Sign up for The Download — your daily dose of what’s up in emerging technology Games, Lee perceived, were also becoming far more immersive, with elements designed to “make the user stay as long as possible.” In 1998 the South Korean gaming company Nexon had invented the “free-to-play” business model, in which games are technically free but require constant cash infusions for the player to meaningfully progress. Since then, companies had been churning out games that enticed users to spend money in ways that seemed to resemble gambling. That explained something else Lee had noticed: the debt his patients were racking up. By 2011, Lee was convinced that gaming addiction was real and diagnosable, and that it was hindering children’s academic performance and sleep. That same year, as national panic mounted, the government proposed the Shutdown Law, a curfew that would block access to online games for those under 16 between midnight and 6 a.m. In a government-commissioned study outlining the policy’s benefits, Lee argued that gaming addiction had inflicted “mass trauma” on the nation and was to blame for suicides and homicides. The law passed by a large majority and is still in effect today.
In 2002, an unemployed 24-year-old man died
after playing for 86 hours straight. It was the world’s first reported case of death by gaming. The following year, Lee joined forces with a newly minted lawmaker named Shin Eui-jin, who had put gaming addiction at the top of her agenda. A former child psychiatrist, Shin was preparing a so-called “addiction bill” that aimed to regulate what fellow lawmakers called the four evils of South Korean society: gambling, alcohol, drugs … and video games. Gaming addiction, Shin claimed, was responsible for schoolyard bullying and violent crime. At a 2014 parliamentary hearing, Lee told lawmakers that gaming might be “an even stronger addiction than drugs,” and when asked whether he would be open to removing it from the list of addictions, he said, “I’d sooner take out drugs.” (Lee now insists the comment was taken out of context: “What I meant was that we need a legal support system to prevent and treat a problem that’s far more prevalent than drug use.”) But whereas the Shutdown Law had passed easily enough, Shin’s bill quickly became bogged down in controversy. While medical experts like Lee said gaming addiction was real, others claimed there was no conclusive evidence that video games were inherently addictive. Critics skewered the bill and said Lee’s comments were a witch hunt. When the legislation failed to pass, it seemed the debate had reached an impasse—until it was recently reignited by an unlikely source. Is this really a public health crisis? On May 25, 2019, in Geneva, Switzerland, members of the 72nd assembly of the World Health Organization unanimously voted to pass the 11th revision of the International Classification of Diseases, the WHO’s official catalogue of illnesses. Among the revisions is the addition of “gaming disorder,” defined as “a pattern of persistent or recurrent gaming behavior” accompanied by a loss of control and functional impairment. It is only the second globally recognized behavioral addiction; the first was gambling, which was approved in the last revision of the ICD in 1990. ICD-11, which goes into effect in 2022, adds thousands of new codes to more accurately capture specific injuries and diseases, as well as correcting historical mistakes. Strokes, for example, will now be classified as a neurological problem rather than a circulatory one; “gender identity disorder” is now “gender incongruence” and is no longer classified as a mental disorder. Adding gaming disorder to the official medical lexicon marks a significant shift. Despite the years of concern and study about the effects of video games, conclusive evidence of any links to addiction or violence has been hard to come by. For many, the idea that somebody can be clinically addicted to behaviors—rather than to substances like alcohol or opioids—remains controversial. Others think the definition of gaming addiction in particular is too woolly to be useful. “We’ve had 30-plus years of research on gaming addiction and we’re not really anywhere closer to understanding what it is that we’re actually talking about,” behavioral researcher Pete Etchells recently told MIT Technology Review. For people like Lee, the psychiatrist, the decision is a vindication. The grounding for the WHO’s decision came out of talks among an advisory group of mental health researchers that he had been invited to join in 2014. Reports from the group’s annual meetings, which were held from 2014 to 2017, noted “the wide-ranging perceived benefits of increased government prevention” in South Korea, as well as “significant developments” in prevention, treatment, and research. Yet some have disputed the caliber of the South Korean work. According to a recent meta-study, 91 of the 614 papers on gaming addiction published internationally from 2013 to 2017 were from that country, making it the single largest contributor by volume. The study’s author, Yonsei University media studies professor Yoon Tae-jin, argues that many of those studies are overly broad, treating gaming as a single category and failing to distinguish specific games or genres. Most of the research, according to Yoon, suffers from a confirmatory approach: assuming that gaming addiction is real from the outset, rather than trying to prove it scientifically. Why was StarCraft so popular? When StarCraft arrived on the scene, the Asian financial crisis of 1997 had just leveled South Korea’s finances, causing mass unemployment and unrest. The International Monetary Fund bailed out the government in Seoul to the tune of $58 billion, an unprecedented sum at the time, but only in exchange for an agreement to completely overhaul the nation’s economy. The following year, acting on advice from Bill Gates and Softbank’s Masayoshi Son, the South Korean government launched aggressive programs to revive the economy by building up internet infrastructure and making computers accessible to the public. By 2002, 10.4 million households had high-speed internet—a 700-fold increase from 14,000 in 1998. Catalyzed by broadband, StarCraft moved into people’s homes and into PC bangs, where it provided a welcome refuge for teens feeling the crush of the post-crisis years. Local competitions made the game important to many communities, as well as giving teenagers a safe release valve for the competitive feelings generated by the country’s high-pressure academic environment. In 1999, a young StarCraft-smitten TV producer came up with the idea of televising a match on a local channel, Tooniverse—the first televised e-sports tournament in the world. Filmed on dusted-off ping-pong tables in an unused studio for $300, it became a hit, and tournaments grew in scale and number. StarCraft cemented itself as a spectator sport to be reckoned with. When game sales in South Korea reached the 2 million mark in 2002, Blizzard founder and then-CEO Mike Morhaime made a pilgrimage to Seoul, where he saw his first live e-sports match and lead programmer Bob Fitch got a standing ovation. The varied and lasting cultural legacy of StarCraft can be felt even today. Game lingo from the era lives on in contemporary youth slang, and it is a touchstone for Generation X nostalgia. When Blizzard released a remastered edition of the game in 2017, it inspired “salarymen StarCraft tournaments” and throwback live events. And even after 20 years, the game still maintains a respectable seventh place on the PC bang most-played list. There have also been suggestions that Asian countries like South Korea—which are generally more sensitive about gaming addiction than their Western counterparts—leaned on the WHO to include gaming disorder in ICD-11. In August 2016, an American clinical psychologist, Christopher Ferguson, emailed the WHO to advise against the inclusion. “It’s probably not an issue that’s quite ready for prime time,” he wrote. One of the email’s recipients, ICD-11 project officer Geoffrey Reed, replied: “Not everything is up to me. We have been under enormous pressure, especially from Asian countries, to include this.” (In an email to me, Vladimir Poznyak, coordinator of the WHO substance abuse department, denied that political pressure had influenced ICD-11.) Surprisingly, the WHO decision has reopened, rather than settled, the bitter debate. Even government agencies have openly feuded; the South Korean culture ministry refused to join a consultative body led by the health ministry last May, effectively stonewalling early moves to implement the classification. The rift has prompted Prime Minister Lee Nak-yeon to create a separate arbitration committee to decide whether South Korea will adopt ICD-11’s recommendations in the coming years. And in the numerous parliamentary forums, televised debates, and academic symposia convened in the wake of the WHO decision, the same question looms large: Has a culture of intensive gaming really brought about a public health crisis? Real Life. Real News. Real Voices Help us tell more of the stories that matter Become a founding member A disorder, or a coping mechanism? When I met him at his office in September, Lee Hae-kook was on edge. Now 50 years old, the psychiatrist is slender and wan, with a haughty and impolitic manner that seems unsuited to public campaigning. His views, at the center of renewed attention following the WHO decision, have made him public enemy no. 1 in the gaming community, where he is widely seen as the architect of a moralistic vendetta. He began our meeting by railing against “fake news” propagated by gaming journalists to distort his views and obscure an obvious public health crisis. “Debating whether it should be a disease code or not is a meaningless waste of time,” he said. The medical authorities had spoken, so what else was there to say?
MS Tech (Source: Unsplash)
To illustrate the dangers of gaming addiction, Lee told me the story of one of his recent patients: a 25-year-old unemployed man who was dragged in by his older sister after racking up around $18,000 in debt from in-game purchases. The patient had spent his adolescent years gaming for two to three hours a day, with little interest in schoolwork. As an adult, Lee said, “he spent 10 hours a day online, five playing games and five watching YouTube videos.” The patient seemed to be a textbook case of gaming disorder under the WHO’s criteria: loss of control, gaming displacing other aspects of life, and functional impairment. So when I asked Lee about the treatment, I expected to hear about some novel form of therapy. “This person eventually fit the criteria for adult ADHD, so we began administering ADHD medication,” he said instead. “He also exhibited temporary symptoms of depression, so his condition was partially improved by the use of antidepressants.” When I asked what made this a “gaming disorder” diagnosis, as opposed to just ADHD and depression, Lee replied that “gaming a lot can cause ADHD-like impulsivity.” The conversation epitomizes one of the central disagreements hanging over the WHO’s decision: Is excessive gaming truly a unique disorder, or is it simply a manifestation of other conditions? Current research confirms that patients with gaming disorder are more likely to have ADHD and depression, but neurologists and psychiatrists who dispute Lee’s claim emphasize that correlation does not equal causation. Others, like the authors of a 2017 open debate paper against the WHO’s proposal to include gaming disorder, believe excessive game-playing is better understood as a coping mechanism for other underlying mental conditions. But of course, this is the sort of debate that Lee says is pointless because of the WHO ruling. The tyranny of the old against the young T o South Korean gamers, Lee’s strident campaigning suggests that the push to codify gaming addiction is being driven primarily by alarmism. The attempt to link violent crimes to gaming—a claim pointedly debunked by criminologists—has made him notorious. So has the comparison to drugs.
“It sounds like what these doctors consider gaming addiction treatment is just neutering basic human urges.”
“No matter how bad games can be, they can never be as bad as drugs or gambling,” says former game designer Kim Seong-hoe. “To create an equivalency with those is completely officious and oppressive.” In 2018, after quitting his job with one of South Korea’s biggest game companies, 41-year-old Kim began working full time on his gaming-themed YouTube channel, where he has been chronicling the controversy over gaming disorder in angry tirades for 336,000 subscribers. A HISTORY OF CONTROVERSY Video games have been controversial for decades. 1994 The US introduces a voluntary rating system for games after Senate hearings on violent titles. 2002 An 86-hour gaming binge leads to the world’s first “death by gaming” in South Korea. 2011 The US Supreme Court rules that video games are protected speech under the First Amendment. 2011 South Korea’s Shutdown Law prohibits under 16s from gaming online after midnight. 2019 The WHO votes to add “gaming disorder” to the upcoming revision of the International Classification of Diseases. While he is critical of companies that make what he calls “slot machines in disguise”—the types of games where users can rack up $18,000 worth of debt—Kim also wonders whether doctors can make sound diagnoses if the research fails to distinguish gambling-like titles from those that require creative problem-solving. “The psychological effects of certain games and genres are far more complex than something like alcohol,” he says. “But to try to judge gaming addiction without even differentiating type or genre? It’s ridiculous.” Kim sees the push to pathologize games as a tyranny of the old against the young, rooted in authoritarian attitudes. He recounts a recent scandal at an orphanage, where caretakers dosed unruly children with ADHD medication obtained from doctors under pretexts like “smartphone immersion.” Could the same happen with gaming disorder? Kim believes so. “It sounds like what these doctors consider gaming addiction treatment is just neutering basic human urges,” he says. One core criterion for the WHO diagnosis, functional impairment, strikes him as particularly vulnerable to abuse: “To me, what that’s saying is that it’s also acceptable to medicate kids underperforming academically.” Most of all, he wants the debate to lead to a wider conversation about the experiences of young people in the country. He cites recent research linking problematic gaming in South Korean adolescents to overbearing parenting and academic stress. The implication is that in focusing on games and the people who play them, the concept of gaming disorder papers over the dysfunctions of a society shaped by adults. Indeed, while South Korea has grown into one of Asia’s strongest economies, that has not translated into broader cultural or social enrichment for the country’s youth. Rather, young people in South Korea’s punishing education system are killing themselves at historically high rates. “Pushed up against relentless competition,” one lawmaker has said, “our children are gradually losing anywhere to go.” Even Lee Hae-kook acknowledges that gaming is one of the few sources of pleasure and recreation available to South Korean youngsters. It’s a grim realization, and just about the only thing on which Lee and his opponents agree.
MS Tech (Source: Unsplash)
A coveted career path Whatever image problems the gaming industry has developed, its sheer position in popular culture has made it impossible to ignore. The global gaming market is projected to reach $152 billion in 2019, and there are now 2.5 billion gamers across the world. E-sports alone are valued at more than $1 billion, a figure expected to double by 2022, and are now gunning for a spot at the Olympics. As a UK proponent has argued, they are “the first world sport outside of football that is truly global.” This was never more apparent than when I met Edgar Choi, the former StarCraft pro, on a sunny day in September. These days he is employed as a head coach at Gen G, a South Korean e-sports organization worth an estimated $110 million. Inside its headquarters, a brutalist-chic multistory concrete building in Seoul’s affluent Gangnam district, Choi trains players in a game called League of Legends—this generation’s StarCraft. The facilities’ careless luxury and startup-campus cool are a testament to the industry’s remarkable expansion since the early days of pro gaming. Gen G recently received $46 million in funding from Silicon Valley venture capital firms and celebrities like Will Smith. Two-time NBA champion Chris Bosh is the “player management advisor.” There are a massage room, a napping room, basement studios for streamers, a buffet-style cafeteria tended to by aproned lunch ladies, two more headquarters in Los Angeles and Shanghai, and aisle upon aisle of sleek black gaming computers in classrooms throughout the building. Professional gaming has become one of the most coveted career paths among South Korean youth, and these classrooms are where Gen G develops future prospects. “Only about 10% of trainees will become pro,” said Choi. Things are far more competitive and regimented than they were in his time; gamers can no longer afford to just play for fun. “Back then, I couldn’t even imagine that it would become like this,” he said. On a row of computers in the employee lounge, three of the team’s marketers played games on their break. Expensive whiskeys and gleaming silver trophies were displayed in cases on the walls. To Choi, who lives in a world where gaming has evolved into a form of work rather than play, the idea of gaming addiction feels anachronistic. He wants to steer his two young children away from the hyper-competitive world of e-sports and has been careful to instill healthy personal gaming habits in them. For the most part, though, he is less worried about games than smartphones. Kids, he says, are mostly on their phones, watching YouTube, going on social media, and reading webtoons as well as playing “free to play” games. With the WHO already behind gaming disorder, there is now talk of government regulation specifically aimed at smartphone use. Perhaps the StarCraft generation, now parents themselves, have found their own bogeyman. Max S. Kim is a freelance writer based in Seoul. He reported on corruption in South Korea’s nuclear energy industry for the May/June 2019 issue.
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