Sexting is a cultural phenomenon that has garnered significant public attention within the last few years. The topic has received media attention from a variety of sources—talk shows, evening news segments, and even situation comedies (sitcoms) (1–4). The Macmillan Dictionary (5) defines sexting as the practice of sending sexual images or messages to a person's cell phone. A more narrow definition is provided by the Pew Research Foundation in their report on teen sexting. They define sexting as “the creating, sharing, and forwarding of sexually suggestive, nude or nearly-nude images by minor teens” (6). Sexting is a relatively recent phenomenon that has only come to public awareness within the past few years, but which has triggered concern among parents, educators, and law enforcement officials.

One major factor in the recent development of the phenomenon is the dramatic increase in cell phone use and ownership by teenagers over the past few years. According to the Pew Internet 2004 survey (7) of 1,102 teens age 12–17, 18% of 12-year-olds and 64% of 18-year-olds owned cell phones. By 2009, these numbers had risen to 58% of 12-year-olds and 83% of 17-year-olds owning cell phones. Among teens, age is the most important variable in cell phone ownership, and older teens are much more likely to own phones than younger teens. The largest increase occurs at age 14, the point when most teens enter high school.

In their January 2010 report on teen consumption of media, the Kaiser Family foundation (8) reported that the 8- to 18-year-olds surveyed spent an average of 7 hours and 38 minutes daily using media. The subjects used their cell phones for a variety of media purposes, not just for chatting with or texting peers. On a typical day, 8- to 18-year-olds reported spending an average of 49 minutes listening to music, playing games, or watching TV on their cell phones. Also, on a typical day, 46% of 8- to 18-year-olds reported sending text messages on a cell phone, and it is estimated that those who text send an average of 118 messages a day. On average, 7th-to-12th graders reported spending about 1½ hours per day engaged in sending and receiving texts. Thus, we see that over the past few years, there has been an explosion in the ownership and use of cell phones by children and teens, and, that, in a given day, teens are using their phones for a variety of purposes, not the least of which is to text peers.

Adolescence marks a key period of development in the human life-cycle. Erikson (9) characterized this life-stage as the time of “identity formation”—a stage when children make the transition from childhood to adulthood and learn to establish their sense of values, self, and relationship to the outside world. This period is marked by an increased interest in the individual's own emerging sexuality and an increased importance of peer relationships.

Also, adolescence is a time of impulsivity, grandiosity, and risk-taking. These developmental norms, coupled with the ubiquity of technology, provide a potentially dangerous combination. Teenagers' tendency toward exhibitionism and narcissism, their desire for intimacy in relationships, their desire and preoccupation with sexual exploration, and the hope of creating their identities as individuals who are attractive and desired may make them more vulnerable to the allure of sexting. Thus, a setting is created in adolescence in which sexting is more likely to occur.

In response to the phenomenon, the American Academy of Pediatrics (10) issued a parent bulletin in August 2009, titled “Help Kids With Cell Phones Get the Message: ‘Say No to Sexting.’” The bulletin educates parents on the phenomenon and advises them to have discussions with their children about the legal, social, and emotional risks involved with sexting.

Also, various research groups have undertaken to study and quantify this phenomenon. One of the first such studies was performed by the National Campaign to Prevent Teen and Unplanned Pregnancy, in conjunction with Cosmogirl.com in 2008 (11). The study was conducted by TRU, a research organization that conducts global research on teens and 20-year-olds. Their study, titled “Sex and Tech,” examined the role of technology in the sex lives of 653 teens (ages 13–19) and 627 young adults (ages 20–26) via an online survey. They selected respondents for the 25-question online survey from among individuals who had already volunteered to participate in TRU's online surveys. They found that 22% of girls and 18% of boys age 13–19 reported having electronically sent or posted online nude or semi-nude photos or video of themselves, and 31% had received a nude or semi-nude picture or video from someone else.

Cox Communications partnered with the National Center for Missing and Exploited Children to also perform a study (12). They commissioned Harris Interactive, who conducted an online survey of 655 U.S.teens, ages 13–18, from across the country and found that 9% of teens age 13–18 had sent a sexually suggestive text message or e-mail with nude or nearly-nude photos; 3% had forwarded one; and 17% had received a sexually-suggestive text message or e-mail with nude or nearly-nude photos. They found that 80% of the teen sexters were under age 18.

MTV and the Associated Press (13) later conducted a study and recruited respondents from KnowledgePanel (an online panel that is purported to be representative of the U.S. population, with members being recruited via random telephone and address-based sampling). They conducted an online survey of 1,247 respondents in September 2009 and found that 10% of young adults between the ages of 14 and 24 have shared a naked image of themselves with someone else; 24% of 14- to 17-year-olds and 33% of 18- to 24-year-olds surveyed had been involved in some form of naked sexting; however, the study is not clear as to what “involvement” means and if it includes the percentage of young people who simply received sexts; 17% of those who had received sexts reported having passed the image on to someone else, and just over 9% had distributed the images to more than one person.

Most recently, the Pew Research Center (6) conducted a nationally-representative telephone survey of 800 teens from June 2009 to September 2009 and found that 4% of all cell-owning teens age 12–17 reported sending sexually-suggestive nude or nearly-nude photos or videos of themselves to someone else via cell phone. Almost four times as many (15%) of those age 12–17 had received sexually-suggestive nude or nearly-nude photos or videos of someone they knew on their cell phone. They found the highest incidence among 17-year-olds, with 8% reporting having sent such a text and 30% having received one.

The findings from the aforementioned studies appear to vary widely, and these differences may be attributable to differences in sampling and methods. The findings from the Pew Research Center and those from Cox Communications are most similar, in that the percentage of teens having received a nude image was approximately 15%–17%. The teens in the Pew Survey may have under-reported the true incidence of sexting, as the surveys were conducted via telephone, and teens may have been less inclined to report their true incidence of sexting to a live person. Also, unlike the other studies, the Pew Research Center focused solely on images sent via text-messaging on a cell phone. Both the Cox Communications study and the MTV study estimate a percentage of approximately 10% of youths surveyed having sent a sexually-suggestive text or nude image.

The Pew Research Center found that there were three basic scenarios in which sexting would occur: exchange of images between two romantic partners; exchange that originated between two romantic partners but was then shared with someone outside the relationship; or exchange between two people not yet in a relationship, but where at least one person hopes to be in a romantic relationship with the other.

Teens cited a number of reasons for sending sexts. Some reported a desire to initiate a romantic relationship, and others felt that sexting provided a means to explore sexuality in a relationship where they were not yet ready to have sex (6); 24% of the MTV sexting respondents sexted to people they wanted to date or “hook up” with (13); 61% of those who had sent the naked photo of themselves identified peer pressure as a motivation; 26% cited boredom; and 30% said that they did it as a “joke” or to be funny (13); 35% reported that they wanted to “show off;” and 52% assumed that others would want to see the photo (13).

Cell phones provide a medium for teens to have 24-hour access to communication with peers, so that it increases the likelihood that a teenager will send a text or picture impulsively, without thinking through the consequences. Also, it provides an easy way for teens to communicate with large groups of people with relatively little effort, so that these texts can become disseminated in a large community fairly quickly and easily.

Unfortunately, many of these teens do not foresee the potentially adverse consequences of their behavior. Many of them may think that a photo of themselves is not a “big deal,” will not get into the “wrong hands,” and will only enhance their social image.

Cox Communications (12) found that 9 of 10 sext-senders thought nothing bad would happen as a result of their sext. However, 3 of 10 of the friends of sext-senders reported that the photos had actually been forwarded to an unintended recipient (12). Among MTV respondents, only 14% of those who had shared a naked photo or video of themselves suspected that the recipient had likely forwarded the image (13). Sadly, there are social implications for sending such a photo—including social ostracism or ridicule by peers and being labeled as a “slut” or “whore” by classmates.

Some of these children are at risk for cyberbullying; that is, being ridiculed and bullied by peers online. There is also the potential for social blackmail by someone who receives the text. The long-term consequences that have many parents and educators worried include the potential effect on future college admission or employment opportunities and the fear that these photos may get into the hands of pedophiles.

Also, in many states, there have been legal or forensic consequences. Some of the children or teens who have posted nude photos of themselves or who have passed on photos of others have been placed on sex-offender registries, charged with production or dissemination of child pornography, or charged with committing a misdemeanor (14–16). The original child-pornography laws were not designed with this phenomenon in mind, but were rather created to protect children from adult offenders. As a result of the new sexting incidents, some state legislatures have scrambled to modify their laws to lessen the penalties in an effort to protect these juvenile offenders. Nonetheless, the legal ramifications of sending these “sexts” vary widely from state to state, and, in many states, there are still legal consequences for both the individual who takes the photo and for individuals who solicit or distribute the photos.

Unfortunately, the potential for serious, devastating consequences is high. The legal, social, and emotional aftermath can be overwhelming for children and can haunt them long after they send the picture. Although many such photos do not result in bad outcomes, there have been reported incidents of children being subsequently bullied. The most worrisome outcome of such bullying has been suicide. The MTV/AP study (13) found that 12% of sexters and 8% of teens who had been targets of cyber-bullying had considered ending their own life in the past year, as compared with 3% of those who had not been bullied or involved in sexting. There have been a few such suicides that have captured national attention, including the tragic case of Jessie Logan, from Ohio, an 18-year-old who finally killed herself after a set of nude photos of herself were sent to the other students in her school (17).

Who are the children who are most at risk of participating in sexting? Some research has shown that girls are more likely than boys to share a naked photo of themselves (12, 13), whereas the Pew Research Center found no difference.

Youth who are sexually active are more than twice as likely to send such photos, with about 45% of young people who reported having had sex in the past 7 days reporting having had at least one sexting-related activity (13). Also, one would hypothesize that kids whose peers are engaging in similar activity are at higher risk, as many respondents cited peer pressure as a factor leading to such behavior.

Being aware that a child is engaging in this behavior, do we have an obligation to notify parents? In our roles as psychiatrists, we are constantly trying to navigate the terrain of confidentiality, respecting the privacy of teens but also protecting their well-being and notifying parents when we think they are engaging in risky behavior. Given the potential for negative outcomes for teens associated with sexting, we are forced to seriously consider whether an incident of sexting warrants a breach of confidentiality.

Although many teens engage in this behavior, for a variety of reasons, we should be aware that, in certain situations, it may be indicative of a deeper, underlying psychological problem, such as mania, depression, or low self-esteem. The incidence of sexting is surprisingly high, and, thus, we know that not all children who send nude photos are manic or depressed.

There are no published studies regarding the amount of sexting done by manic or depressed patients. This would be an interesting and highly informative area of research. However, as clinicians, we need to understand this behavior in a larger clinical context when applicable. If a child is already depressed, with low self-esteem, this behavior may be secondary to the underlying depression, or if a teen is sending multiple photos indiscriminately to multiple boys in the context of decreased sleep, increased sexualized behavior, pressured speech, perhaps it is secondary to mania. Although sexting may not be indicative of a major psychiatric disorder, it may represent acting-out on the part of a teenager, perhaps due to social stressors, family pressures, or other significant psychological or interpersonal problems that may be helped by professional intervention.

Finally, how do we advise parents and children about the potential risks of engaging in such behavior? It is imperative that we let our patients and their parents know of the potential negative consequences of sexting and the risks involved in what may seem to be an innocent behavior. Although it is tempting to rationalize the idea that sexting represents a phenomenon consistent with a normal stage of development in a teenager's life and that it is merely a digitalized version of sexual exploration, we do our patients and their families a disservice if we don't acknowledge the risks associated with sending electronic nude photos of oneself. By virtue of the nature of technology, sexting is more serious than simply taking a nude picture of oneself to share with a boyfriend, and advising parents and kids of the risks involved may help protect kids from making an impulsive decision that later has irreversible and far-reaching consequences.

Of interest, for clinicians who are advising or treating a parent of a teenage child, the Pew Internet Survey (6) found that there was no significant difference in incidence if the parents investigated their child's phone, as children could often password-protect certain images or delete them after having received them. However, they did find that among parents who restricted the number of text messages their children could send and those who paid their teens' phone bills, there was a lower incidence of sending sexts; 8% of sexters had parental restrictions in place, whereas 28% of non-sexters had parental restrictions in place. It is unclear whether this reduction in incidence of sexting had to do more with parental oversight and parental interaction with kids than with solely a numerical restriction of the number of texts.

On the basis of the findings thus far, some recommendations for parents and clinicians would be the following:

1. Parents should become familiar with their child's use of phones, social networking, and computers. They should be aware of what technological capabilities are present on their child's cell phone and should be aware of how their children are using their phones. Also, they should be aware of the social and psychological forces at play in digital communication, as well as the interpersonal and possibly legal consequences of this behavior.

Most phones that have text messaging capabilities include the option to send photos via “picture messaging” as an attachment to a text message or as its own message. Thus, even phones that do not have a built-in camera option allow for users possibly to send and receive nude photos that they may have downloaded elsewhere, such as on their computer, and then sent to their phones. Most phone carriers do provide options for parents to limit text-messaging options, and parents can speak with their providers regarding these options, but the truth remains that most children and teens who have access to the computer or to a phone with texting capabilities can engage in sexting behavior, if they are not closely supervised. This is why it is important for parents and clinicians to have open dialogue with adolescents about sexting.

2. Parents should also begin a discussion with their children when they first start using a cell phone or computer about the potential risks and benefits of instant communication, including the dangers associated with sexting. They should discuss appropriate uses of the phone or computer and what their expectations of appropriate and safe use would include.

Discussions between parents and children regarding technology should begin when “the kids” first start using technology. Just as parents are frequently advised to speak with their children in the preteen years about drugs and safe sex, parents should also be advised to speak openly with their kids (even in the preteen years) about safe uses of technology—exercising caution in how much information is revealed on social-networking sites such as Facebook, appropriate uses of phone texting, and sharing of photos via phone or computer. Parents should discuss the risks associated with sexting (legal, emotional, and social) and should advise their kids of why sexting is not a good idea. Discussions between parents and kids ahead of time may give them an opportunity to think about these issues before an actual situation arises during which they may be pressured or tempted to send such a photo or may be the recipient of such a photo.

If parents suspect that their kids are sending or receiving inappropriate photos, they should address this issue directly with their child. They may want to revisit household rules regarding phone use, and, if this becomes a pattern of problematic, recurrent behavior, they may need to limit use of texting and/or photo-sending properties on the phone until the teen is able to demonstrate safe, appropriate use of the technology.

3. There is a role for clinicians to improve their own media literacy and to become educated further on the phenomenon of sexting and be familiar with the local laws associated with sexting.

4. Clinicians should also incorporate media history-taking as part of their routine diagnostic evaluations, by asking teens or preteens about their use of the computer or cell phones and, more specifically, about various activities on these, including social networks such as Facebook and the use of texting. Media literacy might also include discovering what the teenager is viewing on TV, in movies, and other forms of electronic, media, including video games.

These discussions can take place in the initial interview by asking directly about the teenager's friends, interests, and activities and then asking about use of Facebook or texting. The clinician can ask, in an interested, nonjudgmental manner, to better understand the teenager's life. Just as an initial interview would not be complete without a sexual history, so also it would not be complete without a survey of the teenager's use of technology. Over the course of subsequent sessions, this topic can continue to be explored with the teenager, discussing the teen's communications with peers on Facebook or via texting; feelings about this mode of communication; and information that is relayed via these modes of communication. The clinician can ask gently whether the teenager knows anyone who has ever sent a nude photo of himself or herself and what they think about this. This may be a way to open the discussion with a teenager and to better assess the teen's feelings on the topic.

5. There are no clear practice guidelines regarding when, if ever, to disclose sexting practices or behavior to parents, so the decision to do so remains at the discretion of the individual clinician. However, some recommendations are as follows: A single, isolated episode of sexting may not warrant notifying parents, but if the child is repeatedly engaging in such behavior indiscriminately or it is part of a bigger, more worrisome clinical picture, a clinician may consider addressing this with the teenager and raising the concerns for safety that would prompt a breach of confidentiality.

Any breach of confidentiality should be discussed with the teen in advance, so that the teen understands why the clinician is worried and feels it necessary to inform the parents.

6. Because this is a very pertinent issue for work with children and adolescents, it would be important to incorporate seminars on media history-taking in trainee didactics. A seminar devoted to the topic should include a definition of the topic, the legal, social, and emotional risks associated with the behavior, as well as the importance of screening for sexting in patients. Trainees can be advised of the importance of including it in the initial evaluation, as well as incorporating it in subsequent sessions when appropriate with teens. Given the sensitive nature of the issue, it may be best addressed in an ongoing therapy setting rather than in 30-minute “psychopharm” sessions.

Issues regarding the nature of confidentiality must also be addressed. There are no clear practice guidelines regarding when, if ever, to disclose sexting practices or behavior to parents, so the decision to do so remains at the discretion of the individual clinician.

The following professional organizations have also listed potential resources for parents on their websites:

The American Academy of Pediatrics has issued guidelines for parents on their website: http://www.aap.org/advocacy/releases/june09socialmedia.htm

The American Association of School Administrators (http://www.aasa.org/) provides information regarding sexting and tips for parents.

Some other websites that provide information for parents on technology are listed below:

Common Sense Media: http://www.commonsensemedia.org

Parental Media Guide: http://www.parentalguide.org

GetNetWise: http://www.kids.getnetwise.org

In conclusion, with the rise in the use of cell phones by children and teens in the past few years, various phenomena are appearing. One such phenomenon is sexting, which appears to be on the rise and is here to stay. As clinicians, treating both parents of children and teens and/or treating the kids themselves, we have a professional obligation to educate ourselves on the nature and incidence of this phenomenon and, when applicable, to incorporate it into the care of our patients.

At the time of submission, the author reported no competing interests.