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The role of sexual health nurses in identifying child sexual exploitation

Ann Marie Sangster, Dr Maureen Crowley, and Amanda McGrandles explore sexual health nurses’ perceptions of their role in the identification of children and young people at risk of sexual exploitation, using an interpretivist generic qualitative approach.

Lead author: Ann Marie Sangster, health visiting team leader at NHS Lanarkshire MSc; PgC; BSc (Hons) SPQ; BSc; RM; RGN

Correspondence to: annmarie.hamilton@nhs.net

Second author: Dr Maureen Crowley is former programme lead/lecturer in advancing practice; Amanda McGrandles is programme lead/lecturer in mental health, both at the University of the West of Scotland.

 


Research summary

A form of trafficking, child sexual exploitation (CSE), is a hidden crime and recorded statistics are almost certainly an underestimate. CSE has a significant detrimental impact on children’s mental and physical wellbeing.

  • Sexual health nurses (SHNs) are in a unique position to identify children and young people at risk of sexual exploitation but their voices are under-represented.
  • As no known studies exploring SHNs’ perceptions of their role existed, a study involving five practising SHNs was undertaken by the author at a small study site in Scotland.
  • SHN participants showed experience in identifying children and young people at risk of CSE and recognised the barriers impeding identification.
  • They associated supervision and professional development as requirements to advance their practice and believed that all professionals had a role in CSE identification.

Abstract

The sexual exploitation of children and young people is a real and growing issue within contemporary society. Health professionals are well placed to identify exploited children and young people as they often access healthcare services, including sexual health clinics, seeking treatment for many associated health problems. Despite this, it is claimed that they are failing to identify this vulnerable group. This paper aims to explore sexual health nurses’ (SHNs) perceptions of their role in the identification of children and young people at risk of sexual exploitation.

The study, upon which this paper is based, utilised an interpretivist generic qualitative approach. Non-probability purposive sampling was applied and five SHNs participated in one-to-one, semi-structured interviews, which were analysed thematically.

Findings revealed participants in this study were able to identify young people at risk of sexual exploitation and had experienced this. Furthermore, existing challenges that hindered identification emerged. The paper concludes that support, supervision and professional development were required to advance practice in identification. 

 

Key words: sexual exploitation; sexual health nurses; qualitative; role perception; children and young people.


Introduction

This paper explores sexual health nurses’ (SHNs’) perceptions of their role in identifying children and young people who are at risk of sexual exploitation. Child sexual exploitation is a form of child trafficking which is growing rapidly globally and represents a massive source of income within organised crime (United Nations Office on Drugs and Crime, 2014). Global statistics estimate annually over 1.2 million children are being trafficked (UNICEF, 2016). Described as ‘a form of modern-day slavery’ (Scottish Government, 2013: 3), many forms of trafficking in children exist – in the UK, the most common form is child sexual exploitation (NSPCC, 2013).  

 

Child sexual exploitation can occur in person and/or online and can involve physical or non-contact sexual activities. This can be perpetrated by individuals, an informal or organized group of abusers or by peer exploitation (Scottish Government, 2014).  Any child under 18 years can be affected but the average age of identification of child sexual exploitation is between 12 to 15 years (Beckett and Walker, 2016).  Although it is advocated that girls are more at risk than boys, it has been argued that prevalence among boys is grossly underestimated (Barnardo’s, 2014).

Under the United Nations Convention on the Rights of the Child, children have a right to be protected from trafficking and sexual exploitation (UNICEF, 2016).  International Law, which underpins the Human Trafficking and Exploitation (Scotland) Act 2015 and Modern Slavery Act 2015 (UK) requires that measures be taken to prevent, protect, and prosecute against human trafficking (Council of Europe, 2005). Legally, measures can be taken to obstruct child sexual exploitation by criminalising offences occurring within its context.

Due to compounding effects of this type of exploitation, children and young people are also at risk of multiple forms of abuse including physical, emotional, and neglect.  As a form of child sexual abuse, health professionals have a duty to act and protect children and young people from sexual exploitation (Scottish Government, 2014). 


Background

The current extent of child sexual exploitatoin in Scotland and the UK is statistically undetermined due to its hidden nature (HM Government, 2017; Scottish Government, 2016). Complicating this further, the four devolved UK countries have different definitions of child sexual exploitation (Kelly and Karsna, 2017).  Misidentification is claimed to contribute to inaccurate statistics and it has been alleged that health professionals are failing to identify young people at risk of child sexual exploitation (Jay, 2014; Scotland’s Commissioner for Children and Young People, 2011).  

To contextualise the significance of health identification and reasons for misidentification, primary and secondary literature from the previous 10 years was extensively scrutinised and 28 studies relating to health professionals fulfilled the requirements for inclusion. Key words searched included child sexual exploitation; child sexual abuse; health professional; sexual health nurse; identification; assessment; barriers.   

Information from these studies revealed the significant health impact of child sexual exploitation, justifying the need for health provision and identifying predominant health services accessed. In a mixed method study looking at improving the health of 207 victims of trafficking, Zimmerman et al (2006) found nearly every body system affected. Sexual health problems were reported by 60% of victims and 17% reported having at least one induced abortion.  

Likewise, Lederer and Wetzel (2014) identified widespread health complications similar to Zimmerman et al (2006). In a mixed method approach, 107 participants also reported being sexually exploited typically as much as 30 to 50 times daily.  Furthermore, 71.2% reported at least one pregnancy during captivity and 21.2% of these reported five or more pregnancies.  

In relation to victims accessing medical services while being trafficked, 87.8% claimed they had contact with health services during this time. The most frequently accessed health services were the emergency department and family planning provision, with 80.9% saying they had required contraceptive medication. Findings revealed opportunities existed for victim identification within health provision but were largely missed.

Baldwin et al (2011) corroborated these findings in a qualitative study and found 50% (n=6) of victim’s accessed medical attention while in captivity. Likewise, Family Violence Prevention Fund (2005) revealed similar findings of missed opportunities when 28% (n=6) of participants accessed health care while in captivity.

The challenges professionals face with misidentification were also prevalent.  Various studies identified factors including lack of self-reporting (Jay, 2014; Beckett et al, 2013) confusion over definitions (Pearce et al, 2009); lack of knowledge, skill and training (Brodie and Pearce, 2012); all contributed to misidentification. 

SHNs were recognised as being in a powerful position to identify child sexual exploitation due to the nature of their role in promoting sexual health and wellbeing (Department of Health, 2014). Despite a rigorous search of the literature, to the author’s knowledge, no existing studies could be found representing SHNs’ perceptions of their role in the identification of children and young people at risk of sexual exploitation.


Aim of study

To explore SHNs’ perceptions of their role in the identification of children and young people at risk of sexual exploitation.


Methodology

As no known studies existed, an interpretivist generic qualitative approach was deemed suitable for this study to extract compelling, open and in-depth information from participants. Generic qualitative studies are naturalistic in their inquiry, with no pre-selected variables or commitment to only one type of theoretical view (Sandelowski, 2000). Therefore, this was chosen to avoid jeopardising rigour of the data by making ‘fitting’ compromises into a certain design (Parahoo, 2014). 

Ethical approval

The university ethics committee granted ethical approval in October 2016. Formal discussions with the study site NHS research and development lead clarified the study was considered to be service evaluation and therefore did not require local health board ethics approval.

Participants

Permission was given from relevant nursing management granting access to SHNs.  Non-probability purposive sampling was applied. All practising SHNs (n=10) within the study site who delivered a service to those aged under eighteen years were formally invited to participate in the study and were sent a participant information sheet and a consent form. They were given two weeks to reply, and a further one-week ‘cooling off’ period if they wished to withdraw. Five SHNs agreed to participate.  Years as a registered nurse varied between 15 to 33 years and length of experience as a SHN ranged between five and 25 years.

Data Collection

One-to-one, semi-structured interviews were conducted in January 2017 in health board premises at a time and location suitable to participants. Open-ended questions were used in the interview guide providing the opportunity for further exploration of responses. The interview guide allowed for standardisation; the same questions linked to the research aim was asked to each participant (Parahoo, 2014). Types of questions asked related to experience; feelings; and knowledge. Interviews lasted between 25 and 44 minutes and were digitally recorded with consent. Each interview was transcribed verbatim by the researcher to ensure accuracy and facilitate data analysis. Participants were asked to confirm the accuracy of transcripts and   academic supervisor’s agreement with the interpretation of findings was sought, enhancing confirmability (Holloway and Wheeler, 2010). A secure database was maintained for an audit trail facilitating trustworthiness and allowing for impartial scrutiny from the data analysis. 

Data analysis

Sample questions:

  • Within your role as a sexual health nurse, could you tell me about your experiences in identifying young people at risk of sexual exploitation?
  • What do you feel may be working well to identify children and young people at risk of sexual exploitation?

Data analysis began following the first interview. Thematic analysis was used to systematically structure and interpret in depth meaning from data collected facilitated by the six-step approach as highlighted below by Braun and Clarke (2006). This involved each interview transcription being scrutinised by the researcher. Notes were made to generate initial codes. During this process, themes emerged.

 

Step 1

Becoming familiar with the data

Step 2

Generating initial codes

Step 3

Searching for themes

Step 4

Reviewing themes

Step 5

Defining and naming the themes

Step 6

Producing the report

 


Findings

The table below illustrates three key themes and several sub themes that were identified.

Themes

Sub-themes

Embracing existing opportunities

Opportunities within generic SHN role

Opportunities within specialised SHN role

Recognition of barriers to identification

Service provision for children & young people

Perceptions of role           

Experiences in identifying

Professional knowledge, skill and heuristics

Attitudinal beliefs

Advancing practice

Support and supervision

Professional development

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Theme 1: Embracing existing opportunities

This theme developed from inquiries about SHNs’ experiences in the identification of children and young people at risk of sexual exploitation. SHNs identified existing opportunities within their role of promoting sexual health and wellbeing as often other issues emerged when services were accessed. Electronic patient records also facilitated detecting patterns in movements within/ across geographical boundaries.  

SHN1: “… we have an electronic record so no matter what clinic they go into… this is on the one record… that has allowed us maybe to gather information and think, this is this young person…is her 5th time coming, she goes to 5 different clinics, why is that? …”

All SHNs confirmed they completed the national NaSH (National Sexual Health System) risk assessment tool for every child and young person accessing their service. For those under 16 years old, an additional ‘Under 16 Recording Form for Young Person’s Requiring Sexual Health Advice’ risk assessment form was completed. This informed their analysis of risk and could contribute to early identification of child sexual exploitation. All SHNs voiced that although this assessment was generic, questions accommodated significant indicators of child sexual exploitation.

SHN5: “Do people offer to buy them alcohol, cigarettes in exchange for sex?”

SHN4: “Have you been involved with any abuse... domestic, sexual, any kind of abuse, child, any exploitation?”

However, most SHNs highlighted barriers within their generic role including time constraints, busy clinics and the impact of non-caseload holding on continuity of care as most felt that key to identifying risk was building a relationship and trust with children and young people. All SHNs commented on the uniqueness of the Young Persons’ Sexual Health and Lifestyle Nurse believing this specialised role allowed capacity for better continuity of care with more opportunities to identify. 

SHN3: “A lot of young people that are sexually exploited become aware of hiding things, so it’s about how you build that rapport and break down the barriers.”

When considering what may be getting in the way of identification, SHNs collectively recognised a difficulity in identifying children and young people who did not access services. All SHNs acknowledged that, although predisposing vulnerability is a risk, any child or young person can be affected by child sexual exploitation.   Consideration was given to how to engage with the young people who don’t attend.  Young boys were one particular group that some felt were being missed:

SHN3: “… young boys are equally at risk and making sure that we don’t miss that group…”

Further barriers were recognised including children and young people not disclosing exploitation, withdrawing disclosures, and confusions around sexual exploitation. Opportunities for identification were facilitated by working in partnership with children and young people. Currently, drop-in clinics for young people run most days throughout the organisation’s geographical locations.

SHN4: “What I think is working well is that we have dedicated clinics for the young people that they can walk in, they don’t need an appointment…”

Suggestions for improving identification involved targeting other services that children and young people may attend including youth groups and community pharmacists. SHNs also considered opportunities within social media to promote accessing services including the C-Card App; Facebook and Twitter.

 

 

Theme 2: Perceptions of role

This theme progressed from inquiries about SHNs’ perceptions of their role and experiences in identification. All SHNs provided examples of active involvement in identification and were clear about what their responsibilities were in these situations. 

SHN3: “I’ve dealt a lot with young people that were sexually exploited”

Key indicators of child sexual exploitation were illustrated when recalling their involvement.

SHN5: “… met people online, don’t have any idea who they are… would maybe be going into the city centre and be meeting people… involved in alcohol and drugs…That’s information we would be feeding back to the social work team…”

SHN2: “… presented with goods and things they wouldn’t be able to afford themselves.”

SHN5: “… young girls have been absconding from children’s units all the time…and disappearing out of school…”

Good communication between agencies was highlighted by all SHNs as being crucial for identification. Yet there were challenges and frustrations in multi-agency working; SHNs would make a referral to social work and no feedback was returned or information was not shared timeously, delaying identification. Most SHNs highlighted challenges around multiagency confusion regarding their role and disparities pertaining to the legal age and capacity to consent, which also had implications for identification. 

All SHNs demonstrated processing professional knowledge; skills; and heuristics in identification. It appeared that professional knowledge enhanced continuous awareness of sexual exploitation. Professional skills were used to enhance identification such as preparing children and young people before asking questions, asking the right questions and using the right approach:

SHN1: “I think if you dive in at the deep end with a young person they are just going to clam up and probably walk out…”

All SHNs highlighted often intuitive and sensory knowledge prompted curiosity and further inquiry.

SHN4: “You’re seeing their non-verbal’s and you’re face to face with them… it’s something that they’ve maybe said and you can probe it a wee bit more.”

SHN1: “… I can say that was a gut feeling… the demeanor of the young person… it’s not just about what you hear in the answer…”

SHNs conveyed a culture of belief that everyone had a role in identification. However, misconceptions of immunity were cited as a barrier to fulfilling this role. 

SHN2: “I think a lot of people think, not on our patch it’s not, but unfortunately it is.”

 

Theme Three: Advancing practice

This theme derived from SHNs’ appreciation of support/ training received and future aspirations. All valued accessing peer support from fellow team members. While a process existed for case management review, no formal reflective supervision processes were in place and some expressed the benefit this would provide. 

SHN5: “We don’t have any formal supervision.  I think supervision is very important for the job that we do… a lot of cases are quite traumatic… I think just for our wellbeing doing the job but I think also for to… find better ways of doing things...”

All SHNs recounted attending child sexual exploitation training, including multi-agency training, which positively informed practice. Most SHNs suggested the frequency of training should be more often and mandatory, but financial costs were indicated as barriers to this. 

SHN5: “I feel that the role we are doing is so specialised we really need to be getting as much training as possible.”

Participants recognised how evolving dynamics of child sexual exploitation were reflective of their future training requirements. They specified more training needs around the role of social media and grooming techniques, legal issues and offences occurring within the context of child sexual exploitation, training from the police, and training around the current situation in Scotland.

SHN2: “How young people are getting groomed and exploited is going to change so quickly because of how technology changes now… it’s about keeping up to speed with about what’s going on.”

Some SHNs also stressed the need for child sexual exploitation awareness and training to be given to any professional working with children and young people, as well as parents.  


Discussion

Findings from this study are reported from the under-represented voices of SHNs regarding perceptions of their role in the identification of children and young people at risk of sexual exploitation. Evidence presented suggests SHNs are able to identify young people at risk of sexual exploitation by embracing existing opportunities within their role. Due to the hidden nature of child sexual exploitation, using information from the sexual health electronic record is significant as perpetrators often take young people to different locations for treatment to avoid detection (Kirtley, 2013).

Findings demonstrated SHNs had knowledgeable indicators of child sexual exploitation through provided examples of questions asked in their risk assessment tool. Key characteristics included power imbalance, exchange of tangible or intangible gains, or avoidance of harm, coercion/ enticement, which are highlighted in the national definition of child sexual exploitation in Scotland (Scottish Government, 2017). Existing literature highlighted professional confusions around the definition of child sexual exploitation and lack of knowledge were associated with misidentification (Jay, 2014). In contrast, findings from SHNs who participated in this study did not highlight these confusions and suggested they are taking opportunities to identify risk.

Findings revealed SHNs found barriers within their role affecting continuity of care, which adversely impacted on building relationships with children and young people and subsequent non-disclosure. This was not surprising and mirrored Dagon and Wray (2014) who said building relationships and trust were essential elements for disclosure. However, capacity within the Young Persons’ Sexual Health and Lifestyle Nurse specialised role provided this continuity and could be a highly valuable resource for identifying child sexual exploitation. 

Findings also revealed that SHNs identified similar barriers to identification that echo existing literature (Jay, 2014; Beckett et al, 2013) including the recognition that no child is exempt from sexual exploitation and boys may be overlooked.  Understanding complexities in misidentification helped focus SHNs’ commitment to optimising engagement through effective service provision and partnership-working with young people. These factors have been flagged by other researchers as being essential for identification (Bovarnick et al, 2017). 

Contrary to existing literature, SHNs in this study provided evidence of experiences in identification and their responsibilities in respect of this. Participants endorsed Scottish Government (2016) policy that a multi-agency response was required, but they also spoke of the challenges they faced with this, which may impede identification. An analysis of significant case reviews in Scotland found weaknesses in these same areas, which persistently influenced poor outcomes for children and young people (Care Inspectorate, 2016). 

Findings highlighted multi-agency confusion regarding the SHN’s role. Corroborating this, Kirtley (2013) also found various multi-agency professionals had restricted views on the service that sexual health offered children and young people.  Additionally, disparities pertaining to the legal age and capacity to consent were recognised by Beckett and Walker (2016).

Findings in this study acknowledged the value of processing professional knowledge, skill, and heuristics in managing identification. Participants highlighted that often intuitive and sensory knowledge prompted curiosity and further inquiry, with which Gibbs, Dwyer and Vivekananda (2009) agreed. The use of both cognitive and emotional sources of information for decision-making, including intuitive knowledge, is essential for effective risk analysis in protecting children. The belief that everyone has a role in identification is also supported by the Scottish Government (2016) and misconceptions of immunity have also been previously reported (Beckett and Walker, 2016). 

In respect of identification, SHNs believed support and formal supervision are essential for advancing practice. These beliefs are well supported in existing literature, which substantiated the positive impact supervision has on reflective practice, effective decision making and the health and wellbeing of staff (Care Inspectorate, 2016). 

In this study, SHNs felt advances in practice may be progressed through professional development with regular and mandatory training, which was supported by existing literature (Viergever et al, 2015).  Equally, rapid social changes affecting child sexual exploitation underpinned drivers for additional training needs.


Recommendations

Key Points
  • SHNs embrace existing opportunities within their role to identify children & young people at risk of sexual exploitation.
  • The Young Persons’ Sexual Health and Lifestyle Nurse is a highly valuable resource for identifying child sexual exploitation.
  • Understanding complexities in misidentification informed opportunities for optimising engagement.
  • SHNs had experiences in identifying at-risk young people and acknowledged the value of processing professional knowledge; skill and heuristics in managing this.
  • Attitudinal beliefs may hinder identification.
  • Formal supervision and training are essential to advance practice in identifying children and young people at risk of sexual exploitation.

 

The following recommendations arose from the findings and are aimed at professionals and organisational leaders for whom child sexual exploitation is contextually relevant.

  • The wealth of knowledge, skill, and experience that SHNs have in working with children and young people around sexual wellbeing/exploitation should be harnessed and built upon. Recognition needs given to the valuable resource a specialised SHN has in identification. 
  • SHNs have valuable contributions to make to strategic influencing, organisational policy and the planning of service provision for children and young people at risk of sexual exploitation.

  • Multiagency training programs should raise awareness of SHNs’ work with children and young people and SHNs should deliver multiagency training on child sexual exploitation.

  • For the safety of children and young people, solution-focussed opportunities should be considered to improve multiagency communication and timeous responses to referrals.

  • Continued partnership working with young people is crucial for service improvement and engagement. Opportunities to engage young boys should be further developed, together with identifying other health areas that could be targeted to promote identification and raise awareness of child sexual exploitation. 

  • Develop opportunities for engagement through social media such as providing children and young people with information and links to relevant supports, for example, the ‘thinkuknow’ website. Here, children and young people can directly report to the National Crime Agency if they are at risk of being sexually exploited or experiencing sexual exploitation.

  • Consideration should be made to opportunities around the NaSH system, which generates data for ISD, as to whether this system has potential to provide statistics for child sexual exploitation nationally.

  • Child Protection Supervision should be available for SHNs. 

  • Training should mirror this rapidly changing phenomenon if SHNs are to continue identifying young people at risk. The expressed training needs identified in this study should be honoured. barnardos.org.uk/www.barnardos.org.uk/hidden-in-plain-sight.pdf (accessed 15 May 2018).


Limitations                                         

This study, although small, illuminated the subjective nature of the SHNs’ experiences through in-depth analysis of the phenomenon and added to the body of knowledge. However, limitations exist within all research and must be acknowledged (Parahoo, 2014). Collectively, the small sample size and the use of one health authority had capacity to influence the value of these findings to a wider audience. Although, admittedly not generalisable, they are in line with qualitative approaches - as such, transferability of findings are limited, but contextually rich. The findings may be transferrable to other similar contexts.    


Conclusions                                                  

This study accomplished its aim and represented SHNs’ perceptions of their role in the identification of children and young people at risk of sexual exploitation. While many findings have reflected existing literature some are contrary to this. Three main themes were extrapolated from the narratives of the SHNs. It emerged that the sample in this study were able to identify children and young people at risk of sexual exploitation by embracing existing opportunities within the generic and specialised SHN role. Participants also recognised barriers impeding identification and worked in partnership with young people to improve access to services. This study found that participants had experience in identifying children and young people at risk of sexual exploitation and they used professional knowledge, skill, and heuristics in the process of managing this. Participants also believed everyone had a role in identification, which may be hindered by misconceptions of immunity. Further evidence revealed that SHNs associated supervision and professional development as requirements to advance their practice in the identification of children and young people at risk of sexual exploitation. 


Acknowledgements                                                  

I would like to thank the SHNs who took part, without them this study would not have been accomplished. I would like to thank my managers who supported this study.  This was undertaken as part of the dissertation module for an MSc in vulnerability.


References

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Ann Marie Sangster, Dr Maureen Crowley, and Amanda McGrandles explore sexual health nurses’ perceptions of their role in the identification of children and young people at risk of sexual exploitation, using an interpretivist generic qualitative approach.

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