The prevalence and impact of violence portrayed in media and entertainment have long been a topic of debate in the United States. In 1972, the U.S. surgeon general issued a special report on the large and growing body of evidence on the public health effects of media violence.1 At the time, the report was largely focused on television as the prevailing form of media and entertainment in the United States. However, even as the landscape of media has changed throughout the intervening decades to include other forms of digital media and entertainment, the near-ubiquitous portrayals of violence in various forms of media have remained a topic of intense scrutiny.
The World Health Organization (WHO) has defined violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”2 Violence occurs at an alarming rate in the United States.3 Among Americans aged 15 to 34 years, two of the top three causes of death are homicide and suicide, and many of these deaths involve firearms.4,5 In a given year, more U.S. children will die from gun violence than will die from cancer, pneumonia, influenza, asthma, HIV/AIDS, and opioids combined.6 According to the Children’s Defense Fund, “U.S. children and teens are 15 times more likely to die from gunfire than their peers in 31 other high-income countries combined.”7 In fact, the overall rate of firearm-related death or injury in the United States is higher than the rate in most other industrialized countries.8 There were 39,740 firearm-related deaths in the United States in 2018, which averages to approximately 109 people dying each day from homicides, suicides, and unintentional deaths involving firearms.5 Further, the number of nonfatal injuries due to firearms is more than double the number of deaths.9
While multiple factors can lead to violent actions, a growing body of literature shows a strong association between the perpetration of violence and exposure to violence in media, digital media, and entertainment. This is a serious public health issue that should concern all family physicians, particularly as it affects young patients and their parents or guardians. Children, adolescents, and young adults consume digital media from a variety of sources, many of which are mobile, are accessible 24 hours a day, and offer both passive and active engagement. Many of these media platforms feature entertainment that contains significant doses of violence and portrays sexual and interpersonal aggression.
Multiple studies have shown either a strong association or a suspicion or suggestion of causality between exposure to violence in media and aggressive or violent thoughts, emotions, and behavior in those exposed.10 It is incumbent on family physicians to recognize the intersectionality of risk factors for exposure to violence in media, digital media, and entertainment, particularly for vulnerable populations. For example, some studies have shown that independent risk factors for exposure to extremely violent movies include male gender, racial or ethnic minority status, low socioeconomic status, and poor school performance.11
Call to Action
Family physicians have a unique opportunity to encourage safer use of digital media by working closely with patients and their parents or guardians during well-child and well-adolescent visits. They can connect patients and parents or guardians to resources to promote healthier habits, such as creating a family technology use plan that considers the quality and quantity of media being consumed at home. Family physicians can also engage in local, state, and national advocacy to highlight ongoing concerns regarding violence in media, digital media, and entertainment and support continued research in this field.
● Promote a family technology use plan. This allows parents and guardians to consider the quality and quantity of digital media that is consumed at home and establish guidelines for age-appropriate media exposure.12 Parental use of digital media has been shown to influence media use behaviors in children.13
● Increase personal knowledge of the types of digital media being consumed in households, particularly among children and adolescents.
● Encourage patients, children, families, and caregivers to participate in media education and media literacy programs.
● Encourage parents or guardians to monitor content and not to rely solely on media ratings or advisory labels. Parental monitoring has been shown to have protective effects on several academic, social, and physical outcomes for children, including aggressive behaviors.14
● Advise adults to consume digital media with their children and help them process media violence. Recording programs in advance makes it possible to pause for discussion or processing.
● Consider asking questions regarding media use during well-child and well-adolescent visits, such as:
● Consider asking patients and parents or guardians about exposure to violence in digital media. If you identify heavy exposure (i.e., more than two hours daily), take additional history of aggressive behaviors, sleep problems, fears, and depression. Be ready to discuss the health risks associated with consumption of violent media.
● Work with patients and parents or guardians to create a list of healthy alternatives to consumption of violent media.
● Counsel parents or guardians and caregivers of children younger than two years of age to limit their child's screen time to no more than two hours a day. Discourage routine digital media exposure.
● Encourage use of technology that restricts certain content and turns off the device after a certain amount of time.
● Create a nonjudgmental and culturally proficient environment in which patients and parents or guardians can ask questions and express concerns.
● Provide and/or promote nonviolent media choices in outpatient waiting rooms and inpatient settings.
● Display promotional information for community media literacy education opportunities.
● Become familiar with research on trends in media use and the effects of media violence on individuals.
● Align medical education and residency program training to deliver evidence-based information on the potential health effects of consumption of violent media.
● Expand current continuing medical education (CME) offerings to include evidence-based information on best practices to promote media education and healthy media consumption.
● Support the development of media literacy education programs that focus on understanding the divide between real and fictionalized violence on television, in movies, and in other forms of digital media, as well as the responsibility, complexity, and consequences of real-life violence. Media literacy programs have been shown to be effective in limiting the negative effects of media and exploring potential positive social uses of media.14,15,16
● Partner with medical organizations, government entities, and educators to advocate to keep this issue on the public health agenda.
● Partner with families and community-based organizations to demand that media producers limit the amount and type of violence portrayed in mass media.
● Advocate for research funding to continue studying this topic.
● Advocate for enhancements to media rating systems to help parents or guardians and caregivers guide children to make healthy media choices.
Media Violence in the United States
The term “digital media” refers to all types of electronic data, including text, databases, images, audio, and video; it may also refer to the electronic devices that store the data and to the communications methods that transmit the data.17 Examples include streaming video, messaging and social networking platforms, video games, television, music, music videos, and social media. The expansion of media to include more and more forms of digital media has made it easier to access and be exposed to portrayals of violence. The advent of the internet has further expanded the reach and impact of digital media by encouraging interactivity and group forming through media such as online gaming, virtual reality, digital art, and social media.18
As the cost of televisions and other screen media devices has continued to drop in recent years, screen media, streaming media, and other digital media have become more accessible than ever. In the United States, 84% of households contain at least one smartphone, with the median U.S. household containing five connected devices (e.g., smartphone, laptop or desktop computer, streaming media device) and one in five households containing 10 or more of these devices.19
For decades, watching television was the most common form of daily media consumption, but that changed in 2019, with time on the internet exceeding time spent watching television.20 Research suggests that young people in the United States spend more time interacting with various digital media than in any other activity except sleeping, with a typical 8- to 18-year-old using some form of media for an average of 50 hours per week or more.21 On average, U.S. teens spend more than seven hours per day consuming a variety of entertainment screen media (e.g., smartphone, social media, gaming, music) and 8- to 12-year-olds spend more than four hours per day.22
Studies demonstrating an association between exposure to violence in the media and real-life aggression and violence began appearing in the 1950s. Since then, various government agencies and organizations have examined the relationship, reporting their findings in publications including the surgeon general’s 1972 report, a 1982 National Institute of Mental Health (NIMH) review, and a joint statement on the impact of entertainment violence on children issued following a 2000 congressional summit.1,23,24 In 2000, the Federal Bureau of Investigation (FBI) released a report noting that media violence is a risk factor in shootings in school.25 A 2003 review identified media violence as a significant causal factor in aggression and violence.26 The Federal Communications Commission (FCC) issued a 2007 report on violent programming on television and noted that there is “strong evidence” that exposure to violence through media can increase aggressive behavior in children.27
These reports and others are based on a body of literature that includes more than 2,000 scientific papers, studies, and reviews demonstrating the various effects that exposure to media violence can have on children and adolescents. These include increases in aggressive behavior, desensitization to violence, bullying, fear, depression, nightmares, and sleep disturbances.28,29,30 Some studies found the strength of association between consumption of violent media and these behaviors to be nearly as strong as the association between cigarette smoking and lung cancer, and stronger than the well-established associations between calcium intake and bone mass, lead ingestion and IQ, and failure to use condoms and acquisition of HIV.31
Seventy-one percent of 8- to 18-year-olds have a television in their bedroom.21 In addition, 50% of individuals in this age group access television content online and/or on mobile platforms during a typical day.21 Researchers have found that 8- to 12-year-olds watch television programming for an average of 1 hour and 23 minutes per day and 13- to 18-year-olds watch for an average of 1 hour and 45 minutes per day, with approximately 19 minutes and 38 minutes of this time, respectively, spent viewing television content on other devices (e.g., computer, smartphone, tablet, MP3 player).22
An average American youth will witness 200,000 violent acts on television before age 18.32 Weapons appear on prime-time television an average of nine times each hour.33 The violence depicted in television content is often considerable, even in programs not advertised as violent, and children’s shows are particularly violent. Watching Saturday morning cartoons used to be a common aspect of American life. Now, children can access cartoons on demand. Studies analyzing the content of popular cartoons noted that they contain 20 to 25 violent acts per hour, which is about five times as many as prime-time programs.34 Overall, 46% of television violence occurs in cartoons.35,36,37 Additionally, these programs are more likely to juxtapose violence with humor (67%) and less likely to show the long-term consequences of violence (5%).34,35,36 Although some claim that cartoon violence is not as “real,” and therefore not as damaging, it has been shown to increase the likelihood of aggressive, antisocial behavior in youth.38 This association makes sense in light of children’s developmental difficulty discerning the real from the fantastic.39
Nearly all American teens—97% of males and 83% of females—play video games.40 Eighty percent of teens play at least three hours of video games per week on a game console, with 25% of teens playing 11 hours or more per week.41 Additional exposure occurs among teens who identify as fans of competitive video gaming, or esports; among 14- to 21-year-olds, nearly as many identified themselves as esports fans as professional football fans.42
Many video games contain violent content, and studies have shown a significant association between violent video game exposure and increased aggression, increased desensitization to violence, and decreased empathy.43 Video games that involve assuming the roles of aggressors or soldiers offer players the opportunity to be “virtual perpetrators.” These games also reward players for successfully carrying out violent behavior. Studies have shown that the general effects of violence may be more profound when children play these interactive games than when they are exposed to violence in a more passive manner, such as when watching television.44,45
Music plays a central role in the lives of many adolescents and young adults, helping them sort through their emotions, identify with peer groups, and develop a sense of self. Forty-seven percent of 8- to 12-year-olds listen to music every day, with an average of 43 minutes of listening time per day, and 82% of 13- to 18-year-olds listen to music every day, with an average of slightly more than two hours of listening time per day.22
There have been fewer studies of the effects of violent portrayals in music than studies of violence in other forms of media. One study found a correlation between violent lyrics and aggressive thoughts and emotions, but not actions.46 Additional studies have shown that individuals who prefer heavy metal or rap music are more likely to engage in risky behaviors, have lower grades in elementary school and during adolescence, and have a history of counseling in elementary school for academic problems, compared with peers who prefer other types of music.47
Music videos have been sources of violent content for decades. Content analysis has shown that more than 80% of the violence in music videos is perpetrated by attractive role models and that music videos mainly depict acts of violence against women and people in minority groups.48 In many music videos, violent scenes are of a sexual nature. In addition, artistic choices and editing may juxtapose violence with images such as beautiful scenery, potentially linking violence to pleasurable experiences.49 Several studies that focused on violence in rap music found that this genre contains more violent content than other genres. They also found that viewers of rap music videos were more likely to accept the use of violence, to accept violence against women, and to commit violent or aggressive acts themselves.49
Several researchers have described an increase in violent content in movies, despite a national rating system. For example, studies have found that 91% of movies on television contain violence, including extreme violence.11,36 Although film ratings and advisory labels can help parents decide on movies to avoid, certain labels, such as “parental discretion advised” and the R rating, have been shown to attract children, especially boys.33,35,36 In 2003, 10 million adolescents aged 10 to 14 years, including 1 million 10-year-olds, had been exposed to that year’s most popular R-rated film.11 One study found that between 2012 and 2017, there were twice as many negative themes—most commonly associated with violence—as positive themes depicted in the 25 top-grossing R-rated films.50 Researchers have also noted that the amount of gun violence in top-grossing PG-13 films has more than tripled since the introduction of the rating in 1985.51 In 2012, PG-13 films actually contained more gun violence than R-rated films.52 Further, violence is even present in movies that are not considered to be violent, such as animated films.53
1. Surgeon General’s Scientific Advisory Committee on Television and Social Behavior. Television and growing up: the impact of televised violence. Report to the Surgeon General, United States Public Health Service. U.S. Government Printing Office; 1972. DHEW publication no. HSM 72-9090. Accessed October 16, 2020. https://collections.nlm.nih.gov/ext/document/101584932X543/PDF/101584932X543.pdf
2. World Health Organization. Definition and typology of violence. Accessed July 19, 2020. https://www.who.int/violenceprevention/approach/definition/en/
3. American Academy of Family Physicians. Violence (reviewed and approved 2014). Accessed October 16, 2020. https://www.aafp.org/about/policies/all/violence-position-paper.html
4. Centers for Disease Control and Prevention. 10 leading causes of death by age group, United States -- 2018. Accessed July 19, 2020. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2018_1100w850h.jpg
5. Centers for Disease Control and Prevention. Firearm violence prevention. Accessed October 20, 2020. https://www.cdc.gov/violenceprevention/firearms/fastfact.html
6. Children’s Defense Fund. Protect children, not guns 2019. Accessed July 31, 2020. https://www.childrensdefense.org/wp-content/uploads/2019/09/Protect-Children-Not-Guns-2019.pdf
7. Children’s Defense Fund. The state of America’s children 2020. Accessed July 19, 2020. https://www.childrensdefense.org/policy/resources/soac-2020-overview
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10. Huesmann LR. The impact of electronic media violence: scientific theory and research. J Adolesc Health. 2007;41(6 Suppl 1):S6-S13.
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12. American Academy of Pediatrics. Family media plan. Accessed October 19, 2020. https://www.healthychildren.org/English/media/Pages/default.aspx
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14. Gentile DA, Reimer RA, Nathanson AI, et al. Protective effects of parental monitoring of children's media use: a prospective study, JAMA Pediatr. 2014;(168)5:479-484.https://jamanetwork.com/journals/jamapediatrics/fullarticle/1852609
15. American Academy Pediatrics Committee on Public Education. Media education. Pediatrics. 1999;104(2):341-343.
16. Brown JA. Television “Critical Viewing Skills” Education: Major Media Literacy Projects in the United States and Selected Countries. Routledge; 1991.
17. PC Magazine Encyclopedia. Digital media. Accessed October 20, 2020. https://www.pcmag.com/encyclopedia/term/digital-media
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19. Pew Research Center. A third of Americans live in a household with three or more smartphones. May 25, 2017. Accessed October 16, 2020. https://www.pewresearch.org/fact-tank/2017/05/25/a-third-of-americans-live-in-a-household-with-three-or-more-smartphones/
20. Dolliver M. U.S. time spent with media 2019. eMarketer; 2019. Accessed October 16, 2020. https://www.emarketer.com/content/us-time-spent-with-media-2019
21. Rideout VJ, Foehr UG, Roberts DF. Generation M2: media in the lives of 8- to 18-year-olds. The Henry J. Kaiser Family Foundation; 2010. Accessed July 19, 2020. https://files.eric.ed.gov/fulltext/ED527859.pdf
22. Rideout V, Robb MB. The Common Sense census: media use by tweens and teens, 2019. Common Sense Media; 2019. Accessed October 16, 2020. https://www.commonsensemedia.org/sites/default/files/uploads/research/2019-census-8-to-18-full-report-updated.pdf
23. National Institute of Mental Health. Television and behavior: ten years of scientific progress and implications for the eighties. Vol. I: summary report. U.S. Government Printing Office; 1982. DHHS publication no. ADM 82-1195. Accessed October 16, 2020. https://files.eric.ed.gov/fulltext/ED222186.pdf
24. American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, American Psychological Association, et al. Joint statement on the impact of entertainment violence on children. Congressional Public Health Summit. 2000.
25. O’Toole ME. The school shooter: a threat assessment perspective. Federal Bureau of Investigation; 1999. Accessed October 16, 2020. https://www.fbi.gov/file-repository/stats-services-publications-school-shooter-school-shooter/view
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40. Pew Research Center. Teens, social media & technology 2018. Accessed October 19, 2020. https://www.pewresearch.org/internet/wp-content/uploads/sites/9/2018/05/PI_2018.05.31_TeensTech_FINAL.pdf
41. PricewaterhouseCoopers. The evolution of video gaming and content consumption. 2012. Accessed October 20, 2020. https://www.pwc.com/sg/en/tice/assets/ticenews201206/evolutionvideogame201206.pdf
42. UMass Lowell Center for Public Opinion. 2017 sports poll release – esports and competitive video gaming. Accessed October 19, 2020. https://www.uml.edu/docs/esports-highlights_tcm18-288117.pdf
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44. Hollingdale J, Greitemeyer T. The effect of online violence video games on levels of aggression. PLoS ONE. 2014;9(11):e111790.
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47. American Academy of Pediatrics Council on Communications and Media. Impact of music, music lyrics, and music videos on children and youth. Pediatrics. 2009;124(5):1488-1494.
48. Rich M, Woods ER, Goodman E, et al. Aggressors or victims: gender and race in music video violence. Pediatrics. 1998;101(4 Pt 1):669-674.
49. Ashby SL, Rich M. Video killed the radio star: the effects of music videos on adolescent health. Adolesc Med Clin. 2005;(16)2:371-393.
50. Watts A, Loloi J, Lessner K, et al. Themes depicted in top-grossing rated-R films released from 2012 to 2017. Cureus. 2020;12(2):e6844.
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52. Bushman BJ, Jamieson PE, Weitz I, et al. Gun violence trends in movies. Pediatrics. 2013;132(6):1014-1018.
53. Kirsh SJ. Cartoon violence and aggression in youth. Aggression and Violent Behavior. 2006;11:547-557.