Sex and the Internet: A Guidebook for Clinicians.
Al Cooper, Editor
Chapter 1: Introduction
The Internet: The Next Sexual Revolution
Al Cooper, Ph.D.
Eric Griffin-Shelley, Ph.D.
A new sexual revolution has commenced with the staggering growth of computers, technology, and the exponential expansion of the Internet. While some individuals recognize the profound social changes swirling around the Internet, most are just beginning to grasp both the promise and peril that it brings regarding a host of issues concerning human relationships. The focus of this book is Sexuality and the Internet. In it we explore the major issues that clinicians, mental health professionals and social leaders need to know about the impact of Internet sexuality on their work with clients, families, and society at large. The authors, researchers and clinicians, review the most current empirical data and provide accurate, and in-depth information and analysis designed to update general understanding as well as clinical practice. Internet sexuality already reflects the conflicts around sexual issues that are pervasive throughout our culture, e.g., the tension between freedom of expression and the protection of children. By becoming informed and engaged, clinicians can treat problems and answer questions arising from Internet sexual activity. Armed with knowledge, mental health practitioners can be proactive in shaping the future of the new sexual revolution.
Understanding Sexuality
Love and sex are essential to human life and therefore, integral to clinical work. Generally, people are more open about their romantic lives than the details of their sexual lives. Consequently, our understanding of human sexuality has been more limited than our knowledge of interpersonal relationships. Objective information about sex and love pales in comparison with scientific knowledge of other areas of health. Sexuality remains rather hidden, and for some, stigmatized and shame-filled. As a consequence, research on human sexuality is inadequately funded. In contrast, AIDS, cancer, and mental health and chemical dependency concerns all suffer from similar negative perceptions, but over the past three decades each of these areas have received gradually increasing public and governmental recognition and support. Science rockets ahead in the understanding of the human genome and how to extend life past the century mark, yet we lag far behind in our science and understanding of human sexuality, particularly the non-biological aspects (Donahey and Miller, 2001).
Sexual Revolution
A new sexual revolution has begun with the explosion of the development of electronic technology, computers, and especially the recent, rapid expansion of the Internet, also known as the World Wide Web, ÒNetÓ or Òweb.Ó As we move into the Information Age, it is clear that the world is irretrievably changing. Jerome, DeLeon, James, Folen, Earles, and Gedney (2000) assert that, "rapid and far-reaching technological advances are revolutionizing the ways in which people relate, communicate, and live their daily lives." They go on to say that "increased access to information and individuals will fundamentally alter the way people see the world, establish communities, and work within these structures." (p.407) Most acknowledge that these profound changes are occurring. However, the social implications and effect on members of the global community are poorly understood, at best. One thing is known is that sex has been a major factor in the development of, activity on, and interest in the Internet (Cooper, 1997; Cooper, Boies, Maheu, & Greenfield, 1999).
Staggering Growth
Most people are only marginally aware of how the Internet is changing every facet of our lives, probably more dramatically in the next 20 years than in any previous period in history (Cooper, Boies, Maheu, & Greenfield, 1999). A recent composite profile reveals that about 167 million people in the United States use the World Wide Web. Of those, the average visitor logs on three times, visits an average of five sites and spends a little over three hours per week online (Nielsen-Net ratings, 2001). In October, 2000 the U.S. Department of Commerce, published the fourth report in a series entitled, "Falling Through the Net: Towards Digital Inclusion." They indicated that "more that half of all households (51.0%) have computers, up from 42.1% in December, 1998" (Department of Commerce, 2000) In addition there were 116.5 million Americans online at some location in August, 2000, 31.9 million more than there were only 20 months earlier"(D.O.C., 2000). The amount of information and numbers of opportunities available on the Internet is exploding--with over one billion unique pages available in January, 2000 (Inktomi,2000).
The rate of growth for new Internet service is estimated to be a meteoric 25 percent every three months. New developments in the merging of once separate telephone, television, and computer technologies, a phenomenon known as convergence, are being introduced daily. Work, school, and even social activities are becoming increasingly dependent upon, and centered around, computers (Cooper, 1997). Ten years ago most people could not even imagine the concept of online chatting or shopping. How quickly people adapt to and take for granted that which was science fiction just moments before.
In order to better describe and study this phenomenon, anagreement on terms is needed in order to have a common lexicon. Thus, for the purposes of this text, Online Sexual Activity (OSA) is defined as use of the internet for any activity (including text, audio, graphic files) that involves sexuality whether for purposes of recreation, entertainment, exploration, support, education, commerce, efforts to attain and secure sexual or romantic partners and so on.
Cybersex is a subcategory of OSA, and can be defined as using the medium of the Internet to engage in sexually gratifying activities, such as, looking at pictures, engaging in sexual chat, exchanging explicit sexual images or emails, "cybering" (i.e., sharing fantasies over the internet which involve being sexual together while one or both people masturbate), etc.
Online Sexual Problems (OSP)-includes the full range of difficulties that people can have due to engaging in OSA. Such difficulties include negative financial, legal, occupational, relationship, as well as personally repercussions from OSA. The ÒproblemÓ may range from a single incident to a pattern of excessive involvement. The consequences may involve feelings of guilt, loss of a job/relationship, STDs, etc.
Finally, Online Sexual Compulsivity- (OSC) is a subtype of OSP and refers to excessive OSA behaviors that interfere with the work, social, and/or recreational dimensions of the personÕs life. In addition, there are other indications of the Òloss of controlÓ of their ability to regulate the activity and/or minimize adverse consequences (Cooper, 1998b).
The Internet and Sexuality
Since its inception the Internet has been inextricably associated with sexuality in a synergistic dance, each fueling, and ultimately contributing to the transformation of the other. That people are fascinated with sexuality and sexual relationships is clearly manifested on the Internet. An estimated 20% of Internet users engage in some form of online sexual activity (Cooper, Delmonico, & Burg, 2000). Sexual pursuits may account for almost 70% of all dollars spent online (Sprenger, 1999). One report indicated that 18 million people in the U.S accessed pornography sites in the year 2000, a figure that is three times higher than for 1999 (Carr, 2000). Yet, even as the web continues its exponential expansion, little is known about how this new medium is affecting sexuality in the United States and around the world. However it might first be helpful to provide a little more information on the more general impact of the Net.
The Internet: Connecting or Dividing?
Will the Internet ultimately unite people or divide them by who is "online" and who is not? Will the gaps between generations, income levels, cultures, or countries become even wider? There are already disparities between children and teenagers who have "grown up withÓ computers, and the many adults who lack even basic familiarity with the online world. Will this add to the generation gap or will technology render innovative ways for our younger and older people to ÒconnectÓ? Similarly, the affluent, not surprisingly, have easier access to the Internet than do the poor (Jerome et al., 2000). However, the U.S. Department of Commerce recently reported that "groups that have traditionally been digital 'have nots' are now making dramatic gains." (2000). Perhaps Internet accessibility will some day help to decrease social and economic divisions.
Geographic distribution of online users is uneven. Currently the United States has the greatest number of people online, with Japan (31.9 million), Germany (27.1 million), the United Kingdom (23.4 million), Italy, (18.1 million), Canada (13.2 million) and Australia (9.2 million) following in succession (Nielson-netratings, 2001). The Nua website reports 407 million online users worldwide, with 167 million in the U.S. and Canada, 113 million in Europe, 104 million in Asia and the Pacific, 16 million in Latin America, 3 million in Africa, and 2 million in the Middle East (Nua, 2001). Although their methods of tallying differ, both sets of figures indicate that the online world is primarily English speaking, and that large portions of the world are still unconnected. Yet, even without direct access, the effects of the Internet are being felt around the world and providing opportunities for those who know how to make use of them.
Meeting and communicating with people is no longer limited by propinquity or even time of day (Cooper, and Sportolari, 1997). The interpersonal cues so often relied on in face to face interactions are generally not available online. Cyber-communication is still overwhelmingly text-based so that variables such as age, gender, physical appearance, race, or disability, which are typically subject to visual and auditory verification, are less important online. On one hand, ambiguity is increased but on the other, the Internet can be a means to reducing interpersonal barriers, overcoming common stereotypes and prejudices, disseminating information, as well as increasing variety in relationships, both sexual and nonsexual.
The Internet is Powered by the "Triple A Engine"
Computers speed things up. With regard to sexuality, this shift in speed evokes intense emotional reactions. For instance, flirtation and innuendo, long the staples of leisurely seduction, can rapidly escalate into frank sexual discussions and proposals on the Internet. The changes in speed and intensity of sexual encounters online are without precedent. Cooper (1997) states that the three central components that combine to turbo-charge, i.e. , accelerate and intensify, OSA include Access, Affordability, and Anonymity. These three components are referred to collectively as the "Triple A Engine."
Access
The Internet is available, convenient, and easily accessed by increasing numbers of people worldwide. They log on from their homes, schools, and places of work or leisure. Accessibility has contributed to sex becoming one of the most commonly searched topics (All Knight Systems: 1999, Cooper, 1998a; Freeman-Longo & Blanchard, 1997) on the Internet and to its widespread use for sexual pursuits (Goldberg, 1998). People can find a website to satisfy any sexual need or desire they may have without the need to delay gratification. Consumerism is further facilitated by the ready availability of products, services, and people (Fisher & Barak, 2000). The Internet is a virtual store open 24 hours per day, 7 days a week for social and business transactions.
Affordability
Affordability is based on the economic principle of supply and demand. The seemingly infinite number of sites and products mean that the supply is plentiful and this increased competition, when combined with a lower overhead than a Òbricks and mortarÓ business, leads to lower prices for consumers. This is particularly true for those sexual items and experiences that are less easily available in real time, such as sado/masochistic ("S & M") dating services or a sexual enhancement workshop for lesbians. With improvements in search engines, the Internet serves as a central clearinghouse that keeps time and costs in check. Consumers who know their way around the Net can easily find free sexually-related items and services (Hapgood, 1996). Additionally, the declining costs of server space and increased revenue from banner and link advertising helps keep user fees low.
Anonymity
The belief, whether true or not, that oneÕs identity is concealed online can have a powerful effect on sexual expression. Branwyn (1993) observed that use of the Internet increases the sense of freedom, willingness to experiment, and pace of self-disclosure, as well as enhancing a person`s ability to talk openly about their sexual questions, concerns, and fantasies. For example, those who might be hesitant to purchase sexually explicit materials, products or aids in a face to face encounter, may be more comfortable doing so when protected by the anonymity they feel online.
The Internet and Telehealth: A Tool for Health Promotion
As a communication tool, the Internet offers a means of promoting physical and mental health, especially sexual health, through innovative methods. For example, it is becoming a common practice for health professionals to use video-conferencing as a means to provide patients in rural clinics with access to specialists in other geographic locations (Jerome et al., 2000). Online mental health services currently maintain educational websites that include diagnostic questionnaires, interactive bulletin boards, support groups and chat rooms. Hospitals, insurance companies, and other healthcare organizations are developing ways to communicate with and offer services to their customer base via the Internet.
As people increasingly turn to the Internet for health information and support, it is important that they bear in mind that technology can be misused. Some websites are filled with inaccurate information and biased points of view. Incompetent and unscrupulous people motivated by greed and self-interest, exist online as well as off. As both the benefits and risks of the cyber-world are more fully understood, people will be better able to navigate it safely.
Offerings of online counseling and psychotherapies are proliferating, yet remains controversial. Internet-mediated psychotherapy cannot be adequately dealt with in this book because of the complexities surrounding it at present. Most likely, the ethical, legal and technical concerns will be worked out in the next few years and in future texts one can expect this area to have a chapter of its own.
Commercial, Positive, and Negative Aspects
of Internet Sexuality
Cooper (1998a) notes that the use of the Internet for sexual purposes can be classified in three broad categories: commercial aspects, positive connections, and negative patterns .
Commercial Aspects
Sexuality has long been a significant financial engine driving the growth of the Internet (Hapgood, 1996).The profits generated by sexual commerce have funded major online technological advances that are quickly adopted by mainstream businesses. Analyst Mark Hardie of Forrester Research is quoted as saying, "what I see when I look at this industry [online adult sites]--putting aside any moral judgments about reprehensible content--is an amazing example of an industry that has banded together to protect its business, push revenue across the industry, and innovate cutting-edge technologies" (Branwyn, 1999). Sex sites routinely make money, a still unusual status among businesses in the contemporary world of e-commerce. Given that less than 1% of visitors to adult sites actually spend money on them (Branwyn, 1999) these businesses need to attract and retain large numbers of visitors in order to make a profit and the number of individual visitors at such sites grew more than 27 percent from December 1999 to February this year--to nearly 28 million from 22million. . (Schwartz, 2001). The Internet has become a very common pathway to explore and engage in OSA, particularly for persons and cultures wherein sex and sexuality is a source of shame and embarrassment (Cooper, McLoughlin, and Campbell, 2000). In addition to products, the Internet has also become another medium for marketing romance and sex, from dating services and personal ads to the popular sexual chat rooms. There are a multitude of ways to Òmeet interesting peopleÓ online. Those with an enterprising spirit have found ways to collect fees from those who participate in these activities, i.e., Internet savvy sex workers find search engines and websites to be excellent venues for advertising their services (Cooper et al., 1999).
Positive Potential
In a world fraught with sexual problems, pitfalls, and prejudices, the Internet offers many ways to positively impact sexuality and sexual connections between people. One trend is the proliferation of virtual communities around common sexual interests, whether they be pro-choice or pro-life causes, 'leather aficionados' or those with shared sexual life concerns such as, rape survivors, herpes sufferers, or paraplegics. The sense of community and belonging derived from such contacts can have important and salubrious psychological effects on individuals and contribute to the changing political and social perceptions of these groups. Isolated and disenfranchised individuals such as, gay and lesbian youth, ethnic minorities, or persons with disabilities, can come together online and find social support that may not otherwise be available to them. Professionals are recognizing that these virtual communities impact peoples' lives significantly, and are increasing their efforts to study and understand them (Burke, 2000; Palandri and Green, 2000).
Another important development is the rapid increase in the number of specific websites that educate people about such sexual matters as sexual dysfunction, sexual enhancement techniques, safer sex practices, reproduction, abstinence, sexually transmitted disease, etc. The lack of factual information is a major contributor to the enormous amount of fear and anxiety many feel about sexuality (Williams, 1994). In response, a wide range of sites have been developed to provide sexual education in the form of websites with Frequently Asked Questions (FAQs), advice columns, and discussion groups, and email distribution lists for cutting edge news and information.
In particular, the Internet may offer an alternative way to provide sexual education and interventions for our young people. If used effectively, it may be able to positively influence their perceptions about sexual matters via fresh, hip, accurate and informative websites that combine entertainment, education, and meaningful discussions of sexual values in ways that attract and hold their interest.
Similarly, professionals are finding the Internet can help them stay informed and abreast of relevant developments in their respective fields. Sexual education materials are increasingly available through major sexuality organizations such as, the American Association of Sex Educators, Counselors and TherapistÕs website (www.aasect.org) or that of the National Council on Sex Addiction and Compulsivity (www.ncsac.org). These organizations have their own websites available to the public as well as to their members. Additional Internet-based methods of informing and educating professionals include improved online continuing education courses , email lists, which encourage the exchange of views on current and controversial issues, and bulletin boards, which promote posting recent research findings, questions, and comments among members.
Negative Effects and Risks
The Internet is not without its risks. In addition to expanding knowledge and providing support, the Internet can negatively impact peopleÕs lives and their sexuality. Clinicians are reporting a dramatic increase in the number of patients with issues related to their OSA. For many of these clients the Internet has become an outlet for unresolved sexual difficulties and unfocused sexual energy, including the acting out or repetition of traumatic experiences (Schwartz & Southern, 2000). Some individuals who go online for their social and sexual needs forsake, avoid or neglect real-world relationships (Kraut, Lundmak, Patterson, Kiesler, Mukopadhyay, & Scherlis, 1998; Greenfield, 1999). Others find enough solace in their online lives that they lose the motivation to address dissatisfactions in their offline lives and, therefore, neither address or resolve them. OSA is particularly tempting both for those who already experience problems with sexual compulsivity, as well as those who are psychologically predisposed or vulnerable to act out compulsively (Leiblum, 1997). It is easy to see how many might choose to hide from their real world problems through increased or exclusive online interaction.
Contributors and Chapter Summaries
The contributors to this volume provide in-depth examinations of the trends that individual clinicians may find difficult to keep up with by themselves. The authors represent a diversity and richness of perspectives and viewpoints, much like the web itself. They include a collection of North American and international experts in various areas of sexuality from prestigious universities, private foundations, clinics, and world-renowned hospitals. They represent diverse disciplines including public health, medicine, law, psychology and psychiatry. Each has been selected because of his or her knowledge of some unique dimension of Internet sexuality and we believe their contributions combine to provide a comprehensive foundation for anyone interested in the area of online sexuality.
The book begins with forwards by two of the pioneers in the field of sexuality, Albert Ellis and John Bancroft of the Kinsey Institute. They talk about the profound impact the internet is having on the area of sexuality and help to provide some historical context.
Section 1: Populations of Concern
The five chapters of Section one deal with Populations of Concern and how they are being influenced by online sexuality. Sandra Leiblum and Nicola Doering begin by examining the growing presence of women on the Internet. Then Michael Ross and Michael Kauth explore the role of the Internet for men who have sex with men. Following that Mitchell Tepper and Annette Owens examine how the Internet impacts persons with disabilities, chronic illnesses, and normal lifecycle changes (e.g., puberty, pregnancy, menopause, and aging). The section ends with an important discussion by Robert Freeman-Longo, Stephen Brown, and Deborah Orcutt who look at the impact of online sexuality on our children and adolescents
Section 2: Cybersex problems: Therapeutic considerations.
The next section begins with an exploration of the complex issues of virtual sexuality in the workplace.by Al Cooper, Irene McLoughlin, Jay Kent-Ferraro, and Pauline Reich.
David Greenfield and Maressa Orzach then offer an overview of assessment issues as they pertain to online sexual problems. This is followed by David Delmonico, Patrick Carnes, and.Elizabeth Griffin discussing treatment strategies for these issues. Next Fred Berlin and Nate Galbreath describe some of the most severe types of OSP and the increasing popularity of the Internet as a venue for those with a variety of paraphilic interests. In her chapter Jennifer Schneider focuses specifically on the concerns of partners and family members of those with OSP and examines these issues in the context of cyberspace.
Section 3: Other Areas of Special Interest around Internet Sexuality.
Starting this final section, Al Cooper, Coralie Scherer, and David Marcus suggest practical ways for clinicians to utilize the Internet as an adjunct to more traditional therapeutic interventions used to help improve sexual relationships.
Next, Michael Plaut and Karen Donahey examine how the anarchy of the early Internet is being transformed into a kinder, gentler place where "netiquette" is enforced by internet service providers' (ISP.) policies, ethical guidelines, and laws and regulations.
Eric Ochs, Kenneth Mah, and Irv Binik outline the opportunities for important new research on human sexuality offered by the Internet.
The book concludes with a chapter by Azy Barak and WilliamFisher, who offer their thoughts about the future of Internet sexuality. Their projections about future trends will enable clinicians to be on the forefront of these developments.
Limitations
While this volume attempts to be comprehensive, the field is newly emerging and evolving and, thus, there remain areas that are not adequately represented and in need of further professional investigation. For instance, while mentioned in several chapters, a more in depth exploration of lesbian involvement with the net, as well as more empirical data, is needed. In addition, most current research has their models of internet sexuality primarily based on the presumption that it is as it appears in the United States. This may or may not be true and online sexual activity in this country may be similar to, or vastly different from, how it exists in other parts of the world (or even in different ethnic or cultural subgroups within the USA). At present, there are many more questions than answers.
Professionals, Prevention, and Policies: A call for action
Rather than react to events as they unfold, professionals have the option to forge ahead, using their knowledge and training to proactively develop the content, use, and evolution of online sexual activities. Informed professionals can facilitate the appropriate use of the Internet for sexual health, while attempting to minimize potential problems and adverse effects.
There is an immediate need for more attention to the impact of this rapidly developing technology on sexuality. Mental health professionals need to go online, study online behaviors in schools, homes, businesses, libraries and cafes. They can partner with other interested individuals and organizations such as school administrators, educators, parents, employers, law enforcement agencies and representatives of local, state and national governments to develop strategies to deal with Internet sexuality concerns.
To this end, it is recommended that the following policies and interventions be considered--
1) Develop programs to educate the public about the potential for positive outcomes that the Internet can have on sexuality and public health, such as--
a) the development of healthy sexual self-esteem and behaviors;
b) the correction of misinformation about sexuality and relationships;
c) the development of sex positive virtual communities for minority and disenfranchised populations;
d) the offering of first-line interventions for persons struggling with issues they are not yet ready to acknowledge offline, such as, sexual orientation, survival of sexual abuse or assault, ÒembarrassingÓ and anomalous sexual and somatic concerns, or affairs or domestic violence.
Implementation of these goals via the Internet has the potential to lead to an increase in medical and emotional help-seeking behaviors with concomitant decreases in STDs, unwanted pregnancies, depression, suicide, or divorce.
2) Post warnings and criteria about potential negative effects of going online for sexual pursuits, e.g., "spending more than 10 hours per week or using OSA to relieve stress is likely to be problematic, (Cooper, Griffin-Shelley, Delmonico, & Mathy, 2001) ." These could be placed in appropriate places by Internet service providers (ISPs) and providers of online adult entertainment along with hyperlinks and invitations to visit other websites, such as the American Psychological Association, the American Association of Sex Educators, Counselors, and Therapists, or the National Council of Sexual Addiction and Compulsivity, where online sexual problems, treatments and related issues would be addressed in more detail.
3) Develop and implement programs to educate the public about those who are "at risk" for developing OSP and OSC. It would useful to provide ÒmarkersÓ for individuals to assess whether their particular behaviors might leave them vulnerable to more serious problems or not (Cooper et al., 2001).
At the same time as these larger changes are happening, mental health professionals can become directly involved in Óhands onÓ ways of acquiring and disseminating accurate, ethically rendered, accessible information that is specifically tailored to targeted sexual communities, such as--
1. Becoming familiar with the Internet, visiting sexuality-related websites, and incorporating web-based interventions in their practices.
2. Creating websites (or pages within a website) expressly designed for a single sexuality issue. Such sites would include Frequently Asked Questions (FAQs), screening questionnaires, self-help tests, or interactive behavioral treatment and educational modules, including accurate and ethical online movies and animations, that address the specific sexual concern.
3. Becoming expert moderators for scheduled interactive online chats or monitors of sexuality-focused bulletin boards (BBs).
4. Developing sites for other mental health professionals, independently or through professional organizations, which encourage collegial support, consultation and continuing education. Such sites would include targeted news items and announcements, links to resources, email lists, BBs, or other forums for the exchange of ideas, new research, and resources.
5. Expanding our understanding of Internet sexuality through empirical research. By writing articles and book chapters, presenting at conferences, soliciting funding for research, and developing viable theories about these issues professionals will become increasingly aware of the effects of OSA and develop effective and innovative interventions.
By being involved in these cutting edge activities, mental health professionals can have a presence on the Internet and other forms of telehealth and shape this emerging and central influence on sexuality in the 21st century. However, concerned professionals will only have a voice in these developments if they are informed, active, and contributing. Reading this book will help you to be more informed. As for becoming active and contributing, that part is up to you!
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Glossary
Banner--a rented space on a web page that advertises another site.
Bulletin board--an area on a website where people can post messages.
Convergence--the merging of once separate technologies, such as telephones, televisions, and computers.
Cyberspace--the imagined and real territory inhabited by computers and the Internet.
f2f--an online abbreviation for "face-to-face"
Internet--the interconnection of computers also known as "the web" because of the "www." designation which stands for "World-Wide Web" on website addresses.
Link--short for hyper-link which connects someone to a related Website.
Listserv--an organized email list to which people subscribe.
Online chatting--sending synchronous (same time or "real time") messages in a designated area of a website.
Online search--placing a word or topic on a "search engine," a site dedicated to identifying all related sites and getting a listing of all web pages related to that word or topic.
Server--a central storage space for web information, especially websites.
Virtual--online reality as opposed to concrete or face-to-face reality.
Virtual communities--groups of people who meet online in chat rooms, bulleting boards, or email lists.
Virtual store--online website that allows users to purchase products.
Web--abbreviation of World Wide Web or www. which is part of most web addresses.
Website--the pages that collectively represent the owner at a given web addres