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You've Got Mail (2010)

Rietmeijer, Cornelis A. MD, PHD, MSPH*†

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Sexually Transmitted Diseases: August 2010 - Volume 37 - Issue 8 - p 486-487
doi: 10.1097/OLQ.0b013e3181e5e6db
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It has been 10 years since Klausner et al. first reported on a syphilis outbreak related to finding sex partners on the Internet. In addition to describing a string of chat room-related cases of early syphilis among men who have sex with men (MSM), they also found that during the outbreak, early-stage syphilis cases were significantly more likely than controls to have met their sexual partners online.1 In an accompanying article, McFarlane et al. found that the practice of online sex seeking was already particularly common among MSM at the time and that having sex with partners found on the Internet was associated with risk factors for sexually transmitted disease (STD)/human immunodeficiency virus (HIV) transmission.2 In the decade since the publication of these 2 reports, much has been learned about the interface between sexual behaviors and the Internet. What was an apparently small step for MSM, turned out to be quite the leap for the way partnerships can be initiated, and using the Internet is rapidly becoming an important means to find social, romantic, and sexual partners, especially among older adults.3

Nonetheless, the perception that the Internet is a particularly risky place to find sex partners has prevailed. Indeed, at the writing of this editorial, the social networking site Facebook has just been implicated with the rise of syphilis in a number of UK counties4 and, back in the United States, legislation has been proposed in the state of Pennsylvania to outlaw “sexting,” i.e., sending nude pictures of oneself to partners and friends by mobile telephones.5

However, the evidence that online dating is risky is based largely on circumstantial evidence. Indeed, there are little scientific data to support the suggestion that looking for sex partners online is riskier than doing so in a bar, a bath house, or the annual staff party. It all depends, of course, on the prior risk behaviors of the partners who are met in these places and the sexual networks they belong to. It is conceivable that the dynamics of online partnering, given its intensity and its potential overlap of sexual and social networks, may lead to higher than average risk for STD and HIV, but ultimately we should be able to provide empirical data that this is, in fact, so. Yet, the only study that has investigated the relationship between online partnering and the prevalence of STD (chlamydia or gonorrhea), did not find such an association among MSM or heterosexual women and actually found a negative association, i.e., a protective effect among heterosexual men.6 There may have been biases to this study to explain these findings,7 but alternative explanations should be explored.

Consider the lengthy online courtship before starting an offline romantic relationship as enacted to popular acclaim by Tom Hanks and Meg Ryan in “You've Got Mail” (1998). (As an interesting aside, and adding to the movie's intrigue, the film's protagonists revealed more of their true characters in their virtual communication than in their personal interactions before they become aware of their actual identities.) The film's latency period between virtual and factual dating has a corollary in a study by Padgett who surveyed a large group of women who had used online personal advertisements to find romantic partners. This study found that, before face-to-face meeting, a large number of women reported a high frequency and high intensity of e-mail communication to negotiate safety, boundaries, sexual preferences, STDs, and condom use. On the other hand, perhaps due to a heightened sense of intimacy, a third of surveyed women had sexual intercourse at their first face-to-face encounter, and the majority of them did not use condoms at the occasion.8

The potential for online communication to discuss and negotiate anticipated sexual behavior was also found in a study among MSM that we conducted a few years ago in the Denver STD clinic. In this study, we found that MSM who recruited sex partners online reported discussing HIV serostatus with their prospective partners 4 times more frequently than MSM recruiting sex partners in bath houses.9 This finding may be of particular importance given that “serosorting” (i.e., selecting sex partners on the basis of identical HIV serostatus) is gaining popularity, especially among HIV-infected MSM, and is also increasingly debated as a risk reduction strategy in the public health context.10

There may be a discrepancy between what people tell us they do and what they do in reality, but these findings do suggest that online sex partnering is a complex behavior that may lead to both risk enhancing and risk reducing outcomes. As the Internet and other new media are increasingly used for the purpose of finding romantic/sex partners, more research is needed to better understand the complexities of these behaviors and to better guide our prevention efforts.

From a public health perspective, online partnering has additional, albeit nonintentional advantages that are highlighted in the article by Ehlman et al. in this issue of Sexually Transmitted Diseases.11 In a study of an Internet partner notification (IPN) program, the authors evaluated 361 syphilis cases that were reported to the District of Columbia Department of Health between January 2007 and June 2008. Cases were predominantly male with male partners, and approximately a third reported using the Internet to meet sex partners. Unlike bath houses and bars where most sexual encounters among MSM are anonymous, Internet partnering usually requires some form of identification to allow prospective partners to interact online and ultimately offline, such as an e-mail address or a website screen name (a.k.a “handle”). Thus, these contacts are called “pseudonymous” rather than anonymous and, as elegantly demonstrated by Ehlman et al.,11 this information can be used for partner notification purposes. Indeed, while using the Internet improved the number of case investigations by only 14%, these cases provided an additional 75% of partners investigated, 26% of partners examined, and 8% of additional partners treated over traditional methods. Moreover, even though the manuscript did not present a cost-effectiveness analysis, the use of e-mail and chat room outreach to provide partner notification appears to be very efficient as multiple cases can be worked simultaneously by a single case worker in a single location, rather than traditional PN where case workers spend many hours on the phone or in the community trying to contact an identified partner. In fact, while there may be jurisdictional barriers, technically IPN could be provided state-wide or even across state lines as there are no limits to the reach of the Internet—thus, making this intervention even more efficient. Of course, IPN cannot and should not replace traditional PN, but it can be an effective and efficient adjunct to increase the number of individuals who are notified of exposure to an STD, and the authors make a strong case why IPN should become a routine part of our public health STD prevention armamentarium.


1. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. JAMA 2000; 284:447–449.
2. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. JAMA 2000; 284:443–446.
3. Reuters. Time constraints boost popularity of online dating. 2010. Available at:
4. Facebook “linked to rise in syphilis.” Telegraphcouk. 2010. Available at:
5. Grove Sexting Bill Approved by House Judiciary Committee. Available at:
6. Al-Tayyib AA, McFarlane M, Kachur R, et al. Finding sex partners on the internet: What is the risk for sexually transmitted infections? Sex Transm Infect 2009; 85:216–220.
7. Aral SO, Manhart LE. “Someone naughty for tonight”: Sex partner recruitment venues and associated STI risk. Sex Transm Infect 2009; 85:239–240.
8. Padgett P. Personal safety and sexual safety for women using online personal ads. Sex Res Soc Policy 2007; 4:27–37.
9. Rietmeijer CA, Lloyd LV, McLean C. Discussing HIV serostatus with prospective sex partners: A potential HIV prevention strategy among high-risk men who have sex with men. Sex Transm Dis 2007; 34:215–219.
10. CDC. Meeting Summary: “Consultation on Serosorting Practices among Men who Have Sex with Men.” 2009. Available at:
11. Ehlman DC JM, Saenz G, Novak D, et al. Evaluation of an innovative internet-based partner notification program for early syphilis case management, Washington, DC. January 2007–June 2008. Sex Transm Dis 2010; 37:478–485.
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