Impact of the Media on Adolescent Sexual Attitudes and Behaviors

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  DOI: 10.1542/peds.2005-0355D 2005;116;303-326 Pediatrics Low, Patricia Eitel and Patricia Thickstun S. Liliana Escobar-Chaves, Susan R. Tortolero, Christine M. Markham, Barbara J.  Impact of the Media on Adolescent Sexual Attitudes and BehaviorsThis information is current as of January 12, 2007 http://www.pediatrics.org/cgi/content/full/116/1/S1/303located on the World Wide Web at: The online version of this article, along with updated information and services, is rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly  by on January 12, 2007 www.pediatrics.orgDownloaded from   Impact of the Media on Adolescent Sexual Attitudes and Behaviors S. Liliana Escobar-Chaves, DrPH*; Susan R. Tortolero, PhD*; Christine M. Markham, PhD*;Barbara J. Low, DrPH*; Patricia Eitel, PhD*; and Patricia Thickstun, PhD‡ ABSTRACT.  Background.  Adolescents in the UnitedStates are engaging in sexual activity at early ages andwith multiple partners. The mass media have beenshown to affect a broad range of adolescent health-re-lated attitudes and behaviors including violence, eatingdisorders, and tobacco and alcohol use. One largely un-explored factor that may contribute to adolescents’ sexualactivity is their exposure to mass media. Objective.  We sought to determine of what is and isnot known on a scientific basis of the effects of massmedia on adolescent sexual attitudes and behaviors.  Method.  We performed an extensive, systematic re-view of the relevant biomedical and social science liter-ature and other sources on the sexual content of variousmass media, the exposure of adolescents to that media,the effects of that exposure on the adolescents’ sexualattitudes and behaviors, and ways to mitigate those ef-fects. Inclusion criteria were: published in 1983–2004,inclusive; published in English; peer-reviewed (for ef-fects) or otherwise authoritative (for content and expo-sure); and a study population of American adolescents 11to 19 years old or comparable groups in other postindus-trial English-speaking countries. Excluded from thestudy were populations drawn from college students. Results.  Although television is subject to ongoingtracking of its sexual content, other media are terra in-cognita. Data regarding adolescent exposure to variousmedia are, for the most part, severely dated. Few studieshave examined the effects of mass media on adolescentsexual attitudes and behaviors: only 12 of 2522 research-related documents ( < 1%) involving media and youthaddressed effects, 10 of which were peer reviewed. Nonecan serve as the grounding for evidence-based publicpolicy. These studies are limited in their generalizabilityby their cross-sectional study designs, limited samplingdesigns, and small sample sizes. In addition, we do notknow the long-term effectiveness of various social-cul-tural, technologic, and media approaches to minimizingthat exposure (eg, V-Chips on television, Internet-filter-ing-software, parental supervision, rating systems) orminimizing the effects of that exposure (eg, media-liter-acy programs). Conclusions.  Research needs to include developmentof well-specified and robust research measures andmethodologies; ongoing national surveillance of the sex-ual content of media and the exposure of various demo-graphic subgroups of adolescents to that content; andlongitudinal studies of the effects of that exposure on thesexual decision-making, attitudes, and behaviors of thosesubgroups. Additional specific research foci involve thesuccess of various types of controls in limiting exposureand the mitigative effects of, for example, parental influ-ence and best-practice media-literacy programs.  Pediat-rics  2005;116:303–326;  adolescent sexual behavior, atti-tudes, media impact. ABBREVIATIONS. STI, sexually transmitted infection; HPV, hu-man papillomavirus; CDC, Centers for Disease Control and Pre-vention; TV, television; VCR, videocassette recorder; NIH, Na-tional Institutes of Health. INTRODUCTION A lthough the proportion of high school stu-dents who have had sex has declined in thepast decade, many adolescents in the UnitedStates are engaging in sexual activity at early agesand with multiple partners. Approximately 47% of high school students have had sexual intercourse. 1 Of these, 7.4% report having sex before the age of 13and 14% have had  4 sexual partners. 1 Sexually active adolescents are at immediate riskfor pregnancy and acquiring sexually transmittedinfections (STIs). Each year, nearly 900 000 teenagedgirls in the United States become pregnant (340 000are  17 years old), 2 and 35% of American teenagedgirls have been pregnant at least once by the age of 20. 2 In the United States, the risk of acquiring an STIis higher among teenagers than among adults. 3 Al-most 4 million cases of STIs are diagnosed in adoles-cents each year. 4 In 2002, gonorrhea rates in theUnited States were highest among females in the age brackets of 15 to 19 years (675.6 per 100 000) and 20to 24 years (650.3 per 100 000); among males those inthe 20- to 24-year age bracket had the highest rate(538.1 per 100 000). 5 The most common reported STIin the United States is chlamydia, and it is mostprevalent among adolescents. In 2002 chlamydiaprevalence reported among sexually active adoles-cent females was 6 times as high as that amongsexually active females in the general population. 6 Human papillomavirus (HPV) infection is the mostprevalent of all viral STIs, even more common thanherpes simplex virus and human immunodeficiencyvirus (HIV) combined. Approximately 35 of the 100known HPV strains cause cervical cancer; the re-mainder cause genital warts. HPV seroprevalence is5% in adolescents aged 12 to 19 and 15% amongyoung adults aged 20 to 29. High levels of HPV From the *Center for Health Promotion and Prevention Research, Univer-sity of Texas Health Science Center, Houston, Texas; and ‡Medical Institutefor Sexual Health, Austin, Texas.Accepted for publication Apr 14, 2005.doi:10.1542/peds.2005-0355DNo conflict of interest declared.Address correspondence to S. Liliana Escobar-Chaves, DrPH, Center forHealth Promotion and Prevention Research, School of Public Health, Uni-versity of Texas Health Science Center, PO Box 20036, Houston, TX 77225-0036. E-mail: soledad.l.escobar-chaves@uth.tmc.eduPEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad-emy of Pediatrics. PEDIATRICS Vol. 116 No. 1 July 2005  303  by on January 12, 2007 www.pediatrics.orgDownloaded from   infection are found among high-risk teens: 1 study of inner-city teens found 24% of young women wereinfected with HPV. 4 HIV is the causative agent inacquired immunodeficiency syndrome (AIDS). In2000,   2900 new HIV cases diagnosed in youngpeople aged 15 to 24 were reported to the Centers forDisease Control and Prevention (CDC) from just 30states. Given that it typically takes a decade afterHIV infection for AIDS symptoms to appear, it islikely that most young adults diagnosed with HIVinfection and AIDS had been infected with HIV asadolescents. By the end of 2002,   36 000 cases of HIV/AIDS had been reported in young people aged13 to 24 in the United States. 7,8 By the end of 2001  14 000 young Americans aged 15 to 24 had died of AIDS, according to the most recent CDC data avail-able. 7 Data suggest that sexually active adolescents are athigh risk for depression and suicide. 9–12 Early sexualexperience among adolescents has also been associ-ated with other potentially health-endangering be-haviors such as alcohol, marijuana, and other druguse. 12 Many factors may put teens at risk for becomingsexually active at an early age. Some of the mostimportant risk factors are race, poverty, the use of drugs and alcohol, peer influences, and parental in-fluences. 13 One potential but largely unexplored factor thatmay contribute to sexual activity among adolescentsis exposure to sexual content in the mass media. Theaverage American youth spends one third of eachday exposed to media, and the majority of that ex-posure occurs outside of parental oversight. 14 Al-though mass media have been shown to have aninfluence on a broad range of behaviors and attitudesincluding violence, eating disorders, tobacco and al-cohol use, surprisingly few studies have examinedthe effects of mass media on adolescent sexual atti-tudes and behaviors. This report is a review of thosestudies. Theoretical Perspectives: Media as an Influence onAttitudes and Behaviors The potential for mass media to influence behaviorhas been supported through a number of differentpsychosocial theories, hypotheses, and models. Al-though there is considerable variation in theoreticalmechanisms by which media might affect adoles-cents’ sexual attitudes and behaviors, most posit thatsexually related message content and behavior actover time as stimuli to change consumer psycholog-ical, physiologic, and behavioral function. Social-Learning Theory Bandura’s social-learning theory, 15 one of the mostprominent of these theoretical mechanisms, providesample evidence that even when children and adultshave not actually performed a behavior, they canlearn by imitation. Bandura identifies 3 main pro-cesses involved in learning: direct experience, indi-rect or vicarious experience from observing others(modeling), and the storing and processing of com-plex information through cognitive operations. Thistheory suggests that behaviors are learned and thatthey are influenced by social context: “Television isseen as an increasingly influential agent of socializa-tion that produces its effects through children’s pro-pensity to learn by imitation.” 16 Disinhibition Theory Disinhibition theory posits that existing behavioraltendencies of children and others are inhibited byexperience. 17 Continued exposure to television (TV),however, disinhibits viewers, making them more ac-cepting of the behavior. 18 Priming Theory Research has shown that exposure to an event (ie,sexual stereotypes) from the mass media activatesother similar ideas for a short time afterward. 19 These thoughts, in turn, can activate other semanti-cally related concepts and make them more accessi- ble.  Arousal Theory Arousal theory focuses primarily on the immedi-ate effects that sexually suggestive material mayhave on behavior. 20 TV content, for example, canproduce general emotional and physiologic arousal(ie, activation of the nervous system rather than spe-cific sexual arousal) that is likely to elicit some typeof individual and contextual behavioral response. Cultivation Theory Cultivation theory posits that heavy exposure tomass media creates and cultivates attitudes moreconsistent with a media-directed version of realitythan with reality itself. 21 Media portrayals and mes-sages might affect the behavior of young personsover time by enabling them to acquire new attitudesand behaviors or by changing the likelihood thatthey will perform new or previously learned re-sponses. This may occur when a child’s expectationsabout the outcome of certain behaviors are alteredthrough identification with the character portrayingor providing the stimuli, by raising or lowering be-havioral inhibitions, by modifying the potential forenvironmental cues to foster certain behaviors, or bylinking specific meanings to a behavior.  Media Practice Model This model was developed to explain media use ina comprehensive and contextual framework 22 andhighlights the connections between adolescents’identities and media selection, interaction, and ap-plication 22 : “This model assumes that youth choosemedia and interact with it based on who they are orwho they want to be at the moment.” 23 Theoreticalresearch is borne out by communications-related sur-vey data. Advertisers recognize that the content of their messages will have an effect on consumer pur-chasing behavior. 24 Additionally, young people re-port that media messages are an important influencein their lives 25 and that they receive important infor-mation about life choices from the media. 26 304  MEDIA IMPACT ON ADOLESCENT SEXUAL BEHAVIORS  by on January 12, 2007 www.pediatrics.orgDownloaded from   Third-Person Effect Hypothesis The third-person effect hypothesis states that peo-ple tend to perceive mass media messages to have agreater impact on others attitudes and behaviorsthan on themselves. 27 A practical way of looking atthird-person effect is that messages “have little effecton people like you and me, but the ordinary reader islikely to be influenced a lot.” This phenomenon may be exacerbated for adolescents and may lead to un-derreporting of decision-making factors. Super-Peer Theory This theory posits that the media can represent apotent source of information for teens as to what isnormative behavior 28,29 and may indeed exceed theinfluence of an adolescent’s more traditional peergroup. 30 The effect of exposure to attitudes and be-haviors portrayed in mass media may be com-pounded by the glamour typically associated withthose appearing in it (both the characters and theactors playing them). Moreover, TV programmingtargeted to youth takes advantage of the attraction of children and teens to characters they perceive to be 2or 3 years older than they themselves are 31 —“peers”with whom they typically cannot socialize but whomthey long to be like. Such characters, although olderthan the child’s peer group, provide templates forthe child’s “aspirational” behavior. 31 In short, young-sters model themselves after those who they want to be not those who reflect who and what they cur-rently are. Power of the Indirect Whatever the correct theoretical underpinning(s),data suggest that messages embedded in other me-dia types are more powerful than direct advertisingappeals when it comes to influencing behavior. Ad-vertising is influential, but perhaps because teenshave now become more marketing savvy, they tendto resist direct appeals to change their behaviors andare better persuaded by subtle, embedded messag-es. 32 The result has been greater use of nontraditionalmarketing approaches such as “viral” marketing(any strategy that encourages individuals to pass ona marketing message to others), using “trend-setters”as communication sources, and e-mail. Such nontra-ditional sources de-emphasize the advertising aspectand highlight content to minimize the consumer’ssense of being manipulated, which explains whyproduct placement is so popular in movies and TV: itis indirect and subtle but powerful. 32 The NationalYouth Anti-Drug Media Campaign (sponsored bythe Office of National Drug Control Policy) con-ducted a qualitative and ethnographic studythroughout the country in 6 markets during August2003. Teens were asked to use a diary to keep track of all drug messages (prodrug and antidrug) withwhich they came into contact across all mediasources for a 2-week period, after which focusgroups were held. The main finding was that pro-drug messages were perceived by all teens as morepowerful and compelling than antidrug messagesprimarily because of their subtlety and embeddednature. 33 Media Influence on Other Health-Related Behaviors Although little is known about the effect of massmedia on adolescent sexual behaviors, much more isknown about its effects on other health-related be-haviors. In particular, violence in mass media hasattracted a great deal of ongoing attention. 34 Theeffects of a child or adolescent’s media diet on theirfuture risk of eating disorders and alcohol and to- bacco use have also been subjects for study. Whatfollows is a brief summary, not a thorough survey, of the effects that mass media has on other health-related behaviors in adolescents.  Aggressive Behavior Youth violence as a public health issue was ad-dressed in a 2001 report by the US Surgeon Gener-al. 35 Numerous studies have investigated the associ-ation between media violence and aggression, withmany focusing on children and adolescents. A vari-ety of study designs have been used to understandthe media-aggression relationship, including labora-tory, 36,37 correlational, 38–41 longitudinal, 42–47 andecological designs. 48 Several comprehensive reviewsof youth literature are available. 49–54 Most of thesestudies have supported a positive association be-tween exposure to media violence and aggression.The association has been strong enough to causecongressional concern and the creation of a series of Federal Trade Commission reports. 34 Eating Disorders The prevalence of obesity is increasing in theUnited States. 55 Researchers have repeatedly found asignificant association between obesity and TV view-ing. 56–61 From 1963 through 1965, Dietz and Gort-maker 56 studied 6965 children aged 6 to 11. Resultsshowed that children who watched more TV experi-enced a greater prevalence of obesity or superobesitythan children watching less TV. Crespo et al exam-ined the relationship between TV watching, energyintake, physical activity, and obesity status by usinga national representative sample of US children aged8 to 16 (interviews were done between 1988 and1994). They reported that the prevalence of obesitywas lowest among children watching  1 hours of TVper day and highest among those watching  4 hoursof TV per day. TV watching was positively associ-ated with obesity among girls even after controllingfor age, race/ethnicity, family income, weekly phys-ical activity, and energy intake. 61 In a 1990 study of acohort of 746 youths aged 10 to 15, Gortmaker et al 59 had similar results, finding a strong relationship be-tween the prevalence of overweight and hours of TVviewed.Depending on the methodology used, the reportedprevalence rate for anorexia nervosa and bulimianervosa among adolescent females ranges from  2.4% 62 to 5% 63 and is 0.48% among girls aged 15 to19 for anorexia alone. 64 Although males compriseonly  10% of anorexia cases, both genders are expe-riencing an increase in prevalence of eating disor-ders. 65 Of particular concern is that eating disordersin early childhood are associated with symptoms of  SUPPLEMENT  305  by on January 12, 2007 www.pediatrics.orgDownloaded from    bulimic behaviors in adulthood. 66 Martinez-Gonza´-lez et al 67 found a positive association between theincidence of eating disorders and weekend TV view-ing in a sample of females aged 12 to 21. They alsofound that those adolescent females at higher risk of developing an eating disorder (based on  Diagnosticand Statistical Manual of Mental Disorders, Fourth Edi-tion  criteria) were also more likely to read girls’ mag-azines or listen to radio programs (odds ratio: 2.1;95% confidence interval: 1.2–3.8, for those most fre-quently using both media). 67 Other research hasshown that among 374 girls (mean: 12 years old),over a 16-month period those who reported in-creased eating-disorder symptomatology had signif-icantly increased their exposure to fashion maga-zines but decreased their number of hours of TVviewing, whereas those with decreased symptom-atology had significantly decreased their exposure to both TV and fashion magazines. 68 Trying to look likefemales portrayed on TV, in movies, or in magazineswas also significantly predictive of preadolescentand adolescent girls’ onset of eating-disorder–related behavior (odds ratio: 1.9; 95% confidence interval:1.6–2.3). A study comparing 2 samples of Fijianschoolgirls before and after the introduction of TV tothe region is suggestive: indicators of disorderedeating were significantly more prevalent after pro-longed exposure to TV. Study participants reported adesire to lose weight or to reshape their body to become more like Western TV characters. 69 Tobacco and Alcohol Use Each day   4000 children   18 years old smoketobacco for the first time, 70 nearly 2000 of which will become regular smokers. It is estimated that at least4.5 million US adolescents are cigarette smokers. Ap-proximately 80% of smokers begin smoking beforethe age of 18. 71 Several studies have explored theimpact of advertising on adolescents. 72–74 Many haveshown advertising to be very effective in increasingyoungsters’ awareness of and emotional responses toproducts (recognition of brands, desire to own theproducts advertised). Cigarette advertising seems toincrease teenagers’ risk of smoking by glamorizingsmoking and smokers, 75 and children who are able torecall ads related to tobacco are more likely to viewsmoking favorably and to become smokers. 72–74 Alcoholic drinks are the most common beveragesportrayed on TV. 29 It has been shown that exposureto alcohol advertising and TV programming is asso-ciated with positive beliefs about alcohol consump-tion. 76–78 Although such cross-sectional studies donot prove causation (only association), it is of interestthat in a 1990 study, 56% of students in grades 5 to 12said that alcohol advertising encourages them todrink. 79 A longitudinal study examined the associa-tion between alcohol consumption at the age of 18and alcohol-related messages at the ages of 13 and15. Findings showed that girls who had watchedmore hours of TV at ages 13 and 15 drank more wineand spirits at age 18 than those who had watchedfewer hours of TV. 80 A 1997 study of    300 Web sites found that 25major alcoholic beverage companies were even thenusing the Internet to advertise, promote, and selltheir products through a variety of marketing tech-niques that capitalize on the Internet’s strong attrac-tion for young people. 81 Strasburger’s 2002 review 29 (which also includesdata of interest regarding representations of smokingand illicit drug use) concludes that “[a]lthough theresearch is not yet scientifically ‘beyond a reasonabledoubt,’ a preponderance of evidence shows that al-cohol advertising is a significant factor in adoles-cents’ use of this drug.” 29(p361) Purpose of This Report Effects of the mass media have been found to befar-reaching and potentially harmful in influencingthe health-related behaviors of children and adoles-cents, many of whom are not yet mature enough todistinguish fantasy from reality, particularly when itis presented as “real life.” Furthermore, time spentwith media decreases the amount of time availablefor pursuing other more healthful activities such assports, physical activity, community service, culturalpursuits, and family time. The accumulation of evi-dence across multiple health-risk behaviors suggeststhat media influence on youth is worthy of carefulresearch.This report presents the results of a review of theliterature and other data sources on the impact of mass media (including the Internet) on the sexualattitudes and behaviors of adolescents (ages 11–19)in the United States. For each form of media weinclude the scientific data from the last 2 decades(1983–2004) on adolescent exposure to that medium,its sexual content, and the effects of that exposure.The report concludes with an assessment of futureresearch needs. METHODSDefinitions This study examines the exposure, content, and effect of mediaon adolescent sexual attitudes and behaviors. For this study “ex-posure” refers to the amount of time per day spent with differenttypes of media and the social context of media use. “Content”refers to any dialogue, situation, or behavior that involves sexu-ality, sexual suggestiveness, or sexual activities or relationships, aswell as the nature of sexual depictions in the media.Studies define “sexual behavior” in a wide variety of ways: is akiss sexual? Is dating? Many studies use the term “explicit” tomean “overt” (the opposite of “implied”) rather than to indicate,eg, a degree of nudity or level of physical intimacy. The majorityof recent studies make use of the definitions created for the KaiserFamily Foundation’s ongoing  Sex on TV  82–84 studies: •  “[S]exual content is defined as any depiction of sexual activity,sexually suggestive behavior, or talk about sexuality or sexualactivity. Portrayals involving only talk about sex are measuredseparately from those that include sexual actions or behav-iors…. To be considered a sexual behavior, actions must conveya sense of potential or likely sexual intimacy. For example, a kissof greeting between two friends or relatives would not be codedas sexual behavior, whereas a passionate kiss between twocharacters with a discernible romantic interest would be. Thelower threshold for sexual behaviors measured by the studywas physical flirting, which refers to behavioral actions in-tended to arouse sexual interest in others, such as a womanlicking her lips provocatively while gazing intently at a man ina bar.” 84 ( p7 ) •  “Sexual dialogue, or what we term ‘talk about sex,’ involves awide range of types of conversations that may involve first- 306  MEDIA IMPACT ON ADOLESCENT SEXUAL BEHAVIORS  by on January 12, 2007 www.pediatrics.orgDownloaded from 
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