Meg Barbor, MPH

October 20, 2017

NEW ORLEANS ― The "playboy era," the sexual revolution, and now, in the current technologic era, sexting. Is it just a harmless form of sexual expression, or is this widely prevalent phenomenon causing irreparable damage among adolescents?

Here at the Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference, Swathi Krishna, MD, discussed the advent of sexting and its potential impact on young people.

The term "sexting" is generally used to encompass a wide variety of digital activities. It is most commonly used to describe sending, receiving, or forwarding sexually explicit messages or images, primarily between mobile phones. The term can also refer to sending sexually explicit messages through digital media such as email, instant messaging, and social media apps, such as Snapchat.

According to Dr Krishna, child and adolescent psychiatry fellow at Emory University in Atlanta, Georgia, sexting is an example of a broad shift in sexual expression, similar to the sexual revolution of the 1960s.

Such shifts have changed the way society views existing models of expression, often with unintended consequences that society subsequently must address.

"We tend to think of this as deviant behavior in children, but I think it's more helpful to think of sexting as somewhat of a natural marriage between what was happening previously in sexual expression, combined with technology," she said. "When we think about these behaviors as more normal than we previously thought, that will help us as doctors and mental health providers to talk more openly with kids and understand that this is going on quite broadly."

In a study published in Sexual Health in 2016, investigators surveyed 5805 single adults aged 21 to 75 years. Twenty-one percent of participants reported sending sexually explicit text messages, and 28% reported receiving such messages. About 30% reported sharing them with an average of three friends. Participants in the study also reported concern about the potential consequences of sexting on their social lives, careers, and psychosocial well-being.

"One thing to highlight is that at least adults will maybe think twice," she noted. "They're aware of the potential consequences of their actions, but this isn't the case in many younger populations."

Risky Behavior

Under federal law, sexually explicit images of minors younger than 18 years are considered child pornography, even if the minors created the images themselves. Many minors are unaware of the legal ramifications of sexting, not to mention the possible social consequences, such as humiliation, bullying, and the negative impact on reputation.

Social consequences are also a significant concern with regard to psychological well-being, because they can lead to suicidal thoughts, depression, social isolation, and negative self-image. "Sometimes, in this age group, talking about the social ramifications may go a lot farther than the legal," she said.

In a 2012 sentinel study of 948 high school students aged 14 to 19 years, 28% of the participants reported sending naked pictures of themselves, or "sexts," through text or email. More than half reported being asked to send a sext of themselves, and 31% reported asking someone else to send a sext. Girls were more than 25% more likely to be asked to send a sext of themselves, and boys were 25% more likely to ask for a sext to be sent than girls.

"So more than half reported being asked to send naked pictures, and a third did it. That's quite alarming," noted Dr Krishna. "This was before Snapchat [an image messaging and multimedia mobile app that can be used to send content that can be quickly deleted after sending], so now this is probably happening at a much higher rate with modern technology and social media."

Only 3% of boys reported feeling bothered at having received a sext request, compared to 27% of girls. "This could highlight a slight victimization risk in high school girls," said Dr Krishna. "They are more bothered but may do it anyway, whereas boys aren't really bothered at all." In the study, sexting behavior peaked at age 16 to 17, then declined.

In a 2014 study published in Sexuality Research and Social Policy, investigators polled college students at a large northeastern university about their behavior when they were in high school. More than half reported sexting as minors. The majority of respondents (61%) were not aware that sending a sexually explicit text constituted engaging in child pornography, a prosecutable offense. Additionally, 59% of respondents said that knowing the legal consequences "would have" or "probably would have" deterred them from sexting, "So we can make a difference," said Dr Krishna.

Sexting behaviors have been correlated with having started dating or having had multiple sex partners in high school and with using alcohol or drugs before sexual activity. Suggested, though unproven, are correlations between sexting and other risky sexual behavior, such as engaging in sex without a condom and having multiple partners.

Bad Decisions

Caitlin Costello, MD, child and forensic psychiatrist at the University of California, San Francisco, who co-chaired the session, said that cognitive maturity is attained at around age 16. But psychosocial maturity ― the ability to understand risk, resist impulses, resist peer influence, and think about the future instead of the present ― does not start to mature until age 15. Thus, 15-year-olds have the same level of psychosocial maturity as 10-year-olds.

"So in that 15 to 16 age range, you have a group of adolescents who are cognitively very mature but who are making very bad decisions, because that psychosocial maturity hasn't really started to pick up yet. These are the adolescents that we're worried about. Are they likely to be making good decisions online? Probably not," she said.

According to Dr Costello, consultation with adults is one of the factors that lead to mature decision-making among adolescents. Mental health clinicians can serve as these advisors, potentially mitigating risks or providing help for adolescents who have engaged in behaviors that they have subsequently come to regret.

Healthcare providers should consider the risk of sexual victimization associated with sexting, Dr Krishna said. A recent New York Times article reported that more than half of adolescent girls and boys had dated someone who had tried to monitor or control them through the use of digital content (ie, by spreading rumors, posting embarrassing or hurtful messages, or making threats).

More than one third experienced sexual coercion via digital means, including being pressured to have sex, receiving unwanted sexual images, being urged to send sexual images, or by someone sending nude pictures of them to others without permission.

She urged clinicians to ask about the online activity of teen patients and to tell parents to ask about and talk directly about online risks with their adolescents. Questions such as, "How would you feel if your brother/teacher/coach saw what you were sending?" can be helpful.

She advised that patients be educated about the legal and unintended social consequences, such as losing power over images of one's own body. "Open that dialogue for teenagers," she said.

"We don't know if it's getting better. It's a relatively new area of study, but we're talking about it more as normative behavior, and this could be helping," said Dr Krishna. Counselors and teachers in high schools are now addressing the topic with students, which was not the case a few years ago.

"These are uncomfortable topics with teenagers and parents, but open dialogue is really important. It's been found that talking about suicide doesn't cause someone to commit suicide. It's the same here. If you talk to them about sexting, it doesn't mean they're going to start sexting," she said.

Dr Krishna and Dr Costello have disclosed no relevant financial relationships.

Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference. Presented October 19, 2017.


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