Mitigating Harm: Considering Harm Reduction Principles in Work with Sexually Exploited Young People

A growing awareness of child sexual exploitation (CSE) in the United Kingdom and throughout the world has prompted human service and legal/policy professionals to seek ways of engaging young people experiencing sexual exploitation, although much remains unknown regarding effective practice, and whether or not current knowledge regarding best practices with young people can be expanded to address CSE. This paper considers how principles of harm reduction, a public health approach widely used to engage adults and young people in help-seeking behaviours, can be considered as part of a children’s rights-centred approach to policy and practice with young people experiencing CSE. © 2015 The Authors. Children & Society published by National Children’s Bureau and John Wiley & Sons Ltd.

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Introduction
Harm reduction interventions are utilised throughout the world, and there is a growing awareness regarding their effectiveness in providing people with practical means to engage in healthier, safer behaviour (Stimson, 1998).They originated within and are perhaps best known for success in work with drug users and people suffering from addiction (Friedman and others, 2007).Harm reduction interventions are targeted to meet the needs of specific (rather than universal) groups of people engaged in unsafe behaviour or circumstances (Marlatt andWitkiewitz, 2010) and, as MacCoun (2009) explains, these targeted interventions should be nested within a larger strategy to promote public health and reduce drug misuse and addiction.The term 'harm reduction' has been embraced by the World Health Organization and other international organisations promoting public health (Marlatt and Witkiewitz, 2010) so demonstrating wide acceptance of this approach to promoting health worldwide.Harm reduction, as both a philosophy and a set of strategies, is fundamentally pragmatic as it aligns professionals' and service users' understanding of the problems affecting service users' lives (Pauly, 2008).According to Merkinaite and others (2010: 112), it is also a 'comprehensive human rights and health services approach', as it links vulnerable and otherwise marginalised individuals to health care institutions.While a harm reduction approach has been tailored to meet the needs of young people facing a variety of issues (Stevens and others, 2007), it has not yet been applied to work with sexually exploited children and young people (child sexual exploitation, CSE).This paper aims to consider the ways in which principles of harm reduction can be utilised as part of a children's rights-centred approach to policy and practice with young people involved in CSE that effectively engages young people in support, promotes healthy decision-making and recovery behaviours.We begin with an overview of harm reduction and its underlying principles, before moving on to a consideration of CSE literatures to contextualise our main discussion.It is our intention to provide a conceptual examination of how harm reduction can be useful, whilst considering and reconciling some of the potential challenges in adopting this approach with young people involved in CSE.

Harm reduction
Harm reduction emerged in the 1980s in response to the public health crisis associated with the spread of HIV and injected drug use (Cusick, 2006).It has primarily been an approach utilised in treating substance misuse and addiction, although its application is broader (Myers and others, 2004), encompassing other potentially high-risk behaviours including unprotected sex (Bok and Morales, 2000) and domestic violence (Robinson, 2006).Stimson (1998) describes four primary components of harm reduction: raising awareness, contacting people, providing a means to change behaviour and garnering support for harm reduction work.Awareness raising involves distributing information and providing access to education about a particular health risk.Contacting people involves outreach, providing accessible services that are attractive to service users and maintaining contact by offering ongoing help.Providing a means for behaviour change may involve providing tangible resources and facilitating contact with formal help services.Finally, gaining support for harm reduction interventions involves facilitating alliances between diverse stakeholders (e.g.service users, researchers, practitioners, community and government) to support the inclusion of harm reduction interventions within the broader framework for public health promotion.Friedman and others (2007) expanded upon this notion of gaining support, explaining that service users are the key practitioners of harm reduction, and the policies and programmes aimed at promoting harm reduction are the tools that enable their practice.Importantly, harm reduction interventions set the client, or service user, as central to effective practice.The emphasis is on the client's values and their ability to make personal decisions, based on their individual (and perceived) needs (Stevens and others, 2007).This philosophy aligns with those advocating an ethos of community development or co-production in the development of social care services (see Hunter and Ritchie, 2007); setting a particular framework for the development of services at both strategic and individual leveldemanding that service users are involved in defining their own need, whilst recognising that the problems such as substance misuse and domestic abuse are wider than individuals (see also Sennett, 2003).Allowing service users who are children and young people to define their needs and recognise their right to both provision and participation aligns with how the United Nations Convention on the Rights of the Child (UNCRC) defines children's rights (Reading and others, 2009).
Yet, it is these principles that highlight tensions in social care practice.One potential concern is in how we might justify adopting a public health approach to an issue widely considered to be a problem of child abuse (Chase and Statham, 2005) typically addressed by those responsible for child protection and safeguarding.Reading and others (2009) confront concerns related to using a public health approach in addressing child abuse by explaining that a public health approach emphasises addressing the inequality, poverty and vulnerability that create the contexts in which child abuse occurs.Another more specific criticism of a harm reduction approach is the potential for these interventions to prolong involvement in harmful practices (MacCoun, 2013).Applied to social care practice with children and young people in general, and specifically to safeguarding, these concerns about harm reduction practices become particularly pertinent.Waiting for young people to want to change poses particular difficulties for practitioners with responsibilities for keeping young people safe and ensuring their right, under the UNCRC, to live free from sexual exploitation (Article 34, 1989).From this perspective, an approach allowing for anything less than the immediate end to abusive and sexually exploitative relationships and behaviours would be wilfully negligent and in violation of children's rights.However, Merkinaite and others (2010) assert that harm reduction services can actually be considered a necessary component to providing for health and well-being, rights entitled to all children, under the UNCRC.In discussing substance misuse among young people, they explain that a harm reduction approach allows young people who may otherwise be rejected or excluded from services to have access to 'non-judgemental and low-threshold approaches' that help meet their health needs and promote the well-being of children (p. 112).
So how might a harm reduction approach work with sexually exploited young people whom others are harming, and why is it important, essential even, to consider this?It is this line of argument we pursue, which forms the basis of discussion in this paper.Before doing so, a background to CSE and its relevant literature is provided.

Child sexual exploitation
In recent years, awareness regarding what is increasingly being perceived as widespread CSE in the UK following several highly publicised cases (see Jay, 2014) has grown substantially.As, increasingly, those caught up in this abuse are identified, policy-makers and helping professionals are tasked with reacting to the problem in order to quell anxiety over the 'massive scale' of the problem (Home Office, 2015: 1) despite limited knowledge regarding effective CSE intervention techniques (Fong & Cardoso, 2010).As a result, programmes tasked with helping are often unequipped to address the collective harm and exploitation caused by institutions and harmful policies (Reading and others, 2009), along with the individual, complex traumatic experiences and diverse needs of CSE victims, including the stigma and shame attached to their experiences.

Risk factors for sexual exploitation
Some of these experiences include childhood physical, emotional and sexual abuse (Roe-Sepowitz, 2012), parental substance misuse (Reid & Piquero, 2013) domestic abuse in the home (Pearce and others, 2002) and running away from home or care (Pearce, 2014).In the UK in particular, much of the knowledge and awareness raising around CSE has come about from research and practice work with young runaways and homeless young people (see McMullen, 1987;Newman, 1989).Running away can result in increased vulnerability to sexual exploitation, as sex trading is a means to meet economic need (Williamson & Prior, 2009), especially among young people who are too young to work claim alternative means for housing and alternative accommodation (Melrose and Ayre, 2002).These increased incidents of running away have made service provision difficult for programmes designed to house and support sexually exploited young people (Thomson and others, 2013) as they struggle to keep young people from running away and/or to address the needs of those continuing their involvement in CSE whilst 'going missing'.The links between running away and involvement in CSE belie a bigger problem, and indicate that CSE is part of much wider problems for young people, problems which should ask us to consider what are these young people running from, as well as to what (or who) is it that they are running if we are to intervene and provide support.

Intervening with sexually exploited young people
Meeting the needs of CSE victims with diverse and unique experiences requires a range of intervention modalities (Sherman & Goldblatt Grace, 2011) including outreach, case-management and outpatient services (Edinburg & Saewyc, 2008;Pearce, 2009), along with more resource and residential programming; all of which tend to be both time and cost intensive support strategies.Despite an emphasis sometimes placed on the latter, resources for high cost, comprehensive programming are scarce (Clawson and others, 2009), and the availability of helping professionals specifically trained to work with those abused through CSE is often both limited and insufficient to holistically meet these young people's needs (Pearce, 2014).Thus, social workers and other front line practitioners, such as those employed at youth centres or shelters, are in need of practical tools and resources to work effectively with young people involved in CSE.Young people may already be receiving services of some kind but their exploitative situation remains unaddressed or unrecognised, and they may be reluctant to engage in formal service provision as a result of prior disappointment or feeling that their needs were not met (Pearce, 2006).
Research has consistently argued that those intervening in the lives of young people abused through CSE should develop a multi-systemic approach (see Fong & Cardoso, 2010) one best suited to provide comprehensive, coordinated, consistent and immediate responses (Dodsworth, 2014;Pearce, 2014).Such interventions should promote selfefficacy, empowerment, healthy decision-making skills and should be provided to CSE victims in the context of trusting relationships that pave the way for continued contact and help-seeking behaviours.Drawing upon interviews with adult sex workers who had been sexually exploited prior to age 18, Dodsworth (2014) suggests that interventions should acknowledge the agency and expertise of CSE victims, support their exploration of alternatives to and pathways out of CSE and should be built upon models of good practice in similar fields of social care.This is supported by the work of Warrington (2010Warrington ( , 2013) ) who argues that the views of children and young people should be incorporated into any safeguarding intervention, at the level of both policy and practice between individuals.
There is then, much to suggest that harm reduction in particular is one model of good practice that can serve as a building block in developing a comprehensive, children's rightscentred approach to CSE policy and practice.As such, we now move to a discussion about how principles of harm reduction can be applied to work with young people involved in CSE.We begin by considering the fields of social care more generally, in which harm reduction has worked as an intervention specifically with young people.

Harm reduction approaches with young people
A harm reduction approach has been successfully implemented in interventions designed for work with young people involved in substance misuse, high-risk sexual behaviour (Bok and Morales, 2000), youth gambling problems (Dickson and others, 2004) and online gaming addiction (Xu and others, 2012).This approach takes into consideration that, like those involved in CSE, many young people do not voluntarily seek out support, think they will be able to stop using drugs or alcohol at any point and have low motivation to engage in service provision, relative to adults (Muck and others, 2001).Young people may view their own drug and alcohol use in the context of their relationships with peers, thus seeing it as a normative part of their lifestyle.By nature of their age, most young people will have been mis-using substances for fewer years than adults who are accessing services, and are less likely to perceive their use of drugs and alcohol as misuse or addiction (Stevens and others, 2007).A harm reduction approach acknowledges that young people are not likely to be successful if they are asked to commit to abstinence 'before they have the requisite life skills or psychological ability to successfully maintain their drug free status' (Stevens and others, 2007: 33).It permits practitioners to acknowledge the personal and social contexts in which a harmful behaviour is occurring, and then tailor treatment to meet specific needs (Bonomo and Bowes, 2001).It also supports practitioners' efforts to promote children's rights in practice, as they are able to provide access to services that promote health and well-being for marginalised young people who may be hesitant to disclose substance misuse for fear of judgement or because they are not yet able to engage in services that require a high level of personal commitment (Merkinaite and others, 2010).
The Seven Challenges programme is one such example of a harm reduction approach to reducing and eliminating alcohol or drug (AOD) misuse.It is listed among the Substance Abuse and Mental Health Services Administration's (SAMSHA) National Registry of Evidence-Based Programs and Practices ( 2009) and is widely used throughout the United States, Canada and Puerto Rico.The Seven Challenges programme is informed by the Transtheoretical Model stages of change (Prochaska and others, 1992), and draws upon cognitive-behavioural and motivational techniques to help young people explore their behaviour without demanding abstinence from alcohol and drug use (Korchmaros and Stevens, 2014).The 'seven challenges' include (i) developing an open, honest relationship with counsellors/staff, (ii) considering why they use AOD and what they like about using, (iii) considering the impact of their AOD, (iv) thinking about their own and other's responsibility for their problems, (v) thinking about the future, (vi) making thoughtful decisions about their lives and AOD use and (vii) acting on their decisions, including dealing with setbacks (see Schwebel, 2004).The first stages set a precedence for the remaining stages, as the young person is permitted to be honest about any ambivalence towards change and the counsellor is able to explore the barriers to reducing and eliminating AOD.The remaining stages demonstrate an emphasis on the young person's agency and the active role they can play in improving their present circumstances.

Harm reduction and sexually exploited young people
We now move to consider the practical ways in which a harm reduction approach has purchase in work with sexually exploited young people.Research indicates that young people abused through CSE demonstrate reluctance to engage in services for many of the same reasons young people can be reluctant to stop using drugs (indeed, sometimes these experiences co-occur).Young people are often sexually exploited in the context of peer groups and gangs (Berelowitz and others, 2012).For many young people there can be uncertain sexual boundaries and, particularly for girls and young women in gangs, these peer groups represent a subculture that normalises and glamourises their exploitation (Williamson & Folaron, 2003).Young people may also demonstrate what is perceived as low motivation to get out of sexually exploitative situations, and may not feel ready to leave behind the relationships and sense of belonging that can accompany sexually exploitative situations (Reid, 2014).CSE young people often do not acknowledge their own victimisation or recognise themselves as victims (Thomson and others, 2011).They may perceive sexually exploitative relationships and encounters as the primary means by which to get needs met, albeit in abusive ways, and so may not want to receive support or may be suspicious of support from helping professionals (see Hallett, 2013).Finally, young people may also believe that their current situation is temporary and thus, that they do not need the help of supportive adults to get out.This Harm Reduction, Young People and Child Sexual Exploitation 5 belief may be part of how a perpetrator has groomed the young person to see her/his situation (Reid, 2014).
A harm reduction approach allows professionals interacting with sexually exploited young people to see these beliefs and behaviours as developmentally and practically necessary for young people who have not been able to otherwise get their needs met.Pearce (2014:163) recommends that practitioners working with CSE young people should 'allow time to engage with the young person and to establish a supportive relationship despite episodes of "going missing"'.This can seem contradictory to the 'rescue' rhetoric often used to describe how CSE young people should be treated (see for example, HCHAC, 2013;Van Meeuwen and others, 1998).Rather than one single instance of rescuing the young person and pulling them away from a perpetrator, it is implied that young people may come into contact with helping professionals, but then go missing for periods of time and practitioners should focus on being a stable and trusted person throughout these episodes (Gilligan, 2015).This advice exemplifies the harm reduction principle of working to maintain contact by offering ongoing help (Stimson, 1998).
A harm reduction approach also permits practitioners to develop interventions that promote children and young peoples' rights to health, well-being and safety even if a young person is in the midst of maintaining unsafe relationships and engaging in unsafe behaviour.This is particularly important for children and young people who do not meet safeguarding thresholds that would require immediate intervention.Such interventions may include connecting young people to peer support and providing opportunities for group work with other young people, as this has been shown to help bring about awareness regarding victimisation (Hickle & Roe-Sepowitz, 2014) and promote engagement in other services (Thomson and others, 2011).Practitioners should provide opportunities for education, employment and exploring new interests.These experiences can promote feelings of empowerment and improved self-esteem while weakening connections to perpetrators who have worked to isolate and create a sense of dependency within CSE young people (Reid, 2014).These experiences may provide a means to change behaviour and avoid exposure to further harm, both of which are primary aims of a harm reduction approach (Stimson, 1998).
By exposing young people to these opportunities while they have yet to completely leave exploitative relationships, they are provided with a 'chain of protective factors' that promote resiliency (Meschke and Patterson, 2003) and help pave an easier path out when they are ready to leave.Practitioners cannot always predict when this may happen, as resilience can emerge at any point during a young person's experience with CSE (Dodsworth, 2014).A harm reduction approach provides the framework for practitioners to intentionally develop interventions that engage young people at any point.This can be done actively through education and outreach, and passively through the programme structure that positions young people as the 'primary practitioners' of reducing harm in their own lives (Friedman and others, 2007, p. 107) and requires their active participation at all levels of decision-making.For some, incorporating harm reduction into interventions will involve a paradigm shift away from delivering services to young people and towards a model that delivers services with and through young people.It does not, however, mean harm reduction is the only approach to addressing CSE, and should not be considered in isolation from other approaches.

The importance of harm reduction
We now move to our second aim of the paper, which was to consider the importance of adopting harm reduction approaches in work with sexually exploited young people.We also address some of the potential challenges and difficulties that can lead to resistance toward this approach being applied to safeguarding work with young people.
As we have made clear, in work with young people involved in sexual exploitation, there is a need to recognise their agency (Melrose, 2013), focus on their capabilities and acknowledge that their involvement in risky behaviours can be their attempt at exerting control and power in circumstances in which they often have very little.Harm reduction approaches place the service user at the core of the support, emphasising their agency and thus enabling practitioners to have necessary, open conversations with young people about their sexual exploitation in a safe space.This approach is consistent with how the UNCRC conceptualises children's rights to participation in the decisions that affect them (Reading and others, 2009).Furthermore, it is a necessary and pragmatic children's rights-centred approach to ensuring that all children and young people affected by CSE have access to services that meet their needs and provide space for them to express their views even when they differ from the views held by adults (Panter-Brick, 2002).Finally, it allows for an open acceptance that young people sometimes utilise unhealthy methods of coping to minimise the effects of harmful CSE experiences, without condoning these methods (or blaming young people for the harm done to them by others).These might include running away, staying in exploitative relationships, and engaging in risk-taking behaviour (e.g.unprotected sex, substance misuse, other criminal activity and dropping out of school).Moreover, adopting a harm reduction approach allows us to understand the underlying issues behind these risk-taking behaviours thus opening up our understanding of the problem of CSE as a public concern and setting it within its wider context, allowing for an acknowledgement of the realities of structural inequality and barriers to recovery created by poverty, social isolation, discrimination and cumulative/complex trauma.Acknowledging the problem in this wider way provides the possibility for more appropriate, realistic and targeted responses more generally, and so allows for these to be specifically tailored to individuals.The corollary to this, is that there must also be an understanding that young people may continue to engage in these behaviours whilst they are accessing support.For many services and practitioners this will require a fundamental shift in the way they think about safeguarding-in which protection-as-rescue often dominates over young people's own views.Yet this shift in the ways we think about responding to vulnerable clients and service users is not without precedent.
Placing CSE and harm reduction aside for a moment, we might look to the area of domestic abuse as a precedent for both the challenges and the importance of thinking differently about the ways we respond to sexually exploited young people.As Pearce (2009) argues, much can be learned from the changes in the way we now respond to domestic abuse, specifically with regards to how we might respond to young people involved in CSE.Indeed, victims of sexual exploitation share many common experiences with victims of domestic abuse (Roe-Sepowitz and others, 2014), and our call to acknowledge the importance of interventions that incorporate young people's perspectives on their experiences, and acknowledge their agency, is one also advocated by those writing about abuse and violence in teenage relationships (see Barter, 2009).
Rescuing victims of domestic abuse from their abusive relationships, as a strategy, is now recognised as being unlikely to end the relationship, nor is it likely to encourage help-seeking and recovery behaviours.More importantly, just as services and practitioners working with those experiencing domestic abuse now recognise the complexities of this issue, we would do well to understand that CSE is not a simple case of rescue, abstinence or of victimblaming when a young person doesn't willingly leave an exploitative relationship.Reporting on findings from recent research in the UK involving young people with experiences of CSE, Hallett (2013) writes that many of the young people understood their involvement in the exchange of sex to stem from a lack of care and of alternative support to address underlying problems and needs.The young people considered that dealing with CSE (through abstinence-based initiatives, such as the use of secure residential units) without support to address these wider problems, would be unlikely to provide any long-term change, and could, in the short-term, exacerbate their problems, leading to increased disengagement with services and an increase in risk-taking behaviours (Hallett, forthcoming).These findings very much align with a harm reduction approach to care and support services, and indicate the importance of understanding the needs of sexually exploited young people, and, more importantly, of providing a holistic programme of intervention and support which places the young person and their view and concerns very much at the centre, and certainly alongside, what practitioners might want for them.This is, and will likely remain, a complex way forward as service providers adopting a harm reduction approach must find a way to partner with young people even as they prioritise safeguarding and keep in mind their primary responsibility to protect young people who are victims of a crime.

Concluding comments
Considering CSE in the context of domestic abuse provides a thought-provoking response to the concerns that harm reduction approaches prolong harm, for, as research has suggested, it may also be the case that safeguarding approaches or interventions with an abolitionist agenda may just delay (and so possibly increase) the potential for harm and exploitation.We suggest that in the context of working with young people involved in CSE, it is possible for harm reduction and abstinence-based approaches to operate synergistically rather than opposing one another as harm reductionists who work alongside abolitionists may choose to view 'the abolitionist/prohibitionist ideal as an end point' (Cusick, 2006: 7).It is possible to adopt an approach that sees an end to CSE as its (immediate) aim, whilst also embedding harm reduction principles within a wider public health response to service design, in order to ensure long-term change and to place young people at the centre of that change.It is the latter point that we suggest is important.While harm reduction approaches have been successful in work with young people, this success, in many instances, depends upon those principles by which young people begin to take ownership of their care, and in which practitioners are encouraged and must acknowledge young people's agency in both the problem and in the beginnings of any response to it.We also acknowledge the difficulty for practitioners working in CSE who must balance safeguarding responsibilities with an acknowledgement of young people's agency.This exemplifies the underpinning tensions involved in operating under a Children's Right's agenda.DiClemente (1999) frames harm reduction as an element of tertiary prevention that can be offered alongside early intervention, and this is perhaps the most useful framework for positioning harm reduction alongside other approaches to addressing CSE within a much larger framework of safeguarding young people from harm.In looking specifically at substance misuse, he emphasises the complexity of the problem and acknowledges that no one single intervention or prevention approach has risen above the others as exclusive or superior.When combined with other approaches, harm reduction may then serve to reduce the number of barriers young people face in seeking out other types of support, and allow them to feel empowered in making the decision to enter into recovery, whilst also enabling practitioners to fulfil their safeguarding responsibilities.
As our collective awareness grows regarding the barriers young people face when first engaging with services, so too must our willingness to seek innovative approaches that grow and expand, to proactively meet young people needs.Front line professionals need to have a comprehensive understanding of CSE risk factors and the barriers that victims encounter.This understanding will enable them to recognise the signs of CSE and thus remove the burden of disclosing abuse from young people (Beckett and Pearce, 2015).They must also prioritise trust-building and establishing an open and honest relationship so that young people are provided with the space they need to feel a sense of ownership over their lives.Utilising harm reduction principles as part of a holistic children's right's centred response to CSE, may help practitioners increase engagement, help young people explore the problems that underpin their risk-taking behaviours, and place young people needs at the centre of a safeguarding agenda that seeks to plan for short-term safety and long-term positive change with young people who have a right to participate in making decisions about their lives.Future research should include identifying ways practitioners are successfully utilising harm reduction methods to engage young people experiencing CSE, and involving young people affected by CSE in participatory research that provides increased opportunities for young people to partner in the co-creation of a safer future for themselves and others.
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