized pornographic films. 36% of the female porn actresses report that they were sexually abused in childhood, while only 11% of the male porn actors report that they were molested at an early age. Additionally, 10% of the female performers report earning more than the average salary, whereas only 3% of the male performers report that their income is higher than the average salary (Griffith et al., 2013 ). Further, it has been revealed that actresses are more vulnerable to abuse and brutality on set than their male peers (Carrotte et al., 2020 ). Notwithstanding, recent studies stress that the porn industry can also exploit men. Arguably, internet websites like czechhunter.com present porn films in which straight actors are been demanded to play homosexual sexual scenes (Brennan, 2019 ). In addition, male porn actors, like female porn actors, experience exploitation, servitude, economic damage, damaged self-image, lack of confidence, objectification, self-hatred, drug problems, and increased risk of contracting HIV when they are required to practice unsafe sex (Kendall & Funk, 2004 ).

Amateur pornography

AP is an independent, nonindustrial production (“do-it-your-self”) of pornographic home movies by web users who do not work for the commercial porn industry (Hardy, 2008 ). The amateur actors make their own erotic home videos, and they upload them to Internet websites, which are part of a multi-billion-dollar network of YouTube-style adult streaming websites, whether complimentary or in exchange for little financial compensation (Ruberg, 2016 ). The AP actors work without a producer-director; they can freely choose their partners for the film, and they upload content according to their free will (O’Neal, 2016 ). In many cases, AP intentionally attempts to develop conceptual and aesthetic alternatives to the stereotypic productions of mainstream porn. Thus, AP is regarded as a sort of alternative pornography (Paasonen, 2010 ; Parreiras, 2013 ). AP’s attempt to challenge stereotypes is demonstrated, for example, in its presentation of diverse physicality, in terms of body shape and size of sex organs. At the same time, the emergent AP subgenres include porn that is made and consumed by heterosexual and lesbian women, a growingly popular subgenre (Meehan, 2021 ).

PP and AP are substantially different in many aspects. First, the main motivation of women and men to be a part of PP is economic, as the participants are financially rewarded for their services (O’Neal, 2016 ). In contrast, the main motivation of AP actors is addressing their psychological needs, while the economic aspect of their performance is merely secondary (Kibby & Costello, 2001 ). Another difference is about physical traits and the public image of porn actors. The PP industry aims to provide a sort of “ideal fantasy” embodied by shaped and muscular male and female models with significant genitalia who are involved in “scripted,” artificial sexual intercourse. In contrast, AP actors display a natural body type without selling illusions to the viewers. AP actors upload independent movies, proving that anyone can become an AP actor (O’Neal, 2016 ). Hereby, these films are characterized by the participation of diverse porn actors of all sexes, genders, races, and sorts of physique while ignoring conventional PP aesthetic criteria (Griffith et al., 2013 ).

A possible theoretical explanation of the individual’s motivation to engage in pornography (both professional and amateur) is provided by Kohut’s self-psychology. According to this theory (Kohut & Wolf, 1978 ), the process of human development includes a response to a narcissistic and exhibitionistic need – the desire to be seen and admired by the main characters, usually the parents. A crucial role of the parental object is to mirror the child’s needs for admiration and positive reinforcement, which strengthens the child’s sense of self. When mirroring does not occur, the child experiences a lack of validation that impels the self, without any choice, to resort to other sources of nourishment which provide momentary relief such as substance use. However, these sources do not nourish the self in the long term and the need/drive arises again and again (Summers, 1994 ). In the context of porn actors, it may be assumed that they might benefit from the exposure on the net, which is followed by the viewers’ glorification, who see the actors as objects of admiration and repeatedly provide them with feelings of being seen, validation and loving admiration.

The research objectives

Despite the wide distribution of the AP genre, the AP actors have been highly under-researched. Academic references to porn actors always focus on PP actors, while AP actors are not properly distinguished from PP actors. Thus, the particularities of AP actors are not fully recognized (e.g., O’Neal, 2016 ). Considering the paucity of research in this field, the current study focuses on AP male actors’ lived experiences and initially explores their motivations, challenges, and ways of coping with particular difficulties in this business.

Research approach

This study used interpretative phenomenological analysis (IPA) (Smith et al., 2009 ), a qualitative method focusing on participants’ lived experiences. IPA is based on Husserl’s ( 1999 ) phenomenology, which, in turn, stems from hermeneutics and symbolic interactionism (Smith et al., 2009 ). IPA suggests that the individual’s inner world can be accessed through careful and explicit interpretative methodology. Choosing IPA as the guiding methodology for the present research coincides with the social constructionist theoretical perspective, which assumes that knowledge is constructed through subjective interpretations and social interactions (Denzin & Lincoln, 2011 ). The IPA approach was used with porn actresses such as transgender women in the adult film industry (Role, 2022 ). IPA is most appropriate for research that focuses on the lived experience of AP actors where their inner world can be accessed through careful and explicit interpretative methodology. Considering the rarity of data about AP performers, in general, and their subjective lived experiences, in particular, the current study is warranted.

Participants

This research included 27 Israeli male participants who work as AP actors, whereas only four female participants were recruited. Due to the particularities of female actors in pornography (Griffith et al., 2013 ), the significantly small number of female interviewees that we were able to recruit (four participants), and consequent saturation (Creswell & Poth, 2018 ), we decided not to include interviews with female AP actresses in this study but to save these four interviews for future research. However, our interviewees are highly diverse. 17 out of 27 male participants are involved in a relationship, while the other porn actors are not involved in a relationship. The average age of the participants is M = 32.78, SD = 7.219. 21 out of 27 participants identify themselves as gay; five participants are straight, and one participant is a self-identified bisexual. All the participants perform both in partnered scenes and solo scenes. The gay participants perform only in homosexual scenes. Three of the straight participants perform only at heterosexual scenes, and two (including the bisexual actor) perform at both homosexual and heterosexual scenes. The minimum age for participating in the research is 21 since military service in Israel for males is mandatory by law and ends at this age. Further, in addition to their involvement in AP, the participants are engaged in liberal professions such as advocacy, fitness training, and medicine.

After receiving ethical approval to conduct the research from Bar-Ilan University, the participants were applied through Internet dating sites and advertisements which are the main channels of communication between consumers of pornographic films and actors. We sent them the following invitation: “For the purpose of an academic study that deals with amateur pornography, actors are invited to an open discussion of how they experience their involvement in amateur pornography. The interview will be held when and where it would be convenient for you to meet. Anonymity guaranteed.” Also, amateur porn producers, who are distributing AP films to web consumers, were asked to send forward our invitation to actors. After the initial conscription of interviewees, additional interviewers were recruited in a snowball sampling (Goodman, 1961 ), i.e., interviewees provided the first author with information about additional potential interviewees (after they were permitted to transmit the information). The search for interviewees took two months, while at the same time the interviews began, which lasted seven months. At this stage, the four AP female actresses were omitted from the study. The first author conducted the face-to-face interviews in 60-90-minute meetings after the interviewers signed a consent form. Six out of 27 interviews, however, were conducted during the Covid-19 pandemic. Thus, both parties kept a safe distance and wore face masks.

Data collection

The data was collected through semi-structured interviews. This sort of interview has been selected as it is most appropriate for discussing the current research questions, which focus on the participants’ lived experiences. Semi-structured interviews are compatible with the IPA since they allow the researcher and the participant an in-depth exploration of the participants’ lived experiences by engaging in a dialogue in real-time and allowing enough space and flexibility for original and unexpected issues to arise (Smith et al., 2009 ). According to the principles of this sort of interview, the design of the topics and the research questions is merely tentative as it might change due to the flexible way in which the questions are presented (Rubin & Rubin, 1995 ). The questions were based on an interview guide which comprised the following questions: How did you start engaging in AP? What was the background to your engagement in AP? How do you experience your involvement in AP? What are your motivations for taking part in the AP industry? What are the challenges you have to cope with in the AP industry? What are the implications of your involvement in AP, and how do you cope with them? How does your social environment (family, partner, and friends) perceive your engagement in AP? How do you perceive AP as a social phenomenon? How do you perceive the concept of ‘intimacy’?

Data analysis

The seven IPA steps of data analysis were used in this study: (1) reading and re-reading the transcribed interviews to immerse in the original data; (2) writing initial free associations and semantic notes. For example, the statement “My father raped me for six years. Possibly, this [rape] is why I’m making these films” was initially titled: “Sexual trauma in childhood as an influence on AP practice”; the statement “My parents didn’t look at me. My father was occupied with his own business, and he didn’t see his child […] Maybe this is why I now need feedback and showing. I expose myself to be seen” was initially titled: “A sense of invisibility in childhood by parents”; (3) analyzing and classifying the notes according to emergent themes. For example, the aforementioned statements were classified as “Personal background”; the first statement was placed in the subdivision “Sexual abuse in childhood,” whereas the second statement was placed in the subdivision “Unmet emotional needs in childhood”; (4) integrating themes by identifying connections between the different kinds of statements; (5) bracketing previous themes and being attentive to new data in each new case; (6) searching for patterns across cases and noting idiosyncratic cases; and (7) interpreting at deeper levels through the lens of other theories (Smith et al., 2009 ). A professional editor translated all quotes in our findings section from Hebrew to English.

Trustworthiness

Several measures were taken to ensure the validity and reliability of our findings:

A member check interview (Koelsch, 2013 ) – a few weeks after the interview, the first author asked each participant to be interviewed again in order to validate the “truthfulness” of the data analysis and to examine the correlation between the date and the purpose of its selection. In some cases, the participants decided to add, withdraw, or precise their insights.

A peer debriefing (Spall, 1998 ) – the analysis of the categories was introduced to the two other co-authors of this study, who are well-experienced experts in content analysis, in order to discuss the various categories and to ensure that the categories have been extracted methodologically and that they are logically derived from the interviews.

Reflexivity – conduction of qualitative demands personal reflection to develop the researchers’ self-awareness of their tendencies and personal references (Rabionet, 2009 ). Notably, the first author, who is openly gay, conducted the interviews as part of his dissertation. The other co-authors, who are straight, have supervised his research. None of the authors have personal experience in AP or PP. The primary motivations for thoroughly examining the particular domain are scholarly interest and curiosity about people’s reasons and motivations to be involved in AP. The authors assume that pornography is multifaceted, and despite its multiple transformations over the years, it is still controversial, intricate, and complicated. However, in order to minimize interviewee bias, it was emphasized to all interviewees at the beginning of the interview that there are no right or wrong answers, and that it is their subjective experience that primarily needs to be heard. Additionally, and as mentioned above, member check interviews provided the interviewees an opportunity to refine their subjective experience which served to validate our interpretation during the data analysis process.

To ensure the credibility of the interpretive analysis, a repeated back and forth shifting was made between the data and the conceptual perspective, and between it and the findings (Patton, 2002 ). Additionally, when interviewing participants, the interviewer used participants’ own words without interpreting them (Kelly, 2010 ).

Table 1 presents the following thematic categorization of our findings: (1) AP as a unique genre that promotes diverse human body appearance and free choice while profitability is merely its secondary motivation; (2) the actors’ personal background , including sexual abuse in childhood and unmet childhood emotional needs; (3) moral reasons for engaging in pornography , including an aspiration to challenge sexual misperceptions, to prevent sexual harmfulness, and to promote education for healthy sexuality and gender equality; (4) implications of the involvement in AP , including positive implications like increased self-esteem and gaining admiration and appreciation, as well as negative implications like impaired interpersonal relationships and consequent feelings of guilt, sexual problems in romantic relationships, stigmatization, harassments and persecutions, and physical and psychological work injuries; and (5) ways of coping with sex work’s particular difficulties , including emotional reliance on the romantic partner, condemning the condemners, normalizing the nonconventional occupation, deploying an artistic perspective, hiding one’s involvement in AP, and adopting a work persona.

AP as a unique genre

The analysis of the interviews suggests that the participants in this research believed that AP has its own particularities and that the distinction between AP and PP has two components: diverse human body appearance and free choice. An additional component, the economic incentive, is usually neutralized in AP, whereas it characterizes PP.

Diverse human body appearance

The first component that differentiates between AP and PP, according to the participants, is the actors’ appearance. Notably, AP actors can be overweight, hairy, and, in general, incompatible with the prevalent beauty model in the PP industry. Ziv, a 33-year-old gay man in a relationship, explained that AP actors oppose the society’s conventional model of beauty and are filmed the way they are. Ziv explained:

We have nothing unique or distinctive because we are not overinvested. We are what we are. […] We are not muscular or toned. Some of us have a belly or a hairy back, not exactly what you would expect from a porn actor. […] What is nice in amateur pornography is that there is room for short people, fat people, and others who do not look like models but want to be a part of it.

Dor, a single 23-year-old gay man, explained that what is special about AP is the actors’ pride in the beauty of their body parts that do not conform to the common beauty model:

You are who you are. […] I’m proud to be a fat guy who loves his body. This is who I am. […] For years I was very ashamed of my body and now, engaging in porn has made me proud of my body. That’s what’s special about amateur porn.

Roy, a 32-year-old gay man in a relationship, explained that AP does not adhere to the PP’s model of beauty thus allowing people who would never be accepted to PP because of their appearance, to be part of this industry:

AP actors express who they are through involvement in porn. They do not have to be top models but can be who they are: hirsute, fat, flabby bellied, all is acceptable in amateur porn. […] There is no screening of actors based on body appearance in amateur porn.

Free choice

The participants emphasized that while involved in AP, they enjoyed free choice in every way, including the freedom to choose their film partners and the frequency of filming. Their situation is rather different than the conditions of the professional pornography industry, in which the director or the producer decides how the film is made, including the shooting angles, the participants in each scene, their sexual acts and their duration, etc. Eli, a single 34-year-old gay man, explained that participating in AP is voluntary and it demonstrates his own will independent of any director’s or other authority’s decision:

I haven’t experienced anything I didn’t like. It was my first time on screen, and I was doing things I knew how to do. There wasn’t any surprise. Nobody forced me. They [the participants] check with you in advance if a certain sexual act is acceptable or not, if you feel like doing it or not. It’s very comfortable. In amateur porn, they don’t force you to do anything.

Bar, a 27-year-old gay man who is in a relationship, also emphasized the ability, in AP, to choose and dominate the situation:

You can do whatever you like. You can upload any content you want. You are not dependent on the director or anyone. You do what you feel like doing, that’s the concept.

Profitability as a secondary motivation

Another difference between AP and PP is the issue of moneymaking. For most participants, profiting was not the main motivation for engaging in AP. Alon, a 34-year-old gay man in a relationship, contended that the profit in AP is a marginal factor that does not motivate his engagement in AP:

There’s a way to make money of it, even good money, but it really does not interest me. […] The last thing I’m interested in is money. I’m primarily interested in sexual excitement and satisfying my sex drive.

Yizhar, a single 32-year-old gay man, also said that the profit is not his motivation for being involved in AP. He said that moneymaking might even upset some of the amateur porn participants:

The difference [between AP and PP], in my perspective, is that AP is not made for making a living. […] The money is really not the issue here. […] Some people even choose to be involved in AP because no money is involved. Thus, you don’t feel bad about what you’re doing in AP, in contrast to what you’re doing in PP.

Personal background

The data analysis indicates two main ingredients of the participants’ background that stimulate their involvement in AP: sexual abuse in childhood and unmet emotional needs in childhood.

Sexual abuse in childhood

Most of the participants realized the connection between their childhood sexual abuse or unadjusted sexual discourse and their current involvement in AP. Aviv, a 26-year-old gay man in a relationship, depicted a connection between his raping by his father in his childhood and his current involvement in AP:

My father raped me for six years. Possibly, this [rape] is why I’m making these films. […] Imagine that every orifice in your body is penetrated for six years. You continue to yearn to be exposed. […] I was already deflowered from any direction, so what else can happen?

Omri also portrayed the severe sexual abuse he went through in childhood as a cause for his current involvement in pornography and prostitution:

I was abused for several years. When I studied in elementary school, a group of boys made me their submissive bitch. They were waiting for me at the toilet, and almost every day they were beating me and sexually abusing me in a very brutal and difficult way. […] I think all this stuff I experienced must be connected to my dealing with porno and prostitution. […] I think I have re-enacted the assault through acting in porn films, as their dynamics are very much the same.

Unmet emotional needs in childhood

Some participants reported that they lacked visibility in childhood as their significant other overlooked them. Due to this lack of attention, they needed the exhibitionism embedded in acting in AP films. Yaron, a 41-year-old gay man in a relationship, noted:

My parents didn’t look at me. My father was occupied with his business and didn’t see his child. […] Maybe this is why I now need feedback and showing. I expose myself to be seen. This is what it is all about.

Shlomi, a 42-year-old straight man, talked about his current need for empowering emotional feedback to fill the emotional gap in childhood. He fulfilled his need for visibility by involvement in pornography:

My mother had her own business. My father spent time with his lover. […] And I was the child who plays alone. […] I need feedback. I need to be watched and complimented for my body and sexual performance. Perhaps I always had this need to be looked at and to be placed. Perhaps these needs are met through pornography.

Moral reasons for engaging in AP

Challenging sexual misperceptions.

Some participants claimed that one of the reasons for their involvement in AP is their will to change and challenge conservative social attitudes in regard to acceptable sexual behavior. For example, Ziv noted:

The porn industry is a well-oiled system of servitude and exploitation. AP can challenge this system. It shows that you can have sex in front of a camera without the oppression of women.

Some interviewees claimed that their motivation to take part in AP films is challenging the social difficulty in accepting the other. Amir, a single 36-year-old bisexual man, felt like a misfit and different. Thus, he was involved in pornography because he yearned to dissent and to enable the othered people to cry against society’s discrimination. He explained:

We are weirdos, creeps who are at the margins of society. We are those perverts who like to shoot porn and all this totally crazy stuff. […] This sort of porn is a challenge: “Look at us, we are not transparent!” It’s about a cry, a challenge. You cannot wipe out people’s existence just because they are slightly different than you.

Prevention of sexual harmfulness

Some participants claimed that AP has the social power required for the prevention of mundane sexual abuse because watching AP films vents the viewers’ sexual pressure. For example, Aviv, a 26-year-old gay man who is in a relationship, stated:

As a guy who was sexually abused, I say, ‘Let them jerk off watching porn; it might vent their sexual pressure.’ It’s much better than brutalizing children or women. […] Perhaps [watching porn] might prevent a rape. Watching AP is more facilitating [than PP]; thus, it might stop sex offenders [who jerk off watching porn rather than brutalizing other people].

In the same spirit, Ofer, a 26-year-old gay man who is in a relationship, claimed:

[Watching] pornography, whether it’s professional or amateur, is important. Otherwise, many serious crimes, such as rape or sexual harassment, would happen.

Education for healthy sexuality and gender equality

Some participants regarded pornography as a means of mediating messages of healthy sexuality and educating about values like gender equality. Omri noted that youths learn about sexuality through porn films thus, it is important to use AP as a mediator of healthy sexuality:

Nowadays, adolescents learn what sex is through porn films. At least, these films should teach them how to do it properly. It is important they learn about a variety of genders and that sex shouldn’t be violent.

Aviv, who is overweight, embraces the educational message mediated by AP about inclusion of diverse body types:

When people watch a stocky or unshaped guy represented on screen as sexually desirable, it changes something in their sexual attraction or challenges their usual preference for certain body types. […] Eventually, viewers get used to what they see, and they start liking the body shown on screen, even if it’s not a perfect one.

Implications of involvement in AP

Positive consequences, increased self-esteem.

Participants claimed that their involvement in AP has improved their self-esteem. Aviv specified that the sympathetic audience reactions and his growing sense of desirability have improved his self-esteem:

I personally distribute [my own films] because it’s so much fun to see the nice feedback [I get from the audience]. It significantly improves my self-esteem. People really watch these short films because they really want to have sex with me. It blows my mind.

Ron, a 33-year-old gay man who is in a relationship, admitted that his self-esteem has been improved because he is an actor on demand. He considers this popularity as boosting his ego:

Your ego is boosted. It’s nice that they [the audience] want you to be a part of a porn film because of your dick, because of your ass. […] Each of us is like a little child who only wishes to be told how handsome he is. It improved my self-esteem. I felt much better with myself. People really desired me. It really boosted my ego.

Gaining admiration and appreciation

Another positive implication of being involved in AP, according to some participants, is having a sense of stardom and self-glorification. Ziv said:

[In AP] you’re joyfully complimented for your body and who you are. I felt like a real star.

Tom, a 33-year-old gay man who is in a relationship, considers himself an internet celebrity due to his numerous followers:

I’m being followed by so many people, including men, by the way, and they like me on social media. They ask me to take my shirt off or to jerk off. […] You can say I’m an internet celebrity. What blows my mind is this fandom. They admire me and my body.

Negative consequences

Participants reported damages and negative consequences due to their involvement in AP, including impaired interpersonal relationships and consequent feelings of guilt, as much as sexual problems in their romantic relationships. Additional negative implications reported by participants were social stigmatization, harassment, and persecution as much as physical and psychological injuries at work.

Impaired interpersonal relationships and consequent feelings of guilt

Participants reported impairing familial, romantic, and social relationships due to their involvement in pornography and even difficulty in initiating a romantic relationship due to their engagement in adult entertainment. Gal, a 39-year-old straight man in a relationship, admits:

My family walked out on me. My friends raised some eyebrows. It took me a while to find a partner who accepts me and my involvement in AP.

Additionally, participants described damage to their romantic relationships due to their acting in AP films. Bar confessed his deep regret because of his entrance into the AP world. He particularly emphasized his feelings of guilt because of damaging his romantic relationship, his work, and his mental state:

When I look back upon my life, I deeply regret this step. […] The blame is mainly on me. I brought all the destruction on me. I ruined my chances to rebuild my relationship. […] The porno deteriorated my relationship until it finally terminated. I’m the main one to blame for my declining relationship.

Niv, a single 41-year-old gay man, also depicted his feeling of guilt for not having a romantic relationship due to his involvement in AP:

I sentenced myself to have a bachelor’s life. […] The porn is already my trademark. It’s a lifestyle that cannot be changed, and bringing in a healthy romantic relationship is impossible. […] This is my fault. I take it over myself.

Finally, participants described the damage to their friendships. Noam, a single 23-year-old gay man, said that his addiction to acting in AP films has caused his social distancing:

Slowly, you become addicted to shooting film. […] My friends excluded me. I had no life other than porn – no friends, no work, nothing. […] I’ve been thinking it over and realized it’s all my fault.

Sexual problems in romantic relationships

Participants noted that involvement in AP deformed their sexual perceptions and, consequently, the sexual dimension of their romantic relationships was impaired, as Alon admitted:

You start believing that porno is what life is and that sex is what you do in films. The spirit and the consciousness are scarred. […] It’s all deformed. Seeing people fucking promiscuously while on drugs – it’s a scratch on your soul. […] How can you maintain a relationship when you do porn? It’s contradictory. Eventually, [me and my partner] didn’t have sex anymore, and our intimacy died. […] I hit my head on a wall out of frustration.

In the same manner, Bar described the ruining of sex with his romantic relationship due to his involvement in AP:

The bottom line is that it’s not a good experience. Later, it also affected our sex. It didn’t do any good. When we had dinner, he told me that there was no excitement, and having sex with me became a sort of work. It ruined something in our sexual relations.

Social stigmatization

Participants have experienced social stigmatization due to their involvement in AP. Alon spoke about his coping with the prevalent stigmas:

Soon as they hear that you do porn, they consider you a whore, a slut. They think you’re probably fucked up because all men in town have used you. […] They see me as leprous, and they consider it [my involvement in AP] as a disease.

Additionally, single male interviewees admitted that they had difficulties in initiating a new romantic relationship due to the stigmatization of their involvement in pornography. Danny, a single 37-year-old gay man, said:

Perhaps because I did porn and people already know me, it puts them off, or some of them feel threatened. […] Perhaps they immediately think I’m a whore or that I’m full of STDs.

Harassments and persecutions

Some participants have detailed the dangers of their involvement in AP. They claimed that when they became involved in AP, they were not aware of the risks which were associated with it. Thus, they were swept up in turmoil of unexpected personal risks. Aviv complained about harassment, threats, and persecution:

The exposure stimulates dangers, including harassment, violence, stalking, and annoying people who recognize me from porn films and threaten me.

Gal also described serial online harassment:

I get crazy offers all day. People send me nude photos and try to prostitute me. It really bothers me.

Physical and psychological injuries at work

Participants described injuries and traumas, such as internal bleeding, while they performed in porn films, particularly in group sex scenes. Omri recalled being injured on these occasions:

It hurts me, and I’m already bleeding. […] Sometimes, in violent scenes orgies, everyone is on top of me, and it causes injuries. Once, I passed out, and I even got a fissure, and I was really bleeding. […] You get into such a loop that is uncontrollable; you’re in a loop.

Alongside physical injuries, participants described severe psychological injuries due to their involvement in AP. Bar noted that each scene worsened his mental condition:

There’s a strict, straight line between porn and what this shit has done to my soul. Every scene stuck another knife in my bleeding soul. […] I was burned out.

Ways of coping with sex work’s particular difficulties

In order to cope with some emerging difficulties in acting for AP films, the participants have developed diverse mechanisms. First, they emotionally relied on their romantic partner. Additionally, they condemned those who condemned their involvement in AP while normalizing their apparently aberrant involvement in these films. Significantly, they adopted an artistic perspective on their acting for AP films. Some participants hid their involvement in AP because of their fear of being alienated and distanced. Others detached themselves from this occupation by adopting a “work persona,” which enabled them to deal with negative feelings while shooting a porn film.

Emotional reliance on the romantic partner

Thirteen participants reported that they emotionally relied on their romantic partner, which helped them neutralize the difficulties. Yaniv, a 41-year-old gay man in a relationship, said that his partner is a main source of dealing with the difficulties:

If I didn’t have Jacob [my partner], then I wouldn’t be able to deal with all the feelings provoked by porn. […] He’s my energy source for any coping whatsoever.

Bar also associated his ability to survive the AP world with the self-confidence he builds through his partner:

At the end of a shooting day, after all the shit you had, and the frustrations and the crises, Paul [my partner] is always there, and this is what keeps me on. He’s like a pillar that you can put your head on and relax from all the madness of porn.

Condemning the condemners

In response to the social stigmatization, seven participants tend to blame and condemn society which regards pornography as an aberrance and considers its actors as deviants. Aviv found the society hypocritical:

Society is hypocritical. The society considers porn as something sleazy and pervert. Yet, maybe society is the pervert? What’s better? Raping kids and masturbating on women on the street? At least we are true about our sexuality.

Shlomi also challenged the people who denounced this phenomenon and criticized their hypocrisy:

Some people look at us cross-eyed like we were freaks and perverts. […] Yet, I look at it in an opposite way – you’re the ones who are abnormal, you’re the fucked-up.

Normalizing the nonconventional occupation

Five participants dealt with the prevalent social stigmatization by adopting an alternative perspective that considers pornography as a legitimate and normative social phenomenon. Roy challenged the social stigmatization by describing AP as a normative behavior:

Society regards porn as an aberrant, and it sees us as perverts. Thus, I’m here to say it’s wrong to stigmatize a whole group of people. […] [Acting for AP] is a perfectly normal behavior, otherwise it wouldn’t exist, certainly not on this scale.

Ziv shared Roy’s perspective about AP. He associated this phenomenon with technological advancement and challenged the social stigmatization of AP actors:

Porn touches the raw nerve of society. It diminishes people’s whole world of values because [it involves] nudity and sexuality. […] You can’t escape the fact that AP is currently distributed everywhere, and it’s likely to be increased. […] This phenomenon is legitimate, get over it and realize that it’s part of our life now, just like sex.

Deploying an artistic perspective

Two participants regarded AP as an artistic cinematic genre. As such, it might neutralize its stigmatization as an aberrant phenomenon or social transgression, as Alon suggested:

I see porn as art. I can sit down, watch porn and get some popcorn without touching myself. It’s like a cinematic genre. Art is art, and it doesn’t feel good for some people. […] Any artistic genre, including porn, might upset or be criticized, yet it doesn’t mean that it’s aberrant. […] There’s something in considering pornography as art that makes despair a bit more bearable. […] When you define yourself as an artist rather than a social aberrant, it calms down the whole mechanism.

Amir explained that AP is an artistic genre that might give a voice to society’s misfits, and it is also a unique aspect of the freedom of speech and creativity:

In my eyes, it’s the genre of all freaks. They also have the right to free expression. They are free to create and produce art, and every art is a means of expression in the freest and most creative way. […] AP represents the artistic expression in its glory, even if it stretches the boundaries and upsets us.

Hiding one’s involvement in AP

Five participants confessed about their “living with a dark secret” and hiding their involvement in pornography from their family, friends, and peers at work. Doron, a single 41-year-old straight man, said that he hides his involvement in AP due to particularly deviant content in his movies, such as fetishized smoking women and sex games that include bodily fluids:

For some of my friends, it goes down rough. Such films with hardcore perversions like mine. […] I prefer nobody knows. Otherwise, I’ll have no one. […] At work, I’m X, while in real life, I’m Y. That’s the price of my secret.

Dekel, a single 35-year-old gay man, who is a teacher, referred to the difficulty in keeping his secret due to his fear of getting fired:

You just carry a weight. You have this feeling that they always know about you, but not really, because there’s no way the students will approach it. Yet I’m in an awful, enormous anxiety – are they going to find out? It makes me distance myself from people and get rather anxious.

Adopting a ‘work persona’

Five participants described physically and psychologically offensive situations in this work. In order to neutralize negative feelings, they developed a “work persona”, a sort of detachment while throwing themselves into a role. Among some participants, this figure has become part of their identity in everyday life. Omri explained that while shooting a pornographic film, he threw himself into a role that became part of his daily life, and it helped him deal with the psychological and physical pains involved in this work:

What helps you stand a crazy orgy in which you’re being fucked [by many men] one after another, is throwing yourself into a role that is different than who you really are. […] I delve into this character and truthfully, I feel like it has taken over me and affects how I speak, for example. Today, this character is still a part of my life. It became a part of me.

In the same spirit, Aviv perceived his “work persona” as helpful in coping with the physical pain involved in filming AP and its consequent mental breakdown:

It is so painful. Some guys probed my body mercilessly. At some point, I didn’t feel the pain anymore as I got used to it. […] Yet, my soul was painful. It fell apart, slowly but surely. […] I threw myself into the role of a fuckin’ slut. It made reality a bit easier. I’m not really like that in reality. […] It’s a fake figure that helps to contain the pain.

The current research aimed to examine the lived experiences of AP actors, their motivations, and their ways of coping with the implications of their involvement in AP. Our findings indicate five main themes that will be discussed separately.

AP actors as developers of a unique new genre

This theme is associated with three unique characteristics of the AP genre. The first characteristic of the emerged pornographic genre is diverse human body appearance. It is embodied by the appearance of the actors, which does not coincide with the prevalent model of beauty for the PP industry. The participants assumed that it enables the viewers to better identify with the actors and, consequently, be more aroused. The participants’ emphasis on the importance of diverse human body appearance of the actors, which does not coincide with the prevalent model of beauty for the PP industry, accords with studies about differences between AP’s and PP’s visual characteristics of the porn actors (Griffith et al., 2013 ) and a consequent higher degree of sexual arousal among AP viewers who feel closer and more emotionally attached to the actors (Dekker et al., 2020 ). Whereas feminist activists heavily criticize pornography for its notorious glorification of muscular, well-hung men, AP films present multiple body types. In this respect, both anti-porn feminists and AP films challenge professional pornography’s notorious body fascism (Berg, 2016a ). Yet AP films are not really liberating because they involve objectification and commodification of diverse human bodies. Nevertheless, AP films’ objectification of human bodies is vastly different from PP films’ exploitation of human bodies.

Freedom of choice, the second characteristic of this theme, is associated in AP with greater control of the actors on set. In contrast to PP, AP films have no director or producer who sets the shooting angles, the sexual partners, the duration of the shot, the particular sexual acts, etc. This finding coincides with previous research claiming that PP actors often free themselves from the “chains” of the industry by creating their own AP websites in order to control the content and the actors (Miller-Young, 2007 ). This characteristic coincides with Berg’s ( 2016b ) contention that porn is one of the many neoliberal workplaces in which the exhortation “Just be yourself!” is a useful management tool.

Profitability as a secondary motive, the third characteristic of this theme, relates to the AP performers’ insistence that their main motivation for involvement in AP is their yearning for visibility and attention, whereas economic motivation is merely secondary. This finding accords with studies showing that while the main motivation for taking part in PP is economical (O’Neal et al., 2016 ), the main motivation for taking part in AP is yearning to have a scripted sexual adventure, while the financial aspect is secondary (Kibby & Costello, 2001 ).

Personal infrastructure

This theme refers to psychological factors in the participants’ background, which might explain their motivations to be involved in AP. The psychological factor relates to the participants’ history as sexually abused children, which, according to them, stimulated the development of their hypersexual sexuality. This idea is supported by findings indicating a connection between sexual traumas and hypersexual behaviors which are expressed by distress and impaired functioning (Slavin et al., 2020 ). According to the participants, the damage is also demonstrated in multiple harmful sexual experiences. Previous research shows that sexual abuse in childhood might stimulate excessive masturbation, increased consumption of pornography, and multiple indistinct sexual intercourse with strangers (Chemezov et al., 2019 ).

Furthermore, some participants reported that they were neglected by their parents at an early age and their basic emotional needs were not fulfilled. They did not have loving relationships with their mothers and fathers who did not hug or kiss them. According to the participants, their involvement in AP serves as an attempt to compensate for these basic deprivations. This can be related to the notion of “ relational needs ”, which, according to Erskine ( 2015 ), involve primordial, basic, and initial needs, a sort of developmental touchstones that are bound with a connection with the attentive, close person who addresses the needs of the child/adult. Unmet relational needs might lead to the development of an unsafe pattern of attachment. They might become a fertile ground for relationships based on constant fear of losing contact, vulnerability, and sensitivity. Among these needs are the need to feel validated, affirmed and significant within a relationship, and to be accepted by a stable, dependable, and protective person. According to the participants, the need to be affirmed and the need to feel validated, have been attended by positive feedback they received by chat during their live broadcasting. The need to be accepted by a stable, dependable, and protective person was filled by the actors’ partners, who accepted their involvement in pornography and emotionally supported them.

Moral reasoning of involvement in AP

A somewhat sociological motivation of some interviewees to get involved in AP is their wish to change the Israelis’ puritan sexual perceptions. This ideological motivation is accompanied by challenging traditional gender roles and consequent objectification, oppression, and subordination of women. According to the participants’ feminist approach, industrialized pornography represents acceptable fantasies of men in a patriarchal society that involve the sexual submission, abuse, and degradation of women. This ideological approach is particularly important due to the common perception of sexuality in Israel. Notably, numerous Israeli men tend to support gender inequality. Consequently, patriarchal concepts are reinforced while women are intensively objectified and experience sexism (Bareket et al., 2018 ). Additionally, the research participants seem to share the feminist criticism of commercial pornography that powerfully shapes sexuality, limits the woman’s role, and strictly scripts sexual relations (Smith & Attwood, 2014 ).

Another moral motivation to get involved in AP, according to this research, is the role of AP in regulating bizarre or apparently deviant sexual behaviors and, consequently, preventing sexual abuse. This finding coincides with a recent study that indicates an inverse relationship between the availability of pornography and sexual aggression (Ferguson & Hartley, 2022 ). Other studies, however, determine that pornography which comprises particularly aggressive and abusive content increases the level of aggression, sometimes to the point of actual rape, both among adolescents (Ybarra & Thompson, 2018 ) and adults (Wright et al., 2016 ).

As indicated by our findings, another moral motivation to get involved in AP is that AP promotes education for healthy sexuality and gender equality. In this spirit, Litsou et al. ( 2020 ) explained that gay adolescents, in particular, perceive pornography as a means of learning the mechanics of sex and realizing a variety of sexual identities. Notwithstanding, this finding does not coincide with a study by Hald et al. ( 2014 ), which indicates a positive relationship between viewing violent and nonviolent pornography and the viewers’ support of violence against women.

Positive and negative consequences of the involvement in AP and ways of coping with particular difficulties

The participants’ statements clearly indicate that their involvement in AP positively impacts their lives. They stressed that their involvement in AP increased their self-esteem and addressed their need to be admired. This finding can be explained by the ‘self’ psychology (Kohut, 2009 ), which emphasizes the importance of mirroring, i.e., the person’s need to feel unique and special and to be loved. The AP actors’ yearning for mirroring was possibly fulfilled by the positive feedback they received from the viewers who adore them. Whereas the parent’s admiring glance increases the child’s self-esteem, the grown person’s self-esteem increases by the positive feedback he gets from her/his environment and the consequent feeling that s/he is been noticed (Wright, 2009 ). Likewise, the participants admitted that their self-esteem increased, and they felt they were publicly recognized and admired due to the viewer’s positive feedback.

The participants reported some negative implications of their dealing with AP while developing ways of coping with part of them. The first negative implication is impaired interpersonal connections and consequent feelings of guilt. In order to neutralize the feelings of guilt and shame, some participants used techniques of neutralization (Sykes & Matza, 1957 ). These techniques enable the individual to do things that contradict her/his values by rebutting society’s charges and condemning the social institutions who blame her/him. Some participants have criticized the hypocrisy of society, which regards pornography as an obscene phenomenon, while passively consuming it. This claim accords with finding indicating high rates of porn consumption around the world, including 46% of American men and 16% of American women (Regnerus et al., 2016 ). Another way of dealing with feelings of guilt is the participants’ emotional reliance on their romantic partners who support and accept AP. They mentioned that this support enabled them to continue with their involvement in AP while reducing their feelings of guilt and shame. This way of coping is important as being accepted by a significant other is a basic need, which is essential for mental wellbeing, confidence, and a sense of comfort and making peace with oneself (Erskine, 2019 ).

The second negative implication is the impaired sexual aspect of their romantic relationships. According to the participants, when the sexual energy is transited from their romantic relationship to their involvement in AP, they find it difficult to maintain or even to initiate sexual intimacy within their romantic relationship. This finding is novel in the field of porn actors. Yet, it does coincide with the findings of a study of men in prostitution who reported a severe decline in their pleasure in sexual intercourse within their romantic relationships (Koken et al., 2004 ).

The third negative implication is the social stigmatization of pornography, which is misperceived by society, according to the participants, as a social deviation. This finding coincides with another research claiming that PP actors are negatively regarded as social deviants, which is similar to the way in which women in prostitution are misperceived (Evans-DeCicco & Cowan, 2001 ). This finding also accords with findings showing that women who are involved in PP are socially perceived as indecent and inferior (Polk & Cowan, 1996 ). However, some participants in the current study considered AP a legitimate and normative behavior; some even regarded it as an artistic genre. Probably, this standpoint enabled them to normalize their occupation in AP and cope with its social stigma.

The fourth negative implication is the personal risk due to the exposure to the World Wide Web and the consequent harassment and persecution. Their exposure to the Internet also provoked fear of familial and social alienation. In coping with the various risks, some participants hid their involvement in AP from their partners, family, and workplace. Some admitted that keeping this secret per se stimulated a sense of alienation while distancing themselves from their environment. This finding accords with Jansson et al. ( 2023 ), who show that about one-third of a sample of 218 Canadian sex workers who were involved in a relationship did not say anything about their sex work to at least one partner or disclosed limited information. In this way, the sex workers avoided stigmatization. Yet, the concealment of their sexual occupation created a burden of secrecy. The other two-thirds chose to disclose their sex work to at least one partner. Yet, their openness about their sex work had mostly negative consequences.

The Israeli participants’ tendency to hide their involvement in AP accords with previous research suggesting that sex workers, including people who are involved in prostitution and pornography, typically tend to hide their sexual occupation from their romantic partners and the surrounding society in coping with their shame (Black, 2009 ). Notably, hiding the involvement in prostitution because of the fear of being stigmatized increases the sex workers’ anxiety and stimulates exhaustion among women who are involved in prostitution. It was revealed that hiding requires a highly energetic investment, and it mostly leads to distancing oneself from the environment due to the intensity involved in keeping this secret (Lazarus et al., 2012 ).

Finally, 78% of the research participants are self-identified gay men. Hiding their involvement in AP from the surrounding society is not surprising due to the vulnerable position of the LGBTIQ community in Israeli society, which oscillates between religious and traditional conservatism and liberal, multicultural, and inclusive tendencies. Due to the political power of ultra-Orthodox, conservative Jewish, and Arab political parties, the anti-sodomy clause was only abolished in 1988 (Engelstein & Rachamimov, 2019 ). Workplace discrimination against LGBTIQ people is forbidden, and discrimination against LGBTIQ soldiers in the Israeli Defense Force has been prohibited since the mid-1990s. An Israeli LGBTIQ youth movement, IGY, was established in 2001 (Shilo et al., 2015 ). In 2009, two people were massacred, and others were injured in an unsolved shooting attack on Bar-No’ar, a Tel Aviv LGBTQ youth center (Antebi-Gruszka et al., 2020 ). In 2015, a woman marcher was murdered by an ultra-Orthodox Jewish extremist in the Jerusalem pride march. Yet, since 2022, gay male couples, single Israeli men, and transgender individuals have been permitted to arrange surrogate pregnancies in the country (Kelly et al., 2023 ). Nevertheless, coming out in traditional Israeli families is still difficult, and gay men are still coping with social prejudice. Considering these intricacies, the Israeli gay community is ambivalent towards sex workers (Padva, 2019b ). Padva ( 2019a ) notes that most gay men in Israel embrace pornography as the most pleasurable masturbatory practice. Yet, this does not necessarily mean that Israeli gay men would accept an AP career of their partner. The current findings indicate that the fear of ruining their relationship causes the AP actors to avoid telling their partners about their involvement in sex in front of the camera.

The fifth negative implication of involvement in AP is physical and psychological pains. In coping with these pains, the participants adopted a “work persona”. A work persona is typically connoted with celebrities who create fictional identities to brand themselves according to the public taste, hoping for a financial gain (Marshall, 2014 ). However, the current study relates to this term in a way which is similar to Koken and Bimbi’s ( 2014 ) discussion of this phenomenon in regard to women in prostitution (Koken & Bimbi, 2014 ). These women adopt a fictional sexual figure in order to detach themselves from their true selves, which are injured during their work in the sex industry. The fake persona denies the injury. This phenomenon has not been recognized, until now, among male porn actors. Nevertheless, some studies (e.g., Farley & Kelly, 2000 ) indicate that dissociative symptoms, i.e., disconnecting oneself from her/his thoughts, feelings, physical environment, memories, or sense of identity (Cardena & Spiegel, 1993 ), are prevalent among people in prostitution. Arguably, a detachment from a difficult situation and role-playing conducted by people who are involved in prostitution is a strategy of “management of emotion” that aims to protect them (Abel, 2011 ).

The set of coping strategies deployed by the participants might reflect their sense of potency. Their ways of coping can be analogized with the three tiers of a “potent self” elaborated by Sedikides et al. ( 2013 ). The potency that derives from the personal self is embedded in enhancing the individual’s positive traits. It helps in dealing with factors that might damage the self-identity. Accordingly, the AP participants detached themselves and avoided self-stigmatization by adopting a “work persona”. The second tier, the relational self , relates to dyadic connections or interpersonal attachments and attributes that are compared between the individual and others as part of these relationships. Identities and traits that are attributed to the individual can define her/his roles in a relationship. A potency derived from the relational self relates to stabilizing relationships, which might protect the individual and improve her/his attachment to the other. Likewise, the participants in the current research have strengthened their relational selves by being emotionally supported by their romantic partners. The third tier, the collective self , relates to groups that the individual is a member of and to similarity and identification with a valuable social group. This potency derives from the collective self-embedded in group affiliation that can protect, elevate, and maintain a positive collective image. Similarly, the participants in the current study have deployed three ways of coping on a collective level in order to neutralize their negative attributes as AP actors: normalizing an occupation that is perceived by the society as aberrant, condemning their condemners, and adopting a positive perspective. To summarize, despite the negative implications of involvement in AP, it seems that the participants in the current study have experienced a potent self in a variety of tiers, in contrast to the experience of victimhood, which is associated with a sense of impotency and helplessness.

Conclusions

This study thoroughly reveals the infrastructure of the current participants’ involvement in AP, its positive and negative implications, and the actors’ ways of coping with some of these implications. The personal background of the interviewees includes sexual abuse in childhood, insufficient response to relational needs, and adopting a perception that necessitates social change. The combination of these three ingredients has also been found among women in prostitution who report high rates of sexual abuse in childhood (Chen & Chu, 2021 ; Fagan, 2001 ; Saffy, 2003 ) and unfulfilled need for intimacy, warm and love (Leidholdt, 2004 ). Yet, different than these women, the participants in the current study specified that their involvement in AP (also) resulted from their ideological will to challenge social perceptions regarding sexuality. They contended that during their involvement in AP, they enjoyed free choice in regard to the selection of their partners, the shooting angles, the duration of shooting, the sexual acts, and the frequency of filming. This free choice is essential as it might mark the experience as victimizing or non-victimizing. The absence of free choice acquires a sense of lost control, which characterized victimhood (Van Royen et al., 2016 ). According to Frankl ( 1985 ), free choice and making suffering meaningful through values might elevate the individual’s meaning of life, assist in overcoming difficulties, and improve mental wellbeing. Thus, it is possible that striving for social change has charged the life of the participants in this study with existential meaning, which enabled them to bear with the suffering involved in AP.

Positive implications of involvement in AP were found, including addressing the need for admiration and increasing the participants’ self-esteem. Addressing the participants’ need for admiration, particularly, is interrelated with their quest for validation, an essential need for self-esteem and mental well-being (Erskine, 2015 ).

The negative consequences of the participant’s involvement in AP comprised impaired interpersonal relationships that led to guilty feelings, sexual problems with their romantic partner, stigmatization, harassment, and persecution as much as physical and psychological injuries at work. An observation of all the negative implications indicates a common denominator on the interpersonal level. The involvement in AP affects the actors’ relationships with their partners, families and society. The damage they experience is similar to that of sexually assaulted men and women in prostitution who experience impaired romantic relationship and problems in their intimate sex life (Farley et al., 2004 ; Gibson & Hartshorne, 1996 ). Further, victims of sexual assaults and women in prostitution often experience harassment and violence (Arata, 2002 ; Farley, 2003 ) as well as social stigmatization that labels them “crazy” and makes them feel guilty about the assault they experienced (Benoit et al., 2018 ; Shaked et al., 2021 ).

The similar negative consequences experienced by the participants in our study might possibly imply the AP actors’ victimization, yet this subject deserves further in-depth research. Notably, women in prostitution in Israel are supported by the Ministry of Welfare, which provides them with medical, psychological, and social services (Peled & Lugasi, 2015 ). In contrast, AP performers are not supported by the Israeli authorities. We suggest that policymakers in Israel should consider such support, including designated assistance programs and emergency hotlines that will address the AP actors’ psychological and medical needs.

The actors’ ways of coping with the severe negative implications of their involvement in AP are on the personal and social levels. On a personal level, the participants in our research adopted a “work persona” in coping with their psychological and physical pains. On the family level, they chose to hide their involvement in AP in order to avoid criticism and alienation, and their partner supported them. On the social level, the participants tended to normalize their occupation, which society perceives as aberrant. They adopted an artistic perspective on their involvement in AP to cope with the social stigmatization.

The research findings support Kohut’s (Kohut & Wolf, 1978 ; Summers, 1994 ) self-psychology theory, according to which the preoccupation of AP actors with sexual self-exposure may be understood as a need to be seen and a longing for the validation of others. Accordingly, the individual’s need to publicly expose him/herself sexually (exhibitionism) is rooted in past traumas which made the mirroring process difficult. This might have left the child with unsatisfied relational needs by not having being seen and validated by a meaningful other. This accords with the current finding that points at sexual abuse and unmet emotional needs during the participants’ childhood, along with the increased self-esteem, and admiration and appreciation received from the audience as positive implications of the participants’ involvement in AP.

The innovation of the current study lies in placing a spotlight on the presentation of populations that have not yet been studied: amateur pornography actors. It is possible that a more profound acquaintance with the characteristics of these populations will enable the mapping of needs and the formation of coping and treatment methods, and will lay the foundation for in-depth follow-up studies regarding additional issues that arise as part of the involvement in the world of AP.

From an applied point of view, it is suggested that the various diagnostic books refer not only to those who consume pornography but also to those who create it. It is also recommended for therapists to distinguish the occupation of pornography as an issue that requires a separate therapeutic space for those concerned. Furthermore, this study shows that engaging in AP entails complex issues, such as sexual abuse, sexual problems, physical and psychological damage, feelings of shame and guilt, and damage to relationships as well as social stigmas. These findings point to the need for training mental health care providers to delve deeper into this unique phenomenon. Finally, it is desirable that therapists find benevolent ways to address relational needs without imposing the unduly high mental costs associated with engagement in AP.

Limitations and recommendations for future research

This research has several limitations. First, despite the initial aspiration to interview an equal number of male and female AP actors, such a balance has not been achieved in practice due to difficulties in reaching a sufficient number of female interviewees. Researchers have indicated essential differences between men and women who perform in pornography in regard to perceptions of sexuality, self-image, and patterns of sexual conduct (Griffith et al., 2012 ). Hereby, future studies would thoroughly explore the live experiences of AP actresses.

Second, despite the initial aspiration for an equal number of porn actors, in terms of sexual orientation, such a balance has not been maintained, in practice, due to the difficulty in finding a sufficient amount of straight male porn actors. Due to the differences indicated between homosexual porn actors and their straight peers regarding perceptions of sexuality and masculinity (Ismail, 2012 ), future research would preferably aspire to maintain a balance in regard to the participants’ sexual orientations.

Third, the current research has been conducted under numerous restrictions due to the Covid-19 pandemic. Hence, eight interviews were held outdoors while maintaining physical distancing and wearing face masks. Due to studies indicating that such restrictions might affect the quality of the interview, as the distance disallows complete openness (Chen, 2021 ), it is possible that these interviews have not been conducted in optimal conditions.

Further, the current study suggests that one of the main factors in involvement in AP relies on an ideological basis. Thus, future research would preferably examine whether such a factor exists among PP actors as well and what its existence or absence means. Finally, we suggest that future studies re-examine our findings while interviewing additional male AP performers to establish a durable working model.

Data availability

Data, materials, and code will be available upon reasonable request. Raw verbatim data will not be available for ethical reasons.

Code availability

Not applicable.

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We are grateful to each one of the research participants for their willingness to share with us personal aspects of their lives. This article is part of the lead author’s dissertation to be submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Criminology department of Bar-Ilan University, Ramat-Gan, Israel.

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Yaakobovitch, T., Bensimon, M. & Idisis, Y. A qualitative analysis of male actors in amateur pornography: motivations, implications and challenges. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06329-2

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A qualitative analysis of male actors in amateur pornography: motivations, implications and challenges