Abstract
Given the increasing prevalence of pornography consumption among adolescents, this article explores its impact on sexual health development and emphasizes the crucial role of primary care providers (PCPs) in assessing usage and delivering comprehensive sexual health education. While pornography use is often perceived negatively, fostering an objective understanding is vital to offering non-judgmental, adolescent-centered, and informative care. PCPs, frequently the initial point of contact for adolescents facing medical and behavioral health concerns, must be adept at effectively screening for pornography use, cultivating a secure and confidential environment for discussions about pornography and sexuality, and facilitating open communication between young individuals and their parents. Alongside PCP involvement, parental engagement, informed perspectives, and comfort in discussing pornography with their children are essential for comprehending and navigating pornography use within this demographic. This article aims to provide an unbiased perspective on adolescent pornography use, offering guidelines for screening practices and strategies to encourage constructive conversations between adolescents and caregivers.
Keywords: adolescent health, primary health care, pediatrics, adolescent psychology, teen pornography use, family communication, sexual health education
Introduction
The internet has become indispensable in the daily lives of modern adolescents. This digital integration grants youth effortless access to a vast array of information and topics online, including sexually explicit materials or pornography. Pornography is broadly defined as sexually explicit visuals or videos, professionally produced or user-generated, designed to evoke sexual arousal in viewers.1–3 The enhanced accessibility of the internet and various online platforms has contributed to a significant surge in the number of adolescents encountering and consuming pornographic content.1 4 Consequently, adolescent exposure to pornography has become a major concern for parents, educators, and the wider community.2 Pornography possesses the potential to influence adolescent development in both detrimental and beneficial ways. Its multifaceted nature renders it a particular area of focus for primary care providers (PCPs) and parents, as they are frequently the first resources adolescents turn to when experiencing well-being issues, encompassing physical and mental health concerns.5–7 Cultivating an impartial understanding of pornography use’s effects on adolescent development establishes a foundation for healthcare providers to effectively support adolescents in their sexual development and overall health. This article seeks to offer guidance for medical professionals to integrate routine screening and counseling regarding pornography use into adolescent primary care and to propose recommendations for facilitating constructive dialogues between youth and parents concerning this topic.
Prevalence of Pornography Use Among Teenagers
Adolescent pornography consumption has consistently risen over time, and the age of initial exposure to sexually explicit material has also been decreasing.8 Prevalence rate estimates vary,2 yet nationally representative surveys of adolescents in the USA indicate that 68.4% have reported exposure to online pornography.9 Another US study found that 42% of youth aged 10 to 17 reported viewing online pornography.4 Prior research suggests that 19%–37% of teens reported intentional use10 11, while unintentional pornography use among adolescents ranges from 35% to 66%.4 12 Both intentional and unintentional pornography use have increased in frequency with age and sexual development.1 4 12 Furthermore, social and environmental shifts can also exert influence. Reported pornography use escalated further during the COVID-19 pandemic, lockdowns, and social distancing measures.13 Pornhub, a major pornography website, reported an 11% increase in viewership within a single month, from February to March 2020.14
Gender also represents a significant factor when considering pornography use prevalence, with males more frequently reporting pornography consumption.15 16 Nevertheless, national and international studies have revealed that while pornography use is more common among males, female adolescents also engage in it to a notable extent.17 One study involving 1000 adolescents found that 66% of males and 39% of females had watched online pornography.15 Moreover, up to 93% of male adolescents and 52% of female adolescents aged 16 to 19 in Germany reported having viewed online movies containing pornographic content.16
The Impact of Pornography on Sexual Health and Well-being
Pornography exerts a wide spectrum of effects, both negative and positive, on adolescent sexual health and development, influencing sexual attitudes, beliefs, and behaviors.1 Focusing initially on the negative aspects, research indicates that pornography exposure can cultivate unrealistic beliefs and attitudes about sex.3 Adolescents may anticipate real-world sexual experiences to mirror what they observe in pornography.18 It may also lead them to perceive sex as primarily physical and casual, rather than emotionally and relationally driven.1 19 Furthermore, studies suggest a correlation between increased pornography consumption and heightened sexual preoccupation20 and sexually permissive attitudes.21 22 These attitudes might encompass beliefs that women are primarily sexual objects rather than relational partners.23 Notably, adolescent males exposed to sexually violent media have reported more accepting attitudes towards teen dating violence and sexual violence.24
Pornography exposure can also impact sexual behaviors, including more frequent engagement in casual sex,19 22 high-risk sexual practices like sex with multiple partners, and substance use during sexual encounters.25 Adolescents may also exhibit a greater inclination towards sexual intercourse and experience sexually coercive behavior.26 Male adolescents frequently exposed to pornographic material may also demonstrate higher levels of sexual aggression compared to those with infrequent exposure.27
However, while the influence of pornography on adolescents is often viewed negatively, the empirical understanding of its impact is, in fact, considerably complex.2 Study findings have been contradictory and inconclusive, frequently marked by methodological challenges and cultural biases. The majority of prior studies relied on correlations, not causations, limiting the conclusions that can be drawn from the findings. More recently, however, research has begun to explore potential positive facets of pornography. To provide the most evidence-based counseling to adolescent patients, it is crucial to acknowledge these positive aspects to formulate an objective assessment of pornography’s impact on adolescent sexual health.
Indeed, pornography may contribute to adolescents’ sexual development and enhance sexual relationships and knowledge. Pornography has been considered an educational resource in addition to its use for sexual gratification or as a leisure activity.28 A study29 revealed that when individuals were asked about pornography’s impact, respondents indicated it fostered sexual confidence by introducing them to sexual acts they might not have otherwise explored. Similarly, pornography facilitates experimentation with sexual attraction, which can be valuable in the sexual identification of gender identity and sexual orientation.30 Moreover, pornography can support sexual development by demonstrating sexual acts and enhancing confidence.30 Research suggests pornography may help individuals learn what sexual partners might enjoy, fostering greater self-assurance and a more positive sexual identity.29 Balancing the negative and positive effects of pornography use is essential for achieving clarity for both adolescents and health professionals.
Motivations Behind Pornography Use
Various motivational factors drive pornography consumption, including mood management, habitual use, and fantasy.31 Pornography may serve as a means of sensation-seeking, an impulsivity-related trait. Individuals with higher levels of sensation-seeking behaviors may report greater pornography use frequency and an elevated risk of developing problematic pornography use.18 32
Exploring the motivations behind pornography use can provide PCPs and caregivers with insights into adolescents’ psychosocial needs. Common characteristics in adolescents with higher pornography use rates include more advanced pubertal development, limited caregiver supervision and emotional connection, family conflict, and behavioral issues.2 27 Individuals with attachment difficulties may engage in pornography use to seek relational or sexual connection and/or comfort without emotional commitment, alleviating fears of rejection or abandonment.33 Similarly, another study found that youth might seek pornography to enhance their sense of belonging and reduce loneliness.34 Finally, individuals may consume pornography as a coping mechanism for emotional stress or discomfort.1 35 For example, during COVID-19 lockdowns, individuals may have used pornography to distract themselves from loneliness, distress, boredom, or other pandemic-related negative emotions.13
The Role of Primary Care in Sexual Health Education
PCPs are uniquely positioned to identify and assess behaviors impacting adolescent psychosocial development. Furthermore, PCPs can integrate various aspects of sexual and reproductive healthcare to offer well-informed guidance to adolescents.36 Sexuality plays a vital role in adolescent identity and development. Adolescents may have questions or misconceptions regarding topics such as masturbation, menstruation, sexual fantasies, orgasms, and sexual orientation.37 Clinicians should not only gather sexual history but also assess pornography use as part of sexual history to determine its potential impact on adolescent psychosexual development. However, a significant gap persists between research and clinical practice concerning adolescent pornography use.38 Sexual health or behavior is infrequently discussed during adolescent health visits in primary care39 40, and even when such discussions occur, they are often brief; the average duration of sexuality talks during adolescent health maintenance visits has been found to be just 36 seconds.39
Screening youth for pornography viewing (e.g., frequency of use, pornography content, motivations for use) should be a routine component of pediatric and adolescent healthcare.41 Adolescents visit their PCPs for various reasons, including routine healthcare maintenance exams, urgent care concerns, and sexual and reproductive health matters. Organizations like the Academy of Pediatrics and The Society of Adolescent Health and Medicine recommend that a portion of each visit be conducted with the adolescent alone to foster a confidential, trusting relationship with their provider.42 43 Prior to the confidential segment of the clinical encounter, parents/guardians and adolescents are informed that information shared with the provider will be treated as confidential. Furthermore, any circumstances that necessitate breaching confidentiality (i.e., acute suicidality or other safety concerns) are communicated to all parties. During this private time, providers can normalize discussions about sexual health as a routine part of care for everyone, reducing shame and discomfort associated with discussing pornography use,44 and preventing adolescents from seeking unreliable information online or from peers. School-based sexual health education often has limited scope (e.g., not including porn literacy45 and time allocation), creating an environment where adolescents may not feel safe or comfortable asking questions. However, PCPs can offer guidance in a safe environment, providing accurate information and playing a crucial role in sex education, particularly in settings lacking standardized, unbiased educational curricula. Sexual education provided by PCPs is more accurate, reliable, and safer than online searches, which are frequently adolescents’ initial step in accessing sexual health information.46 Adolescents are often hesitant to seek sexual health services due to concerns about judgment and confidentiality.47 48 Therefore, providers must strive to cultivate relationships with adolescent patients, create a confidential and comfortable environment, and be equipped to inquire about and provide information on sexual health and behaviors.
Clinical Assessment of Pornography Use
Pediatricians are encouraged to specifically screen for pornography use. For clinical interactions with adolescent patients to be effective, providers should engage in self-reflection and acknowledge their own biases concerning pornography and sexual health. Incorporating this discussion into routine clinical care reduces stigma and can reveal underlying reasons for certain concerns in this age group, such as erectile dysfunction, body image issues, and high-risk or sexually aggressive behaviors.
The HEADSS (Home, Education, Activities, Drugs, Sex, Suicide) assessment is a tool offering a framework for conducting comprehensive psychosocial interviews.49 Widely utilized in adolescent healthcare, it provides a structured format to facilitate confidential, respectful communication, fostering an environment where youth feel comfortable discussing sensitive topics. This assessment is recommended at least annually during routine health maintenance examinations. Inquiring about sexuality and sexual practices, a component of this assessment, can help providers initiate this conversation. For adolescents aged 12 and older, discussions about sexual activity (‘S’) or activities in general (‘A’) should include an assessment of pornography viewing within their social media use and patients’ perceptions of such material.36 50 Table 1 is adapted from various studies7 51 52 and outlines three key points for routine visits and guidelines for further assessing pornography use when it is reported. If viewing is confirmed, assessing the frequency is crucial. Inquiring about specific content is important as it can influence sexual intimacy and distort views on real-life intimate relationships.41 If pornography viewing leads to health complications, including sleep problems, immune function issues, and sedentary cardiovascular disease, appropriate referrals should be made for continued evaluation and support. It’s also important to recognize that adolescents may initially be hesitant to disclose pornography use or that other pressing issues may need to be addressed before screening for pornography use. Therefore, routine screening and discussion, at least annually using the HEADSS assessment, are vital. Building rapport and trust will encourage adolescents to feel more comfortable disclosing these behaviors.
Table 1. Provider recommendations for initiating pornography use screening
| All routine visits should include52 | – Discussion about sex and sexuality. – Screening for high-risk sexual behavior. – Creating space for teens to ask questions and access accurate and safe resources. |
|---|---|
| If screening is positive for pornography use7 | History of pornography use – Define the specific behavior – Assess duration (i.e., onset), intensity (i.e., violent, soft porn), and frequency (i.e., how often used) – Identify current behavior symptoms and how it interferes with daily functioning – Determine specific areas of functioning impacted by pornography (i.e., intrapersonal, interpersonal, sleep, academic performance, mood lability, and physical health (neck or genital pain)). |
| Function of the behavior | – Help patient identify the behavior’s function – Examples: avoidance, boredom, negative affect management, emotion regulation, and socialization. |
| Past mental health/physical health history | – Review prior and current symptoms, diagnoses, and treatments – Research indicates higher rates of mental health diagnoses and family challenges among teens engaging in pornography. |
| Review/assess social and developmental history | – Developmental milestones – Academic History (learning disorders, 504 Plans) – Social history (i.e., friends, acquaintances, significant others, social anxiety, social isolation, bullying) – Family history (medical and psychological history, involvement, substance abuse, abuse, neglect). |
| How PCPs can foster parent–child communication about pornography51 | – Encourage early parental education at home about: sexuality, contraception, and pornography – Discuss strategies for promoting healthy and safe pornography use – Ensure education and discussion aligns with ‘family’s attitudes, values, beliefs, and circumstances’ – Help families utilize reputable information sources. |
PCP, primary care provider.
The Role of Parents in Sexual Health Education
Parents, similar to PCPs, play an integral role in adolescents’ sexual health and can influence pornography use based on their perspectives and attitudes towards sexuality.53 Many parents hesitate to initiate discussions about sexuality with their children.54 55 Parental reactions to a child watching pornography can range from anger, shame, and denial to fear and punitive feelings.56 Normalizing these discussions during routine medical visits can help reduce stigma and address parental biases. PCPs can facilitate these discussions, fostering open dialogue within families, which can break the ice if parents or children find the topic awkward. Topics such as privacy concerns, viewing risks, and responsible and safe viewing and interpretation of pornography content are crucial to discuss with adolescents. Adaptations of suggestions for parents on facilitating this discussion57 are outlined in box 1.
Box 1. Recommendations for parents on facilitating conversations about pornography use with your child.
- Educate yourself first. Seek resources from your provider and explore them.
- Reflect on your own emotions and values and identify what you want to communicate.
- Be clear, candid, and admit when you don’t know the answer.
- Establish a shared vocabulary for discussing sexuality and create conversational ground rules for a non-judgmental atmosphere.
- Utilize teachable moments for regular conversations on various related topics (e.g., discovering your child watching pornography).
Adaptations of suggestions for talking to parents about adolescents’ sexuality.57
Research indicates that parents desire guidance and resources from their child’s PCP on how to have family discussions about pornography.56 However, there is a current lack of evidence-based guidance that is adolescent-focused, non-judgmental, and culturally sensitive.56 A pressing need exists for developing and evaluating developmentally and culturally appropriate scripts for parent-child communication about pornography.
Conclusion
As pornography use continues to increase among adolescents, PCPs are increasingly likely to encounter it in clinical settings, necessitating their active role in screening, assessment, and guidance. An unbiased understanding of pornography’s impact and function in adolescents is essential for supporting their sexual development. Equipping adolescents with accurate and helpful knowledge about pornography and enabling critical thinking about its consumption is critical for their sexual health education. Increased stigmatization of pornography only drives it underground, hindering our ability to understand its impact on adolescent sexual health. Future research should evaluate the effectiveness of incorporating pornography use screening into the HEADSS assessment. Furthermore, research could focus on promoting porn literacy and utilizing pornography as an intervention for promoting sexual health, such as demonstrating safe sexual practices, consent, and exploring sexual and gender identity. Normalizing the discussion and integrating screening into routine medical care is crucial for promoting healthy and safe sexual development.
Footnotes
Contributors: GBJ and EP conceptualized the manuscript’s direction, with GBJ leading and overseeing manuscript preparation. GBJ, JA, and EP drafted the initial manuscript, and all authors, including JL, contributed to and approved the final manuscript.
Funding: The authors declare no specific grant funding for this research from any public, commercial, or not-for-profit sector funding agency.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer-reviewed.
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