Swathi Krishna, MD

Many times, as psychiatrists, in a psychosocial assessment we inquire about an individual’s sexual behavior and social behavior. But, as the social habits of our patients change, are we keeping current of the changes we need to make to identify problems that may lead to psychiatric sequelae in the future? Specifically, what is the impact of online sexual behavior and associated factors that have become so prevalent in our current society.

Over the course of human history, there have always been periods of evolution and transformation of existing thought processes in the social, political, and cultural climate. Moreover, personal, artistic, and sexual expression has also evolved over time. From “free love,” to the Playboy era, to the women’s sexual liberation movement there have been many examples of paradigm shifts in adult sexual expression. As with most social shifts, some of these changes have brought unforeseen and unintended consequences and, ultimately, the need for society to address these consequences and associated risks.

The rise of the Internet and smart phones has created a proliferation of “sexting” between adults and, even more concerning, youths. The term sexting is used generally to encompass a wide variety of digital activities: sending, receiving, or forwarding sexually explicit messages, photographs, or images. Although mobile phones are the most common vehicle for sexting, the term can also apply to sending sexually explicit messages through any digital media such as email, instant messaging, and/or social media sites.

Sexting is somewhat of a natural marriage of previous forms of sexual expression and modern day technology. It was once treated as deviant behavior but was not thought to be widespread. But, as we have learned over the past few years, it is actually a widely prevalent phenomenon and is often rapidly replacing more traditional forms of sexual expression and sexual communication. In this regard, mental health professionals should be addressing this behavior as a natural expression of normative sexual behavior between consenting adults.

However, we must also be aware of the potential of sexting to cause catastrophic consequences in vulnerable populations susceptible to victimization such as women, minors, and persons with mental health issues. That is why psychiatrists need to be informed of the practice of sexting and how to talk to patients openly about these behaviors to mitigate psychosocial consequences and psychological risks.

Sexting is becoming a more acceptable and widely used form of sexual communication within the adult population. One study from 2016 included 58045 single adults from the aged 21 to 75 years.

 Findings from this study by Garcia and colleagues indicate that 21% of participants reported sending and 28% reported receiving sexually explicit text messages.

One concerning fact is that 22.9% of those who received a sext shared it with others and some of this sharing was without the permission of the original sender. Almost 3 out of 4 people reported discomfort with unauthorized sharing of sext beyond the intended recipient.

These statistics raise an important point that we should be talking to patients about: the unintended consequences of individuals sharing sexts without permission. The ease of transmission and ability to rapidly disseminate this type of personal and sensitive information on the Internet without permission increases the risk of victimization and psychological consequences that individuals involved in sexting may have not considered.

The adults in this study reported concern about the potential consequences of sexting on their social lives, careers, and psychosocial well-being, which shows the presence of a more mature thought process. But what about the individuals who may not have the biological or psychological ability to engage in this mature process and, therefore, unintentionally open themselves up to significant emotional, social, and psychological risks with sexting behaviors?

The most vulnerable populations are minors. The prevalence of sexting among youths is generally unknown, reported estimates vary widely from 1.3% to 60%. What complicates the issue is that different teenage populations often have individualized definitions of what sexting is. In a 2012 study of teens, after being asked generally if they had engaged in sexting, when specifically asked if they had sent a naked photo of themselves, the rates were much lower.

 This might mean that they considered sending sexually explicit material such as SnapChat videos, Instagram posts, or sexual “memes,” as sexting instead of naked photos of themselves.

 teenagers were specifically asked about texting nude photos of themselves or others; however, not all current studies have controlled for that distinction. Therefore, we cannot know the exact prevalence of teenage sexual messaging. This is an important factor that highlights the importance of asking specific questions about messaging behaviors of young patients.

Furthermore, a distinction has to be made between the texting that occurs within a sexual relationship between teens versus the sexting of nude pictures. One study showed that young adults were using more text messaging in emerging sexual relationships.

Under federal law, any sexually explicit images of minors under age 18 are considered child pornography, even if the minors created the images themselves. Many minors are not aware of the legal and social ramifications of sexting. And, even more concerning, the unintended social and psychological consequences that can occur secondary to sexting behavior such as humiliation, bullying, and the effect on their future.

These social and psychological consequences can often lead to depression, anxiety, social isolation, a negative self-image, and even suicidal thoughts and self-harm behaviors. With all of these factors, why do the rates of sexting among youths continue to rise? Part of the problem is that teens use sexually explicit words and posts on social media to promote themselves. Many of the celebrity role models that youths are looking up to these days are part of the “selfie effect” and often these pictures can be quite provocative for attention.

Additionally, with the competition for number of “likes” develops into a form of positive reinforcement that fuels the motivation to post more often and further test limits. Youth that engage in sexting can have more difficulties detecting and regulating their own emotion, which can result in depression and anxiety as well as low self-esteem, anger, loneliness, and attention seeking.

In a 2014 study of college students, more than half reported sexting as minors.

 About one-third reported sending pictures, others endorsed sending sexually explicit text messages or social media messages. More than half (61%) of the students who reported sexting as minors said they were not aware that sending a sexually explicit text could be considered child pornography under federal law; 59% said that had they known it was a prosecutable offence it “would have or probably would have deterred their behavior.” This highlights an opportunity for discussion points with adolescents regarding the potential consequences of sexting behaviors. Another point is that only 2% reported telling a teacher or adult about a sext they received, this also highlights the need for more open communication about risky online behavior in youth between parents, providers, and responsible adults.

The largest meta-analysis to date focused on sexting behavior in youths.

 It included 39 studies with a total of 111,380 participants between the ages of 11 and 17 (mean age 15.2). It showed that sexting prevalence in this age group has increased over time and increases with age. Mean prevalence for sending a sext was 14.8% and prevalence for receiving a sext was 27.4%. This shows that a smaller percentage of people send sexts than receive them, which suggests that a few people are engaging in the behavior but the sexts are being sent to larger groups of people with or without their knowledge. About 1 in 10 individuals in the analysis reported forwarding a sext without consent and just 8% of individuals reported that their own sext had been forwarded without consent. There was no significant difference between boys and girls in sending or receiving sexts. This study shows the upwards trend of sexting within youth populations and identifies many points to initiate discussion with young patients about their own sexting practices and the associated risks.

Sexting behaviors also show a correlation with other risky behaviors that parents and psychiatrists should be aware of. The study by Temple and colleagues

 shows a significant association between sexting behaviors and having multiple sex partners. It also shows that the use of alcohol and drugs before sex was higher among those who sent, received, or asked for a sext.

Another consequence of the normalization of this type of sexual content among youth is that it may contribute to a normalized culture of sexual violence and exploitation. According to a UK article, sexting is linked to generalized physical and sexual harassment as well as bullying of girls in secondary school.

 The article also highlights the devastation and the sexual and emotional exploitation that the girls felt by having their private information sent out without their permission. At least one girl died by suicide after sexually explicit material was distributed about her. By not addressing the risk for sexual violence and exploitation as an extreme consequence of sexting behavior, we may be leaving our youths in a vulnerable position.

The developmental vulnerability theory posits that early victimization results in vulnerabilities, disinhibiting influences, and conditioning of experiences that manifest over time to create propensities for sexual and non-sexual violence. Sexting can be a form of early victimization and increase the threshold for permissible sexual behavior. It lowers the threshold for recognizing one’s own sexual exploitation or the exploitation of others.

 looked at 200 adjudicated male youths aged 13 to 19 years in the juvenile justice system: 65.5% had engaged at least once in a sexting experience and the number rose to 73.5% when age was increased to 20 years. Study data show a correlation between exposure to violence or adversity in childhood and an emotionally disinhibit state that allowed for more risky behaviors. This study also shows a statistically significant relationship between sexting between friends/acquaintances and dating violence.

Another major significance of all of these finding is the high risk of sexual victimization that can occur with sexting. One NY Times article reported that more than half of adolescents studied had dated someone who tried to monitor or control them using digital content by threatening to spread rumors, post embarrassing or hurtful messages, or making physical threats. About one-third experienced sexual coercion via digital means, they had been pressured to have sex, received unwanted sexual images, were urged to send sexual images, or had their nude photos sent to others without permission.

A thorough psychosocial assessment and social history should include details of online activity of all patients and should address risks associated with any risky online behavior. Provide information to parents of adolescents on how to ask about and talk directly about online risks with their children-statistics show that most adolescents are aware of sexting practices among peers at school.

Psychiatrists should provide direct education to their patients about social, legal, and psychological consequences and risks of sexting. Remind patients that their sensitive information can easily be disseminated without their consent or knowledge. Most important is to approach the patient without judgment and provide open, safe communication about sexting practices.

Dr Krishna is the recent Chief Resident, Emory University Child and Adolescent Psychiatry Fellowship Program, Atlanta, GA. She graduated in 2019 and is currently working in private practice in Atlanta, GA. She reports no conflicts on interest concerning the subject matter of this article

1. Garcia JR, Gesselman AN, Siliman SA, et al. Sexting among singles in the USA: prevalence of sending, receiving, and sharing sexual messages and images. 

. July 2016 Jul 29 [Epub ahead of print].

2. Mitchell KJ, Finkelhor D, Jones LM, Wolak J. Prevalence and characteristics of youth sexting: a national study. 

3. Temple JR, Paul J, ven de berg P, et al. Teen sexting and its association with sexual behaviors. 

4. Braoddus M, Dickson-Gomez J. The use of Text Messaging in Sexual Relationship Scale: associations with risky sexual behavior among at-risk African American emerging adults. 

5. McKenchie A. Majority of Minors Engage in Sexting, Unaware of Legal Consequences. June 18, 2014.

6. Madigan S, Ly A, Rash C, et al. Prevalence of multiple forms of sexting behavior among youth: a systematic review and meta-analysis. 

7. Cooper G. Sexting: A New Teen Cyber Bullying Epidemic. 

8. Yoder J, Hansen J, Precht M. Correlates and outcomes associated with sexting among justice involved youth: the role of developmental adversity, emotional disinhibitions, relationship context, and dating violence. 

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The rise of the Internet and smart phones has created a proliferation of “sexting” between adults and, even more concerning, youths.

Swathi Krishna, MD

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