Identity under threat: internal conflict and stigma in undetected child sexual abuse material users.

Introduction: Individuals who use child sexual abuse material (CSAM) represent an under-researched population, particularly those who remain undetected by the legal system and outside formal treatment settings. Existing research is predominantly expert-driven and rarely captures users' subjective experiences or sociocultural contexts. This lack of perspective limits the development of patient-centered and culturally responsive prevention strategies. Methods: This study utilized a qualitative design to analyze anonymous, chat-based Cultural Formulation Interviews (CFI) conducted within the EU-funded Project Bridge. The sample consisted of 32 help-seeking CSAM users assessed as low-to-medium risk for hands-on offending, representing four language groups (English, Swedish, Czech, and Finnish). Data were analyzed using reflexive thematic analysis to capture the "user-only" perspective. Results: CSAM use emerged as a deeply distressing and heterogeneous experience shaped by a perceived loss of control, internal conflict, identity threat, and experienced stigma. Participants' explanations of causality (e.g., innate, learned, or addiction-like accounts) functioned as meaning-making strategies to negotiate shame, responsibility, and self-concept, which occasionally included denial of responsibility or socially desirable responding. While secrecy, social isolation, and limited access to support acted as major barriers to help-seeking; relational stability, emotional well-being, and structured life circumstances functioned as key facilitators that supported and regulated engagement with support services. Discussion: These findings demonstrate the critical value of informed, patient-centered qualitative approaches for understanding CSAM use beyond traditional diagnostic and risk-focused models. Methodologically, adapting the CFI to an anonymous, chat-based format represents a vital innovation for accessing hard-to-reach populations fearing social condemnation. Culturally sensitive, low-threshold interventions must be designed to address ambivalence, stigma, denial, and contextual life factors as core components of effective prevention and support.