Designing a safeguarding tool for Japanese professionals to identify, understand and respond to adolescent sexual behaviours

Abstract

Objectives

This study sought to construct a developmental and context-sensitive framework that could be used to identify, understand and respond to adolescent sexual behaviours.

Methods

We reviewed work being conducted on adolescent sexual development, health and safety, interviewed UK-based professionals working on sexual health and child protection, and, having identified the Traffic Light Tool (TLT) designed by Family Planning Queensland and then developed by Brook in the UK, we conducted expert interviews. Finally, we reviewed in-house consultation, training and evaluation documentation provided by Brook.

Results

We identified the Traffic Light Safeguarding Project as offering a framework for thinking about and responding to youth sexuality. The concept of safeguarding allows us to go beyond the narrower mandate of child protection, and link up the activities of different stakeholders working around child and adolescent sexual health. We were able to confirm that the TLT was functioning as an effective safeguarding tool to: (1) identify and respond to adolescent sexual behaviours, and (2) support professionals to communicate confidently with adolescents about sexuality and risk taking. We confirmed the possibilities for developing a Japanese version of the tool.

Conclusions

A safeguarding perspective can help us to move away from a narrowly risk-based approach to child and adolescent sexuality. Development and dissemination of a Japanese version of the TLT can help professionals distinguish between healthy (normal) and unhealthy (risky) sexual behaviours at each developmental stage and more confidently respond to these behaviours.

Introduction

Sexuality is increasingly being framed as potentially health affirming [1–3]. For both men and women, ‘sexual activity, quality of sexual life and interest in sex’ have been shown to be associated with ‘health benefits and longevity’ [1]. This has important implications for how we communicate with and think about adolescent sexuality.

In Japan, adolescent sexuality had been discussed largely in terms of sexual behaviour and risk. Little attention has been given to the positive aspects of sexuality and sexual expression [4]. The first interim evaluation of the national Healthy Parent and Child 21 (Sukoyaka Oyako 21) policy in 2005, for example, identified a need to strengthen responses to adolescent risk-taking behaviours, but scant attention was given to promoting any health affirming aspects of youth sexuality [5]. The Healthy Parent and Child 21 policy was launched in April 2001 as a 10-year plan to address major social changes and issues that were affecting the health of children and adolescents directly or indirectly through the behaviours or health status of mothers. It was subsequently extended by 4 years to March 2014.

While some of the targets for improving adolescent health, including sexual health, were achieved over the 14 years of the Healthy Parent and Child 21 policy, in the final report it was emphasised that the hitherto approach had produced insufficient results. There was an unequivocal call not only to expand the qualitative reach of adolescent health promotion, including sexual health promotion, but also for a major qualitative paradigm shift in how we approach these issues [6].

Despite growing recognition of the positive link between health and sexuality, the tendency to view any signs of child and youth sexuality as problematic has yet to change significantly, whether in Japan or the UK [4, 7]. This negative framing can result in professionals and parents overreacting. Behaviours that may not present an inherent risk to a child or adolescent may be viewed as unhealthy or high-risk leading to inappropriate responses. More commonly, however, lack of confidence or difficulty addressing sexual issues may mean that a professional or parent takes no action even though one is warranted [7].

The role of a professional or parent is to support positive behaviours. Nevertheless, sexual expression may result in a child or adolescent causing harm to another or being exposed to risk. Certain behaviours may be a sign that a child or adolescent is being or has recently been harmed. In such cases, the role of a professional or parent is to intervene appropriately to safeguard a child or adolescent’s health and welfare. Knowing when and how to react, however, can prove difficult.

Given that even professionals working in the field may lack confidence to appropriately identity, understand and respond to sexual behaviours, there is a need for some kind of guiding framework. Ideally this should take into account the developmental age of the child/adolescent and the context in which any behaviour takes place [8]. Given the range of professional stakeholders involved, this framework should allow decisions to be made regarding health promotion, sex education and child protection issues.

The purpose of this study was to identify a developmental and context-sensitive framework for developing a diagnostic and communication tool that could be used to identify, describe and respond to child and youth sexual behaviours. This tool should have the scope to be implemented in health promotion, sex education and child protection.

Materials and methods

This qualitative study had three components to the data gathering process. The UK was chosen as the field site to draw on the enormous wealth of data and expertise that has been generated by the Teenage Pregnancy Strategy [9–11], while also building on already established relations of trust between the authors and relevant professionals in the UK setting [12, 13]. With such a sensitive area of research, this latter consideration would play an important part in ensuring the smooth running of this project.

The initial stage of the project involved a review of relevant, recent documentation on child and adolescent sexuality. In particular, we focused on the literature generated by the British Teenage Pregnancy Strategy. We sought to gain deeper insights into the range of behaviours that should be defined as ‘sexual’ and to create a framework for distinguishing those that could be regarded as health affirming and positively supported and those that suggest a child or adolescent is at risk and in need of professional intervention. We reviewed work being conducted by government, municipal and non-profit organisations on adolescent sexual health and sexual risk-taking in the UK context.

From the above activities, we identified the Traffic Light Tool (TLT) developed by the UK youth sexual health charity Brook, as offering a potential framework [14]. Brook is a registered charity that specialises in the sexual and reproductive health of the under 25s.

The second component of this project involved expert interviews with Sian Brady who led the project at Brook to develop the UK version of the TLT. The first interview, in September 2012, was concerned with the aims of the Brook TLT project, the conceptual framework underpinning it, and the process through which a normative list of sexual behaviours was created. The second interview, in September 2013, was concerned with how the tool was being implemented by professionals in the field and with the process of external evaluation and promotion of the tool.

The final component of this study involved a review of in-house consultation, training and evaluation documentation provided by Brook to understand the issues, protocols and development process.

The broader research protocol was approved by the Osaka University, Graduate School of Human Sciences Ethics Committee (Approval No. 12012).

Results

Identifying a framework

We set out to identify a developmental and context-based framework for developing a diagnostic and communication tool that could be used to identify, describe and respond to child and youth sexual behaviours. Through the discussion with Brook and other expert interviews in the UK we were introduced to the concept of safeguarding.

Safeguarding is concerned with protecting all children and young people from impairment to their health or development and promoting their welfare in all areas of life. As such, it has a broader meaning than that of child protection, referring to activities and responses that protect all children and young people from maltreatment; prevent impairment of health or development; ensure that children and adolescents are ‘growing up in circumstances consistent with the provision of safe and effective care’ [15]. Child protection is part of safeguarding, seeking to ‘protect specific children who are suffering, or are likely to suffer, significant harm’ [16]. Thus, while all minors are the targets of safeguarding activities, only high risk children and young people are the targets of child protection activities.

Brook and the safeguarding Traffic Light Tool project

In seeking to identify the range of behaviours that can be classified as sexual and then to determine the circumstances in which a specific behaviour could be understood and responded to as either health affirming or harmful, we discovered the Brook safeguarding project that had developed the TLT.

The TLT was developed between April 2011 and March 2013 as an evidence-based resource and training programme based on funding by the Department for Education to ‘deliver improvements in child protection and safeguarding practices’ using a traffic light system to ‘categorise the sexual behaviours of young people’ [14]. Behaviours that are considered safe and healthy were categorised as green behaviours. Behaviours that ‘have the potential to be outside of safe and healthy development’ are categorised as amber. Behaviours that are ‘outside safe and healthy behaviour’ are categorised as red behaviours [14]. Behaviours are categorised on the basis of four age categories (0–5, 5–9, 9–13 and 13–17 years), adopting a developmental model [14].

Categorizing sexual behaviour

In developing the tool, Brook drew upon a pre-existing TLT created by Family Planning Queensland and the Flagship Tool developed by SENSOA in Belgium. Both tools use colour coding and age-based categorizations.

In categorising behaviours, several factors were taken into account including, the developmental age of the child/adolescent, the nature of the relationship, the context in which the behaviour was occurring and the personal characteristics of the child/adolescent. A green behaviour is one considered normal for a child or adolescent of that age, is ‘displayed between children or young people of a similar age or developmental ability’ and is ‘reflective of natural curiosity, experimentation, consensual activities and consensual choices’ [14]. Amber behaviours potentially fall outside safe and healthy development due to age or developmental differences between those involved, because it is ‘unusual for that particular child or young person’ or due to ‘activity type, frequency, duration or the context in which they occur’ [14]. Red behaviours require immediate intervention due to concerns regarding the type of activity, ‘frequency, duration, or the context in which they occur’, or as a result of significant age, developmental or power differences between those engaged in such activity, or because the behaviour is ‘excessive, secretive, compulsive, coercive, degrading or threatening’ [14]. For example, for the age group 0–5 ‘persistently touching the genitals of other children’ would be an example of a red behaviour due to frequency and the compulsive nature of the activity (Table 1). At age 13–17, ‘attempting/forcing others to expose genitals’ is a red behaviour as it is both coercive and degrading.

Table 1 Concrete examples of the categorizing of sexual behaviours in the Brook version of the TLT for each age group by traffic light code

It is noteworthy that in the Brook model, a green light is given to consensual sexual activity for 13–17-year olds. In the context of safeguarding, consensual sexual activity is considered normative behaviour providing there are no disparities of power based on age or developmental ability. Professionals should act proactively to ensure that young people do not expose themselves to the risk of pregnancy or a sexually transmitted infection (STI).

The consultation process

A wide range of methods were adopted by Brook in the development process, including setting up an Advisory Group of health-care, and child protection professionals to oversee the project and carrying out consultation seminars with professionals working with young people, parents, and young people.

In consultation seminars, Brook found that professionals welcomed the chance to discuss these educational and safeguarding issues around sexuality with others in the field. Workshops highlighted inconsistencies in professionals’ own views, with some reporting that they would not necessarily welcome their own children engaging in behaviours they may categorise as normative in a professional capacity. The chance to discuss such inconsistencies was welcomed. In the final review, the TLT was highly evaluated and professionals regard it as a useful part of their safeguarding repertoire.

Discussion

This study offers important insights into how a relatively simple-to-use tool can be developed to identify, understand and respond to sexual behaviours displayed by children and young people. It is important that the TLT makes use of a developmental framework that understands that the same behaviour can and should be assessed differently depending on the age or developmental capacity of the child or young person. It is equally important that the TLT pays attention to the nature of the relationship, the way the behaviour is presented, and the personality or capacity of the individual child.

Investigating how Brook developed the UK TLT offers important insights for developing a Japanese version. The setting up of an Advisory Group to act as a sounding board for ideas in the early developmental stage meant that a consensus could be formed around what was important. It also formed a ready and sympathetic group from which to disseminate information and to conduct the research necessary to develop the TLT. Seminars provided the research data necessary to create a normative, developmental model of sexual behaviour for the UK context. The most important views here were those of professionals for categorizing behaviours. Nevertheless, parents and young people also provided valuable insights through the seminars. Revisions were made to the wording of questions, for example, based on how parents and young people reacted to the original version.

To develop the tool in the Japanese context, we will need to draw on additional data and know-how. In particular, we will need to pay attention to the very different normative context of child-raising and child development. There are also issues of translation and the appropriateness of language for different groups of stakeholders. Professionals in Japan note that they are unsure what language to use with children and young people when talking about sexual issues [17, 18]. It will be important to consult with those working in the field to find acceptable and appropriate translations for the range of sexual behaviours.

Conclusion

In this mini-review, we have introduced the concept of safeguarding and highlighted its potential for professionals working with children and young people. We argued that approaching the issue of child and youth sexuality from a safeguarding perspective can allow for a positioning that recognizes not only the potential risk of harm, but also the healthy aspects of sexual expression. We identified the TLT as a highly effective, easy-to-use tool for professionals rooted in a safeguarding perspective. The development and dissemination of a Japanese version of the TLT should help professionals distinguish between healthy and unhealthy sexual behaviours at each developmental stage and more confidently understand and consistently respond to any presenting behaviours.