Evidence-Based Evaluation of and Intervention for Adolescent Sexting

Sexting (sending a nude picture of oneself to another person) is a common, but not universal, behavior between adolescents. This article presents research on 2252 18 year old individuals studied between 2020 and 2022. Around 52% sent a sext to a peer. Approximately 70% experienced negative or positive pressure from peers or self-pressure. Approximately 77% of negative-pressured sexters reported challenges with anxiety, compared to 58% of positive-pressured sexters and 41% of non-sexters. This paper also presents typical and atypical sexting cases and notes clinical implications of the research findings.

Key points

  • Sexting is not rare, but sexters are not a monolithic group. They sext for different reasons and motivations.

  • Sexting because of negative pressure (eg, bullying, coercion) is associated with poorer mental health outcomes.

  • Clinical approaches to different types of sexting behaviors should vary depending on risk factors present in each case.

Introduction

Responding to novel behaviors in a clinical setting is often difficult. In lieu of experience in evaluating poorly understood behaviors, judgments regarding the value and risks associated with these actions can be fraught with error. “Sexting,” a term that refers to sharing naked pictures of oneself with another via digital media, can be particularly challenging to assess when presenting among children or adolescents.

Sexting caught the attention of international media prior to the existence of substantial research evidence and was quickly associated in news stories with abuse and pathology. , Sensationalized sexting stories, combined with adult inexperience, lead many parents and practitioners to assume that any such behavior represents a serious psychological problem. The purpose of this article is to update practitioners on contemporary research regarding sexting and to help them identify cases involving high risk of harm compared to those which are more normative and less likely to involve negative outcomes.

Background

Research on the frequency of sexting has produced a wide variety of results. A 2011 telephone poll by Mitchell and colleagues of a national sample of 1560 children and teens revealed variable rates, depending on the age of the respondent. Overall, only 2.5% of subjects reported making a nude image, and 7.1% reported receiving one during the previous year. However, among 16 and 17 year individuals, rates of sexting were 31% and 41%, respectively. A 2012 study of sexting among 11 to 11 year old individuals, conducted by Dake and colleagues, found the same pattern, namely that while only 17% of all students engaged in sexting, 32% of 18 -year olds did so. More recent research confirms that sexting among teens is neither rare nor universal: roughly half of youth reported having sent a sext before turning 19 years. Older teens are substantially more likely than younger teens to endorse sexting, and rates of occurrence during extended time periods are higher still.

Several studies examined the association between sexting and mental health difficulties (eg, depression, anxiety). A study of older youth (18 years old) found no such association. However, both age and context of the behavior have emerged as possible mediators of a link between sexting and psychopathology. One study of sixth graders found those who admitted to sexting also evidenced more depression. Coercive sexting has been particularly associated with trauma and mental health symptoms. Context surrounding sexting behaviors has emerged as key in understanding the possibility of a link between sexting behavior and psychopathology.

Typical and atypical presentation of sexting cases

“Manuel loves me, that’s what my mom doesn’t understand!” insists Shyla, a 13 year old girl with a history of oppositional defiant disorder, major depressive disorder, and mild intellectual disability. Shyla struggles academically despite accommodations afforded by an individualized education plan at school. She feels rejected by most peers at school but has a few male acquaintances, and has recently refused to attend school more days than not. Her single mother works during the day, and Shyla is often home alone, entertaining herself via social media and video games and has made a few online friends. On a dating app, she met Manuel, a boy with whom she frequently discusses her depression and cutting habit, via text and video chat. Shyla recently learned that he is actually an adult and is married, but he reassures her that he plans to divorce his wife and marry her. He lives in a neighboring state and they have made plans to meet up in person.

When Shyla’s mother discovered that she had sent him nude pictures via text, she confiscated Shyla’s phone and forbade further contact. Shyla responded by telling her mother that Manuel is the only person who cares about her, and threatened to kill herself if her mother did not return her phone. Shyla’s mother received numerous calls and texts from Manuel demanding to speak with Shyla to ensure her safety, and threatened to call DCF on her mother for neglect if she did not allow it.

A parent’s worst nightmare, Shyla’s situation constitutes sexual abuse and puts her at high risk of a host of negative outcomes. Similar situations have received a great deal of publicity through news stories, alerting parents and clinicians to the potential dangers of teen sexting. Parents frequently warn their children of just this type of outcome, implying that if they send naked pictures of themselves via text or social media, that it will be passed on and become public, will ruin their social reputation or college prospects, or even result in arrest for child pornography. Abusive situations like Shyla’s serve as cautionary tales, but are they typical?

Let’s consider the case of Cali:

“My daughter is a pervert!” exclaimed the mother of Cali, a 16 year old girl with a history of Attention Deficit Hyperactivity Disorder (ADHD), depression, and generalized anxiety disorder. Cali had been fairly high functioning for the past year with the support of weekly outpatient counseling, methylphenidate extended release, and escitalopram. During a routine follow-up, her mother expresses with great alarm that she looked through her daughter’s phone after observing Cali acting strangely and spending excessive time in the bathroom. Her mother found nearly a dozen nude “selfies” which Cali had texted her long-term boyfriend Caleb, and vice versa. Cali’s mother fears the pictures will be spread around to Caleb’s friends and responds by confiscating Cali’s phone and forbidding her from seeing him. She asks Cali’s psychiatrist whether an inpatient admission would be appropriate to keep her daughter from dangerous sexual activity until she comes to her senses.

Cali is humiliated by her mother’s response to her sexts. She relates that she and her boyfriend are not sexually active but she trusts him enough to send him the nude pictures over the last few months. She believes Caleb to be caring and responsible, which has been borne out by his actions and treatment of her. She feels that her behavior is not pathologic and hopes that her psychiatrist will convince her mother of this and help negotiate lifting her punishment.

Cali’s mother is as concerned as Shyla’s. Both girls engaged in sexting and both mothers are fearful of severe consequences. Are these fears equally justified?

Research examining sexting

Methodology

An anonymous survey examined 2252 youth during 2020, 2021, and 2022. Subjects were aged 18 years and lived in Massachusetts, Colorado, or Virginia. They were never identified and knew the survey was confidential. Subjects were recruited to participate through the Subject Pool at 3 different universities, and most were required to engage in research as part of a Psychology course. The survey was approved by the Universities’ Institutional Review Boards and administered online.

This study measured variables that are potentially useful in a clinical setting, including online sexualized behaviors such as sexting. Sexting, in this survey, was defined as sending a nude picture of oneself to a peer. The definition utilized did not include sexting via text (through messages or emails), or suggestive photos in which the subject was clothed.

Initiation and Frequency

Slightly more than half of all subjects (52%) reported having sent a nude photo of themselves. Almost three-quarters of these sexters (74%) indicated having first sexted before the age of 18 years, but more than half did not send a sext before the age of 16 years (61%). Around 19% sent their first nude picture at the age of 15 years, and another 19% sent it at the age of 14 years or younger.

Education about sexting was uncommon in this sample. Around 20% of subjects reported their parents had discussed sexting with them, while 23% stated that their parents had lectured them about the subject. Seventy percent of them stated that they had either received no education about sexting in school, or that the education they received made no impact on them.

Clinical implications

Sexting becomes more normative as youth age through adolescence. It is rare among pre-adolescents and uncommon among younger adolescents. Practitioners should not expect youth to have been educated by parents or schools about sexting.

Other characteristics of sexters

Both male and female participants engaged in sexting in this sample. Heterosexual females were more likely to report sending a sext compared to heterosexual males (56% vs 45%).

LGBTQ+ youth were more likely to report having sexted (true for male, female, and gender nonconforming subjects). This does not appear to be a consequence of different attitudes about sexting risk. LGBTQ+ subjects were no less likely to believe that sexting can lead to legal trouble, or that sexters can be harassed or bullied. They were, however, more likely to endorse positive views of sexting. For example, they were more likely to believe that sexting is a legitimate way to explore sexuality, that it can make people feel attractive, and that it is fun and exciting.

In this sample, 62 youth reported that they were either transitioning to another gender or were gender fluid or intersex. Among these youth, 60% reported sexting, which represents the highest rate of any group based on gender or sexuality.

Under what circumstances do teens sext?

Most, but not all, teens sexted in the context of an ongoing relationship, as a way of exploring intimacy or sexuality. In this study, 67% of youth sexters sent the nude picture to a person they were dating (11% began dating the person after they sent the picture, and 56% were dating the person before they sent the picture).

Sexting was associated with sexual intercourse, in that youth who were sexually active were about twice as likely to report having sent a sext. However, it is notable that 66% of subjects reported having sexted before becoming sexually active.

Clinical Implications

Many sexters are dating, but they are not necessarily sexually active.

Peer pressure

Many youth reported experiencing pressure or coercion to sext, but not all. Almost one-third (31%) of sexters reported no pressure at all. One-quarter (26%) of sexters experienced negative pressure, and another one-quarter (26%) experienced neutral or positive pressure. In this study, positive pressure was defined as pressure that was experienced as flattering attention or requests. Interestingly, 17% of sexters who were pressured, reported self-inflicted pressure to sext, namely, that they personally held certain beliefs that were central to their sexting behaviors (eg, believing their partner might break up with them, if they did not sext).

Most youth who reported pressure did not report that it was distressing for them, but almost all those who were very pressured (80%–90%) said that it was an upsetting experience.

Clinical Implications

Pressure by itself is not always indicative of a serious problem, but negative pressure or heavy pressure were experienced as noxious. Reports of pressure or coercion to sext—even self-pressure—should be carefully explored in a clinical setting.

Is sexting associated with mental health challenges?

In this sample, sexters were more likely than non-sexters to report mental health challenges. For example, 62% of sexters indicated that they had experienced or were experiencing depression, compared to 43% of non-sexters. Similarly, 58% reported anxiety, compared to 45% of non-sexters. These differences were statistically significant. Sexters were also more likely to report problems with self-control and even self-injury.

Importantly, not all sexters were alike. In this sample, we were able to differentiate high-risk sexters (those who sext with strangers) from low-risk sexters (those who sext within an ongoing peer relationship). High-risk sexters were more likely to report anxiety or depression (69% and 72%). Differences between high-risk and low-risk sexters were particularly noteworthy when it came to problems with self-control (35% vs 22%) and, to a lesser extent, self-injury (26% vs 21%). Around 53% of high-risk sexters reported seeing a therapist or psychologist, compared to 36% of low-risk sexters.

Self-reported challenges with social skills and academic skills were unrelated to sexting, even among high-risk sexters.

The adolescent’s age when sending their first sext was a significant mediator between sexting and psychopathology. As noted above, younger sexters have been found to be at greater risk for depression. The current sample participants were all 18 years old, but they were asked the age at which they sent their first sext. Those who reported sending their first sext while in middle school were significantly more likely to endorse depression and self-injury, and somewhat more likely to report anxiety.

Coercive sexting has been particularly associated with trauma and mental health problems. In this study, we hypothesized that sexting because of pressure, especially negative pressure, would be associated with mental health challenges. That hypothesis was robustly supported by the findings. For every mental health variable, negative-pressured sexters fared significantly worse than both positive-pressured sexters and non-sexters. For example, 77% of negative-pressured sexters reported challenges with anxiety, compared to 58% of positive-pressured sexters and 41% of non-sexters. Similarly, 79% of negative-pressured sexters reported depression, compared to 63% of positive-pressured sexters and 49% of non-sexters. The same patterns were observed for self-control problems, social skills, academic skills, and reports of self-injury.

Clinical Implications

Any sexting increases risk of mental health problems, but sexting in response to negative pressure or coercion is clearly more likely indicative of psychological dysfunction. Any youth who presents with sexting behaviors should be screened for mental health problems, but those whose sexting is a negative or even traumatic experience are significantly more likely to suffer mental illness.

Clinical Evaluation

Available evidence supports screening for risky, traumatic, or negative sexting behaviors in patients whose clinical presentation suggests relevance. Younger teens with poor social skills, those who do most socializing online, those who have engaged in sexting and significant online conflicts in the past, those who spend more time unsupervised online, and those with poor decision making due to ADHD and particularly serious learning disabilities may be most likely to engage in high-risk or negative-pressured sexting, and clinicians should inquire about sexting behaviors in such cases.

At the same time, clinicians should withhold judgment about a patient’s mental health status based only on sexting behaviors. Exploring concurrent risk factors, such as age of sexting onset, coercive peer pressure, and the context of sexting (eg, within an ongoing adolescent relationship) are key in determining psychological risk.

In Cali’s case, some education helped improve the mother–daughter dynamic:

Cali’s psychiatrist explains to her and her mother that sexting is neither rare nor deviant for today’s adolescents. When done in the context of a stable, long-term romantic relationship it is not likely to result in negative outcomes, although those are still possible. Her mother appears dubious, but agrees to consider. Her mother calls the psychiatrist 1 week later to admit to having overreacted; she states, “thank you for talking me off the ledge and helping to put my daughter’s behavior in a different light.” She was able to have an open discussion with her daughter about the decision to engage in sexting with Caleb, express her concerns about the potential risk of harm to Cali. Ultimately, she returned her phone and expressed trust in Cali to make safe online decisions going forward. At the next appointment, Cali is grateful to her psychiatrist for mediating their conflict, happy that her mother accepts her actions and has reconsidered the related consequences.

Practical considerations

Mental health clinicians are often reticent to ask our patients about sexting behaviors, even when it appears clinically appropriate. We fear making our patients uncomfortable, may be uncomfortable hearing details ourselves, or might feel judgmental about a patient’s decisions to engage in sexting. Similarly, patients are often hesitant to share such experiences with their clinicians for similar reasons, often fearing being judged by the clinician, making the clinician uncomfortable, or having their confidential confessions reported to their parents. However, sexting experiences can sometimes have significant ramifications for mental health and safety, so it is clinically relevant to assess these behaviors in high-risk cases.

Assessing for sexting-related experiences should also be developmentally appropriate. For younger children at risk, it may be best to ask “has anyone online ever shown you something or asked you to do or show them something which made you feel uncomfortable?” For teens: “do you know what sexting means?” or “have you ever been asked to send naked pictures of yourself by someone online?”

When asking about sexting, it is also helpful to ensure that youth understand the boundaries of confidentiality. Clinicians can reassure patients by saying “I don’t tell your parents what we talk about, unless you say it’s OK or unless it sounds like someone might be really hurt if I don’t.” This may reassure youth who wish to share certain experiences with clinicians but not their parents.

Finally, it is often helpful to normalize sexting while asking patients about it. For example, a 12 year old girl with depression and self-harm reported to her clinician that she had become a pariah at school, her peers all teased her and rejected her ever since she and a boy in school broke off their romantic interests. This rejection hurt her deeply and drove her to cut herself, but she was vague about why her peers were teasing her. Her clinician neutrally explored the possibility of a negative sexting experience by commenting that “oftentimes girls send nude pictures to a boy they are interested in romantically, and sometimes the boy betrays their trust by passing on the pictures to others, which can be very embarrassing for the girl.” The girl instantly responded, “that’s what happened to me!” Framing sexting as a behavior that regularly occurs (even though it can be harmful) sends the message to our patients that we understand sexting can be normative and would not judge them for having engaged.

Summary: when does sexting indicate a psychiatric emergency?

Many cases of adolescent sexting do not require clinical intervention. Teens who engage in low-risk sexting behavior may not require clinicians to intercede. It may be helpful for such youth to understand the difference between risky and less risky sexting. In cases where parents are worried about negative consequences that seem improbable, it may be helpful for clinicians to inform parents that such behavior is neither rare nor inherently pathologic.

In cases where a child or a teen is sending sexts in what appears to be a risky manner, it may be important for clinicians to explain to the child that while their behavior may be understandable, it can result in negative outcomes, including regret, embarrassment, or even the picture being passed on. It may be helpful for the clinician to problem solve with the youth what to do if and when such negative consequences arrive. Young people who have been exposed to pressure to send such pictures may be helped by problem solving with regard to how best to respond to this pressure, highlighting alternatives to complying.

In cases which involve an adolescent sending sexts to an individual significantly older or younger, it is important to assess whether this might constitute sexual abuse. When there is cause for concern, it falls upon the clinician to take steps to protect the child from further harm, regardless of whether the at risk child is a patient. This will typically include calling child protective services, but may also include informing the parent or even local police so they may take steps to protect the child from further harm. The clinician should inform the child that sexual pictures sent between a child or a adolescent and any significantly older individual is inappropriate, harmful, and often illegal. In such cases it may be helpful to problem-solve with the child on how to resist contact with the offender, and discuss with the child’s caregivers how to prevent such contact. Close supervision of online activities may be warranted. Parental control software, such as that which comes built into devices such as iPhones, should be considered, but cannot completely replace traditional supervision. In serious cases, temporary confiscation of Internet-ready devices may be necessary. Parents have the option to replace a child’s smartphone with a flip phone in cases where Internet access is deemed acutely unsafe but phone access is not. Parental supervision should be done in a manner which minimizes an adversarial relationship with their child whenever possible.

It is important for parents to understand that no method of restriction is foolproof. Motivated children may get a friend to lend them an Internet-ready device, sneak the use of devices when parents think they are sleeping, or find ways around parental control software, in order to contact the offender. However, efforts to prevent contact are often effective and should not be abandoned altogether.

Shyla’s case was, unfortunately, one of these, and more significant interventions became necessary:

Shyla’s psychiatrist expressed to her that her relationship with Manuel is inherently coercive and meeting him in person would risk assault. Shyla rejected these ideas and refused to speak any more about Manuel. The psychiatrist gathered information about Manuel from mother and contacted child protective services with a concern about child abuse perpetrated by Manuel, encouraging mother to do the same and to file charges with police. Mother followed the psychiatrist’s advice to restrict Internet access, but Shyla responded by attacking her mother physically, leaving several bruises on her, and threatening to kill herself. Her mother, feeling unable to keep Shyla safe, called 211 which led to an emergency room visit and inpatient psychiatric admission.

May 20, 2025 | Posted by in PEDIATRICS | Comments Off on Evidence-Based Evaluation of and Intervention for Adolescent Sexting

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