Observations about obsessional love and compulsive sexual behaviors are not new. Since human beings began to express themselves on granite walls and clay scrolls, there has been a fascination with sexuality. Secular and religious literature, oral history, art and music were all replete with both overt and oblique references to the power sex holds. About 4,000 years ago, the Sumarians wrote about the sexual conquests of the warrior Gilgamesh in The Epic of Gilgamesh which describes his behavior and reputation: "His lust leaves no virgin to her lover, neither the warrior's daughter nor the wife of the nobleman." Forty centuries later the Internet burst upon the world and has given us yet another outlet for the expression of sexuality. Its potential seems infinite, frightening and wondrous all at the same time.
In May 1997, theWall Street Journal ran a story about a stripper, Danni Ashe, who was able to use her business skills to market sexually explicit images of herself and other models on the Internet. Lane (2001) reports how the journalist, Thomas E. Weber described how Ashe's site, Danni's Hard Drive, was "bring [ing] in so much revenue that she has given up the stage and nude photo shoots... Now the pay site boasts 17,000 members, putting Ms. Ashe on pace for more than $2 million in revenue [in 1997]... " (Lane, 2001, p. XIII).
Furthermore Lane notes that in just over five years, "the number of World Wide Web users in the US alone has risen from zero to more than 100 million" (Lane 2001, p. 272). With this proliferation of web users, the number of people who use the Internet for online sexual activity has also increased dramatically. It is estimated that 25% of the 100 million users of the Internet engage in some form of online sexual activity (Egan, 2002). Thus approximately 25 million people are online seeking some kind of sexual contact and this number grows every day. Furthermore, in a national survey of youth on the Internet, Finklehor, Mitchell and Wolak (2000) found that an alarming number of children are being exposed to the sexual content of the web and were being caught in it. Among a sample of 1,501 youth aged ten to 17 years, one in 33 received an unwelcome and aggressive sexual solicitation (e.g. a telephone call, letter, money or gifts) and one in four had unwanted exposure to pictures of people having sex or pictures of naked people. We are only beginning to understand the clinical, social and legal implications of such pervasive use of the Internet for sexual activity.
Why does the Internet have such power and popularity? Unlike the warrior Gilgamesh who had to leave home to pursue his prey and could not predict when and where he would find it, today's Internet user can pursue sexual contacts from their home and have an infinite variety of sexual experiences in the world of "virtual sex". Cooper (1997) claims that online sexual activities are turbocharged by a "Triple A Engine" which gives the user a sense of accessibility, affordability and anonymity. Ironically, it is just these qualities of the "Triple A Engine" that make sexual activities on the Internet intrinsically difficult to contain. Certainly the Internet makes the world of sexuality accessible in a way that no one could ever have imagined. Anyone, anytime can visit the Internet and access an infinite variety of sexual content. Affordability, on the other hand, can be an illusion. Some sites are expensive and an obsessed user can be online for many hours accumulating very large credit card charges. The costs in terms of quality of life, employment loss and wasted time are also great. Anonymity, or the implication of secrecy, is also a very powerful quality that may serve to heighten the attractiveness of the Internet. But, as technology improves, anonymity on line is becoming more and more an illusion than a fact. These days even a relatively unsophisticated but determined partner, spouse, family member, employer or police officer can track someone's Internet use and expose sexual pursuits. Exposed, the user may be found to have a more profound problem than was assumed. Galbreath, Berlin and Sawyer (2002, p. 189) characterize "cruising society's new red-light district" for sexual stimulation as being an expression of a powerful biological drive, and "like all basic biological drives... [the user] will recurrently crave satiation". The findings of Cooper, Boies, Mahieu and Greenfield (1999), on the other hand, assure us that the majority of people who visit sexual sites on the Internet do so for recreational purposes and do not suffer any negative consequences.
So one might ask why a chapter about online sexual activity would be included in a book focused on paraphilic behavior? What has cruising sexual sites anonymously and in private got to do with sexual offending? Our clinical work and emerging research informs us that for some who are online for sexual stimulation, it is simply not an occasional and innocent erotic event but instead, it is a result of an obsession that has the real potential for escalating into a criminal act. Indeed, this clearly happens (McCabe, 2000). Most men who are convicted of downloading child pornography from the Internet claim not to have actually offended against children. In fact, they often argue that masturbating to child pornography viewed on the Internet satisfies their urges, which might otherwise be expressed in actual sexual contact with a child. However, recent reports from Hernandez (2000, 2004) contradict these claims. He identified 29 men convicted of possession of child pornography downloaded from the Internet, who otherwise had no documented history of contact offenses and who denied ever committing an offense. After these men had completed an extensive sexual offender treatment program at a United States federal prison, 18 admitted to having molested an average of 12.3 child victims. Whether the remaining 11 were being truthful when they continued to deny contact offenses seems doubtful, but the fact remains that using Internet child pornography does not protect men from abusing children. Given evidence that some users of Internet pornography, with no previous history of deviant sexual interests, progress from original access to appropriate sexual images to progressively more deviant material (Cooper, Delmonico & Burg, 2000; Cooper, Putnam, Planchon & Boies, 1999; Greenfield, 1999; Schneider, 2000), it seems likely that at least some men who access child pornography sites on the Internet are led there by earlier access to more innocent sites.
It is also likely that for some, sexual activity on the Internet will fall just short of illegal behavior but will seriously interfere with the development or maintenance of a satisfying lifestyle. Increasingly we hear of children being pursued by adults in chat rooms for the purpose of arranging meetings for sexual contact. Research and clinical observations are beginning to confirm that online sexual activities can have both benign as well as problematic consequences (Cooper, Scherer, Boies&Gordon, 1999; Leiblum, 1997). Therefore, it is important for the benefit of all involved to better understand the variety of sexual activities online and how they are used if we are going to develop treatment strategies as well as public policy interventions.
Defining And Describing Online Sexual Behavior
Researchers and clinicians in the field of sexology are just beginning to describe the nuances and subtleties of sexual behaviors associated with the Internet. "These behaviors can be obsessive as well as compulsive, can appear to have many of the qualities we associate with addiction and may be either censored or tolerated by society" (Golden, 2001 p. 50).We think it is critical that leaders in the field work to develop a common language and taxonomy that will not only facilitate a dialogue about treatment methodologies but will aid in the development of research and public policy.
A useful way of categorizing and describing online sexual activity (OSA) and its subtypes has been developed by Cooper and Griffin-Shelley (2002).
Online Sexual Activity: the use of the Internet for sexual activity of any type (e.g.: viewing live videos, participating in chat rooms, viewing sexual behavior of any kind, recreational or educational purposes).
- Cybersex: using the Internet to engage in sexually gratifying activities ( e.g. similar to telephone sex and can be called cybersexing).
- Online sexual problems (OSP): the full range of problems people can have by engaging in OSA.
- Online sexual compulsivity (OSC): a type of OSP which refers to the full spectrum of problematic situations that result from excessive OSA including the loss of control over one's behavior and one's activities of daily living.
Personal expressions of sexuality are infinitely unique and evolve over time. OSA is no different. It also has the potential for mutating, escalating and becoming problematic as the behaviors continue. When OSAs become problematic, they may be categorized as hypersexuality. Kafka (2000) defines hypersexuality as "the disinhibited or exaggerated expressions of human sexual arousal and appetitive behavior" (p. 472). Hypersexuality can be either paraphilic or nonparaphilic, both of which are defined by "excesses of fantasies, urges and overt sexual behaviors" (Kafka, 2000, p. 472). The difference between these two types of hypersexual behaviors is that paraphilias are socially censored and may be illegal while nonparaphilic behaviors are not. Kafka (2000) unites nonparaphilic hypersexuality and sexual compulsivity/addiction disorders under a common label he calls paraphilia-related disorders (PRDs). There is evidence that paraphilias and paraphilia-related disorders have common clinical patterns and it has been suggested that PRDs may be common among paraphilic males (Kafka, 2000). Therefore, online sexual problems and online sexual compulsivity can be classified as paraphilia-related disorders and in some cases these may eventually develop into, or become an integral part of, a full-fledged paraphilia.
Not everyone who uses the Internet for OSA is, of course, out of control or has a paraphilia-related disorder but the potential for problems, or even for developing a paraphilia, are realistic concerns for those who pursue sexual stimulation on the Internet. Three common types of OSAs are: (1) cruising the Internet for sexually explicit stimuli such as pictures, stories or videos of a wide variety of sexual behaviors; (2) entering chat rooms for sexually explicit conversations; or (3) finding people to meet off-line for the purposes of romantic or sexual relationships. Cooper, Putnam et al. (1999) describe three types of users who engage in OSA: (1) recreational or nonpathological users; (2) users who have a pre-existing disposition for sexual compulsions; (3) users with no pre-existing disposition for compulsivity but whose exposure to the Internet challenges their inner resources and their impulse control so they cannot resist the Internet's powerful force.
There is a myth that only men develop paraphilias. However, research is beginning to reveal that significant numbers of women are not only involved in childhood sexual abuse but in paraphilias and paraphilia-related disorders as well (David, Hislop & Dunbar, 1999; Fedoroff, Fishell & Fedoroff, 1999; Leitenberg & Henning, 1995). More to the point, Finkelhor et al. (2000) report, in their study of online victimization of children, that the gender of the harasser was female in 24% of the reported incidents. Therefore it is wise to think about both genders as having the potential for developing problems with online sex.
Whether the OSA escalates to the status of a paraphilia-related disorder or to a paraphilia, the consequences can be serious. Golden (2001) notes that "While in fact some of these OSAs may not be illegal, when they are discovered, it may seem to those involved that a major loathsome crime has been committed" (p. 51).
The ripple effect of problematic OSAs can be devastating and pervasive. Not only does the person who suffers from this problem often require intensive intervention, it is also likely that interventions with family and community will be needed. The consequences of pedophilia and Internet use come together in the documentary Capturing the Freidmans (Jareki, 2003). In the documentary, the children who were allegedly victimized were shown sexual "games" masquerading as a teaching technique for learning how to use the computer. Observing the students' reaction to it may have been a covert grooming technique for the subsequent sexual abuse perpetrated by the teacher. The documentary powerfully depicts the vortex of family dysfunction and destruction as well as community hysteria that surrounds these difficult issues. Studies demonstrate that people with both paraphilia-related disorders as well as paraphilias have not only comorbid mental health problems (Kafka, 2000) but also have childhoods that are notable for sexual and physical abuse as well as early and inappropriate exposure to sexual material and over-sexualized environments (Carnes, 1983, 1991; Coleman, 1995).
A case illustration highlights the above discussion and raises many assessment and treatment issues:
Carl is a 42-year old man who has been married eight years and has a two-yearold daughter. He has had trouble holding a job over the years but his wife, Mary, maintains a family business which allows him some structure and therefore he is able to contribute to it. Prior to the referral for marital therapy, he had been in treatment for depression for a year. He was seeing a therapist once a week and was being followed by a psychiatrist for medication. His wife, Mary, learned that he was having sex with a woman he had met online while she thought he was working. He claimed it was an innocent flirtation and did not mean anything, but his wife insisted that they get counseling. She wanted to salvage the marriage but was not sure it was possible. During the assessment phase with a marital therapist who had experience with hypersexuality, Carl revealed that he had a long-standing but secret obsession with exhibiting himself and had masturbated to this fantasy as frequently as five times a day, sometimes at work. It has recently escalated to the point where Carl had taken nude photos of himself and placed them on the Internet. He also spent as many as eight hours at a time in chat rooms, masturbating to images of a voyeuristic nature. He fantasized about contacting "young women" who will watch him masturbate and thinks about going to places where he may be seen masturbating. He denies he has ever actually acted on his fantasy and feels he never would but his habit has escalated over the past few years and his depression is getting worse.
Assessment Considerations
The assessment of Internet-related sexual behaviors, whether they are paraphiliarelated behaviors or paraphilias, presents unique issues and raises difficult questions. For example, the assessment phase and treatment phase need to overlap in these cases, particularly in the area of attempting to contain some of the behaviors. In addition, the taxonomy, treatment methodologies and the law have not yet caught up with some of the issues that are emerging and get uncovered in an assessment. Foley (2002) has recently noted that some of his clients, with no prior history of sexual compulsions or sexual acting out, have eventually accessed the Internet to observe pictures of children although they claim not to have engaged in the behavior off-line. Fedoroff (2003) refers to thesemenas "victimless" pedophiles. However, in so far as the images are of real children, viewing these images may be seen as contributing to the victimization of children. How do we determine how likely it is that these people will act out with children as their inner resources are challenged? As we have seen earlier, recent observations within prison settings suggest that some men who have only been detected for downloading Internet "child porn" have, in fact, molested children (Hernandez, 2000, 2004). Thus, use of the Internet to access sexual images of children appears to be associated with actual molestation. In any case, those who use the Internet for the purpose of accessing sexual images of children clearly have a serious sexual problem whether or not they have, as yet, actually molested children. These clients are likely to appear more frequently at treatment programs over the next few years. At present, unfortunately, we know little about these offenders. It is also possible that now there is more information and education about treatment for paraphilias, more people may ask for help and treatment before they are arrested (Fedoroff, 2003).
While we struggle with these questions, guidelines and laws are just beginning to emerge that can inform us as we make assessments of people who have OSPs, particularly those who access sites involving children. Some people who access these sites may incorrectly assume that it is legal to download all forms of pornography without fear of prosecution. However, paradoxically the United States Communications Decency Act of 1996 protects the net server from prosecution for posting pornography online but does not protect the consumer when they download pornography depicting children (Foley, 2002). As we pointed out above, the assumption of anonymity and confidentiality online is an illusion. Foley (2002) points out that, according to the FBI, illegal sexual activity online includes: "producing or possessing child pornography; uploading and downloading child pornography; and soliciting sex with children"( Foley, 2002, p. 26.2).
In conducting an assessment of OSA it is helpful (and wise) to keep in mind that the sexual activity being scrutinized has been a closely guarded secret that has often been in place for years. People do not give up their secrets willingly. Golden and Cooper (2003) observe that "the subtleties and nuances of sexual compulsivity connected to the Internet are often masked in a routine mental health evaluation or may masquerade as something else entirely" (p. 28). Some of the common problems masking online sexual compulsivity include: marital discord, intimacy and attachment difficulties, lowered work productivity, alcohol or substance abuse, depression and anxiety. The case above underscores just how important an accurate assessment can be. Carl was being treated for depression for a year but his secrets had not been revealed to either his therapist or psychiatrist. Therefore, his treatment and medication were targeting only a part of his problem and thus were not nearly as effective as they might have been. It also speaks to the need for the assessor to be someone who is experienced and knowledgeable in the area of sexual compulsivity and who keeps up with the rapidly evolving area of OSA (Cooper & Griffin-Shelly, 2002).
At the outset of every assessment, it is critical to understand the context of the referral and what the consequences of the desired changes will mean to the life of the person. Experienced clinicians will factor in not only the implications of giving up the pleasure the OSP provided but also the many levels of resistance inherent in the stasis of the family system. For example, in the case outlined above, Mary had a history of sexual abuse and was somewhat relieved to have Carl's sexual interest channeled away from her. In addition, while both of them were dissatisfied with Carl's pervasive sense of inadequacy and recurrent failures in holding jobs, he got gratification from Mary's caretaking and her ability to pick up most of the responsibilities. While she complained about the stress of being a caretaker, Mary had difficulty relinquishing the overt power and control that it gave her and that she needed in order to feel safe in the relationship. Therefore it is important to understand these online sexual behaviors in terms of intrapsychic and dyadic consent (Golden, 2001).
Assessments of OSPs may coincide with the necessity for containment of the behavior. A simple first containment measure might be denying or limiting access to the computer. It is important however to assess what this would mean to the patient, family or employer. In the cases that include illegal behaviors, the legal system provides containment measures and consequences that have a power of their own depending upon the particular jurisdiction, and the judge, as well as the mood of the community. It is notable that systematic analyses have called into question the idea that incarceration without treatment is the most effective way to reduce recidivism (Hanson & Bussi`ere, 1998). The relationship between the legal system and the perpetrator is an adversarial one. The relationship between a therapist and a client demands a supportive, nonjudgmental stance, which at the same time must not be seen as condoning the behavior. Not unexpectedly, those involved, other than the client, feel anger, revulsion and discomfort with the behaviors of the perpetrator. The therapist is also called upon to deal with these feelings in a therapeutic way. Galbreath et al. (2002) spell out what must be the common denominator for all professionals who work with people who have OSPs:
When a person receives a paraphilic diagnosis such as pedophilia, for example, it is important for the clinician to appreciate that it is not his fault that he has such a condition. In growing up, no one would decide to be sexually oriented toward children. (p. 197)
It is an essential ingredient of the assessment, therefore, that the assessor is clearly seen as nonjudgmental, experienced and knowledgeable, and knows about the treatment possibilities. The assessor should also be willing to share information and observations with the client as questions or problems arise. The relationship between this type of client and the person doing the assessment will no doubt be a complicated dance to both obtain honesty and establish trust. Even when the assessment and treatment are conducted by different people, there is much overlap between the assessment and treatment phases in these cases.
It is important to point out that when people who have been online for sexual activity enter the criminal justice system, there are some issues that are both unique and intrinsic to a forensic evaluation. In these cases, the legal system itself presents boundary issues that are complex and important to keep in mind (Doren, 2002). For example, who actually makes the referral for assessment? Is it the legal system, a parent, spouse, employer or the patient? What then are the obligations of the assessor to share the information gathered with someone other than the patient? In assessing paraphilic behavior on the Internet, we must keep in mind that there may be a forensic element to some of these cases and thus the possibility that the assessor will have to appear in court. It is likely that the evaluation and its findings might also be called upon to serve as a guideline for decision making about length and type of incarceration or treatment, in response to which the client may be unhappy. It is prudent, therefore, to consider having a separate person be responsible for the treatment phase following the evaluation. Galbreath et al. (2002) consider the essential elements of a thorough evaluation in the cases of paraphilic activity on the Internet. We have expanded it to include assessment issues in all types of OSPs. First, review as much collateral information as is available. This would include but would not be limited to: all medical (including mental health) records; police and legal records; family members and employers; victim impact statements; copies of any Internet communications; and information from prior therapist or evaluators. Second, conduct face-to-face interviews focussing on: medical history; previous participation in therapy; family and relationship history; sexual development history including any history of sexual abuse; sexual behaviors with partners; masturbatory fantasies; use of phone sex or prostitutes and details of pornography use; and finally, Internet use and sites accessed. When assessing Internet use it is necessary to determine what OSA was engaged in (pictures, jpegs, live streaming videos, chat rooms, sexual bulletin boards, net groups), whether or not images were traded, and whether or not sites were accessed to contact people off-line.
In forensic situations, the courts often want to have psychological testing done, and while psychological tests may be helpful, good clinical observations are also necessary (Galbreath et al., 2002). It is important to note that at the present time "assessment instruments cannot replace the personal interaction and clinical judgment of a trained therapist" (Delmonico, Griffin & Carnes, 2002, p. 150) because tests to evaluate OSAs are still in the very early stages of development (Foley, 2002).
The family, relationships and social milieu of the person requiring attention are also a critical part of the assessment process. The long-term recovery of the person will be enhanced if they are involved in a supportive and stable family or partnered relationship (Wincze, 2000). Also the traumas experienced by the person in the past and the present may also be experienced by family members and others and require attention (Christensen & Cramer Reu, 2002). Unfortunately, the system often overlooks or minimizes the impact on the family and others of an accusation of paraphilic behavior and the ensuing criminal investigations and legal process. We know that children exposed to sexual material beyond their developmental capacity to understand it are often left with negative consequences (Longo, Brown& Orcutt, 2002). Having a parent, relative or friend hauled off by the legal system, chronicling it in the media, exposing them to community censure, and generally terrorizing them can be a crippling life event. Therefore, as the family and social system's needs are assessed, preventive and palliative measures should be applied as soon as possible in the process. Social and legal policy would be well served by more attention to this issue.
Finally, in making an assessment of online sexual problems, the clinician should assess the presence of other comorbid states. In the few studies that systematically evaluated Axis 1 diagnoses in "sexually compulsive" males and females... or paraphilia-related disorders... one of the major findings is that most subjects with these disorders have multiple lifetime comorbid mood, anxiety, psychoactive substance abuse and/or impulse disorder diagnoses. (Kafka, 2000). With the lifting of these often chronic issues, a person can bring much more resilience and perspective to the work of resolving the sexual acting out.
Treatment Considerations
Golden (2001) notes that treatment for online sexual compulsivity needs to be multimodal. Fedoroff (2003) suggests that the relapse rates for people with these problems can be reduced by modern specialized treatment. He adds that if there is a shared vision between therapist and patient and the goal of treatment is the "establishment of a lawful, happy, fulfilling sex life within the context of a meaningful and balanced lifestyle" (Fedoroff, 2003, p. 351), it will result in much higher motivation during the treatment. We must not underestimate that power of the therapeutic relationship and the "safe holding environment" it provides. At the same time, it is not unusual for patients to lie or withhold information from the therapist. When this occurs, understanding and support should also be given by the therapist.
At this time, the state of the art in the treatment of OSPs includes cognitivebehavioral, psychodynamic, medical and group components (Foley, 2002). Group therapy is valuable (Line & Cooper, 2002), and while sometimes therapist-run groups are not available in a particular community, 12-step groups (e.g. SA and SLAA) are not uncommon and even available online.
Cognitive-behavioral interventions are the most prevalent and therefore provide the greatest opportunity for research with sexual disorders (Delmonico et al., 2002; Fedoroff, 2003; Hanson et al., 2002; Marshall, Anderson & Fernandez, 1999). This approach includes, among others: procedures for keeping diaries of fantasies, thoughts and behaviors; understanding the behavioral chains that trigger sexual acting out; and teaching relapse prevention strategies. In addition, when the Internet user is accessing child pornography, he should be seen in the same light as a child molester and offered a full comprehensive sexual offender program (see Marshall et al., 1999 for a description). Such programs address self-esteem, cognitive distortions, schemas, empathy, intimacy, coping, deviant sexual interests and detailed relapse prevention plans (Carich & Mussack, 2001; Marshall, Serran & Moulden, in press).
If the OSA is potentially risky (e.g. loss of employment or professional license, multiple anonymous adult sexual contacts without precautions for STDs, severe sadomasochism or pursuing children for sexual contacts) the need for containment is urgent and might include an intensive course of treatment or even referral to a residential treatment program. The partner, spouse and family should also be referred for help for themselves and begin to be educated about what it means to have this problem, and what the treatment options are.
Psychodynamic psychotherapy may also be a helpful part of the equation in working with people who have OSP (Cooper & Marcus, 2003). As noted above, the therapeutic relationship may provide the first occasion the patient has ever had to reveal his secrets and have them reflected back in a nonjudgmental way. In therapy, both patient and therapist can discover the function secrets served in the life of the patient. Understanding what is behind the acting out and how it is a defensive structure against painful and difficult feelings will provide the patient with a solid foundation for recovery. It is to be expected that the intimacy of the therapeutic relationship will be difficult for a person who has carefully defended against a close meaningful relationship in which the self is exposed. As the secrets come out, the patient typically feels out of control and angry and acts this out in the therapy over and over again.
Transference and countertransference issues are always complex in therapy. Eroticizing the therapist is a common way transference manifests itself when working with a person with sexual problems. For example, when Carl began to keep diaries of his fantasies, thoughts and behaviors early in the treatment process, they were very detailed accounts, to the point where they appeared to have an exhibitionistic quality to them. It was easy to see that he was trying to repeat with the female therapist what he did online. Since she knew he had been rejected by both his parents as well as by many women, she had to be careful to be supportive while also helping him to contain himself. If she had rejected the diaries' content and was judgmental, it would have reinforced rather than contained his behaviors. Rejected, he also might have ended his therapy. In order for the therapist to provide an appropriate response to Carl's diaries she also had to be conscious of her feelings about them. It could have been easy for her to feel angry, exploited and victimized by being exposed to such details. If she had not understood her own reactions that session could have repeated many experiences Carl had had with women in the past. Seemingly small details such as timing of appointments, payments, the space within which the therapy takes place, as well as what the therapist may wear are all possible triggers for transference reactions and will be grist for the therapeutic mill. There are many opportunities when the therapist can both think and behave psychodynamically as well as behaviorally. They are not mutually exclusive styles.
In addition to the above, a comprehensive treatment package for OSPs has also included a 12-step program and a professionally led group if available in the community (Orzack & Ross, 2000). Such 12-step groups are said to decrease the client's sense of alienation and increase the realm of supports he has and, as a consequence, increase his full participation in a cognitive behavioral program (Orzack & Ross, 2000). Neverthless, it is important to assess the effectiveness of these additional groups and their degree of fit for individual goals. Apparently some of these selfled groups actually reinforce dysfunctional behavior rather than support change (Golden & Cooper, 2003).
The role of medication is an important adjunct to therapy and the choices have burgeoned just as choices on the Internet have in the past 20 years. The selective serotonin reuptake inhibitors have had an impact upon the standard of care for people suffering with hypersexuality, sexual compulsions and the comorbid states that accompany them (Nelson, Soutullo, DelBello & McElroy, 2002). They quiet the obsessional thinking in a remarkable way and give clients a sense of control over their thoughts and behaviors that they have never before experienced and thus provide growth in many areas of their lives. In cases of pedophilia, some patients may benefit from the use of antiandronergic medications which serve to lower the sexual appetite of the paraphilic person (Galbreath et al., 2002).
As we have mentioned above, there are also many comorbid conditions in people who have hypersexual habits on the Internet. It is essential to treat these problems as one would any other person with depression, anxiety or obsessive and compulsive habits. Sobriety from drugs and alcohol is essential. It is our observation that once these comorbid problems are treated and contained over a period of time, perhaps four or five years, the developmental steps that were missed because of drugs, alcohol, sexual abuse and chronic mental and emotional issues will begin to take place, allowing the person to have more resilience and control over their impulses.
Conclusions
We cannot help but wonder what the warrior Gilgamesh would think of the Internet and its possibilities. Could he have limited his sexual exploits to the Internet and been an occasional user or would he have used the Internet to enlarge upon his predatory proclivities? Even though we have evolved from writing on granite walls to watching a small flat screen, the need for sexual expression has remained a powerful force. It is only the venue that separates us from Gilgamesh.
Many of the debates about the Internet have the same tone as when the technology of movies, radios and television burst upon the public. Boundaries all over the world are being broken down; we have the potential to be closer to each other than ever before and perhaps it makes us all uncomfortable, this much intimacy with strangers. Maybe impersonal cybersex becomes an easier substitute.
Our warrior Gilgamesh was a sexual predator, a womanizer, before there were labels for these types of behavior. The Internet merely provides a novel and inventive venue for sexual activity in a way that has not been available before. Some are up to the challenge that the Internet lavishly and seductively offers, and some are not. None of us decide one day to be hypersexual any more than we decide how to be sexual in other realms. However, being aware of the potential for losing control and perhaps being in danger of doing something illegal, it "becomes an individual's responsibility to do something about it so as to ensure that he will not cause problems in the lives of others" (Galbreath et al., 2002, p. 196). By developing treatments and creating social policy to respond to these issues, we are not supporting the behavior; rather we are offering the possibility that the person can accept the responsibility to change these behaviors and find a functional and harmless way to fulfill their sexual and relational needs.
Treatment methodologies, research, taxonomy and social policy regarding the Internet are gaining momentum. The opportunities the Internet provides are developing faster than we can respond to them. However, it is remarkable how much more we know about these issues now and how much more we have to offer. It is often useful, in the course of therapy, to look back with the client to consider how much has changed since they first began the journey of recovery. It is equally important for those of us who are trying to keep up with the Internet, and feel it is out-running us, to also remember how far we have come since the journey began. For those of us who treat these clients and know how hard it is for them to deal with their personal issues, help cannot come soon enough.
Al Cooper, Gale Golden, William L.Marshall
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