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Organizational Principles to Guide and Define the Health Care System and/or Improve the Health of all Children Policy Statement—Sexuality, Contraception, and the Media

THE COUNCIL ON AND MEDIA abstract KEY WORDS From a health viewpoint, early sexual activity among US adolescents is sexual activity, adolescents, media, television a potential problem because of the risk of and sexually ABBREVIATIONS STI—sexually transmitted infection transmitted infections. New evidence points to the media adolescents TV—television use frequently (television, music, movies, magazines, and the Internet) This document is copyrighted and is property of the American as important factors in the initiation of . There is a Academy of Pediatrics and its Board of Directors. All authors major disconnect between what mainstream media portray—casual have filed conflict of interest statements with the American sex and sexuality with no consequences—and what children and teen- Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American agers need—straightforward information about and Academy of Pediatrics has neither solicited nor accepted any the need for contraception when having sex. Television, film, music, commercial involvement in the development of the content of and the Internet are all becoming increasingly sexually explicit, yet this publication. information on , sexual responsibility, and re- mains rare. It is unwise to promote “abstinence-only” sex when it has been shown to be ineffective and when the media have become such an important source of information about “nonabsti- nence.” Recommendations are presented to help pediatricians ad- dress this important issue. Pediatrics 2010;126:576–582

INTRODUCTION Early sexual activity among teenagers can be problematic. According to the 2009 Youth Risk Behavior Survey, 46% of all high school seniors www.pediatrics.org/cgi/doi/10.1542/peds.2010-1544 have had sexual intercourse, and 14% have had 4 partners or more.1 doi:10.1542/peds.2010-1544 Although pregnancy rates have generally been decreasing since 1991, All policy statements from the American Academy of Pediatrics the still has the highest teen pregnancy rate in the West- automatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time. ern world,2 and for the first time in 15 years, the increased PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 3% from 2005 to 2006.3 Early intercourse also increases the risk of Copyright © 2010 by the American Academy of Pediatrics contracting a sexually transmitted infection (STI), including HIV, and adolescents have one of the highest STI rates of any age group.4 Al- though 15- to 24-year-olds account for only one-quarter of the sexually active in the United States, they contract nearly half of all new STIs every year.4 A recent study by the Centers for Disease Control and Prevention revealed that 1 in 4 teenagers has had an STI.5 Ten percent of young women who had first had sex in their teenage years reported that their first time was involuntary, and the younger they were, the more likely that was the case.6

WHAT CHILDREN AND TEENAGERS LEARN FROM THE MEDIA American children and teenagers spend more than 7 hours/day with a variety of different media.7 Those media are filled with sexual mes- sages and images, many of which are unrealistic.2 On television (TV), which remains the predominant medium in terms of time spent for all young people, more than 75% of prime-time programs contain sexual

576 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 30, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS content, yet only 14% of sexual inci- per issue to sexual topics.19 Cover- drugs are ubiq- dents mention any risks or responsi- age of sex as a health issue in mag- uitous. In the first 10 months of bilities of sexual activity.8,9 Talk about azines is more common than on TV, 2004, the makers of these drugs sex on TV can occur as often as 8 to 10 but the overarching focus seems to spent nearly $350 million on adver- times per hour.10 Between 1997 and be on deciding when to lose one’s tising.32 At the same time, advertise- 2001 alone, the amount of sexual con- virginity.12,20 ments for birth control products tent on TV nearly doubled.9 ● The Internet has become an abun- are rare.2 So-called reality TV has also entered dant source of both sexual informa- Because so many pro- the picture. In 1997, there were only 3 tion and that cannot grams have recently been focused on reality shows; by 2004, there be regulated.21,22 Online pornogra- abstinence only, the media have argu- were more than 30.11 Some shows, phy is now a $1 billion .12 In ably become one of the leading sex ed- such as Temptation Island, bring par- a national sample of 1500 10- to 17- ucators in the United States today.2 Ad- ticipants together for the sole purpose year-olds, nearly half of the Internet olescents frequently cite the media as of seeing who “hooks up.” A study of users had been exposed to online a source of sexual information.2 For ex- college students revealed that viewing pornography in the previous year.23 ample, in a national survey the media such shows correlated with beliefs in a In addition, unwanted sexual solici- rivaled parents and schools as a double standard—that men are sex tations and harassment are not un- source of information about birth con- driven and that men and women are common,24 although they may not be trol.33 The media are powerful sources sexual adversaries.11 It is interesting to as frequent as parents fear.25 for behavioral “scripts” concerning note that the less sexually experienced ● Social networking Web sites and sexual situations, especially for inex- students were more likely than sexu- home pages enable teenagers to perienced teenagers.2,34 Yet, parents ally experienced students to be watch- present themselves publicly, some- and legislators fail to understand that ing reality shows, which suggests the times in sexually suggestive although they may favor abstinence- importance of such programs for sex- ways.12,26 One study of 233 teen only sex education (despite the lack of ual socialization.12,13 home pages revealed that nearly any evidence of its effectiveness),35 the In addition to TV, other media provide 10% mentioned sex, and girls were 3 media are decidedly not abstinence frequent messages about sexual times more likely to do so than only. In fact, the United States has 27 behavior. boys. A recent study of 500 publicly some of the most sexually suggestive available MySpace profiles revealed media in the world.2 American media ● Music continues to be a major that nearly one-quarter of them ref- make sex seem like a harmless sport source of . In erenced sexual behaviors.28 Also, a in which everyone engages, and re- 1 study, 40% of lyric lines contained national survey of nearly 1300 teen- sults of considerable research have in- sexual material, and only 6% con- agers and young adults revealed dicated that the media can have a ma- tained healthy sexual messages.14 that 20% reported having sent or jor effect on young people’s attitudes An analysis of the 279 most popular posted nude pictures or videos of and behaviors.12–18 In fact, the media songs in 2005 revealed that 37% themselves (“sexting”).29 may function as a “superpeer” in con- contained sexual references and ● Advertisements often use sex to sell. vincing adolescents that sexual activity that degrading sexual references Women are as likely to be shown in is a normative behavior for young teen- were common.15 suggestive clothing (30%), partially agers.2,36,37 In a survey of 2100 11- to ● Virtually every R-rated teen movie clad (13%), or nude (6%) as they are 17-year-old girls, only the 11-year-olds since the 1980s has contained at to be fully clothed.30 As one expert reported that they did not feel pres- least 1 nude scene and, often, sev- noted, “When sexual jokes are used sure from the media to begin having eral instances of sexual intercourse to sell everything from rice to roach- sex.38 (eg, the American Pie movie se- killer, from cars to carpets, it’s hard ries).16 Teen movies also contain to remember that sex can unite two IMPACT OF SEXUAL CONTENT ON distorted views of and nor- souls, can inspire awe. Individually, ADOLESCENT BEHAVIOR mal .16–18 these ads are harmless enough, Numerous studies have delineated the ● Teen magazines are popular with sometimes even funny, but the cu- media’s powerful influence on adoles- preadolescent and adolescent girls mulative effect is to degrade and de- cents’ sexual attitudes, values, and be- and devote an average of 2.5 pages value sex.”31 Advertisements for liefs.2,39–42 Unlike the media violence re-

PEDIATRICS Volume 126, Number 3, September 2010 577 Downloaded from www.aappublications.org/news by guest on September 30, 2021 search literature, in which some 2000 rather than later,63 and sexually ex- that adolescents do not always listen studies exist, there have been only a plicit media may be particularly to their elders.2 In 2007, both CBS and handful of studies on the effects of sex- important.41,64 FOX refused a advertisement ual content on actual behavior. At least as “inappropriate” because it men- a dozen correlational studies have ex- CONTRACEPTIVE ADVERTISING tioned preventing pregnancy rather amined the relationship between the The United States is the only Western than preventing HIV/AIDS.78 Advertise- amount of sexual content viewed on TV nation that still subscribes to the dan- ments for and early onset of sexual inter- gerous myth that giving teenagers ac- are virtually nonexistent on American course.43–53 The most recent studies cess to birth control—and media rep- TV, despite the fact that every year, have revealed that (1) listening to sex- resent a form of access—will make American women have 3 million un- ually degrading lyrics is associated them sexually active at a younger age. planned , which to 1.3 with earlier sexual intercourse,40,53 (2) Other countries advertise birth control million . Advertising for black female teenagers’ exposure to products widely and have a much emergency contraceptives could be an rap music videos or X-rated movies is lower rate of teen pregnancy.12,16 Al- important way to reduce the number 79 associated with the likelihood of multi- though the teen birth rate had been of abortions in the United States. ple sexual partners or testing positive declining in the United States up until POSITIVE IMPACT for an STI,49 (3) teenagers whose par- 2005–2006, it has declined just as ents control their TV-viewing habits much or more in other countries. A re- The media can be powerful for are less sexually experienced,51,52 and cent study revealed that 86% of the re- sexual health education. Socially re- (4) exposure to sexual content in the cent decline in teen pregnancies could sponsible messages can be embedded media is a significant factor in the be attributed to increased contracep- into mainstream programming— intention to have sex in the near tive use, and only 14% was attributable a practice dubbed “entertainment- 39 future.52–54 to increased abstinence.65 The recent education” or “edutainment.” Collab- orative efforts between the Kaiser Nine longitudinal studies have given 3% increase in teen births could be a “blip,” or it could be attributable to an Family Foundation and the producers potential answers to the question of of the hit TV show ER resulted in suc- whether sexy media contribute to increase in abstinence-only sex edu- cation and the concomitant reduc- cessful story lines about the risks of early sexual activity, and the answer human papillomavirus and the useful- 41,55–62 tion in accurate information about seems to be “yes.” Results of 7 of ness of emergency contraception.80 In contraception.66–68 these studies have shown that expo- 2002, Friends aired an episode about sure to sexual content in TV and Eight peer-reviewed, controlled clini- , and 27% of a national sam- other media in early adolescence— cal trials have revealed that giving ple of teenagers saw the program; particularly for white teenagers—can teenagers freer access to condoms many of them reported that they talked as much as double the risk of early does not increase their sexual activity about condom effectiveness with an sexual intercourse. Adolescents whose or encourage virginal teenagers to be- adult as a direct result of the episode.81 parents limit their TV-viewing are less gin having sex, but it does increase the In 2008, a study showed that viewers of likely to engage in early sex.58 Younger use of condoms among those who are a Gray’s Anatomy episode learned that 69–76 children who have viewed adult- already sexually active. Advertising HIV-positive women could still have oriented TV shows and movies are condoms, birth control pills, and emer- HIV-negative infants.82 The Soap Opera more likely to begin having sexual in- gency contraception on TV and radio Summit in Hollywood and international tercourse earlier.61 The study samples could further decrease the teen preg- efforts to embed story lines into popu- together total nearly 10 000 teenagers nancy rate. Yet, several networks lar soap operas are other examples of nationwide, and the most ambitious refuse such advertisements.77,78 prosocial efforts. The media giant Via- studies included other media such as Telling teenagers, “Wait until you’re com and the Kaiser Family Foundation movies, music, and magazines.57 In ad- older to begin having sex, but if you have launched an ambitious project to dition, a recent study revealed that can’t wait, use birth control” is a dou- produce $120 million worth of public early exposure to sexual content dou- ble message. But, it is a double mes- service announcements and print ad- bled the risk of teen pregnancy.60 sage that every teenager in America vertisements concerning HIV/AIDS and Clearly, the media play a major role in can understand and benefit from, and to encourage Viacom producers to in- determining whether certain teenag- it is consistent with normal adolescent clude story lines in their TV shows that ers become sexually active earlier psychology, because it acknowledges will raise AIDS awareness.83 Such ef-

578 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 30, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS forts demonstrate that the entertain- networking sites and how they basic principles of media literacy ment industry can be receptive to out- work so that they can effectively into their sex education pro- side input and that healthier content counsel children and adolescents grams. Studies have shown that can be introduced into mainstream about them.89 effective media literacy programs media without government pressure 3. Pediatricians and child advocacy can be protective against un- or the threat of censorship. groups should encourage the enter- healthy media effects.90,91 Federal Mass media have also been used pro- tainment industry to produce more money should be spent on com- actively to increase parent-child com- programming that contains respon- prehensive sex education pro- munication about sex. In North Caro- sible sexual content and that focuses grams but not on abstinence-only lina, a mass media campaign using on the interpersonal relationship in programs, which have been found billboards and radio and TV public which sexual activity takes place (Ta- to be ineffective.35,65–68,92–94 service announcements delivered the ble 1). One way to do this would be to 5. Pediatricians should urge the message, “Talk to your kids about sex. hold annual seminars for writers, broadcast industry to air advertise- Everyone else is.” In follow-up re- producers, and directors in Holly- ments for birth control products. search, exposure to the message cor- wood, perhaps in cooperation with The federal government also needs related significantly with parents talk- other groups. Similarly, Madison Ave- to encourage the advertising of ing to their children about sex during nue and advertisers need to be en- birth control, especially emergency the following month.84 couraged to stop using sex to sell contraceptives. products. Educational seminars RECOMMENDATIONS might help to achieve this goal. 6. Pediatricians should urge the broadcast industry to limit adver- 4. Pediatricians should urge schools 1. Pediatricians can help parents and tisements for erectile dysfunction teenagers to recognize the impor- to insist on comprehensive sex ed- drugs until after 10 PM. tance of the media by asking at ucation programs (to counter the least 2 media-related questions at influence of sexually suggestive and 7. Pediatricians should urge the each well visit77: (1) How much time explicit media) that incorporate broadcast media to include healthy do you spend daily with entertain- messages about sex and sexuality ment media? and (2) Is there a TV in their programming, especially in set or Internet access in your bed- TABLE 1 Guide to Responsible Sexual Content media that children and early teen- in TV, Films, and Music: Some agers use most frequently.95 room? Research has shown that Suggestions for the Presentation of bedroom TVs are associated with Responsible Sexual Content 8. Pediatricians, the broadcast indus- greater substance use and sexual Recognize sex as a healthy and natural part of try, the federal government, and pri- activity by teenagers.85 A recent life. vate foundations should support fur- study revealed that office-based Parent and child conversations about sex are important and healthy and should be ther research into the impact of counseling is effective and could re- encouraged. sexual content in the media on chil- sult in nearly 1 million more chil- Demonstrate that not only the young, unmarried, dren’s and adolescents’ knowledge and beautiful have sexual relationships. dren and adolescents adhering to 96 Not all affection and touching must culminate in and behavior. A national task force the American Academy of Pediat- sexual intercourse. on children, adolescents, and the me- rics recommendation to limit me- Portray having sexual relationships with dia should be convened by child advo- dia time to less than 2 hours/day.86 feelings of affection, , and respect for one another. cacy groups in conjunction with the 2. Pediatricians should counsel par- Consequences of unprotected sex should be Centers for Disease Control and Pre- ents to recognize the importance of discussed or shown. vention and/or the National Institutes should not be used as a dramatic the media, exert control over their convenience for resolving an unwanted of Health to study the issue of chil- children’s media choices, keep pregnancy. dren, adolescents, and media, devise their children’s bedrooms free of Use of contraceptives should be indicated as a new research, locate funding TVs and Internet connections, and normal part of a sexual relationship. Avoid associating violence with sex or love. sources, and make recommenda- avoid letting their children see PG- should be depicted as a crime of violence, tions to Congress, the broadcast in- 13– and R-rated movies that are in- not one of passion. dustry, and the American people. appropriate for them.61,87,88 Pedia- The ability to say “no” should be recognized and respected. tricians and parents also need to be Modified from Haffner DW, Kelly M. Adolescent sexuality in LEAD AUTHOR aware of the importance of social the media. SIECUS Rep. March/April, 1987:9–12. Victor C. Strasburger, MD

PEDIATRICS Volume 126, Number 3, September 2010 579 Downloaded from www.aappublications.org/news by guest on September 30, 2021 COUNCIL ON COMMUNICATIONS AND Gwenn S. O’Keeffe, MD Brian Wilcox, PhD – American Psychological MEDIA EXECUTIVE COMMITTEE, Kathleen G. Nelson, MD Association 2009–2010 Victor C. Strasburger, MD Gilbert L. Fuld, MD, Chairperson CONTRIBUTING PAST EXECUTIVE CONTRIBUTOR Deborah Ann Mulligan, MD, Chair-elect COMMITTEE MEMBERS Jane D. Brown, PhD Tanya Remer Altmann, MD Regina M. Milteer, MD Ari Brown, MD Donald L. Shifrin, MD Dimitri A. Christakis, MD STAFF Kathleen Clarke-Pearson, MD LIAISONS Gina Ley Steiner Benard P. Dreyer, MD Michael Brody, MD – American Academy of Veronica Laude Noland Holly Lee Falik, MD Child and Adolescent Psychiatry [email protected] REFERENCES

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Downloaded from www.aappublications.org/news by guest on September 30, 2021 Sexuality, Contraception, and the Media The Council on Communications and Media Pediatrics 2010;126;576 DOI: 10.1542/peds.2010-1544 originally published online August 30, 2010;

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