Sexuality, Contraception, and the Media

Early sexual activity among teenagers can be problematic. According to the 2009 Youth Risk Behavior Survey, 46% of all high school seniors have had sexual intercourse, and 14% have had 4 partners or more.¹  Although pregnancy rates have generally been decreasing since 1991, the United States still has the highest teen pregnancy rate in the Western world,²  and for the first time in 15 years, the birth rate increased 3% from 2005 to 2006.³  Early intercourse also increases the risk of contracting a sexually transmitted infection (STI), including HIV, and adolescents have one of the highest STI rates of any age group.⁴  Although 15- to 24-year-olds account for only one-quarter of the sexually active population in the United States, they contract nearly half of all new STIs every year.⁴  A recent study by the Centers for Disease Control and Prevention revealed that 1 in 4 teenagers has had an STI.⁵  Ten percent of young women who had first had sex in their teenage years reported that their first time was involuntary, and the younger they were, the more likely that was the case.⁶ 

American children and teenagers spend more than 7 hours/day with a variety of different media.⁷  Those media are filled with sexual messages and images, many of which are unrealistic.²  On television (TV), which remains the predominant medium in terms of time spent for all young people, more than 75% of prime-time programs contain sexual content, yet only 14% of sexual incidents mention any risks or responsibilities of sexual activity.^8,9  Talk about sex on TV can occur as often as 8 to 10 times per hour.¹⁰  Between 1997 and 2001 alone, the amount of sexual content on TV nearly doubled.⁹ 

So-called reality TV has also entered the picture. In 1997, there were only 3 reality dating shows; by 2004, there were more than 30.¹¹  Some shows, such as Temptation Island, bring participants together for the sole purpose of seeing who “hooks up.” A study of college students revealed that viewing such shows correlated with beliefs in a double standard—that men are sex driven and that men and women are sexual adversaries.¹¹  It is interesting to note that the less sexually experienced students were more likely than sexually experienced students to be watching reality shows, which suggests the importance of such programs for sexual socialization.^12,13 

In addition to TV, other media provide frequent messages about sexual behavior.

• Music continues to be a major source of sexual suggestiveness. In 1 study, 40% of lyric lines contained sexual material, and only 6% contained healthy sexual messages.¹⁴  An analysis of the 279 most popular songs in 2005 revealed that 37% contained sexual references and that degrading sexual references were common.¹⁵ 

• Virtually every R-rated teen movie since the 1980s has contained at least 1 nude scene and, often, several instances of sexual intercourse (eg, the American Pie movie series).¹⁶  Teen movies also contain distorted views of romance and normal adolescent sexuality.^16,–,18 

• Teen magazines are popular with preadolescent and adolescent girls and devote an average of 2.5 pages per issue to sexual topics.¹⁹  Coverage of sex as a health issue in magazines is more common than on TV, but the overarching focus seems to be on deciding when to lose one's virginity.^12,20 

• The Internet has become an abundant source of both sexual information and pornography that cannot be regulated.^21,22  Online pornography is now a $1 billion industry.¹²  In a national sample of 1500 10- to 17-year-olds, nearly half of the Internet users had been exposed to online pornography in the previous year.²³  In addition, unwanted sexual solicitations and harassment are not uncommon,²⁴  although they may not be as frequent as parents fear.²⁵ 

• Social networking Web sites and home pages enable teenagers to present themselves publicly, sometimes in sexually suggestive ways.^12,26  One study of 233 teen home pages revealed that nearly 10% mentioned sex, and girls were 3 times more likely to do so than boys.²⁷  A recent study of 500 publicly available MySpace profiles revealed that nearly one-quarter of them referenced sexual behaviors.²⁸  Also, a national survey of nearly 1300 teenagers and young adults revealed that 20% reported having sent or posted nude pictures or videos of themselves (“sexting”).²⁹ 

• Advertisements often use sex to sell. Women are as likely to be shown in suggestive clothing (30%), partially clad (13%), or nude (6%) as they are to be fully clothed.³⁰  As one expert noted, “When sexual jokes are used to sell everything from rice to roach-killer, from cars to carpets, it's hard to remember that sex can unite two souls, can inspire awe. Individually, these ads are harmless enough, sometimes even funny, but the cumulative effect is to degrade and devalue sex.”³¹  Advertisements for erectile dysfunction drugs are ubiquitous. In the first 10 months of 2004, the makers of these drugs spent nearly $350 million on advertising.³²  At the same time, advertisements for birth control products are rare.² 

Because so many sex education programs have recently been focused on abstinence only, the media have arguably become one of the leading sex educators in the United States today.²  Adolescents frequently cite the media as a source of sexual information.²  For example, in a national survey the media rivaled parents and schools as a source of information about birth control.³³  The media are powerful sources for behavioral “scripts” concerning sexual situations, especially for inexperienced teenagers.^2,34  Yet, parents and legislators fail to understand that although they may favor abstinence-only sex education (despite the lack of any evidence of its effectiveness),³⁵  the media are decidedly not abstinence only. In fact, the United States has some of the most sexually suggestive media in the world.²  American media make sex seem like a harmless sport in which everyone engages, and results of considerable research have indicated that the media can have a major effect on young people's attitudes and behaviors.^12,–,18  In fact, the media may function as a “superpeer” in convincing adolescents that sexual activity is a normative behavior for young teenagers.^2,36,37  In a survey of 2100 11- to 17-year-old girls, only the 11-year-olds reported that they did not feel pressure from the media to begin having sex.³⁸ 

Numerous studies have delineated the media's powerful influence on adolescents' sexual attitudes, values, and beliefs.^2,39,–,42  Unlike the media violence research literature, in which some 2000 studies exist, there have been only a handful of studies on the effects of sexual content on actual behavior. At least a dozen correlational studies have examined the relationship between the amount of sexual content viewed on TV and early onset of sexual intercourse.^43,–,53  The most recent studies have revealed that (1) listening to sexually degrading lyrics is associated with earlier sexual intercourse,^40,53  (2) black female teenagers' exposure to rap music videos or X-rated movies is associated with the likelihood of multiple sexual partners or testing positive for an STI,⁴⁹  (3) teenagers whose parents control their TV-viewing habits are less sexually experienced,^51,52  and (4) exposure to sexual content in the media is a significant factor in the intention to have sex in the near future.^52,–,54 

Nine longitudinal studies have given potential answers to the question of whether sexy media contribute to early sexual activity, and the answer seems to be “yes.”^41,55,–,62  Results of 7 of these studies have shown that exposure to sexual content in TV and other media in early adolescence— particularly for white teenagers—can as much as double the risk of early sexual intercourse. Adolescents whose parents limit their TV-viewing are less likely to engage in early sex.⁵⁸  Younger children who have viewed adult-oriented TV shows and movies are more likely to begin having sexual intercourse earlier.⁶¹  The study samples together total nearly 10 000 teenagers nationwide, and the most ambitious studies included other media such as movies, music, and magazines.⁵⁷  In addition, a recent study revealed that early exposure to sexual content doubled the risk of teen pregnancy.⁶⁰  Clearly, the media play a major role in determining whether certain teenagers become sexually active earlier rather than later,⁶³  and sexually explicit media may be particularly important.^41,64 

The United States is the only Western nation that still subscribes to the dangerous myth that giving teenagers access to birth control—and media represent a form of access—will make them sexually active at a younger age. Other countries advertise birth control products widely and have a much lower rate of teen pregnancy.^12,16  Although the teen birth rate had been declining in the United States up until 2005–2006, it has declined just as much or more in other countries. A recent study revealed that 86% of the recent decline in teen pregnancies could be attributed to increased contraceptive use, and only 14% was attributable to increased abstinence.⁶⁵  The recent 3% increase in teen births could be a “blip,” or it could be attributable to an increase in abstinence-only sex education and the concomitant reduction in accurate information about contraception.^66,–,68 

Eight peer-reviewed, controlled clinical trials have revealed that giving teenagers freer access to condoms does not increase their sexual activity or encourage virginal teenagers to begin having sex, but it does increase the use of condoms among those who are already sexually active.^69,–,76  Advertising condoms, birth control pills, and emergency contraception on TV and radio could further decrease the teen pregnancy rate. Yet, several networks refuse such advertisements.^77,78 

Telling teenagers, “Wait until you're older to begin having sex, but if you can't wait, use birth control” is a double message. But, it is a double message that every teenager in America can understand and benefit from, and it is consistent with normal adolescent psychology, because it acknowledges that adolescents do not always listen to their elders.²  In 2007, both CBS and FOX refused a condom advertisement as “inappropriate” because it mentioned preventing pregnancy rather than preventing HIV/AIDS.⁷⁸  Advertisements for emergency contraception are virtually nonexistent on American TV, despite the fact that every year, American women have 3 million unplanned pregnancies, which lead to 1.3 million abortions. Advertising for emergency contraceptives could be an important way to reduce the number of abortions in the United States.⁷⁹ 

The media can be powerful vehicles for sexual health education. Socially responsible messages can be embedded into mainstream programming—a practice dubbed “entertainment-education” or “edutainment.”³⁹  Collaborative efforts between the Kaiser Family Foundation and the producers of the hit TV show ER resulted in successful story lines about the risks of human papillomavirus and the usefulness of emergency contraception.⁸⁰  In 2002, Friends aired an episode about condoms, and 27% of a national sample of teenagers saw the program; many of them reported that they talked about condom effectiveness with an adult as a direct result of the episode.⁸¹  In 2008, a study showed that viewers of a Gray's Anatomy episode learned that HIV-positive women could still have HIV-negative infants.⁸²  The Soap Opera Summit in Hollywood and international efforts to embed story lines into popular soap operas are other examples of prosocial efforts. The media giant Viacom and the Kaiser Family Foundation have launched an ambitious project to produce $120 million worth of public service announcements and print advertisements concerning HIV/AIDS and to encourage Viacom producers to include story lines in their TV shows that will raise AIDS awareness.⁸³  Such efforts demonstrate that the entertainment industry can be receptive to outside input and that healthier content can be introduced into mainstream media without government pressure or the threat of censorship.

Mass media have also been used proactively to increase parent-child communication about sex. In North Carolina, a mass media campaign using billboards and radio and TV public service announcements delivered the message, “Talk to your kids about sex. Everyone else is.” In follow-up research, exposure to the message correlated significantly with parents talking to their children about sex during the following month.⁸⁴ 

1. Pediatricians can help parents and teenagers to recognize the importance of the media by asking at least 2 media-related questions at each well visit⁷⁷ : (1) How much time do you spend daily with entertainment media? and (2) Is there a TV set or Internet access in your bedroom? Research has shown that bedroom TVs are associated with greater substance use and sexual activity by teenagers.⁸⁵  A recent study revealed that office-based counseling is effective and could result in nearly 1 million more children and adolescents adhering to the American Academy of Pediatrics recommendation to limit media time to less than 2 hours/day.⁸⁶ 

2. Pediatricians should counsel parents to recognize the importance of the media, exert control over their children's media choices, keep their children's bedrooms free of TVs and Internet connections, and avoid letting their children see PG-13– and R-rated movies that are inappropriate for them.^61,87,88  Pediatricians and parents also need to be aware of the importance of social networking sites and how they work so that they can effectively counsel children and adolescents about them.⁸⁹ 

3. Pediatricians and child advocacy groups should encourage the entertainment industry to produce more programming that contains responsible sexual content and that focuses on the interpersonal relationship in which sexual activity takes place (Table 1). One way to do this would be to hold annual seminars for writers, producers, and directors in Hollywood, perhaps in cooperation with other groups. Similarly, Madison Avenue and advertisers need to be encouraged to stop using sex to sell products. Educational seminars might help to achieve this goal.

4. Pediatricians should urge schools to insist on comprehensive sex education programs (to counter the influence of sexually suggestive and explicit media) that incorporate basic principles of media literacy into their sex education programs. Studies have shown that effective media literacy programs can be protective against unhealthy media effects.^90,91  Federal money should be spent on comprehensive sex education programs but not on abstinence-only programs, which have been found to be ineffective.^{35,65,–,68,92,–,94} 

5. Pediatricians should urge the broadcast industry to air advertisements for birth control products. The federal government also needs to encourage the advertising of birth control, especially emergency contraceptives.

6. Pediatricians should urge the broadcast industry to limit advertisements for erectile dysfunction drugs until after 10 pm.

7. Pediatricians should urge the broadcast media to include healthy messages about sex and sexuality in their programming, especially in media that children and early teenagers use most frequently.⁹⁵ 

8. Pediatricians, the broadcast industry, the federal government, and private foundations should support further research into the impact of sexual content in the media on children's and adolescents' knowledge and behavior.⁹⁶  A national task force on children, adolescents, and the media should be convened by child advocacy groups in conjunction with the Centers for Disease Control and Prevention and/or the National Institutes of Health to study the issue of children, adolescents, and media, devise new research, locate funding sources, and make recommendations to Congress, the broadcast industry, and the American people.

Victor C. Strasburger, MD

Gilbert L. Fuld, MD, Chairperson

Deborah Ann Mulligan, MD, Chair-elect

Tanya Remer Altmann, MD

Ari Brown, MD

Dimitri A. Christakis, MD

Kathleen Clarke-Pearson, MD

Benard P. Dreyer, MD

Holly Lee Falik, MD

Gwenn S. O'Keeffe, MD

Kathleen G. Nelson, MD

Victor C. Strasburger, MD

Regina M. Milteer, MD

Donald L. Shifrin, MD

Michael Brody, MD – American Academy of Child and Adolescent Psychiatry

Brian Wilcox, PhD – American Psychological Association

Jane D. Brown, PhD

Gina Ley Steiner

Veronica Laude Noland [email protected]