• Violence in the Media and Entertainment (Position Paper)

    The World Health Organization 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.”1

    Violence occurs at an alarming rate in the United States. Among Americans aged 15 to 34 years, two of the top three causes of death are homicide and suicide.2 In a given year, more U.S. children will die from gunfire than will die from cancer, pneumonia, influenza, asthma, and HIV/AIDS combined.3

    The rate of firearm-related death or injury in the United States is the highest among industrialized countries, with more than 32,000 deaths each year. In recent years, this has meant that 88 people die each day from firearm-related homicides, suicides, and unintentional deaths. Further, the number of nonfatal injuries due to firearms is more than double the number of deaths.4

    While there are multiple factors that lead to violent actions, a growing body of literature shows a strong association between the perpetration of violence and the exposure to violence through the media.

    Media Violence in the United States

    Children and adolescents in the U.S. spend an average of about seven and a half hours a day using various forms of entertainment media, such as television, video games, the Internet, and recorded music. Research suggests that the time they spend interacting with various media surpasses all other activities except sleep.5

    Moreover, studies have shown that by the time young people living today reach their 70s, they will have spent the equivalent of 7 to 10 years of their lives watching television.6

    Today’s children live in environments where, on average, families own nearly four televisions, nearly three DVD players, one DVR, two CD players, two radios, two video game consoles, and two computers.5 Television still dominates children’s media consumption, but the number of kids watching television are dropping with each age group. At the same time, media consumption through mobile devices and the Internet is increasing in every age group.7

    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. These include a 1972 Surgeon General’s report,8 a 1982 National Institute of Mental Health (NIMH) review,9 and a 2000 Congressional summit which issued a joint statement on the impact of entertainment violence on children.10 In 2000, the Federal Bureau of Investigation (FBI) released a report noting that media violence is a risk factor in shootings in school.11 A 2003 NIMH report noted media violence to be a significant causal factor in aggression and violence.12 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 the media can increase aggressive behavior in children.13

    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.14,15,16

    Some studies found the strength of association 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.17

    Violence is ubiquitous in mass media in the U.S., whether consumed through television, video games, music, movies, or the Internet.


    An average American youth will witness 200,000 violent acts on television before age 18.18 Violence is often considerable, even in programs not advertised as violent. Overall, weapons appear on prime time television an average of nine times each hour.19 An estimated 54 percent of American children can watch this programming from the privacy of their own bedrooms.20,21,22

    Children’s shows are particularly violent. Watching Saturday morning cartoons used to be a common aspect of American life. Now, networks feature cartoons continuously. Studies analyzing the content of popular cartoons noted that they contain 20 to 25 violent acts per hour, which is about six times as many as prime time programs.23 Overall, 46 percent of television violence occurs in cartoons.20,21,22 Additionally, these programs are more likely to juxtapose violence with humor (67 percent) and less likely to show the long-term consequences of violence (5 percent).21,22,23,24 Although some claim that cartoon violence is not as “real” and therefore not as damaging, cartoon violence has been shown to increase the likelihood of aggressive, antisocial behavior in youth.24 This makes sense in light of children’s developmental difficulty discerning the real from the fantastic.25

    Video Games

    Nearly all American teens – one survey documenting 97 percent – play video games. Studies have shown the average time spent playing to be around 13 hours per week.26 Many games have violent content and studies have shown a significant association between violent content with increases in aggression, desensitization to violence, decrease in positive social behaviors, and increases in delinquent behaviors.27,28,29 Video games offer players the opportunity to be “virtual perpetrators,” by assuming the roles of aggressors and soldiers. These interactive games also reward players for successful violent behavior. Studies have shown that the general effects of violence may be more profound when children play these interactive games than when they watch violence in a more passive manner, such as when watching television.30,31

    Music (Lyrics and Music Videos)

    Music plays a central role in adolescent and young adult lives, helping them sort through emotions and identify with certain peer groups and develop a sense of self. Children 8 to 18 years of age have been found to listen to at least two and a half hours of music a day.5

    Fewer studies have looked at the effects of violence portrayals in music. One study by the American Psychological Association (APA) found a correlation between violent lyrics, and aggressive thoughts and emotions, but not actions.32

    Music videos have been sources of violent content for decades. Content analysis has shown that in music videos more than 80 percent of violence is perpetrated by attractive people, and that it depicts acts of violence mainly against women and minorities.33 Violent scenes were of a sexual nature in many, with one study showing that 81 percent of videos that portrayed violence contained sexual imagery, often intertwined. Additionally, artistic features and editing may juxtapose violence with beautiful scenery, potentially linking it to pleasurable or pleasing experiences.34

    Several studies have focused on rap music, and found them to contain more violence than other genres. They also found viewers to be more likely to accept the use of violence, to accept violence against women, and to commit violent or aggressive acts themselves.34


    Studies have found that 91 percent of movies on television contained violence, even extreme violence.35 Several researchers have described an increase of violent content in movies, despite a national rating system. They note that the amount of gun violence in top grossing PG-13 films has more than tripled since the introduction of the rating in 1985.36 It was also noted that, in 2012, popular PG-13 films contained significantly more gun violence than R-rated films.37

    Children, adolescents and young adults consume entertainment from a variety of sources that are accessible 24 hours a day, are mobile, and offer passive, as well as more 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 a strong association, and suspicion or suggestion of causality between exposure to violence in the media, and aggressive or violent behavior in viewers. This is a serious public health issue that should concern all family physicians.

    What Can Family Physicians Do

    1.     Clinical Setting

             a. Consider discussing media use during well-child visits       

    • Ask at least two media-related questions: 1) How much entertainment media per day is the child or teenager watching? 2) Is there a television set or Internet connection in the child's or teenager's bedroom?
    • Question patients about excessive exposure to media violence.
    • If you identify heavy use (more than 2 hours daily), take additional history of aggressive behaviors, sleep problems, fears, and depression.
    • Suggest healthy alternatives.
    • Children under two years of age should be discouraged from watching television.
    • Incorporate warnings about the health risks of violent media consumption into the well-child visit.       

    b. Encourage parents and caregivers to monitor content. Parental monitoring has been shown to have protective effects on several academic, social and physical outcomes, including aggressive behaviors.36

    • Urge parents to co-view shows and content with their children.
    • Encourage parents to discuss the content of television, films, video games, music videos, and the Internet with their children and make comparisons to real-life situations and consequences.
    • Consider and discuss movie and video game ratings and labels with parents to set expectations and guide choice of content.

    Although film ratings and advisory labels can help parents decide on programs to be avoided, there are two major problems with relying on this system. First, certain labels, such as “parental discretion advised” and “R” have been shown to attract children, especially boys.20,21,22 Second, violence is present is many programs not considered to be violent, such as children’s cartoons.

               c. Counsel parents and caregivers to limit exposure duration

    • Exposure can be limited by removing televisions, video games, computers, and Internet connection from the bedroom.
    • Limit screen time to no more than two hours a day.
    • Use technology that locks certain channels or turns off the computer or television after a certain amount of time.

            d. Clinical environment

    • Limit video and television use in waiting rooms.
    • Provide only nonviolent media choices in outpatient waiting rooms and inpatient settings.
    • Provide books, toys, and other alternative activities for patients who are waiting.

    2.   Promote Media Education

    In addition to limiting exposure to violent media, educational efforts should be developed to help children understand the divide between real and fictionalized violence. Such media literacy programs have been shown to be effective, both in limiting the negative effects of media, as well as in exploring the potential positive social uses of media.39,40,41

    • Encourage patients, children, families, and caregivers to participate in media education, and media literacy programs.
    • Advise adults to watch with their children, and help them process media violence. Taping programs beforehand enables pausing for discussion or processing.
    • Support the development of media education programs that focus on demystifying and processing media violence. Emphasis should be placed on the inappropriate and unrealistic nature of violence on television and films, and the consequences, responsibility, and complexity involved with true violence.

    3.   Support and Engage in Professional Education

    • Become familiar with the research of trends of media use, and the effects of medial violence on patients.
    • Disseminate this knowledge via teaching at medical schools, residencies, grand rounds, and via community–based lectures.
    • Request, attend, or create CME.

    4.   Advocacy and Policy Changes

    • Partner with other medical organizations, government entities, and educators to advocate keeping this issue on the public’s 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 enable parents and caregivers to guide their children to make healthy media choices.


    1. World Health Organization. Health Topics. Violence. 2015. Accessed July 10, 2015.
    2. Centers for Disease Control and Prevention. Deaths: final data for 2013. National vital statistics reports; vol. 64, no. 2. National Center for Health Statistics. 2013. Accessed June 30, 2015.
    3. Children’s Defense Fund. Protect children instead of guns, 2004. Accessed June 18, 2015.
    4. Weinberger SE, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162(7):513-516.
    5. A Kaiser Family Foundation Study. Generation M2: media in the lives of 8- to 18-year-olds. Accessed March 29, 2015.
    6. American Academy of Pediatrics. Council on Communications and Media. Policy Statement. Children, adolescents, and the media. Pediatrics. 2013;132;(5):958-961.
    7. Adweek. The Kids Issue. Infographic: a look at kids’ media consumption. Where different age groups tend to spend their time online. 2015. Accessed July 10, 2015.
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    9. U.S. Department of Health and Human Services. National Institute of Mental Health. Television and behavior. Ten years of scientific progress and implications for the eighties. Volume I: summary report. 1982. 
    10. American Academy of Pediatrics, et al. Joint statement on the impact of entertainment violence on children, Congressional Public Health Summit. 2000. Accessed March 29, 2015.
    11. FBI Academy. Critical Incidence Response Group. National Center for the Analysis of Violent Crime. The school shooter: a threat assessment perspective.
      Accessed March 29, 2015.
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     (2004) (2016 COD)