DOI: 10.1111/tog.

12389 2017;19:205–10
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Child sexual exploitation: a guide for obstetricians and

gynaecologists
Katherine Gilmore BA (Hons) MBBS (Hons) DFSRH,a,* Laura Mitchell MBChB MSc MRCP DFSRH DipGUM DipHIV,b
Melinda Tenant-Flowers MBBChir FRCP MSc,c Karen Rogstad FRCP MBA PGCert Med Edd
a
Specialty Registrar in Community Sexual and Reproductive Health, New Croft Centre, Newcastle Upon Tyne NHS Foundation Trust, Newcastle
upon Tyne, NE1 6ND, UK
b
Consultant Physician, The Laurels, Gender Identity Clinic, Exeter. EX1 1QA, UK
c
Consultant in HIV and Sexual Health, King’s College Hospital NHS Foundation Trust, London, SE5 9RS, UK
d
Consultant in HIV and Sexual Health, Undergraduate Dean of University of Sheffield Medical School, Sheffield Teaching Hospitals NHS
Foundation Trust, Sheffield S10 2JF, UK
*Correspondence: Katherine Gilmore. Email: katherinegilmore@nhs.net

Accepted on 31 October 2016. Published Online 29 May 2017

Key content and by highlighting appropriate referral pathways, including the

 Child sexual exploitation (CSE) is a child protection issue and can
affect any young person. Healthcare professionals play a key role
in identifying both those who are victims of exploitation, and also
those at risk. The General Medical Council considers that all
doctors have a responsibility for child protection.
 Obstetricians and gynaecologists may come across victims of CSE in
a range of clinical settings, but practitioners may not feel confident
that they have sufficient training to recognise victims or potential
victims or indeed what course of action to take if they do.
 This article provides training in both of these aspects by introducing
Spotting the Signs (a questionnaire-based tool to help detect CSE)
vital role of joint working and information sharing.
Learning objectives
 Understand what is meant by CSE.
 Understand the risk factors for victims of CSE.
 Develop a working knowledge of a validated tool to enable
healthcare workers to recognise potential cases of CSE.
 Understand what to do if you suspect CSE.
Keywords: child sexual exploitation / confidentiality / sexual
abuse / victim

Please cite this paper as: Gilmore K, Mitchell L, Tenant-Flowers M, Rogstad K. Child sexual exploitation: a guide for obstetricians and gynaecologists. The
Obstetrician & Gynaecologist 2017;19:205–10. DOI:10.1111/tog.12389

safeguarding and referral pathways and the vital role of

Introduction
Child sexual exploitation (CSE) is a form of sexual abuse that
involves the coercion or manipulation of a child under the
age of 18 years into sexual activity. This involves the exertion
of power over a child and can be manipulative, for example
offering sexual activity in exchange for gifts or shelter, which
may be exerted through threats or violence. CSE can affect
any child and doctors play a key role in recognising
vulnerabilities and risk factors for it and in supporting
young people and acting on any concerns. The General
Medical Council considers that all doctors have a
responsibility for child protection.1,2 CSE is a child
protection issue and it is everybody’s concern. See Box 1
for a full definition of CSE.3
This article aims to raise awareness of the indicators of CSE
among obstetricians and gynaecologists and therefore to help
clinicians to feel equipped to identify victims and those who
are at risk. It also highlights the safe and appropriate
communication, joint working and sharing of information
among professionals.
CSE is not a new problem but there has been an increase in
public awareness as a result of recent high-profile cases in the
media, and there are concerns about the extent of the problem.
Case reviews have given insight into the types of CSE that can
occur and how professionals can best approach it.
For many reasons it is difficult to accurately measure the
prevalence of CSE but at least 16 500 children are identified
as being at risk each year.4 Between 5% and 17% of children
who are under 16 years of age experience sexual abuse and
more than 1 in 3 choose not to disclose this in childhood.5
CSE occurs across all social and ethnic backgrounds. It is
often unreported and hidden and there are many reasons
why young people delay disclosure or do not disclose abuse,
particularly if the young person does not recognise that they
are being exploited.6 Any child can be at risk, including both
girls and boys, and although the majority of perpetrators are

ª 2017 Royal College of Obstetricians and Gynaecologists 205

 Child sexual exploitation
Box 1. Definition of child sexual exploitation3
Sexual exploitation of children and young people under 18 years of age
involves exploitative situations, contexts and relationships where young
people (or a third person or persons) receive ‘something’ (e.g. food,
accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as
a result of them performing, and/or another or others performing on
them, sexual activities. Child sexual exploitation can occur through the
use of technology without the child’s immediate recognition; for
example being persuaded to post sexual images on the internet/mobile
phones without immediate payment or gain. 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 common,
involvement in exploitative relationships being characterised in the
main by the child or young person’s limited availability of choice
resulting from their social/economic and/or emotional vulnerability.
male, it can be perpetrated by women and by all ages and
may involve heterosexual and/or same-sex relationships.
Furthermore, the child that is being exploited may also be
involved in exploiting others.
There is increasing evidence that CSE is becoming more
organised, with internal trafficking and networks that move
children across cities and countries for the sole purpose of
being abused. Online abuse in the form of grooming and
targeting children via mobile phones and social networking
sites happens frequently. This can be difficult to detect.7
A quote taken from Alexis Jay’s Independent Inquiry into
Child Sexual Exploitation in Rotherham8 describes the internal
trafficking and grooming of children for the purpose of CSE:
‘Victims were raped by multiple perpetrators, trafficked to
other towns and cities in the North of England,
abducted, beaten and intimidated ... Many of the cases ...
showed classic evidence of grooming. Many of the children
were already vulnerable when grooming began. The
perpetrators targeted children’s residential units and
residential services for care leavers ... In just over a third of
cases, children affected by sexual exploitation were
previously known to services because of child protection
and neglect. Many of the case files ... described children who
had troubled family backgrounds, with a history of domestic
Table 1. Patterns of child sexual exploitation in gangs and groups6
Group-associated sexual exploitation Identified in gang and other group contexts
 Exploitation in exchange for accommodation,  Peer-on-peer exploitation
money or gifts  Linked to sexual bullying within schools
 Targeting of a residential children’s home  Commercial exploitation linked to other
 ‘Party model’ of commercial exploitation offending, such as drugs sales
 Linked to intra-familial child sexual abuse  Internal trafficking
 Linked to transport hubs
206
violence, parental addiction, and in some cases serious
mental health problems. A significant number of the victims
had a history of child neglect and/or sexual abuse when they
were younger. Some had a desperate need for attention and
affection. ...Typically, children were courted by a young man
whom they believed to be their boyfriend. Over a period of
time, the child would be introduced to older men who
cultivated them and supplied them with gifts, free alcohol
and sometimes drugs. Children were initially flattered by the
attention paid to them, and impressed by the apparent
wealth and sophistication of those grooming them.
“Boys gave me drink and drugs for free ... I was driven
around in fast cars.”
There are different types and patterns of CSE and
understanding this is fundamental to ensure that all victims
or potential victims are identified. It is important to highlight
that the common theme between all the different ‘types’ is the
power imbalance between the perpetrator and the young
person. There may be multiple perpetrators or just one.
Perhaps the most obvious power imbalance is one involving a
significant age gap, but often the imbalance is more subtle.
The Office of the Children’s Commissioner’s Inquiry into
Child Sexual Exploitation in Gangs and Groups identified at
least 13 different patterns of CSE (Table 1).6
Presentation of child sexual exploitation in
obstetrics and gynaecology
Obstetricians and gynaecologists have the potential to come
across victims of CSE, or those at risk, in a range of clinical
settings. The difficulty can be recognising this in the limited
time that the clinician may have with patients when there is a
clinical agenda as well. Children who have been subjected to
CSE may find it difficult to engage with health professionals
and may appear to be evasive, which clinicians may find
challenging. However, it is vital to approach all children with
patience and vigilance and attempt to understand what may
be underlying certain behavioural manifestations, and
consider whether this could be due to CSE. The child may
Gang-associated sexual exploitation
 As a weapon in gang conflict
 Used to ‘set up’ rivals
 As a form of punishment to members
 As a form of gang initiation
ª 2017 Royal College of Obstetricians and Gynaecologists

or may not understand that the relationship that they are in
is abusive, but they may display signs that something is
wrong and this is where the clinician can intervene.
Girls may present to antenatal services or repeatedly
seeking emergency contraception or termination of
pregnancy. Frequent presentations to services should raise
suspicions of CSE. If vulnerabilities exist, for example,
substance misuse or mental health problems, it may be that
the child is already known to specialist support services. They
may frequently attend for sexually transmitted infections
(STI) testing or for treatment of pelvic inflammatory disease.
STIs and their presentation may be a marker of CSE and is
currently the subject of ongoing research.9
Approach to enquiry about child sexual
exploitation
Many health professionals may not feel confident that they
have sufficient training to recognise victims or those at risk of
CSE or what course of action to take if they suspect it. To
address this, a proforma has been developed by the British
Association for Sexual Health and HIV (BASHH) and the
young people’s sexual health charity Brook.10 It is a national
proforma that aims to help professionals working with young
people to identify CSE by asking questions that can help to
detect possible indicators of CSE.
Spotting the Signs proforma
This proforma10 is designed to be used in its entirety but also has
the potential to be amended locally to fit in with existing
proformas or paperwork. It provides a framework for identifying
and assessing the risk of CSE and encompasses the following areas:
 Relationships (e.g. age of partner, where they met)
 Consent (e.g. coercion, gifts in exchange for sex)
 Home life (e.g. supportive adult, school attendance,
alcohol, drugs)
 Mental health (e.g. self-harm, child and adolescent mental
health services)
 Involvement with agencies.
The proforma suggests specific questions to help the
Child Sexual Exploitation in Rotherham8 highlights key
clinician to explore the situation in a conversational way with
vulnerabilities in a child who became a victim of CSE:
the child. The questions are sensitive and tactful and allow
the child to assess whether what is happening in their
relationship is good for them (Box 2).
The Office of the Children’s Commissioner’s Inquiry into
Child Sexual Exploitation in Gangs and Groups Interim
Report4 highlighted CSE risk indicators to aid professionals
in risk assessment and identification of children showing
warning signs or with vulnerability to CSE (Boxes 3 and 4).
Some of the questions in ‘Spotting the Signs’ and other local
proformas are derived from these indicators.
ª 2017 Royal College of Obstetricians and Gynaecologists
Gilmore et al.
Box 2. Questions to help the clinician to explore the situation in a
conversational way10
 Are you in a relationship?
 Can you tell me about it?
 Are you happy?
 What’s going well?
 How were things at the beginning of the relationship?
 Has anything changed, such as how you feel about yourself, or how
your partner treats you?
 Are you happy with the sex you’re having?
 How do you feel about your situation?
 Do you feel good about yourself?
Box 3. Risk factors or vulnerabilities associated with risk of child sexual
exploitation4
Relationships
 Friends with young people who are sexually exploited
 Gang-association either through relatives, peers or intimate
relationships (in cases of gang-associated child sexual exploitation
only)
 Unsure about their sexual orientation or unable to disclose sexual
orientation to their families
 History of abuse (including familial child sexual abuse, risk of forced
marriage, risk of honour-based violence, physical and emotional
abuse and neglect)
Home life
 Homelessness
 Living in a chaotic or dysfunctional household (including parental
substance use, domestic violence, parental mental health issues,
parental criminality)
 Living in a gang neighbourhood
 Living in residential care
 Living in hostel, bed and breakfast accommodation or a foyer
 Attending school with children and young people who are already
sexually exploited
 Young carer
 Recent bereavement or loss
Mental health
 Learning disabilities
 Low self-esteem or self-confidence
The case of ‘Child E’ from the Independent Inquiry into
‘Child E ... became a looked after child when she was aged
12 years. She had an abusive family background and her
parents had mental health problems. She became a victim
of child sexual exploitation while she was looked after in a
local children’s unit ... Child E was described as very na€ıve,
and desperate for affection. She was very vulnerable to
coercion and was sexually exploited when looked after by
adult males she thought were her boyfriends ... Older
children in the residential units introduced younger and
207
 Child sexual exploitation

and explain to the child that some of the questions that they
Box 4. Signs or behaviours indicating that someone may be affected
by child sexual exploitation4
ask may appear intrusive but they are an essential part of
providing the best care. The clinician must explain
Relationships confidentiality and the limits to confidentiality in a way
 Evidence of sexual bullying and/or vulnerability through the internet that the child can understand. This will empower the child.
and/or social networking sites The clinician should explain to the child that although the
 Recruiting others into exploitative situations service is confidential, if they hear anything that is worrying
 Repeat sexually transmitted infections, pregnancy or terminations
about their safety or that of other young people, they will
 Exhibiting inappropriate sexualised behaviour for their stage of
development need to share information with colleagues and discuss with
 Anxieties around sexual health issues that suggest that they are not outside agencies such as social care or (less commonly)
in control of their sexual activity the police.
 Forming new relationships with people outside of their social circle
Exploring consent is a complex issue but one that is central
Consent to understanding and approaching CSE. The clinician should
familiarise themselves with the law on consent, look at the
 Receipt of gifts from unknown sources
context within which the child has had sexual relationships
– New possessions and assess whether they have the capacity to make the
– Unexplained gifts
– New clothes or jewellery
decision to engage in sexual activity or if they have been
– Mobile phones or money that cannot be accounted for exploited or coerced in some way.
 Change in physical appearance

– Rapid change in weight Communication

– Unkempt appearance
– Physical or unexplained injuries It is important that the clinician maintains professional
curiosity. They should explore why the child is there and
Home life whether there could there be anything else underlying their
 Missing from home or care symptoms or presenting complaint. Important areas to
 Drug or alcohol misuse consider include:
 Involvement in offending  Are there any other significant life events affecting
 Estranged from their family
 Absent from school
this child?
 Deterioration in academic achievement  Are there any nonverbal signs?
 Are they afraid or frightened about discussing or
Mental health sharing information?
 Poor mental health  Is it possible that they have been threatened and warned
 Self-harm not to disclose any information?10
 Thoughts of or attempts at suicide
In view of this, it is vital that the clinician sees the child
alone (i.e. without their parent/carer/friend/partner) for at
Box 5. Sex and the law11 least part of the consultation, in case the accompanying
person may be the perpetrator or have links to them. The
 A child does not become an adult until they reach their 18th
birthday clinician may need to arrange this by normalising it as a clinic
 The age of consent to sex is 16 years old policy (it may be useful to have a nurse present to provide
 Sexual activity with under 13-year-olds is unlawful as they do not support for the child if they wish). At the same time it is of
have legal capacity to consent to it. It therefore constitutes rape
 Any sexual activity involving under 16-year-olds is unlawful although
course important that all children attending a clinic are able
the law takes into account the circumstances of peer-to-peer sex to feel supported. If an interpreter or signer is required they
should be independent and not a relative, friend or carer. The
consultation should not be rushed. Any reluctance from the
more vulnerable children like Child E to predatory adult patient to be examined should be explored and any physical
males who were targeting children’s homes...’ injuries should be documented and queried. As always, STI
screening should be offered to any sexually active child.
The clinician should think about ways that they can ask
Consent and confidentiality questions that support the young person to open up.
For example:
It is vital for the clinician to adopt a non-judgmental
approach, to develop a rapport of trust, to involve the child “Sometimes young people can find themselves in relationships
and to be their advocate. The clinician should acknowledge or family situations that are unhealthy and that can be

208 ª 2017 Royal College of Obstetricians and Gynaecologists


difficult to talk about. Have you ever been
this situation?”11
This may enable the child to open up and discuss their
situation or any concerns that they have. The clinician should
find out what terminology around sex the child is
comfortable with and look interested in them and feel
confident to ask them personal questions. If the clinician is
just ‘ticking boxes’, the child may not feel listened to and may
not feel comfortable to disclose such information.
Developing a trusting rapport and finding out more about
the child may help them to talk and discuss things that they are
worried about. If the clinician loses that trust for any reason,
the child may retract that information and the opportunity to
intervene may be lost.
Privacy
Where the child is seen is important as they may feel safer
disclosing information if they are in a private room where no
one else is listening. Ensure that their phone is switched off
by explaining that it is normal hospital policy.
Other considerations
It is important to find out where the child lives. They may be
in an area with no family, friends or connections. This could
immediately raise concerns about internal trafficking. The
clinician also has a responsibility to consider the wider
context and any other children or young people who may be
at risk.
Action if there is concern about child sexual
exploitation and multi-agency work
CSE is always a safeguarding issue. If the clinician has any
concerns (even in the absence of a clear disclosure from a
child), it is imperative that they raise these concerns with the
child and share information by following local safeguarding
protocols. Confidentiality is key to encouraging children to
access health care when they need it and so any potential
breach of confidentiality (disclosure of information without
the child’s consent) needs to be formally considered as part of
this process. Often a discussion with a senior colleague is the
best first step in this process. If the child is at immediate risk
of danger then local safeguarding protocols must be followed
immediately to minimise this risk. All clinicians working with
children should be aware of named individuals for
safeguarding in their trust and where relevant, the lead
midwife for safeguarding should be informed. If the clinician
has any concerns about a child’s physical or mental health
then onward referral for assessment and treatment may also
be required. Clear documentation is important, both for the
ª 2017 Royal College of Obstetricians and Gynaecologists
Gilmore et al.
in sharing of information and for evidence should a court
case ensue.
Multi-agency meetings are held to discuss cases, and
attendance by referring clinicians or those involved in a
child’s care may sometimes be required. These may be called
multi-agency sexual exploitation meetings (MASE) or multi-
agency child exploitation meetings (MACE). Multi-agency
safeguarding hubs (MASH) also exist to provide a link
between universal services such as schools and healthcare
settings and statutory services such as police and social care.
The aim is to improve joined-up working, reduce duplication
and ultimately prevent young people from ‘slipping through
the net’. Clinicians who deal with young people should have
links to and an awareness of the workings of their local hub.
Further training
Further training can be accessed from a variety of sources. As
a first step, it is important for the clinician to feel confident
about their local CSE pathway (a locally relevant, recognised
referral route with clear decision-making points).12
Further departmental training may be provided through
local safeguarding teams, often involving feedback on
relevant recent case studies. Local safeguarding children
boards run multi-agency level 3 safeguarding training and
this is a mandatory training requirement for all clinical staff
working with children aged 18 years and under.
Various e-learning packages are available online; for
example the short e-learning tool developed by Brook and
the Department of Health, specifically dealing with CSE. This
is available at https://www.brook.org.uk/our-work/cse-e-lea
rning-tool.11
Further online resources
 The British Association for Sexual Health and HIV
(BASHH) website is a useful resource and the ‘Spotting
the Signs’ proforma10 can be found here: https://www.ba
shh.org/.
 The Royal College of Physicians has also recently produced
useful guidance to support physicians to help tackle CSE.12
 The Academy of Medical Royal Colleges, which includes
the Royal College of Obstetricians and Gynaecologists,
have produced a report.13
 There are also many local specialist services for sexual
exploitation and sexual abuse, as well as national
organisations such as NSPCC, Barnardo’s and Brook
who provide invaluable resources and training. An
example of this is a sexual behaviours traffic toolkit,
developed by Brook as a practical aid to help to support
professionals to identify and act on concerns about sexual
behaviours.14 You may also find that local safeguarding
boards have developed risk assessment tools specifically
targeted to the local area.
209
 Child sexual exploitation
Disclosure of interests
There are no conflicts of interest
Author contributions
KG researched and wrote the article. LM edited the article
and revised it critically for important intellectual content.
MTF and KR revised the article critically for important
intellectual content. All authors approved the final version.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
Infographic S1: Child sexual exploitation.
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ª 2017 Royal College of Obstetricians and Gynaecologists