Sexting: What are the clinical and legal implications?

Potential social and psychiatric consequences

What are the social and psychiatric ramifications for K? Aside from potential legal consequences of sexting, K is experiencing psychological and social consequences. She has developed depressive symptoms and suicidal ideation. Her ex-boyfriend’s dissemination of her nude photos on the school computer could be interpreted as cyberbullying. (The National Center for Missing and Exploited Children defines cyberbullying as “bullying through the use of technology or electronic devices such as telephones, cell phones, computers, and the Internet.”¹⁷ All 50 states have enacted laws against bullying; 48 states have electronic harassment in their bullying laws; and 22 states have laws specifically referencing “cyberbullying.”)

Her depressive symptoms developed in response to her feelings of guilt and shame related to sexting as well as the subsequent peer harassment. She is refusing to return to school because of her concerns about bullying. A careful inquiry into suicidality should be part of the evaluation when sexting has led to psychiatric symptoms. Several cases of sexting and cyberbullying have ended in suicide (Table 3).

How to ask patients about sexting

To screen patients for sexting, clinicians need to develop a new skill set, which at first may be uncomfortable. However, the questions to ask are not all that different from other questions about adolescent and young adult sexuality. The importance of patients seeing that we as physicians are comfortable with the topic and approachable about their sexual health cannot be overemphasized. When discussing sexting with patients, it is essential to:

• explain that you are asking questions about their sexual health because they are important to overall health
• engage patients in discussion in a nonthreatening and nonjudgmental way
• develop rapport so patients feel comfortable disclosing behavior that may be embarrassing
• listen to their stories and build a context for understanding their experiences. As you listen, ask questions when needed to help move the story along.

Sometimes when asking about topics that are uncomfortable, clinicians revert from open-ended to closed-ended questions, but when asking about a patient’s sexual life, it is especially important to be open-ended and ask questions in a nonjudgmental way. Contextualizing sexual questions by (for example) asking them while discussing the teen’s relationships will make them seem more natural.¹⁸ To best understand, inquire explicitly about specific behaviors, but do so without appearing voyeuristic.¹⁸

Sexting may precede sexual intercourse. Keep in mind that a patient may report that she (he) is not sexually active but still may be involved in sexting. Therefore, discuss sexting even if your patient reports not being sexually active. By understanding the prevalence of sexting among teens, you can ask questions in a normalizing way. Clinicians can inquire about sexting while discussing relationships and dating or online risk behaviors.

Also consider whether any of your patient’s sexual behaviors, including sext­ing, are the result of coercion: “Some of my patients tell me they feel pressured or coerced into having sex. Have you ever felt this way?”¹⁹ and “Have you ever been picked on or bullied? Is that still a problem?” are suggested safety screening questions about bullying,¹⁸ and one can also ask about specific cyberbullying behaviors.

Table 4 lists additional risk behaviors to ask about in a patient who has been sext­ing. Sexting is a widely accepted behavior among adolescents, yet many adolescents and parents are unaware of the legal implications of such a behavior. As physicians, we have a role in educating our patients about potentially harmful behaviors, and to do so in a manner that is not viewed as lecturing, which may result in receiving poor-quality information.