From the keyboard to the couch: issues for clinicians in the age of the Internet.

Sex and the Internet: A Guidebook for Clinicians. Edited by Al Cooper. Philadelphia: Brunner-Routledge, 2002, 288 pages. Paper, $34.95.

By now, it is a cliche to claim that the Internet has changed the way we think, shop, communicate, conduct research, and interact with one another; however, cliches generally are grounded in truth, and none more so than this one. Whenever a new medium or technology changes human social conduct, it is almost certain to affect sexual interactions as well. When changes in social and sexual technology give rise to new manifestations of pathology, clinicians scramble for guidance in dealing with novel complaints and crises from their clientele. Al Cooper of the San Jose Marital and Sexuality Centre provides some needed guidance for clinicians on the topic of sex and the Internet in his new edited volume.

What motivates individuals to seek sexual information, pornography, cybersex, or face-to-face sexual interaction via the Internet? This is an overarching question for clinicians and researchers alike, and the contributors to Cooper's volume rely for the most part on Cooper's own answer: the Internet's "Triple-A Engine" of affordability, anonymity, and accessibility. Less emphasized are the components of the "Triple-C Engine" of communication, collaboration, and communities. Though these "engines" may explain why people initially seek sex on the Internet, they do not provide a fully satisfactory answer to the questions of how Internet-related pathologies develop and why the Internet may be a more powerful facilitator of such pathologies than offline environments.

To more fully explore the Internet as a breeding ground for sexual pathology, the authors may benefit from exploring the perceived normality of pathological behaviors in online communities. No matter how deviant an individual's sexual desires may seem in an offline context, there is almost always a group of people on the Internet who share those desires. Ready access to people of like minds can feed a need for affiliation as well as a need for sexual exploration and gratification. Also contributing to the power of the Internet for facilitating sexual pathology (but largely ignored by the authors of this volume) is the efficiency with which sexual information, pornography, or sex partners can be acquired online. Some forms of sexual exploration may be difficult to achieve in offline environments, but are available from the Internet at lightning speed. These issues and many others merit more consideration from the contributing authors.

Who is at risk for Internet-associated sexual pathology? The first section of Cooper's volume describes "populations of concern," namely women, men who have sex with men, people who are aging or have chronic medical conditions or disabilities, and youth. We found the chapter on women on the Internet to be slightly disturbing in its heterosexist approach to many of the clinical issues described. A large percentage of the chapter is devoted to examining the effects of partners' Internet use on women in steady relationships, while not enough space is devoted to women who actively seek sex partners online. Women who seek sex partners online are at risk for sexually transmitted diseases as well as emotional and sexual abuse. Therapists should be aware of the risks taken by women who seek sex partners online and should be prepared to counsel patients on such issues as partner choices, safe meeting places, and disease prevention. We were distressed at many of the assumptions of the chapter, such as the assertion that BD/SM sites will appeal more to lesbians and bisexual women than to conservative, heterosexual women. Isn't this the type of assumption that can render therapy ineffective?

Assumptions play a major role in the chapter on men who have sex with men (by Ross and Kauth), as they tightly point out that frequent Internet use does not always imply that the client is sexually addicted or pathological. In fact, in some contexts related to "coming out" and sexuality exploration, frequent use of the Internet may be helpful or healthy. This chapter takes an excellent, whole-person approach to the issue of why men who have sex with men may be motivated to seek sex online, and why this may or may not be an issue requiting clinical care.

The chapter on adolescents (by Longo, Brown, and Orcutt) is a useful guide for clinicians as well as parents and teachers who may encounter youths in need of counseling for Internet-related issues. In an important section of this chapter, the authors take on the delicate issue of contrasting adolescents' healthy and problematic sexual behavior. The chapter contains some of the book's most concrete advice for dealing with clinical situations involving the Internet and sex, and would be an excellent chapter to recommend to school counselors and clinicians who specialize in adolescent sexuality.

While adolescents on the Internet are considered a "hot topic," Tepper and Owens focus their chapter on a population often overlooked by researchers: the aging, disabled, or chronically ill. The authors note that this population consists of individuals who, for various reasons, may be physically and socially isolated, but who find social support and peer interaction online. The authors also point out that clinicians serving this population may be better able to understand their patients' perspectives if they understand the Internet environments in which their patients become immersed. They emphasize that clinicians who are familiar with the Internet can provide useful guidance to their patients regarding healthy use of this technology.

The second section of the book, "Therapeutic Considerations," focuses on the rather difficult question of what clinicians can and should be doing to address patients whose use of the Internet for sexual purposes has become disabling or pathological. The section begins with an interesting chapter by Cooper, McLoughlin, Reich, and Kent-Ferraro that describes the ways in which virtual sexuality can become problematic in the workplace. The authors draw analogies between chemical addiction and addiction to online sexuality to describe the negative effects that online activities may have on both the individual employee and the work environment as a whole. This chapter provides concrete guidance for employers and human-resources departments in determining how serious the problems with a given employee may be and what treatment options are available.

The chapter by Greenfield and Orzack on the clinical assessment of online sexual problems and the subsequent chapter on treating online compulsive sexual behavior by Delmonico, Griffin, and Carnes bring up the most perplexing clinical questions in this field. For example, when is online sexual activity a problem? The natural method for discussing any online behaviors seems to involve drawing parallels to those behaviors and problems commonly seen in offline environments. What are the parallel problems in the case of online sexual addiction? Clinicians (and contributors to this volume) have suggested that sexual compulsivity may be one analogous problem, whereas others prefer to treat online sexual addiction as they would a chemical dependency.

The classification of the problematic behavior brings up the next intriguing dilemma: setting the goals of a treatment plan for people whose online sexual activity has become problematic. What should be the goal of therapy? In a traditional 12-step program for treating an addiction, the goal is complete abstinence from the addictive substance. Is total abstinence from online sexual activity a healthy goal for every client? Or should clinicians focus on helping their clients integrate this new technology into a healthy sexual lifestyle? These questions merit more research and exploration as clinicians begin to counsel more clients with online sexual problems. In the meantime, Delmonico, Griffin, and Carnes present a detailed description of first-order and second-order changes to be undertaken by cybersex compulsives and provide an example of a treatment plan for people whose online sexual activities are problematic. Also included is a list of potential challenges and setbacks that may be faced in the context of administering this type of therapy. This level of concrete guidance, a hallmark of many chapters in this volume, is invaluable to clinicians as they learn to counsel clients with these problems.

Thankfully, this volume does not ignore an important consequence of online sexual problems, namely the effects of Internet-enabled sexual behavior on the spouses and partners of "cybercruisers." A thought-provoking chapter by Schneider raises several concerns for clinicians working with persons in relationships affected by Internet-enabled sexual activity. For example, if a man's wife is engaging in a steamy, online relationship with a man whom she has never met face-to-face, does this constitute adultery? Can the relationship recover from the perceived "cheating" represented by online sexual activity? What behaviors can the Internet-using partner adopt to rebuild trust with the non-Internet-using partner? How can one partner trust that another partner's Internet use, at work or at home, will remain of a nonsexual nature? Schneider helpfully includes some mistakes to avoid in these therapeutic situations, while underscoring the need for further research to determine best practices for counseling.

Although most of the chapters focus on the detrimental effects of sexual Internet use on individuals and relationships, there appears to be some hope for beneficial, therapeutic uses of this technology. Cooper, Scherer, and Marcus illustrate some of these uses in their chapter describing methods of improving sexual relationships using the Internet. These include methods of online group therapy and online teaching, as well as Internet-based individual-level assessments and interventions. Clients may practice social-sexual skills in online environments or may create alternate personae in a therapeutic setting. Amid the multitude of questions and problems raised by the Internet for clinicians, the consideration of beneficial uses of the technology is a welcome breath of fresh air.

The book ends, as most books about the Internet do, with a chapter about the future of the Internet and what it may hold with regard to sexuality. Barak and Fisher gamely and carefully approach this task, with full knowledge that predicting the future of the Internet can be a futile endeavor. They cleverly address most of the topics presented in the rest of the volume, describing the future of each as being dependent on well-thought-out factors. They rightly point out that the next generation of Internet users likely will have even more access, affordability, and anonymity than the current generation. Thus, the problems, questions, and methodological issues raised by the Internet for clinicians and researchers must be addressed if we are to meet the challenges we will face in the future.

Reviewed by Mary McFarlane, Ph.D., and Rachel Kachur, M.P.H., Centers for Disease Control and Prevention, Division of Sexually Transmitted Disease Prevention, 1600 Clifton Road NE, Mailstop E-44, Atlanta, GA 30333; e-mail: [e-mail].