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“Clueless”: Why Do Pediatricians Underestimate the Media's Influence on Children and Adolescents?

2006; American Academy of Pediatrics; Volume: 117; Issue: 4 Linguagem: Inglês

10.1542/peds.2005-2336

1098-4275

Victor C. Strasburger,

Child and Adolescent Health

The media have arguably become the leading sex educator in America today. That's not good news, considering the fact that more than 75% of primetime shows contain sexual content but only 11% discuss the risks of sex.3 How significant is the influence of media on teens' sexual attitudes and behaviors? For 50 years researchers have explored the connection between media violence and real-life aggression in children and adolescents.4 More than 1000 studies show a connection.5 In fact, according to one leading researcher, "the controversy is over"6; now, we have a second major study showing a strong connection between sexual content in all media and onset of sexual activity among teens.7 Is there much doubt that research on the impact of sex in the media is going to parallel the media-violence research? The media represent a powerful teacher of children and adolescents.8 As such, the media cut across virtually every concern that parents and pediatricians have about young people: sex, violence, homicide, suicide, obesity, eating disorders, school problems, and drug use. The only questions are: (1) Why don't pediatricians "get it"? and (2) What can pediatricians (and parents) do about it?In the first study, published just last year, Rand researchers9 found that watching sexual content on television predicts and may accelerate adolescents' sexual initiation. Teens who watched the most sexual content had a twofold increased risk of initiating intercourse the following year or of significantly advancing in noncoital activity. A national survey of nearly 1800 12- to 18-year-olds used a 1-year follow-up survey to yield data that are as close to "cause and effect" as researchers can probably get, given the sensitivity of the subject and the lack of funds for costly long-term follow-up studies. In this issue of Pediatrics, Brown et al7 have gone well beyond the Rand study in looking at all media that teens typically use (except, sadly, the Internet). They performed a 2-year longitudinal study in an effort to capture the transition from precoital sexual activity to intercourse. In-depth, at-home surveys of more than 1000 12- to 14-year-olds were conducted. The preteens and teens were questioned via audiotapes and headphones, and they touch-screened their answers onto a laptop computer; this is the most elegant form of questionnaire research for studying adolescents. The authors then constructed a sexual media diet by using television, movies, music, and magazines, content-analyzing the sexual content, and examining the young people's exposure. They also examined a variety of precoital sexual behaviors including oral sex. Similar to the Rand study, this study found an approximate twofold risk for white teens who were exposed to a heavy diet of sexy media.Other studies have found similar results but lacked the longitudinal perspective that allows cause-and-effect inferences.10,11 Here's what we now know, in addition to the results of the 2 studies mentioned above12: Media research is not easy to perform, and this new study is "as good as it gets" (to continue the movie-title motif begun by the title of this commentary). The sexual media diet is a unique and clever idea conceived by the authors and is the best attempt, to date, to capture the entire media milieu of the average adolescent. Unfortunately, Internet use was not included because of sampling difficulties. Studies show that 70% of all 15- to 17-year-olds have "accidentally" stumbled across pornography online.19 Sex on the Internet is now a $500 million industry.20 In future studies, it would be ideal to capture not only Internet use but access to X-rated magazines and films as well. Again, studies show that most 13- to 15-year-old teenage males have seen an X-rated film or men's magazine.21 Future studies might also lower the initial age for participation by black teens (because their sexual initiation begins at a lower age) to perhaps 10 to 12 years of age, with follow-up at 12 to 14 years, and include Hispanic and Native American youth as well. However, unless you have actually tried to perform research that deals with sex, teenagers, and the media, you have no idea of how difficult and aggravating it is.22 This study is world-class!Where do we go from here? Everyone (pediatricians, parents, teachers, the entertainment industry, and state and federal governments) must share some responsibility if we are to be successful in helping teenagers delay the onset of sexual intercourse until an age at which they can be more responsible about relationships and birth control. (Remember that sex is not like drugs. We want our children to have happy, healthy sex lives—when they are older, not when they are 13. We never want our kids to use cocaine or methamphetamine or ecstasy. "Just say 'no'" doesn't really work the same way for sex as for drugs; perhaps "just say 'later'" might be more appropriate.)Because the media cut across virtually every health concern that pediatricians have, one would think that pediatricians would be lining up at continuing medical education conferences around the country to learn more about media effects, but they are not. Despite the fact that talks on media are usually quite entertaining, many doctors do not feel that the research is "academic" enough. Social science research is very different from medical research, yet at times it can be equally important. Much of the media research can be found in social science journals that are foreign to physicians, although both Pediatrics and Archives of Pediatrics and Adolescent Medicine have done an admirable job of publishing media research in the past several years. Pediatricians are busy, and they probably do not watch a lot of television themselves, certainly not "teen shows." They may recall a gentler, kinder media from the 1950s and 1960s when wardrobe malfunctions never occurred on live television. For whatever reason, pediatricians are often loathe to include media counseling in their office visits with parents.23 Perhaps this is because pediatricians are being called on to do an entire litany of counseling with parents but are never afforded enough time or reimbursed sufficiently for it. Whatever the reason, this clearly needs to change. Two simple questions would take only a few seconds and might give the pediatrician insight into a child or adolescent's media usage: The research is clear about parents' role in teens' sexual activity. If parents discuss their expectations that teens will delay intercourse, teens have to take that opinion into serious consideration and may, in fact, begin intercourse later. However, if parents do not discuss sex with their children and teens, particularly the need for responsibility and the need for birth control, then the media will pick up the slack. Parents, too, can be "clueless" about their teens' sexual activity. In 1 study, 58% of middle school students attending an adolescent clinic were sexually active, whereas 98% of their parents thought otherwise.24 Good communication can yield rich dividends, but it takes time and effort. Parents also need to be on the front lines of supporting effective and comprehensive sex education in their communities, not abstinence-only programs that do not work.25–27Of any professional group, teachers are usually the most receptive to the notion that the media can be an extremely important influence on young people. Consequently, teachers should be at the forefront of the effort to establish good media-literacy programs in schools.28 In addition, teachers need to push for media-literacy ideas and techniques to be added to existing drug abuse–prevention and sex education programs.29The 6 major television networks need to recognize that with their free use of the airwaves comes a certain responsibility to the public health. This includes making and airing shows that model sexual responsibility, especially in teen-oriented shows, and airing advertisements for birth control products. Two national studies have documented that a majority of American adults (even Catholics) favor the airing of birth control advertisements, yet several national networks continue to shy away from any controversy.30,31 Despite recent declines, the United States continues to have the highest teenage pregnancy rate in the Western world.32 Not coincidentally, it is the only country that still subscribes to the old-fashioned notion that making birth control available to teenagers increases their sexual activity. In fact, there are now at least 8 peer-reviewed, controlled clinical trials demonstrating that giving teens freer access to condoms, for example, does nothing more than increase the use of condoms among those who are already sexually active.33–40 That does not influence the 6 major networks, however. Three of them refuse to air advertisements for oral contraceptive pills, and a different 3 refuse to air advertisements for condoms.41 However, all of the national networks run frequent advertisements for erectile-dysfunction drugs including mentions of "4-hour erections." Between January and October, 2004 alone, drug companies spent $343 million advertising Viagra, Levitra, and Cialis.42 Airing of such advertisements needs to be confined to after 10 pm, when children should not be watching television.An episode of Friends that dealt with condom use was very effective in reaching an adolescent audience.43 All too often, however, teen shows seem like "Happy Days With Hormones," according to one national television critic.44The cable industry seems to be immune to regulation, but that does not relieve them of similar responsibility. Hollywood writers, directors, and producers need to exercise greater care in how they portray sexuality, especially in movies that target teenagers. Recording artists and music-video producers also need to recognize their potential role-modeling influence, and video-game manufacturers need to exercise greater caution in how they rate the sexual content in their games (witness the recent "elevation" in rating of Grand Theft Auto: San Andreas from "M" [mature] to "AO" [adults only]).45Finally, state and local governments have a major responsibility to the public to fund sex education programs that are documented to be effective and are endorsed by organizations such as the American Academy of Pediatrics. To date, abstinence-only programs have not met these criteria.25,26 In an era when doctors are being held to evidence-based standards, the federal government needs to be held to similar standards. In 2005, a proposed $170 million will be spent by the federal government to support abstinence-only sex education programs that are ineffective and unwise.46 Similarly, government Web sites need to contain accurate and authoritative information about birth control and avoid scare tactics.47 Meanwhile, the government needs to urge the Internet Corporation for Assigned Names and Numbers to approve a new ".xxx" domain, which would allow parents much greater ability to block children's access to pornographic Web sites.48All in all, Americans need to recognize the power of media to teach children and teens about sex and sexuality. If parents and schools do not provide sufficient information to satisfy teens, the media will pick up the slack, and American media are most decidedly not abstinence-only. As one author sadly notes: