Journal of Adolescent Health
Volume 45, Issue 2 , Pages 156-162, August 2009

Exposure to Sexually Explicit Web Sites and Adolescent Sexual Attitudes and Behaviors

Division of Adolescent Medicine, Mount Sinai School of Medicine, New York, New York

Received 1 August 2008; accepted 9 December 2008. published online 20 February 2009.

Article Outline

Abstract 

Purpose

Mass media play an important role in the socialization of youth. Given its expanding nature and accessibility, the Internet may be at the forefront of this education. However, the extent of the Internet's impact on adolescent sexual attitudes and behaviors is not yet known.

Methods

A total of 433 adolescents completed an anonymous survey at a health center in New York City. The cross-sectional survey assessed Internet accessibility, exposure to sexually explicit Web sites (SEWs), sexual behaviors, and sexually permissive attitudes.

Results

Of the participants, 96% had Internet access, and 55.4% reported ever visiting a SEW. Logistic regression analyses revealed that adolescents exposed to SEWs were more likely to have multiple lifetime sexual partners (OR=1.8, CI=1.2, 2.9), to have had more than one sexual partner in the last 3 months (OR=1.8, CI=1.1, 3.1), to have used alcohol or other substances at last sexual encounter (OR=2.8, CI=1.5, 5.2), and to have engaged in anal sex (OR=2.0, CI=1.2, 3.4). Adolescents who visit SEWs display higher sexual permissiveness scores compared with those who have never been exposed (2.3 vs. 1.9, p ≤ .001), indicating a more permissive attitude.

Conclusions

Exposure to Internet pornography has potential implications for adolescent sexual relationships, such as number of partners and substance use. SEWs can serve an educational purpose and create an opportunity for adults to engage adolescents in discussions about sexual health and consumption of Internet material. Longitudinal research is needed to evaluate how exposure to SEWs influences youth attitudes and sexual behaviors.

Keywords: Internet, Media, Pornography, Adolescent sexual behavior

 

Since the 1960s, researchers have been studying the effects of media on children and teenagers [1]. This is even more relevant today, as American youth spend one-third of each day with some form of mass media including television, video games, music, and computers [2]. Much of media research focuses on television, but an emerging interest involves the Internet. We know that the Internet can provide a wide range of experiences [3], as adolescents use the computer for both entertainment as well as information-seeking purposes [4]. However, as a relatively new medium, the extent of the Internet's impact on adolescent attitudes and behaviors is not yet known.

Research has shown that mass media can affect a broad range of adolescent attitudes and behaviors including violence, eating disorders, and tobacco and alcohol use [5], [6], [7], [8], [9]. Adolescents consistently cite the mass media as an important source of sexual health information, in addition to peers, schools, and parents [10], [11]. Although media can provide positive messages, some material may be distorted and potentially harmful, failing to show the negative consequences of sex [3]. In fact, there is evidence to suggest that sexual references on television and movies may be a key contributor to early coitarche, negative attitudes toward condoms and contraception, having multiple sexual partners, and teen pregnancy [12], [13], [14], [15], [16]. A recent longitudinal study by Chandra et al found that adolescents exposed to a high sexual television diet were twice as likely to experience a pregnancy in the following 3 years, compared with teens with lower levels of exposure [16]. Television often fails to emphasize contraceptive and condom use and the possible health risks associated with sexual activity, including infections and pregnancy [17]. Depictions of responsible sexual behavior may be even less apparent on the Internet because of the unlimited array of sexual material available. Given the popularity of the Internet, this may be the next most influential sex educator for American youth [4], [9], [17], [18].

Nearly 75% of all US households have Internet access, and 93% of adolescents aged 12–17 years are online [19]. On average, children and adolescents aged 9–17 years of age use the Internet 4 days per week and spend almost 2hours online at a time [20]. Much of this activity may be unmonitored, since more than 30% of adolescents have Internet access in their bedrooms [2].

With near-universal and often unrestricted access, what are teens looking at on the Internet? Studies indicate that of the 1000 most-visited Web sites, 10% are sex-oriented [17], [19]. Moreover, sex is the most frequently researched topic on the Internet [21], [22]. Sexual curiosity is a developmentally normal, expected, and appropriate component of adolescent development [23]. As an educational medium, the Internet gives adolescents access to a wide range of sexual content in a private and confidential way. This may be material about sexual anatomy, pregnancy prevention, or transmission of infections; but it also may be sexually explicit material with pornography, violence against partners, or women as sexual objects. A 2001 study evaluating how adolescents use the Internet for health information found that 10th grade students most frequently researched material related to sex, followed by diet and nutrition [11]. Although health information can be intentionally sought out, the Internet can also supply unsolicited material. Recent data suggest that 42% of Internet users between the ages of 10 and 17 years report being exposed to online pornography in the past year, and 66% of this was described as unwanted exposure [24]. What impact does this exposure have on our youth?

There is considerable debate about the impact of pornography on adolescents and young adults, particularly as there is limited scientific research available. However, some cross-sectional studies suggest that prolonged exposure can lead to exaggerated beliefs of sexual activity among peers, sexually permissive attitudes, and sexual callousness [25], including more negative attitudes toward sexual partners [2]. Pornographic influence may not be restricted to attitudes; sexual behaviors can also be affected. Wingwood et al examined the sexual attitudes and behaviors of African-American females who had been exposed to X-rated movies. This cross-sectional study found that females exposed to pornographic movies were more likely to have negative attitudes toward condoms, to have more sexual partners, to have a strong desire to conceive a child, and to test positive for chlamydia infection [15].

In 2001, the Kaiser Family Foundation found that 59% of adolescents think that seeing Internet pornography encourages young people to have sex before they are ready, and approximately one-half believe that it encourages unprotected sex [10]. In all, 70% of 15–17-year-olds have admitted to “accidentally” stumbling across pornography online; almost one-half of these adolescents did not report being upset by what they saw [10]. Regardless of emotional responses to Internet pornography, few studies have examined the actual impact of exposure to sexually explicit Web sites and adolescent sexual attitudes and behaviors [26], [27].

Media research with television, movies, and print pornography have provided some preliminary work on the effects of exposure and adolescent attitudes and behaviors. The question is, can this data be extrapolated to the Internet? The focus of this project is to determine whether exposure to sexually explicit material on the Internet is associated with adolescent sexual behaviors and attitudes. We had three main research questions: 1) Do adolescents exposed to sexually explicit material on the Internet engage in more high-risk sexual behaviors? 2) Do adolescents exposed to sexually explicit Web sites have more permissive attitudes toward sexual activity? 3) Do adolescents with more frequent exposure to sexually explicit Web sites hold more sexually permissive attitudes?

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Methods 

Participants were recruited from the waiting room of a large, adolescent-specific, primary care facility in New York City. Patients come from all five boroughs of New York City and comprise the most vulnerable and underserved populations, with 48% Hispanic and 43% African-American. All youth between the ages of 12 and 22 years were eligible for participation. This project met criteria for expedited review by the Institutional Review Board, and data were collected in the summer and fall of 2007.

This study was designed as a cross-sectional survey, limiting the ability to attribute causal effects. Given the complexity and challenges of a cohort prospective design, we first wanted to assess whether there was an association between the main variables under study. The lead investigator created a questionnaire to assess Internet access and use, exposure to sexually explicit Web sites, sexual behaviors, and sexual attitudes. Basic demographic information was also obtained (age, sex, race/ethnicity, and educational status), but no identifying information was solicited. The self-administered anonymous survey contained 49 items and took approximately 10minutes to complete.

Measures 

A small adolescent focus group was conducted to formulate an appropriate definition of sexually explicit material. It was decided that using the terms pornography and x-rated would be much more understandable to all teens as compared with the commonly accepted legal definition. Therefore, sexually explicit Web sites (SEWs) were defined at the beginning of the questionnaire as: “X-rated or pornographic Web sites that either: describe people having sex, show clear pictures of nudity or people having sex, or show a movie or audio that describes people having sex.” Participants were asked about their Internet access (no time frame specified) and whether they had ever in their lifetime visited a sexually explicit Web site. To assess frequency of exposure, adolescents were asked how often they visited SEWs in the past 3 months using a scale of “none,” “once or twice,” “three to 10 times,” or “more than 10 times.” These frequencies were based on prior research done by Lo and Wei, to categorize level of exposure [28]. A skip-pattern was used for subjects who had never visited a sexually explicit Web site. Adolescents were also asked about the reasons for visiting these Web sites, and were provided with multiple response options (“information seeking,” “curious,” “accidental,” or an open-ended “other”).

Engagement in high-risk sexual activity was assessed using questions adapted from the Center for Disease Control and Prevention Youth Risk Behavior Surveillance System [29]; specific items are listed in Table 1. To capture high-risk sexual behavior, a risk score was created based on the reported sexual behaviors. Participants who engaged in three or more of the risky sexual behaviors were labeled “high-risk.”

Table 1. Unadjusted and adjusted bivariate odds ratios (ORs) measuring the association between exposure to sexually explicit Web sites (SEWs) and high-risk sexual behaviors
CharacteristicPearson χ2 analysisMultivariate analysis∗
ExposedNot exposedOR95% CIOR95% CI
N%N%
Early age of coitarche177.763.5– –
Multiple lifetime partners10247.24928.72.2(1.5–3.4)1.8(1.2–2.9)
More than one sex partner in last 3 months6228.12916.91.9(1.2–3.2)1.8(1.1–3.1)
Condom use at last sexual encounter10346.67945.71.0(.7–1.5)1.0(.6–1.5)
Alcohol/substance use at last sexual encounter4922.1179.82.6(1.5–4.8)2.8(1.5–5.2)
Anal sex5926.62614.92.1(1.2–3.4)2.0(1.2–3.4)
Sexually transmitted infection history5424.73319.11.4(.9–2.3)1.4(.8–2.3)
Using the Web to find a sex partner177.71.6– –
Prostitution83.663.4– –
High-risk sexual behavior score (3+ items)7634.23117.92.4(1.5–3.8)2.1(1.3–3.5)

Boldface type indicates statistical significance (p ≤ .01).

ORs were not calculated where cell sizes were <10.

∗Adjusted for age, sex, race/ethnicity, and education.

Attitudes toward sexuality were measured using the Brief Sexual Attitudes Scale developed by Hendrick et al in 2006 [30]. The scale consists of 23 items and comprises four subscales: Permissiveness, Communion, Birth Control, and Instrumentality. Response options range from 1=strongly disagree to 5=strongly agree. Only the 10 items related to sexual permissiveness were used in final analysis to characterize attitudes toward casual sexuality and permissiveness (Cronbach's α=.93). Those items are presented in Figure 1 [30]. To account for the possibility of individual missing data, the mean of the responses was calculated for each adolescent using no fewer than eight of the items. Sexual permissiveness scores were calculated for each adolescent, with a higher score indicating a more permissive attitude.

Data analysis 

To identify covariates, we examined several sociodemographic variables (age, gender, race/ethnicity, and education) and compared adolescents who were exposed to SEWs with adolescents not exposed. Pearson Chi-square testing then compared adolescents exposed to SEWs against those not exposured on the dependent at-risk sexual behaviors. Outcome variables significantly associated with exposure to SEWs in bivariate analyses were then included in multivariate logistic regression analyses, controlling for age, sex, race/ethnicity, and education. To examine the association of exposure to SEWs with sexual permissiveness, Mann-Whitney testing was conducted using exposure as the independent and sexual permissiveness score as the dependent variables. Kruskal-Wallis testing was used to examine the association between frequency of exposure and sexually permissive attitudes. Data were computer tabulated and analyzed using SPSS version 15.0 (SPSS Inc., Chicago, IL).

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Results 

A total of 492 adolescents were approached for participation. Overall, 433 adolescents and young adults 12–22 years of age finished the survey, for a completion rate of 88%. More than 85% of the sample was female, with a mean age of 18 years (SD=2.1). Additional descriptive statistics for the sample are displayed in Table 2.

Table 2. Sample demographics
Demographicn%
Age in years, mean (SD)18(2.1)
Gender
Female36985.4
Male6314.6
Transgender1.2
Race/ethnicity (multiple categories selected)
White214.8
Asian92.1
Black18643.0
Hispanic22952.9
Other5512.7
Education (highest grade completed)
Middle school (grades 7–9)399.0
Some high school (grades 10–11)11827.3
Grade 12 or completed high school11827.3
Graduation equivalency degree296.7
College, 1 or 2 years9922.9
College, 3 or 4 years306.9

Adolescents were asked about their past and present sexual activity. Of the participants, 91% had ever engaged in consensual sexual intercourse, with a mean age of coitarche of 15 years (SD=1.8). Of those who were ever sexually active, 94.9% engaged in vaginal sex, 60.9% had experienced oral sex, and 19.6% had ever engaged in anal sex.

Internet use 

More than 96% of participants reported Internet access (n=414), and exposure to SEWs was reported by 55.4% (n=240). There were significant differences by gender: 85.7% of the males had visited a SEW in their lifetime, compared with 50.1% of females (χ2=27.56, p < .001). Of all participants who had been exposed to SEWs, 69.9% reported infrequent exposure in the past 3 months (never, or once or twice), and 30.1% reported more regular exposure (3–10 times, or more than 10 times). Reasons cited for visiting these Web sites included sexual curiosity (50.2%), accidental exposure (46.3%), and information seeking (17.4%). For those teens who had not been exposed to a SEW, the most common reasons cited were no interest, followed by “I don't know.”

Sexual behaviors 

Overall, the participants had multiple risk factors for adverse reproductive health: 42% reported condom use at last sexual encounter, 15.2% reported alcohol or substance use at last sexual encounter, and 20% reported ever having a sexually transmitted infection.

Table 1 displays results related to the first research question, that individuals exposed to sexually explicit material on the Internet engage in more high-risk sexual behaviors. Binary logistic regression analyses revealed that adolescents exposed to SEWs were significantly more likely to have multiple lifetime partners, more than one sexual partner in the last 3 months, used alcohol or other substances at last sexual encounter, and ever engaged in anal sex. Participants exposed to SEWs were also more likely to have a composite high-risk sexual behavior score. Condom use at last encounter, sexually transmitted infection history, using the Internet to find a sexual partner, prostitution, and early age of coitarche were not statistically significantly associated with exposure to SEWs.

Sexually permissive attitudes 

Adolescents who visit SEWs were found to have more permissive attitudes toward sexual activity compared with those who have never been exposed, supporting the second research question. Adolescents who have never visited a SEW had a permissiveness score equal to 1.9 (range 1–3.8), whereas those who have visited had a permissiveness score of 2.3 (range 1– 5). Mann-Whitney testing revealed this to be a statistically significant difference at the p ≤ .001 value (U=14825.5).

The third research question focused on the relationship between frequency of exposure and sexually permissive attitudes. Figure 1 represents the 10 items on the Brief Sexual Attitudes Scale that comprise the permissiveness score. On average, adolescents who report no exposure to SEWs in the past 3 months have lower permissiveness scores compared with adolescents with more frequent exposure, indicating a dosage effect. To stratify attitudes by degree of exposure, visitation was broken down into four distinct categories (never, once or twice, three to 10 times, or more than 10 times). Adolescents who report no exposure to SEWs had a total permissiveness score of 2.1 (range 1–4.6), compared with 2.3 (range 1–4.6) for those who have visited once or twice, 2.7 (range 1.1–5) for those who visited three to 10 times, and 3.1 (range 1–5) for those with more than 10 visits in the past 3 months. Kruskal-Wallis testing revealed this to be a statistically significant difference at value of p ≤ .01 value (H=13.1).

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Discussion 

This is one of the first empiric studies to examine adolescents' exposure to sexually explicit Web sites and its relationship with sexual attitudes and behaviors. Results suggest that Internet pornography is readily accessible and available to adolescents, with more than 50% of adolescents visiting a sexually explicit Web site in their lifetime. Consistent with adult literature, adolescent males are more likely to frequent Internet pornography sites [31], [32]. Confirming our primary hypothesis, adolescents who visit sexually explicit Web sites are more likely to engage in high-risk sexual behaviors such as having multiple partners, using substances during sex, and engaging in anal sex. Adolescents who frequent these Web sites are more likely to possess sexually permissive attitudes and acceptance of casual sex. These sexually permissive attitudes vary by the degree of exposure in that adolescents with more frequent exposure to Internet pornography have more permissive attitudes.

Of the adolescents surveyed, 96% had Internet access, and 55% of those had been exposed to Internet pornography. Published reports of adolescent exposure to Internet pornography range from 38% to 87%, depending on age, participant intention, and time frame studied [24], [27], [31], [33], [34]. In the Netherlands, 71% of adolescent males and 40% of females reported exposure to sexually explicit material on the Internet in the past 6 months [34]. In 2007, Wolak et al found that 42% of American adolescents 10–17 years of age reported exposure to Internet pornography in the past year [24]. Given the older age of our study population, it is not surprising that our rates of exposure are higher than previously reported with US adolescents.

Although we did not specifically ask whether adolescents were intentionally visiting these Web sites, we did solicit information about the reasons for visitation. Slightly less than one-half of adolescents reported that it was an accidental occurrence, but an equivalent number indicated that they visited because of sexual curiosity. Visiting a sexual Web site may be a safe and appropriate method of sexual exploration and not necessarily indicative of deviant behavior. As adolescents mature physically and emotionally, the availability of sexual material on the Internet may become more interesting, which would naturally lead them to seek out the material.

The information found on the Internet is not all negative; educational and positive sexual health information is also available. However, exposure to sexually explicit Web sites may be potentially harmful. Our results show that exposure to Internet pornography is associated with high-risk sexual behaviors that have the potential to adversely affect reproductive health. Similar to previous studies conducted with adults [28], [35], we found that adolescent exposure to sexually explicit Web sites is associated with high-risk sexual behaviors such as anal sex, multiple sexual partners, and substance use during sex. Increasing numbers of sexual partners may put adolescents at risk for sexually transmitted infections and HIV. Alcohol or substance use during sexual activity may weaken inhibitions and raise the potential for irresponsible sexual activity, particularly lack of condom use. Attributing sexual behaviors to Internet viewing is difficult. Whether visiting sexual explicit Web sites leads to engagement in high-risk sexual behaviors or vice versa cannot be established from this study. However, the associations do highlight the relationship of the Internet to adolescent sexual health.

Exposure to Internet pornography, as compared with traditional print media, has been shown to be a potent influence on adolescent sexual attitudes [28]. In 2005, Lo and Wei found that Taiwanese adolescents exposed to Internet pornography had a greater acceptance of sexually permissive attitudes and were more likely to engage in sexually permissive behaviors. The Internet has an unlimited array of pornographic material that is changed and upgraded on a regular basis. Some of these Web sites may reinforce negative societal stereotypes around sexuality, particularly as it relates to casual sex. This study measured sexual permissiveness and while it is difficult to translate attitudes into behavior, it suggests that adolescents may be developing or reinforcing these viewpoints by observing sexually suggestive material on the Internet. The media environment may play a pivotal role in attitude formation, in that adolescents who are exposed to Internet pornography have a greater acceptance of casual sexual behavior.

Study limitations 

The cross-sectional design of this study limits the determination of cause and effect. We are unable to establish whether exposure to sexually explicit material leads to engagement in sexual behavior or whether those individuals who partake in more high-risk sexual behaviors also have a tendency to seek out sexually explicit Web sites. Cohort studies with non–sexually active, younger teens may provide more information as to direction of association. Because we did not ask adolescents where they use the Internet, we are unable to determine whether there are other factors affecting their exposure to sexually explicit Web sites. Adolescents who visit at a friend's house or another area unmonitored by parents may have a greater opportunity to seek out sexually explicit material. We were also unable to control for Internet software that may prevent some teens from visiting these Web sites. Nevertheless, there seems to be an association between exposure to sexually explicit Web sites and high-risk sexual behavior, which may help to guide future studies.

Our findings are not based on nationally representative sample, so we must be cautious with generalizations. This was a population of sexually active teens who initiated sexual intercourse at younger ages than the national average. The younger age of coitarche may indicate an underlying sexually permissive attitude, one of the areas of study. In addition, because it was a convenience sample of patients visiting a health center, we were limited by the number of males who participated. Males are known to be greater consumers of pornography, and this limitation may have undermined some of the results. Another limitation was the use of self-reported data on online pornography use, which may have biased recall. We were also unable to control for varying interpretations of sexually explicit material, as the content and definition was up to the discretion of the adolescent. Asking adolescents to keep a diary or simple recall of recent of Web sites visited may have added to the reporting accuracy. Under- or over-reporting may play a factor as well, as participants were asked to complete the survey in the waiting room of a busy adolescent clinic. The anonymous survey should have minimized this potential limitation.

Study implications 

Mass media play an important role in the sexual socialization of American youth and given its expanding nature and accessibility, the Internet may be at the forefront of this education. Cooper et al postulate that there are three main reasons that the Internet has become a prominent sex educator for Americans: accessibility, affordability, and anonymity [21]. It is available 24hours a day and 7 days a week, with relatively little expense; and for adolescents, it can be accessed anonymously away from parental or legal scrutiny. This availability may play a role in the development of adolescent sexual attitudes and behaviors. Therefore, it may be prudent to encourage providers to ask how adolescents are spending their time and where they are seeking their health care information. Judging from the overwhelming popularity of social networking sites, adolescents and young adults are using the Internet for social purposes, and at times meeting partners. Recognizing that the Internet is an important and integral part of an adolescent's life, asking about these activities may help to establish a rapport and to open the door to discussions about where to find reliable health information.

Given what we know about media, and its potential impact on adolescent health, how can we educate our youth? Brown and Witherspoon [9] propose several different mechanisms for improving adolescent health and media. These involve government regulation, media advocacy, public health campaigns, and media literacy. The American Academy of Pediatrics launched the “Media Matters” campaign a decade ago to alert children, parents, and practitioners of the influence the media has on pediatric health [36]. The overriding goal of media literacy is to make young people aware of how media is produced and advertised, teaching them critical thinking skills, with the hope that they will be less likely to engage in unhealthy behaviors promoted by the media [13]. Encouraging adolescents to be more aware of these Web sites, and the potential impact it can have on their life with media literacy, can be productive. Research suggests that providing adolescents with a small amount of knowledge about media effects can improve adolescent health [13]. Regardless of whether sexually explicit media leads to risky behaviors, providers should have a working knowledge of helpful sex education media (including Web sites) to which they can guide their patients and families. Parents can also play an important role in guiding adolescents to positive educational messages on the Internet and viewing that material with their children.

Despite the limitations, the current study provides insight into the association between exposure to sexually explicit Web sites and adolescent sexual attitudes and behaviors. Sexually explicit Web sites can serve an educational purpose and create an opportunity for adults to engage adolescents in a complete, honest discussion about sexual health and informed consumption of information found on the Internet. The Internet is a key part of adolescents' lives, and practitioners should be prepared to integrate it into their discussions about sexual health, to educate adolescents about the potential risks, and to encourage responsible sexual behavior.

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Acknowledgments 

The authors acknowledge the patients and staff of the Adolescent Health Center at Mount Sinai Medical Center. Thanks are expressed to Linda Levin-Carmine, M.D., for her helpful advice and comments.

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PII: S1054-139X(08)00658-7

doi:10.1016/j.jadohealth.2008.12.004

Journal of Adolescent Health
Volume 45, Issue 2 , Pages 156-162, August 2009

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