Sex and Cyberspace—Virtual Networks Leading to High-Risk Sex

In addition to its power and reach for rapid information exchange, the Internet has generated a new debate: does it fundamentally change the way we lead our lives? That the Internet has revolutionized communications and business practices worldwide is clearly recognized. That the Internet may have some psychological effects on individual behavior, molded perhaps by the technology itself, has now been noted. Newly described behavioral disorders possibly linked to Internet use include Internet-related depression^{1 - 2} and cybersex addiction.^{3 - 5} Recent reports have suggested that fully one third of adult Internet visits are directed to sexually oriented Web sites, chat rooms, and news groups,⁴ where Internet users can observe sexual images or participate in online sexual discussions with individuals or groups. Although cybersex may be considered within the broad realm of sexually related behaviors, it carries no risk for sexually transmitted disease (STD) transmission because no direct physical contact occurs. In contrast, use of the Internet to identify sex partners for actual (rather than virtual) sexual activity does impose such risk.

But is this really a new phenomenon, or simply a logical extension of behaviors that are already in place? Persons with the motivation and initiative for making new sexual connections through anonymous or semianonymous means are risk takers, or "sexual adventurers."⁶ It seems clear that such risk taking in their virtual social lives would be accompanied by risk taking in their actual sexual lives, placing them at greater risk for STDs including human immunodeficiency virus (HIV).

The point is well made in the article by McFarlane and colleagues⁷ in this issue of THE JOURNAL. The authors surveyed persons who were seeking HIV testing at a municipal HIV counseling and testing site and found that individuals who sought Internet sex partners reported a higher level of other sexual risk-taking behavior compared with those who did not use the Internet to find sex partners. Compared with non-Internet sex seekers, Internet sex seekers were more likely to be male and homosexual, and reported more previous STDs, more partners, more anal sex, and more sexual exposure to partners known to be HIV positive. The group they identified consisted primarily of gay men (in an increasing proportion in the spectrum from non-Internet sex seekers to online sex seekers who made actual sexual connections using the Internet). Although the authors do not provide separation of groups to permit further delineation of differences in sexual adventurism by sexual orientation, their report confirms the well-known observation of heightened sexual risk among some gay men.⁸

The important conclusion from these observations is that for populations with levels of education and income sufficient to support computer use, the Internet has become an efficient facilitator of behaviors and practices that have been taking place for many years among certain high-risk individuals. The real news is not that such activities are occurring but that the public health establishment had its feet planted firmly in the last century and did not anticipate this inevitable response to the new technology.

Partner notification is the process of identifying sex partners of STD or HIV patients to offer them testing, treatment, and other health and support services.⁹ The term partner notification embraces 2 distinct strategies, patient referral (in which partners are notified by the patient without the assistance of public health personnel), and provider referral or contact tracing, a confidential process in which public health department authorities request names and identifying information about partners to notify those partners of their exposure.¹⁰ Provider referral partner notification, the cornerstone of STD prevention efforts for many years, has changed little since the early era of STD control and is largely dependent on voluntary identification of sex partners by name and provision of other identifying information so that partners can be located by health department staff.^{9 ,11}

Ongoing evaluations of the ethical and programmatic aspects of partner notification^{12 - 14} seem not to have included the parallel universe of online human interactions. The syphilis investigation described in this issue of THE JOURNAL by Klausner and colleagues¹⁵ appears to be an early instance of a new "fingerpost" (from a quotation from Francis Bacon indicating the appearance of a guide at a moment of uncertainty),¹⁶ which, ironically, embodies all the old problems of partner notification, including difficulty in obtaining adequate identifying information needed to locate partners. Klausner et al found a number of persons with syphilis who were linked primarily by use of the Internet to identify new sex partners. In their description, the authors note that sex partners usually were not identifiable by name because connections initiated through Internet chat rooms were frequently anonymous and remained so during actual sexual activity. The authors needed a new public health approach for alerting partners about their risk for STDs.

In 1984, when confronted with the realization that high-risk anonymous sex was taking place in bathhouses, and with the increasing public pressure to take action, San Francisco, Calif, public health officials made the controversial decision to close the bathhouses to reduce the risk for HIV transmission.¹⁷ In this 2000 update, closing "virtual" anonymous meeting sites is not even a consideration, much less a controversy. Instead, in the study by Klausner et al, San Francisco health officials took the appropriate steps to use the virtual medium itself to alert chat room participants of potential disease exposure, using Internet aliases to contact individuals, and Web alerts, rather than direct personal contact, to raise awareness. That the Internet was used successfully by the health department for partner outreach, in a public-private collaboration with an Internet service provider and a marketing firm, was a major step forward by public health into the current millennium.

An important irony uncovered by these events involves protection of patient confidentiality in the Internet era. Protection of confidentiality both for patients with STDs and for their partners has been a basic tenet of traditional public health partner notification programs.¹⁰ However, marketeers, survey researchers, credit entrepreneurs, and computer hackers potentially may have access—perceived, at least, but probably real in many cases—to intimate details of people's lives.¹⁸ The intimate details that are needed for STD control are probably available through the new Internet technology in ways never before imagined, but access to them by public health authorities for the purpose of disease intervention was not permitted.¹⁵

The public health establishment, taking the lead from Klausner et al, instead should explore the potential value of the Internet as a tool for health communication. Such use is already common, and is reflected not only in the number of commercial health-related Web sites, but also in the recent government funding support for "health alert networks" for emergency response to bioterrorism and other disease-related interventions.¹⁹ However, these government efforts are largely directed toward health care professionals, not the public at large, and the information on the Web is not easily accessible via frequently visited public Internet sites.

The old methods of health education used by public health systems (eg, television public service announcements that are seldom shown during prime-time viewing hours) are clearly not the model that new technology makes available. Similarly, government-sponsored Internet sites with health information are not likely to be visited by high-risk individuals and probably are the Internet equivalent of the 3 AM public service announcement. For health education efforts to be effective using the Internet, public health needs to be more market-driven and commercially savvy—to know about and have a presence at the right high-risk sites—and not simply wait for at-risk individuals to stumble onto prevention messages. On the street, public health workers distribute condoms and use other preventive interventions at places where high-risk persons aggregate. By logical extension—yielding to the unfortunate tendency to affix "cyber" to any activity tangentially related to the Web—it follows that public health could offer "cyberprevention" launched from critical "cyberaggregation" sites. However, for public health authorities to successfully develop these new strategies and use the Web effectively requires a greater investment in state-of-the-art information systems and computer technologies, a situation not consistent with the current reality of public health funding and practice in much of the United States.

The challenge, then, is not in describing new risk behaviors but, rather, in identifying new methods to assess how sexual behaviors will manifest, and whether Internet interventions can modify these behaviors and interrupt transmission of STDs including HIV. One such method may be the use of social network theory to understand the dynamics of disease transmission. The Web is, after all, a network, and is amenable to many of the same questions and analyses that are relevant to programs based on social network theory and are now being used with increasing enthusiasm in STD prevention and control efforts.^{20 - 21} Such work has demonstrated that entry into such networks for research and intervention is difficult and fraught with practical and ethical problems. Entry into the real networks of persons who associate online may be substantially more difficult.

Nonetheless, one clear potential function of the evaluation of networks engendered by Internet connections will be to monitor the way in which risky behavior is expressed and acted on. Public health must anticipate the shape that these risks will take. For the current young generation of computer users, their expertise and computer access is unprecedented, and Internet communication has become second nature to them. What will the impact of these virtual meeting grounds be as these young people reach sexual maturity? Public health systems need to be prepared to deal with the consequences of activities involving these new communication media. The opportunity for STD prevention (at least for this segment of the population, which has grown up using the Internet) will truly become lost in cyberspace unless public health can develop new ways to better educate sexual risk takers and provide effective interventions—with or without the assistance of these new technologies.

The message of the 2 vanguard reports in this issue of THE JOURNAL boils down to 2 simple new points for STD control: clinicians and public health practitioners can ask patients if they use the Internet to make sexual connections and thereby identify a group at risk for STDs, and they also can use those same Internet communication channels to let people know how to protect themselves from STDs. The contrast of high technology and ordinary behavior is perhaps the most important fingerpost for future endeavors.