In 2016, in response to concern about the impact of pornography on adolescents, the Boston Public Health Commission partnered with a university researcher to develop a nine-session media literacy curriculum on pornography for adolescents. The curriculum was pilot-tested with five small classes of adolescents between 2016 and 2019 (n = 31). Many adult teachers of sex education also expressed interest in being trained to use the curriculum, so our team has now trained 300 adults to use it.

Since 2016, US state legislatures have been passing resolutions declaring pornography a public health crisis. There is particular concern that the accessibility of Internet pornography may harm adolescents. The evidence regarding the impact of pornography on adolescents is mixed,1 although there is little doubt that media literacy skills help adolescents think critically about sexualized and nonsexualized media to which they are exposed.2 Therefore, we developed an educational program for adolescents about pornography. Here, we relay some information about the program to alert the public health community to its existence. Details about the development of the program and its possible impact are available elsewhere.3,4

INTERVENTION Section: Choose Top of page Abstract INTERVENTION << PLACE AND TIME PERSON PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES We developed a nine-session curriculum called “The Truth About Pornography: A Pornography Literacy Curriculum for High School Students Designed to Reduce Sexual and Dating Violence.” The theoretical underpinnings of the program are the Theory of Planned Behavior and the 3 AM theory.5,6 The goals of the program are to improve knowledge about sexually explicit media and sexual behavior, to increase attitudes consistent with valuing sexual consent and nonaggression in dating relationships, and to increase awareness about media’s power to promote social norms. The expectation is that by providing information; by encouraging critical thinking, self-reflection, and the reevaluation of peer beliefs and social norms; and by practicing new behaviors via role play, some adolescent knowledge, beliefs, and behavioral intentions will change. The nine topics covered in the class are as follows: 1. the rationale for the class; 2. the history of obscenity regulations; 3. social norms related to gender, sex, and violence; 4. the debate about pornography addiction and information about compulsive use; 5. different types of intimacy explained; 6. healthy flirting and setting boundaries; 7. commercial sexual exploitation; 8. the nonconsensual dissemination of sexually explicit images and sexting laws; and 9. how to talk with peers about pornography. In addition to creating the curriculum, we developed a one-session training program for adults who want to teach it. This is an unfunded initiative; this team has received no governmental or private funding to support this work.

PLACE AND TIME Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME << PERSON PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES We pilot-tested the curriculum with five small groups of adolescents in Boston, Massachusetts between July 2016 and November 2019 (n = 31). The primary audience for our curriculum has been the adolescents who join the Boston Public Health Commission (BPHC) Start Strong program, which works with only 20 adolescents per school year. We also separately provided one class to a group of lesbian, gay, bisexual, transgender, queer, and pansexual (LGBTQP) youths at a local nonprofit. The curriculum was designed to be used with small classes to facilitate conversation. For these reasons, few adolescents have been through the class. Many adult educators have been curious about our curriculum and requested training to teach it themselves. We have provided training to over 300 adults from places as diverse as Hawaii, Vermont, Utah, Canada, the United Kingdom, Australia, and Japan.

PERSON Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON << PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES The curriculum was originally designed for high school students participating in the BPHC Start Strong program—a program that trains adolescents to become peer educators about healthy dating relationships. It is not a school program. The training for adults on how to use the curriculum was designed for sex educators, clinicians who work with youths who sexually offend, teachers, advocates for commercially sexually exploited youths, pregnancy prevention experts, public health professionals, religious and nonreligious youth group leaders, and child protective services workers.

PURPOSE Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE << IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES The curriculum was designed to improve adolescents’ knowledge, attitudes, and behavioral intentions related to pornography, healthy relationships, and sexual consent. For example, participants learn that pornography is created for entertainment and generally not for instructional purposes. The curriculum also seeks to improve knowledge about adolescent-specific risk behavior related to pornography, including the legal risks of sending or receiving nude photos. The curriculum was designed to change beliefs about, for example, performing in pornography being an easy way to become wealthy, or pornography being realistic. Finally, the curriculum uses a nonjudgmental approach to sexual behaviors and sexual interests and was not designed to persuade adolescents to stop pornography use. However, it does seek to improve behavior related to sexual consent and dating violence. For example, participants learn that not everyone enjoys being called names like “slut” during sex and that they need to ask partners for consent before each new sexual act that they may want to try during a sexual encounter (e.g., anal sex, hair-pulling, and spanking would each require separate consent, and may not be as widely enjoyed by women as they might presume after watching mainstream pornography).

IMPLEMENTATION Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE IMPLEMENTATION << EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES The program comprises nine 60-minute sessions. It is implemented by two trained facilitators. Our team has trained adolescents who graduate from the class to become peer-facilitators for new groups of students. The training for adults takes three to six hours to deliver. Our team is now exploring an online format for delivering the training to adults.

EVALUATION Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE IMPLEMENTATION EVALUATION << ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES We evaluated the adolescent curriculum by using a nonexperimental, one-group, pre- and posttest design.3 Detailed evaluation information is available elsewhere,3 and additional selected findings are presented in Table 1. Results suggest that, on average, youths who have participated in the program have experienced changes in knowledge, attitudes, and behavioral intentions related to pornography, but a larger-scale, randomized design with a longer-term follow-up would improve what is known about the impact of the program. The adult training has not been evaluated. Information about whether the adult training is effective, and whether in turn the adults who are trained are able to provide effective education to their own classes of adolescents, will be useful to the field. TABLE 1— Demographic Characteristics of Participants and Selected Pornography-Related Knowledge, Attitude, and Behavior Responses, Pretest and Posttest: Boston, MA, 2016–2019 Pretest, No. (%) Posttest, No. (%) Participants 27 (100) 24 (100) Gender Female 14 (52) 11 (46) Male 10 (37) 9 (38) Transgender, intersex, other 2 (7) 1 (4) Missing 1 (4) 3 (13) Sexual orientation Straight/heterosexual 17 (63) 17 (71) Gay/lesbian/bisexual/other 9 (33) 7 (29) Missing 1 (4) 1 (4) Race/ethnicity Black/African American 16 (59) 12 (50) Hispanic 5 (19) 6 (25) Other 6 (22) 6 (25) Pornography-related knowledge, attitude, and behavior (selected) Being in professional pornography is a good way to make a lot of money (somewhat agree or definitely agree) 14 (52) 5 (21) Watching pornography makes me want to try what I see (somewhat agree or definitely agree) 12 (44) 7 (29) Pornography is realistic (somewhat agree or definitely agree) 7 (26) 0 (0) Calling someone nasty or a slut during sex is something that everybody does (definitely disagree) 16 (59) 18 (75) Most pornography helps show people consensual behavior (definitely disagree) 9 (33) 13 (54) I would act in pornography if someone asked me to (definitely disagree) 15 (56) 19 (79) Pornography is my primary source of sex education 7 (26) 4 (17) Have seen Internet pornography for 5 min or longer 22 (81) 19 (79)

ADVERSE EFFECTS Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS << SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES We have not observed any adverse effects of the program. Prior to implementing the program, we wondered if participating youths would be more likely to seek out pornography as a result of the class. However, pre- and posttest survey results indicate that the percentage of participants who had ever seen Internet pornography had not changed over time (Table 1). Other possible adverse effects include youths feeling anxious or upset as a result of program content, or youths disclosing experiences of abuse or neglect during a session that would necessitate filing a report with child protective services. Neither of these possibilities has occurred.

SUSTAINABILITY Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY << PUBLIC HEALTH SIGNIFICANC... REFERENCES CITING ARTICLES The program is low cost to implement. The primary costs are the time of the facilitators, the meeting space, and materials such as markers, paper, and printing handouts. Many of these costs can be absorbed by existing programs. We are investigating options for providing the adult facilitator with training online to make training accessible and inexpensive.

PUBLIC HEALTH SIGNIFICANCE Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... << REFERENCES CITING ARTICLES This program represents a new way to approach the topic of pornography with adolescents, and is an addition to the porn literacy education curricula that have begun to emerge from around the world.7 Pornography viewing is common among adolescents, and there is a potential that uncritical viewing may contribute to unhealthy attitudes about sexual consent, dating violence, and commercial sexual exploitation. However, the potential harms of pornography are frequently exaggerated in the general news media, and antipornography activism has the potential to encourage stigmatization of sexual orientation and gender minorities and of sex workers. This program is designed to help adolescents think critically about the potential harms of making, viewing, and disseminating sexually explicit media, but it allows for the possibility that not all pornography is innately harmful.

See also Landers and Kapadia, p. 140 , and the AJPH Public Health of Pleasure section, pp. 145 – 160 .

ACKNOWLEDGMENTS We thank the adolescents who participated in the pornography literacy curriculum pilot testing.

CONFLICTS OF INTEREST Each of the authors received honoraria and travel expense reimbursement for participating in speaking engagements related to the pornography literacy curriculum described.

HUMAN PARTICIPANT PROTECTION This research was approved by the Boston University Medical Campus institutional review board.

REFERENCES Section: Choose Top of page Abstract INTERVENTION PLACE AND TIME PERSON PURPOSE IMPLEMENTATION EVALUATION ADVERSE EFFECTS SUSTAINABILITY PUBLIC HEALTH SIGNIFICANC... REFERENCES << CITING ARTICLES

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