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Pornography Use and Perceived Gender Norms Among Young Adolescents in Urban Poor Environments: A Cross-site Study

      Abstract

      Purpose

      The purpose of the study is to assess the prevalence of pornography use and its association with a range of perceived gender norms among adolescents aged 10–14 years across five urban poor settings globally.

      Methods

      The study includes 9,250 adolescents aged 10–14 years from Belgium, China, the Democratic Republic of the Congo, Ecuador, and Indonesia, as part of the Global Early Adolescent Study. We examined the percentage of pornography use by sex and site and conducted multivariate logistic regressions to examine the relation between gender norm perceptions and pornography use, adjusting for individual, family, peer, and media exposures.

      Results

      Ever-use of pornography ranged from 14.5% in Ecuador to 33.0% in Belgium and was more common among boys than girls. Overall, boys who perceived greater permissiveness about romantic relations, adolescents who engaged in such relations, and adolescents who assumed that their friends were sexually active had greater pornography exposure. Pornography use did not systematically correlate with unequal gender norms. Such correlations only exist among boys in two Asian sites, where a supportive school environment, more caregiver awareness, and/or neighborhood cohesion were related to less pornography use.

      Conclusions

      Pornography use is a gendered experience that begins in early adolescence. Although factors of pornography use vary across the social context, the exposure to pornography has become a normative part of adolescent sexuality development. Young people, especially those from where sexuality remains taboo, need the ability to critically process information and avoid potential risks associated with pornographic gendered and sexual stereotypes, calling for comprehensive sexuality education programs to help them build the knowledge and confidence they need.

      Keywords

      Implications and Contribution
      Pornography use among young adolescents is more common among boys with unequal gender norm perceptions. More research is needed to better understand this (bi)directional relationship. Comprehensive sexuality education programs are needed to equip young people with the abilities to contest gender and sexual stereotypes and promote healthy sexuality development.
      Pornography, defined as videos or pictures intended to sexually arouse the viewer [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ], is a controversial issue in adolescence (ages 10–19 years), which continues to raise concerns because of its increased accessibility and mainstreaming online as well as offline [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Kyriaki A.
      • Vasileios S.
      • Emma A.
      • et al.
      Adolescent pornography Use: A systematic Literature review of research Trends 2000-2017.
      ]. Global evidence indicates that pornography use is common across countries with large regional variations, ranging from 2% among girls in Cambodia to more than 90% among boys in Sweden and Germany [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Weber M.
      • Quiring O.
      • Daschmann G.
      Peers, parents and pornography: Exploring adolescents’ exposure to sexually explicit material and its developmental correlates.
      ]. However, most studies that originate from Europe and North America rarely address intercultural and cross-cultural issues, and even though some have been carried out in Asia, data on adolescents' pornography use in Africa and Islamic countries remain scant [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Döring N.M.
      The Internet’s impact on sexuality: A critical review of 15 years of research.
      ].
      The predominant lack of perspectives about pornography use among young people outside of the Western world is problematic for several reasons. First, it is based on the assumption that pornography use is mostly a Western issue due to the relative freedom of information and access to the Internet [
      • Brown J.D.
      • X-Rated L'Engle K.L.
      Sexual attitudes and behaviors associated with U.S. Early adolescents' exposure to sexually explicit media.
      ,
      • Doornwaard S.M.
      • Bickham D.S.
      • Rich M.
      • et al.
      Adolescents' use of sexually explicit Internet material and their sexual attitudes and behavior: Parallel development and directional effects.
      ,
      • Martyniuk U.
      • Stulhofer A.
      A longitudinal exploration of the relationship between pornography use and sexual permissiveness in female and male adolescents.
      ,
      • Dombrowski S.C.
      • Gischlar K.L.
      • Durst T.
      Safeguarding young people from cyber pornography and cyber sexual predation: A major dilemma of the internet.
      ]. However, the global rise of the Internet and mobile use among young people has made pornography more accessible in low- and middle-income settings [
      • Pluhar E.
      • Kavanaugh J.R.
      • Levinson J.A.
      • et al.
      Problematic interactive media use in teens: Comorbidities, assessment, and treatment.
      ,
      • Ma C.M.S.
      • Shek D.T.L.
      • Lai C.C.W.
      Individual and family protective factors of intentional and unintentional consumption of online pornography in Hong Kong.
      ], thereby increasing adolescents' exposure to different forms of sexually explicit media, intentionally or unintentionally, through pop-ups or misleading site labels [
      • Livingstone S.
      • Smith P.K.
      Annual research review: Harms experienced by child users of online and mobile technologies: The nature, prevalence and management of sexual and aggressive risks in the digital age.
      ,
      • Collins R.L.
      • Strasburger V.C.
      • Brown J.D.
      • et al.
      Sexual media and childhood well-being and health.
      ]. Second, it fails to understand how pornography consumption relates to sexual and gender attitudes in societies where sexuality may be more taboo and where young people lack access to comprehensive sexuality education—as a means of critically reviewing pornography messages [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ].
      Evidence about the influence and consequences of pornography during this period of life is mixed [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Döring N.M.
      The Internet’s impact on sexuality: A critical review of 15 years of research.
      ]. On the one hand, studies indicate that pornography may be problematic for adolescents' healthy sexuality development. These concerns, generally grounded in moral ideas around the “innocence” and vulnerability of children and adults' responsibility to protect them [
      • Christensen P.H.
      Childhood and the cultural constitution of vulnerable bodies.
      ], are particularly salient for adolescents who often lack the media literacy and related critical thinking skills as well as the experiences to properly evaluate the content of pornographic materials [
      • Livingstone S.
      • Smith P.K.
      Annual research review: Harms experienced by child users of online and mobile technologies: The nature, prevalence and management of sexual and aggressive risks in the digital age.
      ,
      • Collins R.L.
      • Strasburger V.C.
      • Brown J.D.
      • et al.
      Sexual media and childhood well-being and health.
      ]. Some studies suggest that by portraying the primacy of heterosexual men's sexual pleasure, dominance, and aggression [
      • Klaassen M.J.E.
      • Peter J.
      Gender (In)equality in internet pornography: A content analysis of Popular pornographic internet videos.
      ], pornography may favor re-enactment and aggravation of gender power imbalances in sexual interactions [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Wright P.J.
      • Tokunaga R.S.
      • Kraus A.
      A Meta-analysis of pornography consumption and Actual Acts of sexual aggression in general Population studies.
      ,
      • Mellor E.
      • Duff S.
      The use of pornography and the relationship between pornography exposure and sexual offending in males: A systematic review.
      ]. Likewise, the display of unsafe sexual practices (either heterosexual or homosexual) may further promote sexual risk taking, exposing young people to unintended pregnancy and/or sexually transmitted infections [
      • Grudzen C.R.
      • Elliott M.N.
      • Kerndt P.R.
      • et al.
      Condom Use and high-risk sexual Acts in adult Films: A comparison of heterosexual and homosexual Films.
      ]. On the other hand, evidence indicates that in spite of its potentially negative consequences, pornography itself does not constitute a “public health crisis” [
      • Nelson K.M.
      • Rothman E.F.
      Should public health Professionals consider pornography a public health crisis?.
      ] and that its specific consequences depend on the nature and circumstances associated with consumption [
      • Malamuth N.M.
      • Hald G.M.
      • Koss M.
      Pornography, individual differences in risk and men’s acceptance of Violence against women in a Representative sample.
      ,
      • Bridges A.J.
      • Wosnitzer R.
      • Scharrer E.
      • et al.
      Aggression and sexual behavior in best-selling pornography videos: A content analysis update.
      ]. For example, studies among young adults in high-income countries indicate that watching pornography might have a positive effect on body satisfaction, self-exploration, and self-esteem as well as foster more gender-equal attitudes [
      • Vogels E.A.
      Loving Oneself: The associations among sexually explicit media, body image, and perceived realism.
      ,
      • Olmstead S.B.
      • Negash S.
      • Pasley K.
      • et al.
      Emerging adults’ expectations for pornography Use in the context of Future Committed romantic relationships: A qualitative study.
      ,
      • Kohut T.
      • Baer J.L.
      • Watts B.
      Is pornography really about "making hate to women"? Pornography users Hold more gender Egalitarian attitudes than Nonusers in a Representative American sample.
      ].
      Irrespective of its effect, pornography use is highly gendered, with boys reporting earlier and more frequent exposure to pornography than girls [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ], reflecting both social norms that encourage male consumption as well as mainstream production mechanisms [
      • Klaassen M.J.E.
      • Peter J.
      Gender (In)equality in internet pornography: A content analysis of Popular pornographic internet videos.
      ]. Pornography can also reinforce unequal gender norms that in turn hinder adolescent well-being and constrain girls' and boys' life opportunities [
      • Hardy S.A.
      • Hurst J.L.
      • Price J.
      • et al.
      The socialization of attitudes about sex and their role in adolescent pornography use.
      ,
      • Cheng S.
      • Ma J.
      • Missari S.
      The effects of Internet use on adolescents’ first romantic and sexual relationships in Taiwan.
      ,
      • Peter J.
      • Valkenburg P.M.
      Adolescents' exposure to sexually explicit internet material and Notions of women as sex Objects: Assessing Causality and Underlying Processes.
      ,
      • Heise L.
      • Greene M.E.
      • Opper N.
      • et al.
      Gender inequality and restrictive gender norms: Framing the challenges to health.
      ]. Studies indicate how pornography use is linked with more permissive sexual attitudes [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Brown J.D.
      • X-Rated L'Engle K.L.
      Sexual attitudes and behaviors associated with U.S. Early adolescents' exposure to sexually explicit media.
      ,
      • Martyniuk U.
      • Stulhofer A.
      A longitudinal exploration of the relationship between pornography use and sexual permissiveness in female and male adolescents.
      ,
      • Baams L.
      • Overbeek G.
      • Dubas J.S.
      • et al.
      Perceived realism moderates the relation between sexualized media consumption and permissive sexual attitudes in Dutch adolescents.
      ], stereotypical attitudes about the different attributes, roles, opportunities, and power of men and women [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Heise L.
      • Greene M.E.
      • Opper N.
      • et al.
      Gender inequality and restrictive gender norms: Framing the challenges to health.
      ], and sexual objectification of women [
      • Peter J.
      • Valkenburg P.M.
      Adolescents' exposure to sexually explicit internet material and Notions of women as sex Objects: Assessing Causality and Underlying Processes.
      ]. For example, a longitudinal study among 967 adolescents aged 12–14 years at baseline in the United States found that girls who were exposed to sexually explicit materials at early ages developed more stereotypical gender attitudes over time [
      • Brown J.D.
      • X-Rated L'Engle K.L.
      Sexual attitudes and behaviors associated with U.S. Early adolescents' exposure to sexually explicit media.
      ]. The available evidence also points to the ways gender moderates the influence of pornography on attitudes, with boys and girls experiencing different gender socialization mechanisms [
      • Koletić G.
      Longitudinal associations between the use of sexually explicit material and adolescents' attitudes and behaviors: A narrative review of studies.
      ].
      Beyond gender (attitudes), pornography use and its potential consequences are shaped by young people's broader social-ecological context [
      • Pulerwitz J.
      • Blum R.
      • Cislaghi B.
      • et al.
      Proposing a conceptual framework to address social norms that influence adolescent sexual and reproductive health.
      ,
      • Blum R.W.
      • Astone N.M.
      • Decker M.R.
      • et al.
      A conceptual framework for early adolescence: A platform for research.
      ], including their individual attributes (such as age, pubertal onset, sensation seeking) [
      • Kyriaki A.
      • Vasileios S.
      • Emma A.
      • et al.
      Adolescent pornography Use: A systematic Literature review of research Trends 2000-2017.
      ,
      • Livingstone S.
      • Smith P.K.
      Annual research review: Harms experienced by child users of online and mobile technologies: The nature, prevalence and management of sexual and aggressive risks in the digital age.
      ,
      • Nieh H.P.
      • Chang L.Y.
      • Chang H.Y.
      • et al.
      Pubertal timing, parenting Style, and Trajectories of pornography Use in adolescence: Peer pornography Use as the Mediator.
      ], family influences (parents being key in preventing negative consequences related to pornography) [
      • Weber M.
      • Quiring O.
      • Daschmann G.
      Peers, parents and pornography: Exploring adolescents’ exposure to sexually explicit material and its developmental correlates.
      ,
      • Nieh H.P.
      • Chang L.Y.
      • Chang H.Y.
      • et al.
      Pubertal timing, parenting Style, and Trajectories of pornography Use in adolescence: Peer pornography Use as the Mediator.
      ,
      • Boniel-Nissim M.
      • Efrati Y.
      • Dolev-Cohen M.
      Parental Mediation Regarding Children’s pornography exposure: The role of parenting Style, protection Motivation and gender.
      ], peer networks (as a source of access and normalization of consumption) [
      • Kyriaki A.
      • Vasileios S.
      • Emma A.
      • et al.
      Adolescent pornography Use: A systematic Literature review of research Trends 2000-2017.
      ,
      • Nieh H.P.
      • Chang L.Y.
      • Chang H.Y.
      • et al.
      Pubertal timing, parenting Style, and Trajectories of pornography Use in adolescence: Peer pornography Use as the Mediator.
      ], and broader societal factors (such as school, neighborhood and social institutions, and norms) [
      • Brooks F.M.
      • Magnusson J.
      • Spencer N.
      • et al.
      Adolescent multiple risk behaviour: An asset approach to the role of family, school and community.
      ].
      The fact that most data come from Western societies provides little insight into the ways that different social-ecological forces interact to inform pornography consumption and its implications for adolescent sexuality development in different cultural and economic settings [
      • Kyriaki A.
      • Vasileios S.
      • Emma A.
      • et al.
      Adolescent pornography Use: A systematic Literature review of research Trends 2000-2017.
      ]. In addition, most research focuses on older youth or young adults. Evidence on early adolescence (ages 10–14 years), which is a particularly critical time of physical, emotional, cognitive, and social development, is largely missing. This lack of perspective is a critical gap as early adolescence is a time when young people start to develop their sexual selfhood and become increasingly aware of socially constructed gender roles and norms associated with being a boy, man, woman, or girl [
      • Tolman D.L.
      • McClelland S.I.
      Normative sexuality development in adolescence: A decade in review, 2000–2009.
      ,
      • Blum R.W.
      • Mmari K.
      • Moreau C.
      It begins at 10: How gender expectations shape early adolescence around the World.
      ]. It is a period when attitudes and beliefs are constantly evolving and influenced by—as well as influencing—young people's emerging (sexual) identity and experiences as they transit through adolescence [
      • Blum R.W.
      • Mmari K.
      • Moreau C.
      It begins at 10: How gender expectations shape early adolescence around the World.
      ].
      In response to the abovementioned gaps, this study aims to assess the prevalence and correlates of pornography use among young adolescents (aged 10–14 years) across five geographically and culturally diverse urban poor settings. We focus on the gendered patterns of pornography consumption, which we hypothesize to be more common among boys than girls and more common among adolescents who perceive greater gender-unequal norms and those with greater permissiveness toward adolescent romantic relationships [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ].

      Methods

      Study design

      This is a cross-sectional study using data from the Global Early Adolescent Study (GEAS), a multicountry investigation of how gender socialization affects early adolescent health and well-being. The GEAS operates in 11 urban poor sites across five continents, chosen to represent a diversity of geographical, cultural, economic, and social contexts and because of existing research partnerships. The focus on urban poor adolescents was a deliberate choice to shed light on the emerging but understudied urban poor penalty among adolescents [
      • Mmari K.
      • Blum R.
      • Sonenstein F.
      • et al.
      Adolescents' perceptions of health from disadvantaged urban communities: Findings from the WAVE study.
      ].
      For the present study, we used data from five sites which had collected baseline data at the time of this analysis: Ecuador (Cuenca), Belgium (nine cities in Flanders), the Democratic Republic of the Congo, DRC (Kinshasa), China (Shanghai), and Indonesia (Semarang, Denpasar, and Lampung). All sites shared the same study protocol and core survey instruments, although sampling and data collection modes (described in detail elsewhere) were adapted to the local context [
      • Mmari K.
      • Cooper D.
      • Moreau C.
      • et al.
      The social context of early adolescents in the global early adolescent study.
      ].
      The study received ethical approval from each site and was also approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

      Participants and sampling

      Participants included young adolescents aged 10–14 years, recruited using different strategies across sites. These strategies, described in detail elsewhere [
      • Mmari K.
      • Cooper D.
      • Moreau C.
      • et al.
      The social context of early adolescents in the global early adolescent study.
      ], included random cluster sampling in Cuenca, a combination of exhaustive and convenient sampling in Flanders, multistage random sampling in Kinshasa, stratified cluster sampling in Shanghai, and a combination of clustered sampling and random sampling in three cities of Indonesia. Participants were recruited from schools in all sites, with the exception for Kinshasa, where a random sample of out-of-school adolescents from the same commune was selected to complement the in-school sample because of high school drop-out rates in this setting.
      Altogether, 10,841 young adolescents aged 10–14 years were included. After excluding observations that did not reach the preset data quality criteria (<25% missing values for Belgium and <15% for other countries) (n = 490) and observations with missing information on the key dependent and independent variables (n = 1,101), our final analytical sample included 9,250 observations (89.4% of the original sample): N = 532 in Ecuador (85.3% of the original sample), N = 808 in Belgium (79.8% of the original sample), N = 2,720 in the DRC (96.5% of the original sample), N = 1,571 in China (89.7% of the original sample), and N = 3,619 in Indonesia (79.6% of the original sample).

      Procedures

      Data collection took place between June 2017 and June 2019 and involved a 1–2 hour survey using audio-computer/computer-assisted self-interview completed on tablets, with the exception of Kinshasa, where the survey was conducted face-to-face because of the low literacy rate in that setting. All participants provided active parental consent as well as their own assent before data collection began. The survey collected information on a range of topics including sociodemographics, family, peer, school and neighborhood circumstances, as well as perceptions of gender norms, knowledge, and practices related to physical, mental, sexual, and reproductive health. The survey instrument (translated, back translated in sites where English is not the primary language) was tested in 14 urban poor cities around the globe, refined, and validated among adolescents in six sites of the GEAS [
      • Moreau C.
      • Li M.
      • De Meyer S.
      • et al.
      Measuring gender norms about relationships in early adolescence: Results from the global early adolescent study.
      ]. A more detailed description of the GEAS instruments is available at https://www.geastudy.org.

      Measures

      Outcome variables

      Pornography use was assessed via a single question: “Sometimes young people watch pornography, that is, movies or videos that show people's private parts (genitals) during sexual scenes. Have you watched pornography before?”, with a 4-point scale response ranging from “never”, “rarely”, “sometimes” to “often”. Because of the small percentages of adolescents who reported any exposure in some sites, we used a dichotomized variable, opposing any exposure (rarely, sometimes, or often) to no exposure.

      Independent variables

      Perceptions of gender norms

      We used four validated scales to assess young adolescents' perceptions of gender norms in terms of traits, roles, and relationships, grounded in qualitative work conducted in the formative GEAS phase [
      • Moreau C.
      • Li M.
      • De Meyer S.
      • et al.
      Measuring gender norms about relationships in early adolescence: Results from the global early adolescent study.
      ]:
      • The adolescents' romantic relationship scale (ARE), includes five items assessing permissive attitudes toward adolescents' romantic relationships (e.g., “It is normal for a boy/girl your age to want a girlfriend/boyfriend”). The polychoric ordinal Cronbach's alpha ranged from .75 in Cuenca to .90 in Shanghai (for more details, see Table S5);
      • The sexual double standard (SDS) scale includes six items measuring differential expectations for girls and boys in romantic/sexual relationships (e.g., “Boys have girlfriends to show off to their friends”; “Girls are victims of rumors if they have boyfriends”), with the polychoric ordinal Cronbach's alpha ranging from .81 in Shanghai to .85 in Kinshasa;
      • The gender stereotypical traits (GST) scale includes seven items tapping into male toughness over female vulnerabilities (e.g., “Boys should be raised tough”; “Girls are expected to be humble”), with polychoric ordinal Cronbach's alpha ranging from .69 in Cuenca to .80 in Flanders;
      • The gender stereotypical roles (GSR) scale includes four items measuring differential family roles conferring male power in household decisions (e.g., “A woman's role is taking care of her home and family”; “A man should have the final word about decisions in the home”), with polychoric ordinal Cronbach's alpha ranging from .72 in Kinshasa to .86 in Indonesia.
      All scale items used five-point Likert response options, and responses were averaged into mean scores with higher scores signaling more unequal gender norm perceptions. Scores were also dichotomized at the median using site-specific thresholds.

      Social-ecological covariates

      We used Blum et al.’s conceptual framework to guide the selection of covariates [
      • Blum R.W.
      • Astone N.M.
      • Decker M.R.
      • et al.
      A conceptual framework for early adolescence: A platform for research.
      ]. At the individual level, we considered age, sex (boy vs. girl in the absence of information about participants' gender identity), and puberty onset. At the interpersonal level, we included the family structure (living with both parents, one parent, no parents) and caregiver awareness (e.g., the caregiver knows their friends by name; the caregiver knows how they were doing in school), peer attitudes toward sexual relations, and participants' romantic experiences (ever vs. never, with either sex). At the community level, we included a measure of school connectedness (perceived care from adults at school) and perceived neighborhood cohesion (a 4-item scale asking if people in the neighborhood look out for, care, and trust each other). Finally, we included a measure of media diet, assessed via the question, “On a typical day, how many hours in total do you spend using social media, chatting with friends online, playing computer games, or using other interactive media?” (0, 1–2, 3 or more).

      Statistical analysis

      We first assessed missing data on covariates, which ranged from .08% to 25.37%. Missing data were imputed using K-nearest neighbors based on age, sex, and site [
      • Beretta L.
      • Santaniello A.
      Nearest neighbor imputation algorithms: A critical evaluation.
      ]. We pursued with descriptive analysis of the prevalence of pornography use by sex and site. Next, we used analysis of variance models to evaluate the associations between pornography use with each gender norm scale as well as social-ecological factors, controlling for sex. This analysis informed the multivariate model, using Firth logistic regressions, to assess the associations between each gender norm scale and pornography use by sex and site, adjusting for social-ecological covariates. We included an interaction between gender norm perceptions and age when significant. Finally, we conducted a sensitivity analysis among the complete case samples, which mostly supported the same conclusions (results not shown). Data were analyzed using Stata 15.0 SE software.

      Results

      Table 1 shows the characteristics of the final analytical sample in each site. Adolescents were evenly split between boys and girls in each site, with a mean age ranging from 11.93 years in the DRC to 13.05 years in Belgium. Adolescents' family and peer environments also varied by site, with parental closeness ranging from 26.49% in Belgium to 92.43% in China. Conversely, self-reported romantic involvement (ever) and perceptions of peer sexual activity were highest in Belgium (57.28% had ever had a romantic partner and 13.49% thought their friends had had sex), whereas romantic experience was lowest in the DRC (9.41%), and perceptions of peer sexual activity were lowest in Shanghai and Indonesia (3.18% and 4.3%, respectively). Only 16.43% of respondents had access to the Internet in the DRC compared with 98.8% of adolescents in Belgium.
      Table 1Characteristics of the study sample by site
      Cuenca, Ecuador (N = 532)Belgium (N = 808)Kinshasa, the DRC (N = 2,720)Shanghai, China (N = 1,571)Indonesia (N = 3,619)
      N/X¯%/SDN/X¯%/SDN/X¯%/SDN/X¯%/SDN/X¯%/SD
      IndividualSexMale27451.5043153.341,35749.8978650.031,70447.08
      Age (mean ± SD)12.041.3713.05.7511.931.3812.47.9712.18.54
      Pubertal onsetYes46988.1678597.151,70662.721,43991.603,35592.71
      Relationship engagementEver21340.0446257.182569.4118912.031,36837.80
      FamilyFamily structureWith no parent173.20789.6539014.34704.461835.06
      With one parent15629.3210112.5076628.1618411.712627.24
      With both parents35967.4862977.851,56457.501,31783.833,17487.70
      Caregiver awarenessHigh41477.8262276.981,04438.381,30883.262,30763.75
      PeersPerceptions about whether close friends had sexYes407.5210913.4931611.62503.181564.31
      SchoolSchool connectednessHigh37269.9221426.491,44653.161,45292.432,89279.91
      NeighborhoodNeighborhood cohesionHigh23043.2320225.0070625.9698162.442,45567.84
      MediaTime spent on the InternetNone11621.80101.242,27383.5735822.791714.73
      2 hours or less32160.3429035.8935012.871,05266.962,36265.27
      3 hours or more9517.8650862.87973.5716110.251,08630.01
      DRC = Democratic Republic of the Congo; SD = standard deviation.

      Prevalence of pornography use

      The prevalence of lifetime exposure to or use of pornography varied widely across sites from 14.5% in Ecuador to 33% in Belgium (p < .001). Post hoc paired comparison by site indicated similar prevalence in Ecuador, the DRC, and Indonesia (p > .05). Pornography was consistently more common among boys than that among girls in all sites (p < .05), with percentages ranging from 21.9% (Ecuador) to 51.28% (Belgium) among boys and from 6.59% (Ecuador) to 20.64% (China) among girls (Figure 1).
      Figure thumbnail gr1
      Figure 1Distribution of participants' pornography use by site. Note: 1. Differences were compared between sexes within the site using the chi-square test; ∗: p < .05; ∗∗∗: p < .001; 2. Comparisons by site using the post hoc Scheffe test after one-way ANOVA; ns: not significant between sites as p > .05. ANOVA = analysis of variance.

      Perceptions of gender norms by site and sex

      In general, respondents in Belgium reported more gender-equal perceptions, with relatively high acceptance of early adolescent romantic relationships (ARE) and low endorsement of SDS or GST (Figure 2). Conversely, adolescents in Kinshasa generally perceived more gender-unequal norms than those in other sites (p < .001), with low acceptance of ARE, but high endorsement of SDS, GST, and GSR. Although Shanghai respondents expressed low permissiveness toward ARE, they mostly rejected the SDS, as did respondents in Indonesia. Sex differences were evident in each site: in Cuenca and Shanghai, boys perceived greater permissiveness for ARE as well as more endorsement of GST, GSR, and SDS than their female peers. In contrast, in Belgium and Indonesia, boys were less likely to perceive an SDS than girls, while simultaneously expressing more stereotypical GST and GSR.
      Figure thumbnail gr2
      Figure 2Distributions of perceived gender norms by site. Note: 1. The presented spot and lines are the mean score ± standard deviation for each scale in different sites. 2. Differences were compared between each site using the post hoc Scheffe test after one-way ANOVA; ns: not significant between sites as p > .05. 3. Differences were also compared between sexes within the site using the two-sample t-test with equal or unequal variances (tagged above the female group); ∗∗: p < .01; ∗∗∗: p < .001. ANOVA = analysis of variance.

      Factors associated with pornography use

      Table 2 shows the effect size (proportion that could be explained) of gender norm perceptions as well as social-ecological covariates on pornography use (Cohen has provided benchmarks to define small [η2 = .01], medium [η2 = .06], and large [η2 = .14] effects [
      • Cohen J.
      Statistical power Analysis for the behavioral Sciences.
      ]). Overall, pornography use was associated with greater permissiveness toward ARE in almost all sites. Specifically, adolescents who had any romantic experience or who believed their friends had engaged in sexual activities were more likely to have ever watched pornography. None of the other gender norm perceptions were associated with pornography use, except the SDS in Indonesia. Other factors related to pornography use included age, romantic relationship experience, peer sexual norms, and time spent on the Internet for boys and girls alike.
      Table 2Effect size of gender norm perceptions and other ecological factors on pornography use
      η2 (95% CI)Total sampleEcuadorBelgiumDRCChinaIndonesia
      η295% CIη295% CIη295% CIη295% CIη295% CIη295% CI
      Adolescents' romantic relationships (ARE).030.024–.038.015.001–.040.035.014–.063.016.008–.026.075.052–.101.025.016–.036
      Sexual double standard (SDS).006.003–.01000–.008.0010–.010.0030–.009.0010–.006.013.007–.022
      Gender stereotypical traits (GST).003.001–.00600–.01200–.00500–.003.006.001–.015.006.002–.012
      Gender stereotypical roles (GSR)00–.00100–.002--.0020–.006.0020–.009.0010–.005
      Age.015.010–.020.107.058–.153.040.015–.066.025.014–.036.0020–.005.007.002–.013
      Romantic engagement.045.037–.054.039.013–.759.051.025–.083.065.048–.083.078.054–.104.032.022–.044
      Pubertal onset.012.008–.017.031.008–.646.0010–.010.028.017–.042.0010–.007.004.004–.009
      Family structure.0020–.004.0010–.009.012.001–.02900–.003.0020–.008.0020–.006
      Caregiver awareness.003.001–.006.0010–.130.0070–.023.0020–.006.011.003–.024.0030–.007
      Perceived there are peers having sex.044.036–.052.074.037–.120.057.030–.090.056.040–.073.043.025–.064.026.017–.037
      School connectedness.0010–.003.0040–.022.0080–.02400–.003.033.017–.052.0020–.006
      Neighborhood cohesion.0010–.003.0010–.01300–.00600–.001.008.002–.020.0020–.006
      Time spent on the Internet.010.006–.014.057.023–.097.0070–.021.016.007–.026.025.011–.041.008.003–.014
      Note: Effect size η2 was presented for each variable after fitting ANOVA models with the controlling of sex in the total sample and city-specific sample.
      ANOVA = analysis of variance; CI = confidence interval; DRC = Democratic Republic of the Congo.
      Table 3 presents the findings from the multivariable analysis. The odds of pornography use were elevated among boys with higher perceptions of SDS and GST in Indonesia and boys with higher perceptions of GSR in Shanghai. For girls, the SDS was the only gender norm perception associated with pornography use and only in Indonesia. Among the social-ecological covariates, romantic relationship engagement, peer sexual norms, and time spent on the Internet remained associated with pornography use in several sites. (For additional details on the models, see Table S1-S4).
      Table 3Associations between each gender norm scale and pornography use by sex and site: multivariate analysis using Firth logistic regression by sex and by site
      OR (95% CI)EcuadorBelgiumDRCChinaIndonesia
      OR95% CIOR95% CIOR95% CIOR95% CIOR95% CI
      Boys
       AREHigh (ref. low).93.38–2.258.30∗∗∗3.01–22.931.67∗∗∗1.26–2.222.53∗∗∗1.74–3.692.71∗∗∗1.95–3.76
       SDSHigh (ref. low)2.39.85–6.68.91.60–1.371.30.99–1.721.14.80–1.621.74∗∗∗1.40–2.17
       GSTHigh (ref. low).98.50–1.91.85.55–1.33.95.72–1.251.421.00–2.021.42∗∗1.14–1.77
       GSRHigh (ref. low)1.34.67–2.70--.96.72–1.261.511.02–2.231.12.90–1.40
      Girls
       AREHigh (ref. low)4.01.70–22.791.45.68–3.101.25.91–1.712.41∗∗∗1.60–3.621.73∗∗1.23–2.44
       SDSHigh (ref. low).94.33–2.661.40.71–2.741.05.75–1.461.31.88–1.951.92∗∗∗1.36–2.70
       GSTHigh (ref. low)1.06.37–3.06).77.39–1.511.07.78–1.481.38.95–2.001.20.87–1.67
       GSRHigh (ref. low).73.26–2.06--.80.58–1.10.96.65–1.441.36.97–1.90
      CI = confidence interval; DRC = Democratic Republic of the Congo; OR = odds ratio.
      Note:1. ARE: Adolescents' romantic relationships scale; SDS: Sexual double standard scale; GST: Gender stereotypical traits scale; GSR: Gender stereotypical roles scale.2. Covariates adjusted include age, relationship engagement, pubertal onset, family structure, caregiver awareness, if their close friends have had sex, school connectedness, neighborhood cohesion, and time spent on the Internet.3. Interactions between each scale and relationship engagement were tested and were included if significant. 4. : p < .05; ∗∗p < .01; ∗∗∗p < .001.

      Discussion

      This study adds new knowledge on the prevalence and correlates of pornography use among young adolescents across five countries and four continents. It shows that even in urban poor settings where sexual norms remain restrictive and access may be limited, up to a third of 10- to 14-year-olds report to have seen pornographic videos (intentionally or unintentionally), with substantial variations by site and sex.
      Comparing our estimates with previous studies is challenging, given their wide prevalence ranges [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ] which depend not only on the context and adolescent behaviors, but also on methodologies and pornography indicators [
      • Mellor E.
      • Duff S.
      The use of pornography and the relationship between pornography exposure and sexual offending in males: A systematic review.
      ]. Nonetheless, our results suggest a relatively lower prevalence of pornography use in these urban poor settings than the lifetime exposures previously reported among Taiwanese adolescents (25%) [
      • Cheng S.
      • Ma J.
      • Missari S.
      The effects of Internet use on adolescents’ first romantic and sexual relationships in Taiwan.
      ] or German boys and girls (98% and 81%) [
      • Weber M.
      • Quiring O.
      • Daschmann G.
      Peers, parents and pornography: Exploring adolescents’ exposure to sexually explicit material and its developmental correlates.
      ], which likely reflects the younger age of our sample as well as the stricter definition of pornography (revealing of the genital part of the body).
      Our findings indicate that young adolescents who report using pornography in several of the sites differ from those without such experiences in terms of their gendered perceptions and romantic attitudes as well as experiences. Some authors call on the sexual script theory to explain these connections, positing that pornography represents a source of sexual scripts that influence behavior [
      • Gagnon J.H.
      • Simon W.
      Sexual Conduct: The social sources of human sexuality.
      ,
      • Marshall E.A.
      • Miller H.A.
      • Bouffard J.A.
      Bridging the Theoretical gap: Using sexual script theory to explain the relationship between pornography Use and sexual coercion.
      ]. Consistent with this framework, we found that pornography use was more common among adolescents who perceived greater permissiveness about romantic relations, who engaged in such relations, as well as those who assumed that their friends were sexually active. Such associations, which were consistently strong in all sites except Cuenca, may reflect the fact that pornography provides young adolescents with new “sexual scripts” or understandings of boy-girl relationships by portraying these as normative in contexts where premarital sex and adolescent dating or sexuality remain taboo [
      • Blair S.L.
      • Madigan T.J.
      Dating attitudes and expectations among young Chinese adults: An examination of gender differences.
      ,
      • Holzner B.M.
      • Oetomo D.
      Youth, sexuality and sex education messages in Indonesia: Issues of Desire and Control.
      ,
      • Chandra-Mouli V.
      • Ferguson B.J.
      • Plesons M.
      • et al.
      The Political, research, Programmatic, and social responses to adolescent sexual and reproductive health and rights in the 25 Years since the international conference on Population and development.
      ]. As such, it may be that watching pornography at early ages leads to more permissive attitudes toward early adolescent boys and girls being in relationships, but it might also be the reverse—that those who already perceive early romantic relations as something normative seek out pornography as a way to navigate these beliefs [
      • Štulhofer A.
      • Buško V.
      • Schmidt G.
      Adolescent exposure to pornography and relationship intimacy in young adulthood.
      ].
      Confirming the conclusions of Peter and Valkenburg's systematic review [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ], we also observed gendered patterns in the use and correlates of pornography consumption, providing further evidence that gender differences start to emerge in early stages of adolescent development across diverse cultural settings [
      • Blum R.W.
      • Mmari K.
      • Moreau C.
      It begins at 10: How gender expectations shape early adolescence around the World.
      ]. Across sites, boys were more likely to report pornography consumption than girls, and in Asia, male consumption of pornography correlated with unequal gender norm perceptions, promoting male dominance and sexual readiness over female vulnerabilities and sexual self-restraint. The correlations between pornography use and male gender unequal attitudes have previously been reported in other settings among older adolescents [
      • Hardy S.A.
      • Hurst J.L.
      • Price J.
      • et al.
      The socialization of attitudes about sex and their role in adolescent pornography use.
      ,
      • Cheng S.
      • Ma J.
      • Missari S.
      The effects of Internet use on adolescents’ first romantic and sexual relationships in Taiwan.
      ,
      • Peter J.
      • Valkenburg P.M.
      Adolescents' exposure to sexually explicit internet material and Notions of women as sex Objects: Assessing Causality and Underlying Processes.
      ] and feed sexual scripts that are hypothesized to explain the link between pornography consumption and sexual coercion [
      • Marshall E.A.
      • Miller H.A.
      • Bouffard J.A.
      Bridging the Theoretical gap: Using sexual script theory to explain the relationship between pornography Use and sexual coercion.
      ]. However, our results also show that pornography does not systematically correlate with unequal gender norms, suggesting that the meaning and implications of pornography consumption for adolescent sexual development likely vary across the social context.
      The directionality of our findings does, however, warrant further longitudinal investigation. Although permissive and stereotypical views about gender and relationships may indeed trigger greater interest in sexual content, previous longitudinal studies suggest a stronger effect of pornography on stereotypical attitudes than the other way around [
      • Doornwaard S.M.
      • Bickham D.S.
      • Rich M.
      • et al.
      Adolescents' use of sexually explicit Internet material and their sexual attitudes and behavior: Parallel development and directional effects.
      ,
      • Wright P.J.
      Americans' attitudes toward premarital sex and pornography consumption: A national panel analysis.
      ]. These stereotypes, which favor men's sexual pleasure and dominance [
      • Klaassen M.J.E.
      • Peter J.
      Gender (In)equality in internet pornography: A content analysis of Popular pornographic internet videos.
      ], may aggravate gender power imbalances in sexual interactions [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ]. Both longitudinal and qualitative research is needed to better understand the (bi)directional relationship between pornography use with gendered attitudes and expressions in early and later adolescence, as well as its effects on healthy sexuality development—including any potentially positive impacts of different forms of pornography that challenge traditional gender stereotypes.
      Finally, we found that pornography use differs widely depending on adolescents' age (being more common in older age groups) and their social environment. Apart from the peer influences previously discussed, a supportive school environment including connectedness to teachers, as well as more caregiver awareness and/or neighborhood cohesion, was related to less pornography use in the two Asian sites. Pornography use was also more common among those who used the Internet more frequently in the DRC and China. These results underscore the importance of using comprehensive life-course perspectives to understand how young people's social-ecological environments shape how young people make sense of sexually explicit media as part of sexual socialization. Further investigation of the roles of families and school programs as well as media literacy initiatives in equipping young people to contest stereotypical messages, portrayed in mainstream pornographic materials [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ,
      • Baams L.
      • Overbeek G.
      • Dubas J.S.
      • et al.
      Perceived realism moderates the relation between sexualized media consumption and permissive sexual attitudes in Dutch adolescents.
      ], is warranted to promote sexual health and well-being.
      In particular, given that exposure to sexually explicit media has become a normative part of adolescent sexuality development in many settings [
      • Peter J.
      • Valkenburg P.M.
      Adolescents and pornography: A review of 20 Years of research.
      ], interventions need to help young people understand and navigate the messages that they receive—especially in contexts where parents and adults may find it difficult to communicate about this and whether the exposure is intentional or unintentional, online, or offline. Although appropriate child protection mechanisms and regulations of online pornography is needed, comprehensive sexuality education—when implemented with quality and based on evidence in line with international recommendations [
      • UNESCO UNAIDS UNFPA
      • et al.
      International Technical guidance on sexuality education.
      ]—can play an important role to help adolescents critically process information and avoid the potential sexual risks associated with pornographic gendered and sexual stereotypes [
      • Hardy S.A.
      • Hurst J.L.
      • Price J.
      • et al.
      The socialization of attitudes about sex and their role in adolescent pornography use.
      ,
      • Blum R.W.
      • Astone N.M.
      • Decker M.R.
      • et al.
      A conceptual framework for early adolescence: A platform for research.
      ]. As young people grow up in digital communities (with a majority in our sample using the Internet on a daily basis), carefully implemented web-based sexuality education can also present an avenue to provide young people with fact-based information about their bodies, sexualities, and rights, which promotes consent and nonaggression in relationships.

      Strengths and limitations

      A number of limitations need to be considered when interpreting our results. First, because of survey limitations (such as using one singular question to assess the outcome), we were unable to assess the intentionality, frequency, and content of pornography consumption, precluding a more nuanced measurement, as well as comparison with previous studies, of the association between sexually explicit video content and adolescents' gender attitudes. Second, although the survey defined what constitutes pornography, the question could have been interpreted differently depending on the respondent's sociodemographic background and context, calling for cautious interpretation of cultural differences as well as qualitative studies to better understand the estimates and associations yielded in our study. In addition, the independent variables included in the analysis do not fully capture the wide range of possible predictors of pornography use. However, we believe that our comparison of a single indicator across different sites using the cross-cultural validated survey instrument, and inclusion of different individual, family, and community covariates, still adds important information to the field, given the lack of studies focusing on 10- to 14-year-olds in low-income contexts. As in any study on adolescent health, questions may have been subject to social desirability bias, especially in the DRC, where data were collected face-to-face, which we addressed by carefully ensuring adolescents' privacy and confidentiality. In addition, although parental consent was used as a way to maximize adolescents' safety, this may have influenced who participated in the study and their willingness to respond. Finally, the focus of the GEAS on urban poor communities, the nonprobability-based sampling method, the absence of data on perceived gender, and the cross-sectional nature of the study prevent any casual interpretation of the findings as well as generalizability beyond these diverse cultural settings and transferability to youth of gender fluidity or atypical gender identities. Some of these concerns can, however, be further explored as the longitudinal follow-up of the GEAS proceeds.

      Conclusions

      Pornography use and its link with gender inequality in adolescence remains an issue of much global debate. This study shows that lifetime exposure to pornography among 10- to 14-year-olds varies widely across urban poor settings and confirms pornography as a highly gendered experience that begins in early adolescence. The implications of these findings are essential in low-income urban contexts where access to evidence-based sexual education is limited and sexual norms remain restrictive [
      • Nieh H.P.
      • Chang L.Y.
      • Chang H.Y.
      • et al.
      Pubertal timing, parenting Style, and Trajectories of pornography Use in adolescence: Peer pornography Use as the Mediator.
      ,
      • Chandra-Mouli V.
      • Ferguson B.J.
      • Plesons M.
      • et al.
      The Political, research, Programmatic, and social responses to adolescent sexual and reproductive health and rights in the 25 Years since the international conference on Population and development.
      ], impeding young people's ability to challenge the narratives of gender stereotypes propagated via mainstream pornography. These realities call for investments in comprehensive sexuality education programs (including online) that start early and continue throughout adolescence to equip adolescents with the knowledge and skills needed to contest stereotypes and promote healthy sexuality development.

      Acknowledgments

      The Global Early Adolescent Study was supported by Johns Hopkins and World Health Organization as well as other organizations around the world. The authors thank all the researchers and students who participated in the present study and also the administrators and teachers in the target schools or communities who helped facilitating the survey. The authors also thank the GEAS Coordinate Center in Johns Hopkins University for providing the technical support.

      References

        • Peter J.
        • Valkenburg P.M.
        Adolescents and pornography: A review of 20 Years of research.
        J Sex Res. 2016; 53: 509-531
        • Kyriaki A.
        • Vasileios S.
        • Emma A.
        • et al.
        Adolescent pornography Use: A systematic Literature review of research Trends 2000-2017.
        Curr Psychiatry Rev. 2018; 14: 47-58
        • Weber M.
        • Quiring O.
        • Daschmann G.
        Peers, parents and pornography: Exploring adolescents’ exposure to sexually explicit material and its developmental correlates.
        Sex Cult. 2012; 16: 408-427
        • Döring N.M.
        The Internet’s impact on sexuality: A critical review of 15 years of research.
        Comput Hum Behav. 2009; 25: 1089-1101
        • Brown J.D.
        • X-Rated L'Engle K.L.
        Sexual attitudes and behaviors associated with U.S. Early adolescents' exposure to sexually explicit media.
        Commun Res. 2009; 36: 129-151
        • Doornwaard S.M.
        • Bickham D.S.
        • Rich M.
        • et al.
        Adolescents' use of sexually explicit Internet material and their sexual attitudes and behavior: Parallel development and directional effects.
        Dev Psychol. 2015; 51: 1476-1488
        • Martyniuk U.
        • Stulhofer A.
        A longitudinal exploration of the relationship between pornography use and sexual permissiveness in female and male adolescents.
        J Adolesc. 2018; 69: 80-87
        • Dombrowski S.C.
        • Gischlar K.L.
        • Durst T.
        Safeguarding young people from cyber pornography and cyber sexual predation: A major dilemma of the internet.
        Child Abuse Rev. 2007; 16: 153-170
        • Pluhar E.
        • Kavanaugh J.R.
        • Levinson J.A.
        • et al.
        Problematic interactive media use in teens: Comorbidities, assessment, and treatment.
        Psychol Res Behav Manag. 2019; 12: 447-455
        • Ma C.M.S.
        • Shek D.T.L.
        • Lai C.C.W.
        Individual and family protective factors of intentional and unintentional consumption of online pornography in Hong Kong.
        Int J Disabil Hum Dev. 2017; 16: 425
        • Livingstone S.
        • Smith P.K.
        Annual research review: Harms experienced by child users of online and mobile technologies: The nature, prevalence and management of sexual and aggressive risks in the digital age.
        J Child Psychol Psyc. 2014; 55: 635-654
        • Collins R.L.
        • Strasburger V.C.
        • Brown J.D.
        • et al.
        Sexual media and childhood well-being and health.
        Pediatrics. 2017; 140: S162-s166
        • Christensen P.H.
        Childhood and the cultural constitution of vulnerable bodies.
        in: Prout A. Campling J. The Body, Childhood and Society. Palgrave Macmillan UK, London2000: 38-59
        • Klaassen M.J.E.
        • Peter J.
        Gender (In)equality in internet pornography: A content analysis of Popular pornographic internet videos.
        J Sex Res. 2015; 52: 721-735
        • Wright P.J.
        • Tokunaga R.S.
        • Kraus A.
        A Meta-analysis of pornography consumption and Actual Acts of sexual aggression in general Population studies.
        J Commun. 2015; 66: 183-205
        • Mellor E.
        • Duff S.
        The use of pornography and the relationship between pornography exposure and sexual offending in males: A systematic review.
        Aggression Violent Behav. 2019; 46: 116-126
        • Grudzen C.R.
        • Elliott M.N.
        • Kerndt P.R.
        • et al.
        Condom Use and high-risk sexual Acts in adult Films: A comparison of heterosexual and homosexual Films.
        Am J Public Health. 2009; 99: S152-S156
        • Nelson K.M.
        • Rothman E.F.
        Should public health Professionals consider pornography a public health crisis?.
        Am J Public Health. 2020; 110: 151-153
        • Malamuth N.M.
        • Hald G.M.
        • Koss M.
        Pornography, individual differences in risk and men’s acceptance of Violence against women in a Representative sample.
        Sex Roles. 2012; 66: 427-439
        • Bridges A.J.
        • Wosnitzer R.
        • Scharrer E.
        • et al.
        Aggression and sexual behavior in best-selling pornography videos: A content analysis update.
        Violence Against Women. 2010; 16: 1065-1085
        • Vogels E.A.
        Loving Oneself: The associations among sexually explicit media, body image, and perceived realism.
        J Sex Res. 2019; 56: 778-790
        • Olmstead S.B.
        • Negash S.
        • Pasley K.
        • et al.
        Emerging adults’ expectations for pornography Use in the context of Future Committed romantic relationships: A qualitative study.
        Arch Sex Behav. 2013; 42: 625-635
        • Kohut T.
        • Baer J.L.
        • Watts B.
        Is pornography really about "making hate to women"? Pornography users Hold more gender Egalitarian attitudes than Nonusers in a Representative American sample.
        J Sex Res. 2016; 53: 1-11
        • Hardy S.A.
        • Hurst J.L.
        • Price J.
        • et al.
        The socialization of attitudes about sex and their role in adolescent pornography use.
        J Adolesc. 2019; 72: 70-82
        • Cheng S.
        • Ma J.
        • Missari S.
        The effects of Internet use on adolescents’ first romantic and sexual relationships in Taiwan.
        Int Sociol. 2014; 29: 324-347
        • Peter J.
        • Valkenburg P.M.
        Adolescents' exposure to sexually explicit internet material and Notions of women as sex Objects: Assessing Causality and Underlying Processes.
        J Commun. 2009; 59: 407-433
        • Heise L.
        • Greene M.E.
        • Opper N.
        • et al.
        Gender inequality and restrictive gender norms: Framing the challenges to health.
        The Lancet. 2019; 393: 2440-2454
        • Baams L.
        • Overbeek G.
        • Dubas J.S.
        • et al.
        Perceived realism moderates the relation between sexualized media consumption and permissive sexual attitudes in Dutch adolescents.
        Arch Sex Behav. 2015; 44: 743-754
        • Koletić G.
        Longitudinal associations between the use of sexually explicit material and adolescents' attitudes and behaviors: A narrative review of studies.
        J Adolesc. 2017; 57: 119-133
        • Pulerwitz J.
        • Blum R.
        • Cislaghi B.
        • et al.
        Proposing a conceptual framework to address social norms that influence adolescent sexual and reproductive health.
        J Adolesc Health. 2019; 64: S7-S9
        • Blum R.W.
        • Astone N.M.
        • Decker M.R.
        • et al.
        A conceptual framework for early adolescence: A platform for research.
        Int J Adolesc Med Health. 2014; 26: 321-331
        • Nieh H.P.
        • Chang L.Y.
        • Chang H.Y.
        • et al.
        Pubertal timing, parenting Style, and Trajectories of pornography Use in adolescence: Peer pornography Use as the Mediator.
        J Sex Res. 2020; 57: 29-41
        • Boniel-Nissim M.
        • Efrati Y.
        • Dolev-Cohen M.
        Parental Mediation Regarding Children’s pornography exposure: The role of parenting Style, protection Motivation and gender.
        J Sex Res. 2020; 57: 42-51
        • Brooks F.M.
        • Magnusson J.
        • Spencer N.
        • et al.
        Adolescent multiple risk behaviour: An asset approach to the role of family, school and community.
        J Public Health (Oxf). 2012; 34: i48-56
        • Tolman D.L.
        • McClelland S.I.
        Normative sexuality development in adolescence: A decade in review, 2000–2009.
        J Res Adolesc. 2011; 21: 242-255
        • Blum R.W.
        • Mmari K.
        • Moreau C.
        It begins at 10: How gender expectations shape early adolescence around the World.
        J Adolesc Health. 2017; 61: S3-S4
        • Mmari K.
        • Blum R.
        • Sonenstein F.
        • et al.
        Adolescents' perceptions of health from disadvantaged urban communities: Findings from the WAVE study.
        Soc Sci Med. 2014; 104: 124-132
        • Mmari K.
        • Cooper D.
        • Moreau C.
        • et al.
        The social context of early adolescents in the global early adolescent study.
        J Adolesc Health. 2020;
        • Moreau C.
        • Li M.
        • De Meyer S.
        • et al.
        Measuring gender norms about relationships in early adolescence: Results from the global early adolescent study.
        SSM - Popul Health. 2019; 7: 014
        • Beretta L.
        • Santaniello A.
        Nearest neighbor imputation algorithms: A critical evaluation.
        BMC Med Inform Decis Mak. 2016; 16: 74
        • Cohen J.
        Statistical power Analysis for the behavioral Sciences.
        Routledge Academic, New York, NY1988
        • Gagnon J.H.
        • Simon W.
        Sexual Conduct: The social sources of human sexuality.
        Aldine Pub. Co., Chicago, IL1973
        • Marshall E.A.
        • Miller H.A.
        • Bouffard J.A.
        Bridging the Theoretical gap: Using sexual script theory to explain the relationship between pornography Use and sexual coercion.
        J Interpers Violence. 2021; 36: NP5215-NP5238
        • Blair S.L.
        • Madigan T.J.
        Dating attitudes and expectations among young Chinese adults: An examination of gender differences.
        The J Chin Sociol. 2016; 3: 12
        • Holzner B.M.
        • Oetomo D.
        Youth, sexuality and sex education messages in Indonesia: Issues of Desire and Control.
        Reprod Health Matters. 2004; 12: 40-49
        • Chandra-Mouli V.
        • Ferguson B.J.
        • Plesons M.
        • et al.
        The Political, research, Programmatic, and social responses to adolescent sexual and reproductive health and rights in the 25 Years since the international conference on Population and development.
        J Adolesc Health. 2019; 65: S16-S40
        • Štulhofer A.
        • Buško V.
        • Schmidt G.
        Adolescent exposure to pornography and relationship intimacy in young adulthood.
        Psychol Sex. 2012; 3: 95-107
        • Wright P.J.
        Americans' attitudes toward premarital sex and pornography consumption: A national panel analysis.
        Arch Sex Behav. 2015; 44: 89-97
        • UNESCO UNAIDS UNFPA
        • et al.
        International Technical guidance on sexuality education.
        UNESCO, UNAIDS, UNFPA, UNICEF, UN Women and WHO, Paris, Geneva and New York2018