Introduction

The widespread availability of the internet has significantly increased adolescents' exposure to sexually explicit Internet materials (SEIM) via personal computers, tablets, and smart phones [1]. Frequent consumption of SEIM is linked to various negative consequences, including a higher likelihood of early sexual activity, multiple sexual partners, and the use of alcohol and drugs before sexual intercourse [2], as well as an earlier initiation of sexual debut [3]. Additionally, adolescents who frequently consume SEIM often face more relationship problems, develop distorted perceptions of gender roles and body image [4], and experience weaker family relationships [5].

The prevalence of SEIM consumption among adolescents and young adults varies globally. Studies indicate that the prevalence among boys encountering SEIM ranges from 56% to 100% [6]. In Italy, exposure to SEIM among 18-year-olds reaches up to 90% for males and 40% for females [7]. In Africa, 77.2% in Ethiopian adolescents [8], and 65.4% of Nigerian adolescents have reported exposure to SEIM, leading to changes in behavior such as engaging in oral sex and having multiple sexual partners [9]. In Cambodia, 10.9% of adolescents aged 10 to 24 (20.4% boys and 1.5% girls) have used SEIM [10]. These findings indicate that SEIM consumption is a significant global issue among adolescents and young adults, warranting attention and intervention.

Adolescent consumption of SEIM is influenced by a variety of factors, including parental influence, family dynamics, peer interactions, personal traits, and health behaviors. For example, higher levels of parental monitoring have been linked to less frequent SEIM use [11]. Adolescents often consume SEIM due to factors such as sexual curiosity, the desire to enhance sexual performance, various social reasons (ex., social network and peer influences), and a lack of emotional skills in relationships [12]. Additionally, studies indicate that frequent SEIM consumption is associated with lifestyle issues, including increased alcohol and drug use, particularly among male adolescents [13,14]. Factors like sensation-seeking behavior, advanced pubertal development [15], earlier and more diverse sexual experiences, and permissive sexual attitudes have also been associated with higher SEIM usage among adolescents [16].

Research on SEIM and its consequences is vital given the pervasive use of the internet and social media among Cambodian adolescents. While the exposure rate to SEIM among Cambodian adolescents was lower compared to their peers in other countries, the potential impact of SEIM on this population warrants critical examination. Adolescents are in a formative stage of psychological and social development, making them particularly vulnerable to the effects of SEIM. A staggering 97.9% of high school students use mobile phones, and 86.3% access the Internet [17]. With 28.5% of the total population aged 10–24 [18], understanding the correlation between SEIM use and sexual behavior becomes imperative. The exposure of Cambodian adolescents to SEIM consumption poses a risk for the development of unhealthy sexual attitudes, risky sexual behaviors, and negative psychological outcomes. Existing research touches on internet use and sexual exploitation [19], pornography use among expatriate Christians [20], and the impact on reproductive and sexual health [10], but a comprehensive examination of SEIM consumption and its associated factors among Cambodian adolescents is lacking. Therefore, in this study, the level of SEIM consumption and related factors among Cambodian adolescents were investigated. The insights gained from this research are crucial for developing targeted education programs to mitigate potential risks associated with SEIM consumption.

Methods

Study design

We conducted a cross-sectional study to investigate the prevalence of and factors associated with the consumption of SEIM among adolescents and young adults in Cambodia.

Participants and data collection

The study's sample size was meticulously determined using the G*Power 3.1.9.2 program, adhering to a 5% significance level, 95% power, a 0.03 minimum effect size, and 22 variables, resulting in a requirement of 1,076 participants. To account for potential attrition, we initially approached 1,292 individuals. We targeted both urban and rural demographics, selecting Phnom Penh as our urban sample location and the rural provinces of Battambang and Kampong Cham for broader representation.

The research team utilized internet resources to compile a list of schools in Phnom Penh and two other provinces. Employing a lucky draw method for selection, the names of schools were cut out, placed into a box, and thoroughly mixed. Schools were then randomly selected one by one until the required number for the project was reached. This process resulted in the selection of 10 middle schools, 10 high schools, and 5 universities from Phnom Penh, along with 5 middle schools and 5 high schools each from Kampong Cham and Battambang.

Recruitment was strategically conducted outside of school hours to minimize disruption to educational activities. We clearly explained the study's objectives and methods to potential participants, asking about their interest in participating. To maintain consistency, a standard introduction was used across all interactions. Male interviewers asked questions to male students, and female interviewers did the same for female students to prevent any potential gender bias in the responses. We implemented a consent process, where participants above 16 years of age provided their consent, and for those below 16, consent was obtained from their guardians or parents. To mitigate bias and ensure privacy in responses, particularly given the survey's sensitive nature, participants were provided with mobile phones to complete a digital questionnaire independently. The study achieved a response rate of 62.5%. Of the 1,292 adolescents initially surveyed, 1,271 completed the study. The exclusion of 21 participants was due to incomplete surveys (15 cases) and lack of parental consent (6 cases). As a token of appreciation and to encourage participation, each participant who completed the survey was compensated with 3 USD and signed an incentive acknowledgment form.

Measurements

Assessment of SEIM Consumption and Characteristics

SEIM consumption was assessed by asking participants a simple yes/no question: 'Have you ever used the Internet to view a pornography website (a website with pictures or movies that show nudity or people having sex)?' To measure positive perceptions of SEIM, we employed a six-item Likert scale (α=.897) as developed and validated by Mattebo et al. [21]. The response options ranged from 'strongly agree' to 'strongly disagree,' including 'agree to some extent,' 'unsure,' and 'disagree to some extent.' An example item from this scale is 'Pornography can be very arousing.' The study delved into various characteristics of SEIM consumption. Key measures included the age at which individuals first searched for pornography, the company with whom they watched, the initiator of the viewing, fantasies related to sexual actions observed in porn, specific examples of these fantasies (oral, vaginal, anal, group sex), attempts to initiate sexual positions, and the types of sexual activities experimented with.

Measurement of Potential Related Factors

In exploring potential factors related to SEIM consumption, sexual sensation seeking was evaluated using the Brief Sensation Seeking Scale (BSSS). This scale, which consists of eight items with responses ranging from 1 (strongly disagree) to 5 (strongly agree), demonstrates a Cronbach's alpha of .947, which assures its reliability and supports its feasibility for this study [22]. An example item is "I would like to explore strange places." The perceived realism of SEIM was assessed using a four-item scale designed to measure the extent to which individuals perceive media content as realistic. Its Cronbach's alpha was .942 ensuring both its reliability and feasibility for use in the current research [23]. An example question from this scale is "I find sex on the Internet realistic," with response options from 1 (fully disagree) to 5 (fully agree). Attitudes toward sex were measured using the ten-item permissiveness subscale of the Brief Sexual Attitude Scale (α=.971) [24]. This subscale has a solid foundation in research, having been validated for its effectiveness in assessing sexual attitudes across four dimensions: permissiveness, birth control, communion, and instrumentality. An example question from this scale is "How do you feel about casual sex, that is, sex without a committed relationship?" The strong validity of this tool supports its feasibility in examining attitudes toward sex in the context of SEIM consumption.

The study encompassed an examination of sociodemographic background, health behaviors, and personality factors. Sociodemographic aspects were evaluated, including sex, region, grade, and parental education and occupation. For participants not attending school or university, occupation was categorized as blue- or white-collar, small business owner. Cohabitant status was assessed based on whether participants were living with single-, two-, step-parents, relatives, friends, or alone. The frequency of family dinners per week was also recorded, along with current relationship type, which was classified into stable relationships (dating for more than 3 months), open relationships (dating with the option of having other sexual partners), occasional sexual partners (within the last 3 months), or no sexual partner (within the last 3 months). Additionally, health behaviors were analyzed, including drinking (yes/no, and frequency over the past 12 months), smoking (yes/no), and substance use (yes/no). Technology-related habits were assessed by recording the usage time of smartphones, tablets, or computers on weekdays and weekends. Furthermore, personality factors were evaluated, including friends' sexual experience (seldom, some, almost), frequency of thinking about sex (seldom, neither seldom nor often, often), and the level of interest in SEIM compared to peers (less, neither less nor more, more).

Ethical Considerations

The study was approved by the University Institutional Human Subjects Review Committee (IRB No. 2022-05-043-001).

Statistical Analysis

We used SPSS 23.0 to analyze the collected data. The frequency and percentage of SEIM use were calculated based on participants' demographic, health behavior, and personality characteristics, and tested for significance using the chi-square test. The characteristics of SEIM consumption were presented using frequency and percentage. Correlation analysis was conducted among sexual sensation seeking, perceived realism of SEIM, perceived realism of SEIM, attitudes toward sex, and the consumption of SEIM. Last, hierarchical logistic regression analysis was performed to identify variables affecting SEIM use. Model 1 included sociodemographic and socio-environmental characteristics. Model 2 included health behavior characteristics, and Model 3 included personality characteristics.

Results

Consumption of SEIM according to sociodemographic background, health behavior and personality

Table 1 shows the sociodemographic characteristics of the 1,271 participants with a mean age of 18.24 ± 3.02 years. SEIM consumption was reported by 27.2%, with significantly higher usage among males (35.5%) than females (18.6%) (p<.001). Urban participants reported the highest SEIM consumption (36.6%), compared to rural areas (8.3% and 9.4%, respectively) (p<.001). SEIM consumption increased with higher grades and was highest among participants with jobs (41.5%, p<.001), with small business owners having the highest usage (57.4%). Participants with fathers who completed middle school reported the highest proportion of SEIM consumption (39.9%, p<.001). The highest SEIM consumption was reported by those in open relationships, dating with the option of other sexual partners (48.0%, p<.001), compared to those in stable relationships, not in a relationship, or without a sexual partner.

Characteristics of SEIM consumption

Table 1 also presents characteristics of SEIM use among the consumers (n=346). The highest proportion of consumers first searched for SEIM at 15-18 years (67.3%), with a mean age of 16.9 years. Most consumers watched SEIM alone (77.6%) or with friends (13.2%, p<.001). Consumers themselves (43.6%) took the initiative to watch SEIM the most, followed by male friends (39.6%), boyfriends/girlfriends (7.2%), female friends (6.4%), and gender-mixed groups of friends (3.2%) (p<.001). A large proportion of consumers rarely fantasized about trying sexual actions inspired by SEIM (66.2%), while 28.5% fantasized every month and 3.6% fantasized every week. The most common fantasy was vaginal sex (72.8%), followed by oral (24.6%), anal (2.0%), and group sex (0.7%). Approximately 60.5% of consumers had attempted sexual acts inspired by SEIM, with vaginal sex being the most common (71.4%), followed by oral sex (24.6%), anal sex (3%), and group sex (1%).

Table 2 shows the consumption of SEIM according to health behaviors among Cambodian adolescents and young adults. Those who drank alcohol and smoked recently had significantly higher levels of SEIM use than those who did not (drinking alcohol: 52.0% vs. 11.9%, smoking: 62.3% vs. 25.0%, p<.001). Participants who used alcohol 2-4 times a week consumed SEIM at the highest rate (88.1%). Participants who used substances consumed more SEIM than those who did not (52.8% vs. 26.1%, p<.001). Those who spent more than five hours a day on smartphones, tablets, or computers showed the highest SEIM usage rate (51.7% on weekdays and 46.7% on weekends).

Table 3 shows the consumption of SEIM according to the personalities of adolescents and young adults. The more participants thought their friends already had sex and the more participants thought about sex, the higher they consumed SEIM (p<.001). In addition, compared with peers, more participants were interested in SEIM and sex, the more they consumed SEIM (p<.001).

Correlations with SEIM consumption

Positive perceptions of pornography (r=.45), sexual sensation-seeking (r=.38), perceived realism of SEIM (r=.51), and attitude toward sex (r=.47) were positively correlated with SEIM consumption (Table 4).

Influencing factors of SEIM

Table 5 presents the hierarchical logistic regression model for predicting the factors of SEIM consumption. The addition of variables improved the prediction of outcomes. Model 1 explained 28.7% of the overall variance, Model 2 explained 43.2%, and Model 3 explained 61.3%. The increased powers from Models 1 to 2 and from Models 2 to 3 were all significant (both p<.001).

Model 1 revealed that men were more likely to consume SEIM than women (OR=2.57, p<.001), and age (OR=1.09, p=.002) and region (Urban: OR= 4.00, p<.001) were significant predictors of SEIM consumption. Father’s education level (OR=2.41, p<.001) and having open (OR=2.51, p<.001) or stable (OR=2.21, p<.001) relationships increased the ORs for SEIM consumption. Age was the exception in Model 2 (OR=0.99, p=.684), as all other variables from Model 1 retained their significance. The newly added lifestyle variables in Model 2 were alcohol consumption; smoking; use of substances; and smartphone, tablet, or computer time. In this case, alcohol (OR=4.17, p<.001); use of substances (OR=3.51, p=.002); and smartphone, tablet, or computer time (p<.001) were significant predictors of consuming SEIM consumption. However, smoking was not significantly associated with SEIM consumption (OR=1.65, p=.138).

In Model 3, friends’ sexual experience, thinking about sex, interest in SEIM, interest in sex, positive perception of pornography, sexual sensation seeking, perceived realism of SEIM and attitude toward sex were added. In this case, as in Model 1, sex (OR=1.68, p=.012) and father’s educational level (Middle: OR=2.21, p=.002) were significant predictors of consuming SEIM, and the variables in Model 2 remained significant (drinking alcohol: OR=3.39, p<.001; use of substances: OR=3.85, p=.003; smartphone, tablet, or computer time more than 5 hours: OR=5.89, p<.001). Friends’ sexual experience (some: OR=3.52, p<.001, almost: OR=5.04, p<.001), thinking about sex (neither seldom nor often: OR=5.45, p<.001), and being more interested in sex compared with peers (OR=66.91, p=.003) were significant predictors of consuming SEIM. Moreover, the perceived realism of SEIM (OR=1.65, p<.001) and permissive attitude toward sex (OR=1.64, p=.001) were significantly related to the consumption of SEIM.

Discussion

This study was conducted to understand pornography consumption and its related factors among adolescents and young adults in Cambodia. The observed prevalence of SEIM consumption in our study was 27.2%, which is notably lower compared to findings from Sweden (30% for women, 96% for men), the Czech Republic (58.6%), Ethiopia (77.5%), and Vietnam (84.1%) [25-28]. However, this rate still represents a 2.5-fold increase from the previously reported 10.9% SEIM use among Cambodian adolescents and young adults [10], likely due to the easier access to the internet. The relatively low rate of SEIM consumption in Cambodia may be partially explained by social desirability bias in self-reported surveys concerning sexual issues [29], as well as the deeply rooted social norms towards girls in Cambodian culture [25].

In this study, the consumption of SEIM was higher among men than women (35.5% vs. 18.6%, OR= 2.569), which is consistent with previous studies [25,30]. Men tend to have stronger sexual intentions, higher perceived realism of SEIM, and more recreational attitudes toward sex compared to women [23,31]. For women, social norms restrict them from expressing sexual interest and desire and accessing SEIM [25].

In Models 1 and 2, region had a significant effect on SEIM consumption; participants living in urban areas consumed 3.878 times more SEIM than those who lived in rural areas. This finding is congruent with previous studies conducted in Taiwan [32] and in three Asian countries, where Taipei, Shanghai, and Hanoi [30]. Urban adolescents are exposed to liberal sexual culture through easy access to SEIM and learn more about sex from the Internet than rural residents [30]. In the case of adolescents in rural areas, sexual guilt is higher and sexual education is often insufficient than urban adolescents [31], so there may be a difference in SEIM consumption.

Model 1 showed a positive association between age and SEIM consumption (OR=1.09), consistent with previous studies [33,34]. It is important to educate adolescents on the negative consequences of early exposure to SEIM and to provide pornography literacy programs to improve knowledge, attitudes, and behaviors related to pornography [35]. Such programs should include information on the legal risks of SEIM and the fact that it is created for entertainment, not educational purposes, to counter the false belief that SEIM is realistic.

SEIM consumers were more likely to engage in risky behaviors such as alcohol consumption, substance use, and excessive technology use. Among participants, 52.0% of alcohol drinkers reported SEIM consumption (OR=3.39), lower than in a Swedish study [25]. Substance use was significantly associated with SEIM consumption (52.8%, OR=3.85), consistent with previous research [27,33]. The prevalence of substance use before or during sex among young adults has been found to be approximately 36.98%, with alcohol, marijuana, and ecstasy being the most commonly used substances [36], which may increase their likelihood of consuming SEIM to satisfy sexual desires [12].

Spending more than five hours on smartphones, tablets, or computers significantly increased the likelihood of SEIM consumption (OR=5.89), consistent with previous research in Vietnam [28]. The widespread use of mobile phones and the Internet among adolescents has made it easier for them to access SEIM and sexual information anonymously [17,33]. Educational programs that promote conscious and efficient Internet use, academic motivation, and critical thinking skills are needed to address this issue [37]. These programs can help adolescents develop skills to critically evaluate online content and promote effective social media use.

In our research, we observed that adolescents whose fathers had completed middle school were more likely to use SEIM compared to those whose fathers had more than secondary school. This trend contracts with findings from Meilani, Setiyawati, and Barasa (2020) [38], which demonstrated that adolescents with fathers possessing higher levels of education, such as secondary or higher education, showed a higher propensity for SEIM usage. This discrepancy could be explained by several factors. Fathers with lower levels of education may have less awareness or understanding of the potential risks associated with SEIM, resulting in less stringent monitoring of their children's internet activities. Additionally, socio-economic factors associated with lower educational attainment could influence the availability and supervision of internet access in the household. Programs that raise awareness of the risks associated with SEIM and provide guidance on how to foster responsible internet usage are critical. Future interventions should consider these socio-economic and educational dynamics to tailor strategies that effectively mitigate SEIM usage among adolescents.

This study found that having friends with sexual experience significantly influenced the consumption of SEIM. This finding aligns with previous research emphasizing the influential role of peer networks in the use of sexual media, including pornography, as highlighted by Murdiningsih et al [39]. Additionally, the research underlines the relevance of the norms and values held by friends in shaping sexual development, a notion that finds support in the findings of Manago et al [40]. Peer norms, defined as the perceived acceptability of behaviors within a peer group, have been identified by Yang [41] as a key intermediary in the relationship between the use of SEIM and sexual experiences among young adults.

Participants who reported moderate levels of thinking about sex consumed 5.45 times more SEIM than those who thought little about it, while those who were more interested in sex than their peers consumed 66.91 times more SEIM than those who were less interested. These findings are consistent with previous research showing a positive association between SEIM use and higher sexual interest and more thinking about sex [33]. Curiosity about sex and achieving sexual arousal are common reasons for accessing SEIM [34]. Excessive sexual interest and high levels of sexual desire can lead to problematic SEIM use, such as overuse and intentional use of SEIM, which may cause sexual compulsion, impulse control disorder, or addiction [42,43]. Open communication between parents, teachers, and adolescents about their psychological status and Internet use is crucial to prevent compulsive SEIM use.

Perceived realism of SEIM was a significant factor associated with SEIM consumption (OR=1.65) in this study, consistent with previous research in the Netherlands and Vietnam [28,44]. Adolescents and young adults who perceive SEIM as highly realistic may view it as beneficial and enjoyable, leading to repeated consumption [44,45]. Therefore, providing accurate information about SEIM to adolescents and young adults is essential to correct misconceptions and promote responsible consumption.

Attitude toward sex was also a significant factor related to SEIM consumption (OR=1.64). Many previous studies have reported that SEIM and sexually permissive attitudes are correlated [23,46]. Moreover, Peter’s study reported that exposure to SEIM was associated with recreational attitudes toward sex, especially through perceived realism [23]. In addition, the more permissive or instrumental attitudes toward sex, the more SEIM consumption for sexual pleasure and sex for physical release rather than an expression of love or enjoyment together with a partner [46]. The sexual attitude of instrumentality means that the main purpose of sex is to enjoy oneself and see the sexual experience as the only way to achieve personal achievement [24]. Thus, these attitudes toward sex may have influenced the use of SEIM. In our findings on the correlation between SEIM consumption, perceived realism of SEIM (.51) and attitude toward sex (.47) were also correlated with SEIM consumption.

Study limitations and strengths

One of the main limitations of this study is its cross-sectional nature, which precludes causal inference. Therefore, the results should be interpreted as indicating correlations among various factors related to SEIM use, not causal relationships. Moreover, the reliance on self-reported surveys raises concerns about social desirability bias, necessitating caution in interpreting the results. A longitudinal study design would be beneficial to track changes over time and more accurately elucidate the causal relationships associated with SEIM use.

Future research should also focus on problematic SEIM use and investigate the mediating effect of sexual attitudes on the relationship between SEIM use and sexual behavior. Furthermore, exploring the association between SEIM use and health outcomes, such as obesity, depression, and low self-esteem, would be valuable. An intervention study to verify the development, application, and effectiveness of sexual health programs in reducing SEIM consumption among Cambodian adolescents would also be instrumental.

Despite these limitations, the study's strengths are notable. It is the first to investigate SEIM consumption and related factors among adolescents and young adults in Cambodia, providing valuable baseline data for future studies. The survey was conducted across three regions, encompassing both rural and urban areas, and incorporated a variety of factors, including sociodemographics, health behaviors, and personality characteristics.

A notable strength of this article is the extensive participant base, encompassing a large and diverse sample. This breadth contributes to the robustness of the study, potentially enhancing the statistical power and reliability of the analysis. Such a substantial dataset allows for a more comprehensive understanding of the patterns and nuances in SEIM consumption within this demographic, offering valuable insights for both academic and practical applications in mental health and parental guidance.

Conclusion

This research underscores that the consumption of SEIM among Cambodian adolescents and young adults is influenced by various factors, including gender, parental education level, and personal behaviors such as alcohol consumption and extensive use of electronic devices. Notably, the perceptions of SEIM's realism and liberal sexual attitudes also contribute significantly. These insights advocate for targeted educational interventions that aim to mitigate SEIM exposure and promote healthier sexual perceptions and responsible digital engagement among the youth. This strategic approach is vital for shaping safer online environments and enhancing sexual health education in Cambodia.

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