Introduction: A growing body of research has addressed adolescent use of mobile devices to exchange sexually explicit images and messages (sexting). While there are legal consequences in some states for sexting among adolescents, research findings have also demonstrated associations between sexting and sexual activity. The purpose of this systematic review was to synthesize research examining the association between adolescent sexting and sexual activity. Methods: Five databases (The Cumulative Index to Nursing and Allied Health Literature, Embase, Ovid, MEDLINE, PsychINFO, and Scopus) were searched for studies measuring adolescent sexting and sexual behaviors. Studies were appraised for quality using a modified Downs and Black scale. Studies reporting frequencies or odds ratios were eligible for inclusion in random effects meta-analytic models. Results: Of 669 articles retrieved, 9 studies met inclusion for systematic review; of these, 6 were included in meta-analysis. Pooling data from 9,676 adolescents, the odds of reporting sexual activity was 6.3 times higher (95% confidence interval 4.9–8.1; Q=14.3,I2= 65.1) for adolescents who sent sexts compared to those who did not. Discussion: These data suggest that adolescents who send sexually explicit text messages are more likely to report sexual activity than adolescents who do not. Midwives are well-poised to integrate a discussion of sexting into sexual and reproductive health counseling with adolescent and young adult patients.