Child sexual exploitation, recognition and response: guidance for health staff

The sexual exploitation of children and young people is often a hidden form of child sexual abuse with distinctive elements of exploitation and exchange. In practice, the sexual exploitation of children and young people under 18 might involve young people being coerced, manipulated, forced or deceived into performing and/or others performing on them, sexual activities in exchange for receiving some form of material goods or other entity (for example, food, accommodation, drugs, alcohol, cigarettes, gifts, affection). Sexual exploitation can occur through the use of technology and without the child’s immediate recognition.

In all cases those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are often common features; involvement in exploitative relationships being characterised in the main by the child/young person’s limited availability of choice resulting from their social, economic and/or emotional vulnerability. Child Protection Guidance, Scottish Government, 2014

In 2012, the Child Exploitation and Online Protection Centre (CEOP) found almost half of perpetrators were under 25 years of age, mostly men, of all ethnic groups.

The perpetrators of sexual exploitation are known to target areas where children and young people might gather with limited adult supervision such as shopping centres, cafes, takeaways, bus or train stations, local parks, playgrounds and taxi ranks, or through the use of social media. In some cases, perpetrators are known to use younger men, women, boys or girls to befriend the exploited child or young person. Children and young people who are themselves the victims of exploitation may introduce other young people to their abusers in an attempt to deflect the abuser’s attention from themselves.

Young people may have contact with health services due to a sexual health matter or their contact may be about another health matter. This guidance will consider presentations for sexual health or other risk taking/vulnerable presentations plus encourage staff to generally ask about well being at all health presentations.

The following are typical vulnerabilities in children prior to exploitation;

• Extreme poverty
• Living in a chaotic or dysfunctional household (including parental substance use, domestic violence, parental mental health issues, parental criminality)
• History of abuse (including familial child sexual abuse, risk of forced marriage, risk of ‘honour’- based violence, physical and emotional abuse and neglect)
• Recent bereavement or loss
• Gang association either through relatives, peers or intimate relationships (in cases of gang associated CSE only)
• Attending school or being friends with young people who are sexually exploited
• Learning disabilities
• Unsure about their sexual orientation or unable to disclose sexual orientation to their families
• Homeless
• Lacking friends from the same age group
• Living in a gang neighbourhood
• Living in residential care
• Living in hostel, bed and breakfast accommodation or a foyer
• Low self-esteem or self-confidence
• Young carer
• Some young people are trafficked with the purpose of being sexually exploited.

Within family and relationships:

• Hostility in relationship with parents/carers and other family members
• Sudden changes in behaviour or demeanour
• Regularly coming home late or going missing from home, care or education for any period of time whether reported or not
• Unknown older associates and isolation from safe relationships
• Multiple callers or being collected or returned in unknown cars
• Adult or older youths loitering outside place of residency
• Arriving back after long intervals in different clothing or appearing well cared for.

Health and mental well-being:

• Accessing drugs or alcohol without money to pay for them
• Increasing use of drugs and alcohol
• Change in physical appearance-including more or new clothes
• Displaying inappropriate sexualised behaviour
• Repeat sexually-transmitted infections, pregnancy and terminations
• Physical injuries
• Expressions of despair including depression, self-harm, suicide thoughts or attempts
• Attendance at emergency departments due to intoxication.

Behaviour:

• Emotional state upon return – unkempt, agitated, disoriented, hungry, distressed etc
• Secretiveness about whereabouts and/or associates
• Truancy/disengagement with education or considerable change in performance at school;
• Volatile behaviour exhibiting extreme array of mood swings or use of abusive language;
• Getting involved in petty crime such as shoplifting, stealing
• Risk taking behaviours.

Appearance and possessions:

• Unexplained expensive clothes, gifts, money or goods
• Multiple mobile phones
• New social networks
• Receiving calls/texts on mobile phones and leaving soon after

Others:

• Disclosure of unprotected sex or rape, but reluctance to notify police or go through a formal interview
• Associating with other young people involved in exploitation
• Recruiting others into exploitative situations.

It is important to note that not all situations that exhibit one, or even several, of these indicators will necessarily be sexual exploitation. Additionally children and young people that are the victims of sexual exploitation often do not recognise that they are being exploited. 

There are specific risks associated with the internet in terms of child sexual exploitation, including:

• Grooming children on-line for sexual abuse offline
• Children viewing abusive images of children/pornographic images
• Selling children on-line for abuse offline
• Making abusive images of children
• Viewing abusive images of children
• Access to chat lines via the internet or mobile phones
• Sexting (sending or receiving explicit text messages which can include photographs or sexually explicit images).

Therefore when undertaking an assessment around child sexual exploitation practitioners should consider what risks are posed to the child or young person through the internet, and those that are posed by the child or young person to other children or young people. Child Protection Guidance, Scottish Government, 2014

There is increase in concern that sexual exploitation of males is less likely to be recognised and is under reported, this should be borne in mind.

Child Sexual Exploitation: Improving Recognition and Response in Health Settings, Academy of Medial Royal Colleges, 2014

Focus group work has shown that young people prefer to be asked sensitive questions in a professional but conversational manner. Staff may need to rephrase questions to suit individuals, and avoid using language that may be unfamiliar to young people such as medical jargon. Spotting the signs, a national proforma for identifying risk of child sexual exploitation in sexual health services, April 2014

When asking questions about sexual contact, find out what term the young person feels comfortable using as they may not perceive that person as a partner.

If you consider a young person is at risk from their replies to the questions you must follow your current local child protection processes or seek further advice from the Child Protection Unit (0141 451 6605). 

Any health professional that has concerns that a child is at risk of abuse through sexual exploitation must make a referral in accordance with child protection procedures. This includes circumstances where there is a lack of evidence or where there may be concerns which cannot be substantiated. Referrals can help to build up a picture that a child may be suffering harm through sexual exploitation. It is important that practitioners do not wait for a disclosure from a young person or the accumulation of “hard” evidence, prior to making a referral. 

Sexual exploitation is abuse and should be treated accordingly. Practitioners should be mindful that a “dual approach” is key in tackling CSE; whilst a young person must be both engaged with and supported, there must also be a focus on proactive investigation and prosecution of those involved in sexually exploiting the young person. Child Protection Guidance, Scottish Government, 2014

It is important that practitioners are aware that young people who are victims of CSE rarely directly disclose because they often do not recognise their own exploitation. For example, a young person may believe themselves to be in an “adult relationship” with their abuser. Disclosure of sexual exploitation can be particularly difficult for young people; the sophisticated grooming and priming processes conducted by perpetrators and the exchange element of this form of abuse can act as additional barriers to disclosure.

Examples of other reasons for non-disclosure include:

• Fear that perceived benefits of exploitation may outweigh the risks e.g. loss of: supply of alcohol, drugs, the “relationship” and associated “love” and attention
• Fear of retribution or that situation could get worse
• Fear of violence within exploitative relationship
• Shame
• Fear of not being believed
• Fear of labelling e.g. as a prostitute or gay
• Fear of separation from family and /or threat of secure
• Loss of control; fear of police involvement and court proceedings.

Child Protection Guidance, Scottish Government, 2014

Consider the following when seeing young people who present to health about their sexual health/risk taking behaviours/episodes of self harm/strong indicators of CSE:

• Who do you live with?
• How are things at home?
• Do you ever use drugs and/or alcohol?
• Do you feel you can talk to someone at home about;
  • Sex/relationships or
  • Substance misuse or
  • Self harm.
• Are you involved with any other agency or professional’s e.g. social work, mental health services?

Specifically about sexual health contacts: 

• Are you having sexual contact with anyone?
• Are you happy in your current circumstance? i.e. with the person you’re going out with/having sex with?
• How old is the person you are having sex with?
• Where did you meet this person?
• Has anyone ever given you something like gifts, money, drugs or alcohol for sex?
• Have you been made to do something that you did not want to do or been intimidated?
• Do you feel you can say no?
• Have you ever been involved in sending or receiving messages of a sexual nature or does anyone have any pictures of you of a sexual nature?
• What contraception do you use?

Emotional well being:

• Do you suffer from feeling down/depression?
• Have you ever tried to hurt yourself or self harm?

All health contacts:

• Who do you live with?
• How are things at home?
• Do you have someone who you can talk to about things that concern you?
• Are you attending school regularly?
• Have you had any contact with any other health services recently?

Confidentiality must be explained properly to young people, including its parameters and the fact that you will need to seek advice if you believe they are at risk of significant harm. Of note is that a young person may perceive their situation as consensual when in fact they are being groomed. 

Normal child protection procedures should be followed if you have concerns regarding the safety and well being of children and young people. Support and guidance is available via the Child Protection Unit as usual on 0141 451 6605 and via the Child Protection website.

NHSGGC has produced a training module on child sexual exploitation that can be accessed via Learnpro.