Sexting is prevalent among teenagers and is associated with risky sexual activity among girls, according to a study in the Archives of Pediatrics & Adolescent Medicine. Nearly 1000 ethnically diverse students in public high schools in the Houston area completed surveys about sexting and their sexual behaviors. Overall, more than a quarter of the students reported sending a naked picture of themselves via text or e-mail, and over half had been asked to do so. For girls who sexted, the following behaviors were more common: starting dating, having sex, having multiple sex partners, and using alcohol or drugs before sex. The same association was not observed in boys. The authors advise clinicians: “Given [sexting’s] prevalence and link to sexual behavior, pediatricians and other tween-focused and teen-focused health care providers may consider screening for sexting behaviors. Asking about sexting could provide insight into whether a teen is likely engaging in other sexual behaviors.
” Editorial | July 2, 2012 ONLINE FIRST New Media, Old Risks: Toward an Understanding of the Relationships Between Online and Offline Health Behavior ONLINE FIRST Megan A. Moreno, MD, MSEd, MPH; Jennifer M. Whitehill, PhD : Department of Pediatrics, University of Wisconsin-Madison (Dr Moreno); and Harborview Injury Prevention Center, University of Washington, Seattle (Dr Whitehill). Arch Pediatr Adolesc Med. 2012;():1-2. doi:10.1001/archpediatrics.2012.1320 

The Internet began as an environment in which large corporations distributed text-based information to the masses. Technological advancements led to the rise of Internet 2.0, which featured new tools such as blogs and social networking sites and allowed the average user near-instantaneous sharing of text, images, audio, and video with peers and the public. Web users found themselves in the role of both consumers and creators of online content, giving rise to the term social media. In the early days of social media, there were questions about whether the web was a place in which people would form new identities or behave in ways that were dramatically different from their offline selves. Social networking site profiles were suspected of being a shadowy reflection of a person’s persona, rather than a portrayal of their true identity. Parents, law enforcement, and child-welfare organizations were worried that these emerging technologies allowed sexual predators and bullies new access to victims.
There was disagreement about whether acts such as sexting and cyberbullying represented entirely new phenomena or extensions of existing risks, as well as confusion about how pediatricians could interpret these behaviors in the clinic setting. The Internet and cell phones now present an interactive and immersive environment. Many cell phones are so-called smartphones that have the same capacity for exchange of text, audio, and visual information found on web-connected computers. As we have learned more about the culture, rules, and expectations of these digital environments, our understanding of people’s behavior and identity within social media have evolved. The past 5 years have seen exciting new research that allows us to better understand how to address behaviors such as sexting and cyberbullying during a pediatric office visit. These problems can be viewed as part of existing paradigms, but the social media environment also presents new challenges surrounding these issues.

The term sexting refers to sending, receiving, or forwarding sexually explicit messages or pictures, typically over a cell phone or the Internet. A recent survey found that 20% of teens have sent or posted nude/semi-nude photos or videos of themselves. Contrary to some concerns about sexting as a random or anonymous event, most sexting requests occur in existing offline relationships. For example, one study illustrated that in most cases of sexting, the sexual photos were intended to be viewed only by a boyfriend or girlfrie. As reported in this month’s Archives, Temple et al found that 28% of teens had sent a sext, and 31% had asked someone else for a sext.New evidence suggests that sexting can be considered within the context of adolescent sexual behavior. In this issue, Temple et al found that adolescents who engaged in sexting behaviors were more likely to report that they had begun dating and engaged in sexual activity compared with those who did not sext. For girls, sexting was also associated with risky sexual behaviors.
The authors concluded that asking about sexting in a clinical setting may allow insights into teens who are at risk for early sexual behaviors. The Media Practice Model identifies key factors in adolescents’ use of media and argues that adolescents select and interact with media based on who they are—or who they want to be—at the moment. This model posits that behaviors and disclosures made on media reflect actual behaviors and traits or behavioral intent. Previous work found that adolescents’ disclosures of sexual material on social networking sites was associated with self-reported sexual intention. Indeed, sexting appears to be a media expression of adolescent sexual intent or behavior, rather than a distinct phenomenon limited to the digital world. Thus, pediatricians may consider sexual disclosures in a social media setting as an expression of adolescents’ offline sexual intentions or behaviors.

Cyberbullying is defined as the deliberate use of social media to communicate false, embarrassing, or hostile information about someone else. This type of bullying can include calling someone names, spreading rumors, pretending to be someone else, or making threats. Estimates of the lifetime prevalence of cyberbullying range from 6% to 42% in the United States. Cyberbullying is perhaps best understood as an extension of, rather than distinct from, traditional bullying. For example, rather than cyberbullying being a form of bullying prompted by the anonymity of the Internet, one study found that 73% of youth knew the identity of their cyberbully. Recent research has demonstrated that teens who participate as bullies in the cyberworld are also likely to participate in offline bullying. Similarly, we have come to understand that cyberbullying can lead to similar consequences as traditional offline bullying such as depression and anxiety. Thus, a pediatrician who inquires about exposure to bullying should consider that cyberbullying may also be of concern.

While sexting and cyberbullying can be considered in the context of existing paradigms, there are several unique aspects of the social media environment that raise new challenges. First, both sexting and cyberbullying take place via social media, which is nearly ubiquitously available to teens. Thus, these problems can occur at any time, not just during the school day or in the physical presence of a peer. Second, social media is published and can be distributed to others, which can increase the embarrassment factor if a sext or a mean comment is widely circulated. Third, most teens are unsupervised when interacting with social media, which may contribute to the risk for participating in either of these 2 behaviors. Finally, today’s teens spend hours each day interacting with social media. This expansive amount of time spent using media may increase the rates of exposure to both sexting and cyberbullying, whereas exposure may have been less frequent in the offline environment. In summary, pediatricians should view social media as part of the integrated self of the adolescent patient. Pediatricians have new opportunities to ask their patients about social media, including questions about how time is spent in this environment. Discussing social media with patients may provide new ways to identify intentions or engagement in risky health behaviors. Health care providers and researchers may also consider building education or prevention efforts within social media, as previous work illustrates that teens may be willing to investigate topics such as sexual behavior in a social media setting.