PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1116-1119

Exposure to X-Rated Movies and Adolescents' Sexual and Contraceptive-Related Attitudes and Behaviors

Gina M. Wingood, ScD, MPH^*, Ralph J. DiClemente, PhD^{*, , §}, Kathy Harrington, MPH, Suzy Davies, DrPH, MPH, Edward W. Hook III, MD^¶, and M. Kim Oh, MD^#

From the ^* Rollins School of Public Health, Department of Behavioral Sciences and Health Education;  Emory University School of Medicine, Department of Pediatrics; ^§ Emory University School of Medicine, Department of Medicine (Infectious Diseases); ^¶ School of Public Health, Department of Health Behavior, University of Alabama, Birmingham, Alabama;  School of Medicine, Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham, Alabama; and ^# School of Medicine, Department of Pediatrics, University of Alabama, Birmingham, Alabama.

	ABSTRACT

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Objectives.  To examine the association between exposure to X-rated movies and teens' contraceptive attitudes and behaviors.

Methods.  Black females, 14 to 18 years old (n = 522) were recruited from adolescent medicine clinics, health departments, and school health clinics.

Results.  Exposure to X-rated movies was reported by 29.7% of adolescents. Exposure to X-rated movies was associated with being more likely to have negative attitudes toward using condoms (odds ratio [OR]: 1.4), to have multiple sex partners (OR: 2.0), to have sex more frequently (OR: 1.8), to not have not used contraception during the last intercourse (OR: 1.5), to have not used contraception in the past 6 months (OR: 2.2), to have a strong desire to conceive (OR: 2.3), and to test positive for chlamydia (OR: 1.7).

Conclusions.  Additional research is needed to understand the impact of X-rated movies on adolescents' sexual and contraceptive health.  Key words:  media, adolescents, sexual behaviors, contraception.

Adolescents are a population at considerable risk of sexually transmitted diseases (STD), human immunodeficiency virus (HIV), and unintended pregnancy. Identifying the factors that are associated with sexual risk taking among adolescents is critical for the development of effective STD/HIV and pregnancy prevention programs.¹ A significant body of literature exists documenting the diverse array of psychosocial factors associated with engaging in risky sexual and contraceptive behaviors, however, few studies have examined the influence of one of the most ubiquitous social influences; namely, the influence of media.²

During the past few years, significant concern has been raised regarding adolescents' exposure to sexually explicit movies (ie, X-rated films) and the potential impact on adolescents' sexual attitudes and behaviors.³ Previous research in experimental studies have demonstrated that compared with individuals not exposed to X-rated films, individuals exposed to X-rated films are more accepting of premarital sex, more likely to overestimate the prevalence of sexual activity, more likely to regard sex without emotional commitment as important, and less likely to value the concepts of marriage and monogamy.^4,5 Unfortunately, there is a dearth of research examining the behavioral effects of exposure to sexually explicit media, particularly as it effects adolescents' contraceptive behaviors. Practically no studies have been conducted with black female adolescents, a population that is disproportionately affected by the HIV, STD, and unintended pregnancy epidemics, compared with males, teens, and adolescent females from other ethnic backgrounds.⁶

The aim of the current study was to examine the association between exposure to X-rated movies and black adolescent females' sexual and contraceptive attitudes and behaviors.

	METHODS

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From December 1996 through April 1999, project recruiters screened teens in adolescent medicine clinics, health department clinics, and school health classes to determine their eligibility for participating in an HIV/STD prevention study. Adolescents were eligible to participate in the study if they were black females, between the ages of 14 and 18 at the time of enrollment, were sexually active in the previous 6 months, and provided written informed consent. Six hundred and nine teens were eligible. Of the eligible adolescents, 522 (85.7%) agreed to participate in the study. The majority of eligible teens who did not participate in the study were unavailable because of conflicts with their employment schedules. The study protocol was approved by the University's Committee on Human Research before implementation.

Data Collection

Data collection was conducted at the Family Medicine Clinic and consisted of 3 components: a self-administered survey that assessed sociodemographic characteristics, psychosocial factors, media exposures, and attitudes toward condom and contraception use; a structured personal interview that assessed sexual and contraceptive risk behaviors; and self-obtained vaginal swab specimens for STD analysis.

The self-administered survey was conducted in a group setting with monitors providing assistance to adolescents with limited literacy and helping to ensure confidentiality of responses. Subsequently, adolescents completed a face-to-face interview that assessed sexual risk behaviors. The interview was administered by trained black female interviewers in private examination rooms. This data collection strategy has been suggested as an appropriate methodology for obtaining reliable and valid data related to sexual behaviors in black adolescent populations.⁷ Other efforts designed to make the environment more suitable for black female adolescents included having black female study greeters who welcomed adolescents into the Family Medicine Clinic and using study logos that were culturally and gender-relevant for black female populations. On completing their interview, adolescents were asked to provide vaginal specimens for STD testing. Adolescents were reimbursed $20 for their participation.

Laboratory Methods

Adolescents were evaluated for 3 prevalent sexually transmitted diseases: Nesseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis.^8-11 For specimen collection, each adolescent was asked to obtain 2 vaginal specimens by sequentially inserting 2 sterile dacron-tipped swabs ~2.5 inches or as far as comfortable into the vagina, rotating them for 15 to 30 seconds, and removing them.^7-11 Following specimen collection, the first swab was placed in a specimen transport tube for subsequent ligase chain reaction (LCR) testing (Abbott LCx Probe System for N gonorrhoeae and C trachomatis assays) and the second swab was used to inoculate culture medium for T vaginalis (InPouch TV test; BioMed Diagnostics Inc, Santa Clara, CA). Immediately after collection, the specimens for gonorrhea and chlamydia testings were refrigerated at 2 to 8°C for no more than 48 hours until they could be transported to the laboratory where swabs were tested. Vaginal specimen were tested for chlamydia and gonorrhea DNA by ligase chain reaction (LCR) according to the manufacturer's directions.^9,10 Cultures for T vaginalis were held at room temperature until received in the laboratory. In the laboratory, T vaginalis cultures were incubated at 37°C and examined daily by light microscopy (magnification x 100) for 5 days.¹¹ Cultures were positive based on the identification of motile trichomonads within the pouch. All STD assays were conducted at the University of Alabama Division of Infectious Diseases STD Research Laboratory.

Independent Variables

The survey assessed sociodemographic characteristics, parental monitoring, and exposure to X-rated movies. These variables are described below.

Sociodemographics Sociodemographic variables assessed include the adolescents' age, highest grade completed in school, history of school expulsion, hours worked per week, relationship status, involvement in social organizations outside of school, whether they were parttime or fulltime students, and whether the family received public assistance.

Parental Monitoring Parental monitoring was assessed by asking adolescents whether they resided in a 1- or 2-parent family and whether the mother (as opposed to a sibling or another relative) was most likely to know of the adolescents' whereabouts.

Exposure to X-Rated Movies Adolescents were asked how many movies (in movie theaters or on VCR tapes) they had seen in the past 3 months that were 1) rated PG or PG-13; 2) R-rated; or 3) X-rated. The primary independent variable, exposure to X-rated movies, was determined based on whether adolescents reported having viewed an X-rated movie in the past 3 months.

Outcomes

Attitudes Toward Condoms A Condom Impact Scale ( = 0.72) was used to assess adolescents' perceptions about how condoms may affect their sexual relationship. The Condom Impact Scale consists of 5-items, such as, "If I asked my partner to use a condom he would think I didn't trust him". Responses to each item were scored using a 5-point Likert scale ranging from "Strongly Disagree" to "Strongly Agree." Responses to each of the 5 items were summed, creating a scale score. Higher scale scores indicated that adolescents were more likely to perceive that using condoms adversely impacted their sexual relationship.

Sexual Behaviors and STD Status Sexual behaviors assessed include whether adolescents had multiple sex partners in the previous 6 months, the frequency of having sex in the past 30 days, and whether they tested positive for an STD.

Contraceptive Behaviors Contraceptive behaviors assessed include whether contraception was used the last time they had sex and whether contraception was used during the last 6 months.

Desire to Conceive Desire to conceive was assessed by a single item, "How much do you want to be pregnant at this time?" and scored using a 5-point visual analog scale ranging from "very much" to "not at all". Adolescents responding "very much" were categorized as having a strong desire to conceive.

Data Analysis

The data analysis was comprised of several sequential steps. First, descriptive statistics were used to describe adolescents' exposure to X-rated movies. Next, to identify potential covariates we compared adolescents' exposed to X-rated movies with adolescents having no exposure with regards to sociodemographic characteristics and parental monitoring. In subsequent bivariate analyses, we compared adolescents exposed to X-rated movies with adolescents having no exposure with respect to their sexual and contraceptive-related attitudes, behaviors, and STD status. Finally, covariates and outcome variables significantly associated with exposure to X-rated movies in the bivariate analyses (P < .05) were included in logistic regression analyses.¹² Logistic regression analyses examined the associations between adolescents' exposure to X-rated movies and their sexual and contraceptive-related attitudes, behaviors, and STD status. Logistic regression analyses calculated adjusted odds ratios, controlling for covariates, their 95% confidence intervals and corresponding P values.

	RESULTS

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Between December 1996 and April 1999, 522 single, black females 14 to 18 years old participated in the study. Exposure to X-rated movies was reported by 29.7% of adolescents. Analyses describing adolescents' exposure to movies are displayed in Table 1.

Sexual and contraceptive risk behaviors and STDs were prevalent among this sample. Not using contraception at last intercourse and not using contraception during the past 6 months was reported by 14.2% and 44.1% of teens, respectively. Approximately 10% of adolescents reported having multiple sexual partners in the previous 6 months. Additionally, this sample had a high prevalence of STDs. The prevalence of C trachomatis, T vaginalis, and N gonorrhoeae was 17.5%, 12.9% and 5.2%, respectively. Overall, 28% had 1 or more STDs (5.3% were diagnosed with mixed STD infections).

In bivariate analyses, exposure to X-rated movies was associated with having negative attitudes regarding contraception use, engaging in contraceptive risk practices, and having a strong desire to conceive. Additionally, several differences were observed in bivariate analyses comparing adolescents exposed to X-rated videos with adolescents not exposed with respect to sociodemographic characteristics and parental monitoring. Exposure to X-rated movies was associated with residing in a single-parent family and being monitored by someone other than one's mother. Therefore, these variables were entered into the logistic analyses as covariates. Exposure to X-rated movies was not related to any other sociodemographic characteristics (ie, age).

In logistic analyses, exposure to X-rated movies was associated with being 2.0 times more likely to have multiple sex partners, 1.8 times more likely to have sex more frequently, 1.5 times more likely to have not used contraception during the last intercourse, 2.2 times as likely to have not used contraception in the past 6 months, and more than twice as likely to have a strong desire to conceive. Exposure to X-rated movies was marginally associated with being 1.4 times more likely to have negative attitudes toward using condoms. Most important, exposure to X-rated movies was associated with being 1.7 times more likely to test positive for chlamydia (Table 2).

	DISCUSSION

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This is one of the first studies to empirically examine the association between exposure to X-rated movies and adolescents' STD/HIV sexual and contraceptive attitudes, behaviors, and most importantly, their STD status. In this study, adolescents exposed to X-rated movies were more likely to have attitudes nonsupportive of STD/HIV prevention, to engage in STD/HIV sexual risk behaviors, and to engage in contraceptive risk practices; these adolescents were more than twice as likely to have a strong desire to conceive and were more than one and a half times as likely to test positive for chlamydia.

Several theories may assist in explaining the study results. Exposure to X-rated movies illustrating sexually explicit, yet consensual relationships, and having few, if any, pregnancy prevention messages may foster adolescents' attitudes, beliefs, and desires supportive of conception.³ Alternatively, exposure to sexually explicit X-rated films that rarely show contraceptive or STD preventive behaviors or the potential long-term adverse impact of sexual behavior, may influence adolescents attitudes and behaviors about pregnancy and STDs by modeling these unhealthy practices.¹³ Moreover, adolescents may be more vulnerable to the sexual imagery and messages depicted in X-rated movies given their limited sexual experiences, their greater perception of the prevalence of risky sexual behavior among adolescents, and the private nature of sex that confines adolescents from typically observing these behaviors. Similarly, adolescents who have been exposed to violent imagery and messages in the movies are more prone to violence, compared with adolescents who aren't exposed to such media.¹⁴

Limitations

This study has several methodologic limitations. Foremost, this study uses a cross-sectional research design that precludes the determination of a causal direction between exposure to X-rated movies and risky sexual behaviors, contraceptive practices and STDs. Future research examining the impact of media exposure on adolescents' sexual and contraceptive beliefs, behaviors and STDs would benefit from using longitudinal research designs. Second, the sample was limited to black female adolescents. Thus, the findings from this sample may not be generalizable to other racial/ethnic groups or males. Additionally, we do not know the circumstances under which adolescents reported viewing X-rated movies (ie, with their partners). Future research should examine the social context under which these movies were viewed.

	CONCLUSIONS

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These findings have significant policy implications. The American Academy of Pediatrics has proposed limiting adolescents' access to sexually explicit media.¹⁵ These recommendations include enforcing the age limitation required for attending, renting, or purchasing X-rated movies and educating parents about the effects of viewing sexually explicit media on adolescents' sexual attitudes and behaviors. The study findings have important implications for pediatric practice. Pediatricians may want to evaluate and counsel families about the role of media on adolescents' health. This can be conducted in several ways such as: 1) using The Media History Form developed by the American Academy of Pediatrics to better document and understand an adolescents or a family's media use habits; 2) providing guidance about media use in the home to parents and children during pediatric visits; and 3) correlating health or behavioral concerns with media use (ie, adverse sexual health consequences). In addition to educating families, pediatricians are ideally suited to educate communities, schools, and advocacy groups about the public health risks associated with media.

Additionally, public health practitioners should collaborate with movie producers to develop public service announcements that emphasize healthy relationships, a strong self-esteem, responsible sexuality, pregnancy prevention, as well as abstinence.¹⁵ Network executives continue to cite fear of adverse public response, despite numerous polls which show that a large majority of the American public favors contraceptive advertising and responsible portrayal of sexuality in the media.¹⁷ Future research examining the impact of exposure to X-rated movies as well as other sexually explicit media on adolescents' sexual and contraceptive attitudes and behaviors is urgently needed.

	ACKNOWLEDGMENTS

This study was supported by a grant from the Center for Mental Health Research, National Institute of Mental Health (1R01 MH54412).

We thank Dr. Jane R. Schwebke for provision of cultures for T vaginalis and Kim Smith, MT (ASCP), for assistance and oversight of testing for N gonorrhoeae and C trachomatis.

	FOOTNOTES

Received for publication May 17, 2000; accepted Dec 7, 2000.

Reprint requests to (G.M.W.) Rollins School of Public Health, BSHE, 1518 Clifton Rd, NE, Room 548, Atlanta, GA 30322. E-mail:gwingoo{at}sph.emory.edu

	ABBREVIATIONS

STD, sexually transmitted diseases; HIV, human immunodeficiency virus.

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