3.5.9 Sexual Health and Relationships Guidance

Introduction
Definition of Sexuality and Sexual Orientation
Legal Issues, Confidentiality and Fraser Guidelines
Principles and Guidance
Provision of Information and Advice to Looked After Children
Puberty and Sexual Identity
Pornography
Underage Sexual Relationships
Sexual Activity in Homes
Contraception
Pregnancy and Termination
Working with Young Fathers
Prostitution and Sexual Exploitation
Sexually Transmitted Infections
Masturbation
Peer Group Abuse

1. Introduction

This document provides Sexual Health and Relationships guidance to all employees working directly with children and young people. For employees working with vulnerable groups, such as Looked After Children, additional guidance has been provided where appropriate.

Sexual health and relationships should be considered a natural part of personal development. Children and Young People should feel confident in being able to discuss such matters and it is the responsibility of Children's Services to ensure that communication around sexual health and relationships should be encouraged and non-judgemental. When working with children and young people Children's Services shall ensure they are mindful of a number of areas that may have an impact on a young person's understanding and attitude towards sexual health and relationship matters. This includes a young person's ethnicity, gender, disability, age, religion and belief or sexual orientation which can be assured through a personalised approach.

Sexual Health and Relationships Education

Sex and relationships, education and support is part of a life long process of learning, forming beliefs, values and attitudes about sex, sexuality, sexual health and emotions. It should support children and young people in coping with adolescence and enable them to prepare for an adult life in which they can;

Be aware of and enjoy their sexuality
Behave responsibly within sexual and personal relationships
Communicate effectively
Have sufficient information and skills to protect themselves from unintended / unwanted conceptions or sexually transmitted infections including HIV
Access confidential advice and support
Neither exploit or be exploited
Develop a personal values and moral framework that will guide their decisions, judgments and behaviour.

In achieving this it is essential that employees recognise and work with the different needs children and young people may have according to their race, gender, disability, age, religion and belief and sexual orientation. Employees who have a moral or cultural objection have a responsibility, as part of their duty of care to young people, to signpost to another professional.

Looked After Children and Children with Additional Needs

It is important to recognise that Looked After Children may be more likely to be at a different stage of emotional development than their chronological age. It is also important to ensure that Looked After Children have access to resources and information that are age appropriate and gender specific on a full range of sexual health and relationship issues. Some disabled children and young people may require these to be in specific formats e.g. Braille, large print, tapes etc. Children and young people with learning disabilities/ difficulties and those with mental health problems will require tailored support to ensure their needs are met. Consideration must be given to the impact on young people of the emotional aspects of a sexual or physical relationship.

In addition a child and young person's cultural and religious background must be central to planning and carrying out sexual health and relationship work, with employees having an understanding of specific cultural and religious needs when working with children and young people. However, children and young people should not be denied the benefits of information and support on sexual health and personal relationship issues because of religious and cultural values. Disabled children and young people must be regarded like any other child and should have access to resources and information about sexual health, relationships and sexuality, though this should be in a format to suit their disability needs.

Young parents and expectant parents must be offered guidance and sensitive support to enable them to make informed choices about their future and their child's future, and young fathers need to be supported with the level of involvement with their child or children. However, the level will depend on whether they have Parental Responsibility.

Looked After Children should be supported to make their own informed choices about their sexuality according to their age and maturity, and they should also be provided with an environment where stigma and harassment are not tolerated.

2. Definition of Sexuality and Sexual Orientation

An individual's sexuality and sexual orientation is part of an individual's wider development and sense of self. It is an important aspect of identity, security, attachment and relationship with other people, family, peers and wider society. Sexuality and sexual orientation develop continually throughout childhood, pubescence, adolescence, teenage years and younger adulthood.

Sexuality can be defined in terms of gender identity, sexual identity, sexual awareness, physical and emotional attraction, friendships, relationships, and how a child or young person relates to his or herself and to others.

Sexual orientation may be attraction to others of the opposite sex (heterosexual or straight) or it may be attraction to those of the same sex (homosexual; lesbian, or bisexual). Some children and young people may decide not to have a named sexual orientation.

Some young people who identify as lesbian, homosexual or bisexual experience negativity, bullying, stigma and discrimination. This is called homophobia, and can have significant and damaging consequences for children and young people as they grow up. Homophobia should be discouraged and support given to the victims to enable them to deal with such behaviour.

Gender identity can be male or female. Some children and young people identify their social and emotional gender differently to their physical gender. Children and young people who identify as transgender (or Trans) can have a strong, clear and positive gender identity which is different to their physical or birth gender.

Some children and young people who identify as transgender experience negativity, bullying, stigma and discrimination. This is called transphobia, and can have significant and damaging consequences for children and young people as they grow up. Transphobia should be discouraged and support given to the victims to enable them to deal with such behaviour.

3. Legal Issues, Confidentiality and Fraser Guidelines

The Sexual Offences Act 2003 is the main act of law which proscribes sexual activity in the UK.

The age of consent for sexual activity in England, Wales and Scotland is set at 16. In Northern Ireland it is set at 17. The age of consent applies regardless of the type of sexual activity, not simply penetrative sexual activity. The age of consent also applies regardless of the gender or sexual orientation of those involved.

The law states that a child or young person under the age of 13 can never, under any circumstance, give consent to sexual activity of any kind.

Where one, both or all the parties involved in sexual activity are under 16, the situation should be assessed using the Fraser Guidelines . If the age of one, both or all the parties is/ are under 13, the situation must be dealt with through safeguarding procedures.

Situations causing concern involving electronic, cyber or internet activity should be assessed under the Sexually Active Young Persons policy and Safeguarding procedures.

The Equality Act (Sexual Orientation) Regulations 2007 makes it unlawful to discriminate in the provision of goods, facilities and services on the grounds of sexual orientation. This means that all aspects of the work of Children's Services must be free from discrimination on the grounds of sexual orientation.

Confidentiality

Children and young people have a right to confidentiality when discussing sex and relationship issues, including contraception. A disclosure of underage sex is not in itself a reason to breach confidentiality. However, it is paramount that children and young people are encouraged to discuss matters with their parents or legal guardian as part of healthy family relationships and be made aware of any legal issues.

Fraser Guidelines

The Fraser guidelines provide legal guidelines for professionals working with children and young people. Advice and contraception treatment may be given to a person under 16 without parental consent providing the young person can demonstrate they meet the below criteria.

When working with children and young people under the age of 16 years in the area of sex and relationships, it is regarded as good practice for professionals to be guided by the Fraser guidelines. These hold that sexual health services can be offered providing that;

The young person understands the advice that is being given
The young person cannot be persuaded to inform or seek support from their parents and will not allow the doctor to inform their parents that contraceptive advice is being given. Doctors are obliged to respect the young person's right to confidentiality
The young person is likely to begin or continue to have sexual intercourse with or without contraception
The young person's physical and mental health are likely to suffer unless they receive contraception advice or treatment

It is therefore in the young person's best interests to receive contraceptive advice or treatment without parental consent.

4. Principals and Guidance

All sexual health and relationship work with children and young people must be child-centered and children and young people should receive information, advice and guidance to make informed choices about relationships and sexual health.
Employees/carers working with children and young people must work in line with the Lincolnshire Safeguarding Children Board (LSCB) Child Protection Procedures.
Employees/carers should work in partnership with parents providing it does not conflict with the overriding principle that the welfare of the child/young person is paramount.
Employees/carers must maintain professional boundaries with children and young people at all times.
Employees/carers must carry out this procedure in such a way as to respect a child or young person's race and culture, gender, disability, age, religion or belief and sexual orientation.
Employees/carers must explain to children and young people about the principles of confidentiality under which they work. The detail of how information is recorded, shared, stored and used, and for what period of time must be made clear, preferably both verbally and in writing, to all people involved and must be in line with the Safeguarding Children Board Procedures and Children's Policy, Values and Principles, including Principles of Recording, Equality, Confidentiality and Consultation
Employees/carers should not allow their own sexual attitudes to affect their professional work
It is important not to make assumptions about a young person's sexuality and there is a need to support all children and young people to develop a positive sense of their sexuality.
Employees/carers need to be aware of the influences of alcohol, drug and substance use and their effect on sexual activity.

5. Provision of Information and Advice to Looked After Children

Those responsible for the care and planning of Looked After Children must make sure that they are provided with appropriate, accurate and up to date information and advice on matters relating to sexual health and relationships.

The information provided must be discussed with a Team Manager and if appropriate, a specialist in the field of sexual health and must be provided in a manner appropriate to children's age and understanding and should be provided in a creative, child friendly manner.

Before providing such information and advice, relevant Social Workers must be consulted and, if possible and where appropriate, Parents/ Carers to ensure it is provided in the context of children's backgrounds and needs; and any specific arrangements must be incorporated into the Placement Plan/Placement Information Records.

6. Puberty and Sexual Identity

All Professionals and Carers must adopt a non-judgemental attitude towards children and young people, particularly as they mature and develop an awareness of their bodies and sexuality.

Professionals and Carers must adopt the same approach to children and young people who explore or are undecided about their sexual identity or who have decided to embrace a particular lifestyle so long as it is not abusive or illegal.

Children and young people who are undecided about their sexual identity or indicate they have a preference must be afforded equal access to accurate information, education and support to enable them to move forward positively. Employees should be aware and supportive with children and young people who are undecided about their sexual identity as this will often cause stress.

For Looked After Children information regarding sexual identity must be addressed in Placement Plans/Placement Information Records as necessary.. This information is solely recorded so that it may be taken into account when considering the suitability of a placement for a Looked After Child.

7. Pornography

All materials published by Children's Services, circulated or available to children and young people must promote and encourage healthy lifestyles and images of men and women that are positive and encouraging.

Children and young people must be positively discouraged from obtaining material that is potentially offensive and harmful, though it is important to recognise that some young people will access pornography through a variety of means including the internet and magazines, this viewed as part of a child's sexual development. If they obtain material that is suspected to be illegal it must be confiscated and in extreme circumstances consideration must be given to reporting the matter to the Police.

8. Under-age Sexual Relationships

Children under the age of 13 are deemed by the law to be incapable of giving consent to sexual activity. Therefore, children of this age who engage in sexual activity must be referred and supported under Safeguarding Children Procedures (as a Child Protection Referral) as potentially suffering from Significant Harm.

Where one, both or all the parties involved in sexual activity are aged between 13 and 15 the situation should be assessed using the Fraser guidelines.

Placement of Looked After Children

When considering the placement of children under 13, the child's vulnerability to engage in under-age sexual relationships should be carefully considered and children of this age who are likely to be at risk from each other (or from older children) should not be placed together.

When considering the placement (or ongoing placement) of young people over the age of 13, Managers must assess the impact of sexual relationships developing and should ensure strategies are in place to reduce or prevent these risks if they are likely to be exploitative or abusive.

Where young people aged 13 - 18 are placed together with no identified risk of exploitative or abusive behaviour, Carers, Managers and Employees must be mindful of any developing relationships and sensitively but positively support young people to delay early sexual activity, this should be monitored on a regular basis.

Overall, employees should be mindful of their duty to consider the welfare of children and young people and this may mean recognising that illegal activity is taking place, if there is any suspicion that a child is engaging in illegal behaviour it must be discussed with the Child's Social Worker and consideration given to consulting the Child Protection and Support Agencies. Any actions taken in this respect will be subject to consultation and must be addressed in Placement Plan/Placement Information Records.

Should employees suspect that children and young people are engaging in sexual relationships, they should:

Ensure the basic safety of all the children and young people concerned.
Notify the Manager, who should notify/consult relevant Social Workers and if applicable, Line Manager for the Home.
Record all events, distinguishing between fact and opinion.

If employees becomes aware that children and young people are engaging in sexual relationships, they should:

Ensure the basic safety of all children and young people concerned (if necessary employees may consider removal of one or more child).
Inform the Manager, who should notify/consult relevant Social Workers and if applicable, the Line Manager for the Home.
Record all events, distinguishing between fact and opinion.

9. Sexual Activity in Homes

This section must be read in conjunction with Section 8: Underage Sexual Relationships.

Children under the age of 13 are deemed by the law to be incapable of giving consent to sexual activity, but it is understood that older children may develop relationships with each other and that they will wish to express themselves sexually and explore their feelings.

This may be acceptable so long as their behaviour is respectful of the wishes and feelings of everyone they live with including other children. However Employees may not condone or permit unhealthy, exploitative, abusive or illegal behaviour and must take all reasonable steps to reduce or prevent it.

If employees are seriously concerned about a child's behaviour they must draw this to the attention of the Manager who may invoke strategies to reduce or prevent the behaviours from escalating. Such strategies must be developed in consultation with relevant Professionals and consideration given to consulting the Child Protection and Support Agencies.

10. Contraception

This section should be read in conjunction with Enabling Young People to Access Contraceptive and Sexual Health Information and Advice (Every Child Matters Publication).

Employees/Carers should identify local sources of professional help and information for young people, and can accompany them to health clinics if requested to do so.

Employees and carers can contact the Teenage Pregnancy Team for support and access to the c-card condom scheme through venues across the county. This scheme also provides information about where young people can access information and advice e.g. 'Sexwise, C4YP, Contraceptive clinics, Teenage Advice clinics, School Nurse and Clinic in a Box.'

There are a variety of forms of contraception available for young people, for example, the pill, implant or injections. These should be used with condoms to protect against Sexually Transmitted Infections. . Condoms are the most easily available, non-prescribed form of contraception, they also protect against many sexually transmitted infections. Young men and women should learn how to use condoms correctly in order to reduce the risk of condoms being used ineffectively. For this reason it is important that young women are equally confident in using condoms and condom demonstrations are available for this purpose.

Before a decision is taken to make condoms available, Social Workers, Employees/Carers should ensure that the supply of condoms:

Forms part of a broader sex and relationship education programme which includes helping children and young people resist any pressure to have early sex
Is supported by clear protocols which have been agreed with management and are understood by young people
Complements local service arrangements for the distribution of free condoms
Only supply condoms with the British Kite Mark and EC standard
Is always accompanied by verbal and written advice about using condoms correctly, information about sexually transmitted infections and services and where to access emergency contraception if the condom breaks or is not used

Condoms and Under 16's

Through the C Card Condom Scheme employees/Carers can advise and provide condoms where it is clear that a young person aged under 16 intends to engage in sexual activity and the provision of condoms would protect the sexual health of the young person. Provision of these would be seen as an act of protection and not an act of facilitation of sexual activity. For Looked After Children such advice/provision should be subject to consultation with the child's Social Worker.

Emergency Contraception

Children and young people need to know about the use and availability of emergency contraception and emergency health advice.

In the event of contraception failure or it not being used, free emergency contraception for young people under the age of 20 is available from G.P.s, contraceptive clinics and participating pharmacists. Details of participating pharmacists and clinics can be found on the NHS Choices (Sex Worth Talking About) website.

The emergency pill can be taken up to 72 hours after unprotected sex and the coil (IUD) fitted up to 5 days after.

11. Pregnancy and Termination

If a young person presents themselves as pregnant or is suspected to be pregnant employees should refer to the Teenage Pregnancy Pathway.

Looked After Children

If a young woman is suspected or known to be pregnant the Manager should talk openly to the young woman about who should be informed and what support may be required in order to promote the young woman's welfare and that of the unborn baby.

Under normal circumstances, the young woman's Social Worker and Parent(s) should be informed and they should collaborate with the young woman in drawing up a plan which promotes the young woman's and the unborn child's welfare. It is important that employees are mindful of additional considerations when dealing with this situation as a young woman's or families understanding and reaction to such circumstances could be impacted upon by their race, gender, disability, age, religion or belief and sexual orientation.

However, a young woman who has reached the age of sixteen may request that her Parent(s) and/or the Social Worker is not informed. Where a young woman is under the age of sixteen, they may also request confidentiality if they are of an age and level of understanding to make such an informed decision.

Where a young woman under sixteen makes such a request, the Manager should seek legal advice before agreeing.

In all circumstances, should there be suspicions that the pregnant young woman or the unborn child are at risk of Significant Harm, the Manager must discuss it with the young woman's Social Worker/ Professional with a view to making a child protection referral.

Any decision to terminate a pregnancy should be reached by the pregnant young woman. Advice, counselling and support in making the decision must only be given by suitably qualified independent counsellors.

If the pregnant young woman decides to terminate the pregnancy, the Manager must ensure that adequate support is given throughout and afterwards to ensure the young woman's privacy is protected and any physical or emotional needs are addressed sensitively taking into consideration if the young woman has learning or mental health disabilities.

Consideration should be given to the father of the unborn child and support and advice offered where necessary.

12. Working with Young Fathers

The choice and responsibility in decisions relating to the baby lies with the mother, though employees should encourage a joint decision between the father and mother, where communication is ongoing. Regardless of how the mother views the situation, young fathers should be supported. The following points should be addressed/ discussed with both parents:

The role of the young man
The choice and responsibility in decisions regarding pregnancy or termination
Potential conflicts with the mother and if so, how these will be managed
Support strategies for the young father.
The role of the father in the child's life
Support for how to care for baby and if appropriate mediation and support in building relationships between mother and the baby
The young father is informed of his legal rights, choices and responsibilities in relation to his child

13. Prostitution and Sexual Exploitation

This section should be read in conjunction with the Lincolnshire SCB Procedures.

Children and young people of any sexual orientation could be abused through prostitution or sexual exploitation. This can involve more than payment of money in exchange for sexual services; it includes remuneration of any kind, given to a child or young person, for example mobile phones, alcohol, new clothes and other 'treats'. It should be considered that children and young people with learning difficulties/ disabilities and those with mental health problems are particularly vulnerable to sexual exploitation and may not recognise such behaviour.

Children and young people abused through prostitution are regarded as Children in Need, and should benefit from multi-agency planning and services that ensure the child'/young person's immediate protection, and through a longer term strategy, that encourage and support his/her exit from prostitution.

Children and young people can no longer be charged or cautioned by the Police for soliciting. When all efforts to support an exit from prostitution are deemed to have been ineffective, employees should ensure the Police and Youth Justice Board become involved - this would still be part of a multi-agency plan.

Employees/Carers need to be alert to any behaviour that might indicate that a child or young person is involved in prostitution or at risk of becoming involved warning signs include:

Changes in appearance
Getting lifts home from strangers
Unusual eating habits
Having credit on mobile phones that can't be accounted for or updated mobile phones; new possessions,
Mood changes
Different language, new style of dress
Truanting from school and staying out at night
Losing touch with old friends
Telling lies
Drug use
A new name
Starting to visit Red Light areas

Employees should raise any concerns during supervision and a response strategy agreed, such concerns should be shared with the child/young person, employees should consider the need to:

Be supportive and non-judgemental.
Act as a child/young person's advocate regarding liaison with other agencies.
Give immediate practical support needs upon which you can build a relationship.
Go slowly - don't rush in. Befriend and form the beginnings of a trusting relationship before mentioning your concerns (unless you think the child is at immediate risk).
Remember that some children are controlled by pimps and involvement of professionals needs to be handled sensitively in order that the young person's safety is not put at further risk.

Everything that is offered will be developed in co-operation with the child/young person. You need to understand that the plan may fail and the child/young person may drift back into their former life. Do not feel you have failed or are being rejected. Your role is to give support on every occasion it is needed. It has taken a powerful and abusive process to get this person into prostitution and leaving an abusive lifestyle can take years.

Where there is any suspicion that a Looked After Child is engaged in such behaviour it should be addressed in the child's Placement Plans/Placement Information Records together with Strategies to be adopted to help the child find alternative lifestyles. In addressing these behaviours consideration must be given to the extent to which the child is suffering significant harm - and whether it is necessary to refer the child under Lincolnshire's Safeguarding Children Board Procedures. If a child is engaged or suspected to be engaged in prostitution, the Regulatory Authority, Lincolnshire County Council and Police, where the child is placed, must be informed.

14. Sexually Transmitted Infections

It is the absolute right of children and young people to have information and advice on safer sex, HIV, AIDS, Hepatitis (HBV and HCV) and other sexually transmitted infections (STIs). STIs such as Chlamydia (a common sexually transmitted disease or urinary tract infection caused by a bacteria-like organism in the urethra and reproductive system) are currently on the increase. In providing such advice and guidance to children and young people, it is important that they are made aware that there are many safer and pleasurable alternatives to penetrative sex. Guidance should also be provided to the child or young person that they are still at risk to a STI through the alternative practice of oral sexual relations. Further information regarding STIs can be found on the NHS Choices (Sex Worth Talking About) website.

Young People should be encouraged and supported to take responsibility for their own sexual well being. The opportunity to discuss this with Carers and a variety of health professionals should be available.

With regard to sexually transmitted infections including HIV, young people should be advised of clinics where anonymity and appropriate pre and post testing counselling are available. They should be made aware that, if they are tested by their G.P., then the results of this will be recorded in their medical notes. There is, however, complete confidentiality at all Genito-Urinary Medicine (G.U.M.) clinics.

If it is known or suspected that a Looked After Child has a sexually transmitted infection (other than HIV and AIDS) the Manager and Social Worker must be informed and decide what measures to take to ensure both the child's, and other children's welfare and well being.

In principle, the child should be referred, to the local Genito-Urinary Medicine Clinic, who will provide the child and Carer with advice, counselling, testing and other support. Only the immediate Carers of the child will be informed of any suspicion or the outcome of any tests and strategies or measures to be adopted. Other children in the Home should only be informed if there is a direct risk to them; for example if the infected child deliberately attempts to infect them.

The only other individuals who will be told are the child's GP and Health Visitor.

Before disclosing to any other agency or individual, the following criteria must be satisfied:

The child (where appropriate) and the Parents have given their written consent to the disclosure
The disclosure would be in the best interests of the child
Those receiving the information are aware of its confidential nature

Consent to testing

The permission of the child aged 16 or over must be given before testing.

If a child under 16 has sufficient age and understanding, his or her permission must be given before testing.

Wherever possible, the consent of the Parents should be obtained. However, only where it is practical and appropriate parental involvement should be sought. The child should not be put under any pressure to give consent to involve parents. The rights of the child or young person and confidentiality should be considered in line with Fraser Guidelines.

If Parents are to participate in decision-making, they must be provided with adequate information and given appropriate support including access to counselling both before the test and in the event of a positive diagnosis.

Where Parental consent is not forthcoming but there is a clear medical recommendation that testing is in the child's best interests, legal advice should be obtained as to whether the test can proceed.

15. Masturbation

It is accepted that masturbation is part of normal sexual behaviour but young people must be positively encouraged to undertake such activities in private.

16. Peer Group Abuse

The following should be read in conjunction with relevant procedures within the LSCB Child Protection Procedures. The possibility of peer abuse will always be taken seriously but we recognise it is equally important not to label or stigmatise normal sexual exploration and experimentation between young people.. Behaviour is not a cause for concern unless it is compulsive, coercive, age- inappropriate or between children and young people of significantly different ages, maturity or mental abilities.

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