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Kevin Haninger; Kimberly M. Thompson, ScD

JAMA. 2004;291:856-865.

Context  Children's exposure to violence, blood, sexual themes, profanity, substances, and gambling in the media remains a source of public health concern. However, content in video games played by older children and adolescents has not been quantified or compared with the rating information provided to consumers by the Entertainment Software Rating Board (ESRB).

Objectives  To quantify and characterize the content in video games rated T (for "Teen") and to measure the agreement between the content observed in game play and the ESRB-assigned content descriptors displayed on the game box.

Design and Setting  We created a database of all 396 T-rated video game titles released on the major video game consoles in the United States by April 1, 2001, to identify the distribution of games by genre and to characterize the distribution of ESRB-assigned content descriptors. We randomly sampled 80 video game titles (which included 81 games because 1 title included 2 separate games), played each game for at least 1 hour, quantitatively assessed the content, and compared the content we observed with the content descriptors assigned by the ESRB.

Main Outcome Measures  Depictions of violence, blood, sexual themes, gambling, and alcohol, tobacco, or other drugs; whether injuring or killing characters is rewarded or is required to advance in the game; characterization of gender associated with sexual themes; and use of profanity in dialogue, lyrics, or gestures.

Results  Analysis of all content descriptors assigned to the 396 T-rated video game titles showed 373 (94%) received content descriptors for violence, 102 (26%) for blood, 60 (15%) for sexual themes, 57 (14%) for profanity, 26 (7%) for comic mischief, 6 (2%) for substances, and none for gambling. In the random sample of 81 games we played, we found that 79 (98%) involved intentional violence for an average of 36% of game play, 73 (90%) rewarded or required the player to injure characters, 56 (69%) rewarded or required the player to kill, 34 (42%) depicted blood, 22 (27%) depicted sexual themes, 22 (27%) contained profanity, 12 (15%) depicted substances, and 1 (1%) involved gambling. Our observations of 81 games match the ESRB content descriptors for violence in 77 games (95%), for blood in 22 (27%), for sexual themes in 16 (20%), for profanity in 14 (17%), and for substances in 1 (1%). Games were significantly more likely to depict females partially nude or engaged in sexual behaviors than males. Overall, we identified 51 observations of content that could warrant a content descriptor in 39 games (48%) in which the ESRB had not assigned a content descriptor. We found that the ESRB assigned 7 content descriptors for 7 games (9%) in which we did not observe the content indicated within 1 hour of game play.

Conclusions  Content analysis suggests a significant amount of content in T-rated video games that might surprise adolescent players and their parents given the presence of this content in games without ESRB content descriptors. Physicians and parents should be aware that popular T-rated video games may be a source of exposure to a wide range of unexpected content.

Author Affiliations: Center on Media and Child Health, Children's Hospital, Boston, Mass, and Kids Risk Project, Harvard School of Public Health, Harvard University, Boston, Mass.

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