Multiple Forms of Sexting and Associations with Psychosocial Health in Early Adolescents

Despite the recent surge of sexting research, the link between sexting and psychosocial health remains inconclusive. To address this gap in the literature, we examined the link between multiple forms of sexting and a range of psychosocial health problems. Data were from a randomized controlled trial of a school-based dating violence prevention program. Participants were 2199 early adolescents (49.8% female) aged 14 years and under (mean age = 13.53, SD = 0.50) enrolled in middle-schools in southeast Texas. Participants self-reported to be 35.4% Hispanic, 7.9% Non-Hispanic White, 26.2% Non-Hispanic Black, 18.6% Asian, and 11.9% other. Multilevel multivariate regressions found that pressured sexting was associated with hostility and aggressive temperament. Receiving unsolicited sexts was associated with depression, impulsivity, hostility, emotion dysregulation, and aggressive temperament. Forwarding sexts without permission was linked to hostility. Asking someone for sexts was linked to impulsivity and aggressive temperament, while being asked to send a sext was associated with depression, anxiety, impulsivity, hostility, emotion dysregulation, and aggressive temperament. Finally, consensual sexting was not significantly associated with poor psychosocial health of any type. Interventions should focus on preventing pressured sexting and teaching early adolescents on how to respond to being pressured to sext.


Introduction
Sexting, defined as the sending, receiving, or forwarding of sexually explicit messages, images, or videos through electronic means, has become an increasingly prevalent behavior among adolescents [1]. According to a recent meta-analysis [2], 14.8% of adolescents aged between 12 to 17 years have sent a sext, 27.4% have received a sext, and 12.0% have forwarded a sext without consent.
The equivocal findings regarding sexting and psychosocial health are likely due to diverse definitions and measures of sexting [19], as well as the failure to distinguish different forms of sexting (e.g., wanted vs. unwanted sexts) [1]. For example, Klettke et al. [8] examined four forms of sexting and found that sending sexts under coercion and receiving unwanted sexts were associated with higher levels of depression, anxiety, stress symptoms, and lower self-esteem, while no relationship was identified for sending sexts or receiving sexts. Another study found that anxiety was inversely associated with sending and receiving sexts, depression was positively associated with receiving sexts but not with sending sexts, while conduct disorder was positively linked to sending and receiving sexts [15]. These findings suggest that the type, form, or context of sexting is especially important in considering whether and how sexting is related to psychosocial health.
As Englander [20] noted, pressured, coerced, and other nonconsensual sexting is substantially more likely to be associated with negative outcomes, relative to consensual sexting. Indeed, we previously argued that consensual sexting between intimate partners may be developmentally common, and thus is not expected to be associated with poor psychological health [1]; however, when coerced or pressured, sexting can be linked to feelings of guilt, shame, and embarrassment. Thus, to disentangle the complex relationships between sexting and psychosocial health, research needs to differentiate various forms of sexting. However, to date, the majority of existing studies have focused on one or two types of sexting (e.g., sending a sext [13]; receiving a sext [16]; sending and receiving [15]) or a composite measure of various forms of sexting (e.g., sending, receiving, forwarding of nude photos/videos and sexually suggestive messages [14]; combination of sending and receiving sexts [6]). Further, only a limited number of psychosocial health problems (e.g., depression, anxiety) have been considered.
Attempts have been made to summarize existing research to draw a conclusion on the link between sexting and psychosocial health by conducting literature reviews [3] and meta-analyses [21]. However, these efforts are inherently limited by the state of the current literature. For example, a recent meta-analysis [21] identified positive associations between sending sexts and internalizing problems, providing some evidence for the link between sexting and psychosocial health. However, given the novelty of the research area, these analyses were based on only seven studies published in 2019, and were limited to sending sexts and to only two forms of psychosocial health (anxiety and depression combined). Thus, how other forms of sexting (e.g., receiving sexts, coerced sexts) relate to multiple forms of psychosocial health remains unclear. There is a debate in the literature on whether sexting is a modern expression of normative sexual development or a risk behavior that clusters with problematic behaviors like risky sexual behaviors, substance abuse, and violence [19,[22][23][24]. Research is inconclusive on the link between sexting and psychosocial health, likely owing to the fact that most studies have not distinguished between consensual and nonconsensual forms of sexting.
To address these gaps in the literature, we explored multiple forms of sexting, including sending sexts (under pressure vs. without pressure/consensual), receiving unsolicited sexts, forwarding sexts without permission, asking someone for sexts, and being asked to send sexts, and examined their associations with a range of psychosocial health problems (i.e., symptoms of depression, anxiety, impulsivity, hostility, emotion dysregulation, and aggressive temperament). In response to a call for increased sexting research on younger adolescents [19], we examined these behaviors on middle-school-aged youth.

Procedure
Participants were recruited during school hours through mandated classes (e.g., health, science, physical education) in 2019. Participants were informed of the follow-up surveys. Those who returned signed parental consent forms and gave assent completed paper-andpencil surveys in class. During the follow-up years, students who were hard to track or were located outside of the original school completed the survey online. A total of 3738 students were recruited, and 3028 completed the baseline survey (Response Rate: 81.0%). In 2019, 2367 participants completed the first follow-up survey (retention rate: 82.6% of 2865 eligible participants). In this study, only those who were aged 14 years or younger were included in the analysis, resulting in a final sample of 2199. Participants received $5 gift cards for participating at baseline, and $10 at the follow-up survey. All surveys were private and confidential. The study was approved by the last author's Institutional Review Board.

Measures
Sexting. Participants were asked to report yes/no to whether they had engaged in various forms of sexting, including sent sexts under pressure ("Have you ever sent a naked picture of yourself to another person after being pressured to send one through text, email, or things like Snapchat?"), sent consensual sexts ("Have you ever sent a naked picture of yourself to another person without being pressured to send one through text, email, or things like Snapchat?"), received unsolicited sexts ("Has anyone ever sent you a nude photo (not of you) through text, email, or things like Snapchat without you asking?"), forwarded sexts without permission ("Have you ever forwarded the nude photo to others without their permission?"), asked someone for sexts ("Have you asked someone to send naked pictures of them to you?"), and been asked to send sexts ("Have you been asked to send naked pictures of yourself through text, email, or things like Snapchat?").
Depressive symptoms. The Center for Epidemiologic Studies Short Depression Scale [25] was used to measure depressive symptoms. Participants reported on a scale of 1 = rarely or never (less than 1 day) to 4 = more or all of the time (5-7 days) on how often they experienced 10 depressive symptoms (e.g., "I was bothered by things that usually don't bother me") during the past week. The scale had a Cronbach's α of 0.75.
Anxiety. The Generalized Anxiety Disorder subscale of the Screen for Child Anxiety-Related Emotional Disorders [26] was used to measure anxiety. Participants rated on a scale of 1 (not true or hardly ever true) to 3 (very true or often true) on nine items, such as "I worry about how well I do things" in general situations. This scale had a Cronbach's α of 0.88. Impulsivity was measured with the four-item Impulsiveness Scale from the Teen Conflict Survey [27]. Participants responded on a scale of 1 (never) to 5 (always) to items such as, "I start things but have a hard time finishing them". The scale had a Cronbach's α of 0.79.
Hostility was measured with the Symptom Checklist-90 [28]. Participants provided their answers to the question, "In general, how often do you . . . ?" on six items, such as, " . . . feel easily annoyed or irritated" on a scale from 1 (never) to 4 (most of the time). This scale had a Cronbach's α of 0.87.
Emotion dysregulation was measured with 11 items from the Borderline Personality Features Scale for Children [29]. Participants answered on a scale of 1 (not at all true) to 5 (always true) to items such as, "My feelings are very strong. For instance, when I get mad, I get really mad. When I get happy, I get really happy". The scale had a Cronbach's α of 0.92.
Aggressive temperament was measured with the aggression subscale of the Early Adolescent Temperament scale [30]. Participants reported on a scale of 1 (almost always untrue) to 5 (almost always true) to six items, such as, "When I am angry, I throw or break things". The scale had a Cronbach's α of 0.85.
Demographic variables. Age, gender, and race/ethnicity were collected.

Data Analysis
Preliminary analyses were carried out in SPSS 27.0 for Mac [31] to examine variable means, standard deviations, frequencies, and Pearson correlations. The intraclass corre-lation (ICC) in this study ranged from 0.006 to 0.036. To account for school-level ICC, a multilevel multivariate regression analysis was performed in Mplus 8.5 [32] to examine the associations between sexting and psychosocial health, controlling for age, gender, race, and exposure to the intervention. The robust maximum likelihood estimation method was used. Missing data were treated with full information maximum likelihood [33].

Discussion
Using a large, ethnically diverse sample of early adolescents, we identified associations between multiple forms of sexting and psychosocial health. In distinguishing between consensual and pressured sexting, we found that poor psychosocial health was only associated with the latter. Importantly, bivariate correlations suggested that consensual sexting was significantly associated with all psychosocial health types, which may help explain the mixed findings in the extant sexting literature that rarely distinguishes between pressured and consensual sexting [3]. Indeed, the bivariate link in our study was likely accounted for by pressured sexting, as among the 81 participants who had sent a sext under pressure and 81 who had sent consensual sexts (123 total), 42 (30.8%) of the adolescents reported having sent both pressured and consensual sexts. This finding gives credence to the suggestion [20] that pressured sexting is the primary culprit in feelings of guilt, shame, and embarrassment [1], which may contribute to psychosocial health problems. Schools and other communities with limited resources may shift their focus to preventing pressured sexting and how to respond to being pressured to sext.
Consistent with prior research [8,16], receiving unsolicited sexts was also linked to psychosocial health. In a qualitative study [34] exploring how people define sexting, it was found that only consensual messages were viewed as sexting, whereas unwanted sexts were viewed as an assault, which helps explain the psychosocial consequences of unsolicited sexts. Contrary to a previous study that identified a positive link between forwarding sexts without permission and depression [6], we found that forwarding sexts without permission was "only" associated with hostility. This finding was not particularly surprising, given the aggressive nature of this behavior, and suggests that health promotion programs aimed at reducing anger may have the secondary benefit of preventing this form of electronic sexual assault.
Early adolescents who had been asked to send a sext were at a particularly high risk of reporting symptoms of depression, anxiety, impulsivity, hostility, emotion dysregulation, and aggressive temperament. It is possible that being asked to send sexts can serve as a precursor for pressured or coerced sexting, or that simply asking for sexts is tantamount to pressure, given the desire to "fit in" or to get someone to like you [35,36]. Notably, our findings suggest that sending sexts under pressure and being asked to send sexts were independently associated with psychosocial health. That is, they uniquely contribute to psychosocial health, indicating a potential additive effect between these forms of sexting and psychosocial health. In addition to targeting the youth who pressure others for sexts, interventions should address adolescents who have been asked to engage in sexting.
Several limitations should be noted. First, the study examined cross-sectional associations between sexting and psychosocial health, so no causal inferences can be made. Second, the number of participants who reported having sent sexts (pressured or consensual), asked for sexts, or forwarded sexts without consent was relatively small (ranged from 2.6-4.5% of the sample) in this sample of early adolescents, which could have contributed to non-significant findings in regression analyses. Despite the small sample size, significant associations with poor psychosocial health were still identified with several sexting forms (e.g., sending sexts under pressure, being asked to send sexts, receiving unsolicited sexts), making it particularly concerning and highlighting the need for intervention. Third, although the study examined a range of sexting forms and psychosocial health, the included variables were not exhaustive. Future research should consider examining other forms of sexting (e.g., coerced sexting, receiving solicited sexts) and relationship contexts of sexting (e.g., being asked to send sexts from romantic partners vs. peers). Fourth, the survey did not include mental health treatment histories, which may have contributed to the link between sexting and psychosocial health. Lastly, while out of the scope of the present study, future research should consider examining how the associations between sexting and psychosocial health may differ by gender, race/ethnicity, socioeconomic status, sexuality, and other demographic factors.

Conclusions
As one of the first studies to examine multiple forms of sexting and psychosocial health, we found that pressured sexting was associated with hostility and aggressive temperament, and that receiving unsolicited sexts and being asked to send sexts was associated with depression, impulsivity, hostility, emotion dysregulation, and aggressive temperament. Forwarding sexts without permission was linked to hostility. Contrarily, consensual sexting was unrelated to poor psychosocial health. These findings emphasize the importance of sexting education, with a particular focus on nonconsensual and pressured forms of sexting, as well as how to manage being asked to send sexts.  Informed Consent Statement: Parental consent and child assent were obtained from all subjects involved in the study.

Conflicts of Interest:
The authors declare no conflict of interest.