For the Internet generation, access to the Internet through digital devices is an essential part of their daily lives. Approximately 60% of the adult population in developing countries and 90% in developed countries use the Internet, and 67% and 49% of adults use social media, respectively [1]. Although the widespread use of the Internet improves information equality, it also brings about adverse consequences such as cyberbullying [2] or sexting [3].

Sexting, a contraction of “sex” and “texting,” is one of the emerging issues of the Internet age, especially among adolescents [3]. Currently, there is no universally recognized definition of sexting. Some articles define sexting based on its content (texts, images, or videos), mode of transmission (smartphone or social networking site), consent (consensual or non-consensual), and actions (sending, receiving, or forwarding) [4]. However, most studies agree that sexting is the transmission of sexually explicit content (such as texts, images, or videos) to others through digital technology (such as smartphones or computers) [4]. In our study, we identified three types of sexting: sexting of one’s own information, sexting of non-consensual information, and pressured sexting, based on previous theoretical structures [3,5].

Sexting has been linked to negative mental health outcomes such as depression or anxiety [6], although these internalizing behaviors tend to decrease as people age [7]. A qualitative analysis of posts on a peer support mental health forum by Razi et al. [8] revealed that sexting led to self-harm and suicidal ideation, as well as other negative mental health consequences (such as shame, hopelessness, and rage), although there were still some positive feelings present. Another survey of 6,021 high school students in the U.S. showed that adolescents who experienced sexting, whether consensual or non-consensual, had a higher risk for depression, suicide attempts, and self-harm [9]. Additionally, a survey of Mexican university students demonstrated a relationship between sexting, being a victim of cyberbullying, and depression, all of which may contribute to suicidal ideation [10]. Although the connection between sexting and self-harm is still unclear, sexting should be recognized as a factor that may affect mental health among adolescents.

The prevalence of sexting was estimated to be between 14.8% (sending) and 27.4% (receiving) based on a meta-analysis, with a mean age of 15.16 years [11]. There is no consensus on the gender differences in the prevalence of sexting. Some studies reported female predominance [11,12], while others reported male predominance [13-15]. Gender differences may play an important role in sexting. A qualitative study found that although both male and female adolescents agree that victims who share their intimate images to other people should take some responsibility, there was a gender difference in the consequences of sexting among adolescents in New Zealand [16]. Females are viewed as more sexualized [17], while they are shaped by social norms to protect their purity [18]. The consequence of intimate image being shared without consent is usually harmful for females under most of the social norms [17]. On the other hand, most males were less concerned about privacy and took less responsibility [17]. This difference may lead to different association between sexting and self-harm.

Some researchers view adolescent sexting as problematic behavior, but others viewed it as a social phenomenon which may have cultural differences [19,20]. A multinational survey study revealed that China was ranked last of 11 countries with regard to the prevalence of sexting one’s own information (14.4%) or risky sexting (12.2%) [21]. Our previous work had found that sexting prevalence was 1.3% in the Taiwanese adolescent population with a male predominance (1.5% vs. 1.1%) and associated with self-harm risk [22]. However, the motivation, meaning, and impact of sexting may have gender differences [8,16]. Moreover, different types of sexting may also have different impacts on self-harm. On the basis of our previous work, the aim of our study is to analyze the gender difference between different sexting types, and the effect of gender on the association between sexting and self-harm behavior.

In our study, we found that Taiwanese adolescents who have experienced bullying (both cyberbullying and traditional bullying, both as perpetrators and victims) are more likely to engage in sexting. Both sexting of one’s own information and pressured sexting, but not non-consensual sexting, were linked to increased self-harm behaviors in adolescents, as well as being victims of bullying (both cyberbullying and traditional bullying, but not perpetration). The impact of sexting on self-harm was found to differ between males and females. In male students, all forms of sexting were associated with a higher risk of self-harm. However, Taiwanese female adolescents who reported sexting their own information or being pressured to sext showed a higher risk of self-harm behavior compared to their male peers in the two-way interaction analysis.

This is the first study to focus on gender differences in the association between different types of sexting and self-harm in a non-Western society. Unlike previous studies [25-27], we found that fewer Taiwanese female adolescents engage in all forms of sexting compared to males. Previous studies have shown that each gender may have different sexting preferences [28]. For example, boys were found to engage in more non-consensual sexting, while girls experienced more pressured sexting [27]. As a behavior that heavily involves sexual and social contexts, the meaning and consequences of sexting may differ between genders. According to Bandura’s social learning theory [29], adolescents can learn behaviors (such as sexting) from peers through social media. In the era of social media, adolescents often judging themselves according to the comparison with their peer’s behavior online [30]. The number of “likes,” friends, and/or followers can be a strong reward in the reinforcement learning of behavior, and the fear of missing out can cause anxiety and push them to imitate their peers and to under-evaluate the possible harmful outcome [30]. For example, girls are more likely to be viewed as sexually desirable and blamable objects in sexual image-sharing, while boys may view sexting as a way to express their masculinity [31]. Moreover, males and females are shaped into different gender roles in different social structures [32]. In the context of sexting, teenage boys usually accumulated “reputation” by exchanging sexual images, while in contrast, girls are often the providers of sexual images and the objects of gaze in sexting [33]. Moreover, girls face more unfriendly social norms than boys in certain culture contexts. For example, slut shaming, the stigmatizing term referring to girls “who engage in, or are perceived as engaging in sexual behavior or sexualized expression,” [34] is a known form of gender-based victimization and has adverse effects on the psychological well-being and distress of adolescent girls [35,36]. This may possibly explain that only female adolescents, but not males, had a relationship between depressive symptoms and sexting [12].

Different types of sexting may also be associated with different risks of self-harm. In our multivariable model, we found that pressured sexting, but not non-consensual sexting was more strongly associated with self-harm, particularly in females. However, in a previous survey among US adolescents, Wachs et al. [27] found that both non-consensual sexting and pressured sexting were positively correlated with depressive symptoms and non-suicidal self-harm. Another study by Frankel et al. [9] also revealed that non-consensual sexting was positively correlated with depression. This difference may stem from the different social context of non-consensual sexting in Taiwan. Non-consensual sexting is a complex sexual behavior that has diverse meanings in adolescent relationships [37], and may have unique implications in the Taiwanese adolescent population. One possible explanation is that, in cases of non-consensual sexting, the power dynamic may be inverted. In Taiwan, more female than male have reported receiving sexting, e.g. unsolicited “dick pics” as a form of sexual harassment [38]. The act of sharing these experiences with peers—often through humor or collective outrage—may serve to mitigate the emotional harm typically associated with such harassment. This coping mechanism could partly explain why, in our findings, non-consensual sexting was not significantly associated with self-harm risk among female adolescents. However, the nature of female non-consensual sexting and the lived experience of female non-consensual sexting needed further exploration.

Our study found that sexting one’s own information, even if consensual, was associated with self-harm, with females at higher risk compared to males. Previous surveys have found that consensual sexting of one’s own information is a common practice among adolescents and is considered a normal part of adolescent sexual development [9,39]. Young people hold differing views about sexting their own information, from positive to negative, across different European countries [40]. Although initially consensual sexting of one’s own information may not cause harm to both parties [39], it can also result in the risk of non-consensual dissemination of sexual images, bullying, and social shaming, particularly for females [41]. This could contribute to the higher risk of self-harm behavior in adolescents who reported sexting their own information, especially for girls who are more susceptible to slut-shaming based on their sexual image.

There were several limitations in our study. Firstly, its cross-sectional design cannot establish causality between bully experience, sexting, and self-harm, as their relationship may be complex and potentially influenced by other factors, such as personality or mental health conditions including anxiety or depression, that were not collected in our study. Secondly, our study only included three types of sexting and did not collect information on other forms of sexting, such as by text, picture, or video, which may have different effects on self-harm. Third, because the RTSHIA score was not normally distributed in this study sample, the results of the linear regression model, especially the hypothesis testing, should be interpreted with caution. Lastly, there is a lack of widely accepted consensus on the definition of sexting and its measurement, which may hinder the comparability of our results with previous literature.

In conclusion, after controlling for possible confounding factors such as demographic data and bullying experience, our study found that sexting may be associated with self-harm behavior among Taiwanese adolescents, with females having significantly higher risks for sexting their own information and being subjected to pressured sexting. This result expands our understanding of the effects of sexting on mental health outcomes among non-Western adolescent populations and highlights the importance of considering gender issues. Further research is needed to better understand the nature of sexting in specific populations, such as females, gender minorities, and in non-Western cultures.