Childhood exposure to pornography and the... : Nursing

Case scenario

Cassidy is a 16-year-old female. She is being treated in the emergency department for suspected sexual assault after blacking out at a party and waking up without her pants or underwear on; she is having vaginal pain. She is screened for exploitation and sex trafficking by a forensic nurse and discloses that she is creating pornography on OnlyFans and making money so she can “buy drugs.” She states that she is “choosing to do it” and is confused about why it needs to be reported as a crime, saying, “A lot of girls do it.”

Introduction

Rapidly evolving technology is a key factor in how children are learning about sexual “norms” in society. The trends of sexual harm and exploitation are also evolving and increasingly moving online. Nurses need to be aware of current trends because they frequently interact with vulnerable populations. Nurses have an opportunity to educate patients and families, identify red flags that point to online exploitation, screen appropriately, and offer patients trauma-informed interventions and referrals.

Commercial sexual exploitation of children

The Office of Juvenile Justice and Delinquency Prevention defines commercial sexual exploitation of children (CSEC) as “a range of crimes and activities involving the sexual abuse or exploitation of a child for the financial benefit of any person or in exchange for anything of value (including monetary and non-monetary benefits) given or received by any person.” This definition clearly highlights that any sex act involving someone under the age of 18 in exchange for anything of value is sexual exploitation. CSEC may conjure up stereotypical images of trafficking; one might envision children being kidnapped or abducted. But the reality of CSEC is much less obvious. It is hidden in plain sight and continues to evolve as technology increasingly shapes children's lives today. Approximately 43% of 8- to-12-year-olds and nearly 95% of 13- to-18-year-olds have their own smartphones. Not only do many children have their own devices, but they also have unprecedented access to the internet. This is where most minors are being exposed to pornography, both intentionally and unintentionally.

Online pornography is easy to access, free, and anonymous. Children are only several clicks away from sexually explicit material when they are online. Research shows that the majority of children have seen online pornography by the age of 13 and one in three children report they have seen hardcore pornography by age 12. The mainstream pornography that children see online often depicts violence and degradation. Popular themes include acts like punching, gagging, hair pulling, coercion, and ejaculation on the face. Many of the videos depict female actors expressing pleasure when there is violence directed at them. One study highlighted that 44% of males, ages 11 to 16, who saw online pornography said it gave them ideas about the type of sex they wanted to try. There are significant gaps in parents' understanding of what children are encountering online, with studies showing that parents greatly underestimate the fact that their children are being exposed to pornography online. This raises concerns for multiple reasons, especially when much of mainstream pornography depicts sexual violence against women.

Some of the known consequences of childhood exposure to pornography are a greater likelihood of sexual misconduct, increased child-on-child sexual abuse, increased victimization of girls, and violent sexual encounters that often include strangulation. Pornography exposure also leads to impaired family and peer relationships, and substance abuse. Pornography exposure physically changes the brain, leading to lower self-esteem and body image issues. It is also linked with depression, and erectile and sexual dysfunction (see Signs and red flags of pornography exposure and/or online harm).

These consequences have widespread individual and societal impacts. Further, a new trend is emerging: Pornography exposure is grooming youth into believing that self-exploitation is normal.

Self-exploitation

Many children have their sexual templates and sexual education shaped and influenced by pornography. A core message that females, in particular, receive is that their value is determined by the sexual appeal of their bodies. This message is reinforced by the number of people online asking children for sexually explicit photos and videos. One in seven minors is asked by a stranger online for nudes daily or weekly. Instead of adolescents feeling degraded by the objectification of their bodies, some take it as a compliment to be asked to send sexually explicit photos and videos. It has become so normalized that some youth fail to see that they are being groomed and exploited. Research also shows a rise in artificial intelligence (AI)-generated pornography, with 1 in 10 children (ages 9-17) disclosing they have used AI to create sexually explicit images of their classmates.

Many children are watching popular social media influencers, and actresses become famous and wealthy by creating pornography on websites like OnlyFans. This phenomenon is reinforced by influencers such as the BOP House's content creators. The BOP House is a house of young female roommates who all create pornography on OnlyFans. On social media, they show their lifestyle as glamorous and exciting. These performers have a combined 90 million social media followers across all platforms. Many of them are teens. Much of the BOP House content is sexualized and markets self-exploitation with seemingly no downsides. However, research shows that people who are content creators for webcam sites often face trauma, create pornographic content under duress, and experience exploitation in the commercial sex industry. One research study found that the majority (88%) of adults involved in the pornography industry had a history of childhood sexual abuse.

Although it is difficult to establish the exact number, it is estimated that up to 1.4 million women creating content on OnlyFans are between 18 and 24 years old, accounting for 45% of content creators. Teenagers are engaging with the porn industry in higher numbers than ever, in part due to the way that pornography content creators market themselves on popular social media sites such as Instagram, TikTok, and X. They often have links, paid promotions, and ads for pornographic sites on their social media. One research study asked adolescent males and females about their perceptions of OnlyFans. They found that even if adolescents did not directly interact with the site, they were still aware of it due to its popularity on social media. The researchers stated, “A particularly relevant finding is the perception of OnlyFans as an attractive employment alternative, associating self-sexualization with an accessible means of earning income.” In reality, many OnlyFans content creators make less than $200 a month.

Pornography normalizes CSEC

As children spend hours on social media and playing video games, they are often approached by strangers, predators, and peers who ask and pressure them for sexually explicit content. One in four minors reports they have had an online sexual interaction with an adult. Often, these individuals offer minors something of value in exchange for sexually explicit photos and videos, which is exploitation. The items of value exchanged vary widely from tokens in a video game to rides somewhere, gift cards, or cash. Roughly one in eight minors reported having a friend who had received money or gifts in exchange for sexually explicit photos or videos. Instead of youth feeling violated or disclosing exploitation, this type of exchange is becoming normalized.

Nursing implications

Nurses play a pivotal role in helping patients feel safe, asking difficult questions to patients and parents, and directing families to trauma-informed interventions. Many children have no idea that what is happening to them online is exploitation. Although some children have a sense that what is happening does not feel right, they may struggle to name what is happening or be ashamed to talk about pornography or online sexual interactions. Nurses' unique role in asking children and teenagers sensitive questions related to mental health, reproductive history, and safety creates an opportunity also to ask questions about pornography exposure and online exploitation. It is ideal to ask questions in settings where rapport can be built. Questions should be asked to teenagers alone first and then caregivers should be brought into the conversation. After screening, resources should be provided based on the child's answers (see Resources). Settings such as well-child checks, schools, behavioral health settings, forensic settings, and adolescent medicine specialty clinics give nurses opportunities to assess for problematic pornography use and online exploitation.

It is important to understand the signs and behaviors that may indicate a minor is experiencing sexual harm or exploitation. Although certain vulnerabilities are associated with CSEC, such as a history of sexual abuse or foster care placement, any child with internet access is at risk for pornography exposure and/or online exploitation. Health care professionals often encounter children who have been exposed to pornography or have experienced sexually inappropriate encounters online. Screening is imperative because many children will not disclose that information outright. It is essential to interact with patients in an age-appropriate and trauma-informed manner, build rapport, ask open-ended questions without judgment, and avoid retraumatization during the screening process. As patients disclose their experiences with pornography exposure and exploitation, using motivational interviewing can be a good resource to discuss online experiences in a nonjudgmental way. Motivational interviewing is a technique that uses open-ended questions, reflective listening, and affirmation to strengthen a teen's own motivation and commitment to change. Screening can be especially challenging when assessing males, who are less likely to disclose due to stigma, shame, and the false perception that they are “in control” of a sexual situation, even when they are being exploited or extorted. It requires great patience and trust to get honest answers from males who are being sexually harmed.

Health care professionals need enough information during screening to ensure they can take appropriate next steps. Next steps may include referrals to other professionals, such as a forensic nurse, social worker, or therapist. In addition, any suspicions of abuse or exploitation need to follow mandated reporting guidelines, which may include reports to child protective services and/or law enforcement. There are several screening tools and helpful resources that health care workers can use with minors. Culture Reframed has a free toolkit on its website for Child Advocacy Centers and health care workers. The toolkit has short screening tools for young children and adolescents that screen for pornography exposure and online safety. The toolkit also includes pointers for talking with patients and their caregivers, as well as for trauma-informed interventions, including how to educate colleagues on the importance of this topic. There is also a validated CSEC screening tool to identify harm happening to adolescents that covers everything from risk factors to online and in-person exploitation.

Nurses also have a crucial opportunity to educate their pediatric patients about healthy relationships, safety online, and the harms of pornography. Although it is important to talk directly with adolescents about these issues, their parents and caregivers also need to be included in the conversation and provided with education and resources on these topics. Many parents are unaware of the prevalence of pornography exposure or the harms occurring online related to exploitation. Conversations should help parents understand the facts about early pornography exposure, online exploitation, how to have calm conversations about these topics, what to do with disclosures, and how to monitor devices.

Case scenario continued

The nurse sits down across from Cassidy. The nurse's posture is open, and she is calm and unhurried. She makes eye contact as she talks with Cassidy. She understands that Cassidy has a long trauma history and that exploitation feels normal to her. She validates Cassidy's concerns, “I understand that it feels confusing that I have to report this as a crime. Have you ever heard the term exploitation?” Cassidy says, “Not really,” as she stares at the floor. The nurse goes on to explain what exploitation is and, in a nonjudgmental way, reminds Cassidy that she cares about what happens to her. They discuss what healthy relationships look like, and she asks Cassidy what her plans are after she finishes high school. As she ends her conversation, she reminds Cassidy, “You deserve to feel safe. What are ways that we can create safety for you as you leave the hospital today?” Cassidy names several family members with whom she feels safe, and the forensic nurse passes this information to her caseworker as they create a discharge safety plan. The nurse also provides Cassidy with information about an advocacy center where she can access free mental health services and resources.

Conclusion

Many children are being exposed to pornography online. There are many harmful consequences to early exposure to pornography. Pornography exposure among children and adolescents is normalizing self-exploitation and CSEC. Nurses play a crucial role in assessing patient safety, mental health concerns, and reproductive health, which gives them a unique opportunity to ask pediatric patients about pornography exposure and exploitation and ensure there are prevention strategies and safety measures in place for patients who are experiencing online harm. As this trend grows, a call to action for nurses is to understand the current trends that kids are experiencing online, ask age-appropriate screening questions to patients and caregivers related to pornography and exploitation, and make appropriate referrals for investigation and healing as indicated.

Signs and red flags of pornography exposure and/or online harm

• Exhibiting signs of depression and/or anxiety; mood shifts (increasingly angry or aggressive)

• Self-harm

• Isolating from family and friends

• Struggling to understand healthy relationships and boundaries

• Ignoring school-related responsibilities

• Substance use

• Phone calls or texts to unknown numbers

• Changes in appearance or behavior

• Talking about new friends online or gifts they have received

• Compulsive use of screens/digital devices

• Closing devices when someone enters the room

• Spending excessive amounts of time in the bathroom or bedroom with connected devices

• Deleting search histories

• Lack of sleep; disrupted sleep patterns

• Play or language that has become sexualized, secretive, or violent

• Acting out inappropriately with toys, objects, or peers

• Sending and/or receiving inappropriate sexual images/messages

• Erectile dysfunction or sexual dysfunction

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