Worries about the influences that media may have on young people’s sexual knowledge, attitudes, and behaviors range back to the early days of motion pictures. The nickelodeon allowed anyone with 5¢ to view images that they might not see in the course of their everyday experience, short films of burlesque strippers, bare-breasted natives of the South Pacific or Africa, and even a remarkably salacious Kiss made by Thomas Edison, the staid inventor of motion picture technology. The medical community began voicing its concern about the effects that entertainment media may have on sexual activity nearly 3 decades ago. After the 1972 Surgeon General’s report Television and Growing Up: The Impact of Televised Violence1 and a watershed 1975 review article on media violence in the Journal of the American Medical Association,2 the American Medical Association House of Delegates passed 2 media-related resolutions, one calling media violence “an environmental risk factor threatening the health and welfare of young Americans, indeed our future society”3 and another stating their opposition to “television programming that is sexually suggestive or pornographic.”4
The American Academy of Pediatrics (AAP), now the recognized leader among medical organizations on the issue of media effects on health, took another approach to the subject of sex and media. Concerned about media effects on the physical and mental health of children and adolescents, the AAP formed the Task Force on Children and Television in 1983. The Task Force issued the first AAP policy statement on media in following year. They asserted in their policy statement that, next to the family, television may be children’s most important source of information and the most powerful influence on their development.5 They also expressed the AAP’s concern that television’s portrayal of sex roles and sexuality was unrealistic and without health consequences such as pregnancy or sexually transmitted disease. Two years later, the AAP Committee on Adolescence issued another policy statement, Sexuality, Contraception, and the Media,6 implicating television as a powerful teacher of sexual behavior, but also indicating its potentially positive role in educating young people about responsible sexuality. In this statement, the AAP was joined by the American College of Obstetrics and Gynecology, the Society for Adolescent Medicine, and the American Public Health Association in “supporting and encouraging the airing of advertisements for nonprescription contraceptives on television” as long as the content was “educational, realistic and focused on responsible sexual behavior and decision-making.” The AAP urged television broadcasters to “alter the portrayal of sexuality in non-news programming to reflect realistic consequences and responsible behavior and to decrease the association of suggestive and stimulating sexual messages with product advertising.” The very different positions taken by the American Medical Association and the AAP demonstrate the strong opinions of clinicians who care for adolescents, the lack of confidence in the research evidence relating media and sexual behavior, and the ambivalence that the medical community feels about mass media as both a health threat and a powerful teaching tool. What the medical community did agree on, time and again, was the need for more research.
As Escobar-Chaves et al demonstrate with their excellent survey, The Impact of Media on Adolescent Sexual Attitudes and Behaviors,7 the research to date is scant and the findings are difficult to translate into clinical applications. Less than 1% of the 2522 reviewed studies involving media and youth investigate the association between media use and sexual knowledge, attitudes, and behaviors. Studies of media exposure indicate that young people are using more media for longer periods of time at younger ages,8,9 and content analyses of television programming show that the prevalence of sexual content has been increasing over the past 2 decades.10–17 However, there are only 6 published research reports on the associations between media exposure and attitudes toward or beliefs about sex and only 7 more that investigated relationships between media use and sexual activity. Although their outcome measures differed widely, their findings are generally consistent: greater exposure to sexual content in media is associated with more permissive attitudes toward sexual activity, higher estimates of the sexual experience and activity of peers, and more and earlier sexual behavior among adolescents. Although the body of research evidence is small, the findings seem to parallel those for media violence: adolescents accept, learn from, and may emulate behaviors portrayed in media as normative, attractive, and without risk.
How should clinicians and others who care for children and adolescents respond? Does the research evidence exist to limit young people’s exposure to “sexually suggestive” or “pornographic” media, or should we use the power of media to educate young people about the risks and benefits of sex, inform them about contraception, and support the development of mature, responsible, and safe attitudes toward sex? These questions are difficult, if not impossible, to answer with the evidence at hand. Not only are there large areas of this subject that have yet to be investigated, but there are critical methodologic and conceptual concerns with the research and clinical response to date.
The methodologies implemented in these studies need to be assessed for their ability to elicit salient features of what is studied and to yield clinically meaningful assessments. Many exposure studies use hours of media use as their unit of measure without regard to the content or context of that exposure. If 1 young person watches violent and misogynistic music videos for the same amount of time that another watches romantic rhythm and blues videos, can the outcome be assumed to be the same? If 1 youth watches the romantic music video with his girlfriend and another with his male friends, are the effects on their sexual attitudes and behaviors similar? This review of the research correctly notes that there is no research on the influence of cable television or the Internet, which seem to have more highly sexual material than other media. Finally, there are issues with the way data are collected. Most exposure data are self-reported; recall is subject to a variety of biases and, at best, is not complete or accurate. We can no longer assume “one-channel” media use, where the young person sits down to watch television or listen to music. Adolescents multitask with media today,9 using 2, 3, or more types simultaneously, surfing the Internet while listening to music and instant-messaging friends, with the television showing programming time-shifted on a digital hard drive. Traditional data-collection methodology does not capture the nature of multiple simultaneous media use, nor is it designed to assess the relative attention paid by the young person to each medium or the influence of each medium on the young person.
In the research to date, there seems to be an assumption on the part of some, but thankfully not all, researchers that exposure to sexual content in media precedes real-life sex. Because the majority of the research to date has been cross-sectional, some researchers have recognized the equally possible scenario that young people who have initiated their sex lives may be attracted to sexual content in media because it resonates with their experience. From studies of the content of at least 1 teen-oriented magazine, it would seem that some writers and editors have adopted the AAP position of using media to teach responsible and safe sexual attitudes and behaviors.17 The same can be said of at least a few writers and producers in television.18
Although the underlying premise of media-effects research is often that exposure to sexual content in media influences sexual behavior, experience would suggest that it is not just overtly sexual material that motivates sexual thoughts or behaviors. Because of cultural, sensual, and experiential associations that all of us have, the smell of a rose, the roar of a motorcycle, or the image of a sunset may be a much more potent stimulus of sexual drive. If we are to conduct useful and valid research on whether media use predisposes young people toward risky sexual behavior, we need to broaden our vision of what that media input may be.
Similarly, we must consider outcomes carefully. As a social, cultural, and religious issue, as well as a medical one, sex presents the problematic opportunity to present one’s personal values as the “right way.” Although the learning effect seen with media violence seems to be paralleled by associations between media exposure and sexual attitudes and behaviors, the outcomes to be quantified are very different. Unlike violence, which is always aberrant, sex is a normal and healthy human behavior when it is responsible to and safe for the parties involved. Although expert consensus can be difficult in any situation, valid outcome measures of unhealthy interpersonal violence can be agreed on by the health community. It will be impossible to develop valid research outcome measures of unhealthy sex if personal values about the appropriateness of sexual behaviors get mixed with science. It is imperative that the medical community exert its expertise and develop measurable health-related sexual-risk outcomes for this area of research to progress and inform clinical practice.
Medical organizations such as the American Medical Association and the AAP are institutions of education and advocacy. In following their mandate to inform and guide their memberships, they must sometimes take positions that are based in part on research, in part on extrapolation from the data, and in part on clinical judgment. Recommendations made by such organizations with the best of intentions can raise questions of definitions and assumptions. Although there are laws controlling “sexually suggestive” or “pornographic” material, there is no agreement even among legal scholars on the definitions of those descriptors. The medical community specializes in the knowledge of human disease and is qualified to determine, with the support of valid scientific research, what is unhealthy and what is not. Although content that portrays sexual violence19 and misogyny can be agreed on as inappropriate by the medical community because it models behavior that results in negative mental or physical health outcomes, there is a broad range of human sexual activity that some clinicians and researchers would feel was unacceptable to portray in media and with which others would have no concerns. The terms “sexually suggestive” or “pornographic” probably have as many definitions as there are clinicians and thus are unhelpful as a guide to clinical practice.
Although there is good evidence that young people learn from media, the long-term health and sexual-behavior outcomes of advertising contraception on television had not been researched at the time that the recommendation to encourage such advertising was made. Current research evidence suggests that knowledge of contraception does not increase the rate of initiating sexual activity,20 but there is no research indicating that television commercials function in the same way as formal sex education. Ultimately, clinical medicine is as much an art as a science, and clinical judgments must be made without complete data. However, it would be wise for medical organizations to remember that their recommendations can and will change the clinical practice of thousands of members, affecting millions of patients. Those recommendations should be based on science as much as possible, and when they extend beyond the science, be supported by logic and compassion.
For this to occur, research must continue. The study of media effects on sexual knowledge, attitudes, and behaviors is in its infancy. It is a difficult field of study but an important one. Media are arguably the most powerful environmental health influence of the information age. Technologic improvements in medical intervention and prevention have transformed the public health landscape. The leading causes of morbidity and mortality are no longer infections, congenital disorders, and cancers but the outcomes of acquired health-risk behaviors, including risky sex. Heeding the recommendations of Escobar-Chaves et al and keeping methodologic and conceptual caveats in mind, we must move forward toward a better, more precise, and more clinically relevant understanding of the influence that media have on the sexual behavior of young people.
- Accepted April 14, 2005.
- Address correspondence to Michael Rich, MD, MPH, Center on Media and Child Health, Children’s Hospital Boston/Harvard Medical School, 300 Longwood Ave, Boston, MA 02115. E-mail:
No conflict of interest declared.
- ↵Surgeon General’s Scientific Advisory Committee on Television and Social Behavior, National Institutes of Health, National Institute of Mental Health. Television and Growing Up: The Impact of Televised Violence. Report to the Surgeon General, US Public Health Service. Washington, DC: US Government Printing Office; 1972
- ↵American Medical Association. TV violence. H-485.995; 1982, 1992, 2003
- ↵American Medical Association. Objection to Sex on TV. H-485.999; 1977, 1989, 2000
- ↵American Academy of Pediatrics. Children, adolescents, and television. News Comment.1984;35(12) :8
- ↵American Academy of Pediatrics, Committee on Adolescence. Sexuality, contraception, and the media. Pediatrics.1986;78 :535– 536
- ↵Escobar-Chaves SL, Tortolero SR, Markham CM, Low BJ, Eitel P, Thickstun P. Impact of the media on adolescent sexual attitudes and behaviors. Pediatrics.2005;116(1 pt 2)
- ↵Rideout VJ, Vandewater EA, Wartella EA. Zero to Six: electronic media in the lives of infants, toddlers and preschoolers. A Kaiser Family Foundation Report (3378). 2003. Available at: www.kff.org/entmedia/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=22754. Accessed February 2, 2005
- ↵Roberts DF, Foehr UG, Rideout V. Generation M: media in the lives of 8–18 year-olds. A Kaiser Family Foundation Report. 2005. Available at: www.kff.org/entmedia/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=51809. Accessed May 11, 2005
- ↵Greenberg BS, Linsangan R, Soderman A. Adolescents’ reactions to television and movie sex. In: Greenberg BS, Brown JD, Buerkel-Rothfuss N, eds. Media, Sex, and the Adolescent. Cresskill, NJ: Hampton Press; 1993
- Greenberg BS, Smith SW. Daytime talk shows: up close and in your face. In: Brown JD, Steele JR, Walsh-Childers K, eds. Sexual Teens, Sexual Media: Investigating Media’s Influence on Adolescent Sexuality. Mahwah, NJ: Lawrence Erlbaum; 2002:79– 93
- Cope-Farrar KM, Kunkel D. Sexual messages in teens’ favorite prime-time television programs. In: Brown JD, Steele JR, Walsh-Childers K, eds. Sexual Teens, Sexual Media: Investigating Media’s Influence on Adolescent Sexuality. Mahwah, NJ: Lawrence Erlbaum; 2002:59– 78
- Kunkel D, Biely E, Eyal K, Cope-Farrar K, Donnerstein E, Fandrich R. Sex on TV: 2003: a biennial report to the Kaiser Family Foundation. 2003. Available at: www.kff.org/entmedia/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14209. Accessed February 2, 2005
- Kunkel D, Cope-Farrar K, Farinola WJM, Biely E, Rollin M, Donnerstein E. Sex on TV: content and context: a biennial report to the Henry J. Kaiser Family Foundation. 1999. Available at: www.kff.org/entmedia/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14686. Accessed February 2, 2005
- ↵Kunkel D, Cope-Farrar K, Biely E, Farinola WJM, Donnerstein E. Sex on TV (2): a biennial report to the Kaiser Family Foundation. 2001. Available at: www.kff.org/entmedia/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13780. Accessed February 2, 2005
- ↵Rich M, Woods ER, Goodman E, Emans SJ, DuRant RH. Aggressors or victims: Gender and race in music video violence. Pediatrics.1998;101 :669– 674
- Copyright © 2005 by the American Academy of Pediatrics