Adolescence is a period of development whereby a child makes the transition from childhood into adulthood. This is a phase marked by establishing a sense of identity, core values, a sense of one’s relationship to the outside world and putting an increased value on peer relationships. In addition, this is also a period distinguished by risk taking, impulsivity, self exploration and increased sexual curiosity.

In this generation of vast technological advances where adolescents use their cellular phones and computers an average of 50 hours per week [1], a growing concern in society are the societal implications of sexting and cyberbullying on this fragile demographic. Sexting refers to the practice of sending sexually explicit material including language or images to another person’s cell phone. Cyberbullying refers to the use of technology to socially exclude, threaten, insult or shame another person. In 2011, sexting was the tenth top health concern for children in the National Poll on Children’s Health [2].

During this period of impulsivity, curiosity and limited judgment immediate access to such technology can potentially lead to dangerous consequences. Adolescents need to be aware of the dangers of this technology where dissemination can be nearly instantaneous to thousands of recipients and that the images disseminated are essentially permanent. The social interactions of the twentieth century did not carry the dire consequences of this use of newer modern technology.

According to a Pew Internet survey, “Teens, Social Media and Privacy” of 1,102 teens ages 12–17 [3] 58 % of 12 year olds and 84 % of 17 year olds had cell phones. Of those teens that have cell phones, half send at least fifty text messages a day and one-third send more than 100 per day. Text messaging has become the primary mode of communication among adolescents far outnumbering the use of email and telephone calls.

A study by Delmonico et al. [4] titled “Cybersex and the E-Teen: what marriage and family therapists should know” surveyed students regarding their Internet and sexting tendencies. Nearly 20 % of students surveyed reported ever sexting sexually explicit messages and over 40 % indicate that they had ever received such messages. A study by Mitchell and Finkelhor [5], “Youth Produced Sexual Images” interviewed 1,560 adolescents ages 10–17. Of those interviewed, 2.5 % reported appearing in or creating a sext and 61 % of those were females. In that same study, 54 % appeared nude, exposed their breasts, genitals or buttocks.

Today’s youth are using technologies such as the Internet and cell phones to aid in their understanding of sexuality and self. Studies indicate that the most common reason for sexting is in the context of either maintaining or beginning a romantic relationship. The second most common reason found for sending a sexually explicit message is in the context of “a joke.” Reports also show that teens are not only sharing sexually explicit material amongst themselves but there is a significant amount of adult participation. In Wolak et al.’s study, “How often are teens arrested for sexting?” data came from a sample of police cases [6]. The investigators reviewed all cases of youth produced sexting for United States Law enforcement agencies for the years 2008–2009. Of the 3,477 cases reviewed, 1,043 (36 %) involved adults. Of those cases, 38 % included adults over 25 years old and 50 % of the cases included adults, ages 18–24 years and the remaining 10 % included 18–19 year olds.

Sexting is not simply limited to sending sexually explicit messages. Dr. Temple et al.’s study entitled “Teen Sexting and Its Association with Sexual Behaviors” surveyed high school students in Texas ages 14–19 years old [7]. These students were in the tenth or eleventh grade from seven different high schools. Results indicated a significant association between sexting behaviors and all dating, sex and risky sex behaviors. Of the girls that sent a text, 77 % also reported having actual sexual relations compared with only 42 % who did not report sending such a message. For boys that sent a sex message, 82 % also reported having sexual relations compared with 45 % who reported not sending explicit messages. Results indicate that overall, teens that engage in sending sexually explicit text messages are more likely to be engaging in sexual behavior and risky sexual practices. While many teens may be sending these messages, the majority of them reported being genuinely bothered by being asked to send a naked picture. Only 10 % of girls and 50 % of boys reported not being bothered at all by being asked to send a sext.

Bridging the gap between adolescents and adults has forever been a societal challenge. A period of individuation and rebellion, changing bodies and hormones, adolescence can be a smooth transition or tumultuous. However, failure to understand the dangerous implications of the current trends in adolescent sexual behavior can lead to detrimental consequences for all involved. The challenge for psychiatrists is to recognize adolescent trends and the potential repercussions of these trends in order to be able to ask appropriate questions during psychiatric evaluations. Psychiatrists must take care to ask thorough sexual histories and explicit questions regarding the use of cell phones, sex messages and social media sites like Facebook and Twitter. While exploration of such technologies can be developmentally appropriate, the psychiatrist must be able to tease out what is normal and what may be pathological.

Psychiatrists more than ever before have to be astute at understanding the implications of these technological advances. When evaluating an adolescent it is imperative to assess for healthy versus pathological uses of the cell phone and Internet. Adolescents may not volunteer information on their own during an assessment and risky Internet and cell phone behavior may be a contributing factor to their clinical presentation. When asking about high risk behaviors, hobbies and interpersonal relationships the clinician should also ask about their Internet and cell phone usage. Some key questions include: Have you ever felt bullied or forced to do something that has made you feel uncomfortable? Have you ever felt ashamed about something that was posted of you on social media or through text message?

Adolescents that are at risk for victimization also are at risk for psychiatric consequences. Depression, suicide, mood disorder, adjustment reactions and anxiety disorders are some of the potential psychiatric sequelae of falling victim to sexting and cyberbullying.

Regardless if the behavior is normal or pathological, the psychiatrist must provide psychoeducation to patients and their families about the dangerous consequences of such technology. In addition to psychoeducating the patient and assessing for signs and symptoms of mental illness, it is important to educate the parents of the potential risks. Educating the parents about the risks of sexting and cyber bullying and informing them about monitoring their child’s usage, enabling parental controls are just some of the techniques that psychiatrists can tell parents to employ to safeguard their adolescents. Further, the psychiatrist can play an important role in prevention by developing educational programs to teach adolescents about the serious potential hazards of sexting and cyberbullying.

The age of consent has ranged throughout the years and varies by state. In the past it has been as young as 7 years old (Delaware) or as old as 21 (Tennessee). Currently the age in most states is around seventeen to eighteen. Kourany and his colleagues in a paper “Age of Sexual Consent” noted that the age of sexual consent should “Not be so early that little protection is provided for the child but it should also not be so late that a person can be convicted of statutory rape when the victim is fully capable of consent and readily acquiesced to a proposal or even invited a relationship” [8]. In some states for example where the age of consent is seventeen, a 17 year old dating a 15 year old may be charged with statutory rape. These legal standards are in conflict with biology and human maturation. Biologically, adolescents are programmed to be sexually active as early as 10 or 11 years old. This legal quandary is not in synchrony with the concept of nature and biology.

Sexting can entangle a child or adolescent in the criminal justice system. The potential circulation and permanence of the image introduces a range of troubling legal questions. The legal implications are extensive and psychiatrists may play an important role in evaluation of some of these adolescents in the legal context. Currently, the charges in most states range from misdemeanors to B felonies [9]. Since 2009 20 states have enacted or proposed measures that deal with teenage sexting and generally minors are treated more leniently. Most states, however, have yet to enact specific laws regarding sexting and perpetrators are charged under child pornography or child exploitation laws. In New York State there is no specific statute that addresses sexting, however, being caught with or transferring an image of a minor engaged in a sexual act would be subject to prosecution under the State’s Child Pornography Statute. Currently New York is in the process of proposing a bill to send first time offenders to mandatory education classes if the court deems the defendant lacked intent to commit a crime. This would apply to teens 16 years old or younger.

In summary, sexting is a wide spread problem that requires the attention not only of parents but also of psychiatrists. As psychiatrists, more than ever we need to be more diligent about exploring these topics in detail with our adolescent patients. Not only must we educate our patients of the potential dangers and victimization of sexting and cyberbullying but we must also educate parents, guardians and the community. Preventive methods including educational seminars and screening in the schools would be the best approach to educating preteens and young adolescents. This prevention intervention needs to begin as early as late elementary school.