Impact of the Media on Adolescent Sexual Attitudes and Behaviors

DOI: 10.1542/peds.2005-0355D 2005;116;303-326 Pediatrics

Low, Patricia Eitel and Patricia Thickstun S. Liliana Escobar-Chaves, Susan R. Tortolero, Christine M. Markham, Barbara J.

Impact of the Media on Adolescent Sexual Attitudes and Behaviors

This information is current as of January 12, 2007

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S. Liliana Escobar-Chaves, DrPH*; Susan R. Tortolero, PhD*; Christine M. Markham, PhD*;Barbara J. Low, DrPH*; Patricia Eitel, PhD*; and Patricia Thickstun, PhD‡

ABSTRACT. Background. Adolescents in the UnitedStates are engaging in sexual activity at early ages andwith multiple partners. The mass media have beenshown to affect a broad range of adolescent health-re-lated attitudes and behaviors including violence, eatingdisorders, and tobacco and alcohol use. One largely un-explored factor that may contribute to adolescents’ sexualactivity is their exposure to mass media.

Objective. We sought to determine of what is and isnot known on a scientific basis of the effects of massmedia on adolescent sexual attitudes and behaviors.

Method. We performed an extensive, systematic re-view of the relevant biomedical and social science liter-ature and other sources on the sexual content of variousmass media, the exposure of adolescents to that media,the effects of that exposure on the adolescents’ sexualattitudes and behaviors, and ways to mitigate those ef-fects. Inclusion criteria were: published in 1983–2004,inclusive; published in English; peer-reviewed (for ef-fects) or otherwise authoritative (for content and expo-sure); and a study population of American adolescents 11to 19 years old or comparable groups in other postindus-trial English-speaking countries. Excluded from thestudy were populations drawn from college students.

Results. Although television is subject to ongoingtracking of its sexual content, other media are terra in-cognita. Data regarding adolescent exposure to variousmedia are, for the most part, severely dated. Few studieshave examined the effects of mass media on adolescentsexual attitudes and behaviors: only 12 of 2522 research-related documents (<1%) involving media and youthaddressed effects, 10 of which were peer reviewed. Nonecan serve as the grounding for evidence-based publicpolicy. These studies are limited in their generalizabilityby their cross-sectional study designs, limited samplingdesigns, and small sample sizes. In addition, we do notknow the long-term effectiveness of various social-cul-tural, technologic, and media approaches to minimizingthat exposure (eg, V-Chips on television, Internet-filter-ing-software, parental supervision, rating systems) orminimizing the effects of that exposure (eg, media-liter-acy programs).

Conclusions. Research needs to include developmentof well-specified and robust research measures andmethodologies; ongoing national surveillance of the sex-

ual content of media and the exposure of various demo-graphic subgroups of adolescents to that content; andlongitudinal studies of the effects of that exposure on thesexual decision-making, attitudes, and behaviors of thosesubgroups. Additional specific research foci involve thesuccess of various types of controls in limiting exposureand the mitigative effects of, for example, parental influ-ence and best-practice media-literacy programs. Pediat-rics 2005;116:303–326; adolescent sexual behavior, atti-tudes, media impact.

ABBREVIATIONS. STI, sexually transmitted infection; HPV, hu-man papillomavirus; CDC, Centers for Disease Control and Pre-vention; TV, television; VCR, videocassette recorder; NIH, Na-tional Institutes of Health.

INTRODUCTION

Although the proportion of high school stu-dents who have had sex has declined in thepast decade, many adolescents in the United

States are engaging in sexual activity at early agesand with multiple partners. Approximately 47% ofhigh school students have had sexual intercourse.1Of these, 7.4% report having sex before the age of 13and 14% have had �4 sexual partners.1

Sexually active adolescents are at immediate riskfor pregnancy and acquiring sexually transmittedinfections (STIs). Each year, nearly 900 000 teenagedgirls in the United States become pregnant (340 000are �17 years old),2 and 35% of American teenagedgirls have been pregnant at least once by the age of20.2 In the United States, the risk of acquiring an STIis higher among teenagers than among adults.3 Al-most 4 million cases of STIs are diagnosed in adoles-cents each year.4 In 2002, gonorrhea rates in theUnited States were highest among females in the agebrackets of 15 to 19 years (675.6 per 100 000) and 20to 24 years (650.3 per 100 000); among males those inthe 20- to 24-year age bracket had the highest rate(538.1 per 100 000).5 The most common reported STIin the United States is chlamydia, and it is mostprevalent among adolescents. In 2002 chlamydiaprevalence reported among sexually active adoles-cent females was 6 times as high as that amongsexually active females in the general population.6Human papillomavirus (HPV) infection is the mostprevalent of all viral STIs, even more common thanherpes simplex virus and human immunodeficiencyvirus (HIV) combined. Approximately 35 of the 100known HPV strains cause cervical cancer; the re-mainder cause genital warts. HPV seroprevalence is5% in adolescents aged 12 to 19 and 15% amongyoung adults aged 20 to 29. High levels of HPV

From the *Center for Health Promotion and Prevention Research, Univer-sity of Texas Health Science Center, Houston, Texas; and ‡Medical Institutefor Sexual Health, Austin, Texas.Accepted for publication Apr 14, 2005.doi:10.1542/peds.2005-0355DNo conflict of interest declared.Address correspondence to S. Liliana Escobar-Chaves, DrPH, Center forHealth Promotion and Prevention Research, School of Public Health, Uni-versity of Texas Health Science Center, PO Box 20036, Houston, TX 77225-0036. E-mail: [email protected] (ISSN 0031 4005). Copyright © 2005 by the American Acad-emy of Pediatrics.

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infection are found among high-risk teens: 1 study ofinner-city teens found 24% of young women wereinfected with HPV.4 HIV is the causative agent inacquired immunodeficiency syndrome (AIDS). In2000, �2900 new HIV cases diagnosed in youngpeople aged 15 to 24 were reported to the Centers forDisease Control and Prevention (CDC) from just 30states. Given that it typically takes a decade afterHIV infection for AIDS symptoms to appear, it islikely that most young adults diagnosed with HIVinfection and AIDS had been infected with HIV asadolescents. By the end of 2002, �36 000 cases ofHIV/AIDS had been reported in young people aged13 to 24 in the United States.7,8 By the end of 2001�14 000 young Americans aged 15 to 24 had died ofAIDS, according to the most recent CDC data avail-able.7

Data suggest that sexually active adolescents are athigh risk for depression and suicide.9–12 Early sexualexperience among adolescents has also been associ-ated with other potentially health-endangering be-haviors such as alcohol, marijuana, and other druguse.12

Many factors may put teens at risk for becomingsexually active at an early age. Some of the mostimportant risk factors are race, poverty, the use ofdrugs and alcohol, peer influences, and parental in-fluences.13

One potential but largely unexplored factor thatmay contribute to sexual activity among adolescentsis exposure to sexual content in the mass media. Theaverage American youth spends one third of eachday exposed to media, and the majority of that ex-posure occurs outside of parental oversight.14 Al-though mass media have been shown to have aninfluence on a broad range of behaviors and attitudesincluding violence, eating disorders, tobacco and al-cohol use, surprisingly few studies have examinedthe effects of mass media on adolescent sexual atti-tudes and behaviors. This report is a review of thosestudies.

Theoretical Perspectives: Media as an Influence onAttitudes and Behaviors

The potential for mass media to influence behaviorhas been supported through a number of differentpsychosocial theories, hypotheses, and models. Al-though there is considerable variation in theoreticalmechanisms by which media might affect adoles-cents’ sexual attitudes and behaviors, most posit thatsexually related message content and behavior actover time as stimuli to change consumer psycholog-ical, physiologic, and behavioral function.

Social-Learning TheoryBandura’s social-learning theory,15 one of the most

prominent of these theoretical mechanisms, providesample evidence that even when children and adultshave not actually performed a behavior, they canlearn by imitation. Bandura identifies 3 main pro-cesses involved in learning: direct experience, indi-rect or vicarious experience from observing others(modeling), and the storing and processing of com-plex information through cognitive operations. This

theory suggests that behaviors are learned and thatthey are influenced by social context: “Television isseen as an increasingly influential agent of socializa-tion that produces its effects through children’s pro-pensity to learn by imitation.”16

Disinhibition TheoryDisinhibition theory posits that existing behavioral

tendencies of children and others are inhibited byexperience.17 Continued exposure to television (TV),however, disinhibits viewers, making them more ac-cepting of the behavior.18

Priming TheoryResearch has shown that exposure to an event (ie,

sexual stereotypes) from the mass media activatesother similar ideas for a short time afterward.19

These thoughts, in turn, can activate other semanti-cally related concepts and make them more accessi-ble.

Arousal TheoryArousal theory focuses primarily on the immedi-

ate effects that sexually suggestive material mayhave on behavior.20 TV content, for example, canproduce general emotional and physiologic arousal(ie, activation of the nervous system rather than spe-cific sexual arousal) that is likely to elicit some typeof individual and contextual behavioral response.

Cultivation TheoryCultivation theory posits that heavy exposure to

mass media creates and cultivates attitudes moreconsistent with a media-directed version of realitythan with reality itself.21 Media portrayals and mes-sages might affect the behavior of young personsover time by enabling them to acquire new attitudesand behaviors or by changing the likelihood thatthey will perform new or previously learned re-sponses. This may occur when a child’s expectationsabout the outcome of certain behaviors are alteredthrough identification with the character portrayingor providing the stimuli, by raising or lowering be-havioral inhibitions, by modifying the potential forenvironmental cues to foster certain behaviors, or bylinking specific meanings to a behavior.

Media Practice ModelThis model was developed to explain media use in

a comprehensive and contextual framework22 andhighlights the connections between adolescents’identities and media selection, interaction, and ap-plication22: “This model assumes that youth choosemedia and interact with it based on who they are orwho they want to be at the moment.”23 Theoreticalresearch is borne out by communications-related sur-vey data. Advertisers recognize that the content oftheir messages will have an effect on consumer pur-chasing behavior.24 Additionally, young people re-port that media messages are an important influencein their lives25 and that they receive important infor-mation about life choices from the media.26

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Third-Person Effect HypothesisThe third-person effect hypothesis states that peo-

ple tend to perceive mass media messages to have agreater impact on others attitudes and behaviorsthan on themselves.27 A practical way of looking atthird-person effect is that messages “have little effecton people like you and me, but the ordinary reader islikely to be influenced a lot.” This phenomenon maybe exacerbated for adolescents and may lead to un-derreporting of decision-making factors.

Super-Peer TheoryThis theory posits that the media can represent a

potent source of information for teens as to what isnormative behavior28,29 and may indeed exceed theinfluence of an adolescent’s more traditional peergroup.30 The effect of exposure to attitudes and be-haviors portrayed in mass media may be com-pounded by the glamour typically associated withthose appearing in it (both the characters and theactors playing them). Moreover, TV programmingtargeted to youth takes advantage of the attraction ofchildren and teens to characters they perceive to be 2or 3 years older than they themselves are31—“peers”with whom they typically cannot socialize but whomthey long to be like. Such characters, although olderthan the child’s peer group, provide templates forthe child’s “aspirational” behavior.31 In short, young-sters model themselves after those who they want tobe not those who reflect who and what they cur-rently are.

Power of the IndirectWhatever the correct theoretical underpinning(s),

data suggest that messages embedded in other me-dia types are more powerful than direct advertisingappeals when it comes to influencing behavior. Ad-vertising is influential, but perhaps because teenshave now become more marketing savvy, they tendto resist direct appeals to change their behaviors andare better persuaded by subtle, embedded messag-es.32 The result has been greater use of nontraditionalmarketing approaches such as “viral” marketing(any strategy that encourages individuals to pass ona marketing message to others), using “trend-setters”as communication sources, and e-mail. Such nontra-ditional sources de-emphasize the advertising aspectand highlight content to minimize the consumer’ssense of being manipulated, which explains whyproduct placement is so popular in movies and TV: itis indirect and subtle but powerful.32 The NationalYouth Anti-Drug Media Campaign (sponsored bythe Office of National Drug Control Policy) con-ducted a qualitative and ethnographic studythroughout the country in 6 markets during August2003. Teens were asked to use a diary to keep track ofall drug messages (prodrug and antidrug) withwhich they came into contact across all mediasources for a 2-week period, after which focusgroups were held. The main finding was that pro-drug messages were perceived by all teens as morepowerful and compelling than antidrug messagesprimarily because of their subtlety and embeddednature.33

Media Influence on Other Health-Related BehaviorsAlthough little is known about the effect of mass

media on adolescent sexual behaviors, much more isknown about its effects on other health-related be-haviors. In particular, violence in mass media hasattracted a great deal of ongoing attention.34 Theeffects of a child or adolescent’s media diet on theirfuture risk of eating disorders and alcohol and to-bacco use have also been subjects for study. Whatfollows is a brief summary, not a thorough survey, ofthe effects that mass media has on other health-related behaviors in adolescents.

Aggressive BehaviorYouth violence as a public health issue was ad-

dressed in a 2001 report by the US Surgeon Gener-al.35 Numerous studies have investigated the associ-ation between media violence and aggression, withmany focusing on children and adolescents. A vari-ety of study designs have been used to understandthe media-aggression relationship, including labora-tory,36,37 correlational,38–41 longitudinal,42–47 andecological designs.48 Several comprehensive reviewsof youth literature are available.49–54 Most of thesestudies have supported a positive association be-tween exposure to media violence and aggression.The association has been strong enough to causecongressional concern and the creation of a series ofFederal Trade Commission reports.34

Eating DisordersThe prevalence of obesity is increasing in the

United States.55 Researchers have repeatedly found asignificant association between obesity and TV view-ing.56–61 From 1963 through 1965, Dietz and Gort-maker56 studied 6965 children aged 6 to 11. Resultsshowed that children who watched more TV experi-enced a greater prevalence of obesity or superobesitythan children watching less TV. Crespo et al exam-ined the relationship between TV watching, energyintake, physical activity, and obesity status by usinga national representative sample of US children aged8 to 16 (interviews were done between 1988 and1994). They reported that the prevalence of obesitywas lowest among children watching �1 hours of TVper day and highest among those watching �4 hoursof TV per day. TV watching was positively associ-ated with obesity among girls even after controllingfor age, race/ethnicity, family income, weekly phys-ical activity, and energy intake.61 In a 1990 study of acohort of 746 youths aged 10 to 15, Gortmaker et al59

had similar results, finding a strong relationship be-tween the prevalence of overweight and hours of TVviewed.

Depending on the methodology used, the reportedprevalence rate for anorexia nervosa and bulimianervosa among adolescent females ranges from�2.4%62 to 5%63 and is 0.48% among girls aged 15 to19 for anorexia alone.64 Although males compriseonly �10% of anorexia cases, both genders are expe-riencing an increase in prevalence of eating disor-ders.65 Of particular concern is that eating disordersin early childhood are associated with symptoms of

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bulimic behaviors in adulthood.66 Martinez-Gonza-lez et al67 found a positive association between theincidence of eating disorders and weekend TV view-ing in a sample of females aged 12 to 21. They alsofound that those adolescent females at higher risk ofdeveloping an eating disorder (based on Diagnosticand Statistical Manual of Mental Disorders, Fourth Edi-tion criteria) were also more likely to read girls’ mag-azines or listen to radio programs (odds ratio: 2.1;95% confidence interval: 1.2–3.8, for those most fre-quently using both media).67 Other research hasshown that among 374 girls (mean: 12 years old),over a 16-month period those who reported in-creased eating-disorder symptomatology had signif-icantly increased their exposure to fashion maga-zines but decreased their number of hours of TVviewing, whereas those with decreased symptom-atology had significantly decreased their exposure toboth TV and fashion magazines.68 Trying to look likefemales portrayed on TV, in movies, or in magazineswas also significantly predictive of preadolescentand adolescent girls’ onset of eating-disorder–relatedbehavior (odds ratio: 1.9; 95% confidence interval:1.6–2.3). A study comparing 2 samples of Fijianschoolgirls before and after the introduction of TV tothe region is suggestive: indicators of disorderedeating were significantly more prevalent after pro-longed exposure to TV. Study participants reported adesire to lose weight or to reshape their body tobecome more like Western TV characters.69

Tobacco and Alcohol UseEach day �4000 children �18 years old smoke

tobacco for the first time,70 nearly 2000 of which willbecome regular smokers. It is estimated that at least4.5 million US adolescents are cigarette smokers. Ap-proximately 80% of smokers begin smoking beforethe age of 18.71 Several studies have explored theimpact of advertising on adolescents.72–74 Many haveshown advertising to be very effective in increasingyoungsters’ awareness of and emotional responses toproducts (recognition of brands, desire to own theproducts advertised). Cigarette advertising seems toincrease teenagers’ risk of smoking by glamorizingsmoking and smokers,75 and children who are able torecall ads related to tobacco are more likely to viewsmoking favorably and to become smokers.72–74

Alcoholic drinks are the most common beveragesportrayed on TV.29 It has been shown that exposureto alcohol advertising and TV programming is asso-ciated with positive beliefs about alcohol consump-tion.76–78 Although such cross-sectional studies donot prove causation (only association), it is of interestthat in a 1990 study, 56% of students in grades 5 to 12said that alcohol advertising encourages them todrink.79 A longitudinal study examined the associa-tion between alcohol consumption at the age of 18and alcohol-related messages at the ages of 13 and15. Findings showed that girls who had watchedmore hours of TV at ages 13 and 15 drank more wineand spirits at age 18 than those who had watchedfewer hours of TV.80

A 1997 study of �300 Web sites found that 25major alcoholic beverage companies were even then

using the Internet to advertise, promote, and selltheir products through a variety of marketing tech-niques that capitalize on the Internet’s strong attrac-tion for young people.81

Strasburger’s 2002 review29 (which also includesdata of interest regarding representations of smokingand illicit drug use) concludes that “[a]lthough theresearch is not yet scientifically ‘beyond a reasonabledoubt,’ a preponderance of evidence shows that al-cohol advertising is a significant factor in adoles-cents’ use of this drug.”29(p361)

Purpose of This ReportEffects of the mass media have been found to be

far-reaching and potentially harmful in influencingthe health-related behaviors of children and adoles-cents, many of whom are not yet mature enough todistinguish fantasy from reality, particularly when itis presented as “real life.” Furthermore, time spentwith media decreases the amount of time availablefor pursuing other more healthful activities such assports, physical activity, community service, culturalpursuits, and family time. The accumulation of evi-dence across multiple health-risk behaviors suggeststhat media influence on youth is worthy of carefulresearch.

This report presents the results of a review of theliterature and other data sources on the impact ofmass media (including the Internet) on the sexualattitudes and behaviors of adolescents (ages 11–19)in the United States. For each form of media weinclude the scientific data from the last 2 decades(1983–2004) on adolescent exposure to that medium,its sexual content, and the effects of that exposure.The report concludes with an assessment of futureresearch needs.

METHODS

DefinitionsThis study examines the exposure, content, and effect of media

on adolescent sexual attitudes and behaviors. For this study “ex-posure” refers to the amount of time per day spent with differenttypes of media and the social context of media use. “Content”refers to any dialogue, situation, or behavior that involves sexu-ality, sexual suggestiveness, or sexual activities or relationships, aswell as the nature of sexual depictions in the media.

Studies define “sexual behavior” in a wide variety of ways: is akiss sexual? Is dating? Many studies use the term “explicit” tomean “overt” (the opposite of “implied”) rather than to indicate,eg, a degree of nudity or level of physical intimacy. The majorityof recent studies make use of the definitions created for the KaiserFamily Foundation’s ongoing Sex on TV82–84 studies:

• “[S]exual content is defined as any depiction of sexual activity,sexually suggestive behavior, or talk about sexuality or sexualactivity. Portrayals involving only talk about sex are measuredseparately from those that include sexual actions or behav-iors…. To be considered a sexual behavior, actions must conveya sense of potential or likely sexual intimacy. For example, a kissof greeting between two friends or relatives would not be codedas sexual behavior, whereas a passionate kiss between twocharacters with a discernible romantic interest would be. Thelower threshold for sexual behaviors measured by the studywas physical flirting, which refers to behavioral actions in-tended to arouse sexual interest in others, such as a womanlicking her lips provocatively while gazing intently at a man ina bar.”84(p7)

• “Sexual dialogue, or what we term ‘talk about sex,’ involves awide range of types of conversations that may involve first-



hand discussion of sexual interests and topics with potentialpartners, as well as second-hand exchanges with others thatconvey information about one’s prior, anticipated, or even de-sired future sexual activities. For purposes of measuring talkabout sex, both the topic of reproductive issues (such as con-traception or abortion) and sexually transmitted diseases (in-cluding but not limited to AIDS) were considered assexual.”84(p8)

• “Intercourse implied is said to occur when a program portraysone or more scenes immediately adjacent (considering bothplace and time) to an act of sexual intercourse that is clearlyinferred by narrative device. Common examples would includea couple kissing, groping, and undressing one another as theystumble into a darkened bedroom, with the scene dissolvingbefore the actual act of intercourse ensues; or a couple shownawakening in bed together with their conversation centering onthe lovemaking they had performed before falling asleep. Suchportrayals are not necessarily explicit in any way but clearlyconvey the message that sex has occurred, and thus it is essen-tial that such portrayals be reflected in our contentmeasures.”84(p8)

• “[I]ntercourse depicted is judged to occur when a direct view isshown of any person who is engaged in the act of intercourse,regardless of the degree of nudity or explicitness presented.Discreet portrayals may show a couple only from the shouldersup when they are engaged in intercourse.”84(p8)

“Effect” refers to the influence of media content on adolescents’attitudes and behaviors. We use the term “sexual attitudes andbehaviors” to include beliefs, values, and decision-making, as wellas attitudes and behaviors.

“Adolescents” and its cognates are variously defined, as are theexact boundaries of “teenagers” and “youth.” The lines betweenchildhood, adolescence, and adulthood may differ by culture andregion. The World Health Organization defines “true adoles-cence” as “the period of physical, psychological and social matur-ing from childhood to adulthood,” which may occur anywherebetween the ages of 10 and 24.85 The CDC uses the terms “ado-lescents and young adults” for those aged 10 to 24, inclusive,86

usually broken into 3 age groups (ages 10–14, 15–19, and 20–24).At the same time, the US National Library of Medicine, in itsMedical Subject Headings (MeSH terms), defines the adolescent as

“a person 13 to 18 years of age,” whereas the PsycInfo databaseuses the ages of 13 through 17. Although teenagers may legally beadults at the age of 18, they are not for the most part adultsdevelopmentally, emotionally, behaviorally, or socially; most highschool seniors are living at home with their parents. For purposesof this study, “adolescents” are those 11 to 19 years old, and theterms “teens,” “teenagers,” and “youth” may be considered syn-onyms.

Inclusion CriteriaMaterials were restricted to those published in English from

1983 to 2004 (ie, the last 21 years) with respect to youth aged 11 to19 in the United States. In addition, some studies from otherpostindustrial English-speaking populations (eg, Canada and theUnited Kingdom) were included when their results seemed likelyto be relevant or generalizable. Materials had to be peer reviewed(for effects) or otherwise authoritative (for content and exposure),which excluded 2 effects studies that were dissertations.87,88

Literature Search and Other Data SourcesMultiple data sources were used to identify relevant materials

or research documents containing references to sexual exposure,content, and effect. The scientific literature was searched throughthe standard indexing databases for various fields by using ap-propriate indexing terms when controlled vocabularies were inuse and a variety of key words when standardized topic refer-ences were not available. Government documents and congres-sional testimony, the World Wide Web, books and other printedmaterials, and unpublished materials were also sought (see Table1 for details).

Preliminary lists of possibly relevant literature were reviewedat the abstracts level (when available; by title when not available)to exclude those pertaining, for example, to studies that made useof mass media as a deliberate intervention tool (eg, anti–sexuallytransmitted disease campaigns broadcast as public-service an-nouncements). Opinion pieces or other material lacking scientificdata were not considered relevant to this review, although policyrecommendations from such groups as the American Academy ofPediatrics were relevant. Items were entered into a ReferenceManager 10.0.01 database, which allowed the automatic culling of

TABLE 1. Search Methodology: Field or Source Materials, Database or Other Access, and Inclusion Criteria

Field or Source Material Searched Through Inclusion Criteria

Biomedicine, including psychiatry PubMed In EnglishPsychology PsycInfo, PsycLit Published 1983–2004Sociology SocAbstracts One or more forms of mass

mediaOther academic fields Academic Search Premier Youth aged 11–19 y or a subset

thereof in the United States orother postindustrial English-language population

Education ERICTheses and dissertations* ProQuest Digital DissertationsCommunications, media, marketing, and

proprietary advertising studiesResources of a media consultant at a major

advertising firmOngoing research CRISP database In EnglishGovernment documents and

congressional testimonyLexisNexis One or more forms of mass

mediaWorld Wide Web Google, sites of interested organizations

(eg, Kaiser Family Foundation) assuggested by researchers in the field

Youth aged 11–19 y or a subsetthereof in the United States

Books and other printed material Amazon, Barnes and Noble, and LawrenceErlbaum Web sites for items currently inprint; reference lists of other sources

Unpublished materials* Personal communications with expertsidentified through (1) reference lists inthe primary literature and (2)membership of national panels focusedon sexual content in the media andimpact on youth

Experts in the fields of mediaand communication, child andadolescent health, or humansexuality

Available by telephone or e-mailEnglish-speaking

* Not included in the final literature review but used to search for other materials.



duplicates; materials then were obtained, reviewed for relevance,and (if relevant) summarized. Those items available online weredownloaded as Adobe PDF or text files; others were photocopiedfrom the source journal or obtained through interlibrary loan.Those that were found relevant on reading are included in thisreport.

Examination of all data sources revealed 2522 documents thataddressed sexual content, exposure, or effect. The vast majorityaddressed exposure or content; only 12 addressed effects, 10 ofwhich were peer-reviewed, eligible studies.

Excluded StudiesThe vast majority of the material so found proved not to be

relevant. As an example, PsycInfo was originally searched foritems indexed with the term “adolescent” (45 461 hits) and pub-lished 1983–2003 (36 910) in English (34 215) and then crossed withthe term “media” (which includes “mass media”). Of the resulting653 items, a preliminary inspection of title and abstracts revealedonly 24 that addressed exposure, content, or effect. Only 4 of these24 proved relevant to this study.

Several studies that might otherwise have been included falloutside this report’s scope because they focus primarily on col-lege-age students or other adults. Examples include Strouse andBuerkel-Rothfuss,89 Calfin et al,90 Ward and Rivadeneyra,91

Ward,92 and Aubrey et al,93 all of whom studied college students.Other studies such as the Kaiser Family Foundation report re-leased late in 200494 looked at those younger than our targeted agerange (ie, children �7 years old).

RESULTS

Overall Media ExposureThe Kaiser Family Foundation released a study in

2004 that focused on the exposure of very youngchildren (aged 0–6 years) to electronic and printmedia. A nationally representative random-digit-dial telephone survey of �1000 parents was con-ducted in the spring of 2003. The researchers foundthat 99% of the children live in a home with a TV set(one third had a TV in their bedroom); 73% have acomputer at home; and 49% have a video-gameplayer. By parental report, 97% have listened to mu-sic, 91% have watched TV, and nearly half (48%)have used a computer; these are children �6 yearsold! Parents reported that these children spend �2hours per day with screen media, mostly TV andvideos. Among 4- to 6-year-olds, 27% use a computerevery day, spending an average of just over 1 hour atthe keyboard.94

Only a small number of national representativestudies have examined comprehensive media expo-sure in 11- to 19-year-olds. Given the exposure oftheir youngest siblings, it is not surprising that themost recent data indicate that American adolescentsspend an average of 6 to 7 hours per day with someform of media including TV, videotapes, movies,radio, print media, computers and the Internet, andvideo games.95 Many teens use multiple media si-multaneously, such as listening to music while surf-ing the Web.95 Table 2 presents the estimates ofaverage daily media exposure time from a 1999 na-tionally representative sample of 2065 young peopleaged 8 to 18,14 the most recent scientifically con-ducted national study of adolescent media use. Thesample used a stratified, 2-stage national probabilitysample in which schools were selected randomlyfrom a list of �80 000 public, private, and parochialschools in the United States (stage 1), and grades andclasses within grades were selected randomly to par-ticipate (stage 2).95 Their data on the contribution ofeach media type to total daily media exposure arerepresented in Fig 1.95

There is growing concern that youth are accessingmedia in environments isolated from the supervisionor guidance of parents or other adults. Table 3 pre-sents findings from a national survey of Americanyoungsters aged 8 to 18 concerning the type of mediathey report having in their bedroom.14 Informationregarding the social context of their TV viewing (Ta-ble 4) and other media use (Table 5) shows signifi-cant differences between the 8- to 13-year-old and 14-to 18-year-old age groups.14

The Teen Media Study used the US Department ofAgriculture food-group pyramid as a basis for the“media-diet” concept.23 The 2001–2002 study among3261 7th- and 8th-graders (12–15 years old) intro-duced a new measure of exposure to sexual mediacontent called the “sexual-media diet,” which tookinto account both the amount of time spent with 4different media (TV, movies, music, and magazines)and the amount of sexual content in the specificvehicles (eg, programs, music albums).96,97 This re-

TABLE 2. Overall Media Exposure: Average Daily Time (h:min) That 8- to 18-Year-Olds Are Exposed to Each Medium According toAge, Gender, and Race/Ethnicity

Medium Total Sample(N � 2065)

Age, y Gender Race/Ethnicity

8–13 14–18 Boys Girls White Black Hispanic

Total media exposure 7:57 8:08* 7:35* 8:10 7:41 7:16* 9:52 9:02TV 3:16 3:37* 2:43* 3:37* 2:43* 2:47 4:41* 3:50Videotaped TV shows 0:16 0:20* 0:10* 0:17 0:14 0:12* 0:27† 0:18‡Videotapes 0:29 0:29 0:29 0:30 0:28 0:28 0:32 0:34Movies 0:20 0:26* 0:11* 0:22 0:19 0:13* 0:29 0:35Video games 0:27 0:32* 0:20* 0:41* 0:12* 0:23* 0:35 0:35Print media 0:44 0:50* 0:37* 0:41* 0:48* 0:43 0:47 0:35‡Radio 0:48 0:35* 1:05* 0:43* 0:54* 0:49 0:45 0:56CDs and other audiotapes 1:05 0:47* 1:29* 0:55* 1:16* 1:09 1:03 1:08Computer 0:31 0:32 0:30 0:35* 0:26* 0:30 0:31 0:29

For each demographic classification, the mean amount of time youngsters in each subgroup are exposed to each medium are compared.* Means differ significantly within a demographic classification.† Mean for black youth differs significantly from those for white and Hispanic youth.‡ Mean for Hispanic youth differs significantly from those for white and black youth (P � .05, t test for difference between independentmeans).Adapted from table 2, J Adolesc Health. 2000;27(2 suppl):8–14.



search by Brown and Steele23,98 indicates that ado-lescents’ media diets are governed primarily by theteen’s developing sense of self and that their mediadiets differ greatly by gender and race.

The following sections summarize the makeup ofthe media diet of American adolescents and whatlittle we know of its consequences for their sexualattitudes and behaviors.

Broadcast and Cable TV

ExposureTV viewing among adolescents is pervasive, and

many adolescents view TV alone, with or withoutadult input or monitoring.14 Virtually all householdsin the United States have at least 1 TV set, 69% have�3, and 98% have a videocassette recorder (VCR).95

In addition, two thirds of youth aged 8 to 18 reporthaving a TV in their bedroom, and more than onethird have their own VCR.14

Approximately two thirds of US youth live inhomes with cable TV.95 Among those aged 8 to 18,74% reported that their home received cable or sat-ellite TV, and 46% received premium channels. Inaddition, 30% of youth surveyed reported receivingcable/satellite channels in their bedrooms, with 15%receiving premium cable. Black youth (38%) areslightly more likely to report having a cable or sat-ellite connection in their bedroom than white (29%)or Hispanic (31%) youth.14 Black youth report signif-icantly higher cable TV viewing than white and His-panic youth, watching 5.5 hours per week of MTV(Music Television), compared with 90 minutes per

Fig 1. Proportion of time spent on each medium contributes to total media budget according to age. Note that, because of rounding, thetotal may not add up to 100%. Source: Kids & Media @ the New Millennium: a comprehensive national analysis of children’s media use.Available at: www.kff.org/entmedia/loader.cfm?url�/commonspot/security/getfile.cfm&PageID�13267.

TABLE 3. Percentage of 8- to 18-Year-Olds With Media Access in Their Bedroom According to Age, Gender, and Race/Ethnicity

Medium Total Sample(N � 2065)

Age, y Gender Race/Ethnicity

8–13 14–18 Boys Girls White Black Hispanic

TV, % 65 65 65 68 62 61* 81 77VCR, % 36 34 38 39 34 34† 45 37Radio, % 86 81* 94* 85 88 89 82 85Audiotape player, % 81 74* 89* 78 84 84‡ 78 74CD player, % 75 64* 88* 71 78 81* 66 65Video-game player, % 45 47 42 59* 32* 42† 59 51Computer, % 21 23 19 22 21 20 25 22Cable/satellite TV, % 30 28 32 32 27 29 38 31Premium cable TV, % 15 15 15 16 15 14 22 17Internet access, % 10 9 12 13 17 10 10 12

For each demographic classification, the proportions of youngsters in each subgroup using each medium are compared.* Proportions differ significantly within demographic classification.† Proportion for white youth differs significantly from that of black youth.‡ Proportion for white youth differs significantly from that of Hispanic youth (P � .05, t test for difference between independentproportions).Adapted from table 3, J Adolesc Health. 2000;27(2 suppl):8–14.



week for white youth, and 7.7 hours per week of BET(Black Entertainment Television) viewing.99 Teenstend to “channel-surf” through a wide variety ofcable networks, with MTV being predominant; the

advent of digital TV will expand the number ofavailable cable channels to 400 to 500.100 Significantdifferences in cable viewing are apparent by gender.Among girls, the most popular cable stations includeMTV, Disney, and the WB, whereas boys are morelikely to watch Comedy Central, ESPN, and the Car-toon Network.99

The average teenager spends �3 hours per daywatching TV.14 Black youth report significantlyhigher overall daily TV viewing than other racial/ethnic groups, and black and Hispanic youth aresubstantially more likely than white youth to have aTV in their bedrooms.14 Approximately one fifth ofthose aged 8 to 13 and one third of those aged 14 to18 report that their overall daily TV viewing occursalone, without parents, siblings, or peers. Even dur-ing evening hours, when parents are more likely tobe home, 32% of those aged 8 to 13 and 38% of thoseaged 14 to 18 report watching TV alone.14 In addi-tion, seemingly few parents establish rules aboutwhen or what their children may view: only 38% ofyoungsters aged 8 to 18 reported having householdrules about TV viewing.95 However, we do not knowwhether their parents would agree as to the absenceof such rules, and the data are not recent enough tocover the effectiveness of such technologic restric-tions as the V-Chip.

ContentResearch evaluating the sexual content of TV indi-

cates that it is pervasive and seems to have increasedover the past 2 decades,83,101–103 perhaps cresting in1998. In more recent years there are some indicationsof reductions in such content, at least during thebroadcast networks’ “family hour,”104 but the overallproportion of programs with sexual content contin-ues to increase.84

Table 6 summarizes studies examining sexual con-tent in the TV shows (broadcast and cable) that aremost popular with adolescents. The shows mostwatched by adolescents in 2001–2002 had “unusuallyhigh” amounts of sexual content84 compared withTV as a whole: 83% of programs popular with teenshad sexual content, and 20% contained explicit orimplicit intercourse. On average, each hour of pro-gramming popular with teens had 6.7 scenes thatincluded sexual topics.84 In a 1996 study (5 years

TABLE 4. Exposure to TV in Social Context: Percentage (%) of7th- to 12th-graders who report viewing TV mainly alone, withsiblings or friends, and with parents

% Viewing TV Age

8–13 y 14–18 y

MorningsAlone 33* 52*With siblings/peers 49* 32*With parents 20 16

AfternoonsAlone 24* 51*With siblings/peers 47* 36*With parents 23 19

EveningsAlone 32 38With siblings/peers 46 43With parents 31 25

For each part of the day within each column, percentages do notsum to 100% because youngsters may view simultaneously withparents and siblings or friends and because this summary does notinclude other adults. The proportion of younger and older youthviewing in each social context is compared within each row.* Proportions differ significantly across age groups (P � .05, t testfor difference between independent proportions).Adapted from table 2, J Adolesc Health. 2000;27(2 suppl):8–14.

TABLE 5. Exposure to Other Screen Media in Social Context:Percentage of 7th- to 12th-Graders Reporting Using VariousScreen Media Mainly Alone, With Siblings or Friends, and WithParents

Medium % Viewing or Using

MainlyAlone

MainlyWith

Parents

Mainly WithSiblings or

Friends

Video 27 25 56Movies 15 11 60Video games 55 2 36Computer games 64 3 13Chat rooms 61 10 16Web sites 61 6 21

Rows do not sum to 100% because questions about parents, sib-lings, and peers are not independent, and proportions do notinclude other adults with whom youngsters may have viewedmedia.Adapted from table 4, J Adolesc Health. 2000;27(2 suppl):8–14.

Fig 2. Cartoon by Jeff Stahler: © Columbus Dis-patch/Dist. by Newspaper Enterprise AssociationInc.



previously) that looked at the programs most popu-lar with adolescents, two thirds of all shows includedsexual content, and 7% portrayed couples engagingin sexual intercourse.105 Moreover, most sexual be-havior (79%) occurred between participants whowere not married to each other.105

Table 7 summarizes the studies of the sexual con-tent in genre TV. Even in family-hour programming,a 1996 study found that on 1 network, almost half(46%) of the family-hour shows had sexual content ofsome sort, and the figures were 30% and 42% at 2other networks.101 With respect to daytime TV, soapoperas and talk shows have a very high level ofsexual content.84,106–108 Some 3 to 4 million Americanteenagers are regular soap-opera viewers, particu-larly lower-income and minority teens.106 Althoughsoap operas are the most likely type of TV program-ming to present sexual content,84 they rarely portraynegative consequences of sexual activity.108 Sexualrelationships, sexual fidelity, and sexual orientationare frequent topics on TV talk shows: general sexualactivity is featured in approximately one third oftalk-show episodes, and sexual infidelity is discussedin 1 in 5 talk-show episodes.107

The Kaiser Family Foundation biennial studies(Table 8) are the only ongoing monitoring of sex onTV as a whole. Across the TV landscape, the overallproportion of programs with sexual content in 2001–2002 was significantly greater than that observed in1997–1998.84 Over this time period, references to sex-ual intercourse became more frequent (including theportrayal of sexual behavior), the proportion of pro-grams with depictions of sexual behavior rose, andthe average number of scenes depicting sexual be-havior increased.84

Characters involved in sexual behavior in TV pro-grams rarely experience any negative consequences.For example, in the most recent Kaiser Family Foun-dation study,84 programs with a primary emphasison sexual risk and responsibility themes represent

only 1% of all shows that contain sexual content,which means that 3 of the 200 programs in this studyhaving intercourse-related content placed primaryemphasis on sexual risk or responsibility. Moreover,protection against STIs and unwanted pregnancywas observed in only 3% of all scenes with sexualcontent. Risks and negative consequences of sexualbehavior were found in only 2% of all scenes withsexual content (specifically, 75 of 870 scenes of sexualbehavior). Delaying sexual intercourse was depictedin only 1% of all scenes with sexual content.84 Ittherefore would seem that TV programming wouldbe providing parents with many opportunities to“use controversial programming as a stepping-offpoint to initiate discussions about family values, vi-olence, sex and sexuality, and drugs.”109 “Would be”if adolescents watched TV with their parents, but asseen in Roberts’ 2000 study14 (Table 4), they mostlydo not.

EffectsAlthough we know a great deal about the sexual

content of TV, we know relatively little about itseffects (Table 9). Associational studies, while sugges-tive, are not evidence of causality. Only 2 studieshave examined the relationship over time betweenexposure to TV and sexual behaviors in adoles-cents.16,110 In the first study, Peterson et al16 analyzeddata from the first 2 waves of the National Survey ofChildren. The first wave was conducted in 1976–1977 and comprised 2301 children; the second wavewas conducted in 1981 among 1423 from the firstwave. Because this study used secondary analysis ofexisting data that were not intended to examine theserelationships, it has serious methodologic flaws inthe measurement of TV exposure and content as wellas in the measurement of sexual-activity variables.Mixed results were reported indicating the totalamount of TV viewing in early adolescence was sug-gestive of an association between amount of TV

TABLE 6. Sexual Content in TV Programming Popular With Adolescents: Summary of Studies (Listed in Order of Data Collection)

Study Data Key Findings Regarding Sexual Content

Greenberg et al102 (1993)(Project CAST:Children and Sex onTelevision)

Three daytime and 19 prime-time shows mostwatched by 9th- and 10th-graders in survey; TVshows videotaped in 1985, survey done in 1986

Sexual content: verbal reference to or visualportrayal of sexual activity; frequency:3.67 per h (soap operas) and 2.95 per h(prime time)

Ward103 (1995) Dialogue in 3 episodes each of 10 prime-time TVprograms most popular among 12- to 17-y-olds,airing March/April 1993

Statements about sexual issues occurred in20–50% of interactions betweencharacters

Cope-Farrar andKunkel105 (2002)

Three episodes each of 15 programs most popularwith 12- to 17-y-olds, airing January–November1996

Two thirds of programs had sexual content(behavior or talk); 7% of programsdepicted intercourse; 79% of sexualbehavior occurred between people notmarried to each other

Kunkel et al84 (2003) (forthe Kaiser FamilyFoundation: Sex onTV3)

Substudy of 3 episodes from each of the 20 seriesviewed most frequently by 12- to 17-y-olds,2001–2002 (total: 59 programs)

Programs viewed most frequently by teenshave “unusually high” sexual content,greater than prime time in general or TVoverall; 83% of programs had any sexualcontent (behavior or talk); 80% ofprograms had sexual references (talkabout sex); 49% contained sexualbehavior, 59% of which was passionatekissing; 20% contained behavior that wasexplicit or implicit intercourse

These studies focus specifically on shows popular with teenaged audiences. More general surveys are outlined in Tables 7 and 8.



watched and early initiation of sexual intercourse;however, the results did not reach statistical signifi-cance.16

Statistical significance is found in the work of Col-lins et al,110 who conducted a national longitudinaltelephone survey in 2001 and 2002 of 1792 adoles-cents aged 12 to 17. They surveyed the participantstwice, 1 year apart, and found important associationsbetween the amount of sexual content viewed byadolescents and advances in their levels of sexualbehavior during the subsequent year.110 As adoles-cents went from the 10th percentile to the 90th per-centile in exposure to sexual content on TV, thelikelihood they would begin to have sexual inter-course in the next 12 months doubled. It is notablethat, in accordance with social-learning theory, the

study found that exposure to talk about sex wasassociated with the same risk as exposure to morevisually explicit programming.

Initiation of various levels of sexual behavior in-creases as adolescents grow older. Collins et al110

found that watching TV with sexual content has theeffect of artificially aging children: those whowatched more than average (by 1 standard devia-tion) behaved, sexually, as though they were 9 to 17months older and watched only average amounts.The 12-year-olds who watched the most had thesexual behaviors of the 14- and 15-year-olds whowatched the least.

The study also found that, at least for black ado-lescents, exposure to portrayals of sexual risks and ofthe need for sexual safety and delay of sexual behav-

TABLE 7. Sexual Content in Genre TV Programming: Summary of Studies (Listed in Order of Data Collection)

Study Genre and Data Key Findings Regarding Sexual Content

Greenberg and Busselle106 (1996)(based on October 1994 report forthe Kaiser Family Foundation:Soap Operas and Sexual Activity)

Daytime soap operas: analyzed 50 h(10 episodes each of 5 programs)(1994)

Most frequent sexual content: unmarried sexualintercourse, averaging 2.4 incidents per h

Next most frequent content: rape, 1.4 referencesper h

Intercourse among couples married to each other:0.72 incidents per h

Sixty-five percent of the married-coupleintercourse incidents referred specifically topregnancy

Forty-six percent of the married pregnancyreferences were positive, and 21% were negative

Unmarried sexual partners outnumbered marriedpartners 3 to 1

Prostitution: 0.14 references per hMiscellaneous sexual content: 0.70 references per h

Greenberg and Smith107 (2002) Talk shows: analyzed 10 episodeseach of 11 top-rated shows airingJuly 18–August 25, 1995

One third discussed sexual activityOne fifth focused on sexual infidelityOne tenth focused on sexual orientation

Johnson101 (1997) (Parents TVCouncil)

Family-hour programming:analyzed 93 h (144 episodes) onbroadcast networks airingJanuary 30–February 26, 1996

Sixty references to sexual intercourse, 0.65 per h(32 references to premarital sex, 12 to maritalsex, 11 to extramarital sex, 5 unclear)

CBS: 0.82 sexual references per h, 42% of family-hour shows had sexual content

NBC: 0.67 sexual references per h, 30% of family-hour shows had sexual content

Thirty-one percent of family-hour programscontained at least 1 reference to sexualintercourse Of the 86 family-hour shows ratedTV-PG, 36% contained sexual references

Heintz-Knowles108 (1996) (for theKaiser Family Foundation: SexualActivity on Daytime Soap Operas

Daytime soap operas: analyzed 97 hof the 10 nationally televisedshows for motivation andoutcomes of sexual activity inepisodes aired May 27–June 28,1996

Individual sexual behaviors: 594 (�6 per h)Sexual content was twice as likely to be behavioral

than verbal (the opposite was true in 1994),although most behaviors were “modest” (eg,kissing and caressing)

Although discussion and depictions of planningand consequences of sexual activity hadincreased slightly since 1994, they were “largelyconfined to a few discrete story lines dealingwith consequences” “Most sexual interactionsoccurred between participants involved inestablished relationships with each other”

Most sexual activity was portrayed as having “apositive effect on the participants’ relationships”

Parents Television Council151 (2003) Reality TV: reviewed 38 series (25broadcast, 13 cable) for a total of125.5 h of programming (89.5broadcast, 36 cable) airing Jan 1,2001–May 1, 2002

Sexual references per h: 0.9Depictions of sexual activity per h: 0.7UPN had 3.4 instances of sexual content per h;

Fox had 3.1 instances of sexual content per hOne show included 6.5 instances of sexual contentOverall, reality-based series included 3.9 instances

of sexual content per h

Although these genres are known to be popular with teens, the studies did not focus on those shows particularly popular withadolescents.



ior was related to lower levels of noncoital sexualbehavior. However, such portrayals are so rare thatno conclusions could be drawn about their effective-ness with respect to other ethnic groups. Moreover,the researchers knew of no theory that could explainwhy such an effect was present for black adolescentsas distinct from other subgroups. The results there-fore point to an area in need of focused research.110

Although the limited duration (2 years) of thisstudy limits its interpretive power in some respects,the authors were clear: the magnitude of their resultswere such that “a moderate shift in the averagesexual content of adolescent TV viewing could havesubstantial effects on sexual behavior at the popula-tion level.”110 However, they also cautioned thatsuch a reduction might not be easy to effect and thatan approach that does not try to change either thecontent of TV or teenage viewing habits might provemost workable (eg, parents watching TV with theirchildren).110

Other studies have examined the association be-tween exposure to TV and sexual behaviors andattitudes toward sexual activity, but in a cross-sec-tional fashion. These correlational studies do not per-mit inferences to be made about a direct associationbut allow assessments of whether media is at allassociated with sexual attitudes and behaviors. Re-sults from these studies indicate that high schoolstudents in North Carolina who watched TV showswith high sexual content were more likely to havesexual intercourse than those viewing TV shows

with a smaller proportion of sexual content.111 Re-search findings also indicate that adolescents whoview more TV with sexual content tend to overesti-mate the frequency of certain sexual behaviors112,113

and have more permissive attitudes toward premar-ital sex.114 Youth who were exposed to content por-traying sexual relations outside of marriage were lesslikely to rate these portrayals negatively, comparedwith youth exposed to content portraying sexualrelations within marriage or scenes of nonsexual re-lations.113

Although these studies provide support for anassociation between sexual content on TV and ado-lescent sexual attitudes and behaviors, because of thecross-sectional design of the studies the direction ofthe influence is unknown. For example, it has beenreported that sexually experienced students are morelikely to seek out sexual content on TV than nonsexu-ally experienced youth.111 In addition, most studiesare seriously limited by small samples and restrictedsampling frames.

Although experimental evidence is generally con-sidered the gold standard for establishing a causalrelationship between exposure variables and out-comes, methodologic and ethical considerationshinder the use of the experimental designs to assessthese associations among youth.115 For example, it isgenerally considered unethical to expose youth tosexually explicit materials, and therefore most exper-imental studies are conducted among college stu-dents, threatening generalizability of the findings to

TABLE 8. Sexual Content in TV Programming as a Whole: Summary of Kaiser Family Foundation Sex on TV Study Series

Kunkel et al82 (1999),Sex on TV 1

Kunkel et al83 (2001),Sex on TV (2)

Kunkel et al84 (2003),Sex on TV: 2003

Data* 942 programs(1997–1998 season)

938 programs(1999–2000 season)

937 programs(2001–2002 season)

Sexual content of all programsSexual content, % (no. of programs) 56 (528) 68 (642) 64 (595)Sexual talk, % (no. of scenes) 54 (1719) 65 (2470) 61 (2453)Sexual behavior, % (no. of scenes) 23 (420) 27 (608) 32 (870)

Precursory only, % (no. of scenes)† 16 (244) 17 (286) 18 (357)Intercourse, % (no. of scenes)‡ 7 (88) 10 (147) 14 (200)

Sexual content of broadcast prime-time programsSexual content, % (no. of programs) 67 (184) 75 (199) 71 (183)Sexual talk, % (no. of scenes) 65 (763) 73 (931) 69 (903)Sexual behavior, % (no. of scenes) 24 (113) 29 (174) 33 (179)

Precursory only, % (no. of scenes)† 16 (61) 21 (107) 20 (107)Intercourse, % (no. of scenes)‡ 9 (31) 8 (31) 12% (40)

In all programs with sexual contentOverall 3.2 scenes per h;

39% have scene(s) with“substantial emphasis on sex”

4.1 scenes per h;78% have �2 sceneswith sexual content

4.4 scenes per h;82% have �2 sceneswith sexual content

Sexual talk, scenes per h 3.0 3.8 3.8Sexual behavior, scenes per h 1.4 1.8 2.1

Intercourse, no. of scenes‡Strongly implied 71 119 165Depicted 17 28 35

In prime-time programs with sexual content,overall, scenes per h

5.3 5.8 6.1

* The Sex on TV studies all use a “composite week sample” of randomly selected programs from commercial broadcast, public broadcast,basic cable, and premium cable, 7 am to 11 pm, excluding newscasts, sports, and children’s shows. “Program” should be understood as“episode,” not “series.” “Sexual content” includes both sexual behaviors and sexual talk.† Precursory only: sexual behaviors such as physical flirting, passionate kissing, and intimate touching, but intercourse is neither depictednor strongly implied as occurring. However, the action must convey a sense of potential or likely sexual intimacy and be a substantialpart of the scene in which it occurs. Number of scenes is from those programs that only have precursory behaviors.‡ Intercourse is depicted or strongly implied “directly or by portraying characters who are about to begin or have just finished havingsex.” Number of scenes does not include scenes of precursory behaviors in the same program.



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younger, non–college populations. “Natural experi-ments” such as the 1995 introduction of broadcast TVto a media-naive population in Fiji69 are rare; theirresults, although certainly suggestive, may not begeneralizable to media-saturated American adoles-cents. Moreover, experimental studies most often in-volve short-term exposures of specific programmingand thus cannot determine the effects of long-termcumulative exposures over time. The question ofcausality, therefore, must be answered by long-termlongitudinal studies.

Music Videos

ExposureIn a 1999 study, 10% of 8- to 18-year-olds reported

watching music videos on the previous day.95 Astudy of 1533 9th-graders reported average exposureto music videos of 10 hours per week.116 MTV is themost popular TV network for young females and thefourth most popular for young males. Despite anincrease in the amount of time dedicated to actual“programming” on MTV, 53% of all teens cite it astheir preferred source for new music.99

ContentDepending on the music genre, one fifth to one

half of music videos portray sexuality or eroti-cism.117,118 Often, music videos present visual im-ages that are much more sexual than the music.119

Some studies from the 1980s analyzing the content ofmusic videos indicated that sexual intimacy wasshown in �60% to 75% of them, that there was anemphasis on sexual contact without commitment,that physical contact occurred at twice the rate it didon conventional TV, and that 81% of videos thatshowed violence also showed “sexual imag-ery.”118,120 Another study from the same time period,however, indicated that only 47% (of 70 videos) hadeither visual or lyrical sexual references.114

EffectsAs seen in Table 10, in a small 1986 study,114

adolescents who had just watched an hour of MTVvideos were more likely to report approval of pre-marital sex than those who had not. A larger study 1decade later121 found that adolescent girls showed astronger relationship between exposure to musicvideos and attitudes relating to premarital sexualpermissiveness than did adolescent boys, and thatthe association is even stronger for those girls withlow rather than high family satisfaction. Again, how-ever, the data do not determine a causal relationship,and the sample size and study design do not allowcontrolling for extraneous and confounding variables.

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lescents (8- to 13-year-olds) listened to an average of35 minutes per day; overall, 8- to 18-year-old girlslistened �7 hours/week and boys listened just 5hours/week. The current level of exposure is un-known.

As to the social context of this exposure, it is re-ported that during the week, adolescent radio listen-ing is highest at 3 to 7 pm, whereas on weekends,teens listen the most from 10 am to 3 pm. The major-ity of teens listen to radio either at home or in thecar,123 and 86% report having a radio in their bed-room.14

ContentRadio stations targeting adolescent audiences have

become highly specialized (eg, alternative rock, hot100, top 40, rap, country/western).124 According to 1study, among 12- to 19-year-olds, rap/hip-hop (44%)and top 40 (43%) radio stations are the most lis-tened-to radio formats. Rhythm and blues and hardrock/heavy metal tie for third place (21% and 20%,respectively).99 However, few content analyses ofradio programming have been conducted.125 A small

study of 473 teen-oriented radio segments (15 hours)from the week of February 8 to 12, 1999, was con-ducted in the Minneapolis-St Paul market.126 Over-all, 22% of radio segments contained sexual content.Each segment with sexual content was coded on a4-point scale for amount of explicitness: not at allexplicit, a little explicit, pretty explicit, and very ex-plicit; some examples:

“…It was so dumb/should’a used a condom…. Let him dohis thing/I’m the one he’s loving/I’m here to show y’all/having the kid ain’t meaning nothing/That ain’t keepinghim/especially if he in love with another chick/then you’restuck with the infant mother shit” (Foxy Brown, My Life). Thesong was coded as sexual innuendo: pretty explicit, includingdiscussion of responsibilities and consequences.

“It’s been three weeks since you’ve been looking for yourfriend/The one you let hit it and never called you again….You act like you ain’t hear him then gave him a little trim….Plus when you give it up so easy you ain’t even foolinghim/If you did it then, then you probably fuck again…. Thequick to shoot the semen stop acting like boys and be men.”(Lauryn Hill, Doo Wop [That Thing]). The song was coded asdirect discussion of sexual intercourse: very explicit, includ-ing discussion of planning, the benefits of sexual patience,and fidelity.

TABLE 10. Effects of Exposure to Sexual Content in Music Videos, Radio, and Music: Summary of Studies

Study Focus of Study and Study Population Key Findings Regarding Sexual Effects

Greeson and Williams114

(1986)Hypothesis: sexual content of popular music and

MTV reflects and influences adolescent behaviorsand concerns

Sexual references in lyrics or visual scenes werenoted in 47% of the videotapes

Population: convenience sample of 34 10th-gradersand 30 7th-graders (age range: 13–16 y); 80%small-town urban (southwestern Ohio); mostlymiddle-income families; 100% white, 50% female

Younger students were significantly less likelyto report agreement with parent attitudesthan older students

Significant effect was noted for video viewingon the mean score for attitudes towardpremarital sex: after 1 h of MTV videoviewing, both 7th- and 10th-graders weremore likely to report approval of premaritalsex than their peers who had not viewedMTV

Strouse et al121 (1995) Hypothesis: music-video exposure influencesadolescents’ premarital sexual attitudes andbehavior, especially among girls from impairedfamily environments

Girls reported greater TV viewing of MTV andgeneral exposure to popular music, moreconservative attitudes toward premaritalintercourse, and greater prevalence of virginstatus than boys

Population: 214 Midwestern high school students;83% white; ages 13–18 y (mean age: 15 y)

Among girls with low family satisfaction, thosereporting a high level of music-videoexposure were almost 4 times more likely toreport nonvirginity status than were theirlow-exposure peers

Among the high-family-satisfaction group,there was no association between music-video exposure and virginity status,supporting the importance of healthy familyfunction as a moderator for female adolescentsexual attitudes and behavior

TABLE 11. Effects of Exposure to Sexual Content in Movies: Summary of a Study

Study Focus of Study and Population Key Findings Regarding Sexual Effects

Wingood et al130

(2001)Focus: examine the effects of youth exposure to

X-rated films on attitudes and behaviorsrelated to contraception

Population: 522 black females, aged 14 to 18 y,and sexually active in the prior 6 months

Data: Collected in Atlanta, GA, 1996–1999

Exposure to X-rated films was associated with greaterlikelihood of

Negative attitudes toward condom use (OR: 1.4)Having multiple sex partners (OR: 2.0)Having more frequent sex (OR: 1.8)Not using contraception during most recent intercourse

(OR: 1.5)Not using contraception during past 6 months (OR: 2.2)Having a strong desire to become pregnant (OR: 2.3)Testing positive for chlamydia (OR: 1.7)



Of the 100 segments coded as including sexualcontent, 20% were pretty explicit or very explicit.Very few segments included messages concerningplanning or responsibilities (1%), consequences orrisks (4%), or fidelity or monogamy (5%). Sexualcontent on the radio occurred during music seg-ments (45%), during talk segments (30%), and duringcommercials (9%).126

The small sample precludes generalizing. More-over, these data are, in the fast-moving world ofelectronic media, dated. We do not know the currentsexual content of those portions of radio program-ming to which various subgroups of adolescents lis-ten.

EffectsAlthough most teens apparently listen to the radio

every day, no studies of the effects of this exposurewere identified.

Music

ExposureThe amount of exposure to music media including

radio, CDs, and audiotape cassettes doubles fromearly to late adolescence14 (see Table 2 and Fig 1).Among those aged 8 to 13, listening to radio, CDs,and audiotapes collectively comprises 17% of theirtotal daily media exposure; among older teens (aged14–18), it increases to 34% of the total, an average of�20 hours per week.14 Adolescents listen to musicfor several hours per day, usually as backgroundmusic,122 and almost all teens have �1 sources ofmusic in their bedroom.14 Among middle and highschool students, rap/hip-hop and alternative rockare the dominant music genres. Boys are more thantwice as likely as girls to listen to hard rock (27% vs12%), whereas girls are more likely than boys tolisten to gospel (11% vs 5%). White, black, and His-panic youth have very different music preferences.Rap/hip-hop is more widely listened to by black(84%) and Hispanic (72%) youth than by white (43%)youth, whereas white and Hispanic youth are morelikely to listen to alternative rock. White youth aremore likely to listen to hard rock/heavy metal (24%)than black and Hispanic youth (2% and 12%, respec-tively).95

ContentA 1999 study of 10 top-selling music CDs indicated

that of the 159 songs analyzed, 42% contained sexualcontent,126 41% of which were pretty explicit or veryexplicit (see examples in the preceding section).126

Again, the size and date of the sample precludeextending its results to the present.

EffectsNo studies were identified that examined the ef-

fects of sexually explicit lyrics on adolescent sexualattitudes and behaviors.

Movies

ExposureYoung people are a key marketing segment for the

film industry: in a marketing survey of 12- to 17-

year-olds, 20% report going to the movies 2 to 3times per month during the past 3 months; �9%report going �1 per week.123 Black and Hispanicyouth report greater exposure to movies than whiteyouth.14 Teens usually do not go to the movies withtheir parents: 60% of 7th- to 12th-graders report go-ing to the movies mainly with siblings or friends, and15% report going mainly alone.14

Although the Motion Picture Association of Amer-ica will not reveal the current percentage of R-ratedmovies, that rating accounts for 58% of all moviesmade from 1968 to 2003 and 20% of the 20 top-grossing films in 2003.127 In 1993, most young peoplehad viewed an R-rated movie long before theyreached the required age of 16 (now 17).128 A 2004Federal Trade Commission report revealed that, afterwidely publicized pressure on theater owners, only36% of unaccompanied “mystery shoppers” �17years old were able to buy theater tickets to seeR-rated films; however, 81% of them were able tobuy such films on DVD.34

ContentAlthough youth are a primary audience of Holly-

wood movies, few studies have assessed the sexualcontent of movies viewed by youth. Only 2 identifiedstudies have analyzed the content of top movie vid-eotape rentals and R-rated movies frequently viewedby young people.128,129 Both studies reported a highamount of sexual content, with the most commonsexual activity occurring among unmarried partners.For example, the study of top movie videotape rent-als of 1998 reported that 15% of scenes portraying sexoccurred among married couples as compared with85% among unmarried people. The most commonsexual activity (45%) among unmarried partners wasintercourse, and sexual behavior among marriedcharacters was rare and rather mundane comparedwith those having unmarried sex.129 A 1993 Green-berg et al128 study found that in 16 popular R-ratedfilms seen by 14- and 15-year-olds, there were onaverage 17.5 scenes with “coded acts” and 10 in-stances of nudity per film. Coded acts included in-tercourse, long kisses, petting, and visual or verbalreferences to sexual activity. Although the majorityof references to sexual intercourse were verbal, onethird of all references had some visual component.128

Although significant concern has been raised re-garding adolescents’ exposure to NC-17- (no one 17and under admitted) and X-rated movies, limiteddata are available in this area. In a 1996–1999 studyof sexually active black girls aged 14 to 18 years, 30%reported viewing an X-rated movie on videotape orin a theater in the previous 3 months.130

EffectsFew studies have assessed the effects of exposure

to X- and NC-17-rated movies and on adolescentsexual attitudes and behaviors. In 2001, sexually ac-tive black female adolescents aged 14 to 18 who wereexposed to X-rated movies were more likely to havemultiple sexual partners, to have sex more fre-quently, to test positive for chlamydia, to have morenegative attitudes toward using condoms, and to be



less likely to use contraceptives.130 The cross-sec-tional research design, however, does not allow de-termination of causality, and it is unknown whetherthe results are generalizable to other subgroups ofadolescents, such as other ethnic groups or males.130

We do not know if the sexual content of R-ratedmovies has comparable effects and, if so, for whichdemographic groups.

Magazines

ExposureData on magazine consumption also varies de-

pending on the source; for example, data from anonline marketing survey found that 48% of all teensread 1 or 2 magazines per month (P. Eitel, PhD,written communication regarding NeoPets.com on-line study, 2003). Another marketing survey foundthat 85% of teens have read or looked at a magazinein the last 6 months.131 Teen girls read magazinesmore frequently than teen boys, and each genderuses magazines for distinct purposes: girls read forstyle information, taking cues on fashion and beauty,whereas boys choose magazines that focus on theirparticular interests, mostly sports and gaming, fol-lowed by girls and music.99

ContentTeen-girl magazines include an average of �80

column inches per issue on sexual topics (�1–6 ar-ticles). Content analysis indicates that magazinesaimed at teen girls provide messages that girlsshould be beautiful and plan their lives to attract aman, and girls are depicted as objects of male sexualdesire in editorial content as well as in advertisingmaterial.132–134

EffectsNo studies have examined the effects of the sexual

content of magazines (whether explicit adults-onlyor mainstream publications) on sexual attitudes andbehaviors among adolescents, although some havetheorized about the possibilities.134

AdvertisingTeens are one of the fastest growing segments of

the consumer population, having spent an estimated$170 billion in 2002. Marketers have focused atten-tion on how to effectively capture and capitalize onadolescents spending power and have written pub-lications (eg, Getting Wiser to Teens32) dedicated to-ward better understanding teen consumers and howto influence their decisions and purchasing behav-iors. It must be noted that although advertising’sintended effect is to change consumer purchasingbehavior, its unintended side-effects can be bothwide ranging and unpredictable.

ExposureAdvertising permeates almost all media to which

teens attend, and exposure to advertising is perva-sive.135 The average child sees an estimated 20 000advertisements each year. By the age of 12 years theaverage child has taken in �140 000 messages, and

by age 19 this number doubles to nearly 300 000.32

These huge numbers have resulted in decreased at-tention to advertising and an increase in the market-ing savvy of media-saturated teens, who thereforeare less likely to be easily persuaded by advertising.At first glance this may seem positive, especiallygiven the sexual (visual) content of advertisementsselling everything from soda (eg, sexy bikini-clad“Fantanas” in Fanta commercials; Britney Spears’Pepsi commercials) to candy (eg, a girl who unwrapsa Starburst with her tongue) to male body products(eg, Axe body-spray commercials). The data, how-ever, refer predominantly to “traditional” methodsof advertising such as TV, magazine, and radio ad-vertisements. These do not take into account thenontraditional approaches that marketers are adopt-ing to influence teens more effectively, approachesthat are less easily measured and quantified. There isevidence that nontraditional advertising messagesthat feature embedded and subtle messaging mayactually be even more influential, appealing, andpowerful to teens33 (see “Power of the Indirect”above).

ContentThere are little scientific data about the sexual

content of either overt or embedded advertising. Onestudy indicated that the proportion of undressedwomen in advertisements has changed little over thelast 40 years, whereas the proportion of undressedmen has increased significantly, especially since theearly 1980s136; the impact of these increased portray-als of men has not been examined.

EffectsWe do not know the effects of the sexual content of

advertising on adolescent sexual attitudes and be-haviors.

Video and Computer Games

ExposureThe annual industry growth of the video and com-

puter games industry in the United States has beenmeteoric, from $100 million in sales in 1985 to $10billion in 2003.137 Of households surveyed in 1999,70% reported having a video-game system; boys’homes (59%) were more likely than girls’ homes(32%) to contain such a system, and boys were alsomore likely to have a video system in their bedroomthan were girls (43% of boys versus 23% of girls).14

Black and Hispanic youth report greater exposure tovideo games than white youth, and black youth aremore likely than white youth to have a video-gamesystem in their bedroom.14 Fifty-five percent of thosein grades 7 to 12 who play video games report play-ing mainly on their own or with siblings or friends(36%).14 Only 2% report playing with their parents.14

In a study of 7th- and 8th-graders, the average timespent playing video games was 4.2 hours per week.Boys played more frequently in video arcades (50%compared with only 20% of girls).138 A study of 15339th-graders reported average exposure to videogames of 8 hours per week.116



Among 8- to 18-year-olds, a significantly higherproportion of white (78%) than either black (55%) orHispanic (48%) youth report living in computer-equipped households. Of these youth, approxi-mately one fifth (21%) have a computer in their bed-room.14 Among youth who use computers, averagedaily computer use time ranges from 1 hour and 45minutes among those 8 to 13 years old to 1 hour and37 minutes among those 14 to 18 years old, withcomputer games claiming the largest share of leisurecomputer time. Older boys spend slightly more timewith computers than do older girls, and Hispanicyouth report more daily computer use (2 hours, 12minutes/day) than either black (1 hour, 46 minutes/day) or white youth (1 hour, 35 minutes/day).14

Nearly two thirds (64%) of youth report playingcomputer games mainly alone.14 Almost half (49%)of teens who use computers report playing computergames (offline) and estimate spending �2.4 hoursper week doing so. Another 53% report playing com-puter games online during the past week.139

Content and EffectsDespite the pervasive nature of exposure to video

and computer games, no studies were identified thathave examined the sexual content of video and com-puter games or the effects of exposure to that contenton adolescent sexual attitudes and behaviors.

The InternetHere the “Internet” includes e-mail, instant mes-

saging, chat rooms, and the World Wide Web withits linkages and Web rings, including game- andmusic-download sites.

ExposureIt is expected that by 2010 most US homes with

children will have access to the Internet.117 It hasbeen estimated that in 2003, 60.8% of all US house-holds (with and without children) had at least 1desktop or laptop computer, and 92.7% of those(56.4% of all US households) had access to the Inter-net.127

On average, 9- to 17-year-olds use the Internet 4days per week and spend almost 2 hours online at atime.140 It is not well understood how much onlineexposure to sexual content is voluntary or involun-tary. In 1 study of teens using computers, 61% re-ported “surfing the net,” and 14% reported “seeingsomething they wouldn’t want their parents to knowabout.”100 Many of those who do not have computersor Internet access at home can log on at school.139

The majority of teens (88%) use the Internet at leastonce per month: 13% report accessing it daily; 13%more than once a day; 17% 1 to 2 times per week;19% 3 to 6 times per week; and 26% less than onceper week.123 The most frequent activities teens en-gage in online include e-mailing (74% read e-mail,67% send e-mail), instant messaging (58%), listeningto music (56%), and playing games (53%).139 A morerecent study conducted by the Kaiser Family Foun-dation among 809 youngsters aged 10 to 17 in SiliconValley, California, shows that 96% of them have goneonline and most have at least basic access to comput-

ers and the Internet. Among those aged 14 to 17, 16%started using the Internet before age 10, and amongthose aged 10 to 13, 49% started using the Internetbefore age 10.141

Teens are drawn to online activities that allowsocial interaction, entertainment, and informationgathering.99 Girls are more likely to be social surfers,whereas boys tend toward entertainment and pur-chasing online. Overall, 75% of teens access the In-ternet at home, 60% access it at school, and 41%access it “somewhere else.”99 The sites visited mostoften include Yahoo.com, Google.com, Hotmail.com,eBay.com, ESPN.com, and MTV.com.99 Sixty percentof youth report accessing chat rooms and Web sitesmainly alone.14

Internet file-sharing programs using peer-to-peernetworks allow users to share and download fileswithout charge. Users of Gnutella (ages unknown)shared 6.1 terabytes of data during the second andthird weeks of October 2001.142 The pervasiveness ofthe technology and the sheer volume of (copy-righted) content being exchanged finally promptedlegal action. The lawsuits filed by the RecordingIndustry Association of America (RIAA) have forcedNapster to go from a file-sharing program to a fee-for-service Web site, but the Gnutella and Kazaasoftware packages are still freely distributed, and theultimate effect is not yet known. In any case, theRIAA lawsuits affect only copyrighted music; theydo not pertain, for instance, to pornography.

ContentTeens have access to a variety of adult-oriented

Web sites on the Internet. Chat rooms, pornographysites, adult-video sites, and romance/dating servicesare but a few of the many and easily accessible“adult-oriented” materials to be found. Studies indi-cate that of the 1000 most-visited sites, 10% are adult-sex–oriented. In addition, portrayals of violent por-nography on the Internet have increased, and accessto such material has become easier.143

Pornographic Web sites offer both still photo-graphs and X-rated videos of every level of visual(and auditory) explicitness; there is even the Internetequivalent of “phone sex,” sometimes with a livevideo connection.100 Search engines such as Googleallow the user to type in words and word combina-tions and get results in seconds. For example, usinga search engine to type “sex pictures,” in �1 seconda researcher was given a list of �2 million relevantsites.144

One 1999–2000 national survey found that 1 in 5youths aged 10 to 17 had inadvertently encounteredexplicit sexual content, and 1 in 5 (19%) had beenexposed to an unwanted sexual solicitation whileonline in the previous year.145 Moreover, 73% ofthese exposures occurred while the youth wassearching or surfing the Internet, and 27% happenedwhile opening e-mail or clicking on links in e-mail oran instant message. Most of the unwanted exposures(67%) happened while the youth was using the In-ternet at home, but 15% happened at school, and 3%happened in libraries. The remainder occurred atother people’s homes and other locations.145 Most of



the imagery was simply of naked persons, but 32%showed people having sex, and 7% involved violencein addition to the nudity and sex.146

EffectsAlthough most teens have access to the Internet,

no studies were identified that have examined theeffects of Internet use (e-mail, instant messaging, orsurfing the Web) on adolescent sexual attitudes andbehaviors.

DISCUSSIONAlthough numerous studies have demonstrated

the effects of media on various behaviors, includingviolence and aggression, social stereotyping, andprosocial behaviors,13 the systematic process of ex-amining sexual content in the media and its impacton adolescent sexual behaviors is in its infancy.13

Several studies16,111,112,114,121,134 have demonstratedclearly that sexual content is pervasive in TV pro-gramming, movies, music videos, and magazines;however, much less is known about sexual contenton the radio (including remarks by disc jockeys) andthe sexual content of video and computer games. It issurprising that only a few studies have assessed thesexual content of the Internet or cable TV, and nonehave specifically examined this content in relation toadolescent exposure. This is particularly trouble-some given that what little evidence there is indicatesthat the Internet and cable TV may contain the mostsexually explicit content.28,100,143 Additionally, fewstudies have examined the sexual content of music, amedium that reaches virtually all adolescents.

Most studies conducted to date on the effects ofsexual content in the media on adolescent sexualattitudes and behaviors have restricted their focus tothe influence of TV exposure. Research findings in-dicate that adolescents who view more TV with sex-ual content tend to overestimate sexual behav-iors112,113 and to have more permissive attitudestoward premarital sex.114 Although these studiessuggest an association between media exposure andadolescent sexual behaviors, they are limited becauseof their cross-sectional study design,111,112,114 limitedsampling designs, and small sample sizes. A morerecent longitudinal study found a significant associ-ation between frequency of sexual content in TVprograms viewed and likelihood of initiation of sex-ual intercourse, as well as progressive engagement inmore advanced noncoital sexual behavior.110

Until recently, no studies have examined the ef-fects of exposure to radio, music, music videos, cableTV, or the Internet on adolescent sexual attitudes andbehaviors. Moreover, no previous study has exam-ined the cumulative effects of multiple media expo-sures or the pattern of exposures on adolescent sex-ual behaviors. Brown et al23 devised a new measurefor determining the sexual content of 4 types ofmedia: TV, movies, CDs, and magazines. Using thesexual-media–diet measure, these researchers reportthat among adolescents, heavier exposure to sexualcontent is associated with increased sexual activityand intentions to become sexually active.23,97

The existing evidence on media exposure clearly

shows that black and Hispanic adolescents havehigher levels of exposure to TV, videotapes, movies,video games, and radio.14 Black and Hispanic youthalso have the highest prevalence of sexual behaviorsas well as STIs and nonmarital pregnancies,1whereas few existing studies on media exposure andsexual beliefs and behaviors have targeted these at-risk groups.

Most studies conducted to date have failed to ex-amine multiple sexual-related outcomes such asearly initiation of sex, number of sexual partners,sexual beliefs, and intentions to have sex. Addition-ally, sexual behaviors such as oral sex have beenignored as potential outcomes affected by media ex-posure. Although few data exist on the prevalence oforal sex, a recent study indicated that 40% of youthreport ever engaging in oral sex.147 To date, no stud-ies have been conducted to assess the effects of me-dia exposure on oral sex among adolescents.

Several ongoing studies regarding the effects ofadolescent exposure to sexual content in media havebeen funded by the National Institutes of Health(NIH) and the CDC, but they have not yet yieldedpublished findings (see Appendix). Among these are3 short-term longitudinal studies (cohorts followedfor 2–3 years) funded by the NIH (D. L. Tolman,EdD, J. D. Brown, PhD, and R. J. DiClemente, PhD,unpublished data, 1999) and 1 long-term (10-year)study funded by the CDC (M. Windle, PhD, Grun-baum JA, EdD, Elliott M, PhD, et al, unpublisheddata, 1999). Two other NIH-funded studies (J. W.Grube, PhD, and M. Fishbein, PhD, unpublisheddata, 1999) are funded for 5 years but do not specifyin their abstracts the timing of their measurements.Study-population sizes range from 5250 (the HealthyPassages study) to a “probability sample” of 865 inDiClemente’s work. Only 2 studies will be looking atthe youngest adolescents. One study is looking spe-cifically at the World Wide Web, 2 are addressingonly TV, and the remaining 3 are looking at multiplemass media.

FUTURE DIRECTIONSBased on this review of the scientific evidence, we

have identified many gaps in our knowledge of thesexual content of various media, the amount of ex-posure to it by adolescents, and the impact of thisexposure. Although studies have documented expo-sure to sexual content in some types of media such asTV, music, and movies, there is a clear dearth ofinformation about the extent and sexual content inother types of media such as radio, advertising, andthe Internet. Moreover, there is a noticeable scarcityof well-conducted, scientifically rigorous studies thatexamine the impact of sexual content in the media onsexual behaviors among adolescents, and there areno studies that have longitudinally examined thecumulative effects of sexual content in differenttypes of media.

It is critical that longitudinal research be con-ducted, and within the multilevel context of childdevelopment: different groups of adolescents (de-fined by age, geographic location, ethnicity, domesticsituation, and other variables) have different media



diets, and identical diets may have differing effectsdepending on a number of factors. Long-term stud-ies, although expensive, are the best way to discoverif, for example, exposure to certain types of mediacontent at age 12 has a greater impact on an adoles-cent’s later sexual behavior than similar exposure atage 16 or if there is a multiplier effect from repeatedexposures across multiple media platforms overtime.

Other research needs include the development ofwell-specified and robust research measures andmethodologies as well as ongoing national surveil-lance of both the sexual content of media and theexposure of various demographic subgroups of ad-olescents to that content. Such measures need to bespecific enough to yield workable data; defining anyportrayal of dating as “sexual content” yields alarm-ing statistics but no sound basis for public policy.

Additional needed research foci involve the suc-cess of various types of controls (eg, V-Chips) inlimiting exposure and the mitigative effects of suchfactors as parental influence and best-practice media-literacy programs.

Based on this review, future studies should:

1. Refine methodologies to measure (1) exposure tovarious media and (2) exposure to sexual contentin those media: Research is needed to define mea-surement methodology to assess cumulative ex-posure across the various media types and pat-terns of exposure, and standard constructmeasures need to be adopted for future studies.

2. Survey both children and adolescents to deter-mine their exposure to all forms of mass media forwhich data are lacking: Studies are needed toaddress the huge gaps in current scientific evi-dence, including exposure to and sexual contentof radio, music, computer and video games, theInternet, cable TV, and movies seen at home onVCR and DVD. One approach might be to addvalid and reliable (for children and youth) mea-sures13 regarding media exposure to existing sur-veillance studies, eg, the Youth Risk Behavior Sur-vey,148 the Behavioral Risk Factor SurveillanceSystem,149 or the Healthy Passages study.

3. Conduct ongoing national surveillance of the sex-ual content of mass media: Such surveillance iscurrently provided biennially by the Kaiser Fam-ily Foundation regarding national TV broadcast-ing (including cable).82–84 There are no similarongoing studies of other media.

4. Survey parents, children, and adolescents to as-sess the effectiveness of parental involvement,communication, supervision, and monitoring ofmedia sexual content: The effectiveness of paren-tal involvement in relation to their children’s ex-posure to media should be elucidated by usinglongitudinal study designs. Additionally, inter-vention studies should be conducted to examine ifincreased parental involvement, communication,supervision, and monitoring of sexual content inthe media can influence the sexual attitudes andbehaviors of adolescents.

5. Evaluate child, adolescent, and parent media-lit-eracy education to determine best-practice inter-ventions and their impact on youth viewingchoices, interpretation of content, and sexual atti-tudes and behaviors: Intervention studies areneeded to examine whether current media-liter-acy education has an impact on adolescent sexualattitudes, decision-making, and behaviors andhow such programs may be improved to bestprotect children and youth.

6. Evaluate the effectiveness of other technologic,sociobehavioral, and media practices in limitingexposure of youth to explicit sexual content: Theinterventions include, eg, V-Chips and rating sys-tems. Researchers such as those on the Task Forceon Community Preventive Services150 could sys-tematically review and conduct meta-analyses ofpopulation-based interventions. These data canthen guide future development or refinement of,eg, user-friendly technologic approaches to paren-tal controls on TV, the Internet, and other elec-tronic devices.

7. Evaluate the effects of mass media on child andadolescent sexual attitudes and behaviors: Longi-tudinal studies are needed that

• begin at earlier ages;• are large enough to target multiethnic popula-

tions;• address a wide range of determinants of sexual

behaviors;• examine multiple sexual-related outcomes in-

cluding early initiation of sexual intercourse,number of sexual partners, contraceptive andcondom use, STI and nonmarital pregnancyrates, other sexual behaviors such as oral sex,dating violence, and sexual violence;

• address potential mediating variables such asage, puberty, peer factors, and family factors(eg, parental supervision and monitoring of me-dia use); and

• have a follow-up period long enough to exam-ine long-term cumulative effects.

Only in such ways can we determine the effects ofmass media on adolescent sexual attitudes and be-haviors.

APPENDIX: CURRENT LONGITUDINAL STUDIESON THE INFLUENCE OF MASS MEDIA ON

ADOLESCENT SEXUAL BEHAVIORSInformation presented in this appendix was

adapted from the Computer Retrieval of Informationon Scientific Projects (CRISP) database (http://crisp.cit.nih.gov) and other sources.

Healthy Passages

Principal Investigators and FundingPrincipal investigators: Michael Windle (Univer-

sity of Alabama, Birmingham, AL), Mark Schuster(University of California, Los Angeles, CA), Susan R.Tortolero (University of Texas Health Science Center,Houston, TX). Funding: CDC cooperative agree-ments CCU409679, CCU609653, and CCU915773.



Study InformationHealthy Passages is a longitudinal study of child

and adolescent health with a prospective researchdesign. Beginning in the fall of 2004, it will makebiennial assessments of multiple health behaviorsand outcomes in a cohort of 5250 5th-grade children,following them for 10 years. Focusing on both riskand protective factors, it will identify patterns ofinitiation and change in health behaviors across time.Among other multilevel environmental factors, thestudy will examine time spent on music, videotapes,Internet, and video games, TV content, and co-view-ing, as well as how “real” children think TV showsare, how much they relate to their own lives, andparental involvement in media use. Assessmentmethods will include ratings from children, primarycaregivers, and teachers; data from school records;and observations of school and neighborhood envi-ronments.

TV Consumption and Adolescent Sexual Activity

Principal Investigator and FundingPrincipal investigator: D. L. Tolman (Wellesley

College, Wellesley, MA [currently at San FranciscoState University, San Francisco, CA]). Funding: Na-tional Institute of Child Health and Human Devel-opment grant 1R01HD038393-01A1 (September 22,2000, through August 31, 2005).

Study InformationThis study will examine if TV programs influence

adolescent’s sexual beliefs and behaviors. It will fol-low 1 cohort of 8th-graders into 10th grade andanother cohort of 10th-graders into 12th grade. Thestudy will analyze the amount and proportion ofsexual content viewed, the contextual elements ofsexual content viewed, and adolescent involvementin the TV they have viewed. The role of TV consump-tion in adolescents’ sexual beliefs and behaviors willbe described qualitatively (not quantitatively), aswill the ways in which adolescents make sense of thesexual content that they view, the significance andmeanings that they attribute to this content, and theirperceptions of how it affects their own sexual beliefsand decisions about sexual behavior (as revealed incontent analyses of focus groups).

Effects of Media on Adolescent AIDS-Related Behavior

Principal Investigator and FundingPrincipal investigator: M. Fishbein (University of

Pennsylvania, Philadelphia, PA). Funding: NationalInstitute of Child Health and Human DevelopmentGrant 5R01HD044136-02 (September 3, 2002,through June 30, 2007).

Study InformationThis is a 3-wave longitudinal study to examine the

association between exposure to sexual content inthe media (including TV, movies, music CDs, theInternet, video games, and magazines) and sexualbehavior among young adolescents. It focuses on themedia’s role in presenting sexual content, implyingsexual norms, modeling sexual decision-making

(“self-efficacy”), and displaying the outcomes of sex-ual behaviors.

Adolescent Sexuality and TV

Principal Investigator and FundingPrincipal investigator: J. W. Grube (Pacific Insti-

tute for Research and Evaluation, Calverton, MD).National Institute of Child Health and Human De-velopment Grant 5R01HD038906-05 (September 25,2000, through June 30, 2005).

Study InformationThis is a longitudinal study with the goal of deter-

mining if and under what circumstances sexuallyrelated content in TV programming predisposesyoung people to engage in sexual activity. Study 1will be a content analysis of the sexual language andimages in TV programming, documenting the natureand frequency of sexual content on TV overall byprogram type and genre. Study 2 will be a longitu-dinal survey of adolescents (aged 11–16 at wave 1)and their parents. The samples will be selected fromthe greater San Francisco Bay Area and from LosAngeles County using random-digit-dialing meth-ods. The primary objective of study 2 is to investigateif exposure to, awareness of, and affect toward sex-ual content on TV influences changes in adolescentsexual knowledge, expectancies, norms, intentions,and behaviors. A secondary objective of study 2 is totest and extend a theoretical model of media effectsthat was developed in the context of alcohol adver-tising. This model specifies how the effects of expo-sure to media content on beliefs, knowledge, andbehavior are mediated through affective and cogni-tive processes and how these relationships are mod-erated by important personal, environmental, andmessage variables.

Mass Media and Adolescents’ Sexual Health

Principal Investigator and FundingPrincipal investigator: Jane D. Brown (University

of North Carolina, Chapel Hill, NC). Funding: Na-tional Institute of Child Health and Human Devel-opment Grant 5R01HD038508-05 (September 26,2000, through July 31, 2005).

Study InformationThis is a longitudinal study with the goal of deter-

mining if there is a link between teens’ exposure tosexual content in the media and their sexual beliefsand behaviors. The project is based on the MediaPractice model that assumes that adolescents mustchoose among the array of media now available tothem. Data will be gathered in 5 phases. First, all 7th-and 8th-grade students (�3000) enrolled in 9 middleschools in central North Carolina will complete aself-administered questionnaire about their use ofthe mass media. Second, the content the teens mostfrequently attend in that medium to create a measureof their sexual-media diet: the time each teen spendsattending to sexual content in the media. Third, astratified (by race and gender) random sample of1000 of the students who completed the in-school



media questionnaire about their use of the mass me-dia. Two years later, in phases 4 and 5 of the project,the 1000 students will be reinterviewed in theirhomes, and another sample of media content will beanalyzed to assess how media diets and sexual atti-tudes and behaviors have changed. The longitudinaland comprehensive design of this study will providethe most current understanding of how the massmedia affect the sexual beliefs and behaviors of ad-olescents.

Teens and Exposure to HIV Risk on the Web

Principal Investigator and FundingPrincipal investigator: Ralph J. DiClemente

(Emory University). National Institute of MentalHealth Grant 5R01MH063696-04 (July 1, 2001,through June 30, 2006).

Study InformationThis prospective study will examine the effects of

adolescents’ exposure to Web pages that contain sex-ual content on the sexual health-related attitudes,beliefs, and behaviors of a national probability sam-ple of 865 teens (615 white and 250 black male andfemale teens) 14 to 16 years of age. The aims are to (1)describe characteristics of teens who access Webpages that contain sexual health, sexually explicit,and sexually related content, (2) develop cross-sec-tional models examining the association between ex-posure to Web pages that contain sexual content andtheir sexual health-related knowledge, attitudes, be-liefs, intentions, and behaviors, (3) prospectively ex-amine the association between exposure to Webpages that contain sexual content and its effect onteens’ sexual health-related knowledge, attitudes, be-liefs, intentions, and behavior over a 16-month fol-low-up period, and (4) examine the effects of hypoth-esized moderators (ie, parental monitoring, parentalcommunication about sex, sociodemographics, othermedia exposures, and exposure to sex-educationprograms on the association between exposure tosexual content on the Web and hypothesized medi-ators and outcomes. Teens will be asked to completeWeb-administered interviews at baseline and at 4-,8-, 12-, and 16-month follow-ups. Teens will also beasked to download and install Web-tracking soft-ware on their home computer, which will provide anobjective measure of Web exposure to sexual content.Analyses will construct cross-sectional models to ex-amine the relationship between teens’ use of Webpages that contain sexually explicit, sexual health,and sexually related content, and their sexual health-related attitudes, beliefs, intentions, and behaviors at16-month follow-up. Statistical analyses controllingfor baseline assessments will prospectively examinethe relationship between teens’ use of Web pagesthat contain sexually explicit, sexual health, and sex-ually related content and adolescents’ sexual health-related attitudes, beliefs, intentions, and behaviors.

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DOI: 10.1542/peds.2005-0355D 2005;116;303-326 Pediatrics

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Impact of the Media on Adolescent Sexual Attitudes and Behaviors

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