Is the Internet Filling the Sexual Health Information Gap for Teens? An Exploratory Study

Abstract

At the same time that there was a decline in comprehensive school-based sex education, adolescents' use of the Internet became nearly universal. This study explores adolescents' use and evaluation of the Internet for sexual health information, with a focus on the issues of contraception and abstinence. The authors conducted 58 in-depth interviews with juniors and seniors in 3 public high schools in New York City and Indiana. Most of the adolescents used the Internet on a daily basis, but few considered it a main source of information about contraception or abstinence. Students were more likely to rely on and had greater trust in traditional sexuality education sources such as school, family members, and friends. Most of the adolescents the authors interviewed were wary of sexual health information on the Internet, and the authors describe strategies adolescents used to sort through the abundance of sex-related material. Formal and informal efforts to provide sexuality education to adolescents should include specific age- and content-appropriate Web sites because many teens are not actively searching on their own, and they express reservations about relying on the Internet as a source of sexual health information.

Sexuality education in the United States has changed significantly over the past decade. Funding for abstinence-only-until-marriage programs has increased substantially, and research has suggested that fewer adolescents are getting comprehensive information about contraception at school (Santelli et al., 2006). For example, the percentage of 15–19-year-olds receiving any formal instruction about birth control declined from 81% of male adolescents and 87% of female adolescents in 1995 to 66% of male adolescents and 70% of female adolescents in 2002 (Lindberg, Santelli, & Singh, 2006).

During this same time period, teens' exposure to other potential sources of information about sexuality also changed. The majority of teens (93%) are users of the Internet, including approximately three quarters who have a high-speed connection at home (Zhao, 2009). Data from 2006 show that more than one in four teens looked for health, dieting, or physical fitness information online (Lenhart, Madden, Macgill, & Smith, 2007). A study of teens and young adults (18–29 years old) showed similarly high levels of Internet use and of those using the Internet, 72% had gone online for health or medical information (Fox & Jones, 2009).

There are substantial and growing efforts to provide teens with sexual health information on the Internet. Web sites such as sexetc.org, iwannaknow.org, and scarleteen.com are intended to provide factual and real-world information about a range of sexual health issues as well as a forum for adolescents to (anonymously) submit questions and participate in discussions. Two small-scale and somewhat dated studies found that approximately one in four young adults used the Internet to find information about sex (Borzekowski & Rickert, 2001a; Rideout, 2001). A study of 412 10th graders in 2000 found that the Internet was teens' most common source of information about birth control and sex, although friends and parents were identified as more valuable sources (Borzekowski & Rickert, 2001b). Yet, despite the rapid growth in teens' use of the Internet, recent evidence has lagged about the ways that teens use, view, and trust the Internet as a sexual health information source, particularly in relation to more traditional sources such as family, friends, and school. To address this gap, we conducted an exploratory study with 58 high school students to find out how they used the Internet for sexual health information, particularly contraception and abstinence. We focused especially on how these teens discerned whether information or Web sites were trustworthy and discuss opportunities for improving links between accurate teen sexual health Web sites and teens.

Methods

Our analysis is based on interviews conducted April to June 2008 with 58 high school juniors and seniors recruited from three sites: a large public high school (approximately 3,700 students) and a small public high school (approximately 400 students), both in New York City, and a large public high school (approximately 1,800 students) in a mid-sized city in Indiana. After obtaining administrative approval, we worked with a health teacher or key contact at each school to develop recruitment strategies. At the Indiana school, a short description of the study was read during the morning announcements for three weeks, a brief video clip about the study aired each morning during the schools' in-house television programming for 1 week and a health teacher introduced the study in health classes. At the small public school, the director of special programs briefed teachers on the project. Teachers then explained the study to all junior and senior classes using a short study description 3–4 weeks before the interviews took place. At our third site, the large public school in New York City, we worked with the vice principal of health education once we had obtained study approval from the New York City Department of Education. Several days before the interviews, we went to junior and senior gym classes and briefly explained the study.

Information packets were made available to all interested students and included a short study description, a parental consent form (available in Spanish and English, as well as Chinese and Korean at the large New York City school), a form collecting students' age, gender, grade, and race/ethnicity and an envelope for returning the forms confidentially. Packets were returned to designated staff members, and all students had to submit signed parental consent forms to be eligible for selection. We obtained signed consent from all students before starting the interviews.

Students were selected for interviews at each site on the basis of our study goal of racial and ethnic diversity as well as students' availability during the school day. We interviewed a total of 26 students at the Indiana school, 9 students at the small New York City public school, and 23 students at the large New York City public school. Students ranged in age from 16 to 19 years. Table 1 indicates the distribution of respondents by gender, race/ethnicity, state, and grade.

Table 1. Demographic characteristics of in-depth interview respondents

	Female	Male	Total
Race/ethnicity
White	9	9	18
Black	8	5	13
Hispanic	9	5	14
Asian	7	6	13
State
Indiana	16	10	26
New York	17	15	32
Class
Junior	20	14	34
Senior	13	11	24
Total	33	25	58

To ensure a diversity of perspectives, we aimed to interview seven students in each gender by race/ethnicity category of Table 1. We fell short of that goal by one interview for Asian male students and two interviews each for Black and Hispanic male students. The two coauthors who conducted the interviews are White, non-Hispanic, middle-aged women, which may have presented more of a barrier to participation for teenage males, particularly those of a different racial/ethnic background.

Interviews were digitally recorded and 40 minutes long, on average. Every participant received a $25 gift certificate as a token of appreciation. The project was reviewed and approved by the Guttmacher Institute's institutional review board.

Although this article focuses on information about contraception and abstinence obtained online, the interviews covered an array of potential sources: school, friends, boyfriends/girlfriends, family, mass media, doctors/nurses, and religious groups. We asked similar questions about each source, namely what the teenager had learned (probing on the specific topics of abstinence and contraception/safe sex) and how much they trusted the source for this kind of information. Similarly, although we outlined the questions to be asked during the interviews (see the Appendix for the interview guidelines) we were flexible about question order and language. For example, during the interviews, we generally tried to avoid using the term contraception because it was not understood by some teens. We determined during pretesting that the term birth control was sometimes interpreted to mean (only) the pill (or, occasionally, other hormonal methods). We also found that some teens used the term safe sex as shorthand for using contraception (usually condoms) to prevent sexually transmitted diseases and/or pregnancy. Thus, during the interviews we typically used the terminology birth control, condoms, or safe sex as in “Tell me about any discussions you've had with family members about birth control, condoms, or safe sex.” For brevity, in our analysis we often used the term contraception in reference to all three issues but distinguished among birth control, condoms, and safe sex when appropriate.

The Internet can also be a source of sexually explicit material or pornography for teens (Wolak, Mitchell, & Finkelhor, 2007; Ybarra & Mitchell, 2005). We attempted to increase respondents' willingness to share these experiences with the following statement, read before the series of questions about online sexual health information: “I know that there's a lot of information out there on this topic, some of it sexually explicit. My questions refer to all the different types of information.”

We developed a scheme of approximately 20 codes based on the guidelines to capture the main issues discussed and coded the 58 transcripts using QSR NVivo (Version 8.0) qualitative software. Each coauthor read through text searches for specific codes and prepared a matrix of the substantive themes on the topic for each study participant. Results are based on the common themes arising from these matrices. Quotes from the interviews are identified by geographic place, gender, race/ethnicity, age and whether the respondent was a daily or less frequent Internet user.

Results

Sexual Health Information on the Internet

All of the respondents reported exposure to, and familiarity with, the Internet. Most teens (n = 43) used the Internet on a daily basis, ranging from 30 min to several hours. There was substantial variation in Internet use among the remaining 15 teens; some reported using it every other day whereas others reported less frequent use. E-mail, instant messaging, and social networking (MySpace and Facebook) were the most common Internet activities, and almost all of the teens used the Internet for these purposes. Although less common, homework/research, music, shopping, and gaming (mostly limited to male respondents) were other Internet activities.

A minority of teens (n = 21) were exposed to contraceptive information online. Most of these teens had actively accessed this information in response to school assignments and less often because of a personal situation or because they had stumbled upon it in the course of other searches. In a few cases, teens talked about going online to confirm or double-check contraceptive information they heard or learned from other sources. Although these adolescents technically had obtained sexual health information from the Internet, their limited exposure to this information suggests that it was not a primary source of sex education.

Well I haven't really seen a lot on birth control, but only when I have to do a project, I found some very like good information, because we had to do like a health project and stuff and we had to have some good information and stuff like that. But like when I am searching the Internet, like pop-ups I never see anything about that.

(New York, Black female, 16 years old, less frequent Internet user)

Like, I, this one time I had a question, you know? I didn't really feel comfortable asking like my mom, ‘cause she was the only one around. You know, I was like, I went on the Internet and I was like, “Can a girl get pregnant during her period?”

(Indiana, Hispanic male, 17 years old, daily Internet user)

Teens who used the Internet regularly and proactively to educate themselves about contraception and safe sex were the exceptions rather than the rule.

Like this one Web site, I have gone to, like when I have personal problems dealing with periods and stuff, they have like a search forum where you can look up anything that has to deal with sex and health and it tells you about birth control and it tells you about condoms, it tells you about different things that could be, like, going on with you. It's really informational and it's, like, teen comfortable.

(Indiana, White female, 18 years old, less frequent Internet user)

Most teens reported no exposure to contraceptive information on the Internet. In some cases, they related that they knew the information was there if they needed it, but they were not motivated to look it up or click on it. Others related that they would go to other sources, such as school, friends, and family, or that they had the information already. Some teens had not been exposed to contraceptive information per se, although they could recall seeing online advertisements (e.g., pop-ups or sidebar ads). However, few teens suggested that Internet ads provided them with new or substantive information, and most seemed to regard them as increasing brand name awareness or something to be ignored.

A minority of teens (n = 14) recalled exposure to abstinence information on the Internet. This information was related in varied formats, including articles or discussions about “how to decide when to have sex,” in the context of their religious groups/Web sites, for a school assignment, by chance, and via advertisements to delay sex. Overall, the online abstinence information described by teens was superficial and lacked depth; relative to contraception, even fewer teens described actively seeking out abstinence information on the web. Several teens who could not recall seeing abstinence information online expected that they could find it if they needed it. The more common sentiment was that the Internet was an unlikely place for abstinence information.

I think maybe once and I might have gotten to a Web site that talks about abstinence and safe sex. And that was just like probably by chance, that I got to that web site, I know there is definitely a lot of information out there.

(Indiana, White male, 17 years old, daily Internet user)

I really don't think they have that [abstinence], I mean, I think they more try to pressure you to have sex earlier than trying to prevent you from doing it.

(New York, White female, 18 years old, daily Internet user)

Female participants were more likely than male participants to report exposure to information about contraceptives. However, apart from this pattern, the information teens reported receiving from the Internet about contraception and abstinence did not differ substantially by gender or ethnicity.

Although we were most interested in online information about contraception and abstinence, teens also related that they had sought out, or were exposed to, information about sexually transmitted diseases (including HIV), pregnancy, pornography, sexual anatomy, abortion, sexual pleasure, sexual terminology, and reproductive cancers. Almost as many teens volunteered that they had been exposed to online information on sexually transmitted diseases (n = 15) as had been exposed to contraceptive information. Information on sexually transmitted diseases was accessed out of curiosity, concern or for a class assignment, and the online pictures that often accompanied the information made an impression on a number of teens. Although we did not consider it a type of sexual health information, it is worth noting that almost all of these teens recalled involuntary exposure to advertisements (pop-ups, spam, or sidebar ads) for pornography or sexually explicit photos or pictures.

Savvy and Wary Internet Users

Overall, only 5 of the teens we interviewed mentioned the Internet as one of their most trusted sources of sexual health information. Teens were more likely to trust (in order) family members (usually parents), school, medical professionals, and friends for sexual health information. The majority of these teens indicated wariness of online sexual health information, regardless of whether they had actually sought it out or been exposed to it. Among the remaining teens, most described outright distrust and only a few indicated trust in the Web. There was no pattern in the degree of trust in the Internet by gender, race/ethnicity, or actual Internet use; heavy Internet users (several hours per day), daily but not heavy users, as well as less frequent users were included in the groups of teens who qualified their trust or categorically distrusted the Internet.

Some teens described ways they evaluated sexual health information online. Most commonly, their trust depended on whether the Web site was a reputable or known source. News Web sites and those associated with general health or medical sources (e.g., WebMD or public health departments) were considered trustworthy, and a few teens indicated that sites with the suffixes.gov, .org, and .edu were more likely than.com Web sites to contain accurate information.

[I]t depends on the Web site. Wikipedia would be like 60%. But like on [Web]MD, I would be like 90% because those are like information from doctors and stuff, yeah.

(New York, Hispanic male, 17 years old, daily Internet user)

I guess it just depends on where you go. I guess if I went to like to an actual Web site that I got from like the doctor's office or something, I think I would trust it. Yeah I would probably trust everything they say because it's from the doctor. And if I went to like a Web site I had heard from … students or something like that, I probably would believe half the stuff.

(Indiana, Black female, 17 years old, daily Internet user)

Some teens related that trust in an Internet source was qualified by whether the information corresponded with what they had learned from other sources. In the other direction, some teens (n = 8) talked about purposefully using the Internet to cross-check or validate information from other sources, including friends, school, magazines, and other Web sites.

I trust it as long as it's from a source that I know adds up to everything else I have heard.

(Indiana, White female, 16 years old, daily Internet user)

I can't say that I've got too much information from them [his friends], but depending on what it was, I might like look it up on the Internet and see if I can trust them about it or not.

(Indiana, White male, 17 years old, daily Internet user)

Teens were aware that a lot of information on the Internet was user-generated (“Anyone can make a Web site”) and this was another reason teens did not unquestioningly consume or seek out sexual health information from this source. Some teens expressed concern that information about sexual health issues may have been generated by someone who was not an expert in the area and could, therefore, be incorrect. The Web site Wikipedia was a common example of user-generated information that may not be definitive.

Like the Internet, you see these things like Wikipedia and stuff like that; and you know people can edit out information and stuff like that. So like mainly, I just go to friends and stuff. Like I don't really look online because like those sources I can't really trust. Because some of them could be lying, some of them could be fake.

(Indiana, Hispanic female, 18 years old, daily Internet user)

You know sometimes you can identify, like you know, in my own personal experience like .com, anyone can make up a Web site but .org is more like an organization, it's more reliable, but that doesn't mean that I will fully trust it.

(New York, Asian male, 18 years old, daily Internet user)

Last, the seemingly ubiquitous nature of sexually explicit or sexually oriented material on the Internet made some adolescents reluctant to trust it for factual information about sex. Moreover, sex and sexual imagery being used to sell or market products (“sex sells”) made some teens skeptical of the factual information being provided.

Like the Internet, it's pretty much just like giant billboard for sex. It's really, it's not a good place to go if you are young, because being on Internet, because all the pop ups and things you could type in kind of makes you want to have sex. So it really doesn't enforce the abstinence rule and birth control, safe sex anything.

(Indiana, White male, 17 years old, less frequent user)

Well it's really difficult because people, like, when you search for like birth control options, like they “Oh, here, you wanna buy some condoms?” you know and stuff like that, instead of giving me information on it, they want to like sell it to you.

(New York, Black female, 16 years old, less frequent user)

The fact that there are so many different Web sites and that different Web sites will often give different answers to the same question contributed to some teens' wariness. Adolescents also related that using relevant sexual health search terms often meant having to sort through a lot of unrelated material or evaluate different answers to the same question.

I have done it once and they usually send you around the loop, like you are just on like a massive hunt for information. Yeah, I usually just give up … . when it comes to like things like sexuality, usually Web sites are like, either they are for it or they are against it. And there is no real information about it.

(New York, Hispanic male, 17 years old, daily Internet user)

Discussion and Conclusion

School-based comprehensive sex education has declined over the past decade, but the dramatic rise in teens' use of the Internet raised the possibility that it could fill the sexual health information gap. However, the results from this exploratory study suggest that a number of teens do not frequently use the Internet to obtain educational information about sexual health, at least not as it pertains to contraception and abstinence. Although most of these teens were online daily, few of them had proactively searched, apart from school assignments, for substantive information about these issues. These teens were also wary and discerning consumers: They were aware of the abundance of online sexual health information but had criteria to help evaluate the trustworthiness of information. The interactivity of the Internet that makes it popular for social networking, its platform for advertising and the openness that allows so many people to create and upload content of a wide-ranging nature are the same characteristics that made these teens generally wary. These findings suggest that the Internet reflects more potential than reality as a substantive source of sexual health information for teens.

These findings must be interpreted with the several study limitations in mind. First, the extent to which this study reflects these adolescents' actual experiences is only as accurate as the respondents' memories. It is possible that some teens did not recall, or failed to relate, exposure to substantive online information about contraception and abstinence. Second, the study focus and recruitment materials may have deterred sexually experienced teens from participating. Although the recruitment materials indicated that the interviews would focus on where students' obtained information about sexual health issues, several respondents related that they had expected us to question them about their sexual behavior. Moreover, more than half of the teenagers we interviewed related in an unprompted way that they had not had sex. While this proportion seems reasonable, especially given that there were more juniors than seniors in the sample, we still speculate that sexually experienced teenagers may have been more uncomfortable or embarrassed talking to strangers about these issues. Alternately, sexually experienced teens may have worried that simply asking parents to sign the consent form would result in questions about their own sexual behavior. This latter situation also raises the related limitation that the requirement of written parental consent may have prevented some high school students from participating because of parental refusal (real or anticipated) for other reasons. Last, as we previously note, the gender, age, and race/ethnicity of the two interviewers may have deterred male and youth of color from participating.

Although our study suggests the Internet is not filling a gap in sexual health education for a number of adolescents, the medium shows much promise. There are many teen-friendly Web sites that provide comprehensive information about these issues, and some of these sites get tens of thousands of unique visitors per day and are connected to popular social networking Web sites. Even though it is useful to examine the traffic to these sites and the kinds of questions submitted, there are many more teens who, while Internet savvy, never make it to the sites or may do so but without being certain if they can trust the information (Gilbert, Temby, & Rogers, 2005; Harvey, Brown, Crawford, Macfarlane, & McPherson, 2007; Suzuki & Calzo, 2004). The potential is great for the Internet to link teens to accurate sexual health information and to build their trust and confidence in the information they get, but doing so only through Internet-based approaches may not be completely effective.

Given that schools and family members still play an important role in providing information about sex and are generally trusted by teens, it may be particularly effective to capitalize on these information sources to link teens to reliable and comprehensive sexual health information on the Web. Possible strategies for schools include class assignments that require online research on sexual health topics, training students how to conduct basic and effective searches for sexual health information, and ensuring that students receive a list of comprehensive sexual health Web sites for later reference. Organizations and individuals that work with adolescents, particularly around issues of health, should provide teens with lists of Web sites they can access for factual information about a range of sexual health issues. Connecting teens to credible Web sites by way of parents or other family members is more challenging, but often parents are as eager for reliable health information sources as are their children. Professional organizations such as the Society for Adolescent Medicine, the National Parent Teacher Association, and youth-serving organizations such as the Boys and Girls Club of America should consider compiling lists of Internet resources that can be used by parents and adolescents.

Acknowledgments

This work was supported by a grant from the Ford Foundation.

The authors thank Luciana Hebert and Ruth Milne for their substantive contributions to the project, and Heather Boonstra, Lawrence B. Finer, Laura D. Lindberg, and Susheela Singh for providing feedback on the article. The authors are also grateful to several school staff members (names purposely excluded to protect the identities of the schools) for their invaluable guidance and help with recruitment activities.

Additional information

Notes on contributors

Ann E. Biddlecom

Ann E. Biddlecom was formerly a Senior Research Associate at the Guttmacher Institute. The views expressed herein are those of the author and do not necessarily reflect the views of the United Nations.

Appendix: Interview Guidelines

1.	Take a couple of minutes, just two or three, and tell me a little bit about yourself.
	a. Tell me about any extracurricular activities or groups that you participate in [PROBE: school-related or other kinds of youth groups (e.g., sports, dance, religious groups)?]

Now I have just a quick question about abstinence, there are no right or wrong answers.

2.	What do you think about when you hear the term “abstinence?”
	a. What do you think about teens getting information about abstinence, or how to say no to sex?

Now I want to find out about where you get information about sex-related issues.

3.

[school] Tell me about the sex education talks or classes you've received at school?

a. At what grade did you receive these classes or talks? b. Content: what did you learn about: About abstinence/how say no to sex? About birth control/pregnancy prevention? c. Who taught the class? What was ________ like when s/he taught this class?i. If needed: Environment/class attituded. d. What did you like about the class? What did you dislike about the class? Did you learn anything new? e. Do you trust the information you get in sex education classes?

4.	[friends] Tell me about your friends—what they're like and some of the things you usually do together.

5.	Tell me about conversations you have had with friends about things having to do with sex.
	a. Probe on abstinence/how to say no, birth control/pregnancy prevention b. Do you trust the information that you get from your friends about things related to sex? c. And what about someone you've gone with, what kinds of conversations have you had with them?

6.	[family] Tell me who you live with and your relationships with them.
	a. When you have problems, how supportive are these family members.

7.

Tell me about conversations you have had with anyone in your family about things having to do with sex. [If answer “none,” PROBE: on whether or not biological issues were discussed: did anyone talk to you about periods or how girls get pregnant]

a. [PROBE if not covered: birth control, abstinence.] b. Who starts these conversations? Who does most of the talking? c. Do you trust the information about sex that you receive from different family members [PROBE on each mentioned]? d. What other types of things about sex would you like to discuss with (each family member listed)? e. What would you say are your parents' attitudes about teens and sex?  i. [PROBE: distinguish between mom and dad, other family members identified]

8.	Now I want to find out how you use the Internet in general. Walk me through a typical day and how you use the Internet. [PROBE: where at when using it, approximate hours, popular Web sites, online activities]

Now let's focus on using the Internet to find out about things related to sex. I know that there's a lot of information out there on this topic, some of it sexually explicit. My questions refer to all the different types of information.

9.

[Internet] Tell me what kinds of things you see about sex on the Internet [if appropriate: for example, on some of the Web sites you just mentioned]?

a. What kinds of things have you seen about birth control? About abstinence/delaying sex? b. Tell me about a time you used the Internet to find out the answer to a question about sex. [PROBE: birth control or how to not get pregnant, abstinence] c. How can you tell if you can trust the information about sex that you see on the Internet? d. Tell me about any situations when you've been online and found yourself looking at things that offended you, that you didn't mean to, or didn't want to look at. [PROBE: how often?]

10.	[other media, television/movies] Can you tell me about any times when you've been watching television or movies and seen anything about abstinence or birth control?

11.	[other media, magazines and books] What kinds of things about birth control and abstinence/delaying sex have you seen or read about in magazines and books? [PROBE: Any examples of a time when you learned something that you didn't know about sex from a magazine or a book?]

12.	[advertisements] Tell me about any advertisements that you have seen for birth control, including condoms, birth control pills, the ring, etc.
	*Did you learn anything new about these methods?

13.	[other information sources] Are there any other places you've learned about things related to sex that we haven't talked about already. [PROBE: church/religious groups, doctors or nurses]

14.	[most useful source] What is your most trusted information source for things about sex?
	a. What was it about the information from this source that makes you trust it?

15.	If a female friend of yours wanted to get on the pill, what advice would you give her, where would you tell her to go? How would you know to recommend this?

16.	If a friend of yours wanted to get condoms, what advice would you give them, where would you tell them to go? How would you know to recommend this?

17.	[information needed by all/other kids] What kinds of things about sex do you think teenage [SAME SEX AS RESPONDENT] really need to learn about nowadays?
	a. What kinds of people or sources do you think are best to give this kind of information? [PROBE: on reasons why] b. How about teenage [OPPOSITE SEX], what do you think they need to know? [PROBE: on reasons why]

18.	Finally, is there anything related to where kids get information about sex that was missing from this interview that you want to tell me about?