International Journal of

Environmental Research
and Public Health

Review
Sexting, Mental Health, and Victimization Among
Adolescents: A Literature Review
Aina M. Gassó 1, * , Bianca Klettke 2 , José R. Agustina 1 and Irene Montiel 1
1 Faculty of Law, Universitat Internacional de Catalunya, 08017 Barcelona, Spain
2 School of Psychology, Deakin University, Burwood, Victoria 3125, Australia
* Correspondence: [email protected]; Tel.: +34-659-026-014




Received: 28 May 2019; Accepted: 2 July 2019; Published: 3 July 2019


Abstract: The practice of creating and sharing sexual images via technological devices, known as
sexting, has received crescent attention in the past years, especially due to the increase of adolescent
engagement in this behavior. Although consensual sexting is not prima facie a crime, as some research
has shown, it has the potential to be a risky behavior, and a threshold to get exposure to dangerous
kinds of victimization as sextortion, online grooming or cyberbullying. In this context, teenagers
represent a vulnerable group due to their limited ability of self-regulation, their high susceptibility
to peer pressure, their technophilia, and their growing sexual curiosity. The present paper aims to
review the scientific literature to analyze the relationship between mental health and sexting as a
potentially risky behavior and its association with online victimization. The results and implications
will be discussed.

Keywords: adolescents; sexting; child victimization; mental health; threshold

1. Introduction
The term sexting was first used in 2005 by the Daily Telegraph, to unify the terms “sex” and
“texting” and became an official word in 2009 [1]. It is generally known as “Sending and receiving
sexual content (e.g., photos, videos) via the Internet and mobile phones” [2], but there is no consensus
around the definition of the term sexting in the scientific community. Therefore, it has been diversely
defined, including from broad definitions that include the sending of any kind of sexual content to
narrower definitions, which are image-based only [3]. Some authors include coercion as part of the
sexting behavior [4], while others consider that sexting is voluntary by definition [5]; some definitions
include sending text messages (non-image based) as part of the sexting behaviors [6,7], while others
exclude them from the definition [8,9]. The existing literature on sexting also differs in the population
samples used for the research (teens vs. adults), and in the items used to measure sexting, which might
be some of the reasons for the lack of a unified definition of the term.
The research on sexting has widely grown over the past few years, especially regarding adolescents
and the negative effect it might have on their sexual development and mental health, specifically after
the publication of the Sex and Tech Survey (2008) results, which was the first broad survey to examine
this phenomenon [10,11]. There is a conceptual debate in the scientific community that distinguishes
between two clear arguing lines: one side tends to argue for a normalizing discourse whereby authors
believe sexting to be a normative behavior as a part of sexual expression in a relationship [10,12], and it
is possible to practice “safe sexting” to avoid negative consequences. The other side tends to argue that
sexting is a risky behavior that requires intervention and prevention to diminish its prevalence, and has
been labeled as “deviance discourse” [10,13–15]. Although sexting is a common behavior among the
adolescent and young population, the deviance discourse seems to have more scientific support than
the normalizing discourse. For example, a recent meta-analysis published by Kosenko et al. [16] found

Int. J. Environ. Res. Public Health 2019, 16, 2364; doi:10.3390/ijerph16132364 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 2364 2 of 14

a significant relationship between sexting and three aspects of sexual behavior: general sexual activity,
unprotected sex history, and number of sexual partners, that are all considered sexual risk behaviors.
Similarly, a recent meta-analysis by Mori, Temple, Browne, and Madigan [17] has indicated that sexting
behaviors were significantly associated with sexual behaviors, such as sexual activity, having more
than one sexual partner, and lack of contraception use. It was also found that sexting behaviors and
internalizing problems, such as anxiety and depression, were significantly associated. Importantly,
the younger the adolescents, the stronger the observed association.
Klettke et al. [18] in their literature review found significant relationships between sexting and
risky sexual behavior and with several other adverse outcomes, such as (a) the sharing of sexual
content without consent, (b) legal consequences, and (c) negative mental health repercussions [18].
Furthermore, research highlights an existing relationship between mental health or psychological
health and online victimization behaviors, such as cyberbullying, online dating violence or revenge
porn [18–21], which are closely related to sexting [5,15,22,23].
Several studies have identified a relationship between cyberbullying and sexting behaviors [24,25].
Fahy et al.’s [19] investigation emphasizes the high prevalence of cyberbullying and the potential of
cyber-victimization as a risk factor for future depressive symptoms, social anxiety symptoms, and below
average well-being among adolescents. Their results show that cyber-victims and cyberbully-victims
were significantly more likely to report symptoms of depression and social anxiety. According to these
results, it would be expected that sexting behaviors as a form of victimization might also be related to
a higher likelihood of reporting depressive and anxiety symptoms. Along the same line of reasoning,
research findings indicate that a higher degree of depressive symptoms is associated with greater
Internet use [26,27], and a more frequent and problematic internet use is associated with higher rates
of sexting behavior [27,28]. Therefore, it would be reasonable to hypothesize that higher engagement
in sexting behaviors might predict higher rates of depressive symptoms.
Considering the increasing number of suicides related to sexting [29], the relationship between
sexting and mental health seems of particular interest, even though results up to date are somewhat
mixed [18,29]. A few studies have investigated personality traits and their relationship with
sexting [2,30]; others have explored the relationship between sexting and sexual risky behaviors
or substance abuse and emotional problems [8,31–33]. However, only a few studies have investigated
the relationship between negative mental health symptoms and sexting [4,34,35]. Discrepancies found
in the literature may be due to differences in the definition of sexting, its measurement, methodologies
or even due to the difference between those teens that sext consensually versus those who are pressured
into sexting [29,36]. For the purpose of the present review, Wolak and Finkelhor’s conceptual framework
of sexting will be used [37]. According to these authors’ typology, sexting behaviors can be divided
into two broad categories: aggravated sexting and experimental sexting. Aggravated sexting behaviors
encompass all types of sexting that may involve criminal or abusive elements beyond the creation,
sending or possession of youth-produced sexual content, including (1) adult involvement; or (2)
criminal or abusive behavior by minors. On the other hand, experimental sexting behaviors comprise
those instances that do not include abuse or coercion, whereby teens voluntarily took pictures of
themselves to create flirting or romantic interest in others.
The main research questions this narrative review seeks to answer is: Is there a relationship
between teen sexting behaviors and mental health? And, if so, which negative mental health impacts
have been found when teens engage in sexting behaviors? Considering this, the present study aims to
review research studies which have explored mental health variables associated with sexting behaviors
and whether a significant relationship between sexting and negative mental health symptoms has been
found. If sexting were found to have a negative mental health impact on adolescents, these results
could have important implications to inform prevention campaigns targeted at schools, parents,
educational communities, and healthcare providers.
Int. J. Environ. Res. Public Health 2019, 16, 2364 3 of 14

2. Method
In previous years, the body of research regarding sexting behaviors has increased dramatically,
especially research focused on adolescent and teenage population. As such, several studies have
highlighted that sexting behaviors increase as adolescents grow older [2,10]. Furthermore, an extended
body of literature suggests that some sexting behaviors (e.g., sending or distributing) can be a risk
behavior that can lead to or be seen as a form of online victimization of those depicted in the images,
similarly, to cyberbullying or grooming [15,20]. On the other hand, the number of studies exploring
the relationship between sexting and psychological variables has been growing in the past years,
focusing especially on young adults or adult population [2,18,28], even though up to date there have
been no conclusive results on the matter. For this reason, this narrative review aims to identify
both empirical and non-empirical research addressing the relationship between sexting behaviors
among teenagers and mental health. We consider this topic to be of considerable relevance to parents,
the education community, and health care practitioners working with young people who engage in
this behavior.
Criteria for the inclusion in the review were as follows:

• Research (either empirical or non-empirical but excluding doctoral dissertations) exploring sexting
behaviors amongst adolescent population between the ages of 10 and 21 years old.
• Examination of the relationship between sexting behaviors and mental health variables either as
predictors or as consequences.
• Discussions around any psychological consequences related to young people’s sexting practices,
emotional well-being or psychosocial health.

The following databases were searched: SCOPUS, PsycInfo, MEDLINE, and PUBMED, using the
key words “sexting” AND “mental health”, “anxiety”, “depression”, and “psychology”. In addition,
reference lists of reviewed articles were examined in relation to the topic of search, such as the one
found in [29].
Keeping in mind the extensive body of existing literature and the continually changing nature
of online media technology-related research, the review was restricted to search literature published
between January 2012 and March 2019, written either in English or Spanish, and appearing in
peer-reviewed journals. The search was conducted in April 2019. A visual summary of the process is
presented as a flow chart in Figure 1.
As exclusion criteria, those articles that did not include the review topics in their abstracts or were
not directly related to the topic were excluded from the review. For instance, studies investigating
sexting prevalence or mental health variables in adults, or mental health variables associated to other
forms of victimization, such as bullying, were excluded.
The initial bibliographic database search produced 212 articles. In addition to this, 19 articles were
added following hand-searches through reference lists. These 231 articles were included in the first
review and were screened by title and abstract. A total of 138 articles were excluded for not meeting
the inclusion criteria, as they did not address the key areas of interest.
The remaining 93 articles were then assessed for eligibility based on their full text. At this
point, any articles that focused on mental health related to sexting in an adult population were
excluded. Similarly, articles were excluded if they focused on information regarding new technologies,
social media, sexting or cyberbullying in teenage population but did not relate to mental health. Finally,
given the wide amount of international literature based on legal aspects of sexting, articles relating to
this topic were excluded. This led to the exclusion of 63 more articles, for not meeting the relevant
search areas. In total, 30 studies were identified for inclusion in this review.
Int. J. Environ. Res. Public Health 2019, 16, 2364 4 of 14
Int. J. Environ. Res. Public Health 2019, 16, x 4 of 16

Figure 1. Flow chart of record identification, selection, and inclusion of articles.

Figure 1. Flow chart of record identification, selection, and inclusion of articles.
3. Results
As exclusion criteria, those articles that did not include the review topics in their abstracts or
were not directly related to the topic were excluded from the review. For instance, studies
3.1. Psychosocial Health and Sexting
investigating sexting prevalence or mental health variables in adults, or mental health variables
The resultstoshown
associated by Mitchell
other forms et al. [8]such
of victimization, reveal that 21%were
as bullying, of teens appearing or creating sexually
excluded.
The initial
explicit images and bibliographic
25% of teensdatabase
that hadsearch produced
received such 212imagesarticles. In addition
reported to this,
feeling very19orarticles
extremely
were added following hand-searches through reference lists. These 231
upset, embarrassed or afraid as a result of their actions. Livingstone and Görzig’s [32] researcharticles were included in focused
the
first review and were screened by title and abstract. A total of 138 articles
on explaining the incidence of risk and harm reported by children and adolescents in relation to were excluded for not
meeting the inclusion criteria, as they did not address the key areas of interest.
sexting behaviors. In a sample of 2036 European 11 to 16 year-olds reporting that they had received
The remaining 93 articles were then assessed for eligibility based on their full text. At this point,
a sexual message on the Internet in the last 12 months, 24% responded “yes” when asked: “In the
any articles that focused on mental health related to sexting in an adult population were excluded.
last 12Similarly,
months,articles
has anyweresexual message
excluded if theythat youon
focused have seen or regarding
information received bothered you in any
new technologies, socialway?
For example, made you feel uncomfortable, upset, or feel that you should
media, sexting or cyberbullying in teenage population but did not relate to mental health. Finally,not have seen it?” [32].
Subjects who
given thewere
wideyounger,
amount offemale, less sensation
international literatureseeking,
based onhad legalpre-existing psychological
aspects of sexting, difficulties
articles relating
and used
to thisthe Internet
topic less, wereThis
were excluded. more
ledlikely to experience
to the exclusion harmarticles,
of 63 more from the formessage.
not meetingThe
thedetails
relevantof the
search areas. In total, 30 studies were identified
studies included in the review can be found in Table 1. for inclusion in this review.

3. Results

3.1. Psychosocial Health and Sexting

The results shown by Mitchell et al. [8] reveal that 21% of teens appearing or creating sexually
explicit images and 25% of teens that had received such images reported feeling very or extremely
upset, embarrassed or afraid as a result of their actions. Livingstone and Görzig’s [32] research
focused on explaining the incidence of risk and harm reported by children and adolescents in relation
to sexting behaviors. In a sample of 2036 European 11 to 16 year-olds reporting that they had received
Int. J. Environ. Res. Public Health 2019, 16, 2364 5 of 14

Table 1. Details of studies included in the review.

Type of N (% Age
Author Definition of Sexting Results (Mental Health)
Article Women) Range
“Sexting (texting plus sex) includes behaviors, such Sexting may be associated with depression, contemplation
Ahern and
NE - - as sending, receiving, or forwarding of nude or of/attempted suicide, or a victimization of physical abuse or
Mechling [38]
partially nude images via cell phones” cyberbullying [31]
“The term sexting refers to the practice of
transmitting sexual content via digital technology Targets of cyberbullying and young people involved in
and includes images, video, and text”. According to sexting had higher rates of suicidal thoughts than those
Bauman [39] NE - -
this author, sexting is a form of cyberbullying when who were not involved, and they also had higher rates of
“the messages or images are used to inflict harm on a high-risk behaviors (alcohol, drugs, stealing).
target by causing humiliation and embarrassment”
The authors found three significant predictors of sexting
Brenick, Flannery, “The sending or receiving of sexually suggestive experiences and evaluations of sexting and sexting
E 169 (80) 18–25
and Rankin [15] written messages, pictures, or videos” victimization: anxious and avoidant attachment and
rejection sensitivity.
Brinkley,
“Sexting refers to sending sexually explicit or
Ackerman, Sending sex texts at age 16 predicted for borderline
E 181 (46.9) 15–16 suggestive images, videos, or text messages via
Ehrenreich, and personality traits at age 18.
digital communication”
Underwood [30]
Authors found that youth who reported sexting were
“The practice of sending or posting sexually
Chaudhary, significantly more likely to report symptomatology for
suggestive text messages, videos, and images,
Peskin, Temple, depression and anxiety as compared to those who did not
E 1760 (52.4) M = 12.2 including nude or semi-nude photographs or videos,
Addy, Baumler, report sexting (between 20% and 27% of youth who sexted
via cellular telephones or over the Internet (such as
and Shegog [40] had depression, and between 57% and 61% of youth who
email or social networking sites, such as Facebook)”
sexted had anxiety.
Research findings suggest a link between sexting behaviors
and higher rates of problematic alcohol and recreational
drug use.
Dake et al. [31] found a correlation between self-producing
Cooper, Quayle, “Sending or posting of sexually suggestive text and sending sexual images and being depressed, having
Jonsson, and NE - - messages and images, including nude or semi-nude contemplated or attempted suicide in the past year, having
Svedin, [41] photographs, via mobiles or over the Internet” been cyber or indirectly bullied, and having encountered
physical force within a relationship.
Victimization corresponded with negative psychological
outcomes including feelings of sadness, anger and anxiety
disorders as well as depression and ultimately, suicide.
Int. J. Environ. Res. Public Health 2019, 16, 2364 6 of 14

Table 1. Cont.

Type of N (% Age
Author Definition of Sexting Results (Mental Health)
Article Women) Range
Associated with sexting: emotional health issues, including
“Sending, receiving, or forwarding sexually explicit being depressed, having contemplated or attempted suicide
Dake, Price,
messages or nude, partially nude, or sexually in the past year, having been cyber or indirectly bullied, and
Maziarz, and E 1289 (48) 12–18
suggestive digital images of one’s self or others via a having encountered physical force used against the student
Ward, [31]
cell phone, e-mail, Internet, or SMS” in the form of being hit by a boyfriend or girlfriend or being
forced to have sexual intercourse.
Sexting is related to suicide. Sexting behavior is placed in a
context of adolescent impulsivity, bad judgment, sensation
“The private exchange of self-produced sexual
Döring [10] NE - - seeking, and problematic alcohol and drug use. Sexting is
images via cell phone or the internet”
seen as a manifestation or moderator of problematic and
age-inappropriate sexual behavior.
Sexters had less depression than non-sexters but more
Englander, E. [4] E 617 (-) 18 only “Sending nude pictures of yourself”
anxiety. Relationship not significant.
Sexting linked to risky sexual behaviors and a number of
“Sending or showing someone sexual pictures of
Eugene, [42] NE - - psychosocial issues, such as depression, anxiety, and low
yourself nude or nearly nude”
self-esteem.
Significant relationship found between consensual sexting
Frankel, Bass, “To share nude, sexually explicit, or sexually
and depressive symptoms, suicide attempt and self-harm,
Patterson, Dai, and E 6021 (49.4) 14–18 suggestive photos via text or social media
but depressive symptoms were more prevalent in students
Brown, [29] platforms”
who reported non-consensual sexting.
The authors found that more depressive symptoms
Gámez-Guadix “The voluntary creation and delivery of text
predicted more sexting. Regarding psychological
and De E 1208 (52.8) 12–16 messages, photos, or videos, with personal sexual
adjustment, adolescents presenting more depression
Santisteban. [43] content via the Internet or mobile devices”
symptoms tended to participate more in sexting over time.
Gámez-Guadix, de “The voluntary creation and delivery of text The personality profile of those involved in sexting was
Santisteban, and E 3223 (49.9) 12–17 messages, photos, or videos, with personal sexual characterized by higher Extraversion and Neuroticism and
Resett, [2] content via the Internet or mobile devices.” by lower scores in Conscientiousness and Agreeableness.
Holoyda, Landess, The evidence regarding the relationship between teen
“It generally involves the transmission of text,
Sorrentino, and NE - - sexting and specific psychiatric disorders or psychological
pictures, or videos containing sexual material”
Friedman, [27] sequelae remains scant and inconclusive.
Sexting may be viewed as an emotionally driven behavior
“The exchange of sexually explicit images between
Judge, [44] NE that is often impulsive and without a clear anticipation or
adolescents via cell phone”
understanding of the potential adverse consequences.
While some findings indicate sexting behavior as being
Klettke, Hallford,
NE - - - associated with lower well-being or higher psychological
and Mellor, [18]
distress, findings across the literature appear to be mixed.
Int. J. Environ. Res. Public Health 2019, 16, 2364 7 of 14

Table 1. Cont.

Type of N (% Age
Author Definition of Sexting Results (Mental Health)
Article Women) Range
The results showed that having sent or received sexts was
not associated with any psychological variables. Receiving
“The sending, receiving, or forwarding of sexually
Klettke, Hallford, unwanted sexts and sending sexts under coercion were
explicit messages, images, or photos to others
Clancy, Mellor, and E 444 (50.7) 18–21 associated with poorer mental health. Specifically, when
through electronic means, primarily between
Toumbourou, [36] receiving or sending unwanted but consensual sexts,
cellular phones”
respondents reported higher depression, anxiety, and stress,
and lower self-esteem.
“Sending, receiving or forwarding of sexually
Klettke, Mellor,
598 explicit messages, images or photos to others Only higher levels of stress were significantly associated
Silva-Myles, Clancy E 17–21
(75.5/56.3) through electronic means, primarily between with sending sexts, not depression or anxiety.
and Sharma, [45]
cellular phones”
“Sexting refers to the practice of sending sexually Depression, suicide, mood disorder, adjustment reactions,
Korenis and
NE - - explicit material including language or images to and anxiety disorders are some of the potential psychiatric
Billick, [24]
another person’s cell phone” sequelae of falling victim to sexting.
“The peer-to-peer exchange of sexual messages
using digital technologies (known popularly as
The risk of receiving sexually explicit images was higher for
sexting). Such messages may be created and
those with psychological difficulties. Adding the behavioral
Livingstone and exchanged via text or image messaging on mobile
E 18,709 (50) 11–16 variables reduced the effect of the psychological variables
Görzig, [32] phones, though they also include peer-to-peer
and age, suggesting that the behavioral variables mediate
messaging on diverse internet-enabled devices,
the effect of the psychological variables and age.
particularly using social networking sites and
instant messaging services.”
“Sexting is the sending or forwarding of sexually
Lorang, McNiel, and
NE - - explicit photographs or videos of the sender or Sexting cases followed by suicide.
Binder, [46]
someone known to the sender via cell phone”
21% of respondents appearing in or creating images
“Sexting generally refers to sending sexual images
Mitchell, Finkelhor, reported feeling very or extremely upset, embarrassed, or
E 1560 (50) 10–17 and sometimes sexual texts via cell phone and other
Jones, and Wolak, [8] afraid as a result of engaging in sexting, as did 25% of
electronic devices”
youth receiving images.
Results showed that high/moderate users of sexting
“Sexting is the exchange of sexually explicit or
Morelli, Bianchi, committed more offline and online dating violence.
provocative content (text messages, photos, and
Baiocco, Pezzuti, E 1334 (68) 13–30 Regarding psychological distress, no differences were
videos) via smartphone, Internet, or social
and Chirumbolo, [6] found between high and low/moderate users of sexting.
networks.”
No relationship with anxiety and depression symptoms.
Moreno-Bernal,
“The act of sending, receiving or publishing sexually Studies showed that the practice of sexting is increased by
Valdez-Montero,
NE - - provocative or explicit messages, images or videos consuming some type of drug, as well as engaging in risky
Gámez-Medina, and
through a mobile phone or social media” sexual behaviors.
Cortez, [47]
Int. J. Environ. Res. Public Health 2019, 16, 2364 8 of 14

Table 1. Cont.

Type of N (% Age
Author Definition of Sexting Results (Mental Health)
Article Women) Range
“Sexting refers to the electronic exchange of sexually Having more emotional problems was associated to having
suggestive messages (i.e., sexts), mainly pictures a higher likelihood of involvement in sexting behavior.
Ševčíková, [48] E 17,016 (50) 11–16
depicting their authors in nude or semi-nude Sexting might not necessarily be a marker of poor mental
positions” health.
Predictors of risk of harm from receiving sexts are being
younger, female, and scoring higher on psychological
“The sending, receiving, and forwarding of sexually difficulties and lower on sensation seeking. Other
Smith, Thompson, explicit messages, images or photos to others predictors of involvement in sexting are being sexually
NE - -
and Davidson, [49] through electronic means, primarily between active, involvement in alcohol and drug use, having
cellular phones’ unprotected sex, engaging in web-based chatting with
strangers and viewing adult pornography and personality
variables of neuroticism and low agreeableness.
Significant association between sexting and symptoms of
Temple, Le, van den
“Electronically sending sexually explicit images depression, impulsivity, and substance abuse but not when
Berg, Ling, Paul, and E 937 (57) 14–18
from one adolescent to another” adjusted for other variables: sexting is not a marker of
Temple, [34]
mental health.
Van Ouytsel, Van
“Sending sexually explicit pictures through the Significant relationship between depression and
Gool, Ponnet, and E 1028 (58) 15–18
internet or the mobile phone” engagement in sexting.
Walrave, [35]
Adolescents who engaged in sexting were more likely to
ever have become victims of traditional forms of
“The exchange of sexually explicit content
Van Ouytsel, bullying [31]. Youth who engaged in sexting had lower
communicated via text messages, smartphones, or
Walrave, Ponnet, NE - - awareness and understanding of their emotions and
visual and web 2.0. activities, such as social
and Heirman, [50] experienced more difficulties with regulating their
networking sites”
emotions. And an association between sexting and
impulsivity was found.
Ybarra and “Sending and sharing sexual photos online, via text Adolescents who sexted were more likely to use substances
E 3715 (56.6) 13–18
Mitchell, [33] messaging, and in person” and less likely to have a high self-esteem.
Note: E = empirical study, NE = non-empirical study; - = no data found
Int. J. Environ. Res. Public Health 2019, 16, 2364 9 of 14

A study carried out by Ybarra & Mitchell [33] evaluating psychosocial problems from a sample of
3715 teens aged 13 to 18 years old, found that psychosocial problems were more frequently observed
in teens who had sent or showed sexual photos of themselves. In addition, they found that high
self-esteem was negatively associated with having sent or showed sexual pictures, and for female teens,
results showed a significant association between sexting and depressive symptomatology. Similarly,
Ševčíková [38] found that sexting was associated with emotional problems, and explored the possibility
that this correlate might be both a predictor, as well as an outcome of sexting behaviors.
Regarding sexting and personality, the research carried out by Gámez-Guadix et al. [2] shows
an existing significant positive relationship between sexting and higher scores in Extraversion and
Neuroticism and a negative relationship between sexting and Conscientiousness and Agreeableness.
Brinkley et al. [30] conducted a study with a sample of 181 adolescents to evaluate the relationship
between sexting and Borderline Personality Disorder (BPD), amongst other variables. Their results
supported the hypothesis that sexting at age 16 would be associated with borderline personality feature
at age 18. In addition, the authors affirm that their findings suggest that sexting may contribute to
psychological distress for adolescents.
Following these results, many investigations have linked sexting behaviors to impulsivity and
substance abuse problems. Döring [10] points out that sexting is related to impulsivity, bad judgment,
sensation seeking, and problematic alcohol and drug use, as well as to suicide. This author considers
sexting to be either a manifestation or moderator of problematic sexual behavior. On the other hand,
Judge [39] defines sexting as an emotionally-driven behavior, that is often related to impulsivity and a
lack of anticipation of adverse consequences.
Englander [4], on the other hand, distinguished between pressured-sexters and non-pressured
sexters, and her results show that pressured-sexters were more likely to report having problems
during high school with excessive anxiety, although results were not statistically significant. Along the
same line, Temple et al. [34], did not find sexting to be a marker of mental health. In their study,
they evaluated 937 teens from Texas public high schools on rating scales for depression, anxiety,
impulsivity, and a positive response for a history of substance use. Their results show that subjects who
had sent naked pictures of themselves to someone else through text or email were more likely to score
higher on scales of depression and impulsivity, as well as more likely to report a history of substance
use. However, when the results were adjusted for prior sexual behavior, age, gender, race/ethnicity,
and parent education, sexting was only related to impulsivity and high-risk behaviors, but not to
depressive symptoms.

3.2. Sexting and Depression

When considering research regarding sexting and depression, specifically, the vast majority
of studies have found a positive association between depressive symptoms and sexting behaviors.
Out of a total of 14 publications addressing this issue, 12 found a positive association between sexting
behaviors and depressive symptoms [4,6,24,29,31,34–36,38,41–43,45].
One such example is a study by Dake, Price, Maziarz & Ward [31] who conducted research
based on 1289 middle school and high school students. Their results showed that being depressed,
having contemplated or attempted suicide in the past year, or having been cyber or indirectly bullied
were significantly correlated with sexting. Similarly, Van Ouytsel et al. [35] found a significant
relation between teen sexting and depressive symptoms. These results are in line with those found by
Chaudhary et al. [40], who conducted a study with 1760 teens and found that youth who reported
sexting were significantly more likely to report symptomatology of depression and anxiety, as compared
to those who did not report sexting. Specifically, their results showed that between 20% and 27% of
youth who sexted had depressive symptoms. In addition, Bauman [39] in a book chapter regarding
sexting and cyberbullying and mental health consequences, explains that young people involved in
sexting had higher rates of suicidal thoughts than those who were not involved, and they also showed
higher rates of high-risk behavior.
Int. J. Environ. Res. Public Health 2019, 16, 2364 10 of 14

Finally, Gámez-Guadix and De Santisteban [43] in a recent study carried out with 1208
Spanish adolescents between ages 12 and 16, found that a higher degree of depressive symptoms
predicted a higher degree of sexting behaviors. At the same time, they found that teens who
presented greater depressive symptoms were more likely to participate in sexting behaviors over
time. Findings suggested a significant association between sexting behaviors and suicidal thoughts,
suicide attempts, depressive symptoms, and feelings of sadness [31]. Teenage boys and girls who
engaged in sexting behaviors showed a higher risk of reporting suicidal thoughts even after controlling
for cyber victimization and depression [28]. One explanation for this relationship has been suggested
by Medrano et al. [28], who proposed that the relationship between sexting behaviors and depressive
symptoms may be partially mediated by cyber-victimization. The exchange of intimate photos or
videos increases the risk of being victimized, not only by the direct sender of the image-based sexual
content but by anyone who might have access to it, as teens might find themselves involuntarily
exposed to unwanted sexual content [28].
However, some research has found no association between mental health symptoms and sexting
behavior. Morelli and colleagues [6] conducted a study with 1334 teens and young adults between the
ages of 13 and 30 years old, trying to assess the relationship between sexting, psychological distress,
and online dating violence. Their results showed that a higher engagement in sexting was associated to
a higher likelihood of offline and online dating violence. Moreover, their findings show no differences
in psychological distress between people who sexted frequently and those who did not. Further,
no relationship was found between sexting behaviors and symptoms of anxiety or depression. Finally,
recent research conducted by Klettke and colleagues [45] based on 598 young Australian and Indian
adults did not find an association between the sending of sexts, depression, or anxiety. However,
higher levels of stress were significantly associated with the sending of sexts. Regarding gender,
for males overall, higher levels of stress and lower levels of depression were associated with sending
sexts, while for females, there were no associations with mental health variables. In terms of cultural
differences, higher levels of stress were associated with sending sexts for participants overall, and for
Indian respondents, but not Australians when analyzed separately.
One explanation for why some studies have not found an association may be due to the level
of consent. Frankel et al. [29] collected data from a sample comprising 6021 US students between
9th and 12th grade to examine the relationship between consensual and non-consensual sexting and
mental health. Their results show a correlation between consensual sexting and alcohol and tobacco
use, being cyber-bullied and reporting both depressive symptoms and previous suicide attempts,
especially in male respondents. Moreover, they found that non-consensual sexting was more prevalent
among students who reported serious depressive symptoms, attempting suicide and self-harm.

3.3. Sexting and Anxiety Symptoms

Similar to the results observed regarding the analysis of the relationship between sexting behaviors
and depression, the existing literature was reviewed to explore the relationship between sexting
behaviors and symptoms of anxiety. Research exclusively investigating the relationship between these
two variables is scarce; however, the majority of studies have found an existing relationship between
the two variables. Out of a total of eight studies [4,6,24,36,40–42,45] seven studies found a positive
association between sexting behaviors and symptoms of anxiety.
For example, Chaudhary and colleagues [40] found that youth who reported having engaged in
sexting behaviors, based on 1760 teens, were significantly more likely to report symptomatology of
anxiety. Their results show that between 57% and 61% of adolescents who sexted had symptoms of
anxiety. Similarly, Cooper et al. [41] reported that sexting victimization corresponded with negative
psychological outcomes, including feelings of sadness, anger, and anxiety disorders. Finally, Klettke and
colleagues [36] collected data from a sample comprising 444 late teens and found that receiving
unwanted sexts and sending sexts under coercion was associated with poor mental health; they found
Int. J. Environ. Res. Public Health 2019, 16, 2364 11 of 14

that, especially, when receiving or sending unwanted but consensual sexts, respondents reported
higher levels of depression, anxiety, stress, and lower self-esteem.

4. Discussion
Research on sexting has grown widely over the past few years, especially regarding adolescents
and the negative effect it might have on their sexual development and mental health, and specifically
after the publication of the Sex and Tech Survey (2008) results [10,11]. Many studies have defined
sexting as a form of victimization and have highlighted the potential for a relationship between
victimization and mental health or psychological health and other online victimization behaviors,
such as cyberbullying, online dating violence or revenge porn [18–21]. This review gathered the existing
literature published from January 2012 to March 2019 that fit under the inclusion criteria (30 articles),
to explore the relationship between sexting and mental health variables in the adolescent population.
The relationship between these variables will be of interest to parents, educators, and the health care
community to have a deeper understanding of the phenomena, so that appropriate prevention plans
and campaigns, as well as intervention programs, can be developed and put into motion.
Overall, and in line with Klettke et al.’s [18] results, the evidence regarding the relationship
between teen sexting and mental health symptoms remains scarce, to some degree inconclusive and
heterogeneous, and there is little empirical evidence on half-term and long-term consequences on
adolescents. While the majority of studies have found significant associations between sexting and
mental health symptoms, others did not find significant results [34]. One of the reasons for these
equivocal findings may be because most studies do not differentiate between consensual (experimental)
and non-consensual (aggravated) sexting. This may be a critical factor, as it has been shown that
psychological outcomes vary when it comes to sexual coercion [51]. Another reason might be that
different studies focus on measuring different psychological variables which could be interrelated.
For instance, some studies focused on measuring personality traits [2,30], while others measured
emotional problems [38], psychosocial problems, self-esteem, or depressive symptoms [33]. In addition,
some studies explored the psychological variables as predictors of sexting [32,35], while others
measured them as consequences of the behavior [8].
However, in general, findings suggest a significant association between sexting behaviors and
suicidal thoughts, suicide attempts, depressive symptoms, and feelings of sadness [31]. Teenage boys
and girls who engage in sexting behaviors have shown a higher risk of reporting suicidal thoughts
even after controlling for cyber victimization and depression [28]. A possible explanation for this
relationship is that both sexting behaviors and suicidal thoughts are risky behaviors in the adolescent
population and tend to appear in conjunction [52].
The present review showed that 12 out of the 14 reviewed studies found a relationship between
sexting behaviors and depressive symptoms, and findings lead to the conclusion that this relationship
may be bi-directional. Gámez-Guadix and de Santisteban [43] argue that depressive symptoms and low
self-esteem can predict sexting over time because sexting might be a way for teens to feel considered
and desired. Moreover, they argued that adolescents with depressive symptoms might have fewer
coping skills when pressured by peers to engage in sexting, which would explain why teenagers who
sexts reported more depressive symptoms than those who do not.
According to Medrano et al. [28], the relationship between sexting behaviors and depressive
symptoms may be partially mediated by cyber-victimization. The exchange of intimate photos or
videos increases the risk of being victimized, not only by the direct sender of the image-based sexual
content but by anyone who might have access to it [28].
Similarly, seven out of the eight reviewed articles found a relationship between sexting behaviors
and anxiety symptoms. Chaudhary et al. [40] found a significant relationship between youth who
sexted and anxiety symptoms and argue that their results might be contrary to other findings due to
the young age of the participants. This supports results obtained by Klettke et al. [36] who found a
Int. J. Environ. Res. Public Health 2019, 16, 2364 12 of 14

relationship between sexting and anxiety in an older sample but only related to receiving unwanted or
sending unwanted but consensual sexts.

5. Conclusions
The findings of this narrative review seem to point towards the presence of mental health
symptomatology, particularly depression and anxiety, in the adolescent population when related to
sexting behaviors. However, the age of the adolescents also seems to play an important role, as observed
by Mori et al [17]. As adolescents get older, mental health symptoms seem to be increasingly associated
with aggravated sexting, but not when related to consensual sexting behaviors whereby older teens
have not been pressured (experimental sexting) [36,37,51]. Therefore, it might be probable that the
relationship between sexting and poor mental health, depression, and anxiety symptoms is mediated
by coercion, victimization, and age. Future research is needed to explore this hypothesis further.
Despite the inconclusive results, this review shows that psychological aspects are related in
some way to sexting, potentially as predictors of sexting behavior or as consequences, however,
especially when taking into consideration sexting coercion or victimization. This finding is relevant
because it can help raise awareness about the fact that sexting in adolescent populations should be
further studied to establish effective mental health response programs and prevention programs,
and that in some individual cases it might be a risky or dangerous behavior for teens to engage in
or an indicator of some form of victimization. Along the same line, these findings suggest that both
parents and educational communities should pay attention to both psychological symptoms and
sexting behaviors since one can be a predictor of the other and vice versa.

Author Contributions: A.M.G. performed the literature review, analyzed the results, and wrote the paper.
I.M. and Agustina, J.R.A., contributed to conceiving the review, establishing the aims and review of the paper.
B.K. contributed to the methodology and review of the paper.
Funding: No funding for this study has been received.
Conflicts of Interest: The authors declare no conflict of interest.

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