Sexual Compulsivity, the Internet, and HIV: A Focus on Gay and Bisexual Men

Sexual compulsivity, also known as sexual addiction, is characterized by sexual fantasies and behaviors that are frequent and intense enough to interfere with personal, interpersonal, or vocational pursuits (see Black, 1998 for a review). Sexual compulsivity can result in interpersonal conflict and distress, social and occupational problems, psychological distress (especially damage to self-esteem), and financial problems.

Over the past two decades, research interest in the phenomenon of sexual compulsivity has grown, in part because of concerns that “out-of-control” sexual behavior may be linked to risk for acquiring and transmitting HIV. During the last decade, researchers have also begun to explore the role of the internet use in facilitating HIV risk-related behavior. With studies reporting that 40 percent to 66 percent of men who have sex with men seek sex partners online, it is clear that the internet provides an increasingly common means of sexual connection, often surpassing venues such as bathhouses, gay bars and clubs, private sex parties, gyms, or public cruising venues (Grov, Parsons, & Bimbi, 2007; Liau, Millett, & Marks, 2006). It seems intuitive that when men who experience out-of-control sexual behavior use technology that allows them to meet sexual partners quickly and easily, HIV risk may be increased, but much about the true nature of the interaction between sexual compulsivity, the internet, and HIV risk in the lives of gay and bisexual men remains unclear.

While researchers have documented the association between sexual compulsivity and HIV risk, and have investigated the association between the internet and HIV risk, only recently has research begun to focus on the overlap of sexual compulsivity and internet use as related to HIV risk. This article explores the links between sexual compulsivity and HIV risk, discusses why these links may be especially significant for men who have sex with men, and examines the role of the internet in both facilitating and curtailing HIV risk among sexually compulsive gay and bisexual men.

In exploring these links, is important to avoid pathologizing either sexual activity itself (including sex outside of committed relationships) or seeking sexual and romantic partners online. Rather, the focus of this article is the beginning exploration of problematic internet use by individuals with a compulsive sexual disorder.

Sexual Compulsivity Among Gay and Bisexual Men

Without clear diagnostic criteria, it is difficult to estimate the prevalence of sexual compulsivity, but some researchers have suggested that it lies between 3 percent and 6 percent in the general population, with a higher prevalence among men than women (Black, 1998). Some researchers have suggested that rates are higher among gay and bisexual men (Cooper, Delmonico, & Burg, 2000), while our community-based survey data of 1,214 gay and bisexual men in NYC found 30 percent reporting sexual compulsivity symptomatology (Grov, Parsons, & Bimbi, in press).

It is unclear why rates of sexual compulsivity may be higher among gay and bisexual men. The high rate of child sexual abuse among those with sexual compulsivity and the marginalization of gay sexuality and relationships are possible factors (Parsons, et al., 2008). In addition, gay men typically report more sexual partners and have access to a greater variety of sexual venues than do other people (Parsons, et al., 2008). These increased opportunities for sex may allow gay and bisexual men who are already predisposed to sexual compulsion to actually engage in behavior that could lead to the development of the disorder. This is similar to the finding that increased access to gambling opportunities is related to a rise in the incidence of pathological gambling.

Sexual compulsivity has been consistently associated with HIV risk behavior in both heterosexual and gay male samples. Compared with men not experiencing symptoms of sexual compulsivity, researchers have found that sexually compulsive gay and bisexual men are less likely to disclose their HIV serostatus to sexual partners (Reece, 2003), and that they report lower capability of using a condom during sexual encounters (O'leary, et al., 2005). Our survey data with 1,214 gay and bisexual men in NYC found HIV positive men (compared with other men), those who reported recent (< 90 days) sex under the influence of drugs (compared with those who did not), and those identified as barebackers (compared with those who did not) reported significantly higher scores on measures of sexual compulsivity (Grov, et al., in press). These data also found temptation for unsafe sex was significantly correlated with sexual compulsivity score.

Where’s the Risk?

Because rates of sexual compulsivity appear to be higher among men who have sex with men, and because some researchers suggest men who seek sex online may be at increased risk for acquiring or transmitting HIV, the question arises: Is there a significant relationship between sexual compulsivity, internet use, and HIV risk for men who have sex with men? Preliminary research on the subject has produced mixed results.

Between 2002 and 2003, the research team at the Center for HIV/AIDS Educational Studies and Training in New York conducted Project SPIN, interviewing 183 gay and bisexual men who were experiencing symptoms of sexual compulsivity (Grov, et al., 2008; Parsons, et al., 2008). Though the internet was not the focus of Project SPIN, it emerged as a significant theme in men’s compulsive behaviors.

Most men (80 percent) had access to the Internet, and 59 percent had used the internet within the last 90 days to search for sex partners. Among internet users, 61 percent thought their use was a problem, and those who thought their use was a problem spent significantly more time online than those who did not view their use as a problem. Interestingly, time spent online was unrelated to a variety of clinical conditions (such as depression and anxiety) or psychosocial variables (such as loneliness and sexual sensation seeking).

Drawing from the data from Project SPIN and other studies, below are three ideas about the ways that sexual compulsivity, the internet, and HIV risk may interact in the lives of gay and bisexual men. These ideas highlight both the risky and protective aspects of internet use. None of the dynamics is mutually exclusive, and several may operate simultaneously for any given person.

The Internet as a Facilitator and Trigger for Sex and Sexual Compulsivity

Clearly, the internet facilitates sexual contact by allowing people to meet potential partners quickly and easily. Because the internet is so accessible and can be anonymous, it is an ideal environment to explore the marginalized aspects of one’s sexuality. This can be particularly salient for gay and bisexual men who are not entirely “out” about their sexual identity, who seek alternatives to more “traditional” venues (such as bars) for meeting men, who live in areas without a visible gay and bisexual community, or who want only to meet partners of the same HIV status.

In Project SPIN, some men reported that the internet was the medium through which they enacted their sexually compulsive episodes. That is, they had a pre-existing problem with sexual compulsivity, and the internet was simply the tool they used to identify and meet partners. Had the internet not been available, they could have turned to another source for partners, such as visiting a bathhouse. SPIN participants highlighted how the internet “replaced” more traditional venues (such as bathhouses and public cruising spots) where they had previously engaged in sex and enacted their sexually compulsive episodes.

In contrast, some Project SPIN participants reported that the internet sparked additional sexually compulsive behavior. Some of these men indicated that the persistent availability of the internet (unlike bars, bathhouses, and public cruising areas, which had more defined hours of “operation”) allowed them to act out more often, when time-limited venues would have curtailed them.

Some men felt triggered to act out when checking their e-mail and seeing a message from a previous sex partner, which resulted in back-and-forth dialogue that eventually led to a compulsive episode (either with that partner or with others). Others viewed online pornography or cybersex (“virtual” sex where the encounter is confined to online communication), which increased their arousal and lead them to search for and meet partners off the internet. Given the frequency of sexual behavior during a protracted sexually compulsive episode, the potential for irritation to both the penile tissue and rectal lining (through masturbation and oral and anal sex) can increase opportunities for HIV and STI transmission/exposure (even if condoms are used).

In contrast, while many men described compulsive, internet-related, sexual behavior that caused them and others painful negative consequences, much of this behavior was not inherently linked to HIV risk. Men who described how they could not pull themselves away from the internet once online did not necessarily engage in sex with partners, but rather spent such a significant amount of time looking for sex or viewing pornography that they neglected important social responsibilities. These men called the internet as a “black hole” that consumed all their time—either facilitating sexually compulsive behavior or triggering episodes.

The Internet as a Facilitator for HIV Risk

Research to support the contention that the internet is related to HIV risk is mixed. One 2006 meta-analysis examined 22 studies of online sex-seeking among men who have sex with men. The researchers reported that men who sought sex online were more likely than men who did not to report unprotected anal intercourse (Liau, et al., 2006). It is unclear, however, whether the instances of unprotected sex occurred with the partners that study participants met online.

Other reviews of HIV research note that while some studies have linked internet use to HIV risk, others have not (for a review, see Chiasson, et al., 2006). One 2004 study found no differences in rates of unprotected anal intercourse between men who met their partners exclusively offline and those who met partners exclusively online, while those who met partners both online and offline were the most likely to also report HIV risk behaviors (Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004).

Research methodology may make a difference. One 2007 study found that when participants were asked to recall their past behavior, a history of online sex-seeking was associated with greater numbers of sexual partners in the prior year, greater likelihood of one-time sex partners, greater likelihood of sex without condoms, and more frequent failure to discuss partners’ sexual histories. In contrast, when the same respondents used daily diaries to record their sexual behavior, unprotected anal intercourse was less likely to occur with partners met online than with partners met by other means (Mustanski, 2007).

One way that the internet may increase HIV risk is by expanding sexual networks, allowing men who might not have otherwise met to connect. One 2008 study of 2,312 men who have sex with men found that those who met partners online had significantly more sex partners within the previous year than men who did not meet their sexual partners online. Network expansion can also expose men to ideas and norms they may not have otherwise encountered. For example, the growth in the “popularity” of a barebacking identity (identifying a person who seeks intentional unprotected sex) and “party-n-play” (drug-enhanced sex often involving the use of methamphetamine) have both been linked to the internet (Grov, 2006; Hirshfield, et al., 2004).

The Internet as a Facilitator for Harm Reduction

The internet can also facilitate harm reduction. Just as men can search for partners willing to participate in behaviors such as barebacking or ”party-n-play,” users can also search specifically for partners of the same HIV status or partners who are interested in protected sex only or other lower-risk practices such as oral sex (Chiasson, et al, 2006).

Project SPIN findings revealed that cybersex can replace “real” sex, such that men could use online pornography (or cybersex) and masturbate at home, quelling the urge for sex with a “real” partner (and eliminating HIV risk altogether) (Grov, et al., 2008). Some participants stated that they would have sex with a single partner when using the internet (versus multiple sex partners during the course of a multi-hour visit at a bathhouse).

While the possibilities for using the internet as a tool for HIV and other STD prevention and care are wide and varied, most of its potential lies unexplored. Partner notification services via the internet are an exception, offering one successful example of online sexually transmitted disease prevention and care.

Conclusion

Though many of the studies cited herein have explored the impact of the internet on sexuality, sexual compulsivity, and HIV-associated risk behavior, these data were collected prior to recent expansions in high-speed networks. Meanwhile, advances in mobile technology—lightweight notebook computers, improved battery life for laptops, expanded wireless networks, and mobile “smart” phones—have put the full capabilities of the internet into our pockets.

Despite what appears to be a large overlap between men who experience sexual compulsivity and men who seek sexual partnership or gratification online, to date, there are no empirically validated computer-based interventions that specifically target those who engage in sexually compulsive behavior. Indeed, thus far, there has been little empirical validation that effective behavioral interventions can be delivered via the internet. The variety of offline interventions to treat sexually compulsive behavior includes 12-step group membership, medication, cognitive-behavioral interventions, and psychodynamic treatments. Given that sexual compulsivity is more prevalent among gay and bisexual men, and that many gay and bisexual men use the internet for sex-related activities, it is essential to improve our understanding of how to deliver effective online interventions to this population.