The worldwide web and sexual health.
The internet has become an important part of our lives, and most people in developed countries now use it every day. Currently around 30% of the world's population has access, with growth estimated at 480% over this decade, most notably in Africa .
On the subject of sex and relationships, a large number of resources are available on the 'worldwide web'. Sites offer help, advice or information but also opportunities to 'chat', network and find new partners--but there is also potential for illegal activity in terms of the portrayal of sex online.
For those of us working in the field of health, awareness of what is 'out there' is important because it is often the basis of our patients' knowledge and can be a powerful influence on their beliefs about their illness, treatment and care.
Value and potential
Young people in particular find the internet an important source of information and advice--an American survey found that 75% of young people use the internet to look for health information . The availability of such information can also be especially important for those living in areas where access to health information is limited. A study in Ghana found that 53% of young people used the internet to find health information, and that its use was particularly extensive among young people who were not attending school .
It can be argued that one of the internet's greatest strengths is the privacy it affords its users. Most people access the internet by themselves, at a computer they have control over. They have the scope to explore questions on any subject they choose without having to engage others in the process. As all of us working in sexual health are fully aware, there is a strong reluctance for people to ask healthcare professionals (HCPs) questions about sex. This reluctance can be compounded by anxiety, doubts and limited understanding. The internet, which provides a method of communication where confidentiality is seen as assured, can go a considerable way to enhancing knowledge and confidence. Anderson  concludes that not only does this privacy 'provide a unique opportunity for personal questions to be asked and pursued', it also 'encourages personal reflection and honesty about sexual health issues'.
Internet use for health promotion
As healthcare professionals, we should seek opportunities to enhance the public's understanding of sexual health-related issues--and developing online resources may be one such opportunity. Almost all internet sexual health promotion initiatives now take place via websites where professional control of content is assured. The web is attractive because it is a publishing format and can therefore be given the same professional care and attention as books, newspapers and similar media. Interactive websites are an option but this can be very challenging, both for site designers and for those offering health advice. Although the open-access format gives the web huge potential for public education, it also makes dealing with the potential diversity and magnitude of individual responses extremely challenging which may deter websites from allowing qualitative interaction with individual users. We must acknowledge that as HCPs we are likely to encounter considerable hurdles in using this medium, not least due to ambiguities in UK law in respect of 'publishing' sexually explicit material. It has so far proved impossible to set out a standard of practice guaranteed to remain within the law. However, the Health Education Authority (now the HDA and part of NICE) issued a number of key principles encompassing both conduct and content that can be used to guide us (Panels 1 and 2).
The internet also provides an important means of sexual expression and fulfilment for a growing number of individuals and has transformed vicarious sex into an increasingly possible and attractive substitute for direct interpersonal contact . 'Cyber-sex' can substitute for actual sexual contact, offering sexual gratification with no risk to physical safety. Increased concern about risk of sexually transmitted diseases and HIV, and a greater range of sexual content available, have led some people to experiment with new sexual activities, such as voyeurism by mutual consent or 'telephone sex', and this trend has been widely evidenced, for example by Gauthier and Forsyth and by Bergling et al. .
The internet also provides a mechanism for linking individuals 'with like-minded partners for social interaction including sexual experimentation' . One means is through 'internet relay chat' (IRC). This is a way of communicating online, whereby two or more people interact in real time. Typically, the IRC user accesses a 'chat room', with a defined topic; all the people in the chat room can see each **other's messages popping up on the screen and add to them. IRC is completely public and so open to the interests, desires and prejudices of the entire online world. The uncontrolled, 'live' nature of IRC has so far made it unpopular as a medium for health promotion. However, given that it may allow access to the 'hard to reach', one could argue that this mode of communication should be explored further.
Potential pitfalls and limitations
From the perspective of global health promotion, those who are probably most at risk of preventable health problems, due to lack of education or living in poverty, are unfortunately the least likely to have access to such technologies. Barriers to access include cost, geographical location, illiteracy, disability and other factors that may limit people's ability to use such IT appropriately and effectively.
In addition, access to this information is unregulated and internet sites may have hidden agendas--for example, religious organisations that oppose sex before marriage or termination of pregnancy may offer links to seemingly genuine information and advice sites. It can be difficult for users to determine honest, accurate information from that which can be inaccurate or misleading, perhaps even dangerously so.
As a means for sexual gratification the internet is obviously not limited by the 'normal' constraints of society, so these avenues may also fuel some unsafe (and perceived by some as 'deviant') behaviours. 'Bare-backing' (sexual penetration without using a condom) and 'bug-chasing' (promotion and pursuit of sex with HIV-positive people without using a condom) have both been facilitated by internet forums, and many research findings provide evidence for this .
IRC communications, mentioned earlier, disappear as rapidly as they are generated, and this form of internet use has thus not been a major focus for anxieties about internet content. Even so, there are some concerns that IRC could be a means of gaining the confidence of individuals (such as children) with the intent to abuse this confidence.
Influence on sexual behaviour
While the role of the internet in making contacts for sexual reasons is widely recognised, data on partner-seeking activities on sex-oriented contact websites is still limited. However, we do know that while online (or indeed by text messaging), some people self-disclose or 'act out' more frequently or intensely than they would in direct person-to-person contact. They feel less inhibited--the so-called 'disinhibition effect'--whereby, for example, people reveal secret emotions, fears and desires, or show unusual generosity, kindness or aggression.
This behaviour may arise from the anonymity and invisibility when communicating online, and the resulting reduced sense of authority and responsibility--ironically identified earlier in this article as one of the internet's strengths. It has been suggested  that in most cases several causative factors interact and/or supplement each other, resulting in a complex, amplified effect. The authors list a number of factors that can lead to this 'disinhibition effect':
* You don't know me (dissociative anonymity)
* You can't see me (invisibility)
* See you later (asynchronicity, likened to an 'emotional hit-and-run')
* It's all in my head (When reading another's message, people may "hear" the words in their own voice, sub-vocalising as they read, thereby projecting the sound of their voice into the other person's message.)
* It's just a game (dissociative imagination)
* We're equals (minimising authority)
Of course, there is a wide variation in activity and behaviour. Personalities vary greatly--for example, in the strength of defence mechanisms and tendencies towards inhibition or expression. Equally, the strength of underlying feelings, needs, and drive level are also significant. The above factors will interact with the personality variables, in some cases resulting in just a small deviation from the person's usual (offline) behaviour, while in other cases causing dramatic changes.
Furthermore, internet forums can create environments where exploitive behaviours may be perceived by those participating as 'normal' since they are not alone in their activities. A previously socially sanctioned behaviour that occurred in secrecy, among isolated individuals, may now generate a 'cyber-community' which supports and facilitates the behaviour.
Potential for abuse
The internet is the world's biggest publisher of pornography, so concerns about the easy availability of pornography on the web are certainly justified. Ironically, it is mainly the ever-increasing quality of the information on the web, and its potential as an educational tool, that have made its perceived dangers a focus for public attention. There is particularly strong public fear that children using the web will inevitably encounter pictures of pornography --indeed, research in 2005  found that 90% of 8-to-16-year-olds had viewed pornography online, mostly when doing their homework.
Many believe that these IT innovations have created a global medium that facilitates exploitation and abuse--enabling trade in sex workers, child prostitution, and paedophilia, for example--and that the internet has facilitated the visibility and exposure of 'at-risk populations', such as (but not exclusively) women and children, while at the same time increasing the privacy and anonymity of sex offenders and perpetrators. These fears have been backed by a number of studies [8,9] contending that the internet has caused a surge in the production and distribution of child pornography and opportunities for predatory paedophiles to access children.
Attempts to respond to public anxiety about the availability of pornography, and other sexually explicit material, have highlighted to those of us working in sexual health promotion, just how difficult it is to control access to such websites.
Our perception of the internet may be a very positive one, whereby we see it as bringing the world's worth of information to our fingertips, the 'information super-highway' on which we all must travel if we are not to be left behind. At the other extreme, the internet is viewed as the most powerful tool of pornographers, paedophiles and extremists, an uncontrolled source of exploitation and corruption. A more balanced view sees the internet as much too complex to be assigned to either of these extremes--nevertheless, many of us are deterred from its use, for example, accessing explicit material to inform us in our work in sexual health.
The good news is that these technologies may help reduce health disparities by promoting health, preventing disease and supporting access to clinical care. However, both public and private sectors must work collaboratively to reduce the gap between those who have access and those who do not. This will need to include supporting health information technology access (both domestic and public), ensuring developments take into account the growing diversity of users, funding related research, ensuring quality of health information and support, and enhancing 'literacy' in technology . Furthermore, researchers will need to explore the impact of technology on sexual and other behaviours.
[1.] www.internetworldstats.com, 2011. [C]2001-2011, Miniwatts Marketing Group (accessed October 2011).
[2.] Rideout V, for The Henry J Kaiser Family Foundation, 2001. How young people use the internet for health information. Available at www.kff.org (accessed October 2011).
[3.] Borzekowski DL, Fobil JN, Asante KO. Online access by adolescents in Accra: Ghanaian teens' use of the internet for health information. Developmental Psychology, 2006, 42, 450-458.
[4.] Anderson W, for the National HIV Prevention Service, 1998. Sexual health in cyberspace; overcoming the obstacles to promoting sexual health on the internet. Available at www.nice.org.uk/nicemedia/documents/cyber.pdf (accessed October 2011).
[5.] Quinn J, Forsyth C. Describing sexual behaviour in the era of the internet: a typology for empirical research. Deviant Behavior, 2005, 26, 191-207. Online doi: 10.1080/ 01639620590888285 (accessed October 2011).
[6.] Durkin KF, Bryant CD. Log on to sex: some notes on the carnal computer and erotic cyberspace as an emerging research frontier. Deviant Behavior, 1995, 16, 179-200.
[7.] Suler J. The online disinhibition effect. CyberPsychology and Behavior, 2004, 7, 321-326. Online doi: 10.1089/ 1094931041291295 (accessed October 2011).
[8.] Fisher WA, Barak A. Internet pornography: a social psychological perspective on internet sexuality. Journal of Sex Research, 2001, 38, 312-325.
[9.] Spranza M, Spranza F. Preying on predators. Law Enforcement Technology, 2000, 27, 24-32.
[10.] Eng TR, Maxfield A, Patrick K et al. Access to health information and support: a public highway or a private road? Journal of the American Medical Association, 1988, 280, 1371-1375. Online doi: 10.1001/jama.280.15.1371 (accessed October 2011).
Panel 1: Online education method guidance: practice/conduct
* The approaches and methods adopted to promote sexual health should recognise the diversity of sexual attitudes and sexual lifestyles.
* Communications should also promote mutual respect for self and others and the benefits to wellbeing that come from caring and emotionally fulfilling relationships.
* Messages should be accurate, clear and honest where there is uncertainty; they must not be victim-blaming, anti-sex or stereotyping.
* The target audience should be carefully defined and described--catch-all terms such as 'general population' 'Black and minority populations' should not be used.
* The language used should be carefully chosen and properly justified by its purpose and intended outcome.
* The design and construction of all materials in the field o sexual health must be based on thorough research with nationally representative target audience.
* The reaction of other audiences who may be reached by this material should also be assessed. All materials must be thoroughly pretested and modified accordingly.
Panel 2: Online education method guidance: materials/content
* Websites should demonstrate an integral commitment to educational objectives.
* Websites should be carefully targeted and should make clear at every level who the information is intended for.
* Explicit material should be sited in a broader context which demonstrates the purpose of using it; in particular, images should always be used alongside text.
* Explicit images should always indisputably show people aged 16 or over.
* Links to other websites should be made after proper review and should include details of the content of the remote site.
* Professional advice should always be sought if there is any doubt about the legality of a website's content.
Independent Nurse Advisor
Correspondence to: Juliet Bennett (email: firstname.lastname@example.org)
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|Date:||Dec 22, 2011|
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