Teen Sexual Development in the Digital Age

By Brandon DeLiberato, DO

Not long ago, a teenager presented in our adolescent psychiatry unit with two distinct paraphilias (abnormal sexual desires involving extreme or dangerous activities). The time it took to accurately diagnose this boy made me realize I was not asking the right questions regarding sexual history. It prompted me to begin researching issues that teens routinely encounter today: pornography, sexting and hooking up.

While humans are inherently sexual creatures who have always been on individual paths of sexual development that begin in childhood, today’s children and adolescents face a new world when it comes to sexual socialization. Long gone are the days of necking and petting, dances and going steady. Even the sexual revolution is passé. Instead, sexting and frequent exposure to pornography have become commonplace among adolescents, and this can engender greater openness to hooking up and other potentially risky sexual behaviors.

I summarize my findings about pornography and sexting here, and conclude with some guidance for providers.

Online porn: Widespread, and not always benign

Pornography, both online and print, is a gigantic industry worldwide, and the Internet has made it accessible to teens through just a few taps on a phone or tablet.

Studies by Wolak and colleagues and Ybarra and Mitchell reveal that by age 17, up to 90 percent of teenage males and 60 percent of females have been exposed to online pornography, and 66 percent of this exposure is accidental or unwanted.

Often, pornography portrays negative sexual activity in a positive way. For instance, Gorman and colleagues found that only 2 percent of video clips depict protected sex (use of a condom). Group sex, sex with strangers, and nonrelational and recreational sex are common depictions — all behaviors that increase risk for sexually transmitted infections (STIs), unplanned pregnancy and sexual violence.

Associations have been drawn between pornography and increasing acceptance of rape, violence against women, objectification of women, male-on-female aggression and decreased sexual satisfaction within romantic relationships.

Compared with couples viewing pornography together, solitary pornography users report less commitment and less sexual satisfaction, according to several reports. Researchers have also found that compared with nonusers of pornography, pornography users experience poorer communication within couples and poorer relationship adjustment, commitment and sexual satisfaction — as well as higher levels of infidelity.

Pornography shapes teens’ sexual scripts

Pornography’s most important effect in this setting may lie in how it impacts an adolescent’s “sexual script,” or his or her easily accessible memory structure about sex that is used for real-world decision-making but which often circumvents critical analysis and is significantly shaped by media.

Children and adolescents with minimal personal sexual experience may be more prone to use pornography to develop a sexual script. First exposure to pornography typically far predates a youngster’s first sexual encounter, giving pornography the opportunity to shape sexual scripts in key ways. Pornography can become more than just fantasy; it can become an accessible template for actual sexual behavior and may increase potential for psychological and emotional risk or vulnerability.

Mental health implications of sexting

Sexting — sending images or language that are sexual in nature, generally over smartphones — is fraught with issues. Klettke and colleagues estimate that 10 to 12 percent of adolescents have sent a sext, while about 16 percent have received one. Sexting is associated with being sexually active and sexual risk-taking behavior (e.g., having sex while intoxicated, having unprotected sex, having multiple sex partners or others behaviors that increase risk for STIs, unplanned pregnancy and sexual violence).

Sexts, which are reported to be most widely sent and received among 18- to 26-year-olds, are exchanged in relationships for a variety of reasons — to be sexy or initiate sexual activity, to gain attention from a partner, to be fun and flirtatious, as a result of peer pressure or as a form of self-expression. But sexters may be surprised to learn that more than half of sexts are shared by the recipient without the sender’s knowledge, as one study found. Recipients share sexts without permission out of a desire to show off, because it is perceived as funny, or simply out of boredom.

A recent systematic literature review showed that a few positive correlations have been associated with sexting, including higher self-esteem and less depression in certain circumstances. But sexting carries potentially grave negative outcomes. These include possible exploitation or bullying, sexual attacks, abuse, public disgrace, unwanted dissemination, legal ramifications and disciplinary punishment from school. Another study showed that individuals under pressure to sext in high school were more likely to report problems with anxiety and prior dating violence compared with nonsexters and people not under pressure.

Also, a survey of sixth- to twelfth-graders in one Midwestern state found that sexters were significantly more likely to have considered or attempted suicide and more likely have reported feelings of sadness or hopelessness for at least two weeks during the previous year.

What health professionals can do

Guidelines for discussing sexuality during primary care visits are inconsistent, content is not well defined and recommendations lack specifics regarding pornography or sexting. Only 60 percent of primary care practitioners report having discussions around sexuality of any kind. This represents a key missed opportunity to identify behavior that can have important effects on mental health.

From the case example above, I learned that asking questions about symptoms and scripted sexual history may not be enough to discover the correct context for a patient’s impairment. Employing narrow language and avoiding details of behaviors can cause you to overlook what is actually occurring. Below is some general advice I would offer fellow providers who care for young patients.

Ask about sexting. We don’t need to ask every patient about these issues, but I do recommend asking most teens about sexting. Because the abovementioned systematic review shows that knowing someone who has sexted makes youth more likely to engage in sexting themselves, providers are well advised to ask young patients whether their friends sext. This approach may provide a nonconfrontational way to break the ice and enable discussion about the consequences of unintended distribution and legal ramifications.

Seize opportunities for education. Asking about sexting among friends can also yield opportunities for patient education, which includes discussion of sexual history, risk assessment, anticipatory guidance, reinforcement and referral. Discussion regarding sex should include development, orientation, identity, genital and extragenital intercourse behaviors, protective behaviors, communication with partners, healthy and unhealthy relationships, and abuse.

Pornography exposure is practically unavoidable. However, providing appropriate sex education can help provide safe sexual scripts prior to pornography exposure and impact and can help young people view pornographic material analytically.

The big picture — and a helpful resource

It’s likely that sexting, hooking up and even pornography can be part of normal sexual development for teens today. As healthcare providers, we need to remain educated and aware and be willing to discuss these sensitive topics with our young patients.

We also can guide patients to healthy sources of information. One site I recommend is Sex, etc., a comprehensive sexuality education website for kids ages 13 to 19 that’s published by Answer, a program of the Center for Applied Psychology at Rutgers University.

Dr. DeLiberato is a fifth-year fellow in child/adolescent psychiatry at Cleveland Clinic. He can be reached at 216.444.2156 or delibeb@ccf.org.