The historical landscape of child and youth sexual exploitation provides a crucial context for understanding current challenges and future policymaking and service provision opportunities. The independent inquiry into child sexual exploitation in Rotherham (Jay, 2018) unveiled a disturbing reality, where local political and other leadership displayed a dismissive stance towards sexual exploitation, neglecting pertinent reports and downplaying its severity. This negligence created an environment of vulnerability for children and young people (Anonymous/Community Practitioner, 2014; Bradbury-Jones et al, 2019). Comprehensive reviews by Williamson et al (2020), Brady et al (2022), and Mythen and Weston (2023), complemented by the UK's Independent Inquiry into Child Sexual Abuse (IICSA) (2022), have reaffirmed the persisting issue of sexual exploitation. These studies further show that children and young people are still susceptible to sexual exploitation, imposing substantial burdens on service providers and policymakers.
Sexual exploitation and sexual abuse
According to the World Health Organization (WHO) (2017), sexual exploitation is
‘Any actual or attempted abuse of a position of vulnerability, differential power, or trust, for sexual purposes, including, but not limited to, threatening, or profiting monetarily, socially or politically from the sexual exploitation of another.’
Sexual abuse is defined as:
‘The actual or threatened physical intrusion of a sexual nature, whether by force or under unequal or coercive conditions.’
In the course of their work, nurses may meet young people who are vulnerable to or the victim of sexual exploitation. These include homeless young people, young people who are from unstable homes, young people in care, young people with mental health issues, young people addicted to cigarettes, drugs and/or alcohol and young people with learning disabilities. Within these groups, they may come into contact with:
- Young people who have been persuaded, bullied or coerced into sharing sexually explicit photos or videos on their mobile phones
- Young people who have been persuaded, bullied or coerced into engaging in sexual activities
- Young people who have been trafficked for sexual exploitation purposes, often from abroad.
The terms ‘sexual exploitation’ and ‘sexual abuse’ can encompass any sexual relations involving a child or young person aged under 18 years. This inclusive definition ensures that all sexual involvement with people under 18 years old can be considered within the scope of these terms (WHO, 2017; Public Health England (PHE), 2019; WHO, 2021).
Human trafficking
At the core of sexual exploitation is human trafficking, where 97% of victims are young females, with young boys also vulnerable (All-Party Parliamentary Group on Prostitution and the Global Sex Trade (APPG), 2018; Cole, 2018). Sex trafficking is a form of human trafficking defined as
‘The recruitment, harbouring, transportation, provision, obtaining, patronising, or soliciting of a person for a commercial sex act.’
Centers for Disease Control and Prevention, 2022
This summarises the definition of the UN Convention against Transnational Organised Crime (United Nations Office on Drugs and Crime, 2004) and the Palermo Protocol regarding human trafficking (United Nations Office of the High Commissioner, 2000). In the UK, the Serious Crime Act 2015 has established a legal framework to combat abuse involving children and young people. This acknowledges that children are victims of sexual exploitation, which addresses the previous misconceptions and attitudes towards sexually exploited children and young people. These definitions inform measures to protect vulnerable people, guide interventions, and provide a basis for comprehensive safeguarding initiatives in sexual exploitation (Department for Education, 2017). In addition, A Framework for Sexual Health Improvement in England also sets out Government policies about a person-centred approach to reproductive and sexual health services (Department of Health (DH), 2013).
In recent years, evidence suggests that the use of technology in the sexual exploitation of young people is becoming prevalent and gaining much attention in academic, media and political discourse (Shaughnessy et al, 2011; DH, 2012; Clark et al, 2018; PHE, 2019; Bradbury-Jones et al, 2019). Technology is used in various ways to facilitate sexual exploitation, such as through online platforms, social media, and communication tools. These technologies create avenues for sexual exploitation, including the dissemination and sharing of explicit content, grooming, coercion and recruitment. Social media and online platforms are used by traffickers for recruiting and exploiting their sex-trafficking victims, especially those from Eastern Europe (Voronova and Radjenovic, 2016; APPG, 2018). Recently, women from Romania have been particularly vulnerable to sexual exploitation; 86% of the women in the 156 brothels in Leicestershire investigated by the police were Romanian (APPG, 2018). In part, sexual exploitation is due to men opting to pay for sex. According to a University College London study of 6000 men, 3.6% of the men had paid for sex in the past 5 years (Mercer, 2014; APPG, 2018).
Nurses' responsibilities
Nurses across diverse areas of practice have a responsibility to identify and respond to suspected cases of sexual exploitation and sexual abuse across various age groups, given the profound negative impacts these experiences have on health outcomes, mental wellbeing, and overall welfare (Oram et al, 2016; Fraley and Aronowitz, 2017; Williamson et al, 2020). Whereas this article discusses many health services, previous research has shed light on specific challenges encountered by young people within reproductive and sexual health promotion programmes targeting young people (Hayter, 2005; Wellings et al, 2016). These challenges encompass a perceived lack of respect from service providers, inadequate privacy for discussions, and judgmental attitudes. These were all barriers to accessing mainstream sexual health provisions.
The age range addressed in this review spans 16 to 25 years, encompassing both young people and adults, as acknowledged by pertinent legal frameworks and policy guidelines, highlighting the need for a comprehensive approach to safeguarding (Home Office, 2015; NHS England/NHS Improvement, 2019). These documents acknowledge that young people and children are the victims of sexual exploitation and clarify the roles and responsibilities of the NHS workforce, including nurses, in safeguarding young people who may be at risk of being sexually exploited.
Within the context of young people aged 16 to 25, it is crucial to explore the concept of the ‘adolescent brain’, which refers to the ongoing biological maturation and cognitive development during this period, exerting significant influence on the lived experiences of young people and the professional practices surrounding them (Casey et al, 2008). This transitional phase, often characterised as the journey from childhood to adulthood, necessitates an understanding of ‘transitional safeguarding’, emphasising the importance of continuity in providing protective measures for young people navigating this critical developmental juncture. However, it is noteworthy that available evidence (Wurtele, 2012; Cole, 2018; Franchino-Olsen, 2021 among others) predominantly focuses on children below the age of 18, providing limited insights into the experiences of those transitioning from childhood to late adolescence and young adulthood.
Aim
This current review focused on exploring the strategies employed by nurses in identifying and responding to sexual exploitation among young people aged 16-25 years. The focus was on examining the role of technology, effective practices in clinical and non-clinical settings, and the facilitators and barriers encountered in identifying and responding to sexual exploitation.
Methodology
This narrative review aimed to synthesise and analyse empirical evidence about the identification and responses by nurses to the sexual exploitation of young people. A comprehensive search of relevant literature was conducted using electronic databases, including CINAHL-EBSCO, ASSIA and PubMed/Medline. In addition, a manual search of abstracts from reviewed articles was performed to ensure inclusivity.
Twelve studies were identified as relevant to the review (Box 1) and were included for thematic analysis using the Ritchie and Lewis Framework approach (Ritchie and Spencer, 1994) to synthesise and interpret the data and generate the themes discussed in this article. This was chosen over other approaches, such as thematic analysis, due to its systematic nature and ability to handle large qualitative datasets.
Box 1.The 12 studies identified in the literature search
Findings
A plethora of qualitative evidence focused primarily on the intersection of technology and the sexual exploitation of young people. It highlighted the role of ‘sexting’ as a recent phenomenon among young people and the associated risk of exploitation, emphasising the need for nurses to stay informed and up to date. The research also highlighted the importance of professional development and support for nurses in sexual exploitation identification. The findings included exploring effective intervention strategies, notably in clinical and non-clinical settings and via street outreach.
Technology and sexual exploitation of young people
Bradbury-Jones et al (2019) noted that using technology for sexting among young people was a new phenomenon, with most public health nurses (PHNs) reporting that they hear about sexting from the news media. The National Society for the Prevention of Cruelty to Children (NSPCC) (2024) defines sexting as:
‘… when people share a sexual message and/or a naked or semi-naked image, video or text message with another person.’
Such messages and images could be exploited as part of bullying or blackmail, which makes it imperative for nurses to have a greater knowledge of information technology to safeguard young people from the risks of sexual exploitation adequately. For this reason, Murphy and Spencer (2021) emphasised the need for nurses and other health professionals to acknowledge sexting as part of teenage development and culture to be able to adequately support teenagers in managing sexting behaviour safely.
Sangster et al (2018) observed that sexual health nurses (SHNs) needed more professional development, support and supervision in sexual exploitation identification. This will equip them with the required skills to better support young people. They found that technology presents risks to young people, such as being coerced and enticed into engaging in risky sexual behaviours using mobile phones and social media.
Identifying and responding to the sexual exploitation of young people in clinical and non-clinical settings
When exploring the perspectives of sexually exploited young people through outreach to support their needs, Holger-Ambrose et al (2013) observed that using street outreach interventions by healthcare workers to meet young people in various settings effectively supports those at risk of sexual exploitation. Furthermore, they noted that this method of engagement is rooted in the principle of harm reduction by meeting young people in an environment where they feel comfortable, free from the judgement of peers or family members.
Cole (2018) investigated service providers' perspectives on the sex trafficking of young male people and compared the background and trafficking situations of male and female victims in the USA. The study reported two common pathways affecting the commercial sexual exploitation of male young people. These were first, running away or homelessness and, second, coercion and use of force by family members to support the family and to fund the family member's substance use problem, similar to outcomes found in research on teenagers (Farrow et al, 1992; Tyler, 2002). They indicated that half of the health professionals had worked with at least one victim of child sex trafficking and, of these respondents, 57.8% had worked with at least one male victim.
Donahue et al (2019) reported that healthcare settings such as emergency departments (EDs), sexual health clinics and other primary care settings were common areas where young people trafficked for sexual exploitation could be identified and supported. For instance, if a young person often presents with a history of alcohol and drug use as a coping mechanism, along with other concerning factors such as signs of physical or sexual abuse, or inconsistent explanations for injuries, it could signal a potential involvement in sexual exploitation.
It may be possible to use electronic patient records to detect patterns of movement of young people who are trafficked for sex within and across geographic boundaries (Sangster et al, 2018; Katsanis et al, 2019).
Additionally, Holger-Ambrose et al (2013) noted that sexually exploited young people struggle to distinguish their perceptions of their risky behaviours from the reality and experience mental health issues because of the experience of sexual exploitation. This experience makes it difficult for them to get out of the trap of sexual exploitation and hence they require mental health support to cope with their struggles in addition to the medical and social elements of sexual exploitation.
Although direct knowledge of a young person being trafficked may not be readily available, some signs and presentations can raise suspicions that merit a response from nurses. For instance, Donahue et al (2019) noted that the sexual exploitation of young people can take place in multiple venues, including the internet; the street outreach setting can be a creative and effective method for locating young people at risk of sexual exploitation. This is where information sharing requires proper emphasis so that young people can be identified and supported regardless of where they may be located (Katsanis et al, 2019).
Ensuring privacy and confidentiality is a central concern for young people at risk of sexual exploitation. As Katsanis et al (2019) highlighted, a private area away from family, friends and traffickers is critical in enabling young people to access services confidently. However, this need for privacy extends beyond the physical setting and into the digital realm. In a study by Williamson et al (2020), the challenges of navigating data protection and confidentiality issues for vulnerable young people, especially within the NHS, were significant obstacles for many nurses and other health professionals. Similar concerns were echoed by Donahue et al (2019), who identified the importance of educating ED staff about the careful handling of sensitive information related to victims of human trafficking. Holger-Ambrose et al (2013) further underscored the importance of privacy and confidentiality, particularly in outreach work with sexually exploited young people. They found that privacy concerns could impact the willingness of young people to engage with outreach services and suggested that service providers consider these issues carefully when planning and implementing interventions.
Moreover, issues related to privacy and confidentiality may also be implicated in the delivery of sexual health services. Sangster et al (2018) noted that the nurse's role in identifying sexual exploitation requires careful management of sensitive information, adding another layer to the complexities of providing care in this context. Furthermore, Bradbury-Jones et al (2019) found that concerns around privacy could deter young people from discussing their experiences with sexting practices, a potential precursor to sexual exploitation. They suggested that practitioners ensure a safe and private environment for discussing such sensitive topics.
Organisational support, knowledge and training
The need for organisational support was explored by Salami and Alhalal (2020), who reported in their study conducted in Saudi Arabia that 91.1% of nurses had not reported any child abuse cases and that only 41.5% of nurses were aware of their organisation's guidelines and the support available. They noted a lower level of reporting in primary care settings than in acute settings; this was attributed to less organisational support in primary care settings than in acute settings.
All nurses need more education in identifying young people at risk of sexual exploitation. For this to happen, Williamson et al (2020) reiterated the relevance of organisational support to facilitate appropriate interventions. Nurses and others working with young people could use interagency collaboration and information sharing to effectively support those at risk of sexual exploitation (Sangster et al, 2018).
Crisp and Green Lister (2006) examined the perceptions of nurses in Scotland about their current skills, knowledge, and training needs to identify and respond to cases of child abuse and reported that 92.2% attended training on interagency work with child protection elements. Viergever et al (2015), while investigating what health professionals knew and needed to know about human trafficking training programmes in the Middle East, Central America and the Caribbean, observed the limited focus on their information and training needs to be fully involved in a broader counter-trafficking response. Similarly, Donahue et al (2019) observed that only 11% of participants from a north-eastern metropolitan city in the USA reported that they had human trafficking training in the past, with less than 50% of those indicating that they had general human trafficking knowledge before the training.
In addition, the use of screening tools in identifying potential victims of sexual exploitation and intimate partner violence has been underscored in several studies, yet various factors often hinder their application. As Moscou (2015) has shown, using an intimate partner violence and molestation tool can be instrumental in pinpointing college students at risk during consultations. However, the inconsistent application of the tool, mainly due to time constraints and discomfort with sensitive topics on the part of clinicians, often leads to missed opportunities in identifying and supporting such victims. Several studies corroborate this finding. Without adequate knowledge and being comfortable in dealing with the topics of sexual exploitation and intimate partner violence, the efficacy of any screening tool could be compromised. This is particularly pertinent given the finding from Katsanis et al (2019) that electronic health records can play a pivotal role in caring for trafficked patients. Integrating screening tools into such systems could streamline the identification process and make it more consistent and efficient, as identified by Moscou (2015).
When language barriers exist, these challenges are exacerbated, underscoring the importance of readily available and reliable interpretation services in healthcare settings. The significance of proper interpretation services in identifying and managing cases of human trafficking and sexual exploitation cannot be overstated. As Williamson et al (2020) observed, inadequate access to these services often hinders healthcare providers' ability to fully comprehend and address the situation, especially when the traffickers offer to translate, consequently controlling the narrative. This creates a complex ethical and clinical scenario for health professionals.
Salami and Alhalal (2020) found in their cross-sectional study that nurses often face difficulties reporting child abuse cases, primarily due to a lack of understanding of how to approach the issue. This lack of understanding could be compounded by language barriers, further emphasising the need for effective interpretation services in health care. In research on service providers' perspectives, Cole (2018) found that it is often challenging to distinguish between victims and their traffickers when language and cultural barriers exist.
Discussion
The potential for sexual exploitation of young people through technology is significant (Holger-Ambrose et al, 2013; Bradbury-Jones et al, 2019). However, the capability to effectively recognise and address these risks among nurses and other health professionals appears inadequate (Bradbury-Jones et al, 2019). Investigations have not suggested effective interventions, particularly when young people are pressured into sharing explicit photos by people with whom they are in a relationship, resulting in the potential for the misuse of those images (WHO, 2017; Bradbury-Jones et al, 2019). Consequently, it is important for young people to be aware of the risks of coercion and blackmail while using social media apps, as well as the dangers of online grooming and trafficking for sexual exploitation. School nurses and those working in sexual health services should be particularly aware of the potential problems and able to inform and advise young people.
Nonetheless, the bidirectional communication potential of electronic media could offer promising solutions for preventing sexual exploitation. For instance, mobile technology could be used to engage young people in promoting sexual health awareness and protective measures against sexual exploitation (Bailey et al, 2015). Additionally, expanding the scope of internet outreach to include novel platforms may enable better connection with at-risk youth, particularly young women (Holger-Ambrose et al, 2013). Street outreach interventions could also help reach those less likely to access mainstream sexual health resources (Holger-Ambrose et al, 2013). Within the clinical setting, the initial contact with young people about their reproductive and sexual health can provide an opportunity to encourage them to access additional services (Myers, 2009; Adakpa et al, 2016; Wellings et al, 2016; Katsanis et al, 2019). Consideration should also be given to the role of schools, where children and young people often disclose health concerns to trusted teachers or school nurses; many school nurses are already delivering sexual health services in UK schools.
Interagency collaboration is crucial in protecting young people from sexual exploitation (Hunter et al, 2010; Bradbury-Jones et al, 2019). Challenges may arise from professional territoriality or imposed boundaries, which hinder the sharing of information – an integral aspect of safeguarding against sexual exploitation (Fraley and Aronowitz, 2017; Cole, 2018). This issue could be mitigated through clear role definition and training to promote multidisciplinary approaches to sexual exploitation (Cohen and Reutter, 2007), particularly given recent developments in child protection (Jay, 2018).
There appears to be a disparity in the research focus on sexual exploitation victims, with more emphasis on young females than young males (Cole, 2018). Although reports by Voronova and Radjenovic (2016) for the European Parliamentary Research Service suggested that 97% of people trafficked for sexual exploitation are female, the experiences of young male victims deserve as much attention and public discourse. For young male victims of sexual exploitation, shame, embarrassment, and fear of not being believed often deter them from seeking help (Cole, 2018; Porta et al, 2018), an issue that needs further exploration and understanding. For these reasons, victims of sexual exploitation would benefit from mental health support to deal with feelings of shame, guilt and helplessness (Mullers and Dowling, 2008).
Evidence suggests that the use of alcohol and drugs, which are frequently used as coercive tools, increase the vulnerability of young people to sexual exploitation (Holger-Ambrose et al, 2013; Cole, 2018). Given that these substances are often used as a coping mechanism by exploited youth, specialised substance abuse interventions are necessary (Holger-Ambrose et al, 2013). Such support must address the trauma and related issues such as mental health problems. Traditional post-trafficking interventions often lack a comprehensive approach to recovery, being predominantly medically focused (Cole, 2018).
As has been stated, a noticeable training gap often exists, limiting nurses' ability to effectively support young people at risk of sexual exploitation (Crisp and Green Lister, 2006; Donahue et al, 2019). Taking a proactive approach to this problem requires leadership and management support so that nurses in EDs and other settings are trained, equipped, and confident to respond to the sexual exploitation of young people. Although training and organisational support are needed, nurses must take responsibility to become competent and accountable professionals in this area (Viergever et al, 2015; Nursing and Midwifery Council (NMC), 2018; Katsanis et al, 2019).
Implication of findings
This review acknowledges that safeguarding guidance exists, as outlined in various policies and guidelines (DH, 2012; Home Office, 2018). However, it emphasises the need for effective implementation and dissemination of this guidance within healthcare organisations. Ensuring that nurses and other health professionals have access to clear clinical guidance on recognising signs of sexual exploitation and making appropriate referrals, is essential.
Although effective collaboration has been advocated for over a decade in policy and guidance, this review adds to the existing knowledge by emphasising the specific focus on trafficked young people and collaboration among medical, social, and law enforcement personnel. It also highlights the importance of understanding this population's unique experiences and calls for specialised teams within healthcare settings who can provide culturally sensitive support and facilitate the disclosure of sensitive information.
Furthermore, the review underscores the significance of addressing issues related to interpretation services and data protection and establishing dedicated electronic records for timely intervention. Exploring the informal roles of health professionals who can speak the language of trafficked young people and establishing specialist teams to build trust and support to encourage the disclosing sensitive information is essential to improving care for sexually exploited young people from overseas.
Limitations and strength
Few studies have dealt with how nurses identified and responded to sexual exploitation among young people, especially those aged 16–25. It was not easy to extrapolate the data for this age group from the literature; an attempt was made to identify studies that address specific areas of the review question. Due to the strict inclusion and exclusion criteria, evidence from grey literature such as government reports, policy documents and guidance was not included. The role of the sexual assault nurse examiner was only explored at a superficial level concerning sexual assault. There was a possibility of selection bias regarding studies included in the literature review; this impact was minimised by working with a colleague to screen the included studies to ensure they met the inclusion and exclusion criteria. Using a PRISMA flow diagram at the search and selection stage limited selection bias and was a strength in the design of this study because of its transparent nature and the step-by-step processes used to select studies included in the review.
Conclusion
The findings of this review highlight the importance of expanding interventions beyond a solely medical focus when addressing the needs of sexually exploited young people. Although medical interventions are crucial, there is a need for a more comprehensive approach that acknowledges the social aspects of exploitation. This necessitates a deeper understanding of social needs, including shelter provisions, collaboration with social services, and engagement with law enforcement agencies. In addition to their duty of care in safeguarding and protecting vulnerable populations, nurses, including nursing students, should embrace the guiding principle of ‘promoting safety’ as stipulated by the NMC Code (NMC, 2018). To effectively address the complex challenges of sexual exploitation, interventions must go beyond the immediate medical concerns and encompass a comprehensive response that addresses the social determinants of health. This necessitates further research, empirical evidence, and a focus on interagency collaboration to develop and implement effective interventions that meet the unique needs of sexually exploited young people.
This review has emphasised the imperative of a holistic approach to nursing care that recognises the multifaceted nature of sexual exploitation. By integrating social support measures into interventions and strengthening collaboration with relevant stakeholders, nurses can play a pivotal role in mitigating the impact of sexual exploitation on the lives of young people.
KEY POINTS
- The use of technology exposes young people to the risk of sexual exploitation, and internet outreach intervention is an innovative way to safeguard young people aged 16–25 years from such risk
- Nurses are strategically positioned to identify and support young people at risk of sexual exploitation in clinical and non-clinical settings; organisational support through adequate training and implementation of guidance and local policy serve as crucial catalysts
- Safeguarding young males against sexual exploitation is not given much attention, given that they are equally at risk of sexual exploitation as girls
- Concerns around privacy and confidentially are deterrents to seeking help early for young people at risk of sexual exploitation
CPD reflective questions
- What different kinds of support are available to nurses to help them identify and respond to the sexual exploitation of young people in clinical and non-clinical settings? Do you know how to access these supports in your organisation?
- How can managers support nurses in identifying their knowledge gap and provide appropriate training and support to implement guidelines, local policies and standard operating procedures relating to sexual exploitation of children and young people?
- Have you worked with young people at risk of or the victim of sexual exploitation in your clinical area? Are you aware of other services and support to which you could refer these young people?