Doing relationships and sexuality education with young people in state care

The multi-dimensional nature of the sexual health needs of young people in care

A range of factors were identified as being important to meeting the sexual health needs of young people in state care, and participants highlighted practices and techniques that they used in their everyday work or that they believed constituted good practice. Among these factors were a positive and meaningful relationship between professional and young person, sound knowledge and a confidence to deliver this, and a non-judgemental approach.

A number of participants referred to the myriad of sexual health needs of young people in state care in terms of ‘pieces’, reflecting the multi-dimensional nature of sexuality. The need for a holistic approach was illustrated in the following quotation, where the range of components of sexuality education normatively expected to be met within the family environment is identified:

Well again, like that, I suppose when they are in care it is like you are in loco parentis and so in that sense if you are looking at it from the family dynamic. It is providing them with all of the education of the academic piece, the skills’ piece but also just the human development piece about who they are and what they are and where they are going. (Aimee, female, sexual health trainer of professionals)

Another participant (Eiblín, female, sexual health trainer of professionals) described the needs of young people in state care with the analogy of a ‘jigsaw’. She noted that service-providers whom she encountered frequently needed support themselves to understand how to integrate ‘the pieces of the jigsaw’ that went beyond the bio-scientific dimensions of sexuality. The holistic approach was otherwise described as a ‘layered process’, involving programmes that started with ‘self-esteem, self-confidence and self-awareness’, with sexuality and sex education ‘worked in’ (Jackie, female, social worker). Another, Julia (female, teen-parent support worker), described this as ‘tiered’ noting that with respect to young people with a relatively stable upbringing, providing factual and scientific information would be acceptable since these teenagers experience normative stable relations played out in their everyday lives through which to process information. For young people in state care, however, she contended that ‘sexual health work needs to be more therapeutic and thought out’.

While emotional and social aspects of relationships and sexual health education are heavily intertwined, they are explored separately below in order to understand them more clearly.

Personal and emotional development education

A dominant theme across the interviews was the centrality of emotional issues that young people in state care tend to have, though the degree of emotional need was deemed to vary depending on the young person’s background. The problems of poor self-esteem, emotional disconnectedness and inability to recognise and express emotions among young people in state care were a recurring theme. The problems identified by service-providers here strongly reflect those identified in international literature on the mental health of young people in state care (McAuley and Davis, 2009).

Alicia (female social care worker) described the emotional learning that occurs in emotionally healthy and stable contexts as happening covertly and through unconscious approval and disapproval, a phenomenon well established within socialisation theory (Handel et al., 2007). However, those with a history of childhood trauma, she noted, ‘have been denied that “natural” opportunity to learn these things’. Hence, Alicia perceived formally teaching emotional consciousness as part of her role. Other participants also spoke of the need to facilitate those who had experienced emotional deprivation to connect with a spectrum of human emotions. They also noted that emotional expression among those who had experienced emotional instability tended to be confined to anger or aggression:

A whole nurturing factor as well; a lot of them [in care] would be deprived of that from a very young age. Instability can cause them to be aggressive and that … is all they know how to express themselves a lot of the time. (Georgina, female, currently aftercare worker, previously residential care worker)

Participants who delivered sexuality education described the process of self-awareness education that is required to enable young people to identify a range of emotions, so that these may be expressed in a safe environment, without the threat of negative responses from those in authority.

While a non-judgemental disposition in sexuality education was generally advocated by participants, they reported that there were times when the educator needed to take an ethical stance. Enabling a young person to become emotionally sensitive to behaviours considered by the educator to be unethical required the educator to take a clear position and to convey this in a transparent way to the young person. This ability to discriminate appropriate from inappropriate behaviour was considered to be an important part of a young person’s emotional development:

You need to have a value system that says when is something not okay. It’s not okay to say to young person, ‘It’s okay for a 13-year-old to have sex with a 19-year-old’. (Regina, female, advocacy worker)

Now there are some things you don’t want to be neutral on: You don’t want to be neutral on abuse, you don’t want to be neutral on things that ultimately would give the young person the wrong message. So you are not going to be neutral on rape, you are not going to be neutral on abuse, those kind of things. (Eiblín, female, sexual health trainer of professionals)

Norma (female, residential care psychologist) reported that part of her educational role was to help young people understand the characteristics of an abusive relationship, what emotions might mediate it and what an egalitarian relationship should feel like. She did this through consciousness-raising activities with young men. Understanding that one should choose to have sex when one was emotionally ready rather than drift into sexual relationships was the key, according to Megan (female, social care worker), as was equipping young people with the social skills to engage in sexual activity safely if they so chose.

The issue of embedding elements of ‘formal’ emotional and social skills’ learning into everyday life will be considered further on.

Social skills’ education

One part of the ‘jigsaw’, and something that was reportedly transmitted in a deliberate formal way as well as reinforced through everyday interaction in the social care environment (that we consider later), was a range of social skills as follows:

Skills in making decisions, skills in being assertive, skills in being able to take ‘No’ for an answer. Those kind of basic skills for negotiating with other people are really essential. (Eiblín, female, sexual health trainer of professionals)

Other skills referred to by interviewees were those of listening, asking questions and seeking clarification. These skills are critical in maintaining mutually respectful relations and in negotiating safer sex – conveying consent to sexual advances or signalling sexual boundaries. Indeed, the skills to manage consent were referred to by several participants engaged in front-line RSE. One of these, Norma (female, residential care psychologist) working in a residential centre, described alerting boys to the complexities around consent and the grey area that may arise around interpretations of rape:

We do a lot around the question of consent and I think they are quite shocked of how easily they could be accused of rape. And that does make them sit up and take notice. Consent is much more complex – how do you know how far to go? Do you stop and ask her every so often? How can you be sure that she is willing to do this? These are the issues to be teased out. (Norma, female, residential care psychologist)

The reference to asking ‘her’ about issues of consent suggests a hetero-normative stance on the part of the educator. However, it should be noted that when asked about lesbian, gay, bisexual and transgender (LGBT) identities, participants across the sample expressed an openness to engaging with these when considering the sexual health needs of young people in state care.

Aimee (female, sexual health trainer of professionals) also spoke of her attempts to convey the notion that consent is far from straightforward. She noted that its complexity is intensified because the social cues in an environment of abuse and emotional disconnectedness are different from those in a more normative context:

We would look right down to the basics: How do you know if somebody is consenting, what are the signs that they are consenting and how would you know if somebody consented but then changed their mind? What are the signals? And again it might seem like a very basic thing but for a lot of young people who have been brought up in difficult environments, that message would have passed them by. And young people who have been sexually abused would be totally confused about that message. (Aimee, female, sexual health trainer of professionals)

The notion that verbalising ‘No’ as the only clear signal of refusal has been problematised in academic literature (Kitzinger and Frith, 1999), since more subtle cues of refusal (about any social offer) are often used instead within Western cultures. Aimee’s recognition of this as an area requiring special skills and cultural literacy is supported in literature.

Aimee also drew attention to another challenge for sexuality educators, namely, to familiarise themselves with rapidly shifting norms of early teen intimacies that differ from those into which educators themselves were socialised.

The application of social and emotional skills in everyday life

While the need for young people in state care to learn discrete social and emotional skills (listening, reflecting, etc.) through role play or another educational strategy was recognised as forming part of their RSE, embedding this learning in the real world was also viewed as highly important. One way of integrating social skills (e.g. of questioning, seeking clarification, self-awareness) in ways that may passively yet effectively be imbibed by the young people was described by Eiblín (female, sexual health trainer of professionals) as follows:

Very often a young person who has got low self-esteem or who is struggling in any way, they might feel ‘I can’t ask a question because they will think I am stupid’, or ‘I am 16 so I have to pretend I know that’. So it is about teaching young people that actually, learning is all about asking questions; there is no such thing as a stupid question and we model that on an ongoing basis. (Eiblín, female, sexual health trainer of professionals)

What care workers appear to be doing in deliberate yet subtle ways is weaving good communication skills into their everyday interactions with young people. This promotion of social skills’ learning by immersion and modelling is supported within scholarship on social learning theory (Bandura, 1977). As Aimee (female, sexual health trainer of professionals) described this, the unconscious learning of mutually respectful normative rituals of interaction mediates sexuality education (in its broadest sense) in stable family environments through unconscious learning. Without this unconscious learning, she contended, ‘school based’ (or formal) sexuality education is insufficient:

So much of the sexual health needs of children in more stable families are met without them even knowing that they are doing sexuality health. Just in the way they relate to each other and the positive affirmation that kids might get, you know, all those bits that build up their self-esteem and their image of themselves, the man or woman, you know all that piece that happens in more stable families. And if that is not happening for those young people who are already disadvantaged, who already have experienced huge gaps in their development in terms of who they are and how valuable they are and what a healthy relationship is, what they can expect and what they should be able to demand in terms of respect and just acceptance and value of themselves. If that is not there then the stuff in school is not enough. (Aimee, female, sexual health trainer of professionals)

The application of emotional awareness learning was also articulated by Crona (female teen-parent support worker) who described the importance of simply making the young person in care aware that someone else is engaged in sharing with them their thoughts and emotions:

If the child feels thought about, they are experiencing something, they are experiencing being thought about and that can happen in the most simple way or complex. Even showing interest, it’s also important to wonder with the child, to ask with the child. Let’s make it explicit that we are holding them in our minds. (Crona, female teen-parent support worker)

Connor (male, social worker) described the process of embedding social and emotional learning in everyday life as ‘giving them some sort of normality or some kind of sense of what is normal and what is okay’. Interactions in residential centres, according to Loretta (female, social care worker), should create an environment in which ‘people negotiate with one another how they make decisions together’ suggesting that decisions are usually made for young people in residential care without sufficiently involving the residents. Margaret (female, aftercare worker with considerable previous residential experience) similarly promoted role modelling by staff as a social learning strategy, noting that, ‘They [those with emotional issues] don’t know how to be nice or affectionate towards people. And working on the staff team it’s up to us to show by example’.

Yet even if civility and courteousness through interactions were displayed by staff, an obstacle to a young person in residential care practising social and emotional skills was the reluctance of some care staff ‘to reveal their own lives and relationships’. As Regina (female, advocacy worker) observed, the relationship was blatantly hierarchal, insofar as staff were privy to a considerable amount of information about that young person (for a detailed analysis of this, see Hyde et al., 2016c), but the exchange of personal knowledge was not reciprocal. She noted that the relationships that the young people see played out in residential care were not ‘real’ relationships, but are professional relationships that are very guarded. This impacts on the young person being ‘held’ emotionally and physically in a reciprocal way, she observed, and drives them to seek ‘intimacy and sex as a means of having a close connection, rather than have that sterile environment that you get in residential care’. One means for addressing the inherently hierarchical nature of relationships between young people and staff proposed by Gerard (male, outreach programme worker) was to have those leaving care or in aftercare mentored by older peers who had formerly been in care and who had shaped their lives positively after leaving care.

It is worth noting the reservations of two participants who raised issues about the extent to which young people were allowed to develop (or practise) their social skills within residential settings. The first, Olive (female, psychologist on a multi-disciplinary team), conveyed the view (based on clients of hers from care settings) that relations between care staff and service-users were excessively authoritarian, with insufficient emphasis on negotiation:

They tend to be ruled by the rules a bit too much. I think that there should be more flexibility. I think the behavioural management piece can be a little harsh. I know resources are tight, but there is a lot of emphasis on control rather than discipline. They need to be able to make decisions. Even in the most stable backgrounds there are meltdowns. Young people need to be listened to, and there needs to be more counselling skills into training for social care people … it needs to be collaborative rather than dictatorial. (Olive, female, psychologist)

Norma, also a psychologist, lamented that being in residential care meant that young people had limited opportunity to try out new techniques for negotiating relationships to which they were introduced during her group work. Although she acknowledged the positive efforts of residential care staff in embedding social skills into everyday encounters, some of the feedback that she received from service-users indicated that there were areas for improvement:

I hope a lot of it [the social skills piece that she teaches] is apparent in their day-to-day work within care: seeing and experiencing positive relationships, seeing different ways in which adults deal with young people, therapeutically in the living environment. I think it has to be done in residential care across the entire setting to give them opportunities to be positively assertive … when dealing with staff they will often say ‘But there is no point, what’s the point in trying to argue my case or raising this particular grievance because it doesn’t get anywhere’, or ‘We’ll just be labelled as argumentative’, so we are trying to give them experience in this setting of managing themselves. (Norma, female, psychologist residential care)

Factual sexuality education

Although a minority of participants regarded the RSE needs of young people in state care to be no different from their peers not in care as far as biological (i.e. reproduction and safer sex) and other factual (i.e. legal issues, sexual health services, etc.) information was concerned, most contended that young people in state care had additional needs in this regard. In view of the tendency for young people in state care to have complex needs (e.g. attention difficulties), the capacity of some of them to process the information was raised. Olive (female, psychologist) observed that some fairly basic biological information ‘[goes] right over their heads’ and the level of detail needed to be modified accordingly. This would appear to be important in light of Dale’s (2009) finding of a gap between the formal knowledge of health professionals and the ‘everyday ways of speaking’ of service-users in her study of 10 young people in state care in Scotland (p. 30).

Eleanor (female, service manager) indicated that assessing exposure to prior knowledge was important in delivering factual sexuality education and informed the decision as to what content to deliver:

I think again it depends on what stage they have come into care and what they have already learned. I mean the other thing is whether they have had any sex education before and what that has been. If it has just been the fifth class talk or the sixth class talk, that is going to be very different from somebody who has had some education all the way through or a young person who has been in care where there has been ongoing development of their sexual needs or assessing their sexual needs than somebody who has come in at 14 who has never been told anything. (Eleanor, female, service manager)

A few participants suggested that while young people (including those in care) may give the impression that they are well-informed about the scientific facts about sex, this was not always the case. Young people may have missed out on this teaching at school, may not have attended to the lesson, or may have been exposed to misinformation through friends. One proposed approach to teaching was to acknowledge that young people may have information already and hence affirm their prior knowledge but not assume this. The sensitivity required to engage young people is captured by the following quotation:

But again you have to be very careful in how you present it. So we would say to young people, rather than something that isolates them or alienates them, like we would never say, ‘We are going to do the basics with you’; We would say, ‘You probably know all this already but let’s just do a recap’. And that way then we’re giving them permission to sit there and they don’t have to feel insulted, they don’t have to feel embarrassed if they don’t know stuff … I would say certainly we would start with the biological. (Aimee, female, sexual health trainer)

The above examples illuminate how a practice ordinarily constructed as perfunctory (conveying biological ‘facts’) actually demands a highly skilled approach. A few participants referred to the need for the educator to tailor the level and substance of the educational materials to the needs of the learner, based on his or her past experiences:

You could be talking about children who have been abused or may have abused themselves, so knowing your client is very relevant. (Georgina, female, currently aftercare worker, previously residential care worker)

For some young people in care they may not have had the parental supervision that would have protected them from early sexual experiences. So my view would always be if they have had sexual experiences or if they plan on continuing to be sexually active you need to give them a level of information that matches their past or current experiences. (Eiblín, female, sexual health trainer of professionals)

While age-appropriateness was mentioned as a factor that mediated the factual content of sexuality education, it was not the only guiding factor in delivering sexuality education. Educators were also challenged to attune their educational endeavours by discriminating within an age cohort. This required the careful appraisal of environmental and contextual factors:

So what you might think wholly inappropriate for a 13-year-old brought up in a protective loving caring environment might actually be crucial for the well being and safety of another 13-year-old in residential care who didn’t have that kind of safety and security in their lives … even within residential care the information we would give to one 13- or 14-year-old might not necessarily be what another needs. (Eiblín, female, sexual health trainer of professionals)

In terms of the content of biological information, a participant working in aftercare stressed the need for more education around STIs, as in her experience, care leavers tend to ‘bury their head in the sands’ about the dangers to which they exposed themselves.