Author: Andre Coleman

Prostitution is a contentious issue in India. Although, prostitution (exchanging sex for money) is not illegal, but the surrounding activities (operating brothels, pimping, soliciting sex etc.) are illegal. In fact the worst part is that the people in India forget that in series of insulting this profession, they put a question mark on the life of that person…of that girl who had possibly been just another victim of unexpected and unwanted assault of bad times. It is being heard often, rather always from people that call girls are like this, they are not good, it is not preferred for decent people to be friend with them or to be in contact with them though they forget that it is this crowd who exploits the helplessness of these girls. It is easy to make out from outside that they are themselves indulging in these activities but nobody bothers to take charge to rebuild them. Once these innocent souls of 11 or 12 years are forced into the hell like brothels…a word called ‘LIFE’ goes away from their ruined being and self respect.

In 2007, the Ministry of women and child development reported presence of 2.8 million sex workers in India, with 35.47 percent of them entering the trade before the age of 18 years. The number of prostitutes has also doubled in the recent decades. It itself is a proof of one thing that India’s male dominated want this ,do this..that is why prostitution is augmenting at such a pace. Sonagachi in Kolkata, Kamathipura in Mumbai, G.B Road in New Delhi, Reshampura in Gwalior and Budhwar peth in Pune host thousands of sex workers. These are also known as red light areas in the country, where everyday thousands of girls are browbeaten. Ones who are considered to be so called lucky get freed from this cage because of intervention of police or NGOs but being rescued from a brothel is not always the end of a dark tunnel. Rather, it could be the beginning of a more traumatic life. A number of sex workers rescued and repatriated show higher-levels of traumatic disorders than those living in brothels, according to an all-India study. The study conducted by Swanchetan, an NGO, from October 2007 to March 2008, used the five-point Likert scale to map the relative intensity with which each victim experienced and demonstrated trauma. Human trafficking is illegal but prostitution is not ….the difference of which people rarely understand. Films made on the life of sex workers or bar girls like Chameli, Chandni bar, Mandi show the true picture of our society where the situation and their family members themselves do not think twice to make life of those girls a deal for them. According to a Human Rights Watch report, Indian anti-trafficking laws are designed to combat commercialized vice; prostitution, as such, is not illegal. A sex worker can be punished for soliciting or seducing in public while clients can be punished for sexual activity close to a public place, and the organization puts the figure of sex workers in India to be around 15 million, with Mumbai alone being home to one hundred thousand sex workers, the largest sex industry centre in Asia. Over the years, India has seen a growing mandate to legalize prostitution, to avoid exploitation of sex workers and their children by middlemen and also in the wake of growing HIV/AIDS menace. Many NGOs are working towards it but still a considerable change has not been brought in the lives of these girls or women. So the need of the hour is to enlighten ourselves, our spirit and our unconscious soul to rein in the chances of innocent girls getting exploited by the animals in disguise of men in our society.

The sexually abused child in the foster setting

Current researchers believe the majority of children entering the foster system have been traumatized physically and emotionally and now require care the foster system was not originally created address^[1]. Additionally, foster children are reported to have “three to seven times as many acute and chronic health conditions, developmental delays and emotional adjustment problems” as their non-foster peers^[2]. The care provided in foster care is of critical importance, as research emphasizes the remaking of an attachment based relationship, such as the foster parent-child relationship, is the focal emotional need during the foster experience^[3]. When a child has been sexually abused, the care required is of paramount importance, however, a careful and comprehensive assessment of the child is required as childhood sexual abuse affects different children completely differently, displaying a range of symptoms or lack thereof^[4]. Cicchetti and Toth^[5] emphasize the individual differences that abuse has on individuals is most often based on the child’s level of functioning at the time of the sexual abuse, such that the sexual abuse and/or other forms of concurrent child abuse will be interpreted by one child differently from another. As the child matures, the abuse will also carry different meanings, therefore Cicchetti and Toth^[6] tell us that [foster] caregivers must readily adapt to the changing issues the child is dealing with and manner in which he/she relates.

This essay will present a brief case study followed by an examination of the foster parent skills, qualities and understanding needed to engage in a relationship with a child who has been sexually abused, critically reflecting on actions taken with the child.

For purposes of this paper, the child discussed is an adolescent who suffered repeated sexual abuse in an intra-familial setting. Issues relating specifically to infants, preschool or younger children victimized by sexual abuse and placed in a foster care setting are considered beyond the current scope of this essay. Additionally, issues pertaining to the legalities implicit in a childhood sexual abuse case, abuse by an extra-familial individual or issues pertaining to abduction and violence perpetrated upon a child in conjunction with sexual abuse are considered beyond the scope of this essay.

Case study

J is a 14-year-old female who was repeatedly sexually abused by her step-father from the age of five years. J’s mother was an alcoholic and unable to hold a job. J’s step-father threatened that he’d kill her mother and J if she told anyone. J remained silent for the first eight years, displaying a variety of emotional and physical problem that doctors and school officials put off to developmental disturbances. When J finally told her mother when she was 13 years-old, her mother said it was because J was such a pretty girl and to just go along with it because after all, he provided for them all and they’d be on the street otherwise. When J was called to the principal’s office for disruptive and aggressive behaviour towards a boy who made sexual advances to her in the hallway, J finally told her principal what was going on at home and family service and police officials were called in. J was removed from the home and placed in foster care.

J was 15 by the time she was placed in this writer’s foster care. J exhibited many of the common mannerisms common to adolescent females victimized by intra-familial sexual abuse including adopting sexually promiscuous and extremely flirtatious behaviour with other males, engaging in self-injurious behaviour such as cutting coupled with distancing herself from trusting authority figures. Also noted by this writer were J’s frequent depressive episodes and affect. It was important to note, consistent with current research, that the British child welfare authority over two-thirds met current diagnostic criteria for at least one or more psychiatric disorders^[7], emphasizing that older individuals in foster care have a higher rate of lifetime and past year psychiatric disorders, frequently onset prior to the initiation of the foster situation.

Fostering J

Consistent with research by Yancey^[8] an appropriate combination of mentoring and role-modelling for J was an integral part of her fostering. Role modelling does not necessarily necessitate personal interaction, whereas mentoring also includes deliberate support, guidance and an effort to help shape the adolescent, as in the case of J where she had not developed the appropriate skills with which to weather difficult periods in her life or make sense of what had happened to her in real world terms^[9] and examine the skills, qualities and understanding needed to engage in a relationship with that child.

J’s brain anatomy was modified by the repetitive abuse, accounting for much of her depression and other personality disorders^[10] through the L-HPA axis impact^[11]. Explaining this to J in terms she would understand was difficult as she was not overtly trusting of authority or parental figures; the information only seemed to fuel her rage at her role of helpless victim and further emphasize her own role in the abuse process rather than appropriate placement of blame externally on her step-father. Similarly, research highlights the persistence of depression and other emotional areas of dysfunction up to and extending beyond five years following childhood sexual abuse^[12]. Given the goal of foster placement as the reunification of the family unit^[13] occasional visitation with J’s mother caused greater depressive episodes and more dramatic episodes of self-injurious behaviour, which is consistent with the literature stating further abuser contact within five years can be used to predict higher levels of depression in the abused child^[14].

Significant mentoring with J focused on building her sense of self-esteem and orienting her towards healing her own inner hurt child, mothering it in ways that were not provided to her in her critical early childhood years. For example, it was important to help J search for solutions and focus on how to overcome her current issues and for her to admit problems exist with her normal day to day actions. Rather than nurture her child’s mind questioning “why” did this happen to me, this writer had to stress that she is responsible for her own thoughts, feelings and behaviour at this point in her life and as it moves forward, that she can construct her own destiny, especially since she is within years of adulthood^[15]. It was difficult explaining that her sexually aggressive behaviour was not considered normal, but an affect of her abuse^[16] as she continued to seek the physical intimacy with a male as an expression of their love for her rather than simply sexual gratification^[17], still replaying her step-father’s verbal expressions of his love for her, how attractive she was, etc.

Given J’s level of problems with attachment relationships, it was instrumental working with her coming from the transactional analysis framework emphasizing relations needs both current and in the archaic ego, emphasizing J’s need for security and protection experienced within a relationship^[18].

One of the most difficult issues relative to providing care for J was to nurture her commitment to positive change, as considered a fundamental principle of transactional analysis based integrative therapy^[19] as J demonstrated oppositional and defiant behaviours on a regular basis.

J’s continual behaviour issues emphasized the need for working with her as a role model and mentor rather than being directly confrontational with her regarding her dysfunctional behaviour or inappropriate thinking. This emphasized keeping control of J’s life in her hands, considered by research as critical for survivors of sexual abuse^[20]. Research demonstrates that combining therapy in the foster setting can reduce stress for the child and caregiver, increase the development of positive attachment relationships and corresponds with an increase in positive behavioural change^[21].

While the interaction with J was a positive, albeit difficult one, upon reflection, however, one major change would have been to mutually establish J’s goals for growth into an integrated and intact adult. This would have helped establish a foundation and framework for working together.

Bibliography

Alfaro, Jose, Fein, Edith, Fine, Paul, Halfon, Neal, Irwin, Martin, Nickman, Steven, Pilowsky, Daniel K., Rosenfeld, Alvin A., Saletsky, Ronald, Simms, Mark D. & Thorpe, Marilyn. Foster Care: An Update. Journal of the American Academy of Child and Adolescent Psychiatry, 1997.

Auslander, Wendy F., McMillen, J. Curtis, Munson, Michelle R., Ollie, Marcia T., Scott, Lionel D., Spitznagel, Edward L. & Zima, Bonnie, T. Prevalence of Psychiatric Disorders Among Older Youths in the Foster Care System. Journal of the Academy of Child and Adolescent Psychiatry, 2005.

Baird, Frank. A Narrative Context for Conversations with Adult Survivors of Childhood Sexual Abuse. Progress – Family Systems Research and Therapy, 1996.

Black, James E., Haight, Wendy L. & Kagle, Jill Doner. Understanding and Supporting Parent-Child Relationships during Foster Care Visits: Attachment theory and Research. Social Work, 2003.

Chamberlain, Patricia, Fisher, Philip A., Gunnar, Megan R. & Reid, John B. Preventive Intervention for Maltreated Children: Impact on Children’s Behaviour, Neuroendocrine Activity, and Foster Parent Functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 2000.

Cicchetti, Diane & Toth, Sheree L. A Developmental Psychopathology Perspective on Child Abuse and Neglect. Journal of the American Academy of Child and Adolescent Psychiatry, 1995.

Erskine, Richard G. A Gestalt Therapy Approach to Shame and Self-Righteousness: Theory and Methods. The British Gestalt Journal, 1995.

Green, Arthur H. Child Sexual Abuse: Immediate and Long-Term Effects and Intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 1993.

Oates, R. Kim, O’Toole, Brian L., Swanston, Heather & Tebbutt, Jennifer. Five Years after Child Sexual Abuse: Persisting Dysfunction and Problems of Prediction. Journal of the Academy of Child and Adolescent Psychiatry, 1997.

O’Reilly-Knapp, Marye & Erskine, Richard G. Core Concepts of an Integrative Transactional Analysis. Transactional Journal, 2003.

Temple, Susannah. Transactional Analysis Philosophy, Principles and Practice. Temple Index of Functional Fluency, 2006. Retrieved from: http://www.functionalfluency.com/articles_resources/Philosophy_Principles_Practice.pdf Cited 10 September 2007.

Yancey, Antoinette, K. Building Positive Self-Image in Adolescents in Foster Care. Adolescence, 1998.

The main concern as a counselor is creating and managing professional limits, which must always center on the best interests of the client. However, except for behaviors of an illegal nature, ethical concerns can negatively interfere with one’s work because there are no straightforward answers. The detrimental effect of sexual intimacies within a professional counseling relationship makes it apparent that it is always inappropriate to have a sexual relationship with a client. In the first part of this paper, a case study of a client who engaged in a sexual relationship with her former psychologist is illustrated. Main ethical concerns, application of specific ethical codes, techniques to address the issue, and an ethical decision-making process are analyzed to resolve the case. In the second part of this paper, an interview is conducted with a clinical psychologist, which highlights the issues relating to ethical standards and practices, transference, multicultural concerns, boundary violations, and supervision.

Introduction

The structure within which a therapist and client relationship occurs is beneficial for adequate counseling. Healthy limits create a relationship that is proficient, trusting, and demonstrates an environment for competent psychological counseling. Therapists must know that ethical violations can relate to the gray areas between transference and countertransference (Redlich, 1990). Corey, Corey, & Callanan, (2011) state that sexual relationships between therapists and clients continue to receive substantial research in the professional literature. Sexual relationships with clients are undoubtedly unethical, and all of the main professional ethics codes have explicit prohibitions against these violations. Furthermore, such relationships are a violation of the law. The power imbalances may continue to sway the client well after the end of the counseling relationship, and professional standards forbid a therapist from engaging in any sexual relationship with a past client in which counseling service was provided in the past five years (Bouhoutsos & Greenberg, 1999). Therapists must know that any dating relationship is considered a form of inappropriate behavior that could fall within the classification of sexual abuse. The harmful effects of sexual abuse within the professional standards makes it obvious that it is inappropriate to have a sexual relationship with a client.

The Dilemma

Rachel, a 24-year-old client, comes into her counselor’s office and states that she feels suicidal because she engaged in a sexual relationship with her former psychologist. Because the assessment and management of a suicidal client is extremely serious, the counselor addresses this issue immediately. As she approaches the suicide assessment, the counselor keeps three things in mind: consult with a colleague for another opinion, document the process, and evaluate the client’s risk for harming herself (Corey, Corey, & Callanan, 2011). The counselor asks Rachel to sign a no-suicide contract. In the contract, she agrees to avoid harming herself, but if she feels she cannot control herself, she would call 911, or another person who is close to her and she can trust. The counselor also asks her to talk with her family about her feelings. Rachel states that she disclosed to them that she is very depressed and is feeling suicidal.

The counselor explains to Rachel at length about dual relationships. Usually when there is an ethical infringement such as a psychologist having a sexual relationship with a client, the relationship begins with a non-sexual relationship (Brown, 2002). Rachel says the relationship began in “good faith” and as time passed, the boundaries between her and the psychologist began to weaken. The risk of harm occurring to Rachel increased as the psychologist and client became more intimate, and there is a greater power differential just as there exists between men and women in general. The counselor explains about how these professionals may exploit and seduce female clients intentionally for their own satisfactions.

Rachel proceeds to tell her counselor about the symptoms and feelings she is experiencing: a sense of guilt; emptiness and isolation; sexual confusion; trust issues; role confusion in therapy; severe depression and acute anxiety; suppressed anger; and cognitive dysfunction involving flashbacks, nightmares, and intrusive thoughts. The counselor concludes that the client is indeed experiencing almost all of the symptoms described as Post Traumatic Stress Disorder.

Main Ethical Concerns

A professional counseling relationship, which involves sexual relations, is against the law. Sexual exploitation in a professional counseling relationship is described as, “sexual involvement or additional forms of physical relations between a practitioner and a client” (Brown, 2002, pg. 79). Situations involving sexual actions between a counselor and client are never acceptable. According to Moustacalis (1998), sexual activity between a client and counselor is always damaging to client well-being, despite of what reason or beliefs the counselor chooses to justify it. However, client consent and compliance to participate in a sexual relationship does not diminish the practitioner of his duties and responsibilities for adhering to ethical standards. Failure to take responsibility for the professional relationship and permitting a sexual relationship to develop is a mistreatment of authority and confidence, which are exclusive and fundamental to the therapist and client relationship.

In any professional counseling relationship, there is an innate power inequity. In this case study, the former therapist’s power arises through the client’s belief that the therapist has the proficiency to help with her problems, and the client’s confession of personal information, which is usually kept secret. The reality that counseling services cannot be successful unless clients are willing to open up does not change the main power imbalance (Moustacalis, 1998). Therefore, the psychologist has an important responsibility to take action, do no harm, and is ultimately liable for managing boundary issues if violations occur. Ironically, the former therapist in this case failed to maintain appropriate professional ethical standards and caused psychological damage to his client instead of promoting a trusting and healthy professional relationship. Because of the seriousness and complexity of these sexual boundary violations, Rachel currently suffers from suicidal thoughts, depression, anxiety, and post-traumatic stress disorder. The power difference that is in the therapist-client relationship causes Rachel to find it complicated to discuss boundaries or to recognize and defend herself against ethical violations. In addition, clients may at times prompt a sexual relationship and their behavior could promote violations (Marmor, 2000).

Application of Specific Ethical Codes & Techniques to Address Dilemma

According to the 2005 American Counseling Association’s (ACA) Code of Ethical Standards, “Sexual or romantic counselor-client interactions or relationships with current clients, their romantic partners, or their family members are prohibited” (A.5.a). Relating to former clients, “Sexual or romantic counselor-client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners, or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship” (A.5.b). In this case, Rachel’s emotional intensity and stress generated due to difficult or conflicted personal relational situations may override her understanding of healthy therapeutic and relational processes. In addition, it suggests clients, such as Rachel, who possess little therapeutic knowledge relating to boundary violations, or with limited understanding of therapy, are particularly vulnerable (Marmor, 2000). The ACA Code of Ethical Standards also states that counselors act to avoid harming their clients (A.4.a). During their sexual relationship, Rachel’s former practitioner may assume she is responsible in the relationship and can sustain herself emotionally and psychologically. However, not all clients have this ability and look to their therapist for support. Engaging in a dual sexualized relationship is destructive to client welfare and is a dysfunctional means to offer ‘security’ to a vulnerable client (Robinson, & Reid, 2000).

Techniques to address this case are complex, yet imperative to consider. First, Rachel’s former therapist needs to be reported to the state licensing board for ethical complaints of sexual intimacies with a client (Hall, 2001). During this process, Rachel should know that a breach of client confidentiality will occur as a part of the reporting process. Next, Rachel must find a reputable attorney because there is a good possibility that the former therapist may deny the accusation or blame Rachel by saying she is making false claims. The former therapist could be the subject of a lawsuit. Malpractice is a serious legal concept involving the failure of a professional to provide the level of services or to implement the skill that is normally expected of other professionals (Hall, 2001). He risks having his license taken away or suspended as well as losing his insurance coverage and his credibility as a therapist. This ethical violation could have been avoided if the therapist carefully considered the dynamics of a healthy therapeutic relationship and put the client’s needs before his own.

Decision-Making Process

The ethical decision making process used for the case of Rachel would be to first define the problem. Rachel is in search of counseling because she engaged in an intimate, sexual relationship with her former psychologist. Rachel currently feels guilty and resentful toward her former psychologist and is experiencing suicidal thoughts. The next vital step in ethical decision making is evaluating moral principles (Corey, Corey, & Callanan, 2011). In this case, the moral principle that would take priority is non-maleficence. Rachel expressed her need to talk with a counselor and feels she has a limited number of people she can trust. Since the former therapist violated the sense of non-maleficence, it may cause Rachel harm if the current therapist were to defy her trust because Rachel could panic and hurt herself if she feels she has no other option. Rachel must form a trusting relationship with her current counselor, and the counselor must maintain that sense of trust. The next step would be to talk with a supervisor or colleague to hear other perspectives or ideas. The fourth step is to make sure as her current therapist, decisions are not influenced by emotions (Corey, Corey, & Callanan, 2011). Having emotional awareness can ensure an accurate assessment of the situation. Therefore, encouraging Rachel and building up her sense of self-worth is essential. By creating a plan that includes psychological help along with legal action, Rachel will likely feel as though she has some control when assessing each option. The final step is implementation, and the therapist should help Rachel follow through with her plan.

Interview

Dr. Jennifer Lambert is a clinical psychologist and received her Psy.D from the University of Illinois. During the 45-minute interview, she provided thoughtful insight into the issues relating to ethical standards and practices, transference, multicultural concerns, boundary violations, and supervision. First, making ethical decisions involves developing an acceptance for dealing with gray areas and coping with uncertainty. Even though awareness of the ethical standards of one’s profession is significant, this knowledge is not enough. Ethical codes provide direction in assisting one in making the best informed-decisions for the benefit of clients and the practitioner. These standards may differ among agencies, and it is vital that every human service professional becomes aware of the exact policies of the agency.

Secondly, Dr. Lambert discussed an example of transference. She is a supervisor for an adolescent mental health clinic and works with many great colleagues. One of her colleagues is an excellent therapist, but often she asks Dr. Lambert for marital advice. She does her best not to sway her colleague because Dr. Lambert knows the harm it could cause to their relationship. Instead, she encourages her colleague to inspect her own beliefs and values without imposing or giving direct advice. This story is an example of colleague transference and possible dependency if Dr. Lambert is not cautious when discussing these issues.

Next, Dr. Lambert spoke about multicultural concerns and boundary violations in therapy. As a therapist, it is key to know and appreciate one’s own cultural background, yet not push values onto clients. To be effective with diverse clients, therapists must accept and celebrate cultural differences and view them as a positive learning experience. By practicing acceptance while being curious, it will bring understanding between cultures and assist in expanding trust in the therapeutic relationship. Maintaining professional and personal boundaries is a necessity in the therapeutic process. If a therapist becomes emotionally over-involved with a client, counselors will likely lose their objectivity and ultimately cannot exercise proper judgment in the helping process. When counseling adolescents, maintaining appropriate boundaries can be complicated. Often, an adolescent sees the therapist as a friend to confide in, but if the young client becomes too dependent, relationship boundaries may be crossed. This can also violate boundaries if the therapist does not address the dependency.

Lastly, a vital element in the licensing process is supervision. Dr. Lambert believes the role played by the supervisor is important for the appropriate development of the trainee. The supervisee should be open to the ideas and leadership style of the supervisor. Above all, supervision was developed to help future therapists enhance their competency and during this process, the trainee will learn the necessary skills that will assist them in their entire professional career. One challenge to supervision is the continuous shortage of qualified professionals and the incapability to supply sufficient hours for proper competency development. When choosing a supervisor, an individual with a good moral and ethical approach is an area of concern. This factor would assist in developing a proper personal approach, and a supervisor must teach by example the importance of understanding transference/counter-transference, diversity, and rapport. Supervision is a support system, which gives the opportunity to present challenges that one may not be prepared to deal with when they occur.

Summary

Ethical decision making in the counseling field is a continuing assessment with no simple answers. In order to encourage the well-being of clients, counselors must always balance the professional ethical codes with their own life experiences and personal values to make critical decisions about how to assist their clients successfully (Redlich, 1990). Therefore, understanding the ethical codes and the effect of inadequate counseling practices are helpful for counselors as they maintain therapeutic relationships with clients. Nonetheless, even though professional codes of ethics offer guidelines for how counselors should act with clients, they do not give complete answers for how counselors must act in every circumstance. Ideally, counselors should integrate their knowledge of professional ethics with good judgment to facilitate the best interests of their clients. It is imperative for counselors to create personal and professional boundaries with their clients in order to avoid problems such as unethical counseling, favoritism, exploitation, harm, etc (Corey, Corey, & Callanan, 2011). Counselors must treat all clients respectfully, compassionately, and responsibly, while not compromising the professional relationship established with them.

Sexual Health For People With Learning Disabilities

This leaflet is about people with learning disabilities and their sexual health. While there is considerable legislation concerned with disability from the 1970 Social Services Act to the 1995 Disability Discrimination Act and beyond, it is not always clear that the needs of this user group are being addressed in appropriate ways. This is because there is a lack of research into how this user group live their lives and how they feel about life and sexuality.

Legislation and Anti-Oppressive Practice

Under the terms of the NHS and Community Care Act of 1990 social services have a duty to make an assessment of need to any person in their area who may have need of their services. With regard to people with physical or learning disabilities the department also has a duty to find out about such people in their area and to offer an assessment of need even if that has not been requested. The social worker must take account of the 1998 Human Rights Act when dealing with anyone. It is illegal for social workers to discriminate against people or hinder their access to services on any basis. A social workers should act in the best interests of their clients, the service users, and engage in anti-discriminatory and anti-oppressive practice.

Anti-oppressive practice can involve the social worker attempting to take care over the way in which he/she uses language. In order to fully engage in such practice a social worker would need to take care that in dealing with service users who may have difficulty in communicating their needs the social worker does not end up imposing their own agenda on the service user. When it comes to people with learning disabilities here is a need for different models and levels of participation depending on the service user’s circumstances. Participation empowers some service users while others may not be able to be truly involved at any recognisable level without the intervention of a third person – an advocate. The agency for mental health MIND suggests that many people with learning or mental health difficulties should have an advocate who is impartial and who can inform them what is available in terms of services and support and who will promote their best interests as service users. Those who are able to engage with the process often go on to promote the rights of other service users.

The service user movement has been a driving force in the struggle for people with mental health problems or learning difficulties’ entitlement to live as ordinary a way of life as they can (Carr, 2004). People with learning difficulties may have multiple and complex needs, nevertheless under the 1998 Human Rights Act, they are entitled to be treated with dignity and local authorities have a duty to abide by the requirements of this Act (Moore, 2002). Nevertheless there are areas where the Act is sometimes ignored and this is most apparent when it comes to the sexual health of people with learning disabilities.

Learning Disabilities and Sexual Health

There has been very little research into the lives of people with learning disabilities. The first of its kind was a government survey of 2,898 people which was carried out between June 2003 and October 2004. The report dealt with people with learning disabilities (to what extent they were learning disabled is not always defined) between the ages of 16 and 91. The report found the following:

45% of the people interviewed were under the age of 30
6% were from minority ethnic communities.
92% of all people with learning difficulties who took part in the study were single and 7% of these had children but only half that number looked after their children themselves.
7% either lived alone or with a partner.

There is an even greater dearth of information when it comes to the sexual health of people with learning difficulties. In fact media reports suggest that many people with learning difficulties are actively discouraged from engaging in what most people regard as a healthy sex life. There have even been instances where family members have tried to have girls with learning disabilities sterilised so that they could not bear children. A (2006) report from the University of Ulster Out of the Shadows, found that the sexual health of people with learning disabilities was all too often ignored. This is because family members and professionals do not want to acknowledge that this user group has such needs. The report found that:

People with learning disabilities want to have relationships and express fears of being lonely. But the feel over-protected by professionals and family carers. Consequently there are few opportunities to develop relationships and meet new people.
Some family carers want their child to have the same rights as everyone else. But they feel embarrassed to talk about sex with their children and are concerned for their safety. Feeling unsupported and isolated stops them from raising these issues in the home.
Professionals and front line staff are aware that the issues around sex and sexuality are not being addressed. However they are inhibited by being under resourced, under trained, and at times restricted by a lack of clear guidelines and policies to support them (http://news.ulster.ac.uk/releases/2006/2892.html).

Clearly insufficient attention is being paid to what this group of service users actually want. People are embarrassed by the fact that people with learning difficulties may have the same hopes, fears, and aspirations as everyone else. Clearly there is a need for more research and for education so that a greater understanding of people with learning disabilities and their needs is actually met.

Further information on people with learning disabilities and their needs can be found at the following websites:

http://www.lancaster.ac.uk/fass/ihr/index.htm website concerned with the inclusion of adults and young people with learning disabilities in all areas of life.

http://www.inspiredservices.org.uk/ website about community living, when it may be necessary and how it is meant to empower people.

http://www.ndt.org.uk/ website that campaigns for inclusion of people with learning disabilities at all levels of ordinary life http://www.dh.gov.uk/en/Publicationsandstatistics/Surveys/Othersurveys/Generalsurveys/DH_4081207.Government survey

Elder Abuse

The agency called Age Concern is concerned that the rights of older people often get overlooked. This is particularly the case where the person is either unable or unwilling to speak for themselves. Thus Age Concern maintains that older people need advocates (a disinterested third party) to put their case when the rights of an older person are being ignored or overlooked. Since the publication of the National Service Framework for Older People in 2000 there has been a directive for more advocacy when it comes to addressing the needs of older people and this move that has been welcomed by Age Concern.

Advocacy is about protecting the rights of people as human beings and making sure that their wishes are taken into account when decisions are being made that affect what may happen to them. Advocacy therefore, is meant to empower those people who may have the least power in society. There are those who maintain that there should be specialist advocacy with regard to the problems of age. Service user participation involves rights and responsibilities on behalf of both the service user and a service provider. When it comes to older people who may be confused about what is happening, or who refuse to become involved in the process then a definition of rights and responsibilities is problematic because without equal cooperation it is difficult to find a way of ensuring that these are fulfilled.

At the very least it has to be acknowledged that everyone has the right to be protected from abuse and to be treated with respect. The aim of good advocacy is to ensure that older people are aware that the local authority has a duty of care with regard to their needs. Advocates also try to ensure that older people have an understanding of what to ask for and what to expect when it comes to support and services. When this is possible it enables older people to exercise their rights as citizens, however, some elderly people may have no idea what is going on and may be confused by the whole process. In cases like this an advocate would look at the older person’s circumstances and needs, as well as listening to the carer’s input, and would then put forward a case for their care and ask for an assessment. This is not, however, a guarantee that the person will receive residential care, however much a family might want it.

A social worker would listen to what the family and perhaps the advocate had to say and would then ask what provisions were currently in place, whether these were provided by social services or by the family. Once they had assessed the situation the information would be given to a care manager who would decide what could be offered (Moore, 2002). In some cases this would be residential care.

As people grow older they can develop fears that they did not have before. Many older people, for example, are afraid to leave their homes for fear of being attacked, and numbers of them are also afraid of being attacked in their own home. However, figures from the British Crime Survey 2001, tend to suggest that the likelihood of being a victim of crime decreases with age. Despite this, many elderly people live in fear of being burgled or attacked in their homes by a stranger. Yet the figures support the idea that this fear is largely unfounded the burglary figures for 2001 yield the following information:

In 1000 households of people aged between 16 and 24 17.6% had been burgled
In 1000 households with residents of 75 and over only 2% were burgled

Despite these figures many elderly people are haunted by the fear that they are not safe on the streets and may not be safe in their own home. At the same time some media reports tend to suggest that older people are safer in their own homes than they might be if they went into residential care. Older people may not always be willing to go into residential care but an assessment may be asked for by other family members or by carers who are feeling the strain of looking after a demanding elderly relative. Some older people, however, may have become so frightened in their own homes that they want to go into residential care.

Care and Abuse

Despite the fact that some elderly people feel that they will be safer in residential accommodation there are factors which suggest this feeling may be misplaced. The marketisation of care, and the growth of private care homes means that there is some evidence which supports the view that the elderly may be more at risk of abuse of their rights and criminal assault in residential settings than in their own home (Ward et al, 1986). The 1990 NHS and Community Care Act, and the introduction of market forces into the care sector has meant that many former council run residences are now privately owned and run for a profit. This is the case even if the person does go into a council run home, they or their family members will be expected to make some contribution to the cost (Kerr et al, 2005).Even if people are in council run homes then they or their families are expected to make at least some contribution to the cost of their care. The shift to a mixed economy of care means that some carers have little or no personal care about the job they are doing and this can lead to older people being at risk of neglect and abuse. There have been plenty of media reports of neglect and abuse in residential care where older people’s human rights go unacknowledged and mismanagement and a lack of proper supervision can lead to neglect and abuse (Smart, 1997).

At a time when they should be receiving more care and attention some older people are being abused by the very people who are meant to be looking after them. It would seem that marketisation has led to a lack of proper control over what goes on in some residential homes and there needs to be some mechanism whereby such places are inspected on a regular basis.

Useful resources

http://www.elderabuse.org.uk/Media%20and%20Resources/Useful%20downloads/AEA/AP%20Monitoring.pdf

http://www.elderabuse.org.uk/

http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/Elder_Abuse.asp

Vulnerable Adults

There are general guidelines related to social work practice and this is especially the case when it comes to the protection of the weak and vulnerable. All local authorities have a duty to be aware of the number of people in their area who might be considered vulnerable adults. The legislative framework that governs the actions of a social worker working with vulnerable adults is based on the following:

1948 National Assistance Act Part 3
Local Authority Social Services Act 1970
The Chronically Sick and Disabled Persons’ Act 1970
National Health and Community Care Act 1990

Depending on the age of the vulnerable adult they are dealing with then the social worker will also have to bear in mind:

Section 45 of the Health Service and Public Health Act 1968
Section 117 of the Mental Health Act of 1983
General understanding of the 1998 Human Rights Act
The National Services Framework for Older People

Social workers should also be conversant with the terms of the 1995 Disability Discrimination Act before they make any assessment of a vulnerable adult. A lot of the problems that vulnerable adults experience, particularly if they have mental health problems, are due to the fact that many professionals (particularly medical professionals) still work with the medical model of disability. This model holds that a person’s problems and vulnerabilities are rooted in their pathology i.e. they are part of that person’s make up. The problem with this model is that there is a tendency to hold the person responsible for whatever their problems may be (Oliver, 1996). A more favorable model for the service user is the social model. This model looks at factors that are external to the service user such as environmental factors and any other social factors that may give rise to ill health or vulnerability.

Who Are Vulnerable Adults?

Vulnerable adults might be those people who need care because for one reason or another they cannot look after themselves. This might include the following:

Older people
People with mental health difficulties
People with physical disabilities
People with learning disabilities
Substance Misusers
Homeless People
In an abusive relationship

According to media and Government reports, older people are often subject to abuse by the people who are meant to be caring for them. The same thing happens to people with the sort of physical disabilities that prevent them caring for themselves, people with mental health difficulties and people with learning disabilities. In some cases women are more vulnerable and more at risk than men as in some cases they face the risk of sexual assault by carers, particularly if they are not family members. Government concerns over the abuse of vulnerable adults led to the setting up of the POVA the Protection of Vulnerable Adults Scheme in England and Wales. The scheme is implemented with regard to care homes for vulnerable adults, checking the backgrounds of people who work with vulnerable adults, either in a care home or in the person’s own home. The problem is that until a crime is committed there is no actual legislation that deals with the protection of vulnerable adults. Some local authorities have produced guidelines for multi-agency working in case of the abuse of vulnerable adults.

Harm and Abuse of Vulnerable Adults

Vulnerable adults can be abused or harmed in a number of ways, some of which are criminal. Non-criminal abuse might include not paying sufficient attention to their needs, denying them their human rights by not treating them as a person of equal human worth. Abuse can also occur by default when a carer neglects to take proper care of someone who is vulnerable by leaving them in an unclean state or leaving a confused person to wander without supervision. The more criminal aspects of the abuse of vulnerable adults can include stealing from them, misappropriating money from their accounts and physical or sexual assault. Sometimes it is as a result of harm that a vulnerable adult comes to the attention of social services and it is then the social worker’s job to assess the needs of that person.

When a social worker makes an assessment of need, even if the person in need is recognized as a vulnerable adult, they can only provide services if certain criteria are satisfied. Those people who have a score lower than 4,5 or 6 may only be entitled to information and advice (Moore, 2002). This means that a lot of vulnerable adults are left out in the cold and it is sometimes the case that they become involved with mental health services by being sectioned under the 1983 Mental Health Act. Here an ASW or Approved Social Worker can recommend to a mental health team that a person be sectioned or forcibly detained for a period of 28 days if they are regarded as being at risk or posing a risk to others. Vulnerable adults are another group who may at sometime need the services of an advocate to put forward their concerns. It is also the case that unless and until there is some legislation in place for the protection of vulnerable adults this abuse and neglect will continue.

Useful resources

Disability Discrimination Act 1995 http://www.drc-gb.org/thelaw/thedda.asp

http://www.after16.org.uk/pages/law5.html

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4085855

Moore, S. 2002 3^rd Edition Social Welfare Alive Cheltenham, Nelson Thornes

Mental Health

Local authorities now have a duty to act in ways that are conversant with the 1998 Human Rights Act and this means that social workers have a duty to help people with mental health difficulties to deal with any problems they encounter. Some research tends to suggest that over the last fifteen years those who use mental health services have been treated in a prejudicial way. This is largely a result of the fact Government discourse is phrased in such a way that this group is seen mostly in terms of the risks they may pose to the rest of society.

Some social workers have a lot of power when it comes to people who are assessed as having mental health problems. In Britain we have what are known as Approved Social Workers, these social workers are often involved in sectioning a person – that is to say a person can be detained for twenty eight days without their consent for assessment of their mental capabilities. This can be problematic because if a service user is being aggressive it is not always easy to tell whether this is just in response to whatever is going on at that moment or whether the person actually does have a mental health problem or a psychosis.

Hannigan and Cutliffe (2002) argue that the medical model of health is the most prevalent in the mental health sector. Under the terms of the 1983 Mental Health Act this often results in medical treatments that may involve, for example, the use of drugs or electro-convulsive therapy without the person’s consent. What is most worrying about this is that it can be used as a threat against vulnerable adults who may not need this kind of treatment but who may be irritating the professionals with whom they come into contact. This is especially the case if the adult concerned has a tendency to be a bit aggressive. Professionals may often assume that this person is displaying psychosis when they are simply displaying an exaggerated form of annoyance at what is going on. Current legal definitions of what constitutes a mental disorder (and the guidelines with which many professionals work) are not necessarily the same as psychiatric definitions of what constitutes mental illness. With recent changes to the Mental Health Act this situation becomes even more worrying because it widens the net to include other definitions of mental illness, definitions which could just as well be a result of social misfortune as something inherently wrong with a person.

Some research tends to suggest that the mental health system is racist and that black and white youths who may behave in a similar manner are treated differently and black youths are more likely to be assessed as having a mental health problem.

The disproportionate use of compulsory sections of the Mental Health Act 1983 for black people, and the links between mental health and the criminal justice system, suggest that the basic rights of many black service users are under threat. A holistic model would emphasise basic human rights and require great caution in the use of statutory powers in mental health services. Black service users’ rights would be safeguarded through anti-discriminatory procedures, accessible appeals and complaints systems, and accurate monitoring. Safeguards include quality assurance systems based on service users’ views. These should incorporate indicators of service outcomes based on improvements to black service users’ quality of life (Ferns, P. 2000 no pagination)

Increased use of sectioning under the Mental Health Act could be regarded as a form of blackmail in mental health – just another way of saying you behave the way I say you will behave or this is what will happen to you. The police also have greater powers under the 1983 Act. Section 136 gives them the right to detain people in a safe place for 72 hours if they are considered to be a risk to themselves or others, even if they haven’t been aggressive or done anything else that would warrant being detained. This is a frightening state of affairs because it means that anyone who upsets authority in some way could be at risk of losing their liberty without charge and without trial.

The mental health charity Mind say that actual psychosis is far less prevalent in Britain than some figures would have us believe and that the 1983 Act is in danger of being used as a means of social control rather than the protection of the public and of vulnerable adults.

Clearly there are many issues around Mental Health that are extremely worrying. If you are homeless you are automatically seen as having mental health problems and some literature also refers to women who have experienced domestic violence in these terms. Mental health issues and social blackmail it would seem are very closely related.

Useful resources

http://www.communitycare.co.uk/articles/article.asp?liarticleid=7951 Full ref. in bibliography

http://www.esrcsocietytoday.ac.uk/ESRCInfoCentre

http://www.lho.org.uk/HIL/Disease_Groups/MentalHealth_Inequalities.htm London Health

http://www.mind.org.uk/Information/Factsheets/Statistics/Statistics+3.htm

http://www.mind.org.uk/Information/Factsheets/Statistics/Statistics+3.htm

http://www.nacro.org.uk/about/Youth justice – are we getting it right.pdf

Sexual Harassment in the Work Place

The Clarence Thomas Supreme Court case confirmation hearings in 1991 were the first to bring the issue of sexual harassment into increased standing. Anita Hill, a former employee of Thomas, alleged that he had sexually harassed her while she was working under his supervision. Although the allegations where never sustained, the hearing made many people more aware of how often employees are sexually harassed in the work place. This, combined with other events lead to a tremendous increase in the number of sexual harassment complaints bring filed with the Equal Employment Opportunity Commission (Chapter 3, 123).

In addition to the early allegations, there have been more recent incidents that have brought more attention to sexual harassment in the workplace. One major incident took place after President Clinton took office and faced a sexual harassment lawsuit by Paula Corbin Jones. Jones alleged that Clinton sexual harassed her during a business trip in a Little Rock hotel room. This caused the number of sexual harassment complaints to jump in number, again, between 1993 and 1994. However, the number of cases filed has decreased substantially since 2000 (Chapter 3, 123).

There are two specific legal definitions of sexual harassment that have been established in employment law. Quid Pro Quo Harassment; this is transferred into “something for something,” or “you do something for me and I’ll do something for you” (Sexual Harassment, 2009). This happens when unwelcome sexual advances are expected in exchange for certain job benefits. An example of this would be an employee being offered a raise or a promotion if they go out on a date with the particular supervisor. This also happens when an employee makes a decision, or provides or withholds certain opportunities based on another employee’s submission to verbal, non verbal or physical conduct (Sexual Harassment, 2009). Quid pro quo harassment is just as unlawful whether the victim resists and suffers the threatened harm or submits to avoid the harm (Sexual Harassment, 2009).

The Bundy v. Jackson case illustrates quid for quo sexual harassment. Bundy was a personnel clerk with District of Columbia Department of Corrections. She received repeated sexual propositions from Delbert Jackson, who was currently another employee when this happened. He later became the director of the agency. After this she began to receive propositions from two of her supervisors. She took the issue to their supervisor, Lawrence Swain, who dismissed her complaints; telling her that “any man in his right mind would want to rape you,” then proceeded to ask her to begin a sexual relationship with him (Chapter 3, 123). When Bundy was eligible for a promotion, she was passed over because of her “inadequate work performance,” although she had never been told that her work performance was unsatisfactory (Chapter 3, 123).

The second definition is Hostile Environment Sexual Harassment. This happens when an employee is “subjected to comments of sexual nature, offensive sexual materials, or unwelcomed physical contact as a regular part of the work environment” (Chapter 3, 123). Normally if this were to happen once it would not be considered hostile environment harassment unless it is extremely outrageous conduct. Under this definition the courts look to see whether the conduct is both serious and frequent. Supervisors, managers, co-workers and even customers can create a hostile environment (Chapter 3, 123).

These types of behaviors are also covered under Title VII because they treat individuals differently based on their sex. Also, although most harassment cases involve male on female harassment, any individual can be harassed. For example, male employees at Jenny Craig alleged that they were sexually harassed, and a federal jury found that a male employee had been sexually harassed by his male boss (Chapter 3, 123). In addition, Ron Clark Ford of Amarillo, Texas, recently agreed to pay 140,000 dollars to six male plaintiffs who alleged that they and others were subjected to a sexually hostile work environment and treated differently because of their gender by male managers (Chapter 3, 123).

There are three critical issues when dealing with sexual harassment cases. First, the plaintiff cannot have “invited or incited” the advances (Chapter 3, 123). Most of the time the plaintiff’s sexual history, whether she or he wear provocative clothing, and whether she or he engages in sexually explicit conversations are used to prove or disprove that the advance was unwelcome (Elements, 648).

The second critical issue if that the harassment must have been severe enough to alter the “terms conditions and privileges of the employment” (Chapter 3, 123). Many courts have used the “reasonable woman” standard in determining the severity or pervasiveness of the harassment (Elements, 648). This consists of assessing whether a reasonable woman, faced with the same situation, would have reacted similarly. This recognizes that behavior that might be considered appropriate by a man may not be considered appropriate by a woman (Elements, 648).

The third issue is that the courts must determine whether the organization is liable for the actions of it employees. To determine this, the courts normally examine two things. First, did the employer know about the harassment? Second, did the employer do anything to stop this behavior? Normally if the employer knew about the actions and didn’t do anything to stop them then the court would find the employer guilty of not appropriately stopping the harassment (Elements, 648).

The US Equal Employment Opportunity Commission (EEOC) describes sexual harassment as a “form of gender discrimination that is in violation of Title VII of the 1964 Civil Rights Act” (Abdulaziz, S. 2009). In 1998, the US Supreme Court made employers more liable for sexual harassment of their employees. Since then, the Society for Human Resource Management has reported that 62 percent of companies now offer sexual harassment prevention training programs, and 97 percent have a written sexual harassment policy (Abdulaziz, S. 2009).

The number of cases filed with the EEOC has gradually decreased. In 1997, close to 16,000 charges were filled. Ten years later in 2007, only 12,510 were filed. “A telephone poll done by Louis Harris and Associates on 782 US workers revealed the following statistics: 31 percent of the female workers and only 7 percent of male workers reported they had been harassed at work, 62 percent of targets took no action, 100 percent of female workers were harassed by men, where as, 59 percent of men reported the harasser was a woman and 41 percent said the harasser was another man” (Elements, 648).

Remedies for sexual harassment depend on the severity of sexual harassment complaints and findings of the investigator, as well as, the situation. When the person lost an employment opportunity the following could happen: hiring the person for the job or opportunity lost, providing the person with the opportunity with he or she missed to the extent possible, and providing financial compensation for the lost opportunity (Discrimination, 2009).

If the person has lost wages the following could happen: all or part of the lost wages or salary would be compensated, lost pension or other benefits would be compensated, lost raises, overtime, shift bonuses, or higher rates of pay which should have been earned by promotion would be compensated, and any lost wages or benefits which can reasonably be linked to the act of sexual harassment would be compensated (Discrimination, 2009).

Typically all expenses attributed to the enforcement of the person’s rights can be compensated. Such expenses include: medical expenses, such as psychological care, travel expenses for attending physician, preparation of reports and costs of experts’ attendance at a trial, travel costs to attend a hearing, and wages and/or tips lost as a result of attending a hearing (Discrimination, 2009).

Sexual harassment in a work place is any form of unwanted or unwelcomed behavior, or attention of a sexual nature that interferes with your ability to function at work. It is also, largely a form of gender discrimination that is covered under Title VII of the Civil Rights Act (Sexual Harassment, 2009).There are many cases that have resulted from sexual harassment and many different forms of remedies of such harassment takes place.

Social Work and Criminal Justice: Victims of Violent Crime Analysis

Abstract

This report explores many factors of sexual abuse, specifically sexual exploitation of children. Ethical and policy issues that may affect practice with this population as well as the nature of the violent crimes are some of the factors explored in this report. The sexual exploitation of children is widespread and exists worldwide. Many of these children have long-term effects from sexual abuse that follow them into adulthood. In order to provide the adequate and appropriate treatment to sexually abused and exploited children, one must understand the magnitude of this heinous epidemic that is steadily increasing.

Introduction

The role of a generalist social worker who works with victims of violent crimes is of extreme importance. This is significantly true for social workers working with children who are victims of sexual exploitation. When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps to ensure the competence of their work and to protect clients from harm (Reamer, 2010). A generalist social work base provides an existing foundation on which direct intervention, policy formation, advocacy, and networking may be implemented (Herrmann, 1987). Social workers confront child sexual exploitation as school social workers, at runaway shelters, at counseling agencies, and within the court system. The history of the profession provides the precedent for social work’s involvement in ending child sexual exploitation.

Sexual abuse is any sexual activity with a child where consent is not or cannot be given. This includes sexual contact that is accomplished by force or by threat of force, regardless of the age of the participants, and all sexual contact between an adult and a child, regardless of whether there is deception or the child understands the sexual nature of the activity (Zastrow & Kirst-Ashman, 2013). The sexual exploitation of children includes sex trafficking, child pornography, and child prostitution. Exploited children carry the effects of sexual abuse for many years in an agonizing struggle with sexual dysfunction, depression, insomnia, suicide attempts, and self-mutilation.

The population mostly affected by child exploitation is usually children from infancy to adolescence. These children often live in poverty or live in low-income environments. Often, these children lack parental guidance or have parents who are involved in substance abuse. This population is usually the target of sexual abuse. Because of the anxiety most people harbor about sexuality in general, children have little information about sex. They have limited life experience upon which to base judgments. Thus, children can be easily misled or tricked (Zastrow & Kirst-Ashman, 2013). Those who sexually abuse children are referred to as pedophiles. Many pedophiles report a history of sexual victimization as adolescents. Occasionally, many children find themselves blackmailed into adulthood by their exploiters. Not all victims become victimizers. All, however, may experience guilt, confusion, shame, and anger as a result of exploitation (Herrmann, 1987).

Risk Factors of Child Sexual Abuse

Risk factors associated with sexual abuse and the exploitation of children includes the facts that suggest that girls are more likely to be victimized than boys. However, boys are equally as vulnerable as girls. The average age for the abused is between ages 4 and 6 years for boys and ages 11 and 14 years for girls. Children who have disabilities are at greater risk for sexual abuse. These children are more vulnerable and less likely to defend themselves (Zastrow & Kirst-Ashman, 2013).

Nature of Violent Crime

The nature of this particular crime can be heinous. This includes physical abuse, sexual abuse, and power of manipulation. Often, children are profiled and sought for their openness to trust others. The children are misled and manipulated into thinking the perpetrator will provide conditions that are better than their current situation. Children are often beat and drugged then sold into human trafficking. These children are forced in prostitution and forced to participate in horrible sexual acts. This includes intercourse, fondling, pornographic photography, and other unthinkable acts.

Scenario

Angel is a 14 year old African-American girl living in an inner-city neighborhood. Angel has four siblings and both parents are incarcerated for substance abuse. Because of the absence of her parents, Angel and her siblings are cared for by their elderly grandmother. The family does not have much money and often goes without basic needs such as food and clothes. Angel dropped out of school due to the constant judgement and bullying from other students. Without anywhere to go, Angel would often walk the streets to pass away the time.

While hanging out in the neighborhood, Angel was approached by an older man who mentioned he had taken an interest in her. He complimented Angel on her looks and told her that she should not be walking the streets, but pampered instead. Daily, the man would complement Angel and showered her with gifts. She had never been shown this kind of love before and felt she was in love. She was invited to the man’s home for dinner. Although the man was much older, Angel was eager to receive his charm. She agreed to dinner at his home.

On the following evening, Angel met the older man around the corner from her family’s home. She was instantly swept off of her feet. The man arrived in a shiny, red convertible sports car with a bouquet of roses in hand. When she arrived to the man’s home, she was greeted with more flowers, candles, and wine. Although she had never had wine before, Angel felt a sense of maturity and drank the wine. During the dinner, the man told Angel that he was aware of her conditions at home. He promised her that he would make all of her sorrows go away if she allowed him to take care of her. He promised to provide all of her needs and that she will never have to go without any of her basics needs anymore. He promised to shower her with gifts and to show her the world. Angel felt all of her prayers had been answered and that she had met her knight in shining armor. Although the room began to spin and she felt slightly ill, Angel agreed to spend the night with the man. He insists that she should not go home in her condition.

The next morning Angel awoke feeling very ill and confused. She could not remember where she was. Angel’s clothes had been removed and she was chained to a bed at her wrist and ankles. She is in a lot of pain and begins to cry out for help. Angel is aware that her body has been violated and wonders who could do this to her. Although she has been crying for hours, no one answers her cries for help. Eventually, a man she does not recognize enters the room and begins to yell and curse at her. He tells her that no one is going to help her and threatens to hit her if she does not stop crying. Although she tries to control her sobbing, Angel continues to cry. The man kept his promise and began to violently beat her. The violent beating left Angel unconscious and she never saw her knight in shining armour again.

On the following afternoon, again, Angel awoke dazed and confused. She noticed that she was chained to a radiator and had been moved to another location. She was later approached by two men who informed her that she now works for them. She was promised shelter and protection in return for following their orders. Daily, Angel found herself in different locations servicing men for money. Often, Angel would be transported from state to state and advertised on the internet. Although Angel wants to escape the life she was forced to live, she often finds herself drugged, beaten, and far from home. She has no resources and is not allowed to make calls or befriend anyone. Angel feels trapped. She often contemplates suicide and feels that taking her life is the only way out of her lifestyle.

Although Angel’s family attempted to find her, they had no luck. She was reported missing to the police, but dismissed as a delinquent runaway. Months began to pass and Angel became another statistic. Angel is now a part of the child sex trafficking ring. Daily, she is forced into prostitution and forced into a life she should not have to live. This commercial exploitation is the result of the lack of importance given to human rights around the world, the disregard of children’s needs, and the vast amount of money involved (Herrmann, 1987).

Ethical Issues

There are several ethical issues that may affect practice with this population. Although social workers are mandated to report sexual abuse of children, ethical and legal considerations for treatment of sexually exploited children remains an issue. Before treatment begins with the victim, is it appropriate for a practitioner to directly inquire and/or process information with a victim about an alleged offense in a pending criminal matter? To what degree can such inquiry, recounting, or processing of the events in question alter the child’s recollection of what took place (Branaman & Gottlieb, 2013)? Social workers must consider ethical issues of the effects of questioning, retelling, and suggestion on perceived personal experience. These processes operate in all therapeutic settings, but when they arise in the context of treating a child witness, they may influence, if not dramatically alter, a child’s memory (Branaman & Gottlieb, 2013). Also, social workers should be cautious when considering introducing a new treatment approach to these children. New approaches to the profession usually generate controversy among social workers because many unknown issues may arise. Social workers should attempt to locate empirical literature documenting the effectiveness of new approaches. Most social workers will conclude that using a controversial new treatment approach is too risky, ethically and clinically (Reamer, 2010).

Policy Issues

Often, policy issues may affect practice with this population. Child sex abuse issues are handled by state and local authorities, and not by the federal government. This is because of the relationships between the states which have broad authority within their jurisdictions. Unfortunately, the federal government has constitutional limitations on its authority. Because of this matter, the Department of Justice generally has no authority over child sex abuse issues. However, if a child is sexually abused or sexually exploited on federal land, the offender may be prosecuted under federal law in addition to state law. Another policy issue is the statute of limitations in child sexual abuse cases. Every state has a standard suspension of the statute of limitation for legal actions while a person is a minor. Most states have adopted additional extensions for cases involving sexual abuse of children. In the state of Mississippi, victims must file their claim within 3 years of the sexual abuse and/or within 3 years of the victims release from incarceration.

Assessment and Evidenced-based Practices

Treatment and assessment of child victims of sexual exploitation has several objectives. According to Zastrow & Kisrt-Ashman (2013), the first objective is to provide a safe environment where the survivor feels comfortable enough to talk. The survivor must learn to identity, express, and share feeling, even when they are negative and frightening. A second treatment goal is to have the survivor acknowledge that the abuse was no fault of theirs. The third objective involves teaching the child new ways to express their feelings. A fourth treatment goal is to address and special treatment needs of the child. These needs may include medical treatment or behavioral modification programs. The fifth goal is to enhance family communication, support, and understanding of the abuse.

On a micro-level of intervention, practitioners have been known to use several evidence-based treatment modalities when treating sexually abused children. Often, the psychodynamic theory and treatment is used. Psychodynamic theories emphasize the importance of stages of psychosocial development and the unconscious mental processes of human behavior. According to Walsh (2010), in ego psychology, problems or challenges may result from conflicts within the person or between the person and external world. Also, crisis theory and intervention is used. A crisis is defined as the perception or experience of an event as an intolerable difficulty. Crisis intervention represents a strengths approach because it underscores the possibility of client growth, even in horrible situations. The social worker must build upon clients’ strengths in order to help them adapt to, and grow from, the experience (Walsh, 2010).

On the mezzo-level of assessment and intervention, structural family theory (SFT) and intervention is often used. This theory attempts to bring structure back to the family. The focus of the theory is family structure. Family structure is a concept that refers to the invisible and often unspoken rules that organize how family members interact. In this intervention, the social worker is highly directive and directly leads the family’s process of problem resolution. During the intervention of SFT, role plays and role reversals are often employed by practitioners. The role plays are enactments of possible family situations that aim to adjust family interactions. The goal of role reversal is to sensitize family members to the feelings of other members in the family. Also, the Family Emotional Systems Theory is used. The theory provides a comprehensive conceptual framework for understanding how emotional ties within families of origin influence the lives of individuals in ways they often fail to appreciate and may tend to minimize (Walsh, 2010). The theory offers broad intervention strategies with which the social worker can utilize techniques in accordance with a family’s particular concerns.

On a macro-level of assessment and intervention, the ideal way to treat sexual abuse of children is to prevent the events from happening. Information and education are significant factors of prevention. In the community, parents need both education about how to raise children and knowledge that in the event they are in crisis resources are available to help. Special programs could be readily available in the community to help parents with these issues ((Zastrow & Kirst-Ashman, 2013). These programs would be beneficial to the community on many levels.

Diversity Issues

There are diversity issues that affect this population. Minorities from different backgrounds are at higher risk of child sexual exploitation. Many children from low-educational backgrounds are also at higher risk for exploitation. Most of the children that are misled into sexual exploitation are from impoverished areas of the world. In some cases, racial disparity has become an issue in the matter of child sex trafficking.

Often, cultural difference must be taken into account when working with sexually abused children. In some countries, touching of a child’s genitals is accepting. In the Philippines, it is culturally accepting to touch a child’s private area and not seen as deviant behavior. In the Korean culture, touching a child’s genital area is also an acceptable behavior. This behavior is considered an expression of adoration and pride for a male child who is to carry on the family name and tradition. In the Vietnamese culture, this behavior is thought of as an expression fondness, not a crime.

The cultural differences of the world suggest that some cultures do not view the sexual abuse of a child in the same context as others. Although most societies view these behaviors as deviant and unacceptable, others view these behaviors as normal and accepting. These accepting views can be related to family pride or superstitions. It is of the most importance for practitioners and other health professionals to be aware of the cultural difference in order to provide adequate and effective treatment to children in need. This knowledge will help to ensure that social justice is granted to those who need it the most, sexually abused and exploited children.

References

Branaman, T. & Gottlieb, M. (2013). Ethical and Legal Consideration for Treatment of Alleged Victims: When Does It Become Witness Tampering? Professional Psychology: Research and Practice, 44(5). 299-306.

Herrmann, K. (1987). Children Sexually Exploited for Profit: A Plea for a New Social Work Priority. National Association of Social Workers, Inc., 523-525.

Reamer, Frederic. (2010). Ethical Standards in Social Work: A Review of the NASW Code of Ethics. (2^nd ed.) Baltimore, MD: Port City Press.

Walsh, J. (2010). Theories for direct social work practice. (2^nd ed.) Belmont: Wadsworth Cengage Learning.

Zastrow, C. & Kirst-Ashman, K. (2013). Understanding Human Behavior and the Social Environment. (9^th ed.) Belmont, CA: Brooks/Cole Cengage Learning.

Literature review that critically analyses the sexual abuse of people with learning disabilities in institutions

There are a great many facets to the problem of sexual abuse of people with learning disabilities in institutions. The wide variety of learning disabilities, the wide scope for different types of sexual abuse and indeed the huge variety in the institutions themselves, means that there is not any unified standpoint or all-encompassing view that can be taken on the subject. (Ryan J et al 1987). This review will therefore consider each of these aspects in turn together with the literature associated with them and then attempt to draw conclusions from a critical evaluation of each

The term learning disability is applied to cover a wide range of different clinical entities. Differing impairments due to differing aetiologies are typically “lumped together “ under this one term. In the context of this review, differentiation of the various types of learning disability is largely irrelevant and the only discriminating factor that may be relevant is the degree of disability or impairment. For that reason alone we shall consider all causes of learning disability and the conclusions reached will therefore largely be generalisations in the area.

Approximately 2% of the UK population are currently classified as having a learning disability and this proportion has been slowly rising over time. In their comprehensive review of the subject, Xenitidis suggests that the reasons for this growth are manifold and complex. (Xenitidis K et al 2000). Part of the reasons given are that the definitions and criteria for the diagnosis of a learning disability are progressively changing as our knowledge of the area expands together with the fact that other relevant factors are changing such as the socio-economic conditions together with the fact that pre-term neonates who would previously been expected to die are now helped to survive but with an increased risk of cognitive impairment and learning disability (Aspray TJ et al. 1999).

The McGrother study suggests that over a 35yr period from 1960 the prevalence of learning disability has increased at an average rate of 1.2% per year (McGrother C et al. 2001).

One of the difficulties encountered in the context of sexual abuse is the problems that there are in discovering it. The typical person with a learning disability may have differing perceptions of “right and wrong” and therefore may not be in a position to make a judgement about what is happening. Other factors are that they have a greater difficulty in accessing professional help. (Wilson D et al 1999).Clearly this is less of a problem if we consider the group who are in institutions rather then those who live in the community, but against this is the argument that those in institutions generally tend to be those with the greatest disability and therefore would intuitively be less able to draw attention to a potential problem. (Patja K. 2000)

The literature in this area is not particularly extensive but there are a few high quality papers that stand out. The first is by Sequeira (Sequeira H et al 2003) which was a case controlled study (a rare construction in this particular area) which set out to consider any correlation between sexual abuse, mental health and behavioural problems in people with learning disabilities. The authors suggest that this is the first study to seek such a connection. They matched a surprisingly large entry cohort of 54 adults with learning disability in a residential setting who had suffered from sexual abuse with a similar cohort who had not been abused. The actual study was both carefully constructed and meticulously carried out. In broad terms the findings of the study were that there was a statistically significant correlation between sexual abuse and mental illness and behavioural problems together with symptoms of post-traumatic stress.

Reassuringly, the authors found that the reactions to abuse were essentially the same as in the general population which suggests that when recognised, the symptoms were evident to observers, but equally this implies that a significant amount of abuse is undetected. (Thompson D et al 1997).

With the group with learning disabilities, the authors concluded that in addition, the study group tended to exhibit stereotypical behaviour patterns and that there was a positive correlation between the degree of abuse and the severity of the symptoms reported. We can confidently conclude therefore that there is a positive association between sexual abuse and both psychiatric and behavioural abnormalities in people who have learning disabilities.

How does the design and architecture of institutions foster abuse?

It has to be observed that an extensive literature search reveals no specific studies on the issues of institution structure and opportunities for abuse. There are a number of papers that refer tangentially to the issue however, and we shall assimilate the points raised in them. Brown, (1999) and Manthorpe (et al, 1999), both observe that institutions, both large and small, are not specifically immune from sexual abuse of their residents. They point to working practices that allow professionals a degree of privacy when dealing with residents in vulnerable situations. (Burke K 1999).

It would be unlikely that anyone would disturb a nurse giving a patient a bath or a doctor conducting an interview or examination of a patient. In this respect, it is not the actual architecture of the institution, it is the structuring of the working practice that fosters the possibility of abuse in this area. (Churchill J 1998).

Some institutions have mixed sex dormitories and areas which can be difficult for nursing staff to monitor. Inter-resident abuse can therefore take place in areas which may be less easy to detect than the open plan structure of many wards in general hospitals (Brown H et al 1997)

Who are the perpetrators of abuse against people with learning disabilities?

This is clearly a difficult area in which to be dogmatic, as one can cite evidence from various enquiries which have examined the issue and have implicated virtually every category of professional from medical staff, (COI 1969), through nurses (COI 1971), to care assistants and sub-contracted employees (DOH 2000). Equally, to be balanced, one has to also examine the recent spate of prosecutions form residential care home workers that have been overturned in the appeal court where allegations of abuse have been found to be vindictive or fraudulent. (also COI 1978)

What impact does power imbalance between carer and service user have over occurrence of abuse?

Abuse, almost by definition, implies an abuse of power.(Northway R 1998).There is automatically an imbalance between those with learning disabilities and those in the general population as, by the very nature of their disability, the majority of those with a learning disability are dependent on other carers for their own protection and safety. (Pillemer K et al. 1993).This power imbalance is taken to a greater extreme when those (healthcare professionals) who are employed to care for their patients, and thereby are generally invested with a degree of trust give instructions to those who are more vulnerable. As Rogers points out, (Rogers AC 1997) the moment a nurse puts on a uniform or the doctor a white coat, they are invested with an automatic degree of authority and respect by the general population and possibly all the more so by those with learning disability, who may well have learned to be more deferential or respectful because these healthcare professionals are effectively the gatekeepers to their own security and well-being. (Sines D 1995)

What can be done to reduce abuse in institutions?

It is clearly important to be able to restore confidence in the residential settings for the care of those with learning disabilities. One of the prime mechanisms of reduction is to place professional emphasis on detection of abuse together with implementation of management procedures that will minimise the potential for abuse. The recent Government White Paper “No Secrets” (DOH 2000) has gone a long way into implementing such measures, and this, together with provincial measures in other parts of the UK (NAW 2000), presents guidelines which will help to prevent sexual abuse and also facilitate the investigation of such abuse when it is alleged.

Professional bodies have publicly proclaimed a policy of Zero tolerance in this area and have encouraged the philosophy of “whistle blowing” (NMC 2002 a) it should be noted however, that a study commissioned by the same group, The Nursing and Midwifery council (NMC 2000 b) suggested that despite the guidance and directives given there is clear evidence that nurses, in particular, do not have sufficient knowledge or have received sufficient training in the area of prevention of sexual abuse to effect the recommendations in the Government White Papers.

References

Aspray TJ, Francis RM, Tyrer SP, and Quilliam SJ 1999 Patients with learning disability in the community BMJ, Feb 1999; 318: 476 – 477

Brown H & Stein J 1997. Sexual abuse perpetrated by men with intellectual disabilities: a comparative study. Journal of Intellectual Disability Research 41 (3) 215-224.

Brown H 1999, Abuse of people with learning disabilities. In: N Stanley J Manthorpe &r B Penhale (Eds) Institutional Abuse: Perspectives Across the Life Coarse. London: Routledge. 1999

Burke K 1999, Nurses told to avoid close relationships with their patients. Nursing Standard 13 (49) 4.

Churchill J 1998, It doesn’t happen here! In: T Thompson & P Mathias (Eds) London: Sage/Open University Press. 1998

COI 1969, Committee of Inquiry (1969) Report of the Committee of Inquiry into Allegations of Ill-treatment of Patients and Other Irregularities at the Ely Hospital, Cardiff. Cmd 3975. London: HMSO.

COI 1971, Committee of Inquiry into Farleigh Hospital (1971) Report of the Committee of Inquiry into Farleigh Hospital. London: HMSO. 1971,

COI 1978, Committee of Inquiry into Normansfield Hospital (1978) Report of the Committee of Inquiry into Normansfield Hospital. Cmd 7357. London: HMSO.1978

DOH 2000, Department of Health (2000), No Secrets: Guidance on Developing and Implementing Mula-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: The Stationery Office. 2000

Manthorpe J & Stanley N 1999, Shifting the focus: from ‘bad apples’ to users’ rights. In: N Stanley J Manthorpe &r B Penhale (Eds) Institutional Abuse: Perspectives Across the Life Course. London: Routledge 1999

McGrother C, Thorp C, Taub N, Machado O. 2001, Prevalence, disability and need in adults with severe learning disability. Tiz Learn Dis Rev 2001;6: 4-13

NAW 2000, National Assembly for Wales (2000) In Safe Hands: Protection of Vulnerable Adults in Wales. Cardiff: Social Services Inspectorate for Wales.

NMC (2002 a), Code of Professional Conduct. London: Nursing and Midwifery Council.

NMC (2002 b), Practitioner-Client Relationships and the Prevention of Abuse. London: Nursing and Midwifery Council.

Northway R 1998, Oppression in the Lives of People with Learning Difficulties: A Participatory Study. PhD Thesis. Bristol: University of Bristol.

Patja K. 2000, Life expectancy of people with intellectual disability: a 35-year follow-up study. J Intellect Disabil Res 2000;44: 590-9.

Pillemer K & Hudson B 1993, A model abuse prevention programme for nursing assistants. Gerentologist 33 (1) 128-131.

Rogers AC 1997, Vulnerability health and healthcare. Journal of Advanced Nursing 26 65-72.

Ryan J & Thomas F 1987, The Politics of Mental Handicap. London: Free Association Books.

Sequeira H, Howlin P, Hollins S 2003, Psychological disturbance associated with sexual abuse in people with learning disabilities, The British Journal of Psychiatry (2003) 183: 451-456

Sines D 1995, Impaired autonomy: the challenge of caring. Journal of Clinical Nursing 4 (2) 109-115.

Thompson D, Clare I & Brown H 1997, Not such an ordinary relationship: the role of women support staff in relation to men with learning disabilities who have difficult sexual behaviour. Disability and Society 12 (4) 573-592.

Wilson D, Haire A. 1999, Health care screening for people with mental handicap living in the community., BMJ 1999;301: 1379-81

Xenitidis K. Thornicroft G. Leese M. Slade M. Fotiadou M. Philp H. Sayer J. Harris E. McGee D. Murphy DG. 2000, Reliability and validity of the CANDID-a needs assessment instrument for adults with learning disabilities and mental health problems. British Journal of Psychiatry. 176:473-8, 2000 May

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Promotion of sexual health, and all Adolescence, the second decade of life, is increasingly recognized as a critical phase in the life course, especially from the health and social perspectives. The most challenging aspect of adolescence is sexual and reproductive health, as it is aspect of adolescence is sexual and reproductive health, the area that poses the greatest difficulty in maintaining adolescents’ health and implementing appropriate and effective interventions. For a start, there is a paucity of information and, if there is information, it is often uncoordinated and fragmented and not very useful for policy-making and programme interventions (WHO, 2005)

Understanding human sexuality is a prerequisite to the promotion of sexual health, and all over the world sexuality remains one of the most problematic and dangerous aspects of person-hood (Wilson and Mcandrew, S, 2000). Professor Catherine Ingram of the school of Nursing at the University of North Carolina at Chapel Hill has defined sexuality perhaps more succinctly than most authors in this field. She describes sexuality as ‘an important dimension of the human personality’ and sees it as being ‘inextricably woven into the fabric of human existence (Catherine Ingram, 1990)

The belief prevalent in the early part of the twentieth century, that sexual education of the intelligent adolescent was best served by one short, sharp talk- in the fifth if the school was enlightened, in the sixth if it was felt to be an unpleasant but unavoidable duty-was perhaps typical of attitudes to education in many other disciplines. Facts were enough, and sex was put over in a way similar to that used when dealing with the maps of the coalfields. The only difference was the special atmosphere which surrounded the short, sharp talk. It must often convey to its victim that these matters were unspeakable and no well-bred pupil would either need or investigate them further. This method had at least one advantage- it did not attract unfavourable critic from parents or education committees large because all concerned were much too embarrassed to mention it.

After the first World- war, pragmatic objectives in sex education become more apparent and by early 1930’s several of our national agencies with the prevention the prevention of illegitimacy, the spread of knowledge about contraceptives and marriages guidance had begun. There was a small but interesting upsurge of intellectuals who nobly hid their embarrassments they discussed sexual matters with their children and solemnly left the bathroom door unlocked so that nudity could be rationally displayed. There were, however, even in those days, teachers in schools effectively relieving adolescent anxiety and ignorance about sex often under the name of human biology, wit equivocally worded syllabuses, and without a word to the head. Such strategies are still in use today.

The ironic evidence from research on the effects of fear-arousing information in connection with types of preventive health behaviour is that people tend to reject the information rather than change their behaviour (Radelfinger, 1965; Young, 1967)

In 1936, Wilhelm Reich commented that sex education of his time was a work of deception, focusing on biology while concealing excitement arousal, which is what a pubescent individual, is mostly interested in. Reich added that this emphasis obscures what he believed to be a basic psychological principle: that all worries and difficulties originate from unsatisfied sexual impulse (Reich W, 1936)

The existence of Acquired Immunodeficiency Syndrome (AIDS) has given a new sense of urgency to the topic of sex education. In many African nations, where AIDS is at epidemic level, sex education is seen by most scientists as a vital public health strategy. Some international organizations such as Planned Parenthood consider that broad sex education has global benefits, such as controlling the risk of overpopulation and the advancement of women’s rights.

According to the Sexuality Information and Education Council of the United States (SIECUS), 93% of adults they surveyed support sexuality education in high school and 845 support it in junior high school (SIECUS,1984). In fact, 885 of parents of junior high school students and 80% of parents of high students believe that sex education in school makes it easier for them to talk to their adolescents about sex. Also, 92% of adolescents report that they want both to talk to their parents about sex and to have comprehensive in-school examination.

When sex education is contentiously debated, the chief controversial points are whether covering child sexuality is valuable or detrimental: the use of birth control such as condoms and hormonal contraception: and the impact of such use on pregnancy outside marriage, teenage pregnancy and the transmission of sexually transmitted diseases (STIs.) Increasing support for abstinence-only sex education by conservative groups has been one of the primary causes of this controversy. Countries with conservative attitudes towards sex education (including the United Kingdom and the United states ) have a higher incidence of STIs and teenage pregnancy (Monbiot, 2004)

The proportion of women aged 20-24, who had a child before age 20 is a useful summary indicator that reflects the differences in teenage birth rates by country. This proportion is lowest in Sweden (4%), slightly higher in France (6%), much greater in Canada and Great Britain (11% and 15%, respectively) and highest in the United States (22%). Differences in the proportion giving birth by age 15 and by age 18 are also much higher in the United States than in the other four countries (Jacqueline et al, 2001)

Teenage pregnancy is times is a factor of early sexual exposure. Immaturity, inexperience or risky sexual experience often results in the unplanned pregnancy. In the study carried, between 1980 and 1998, among men and women to determine the age of first sexual experience, women were found to be exposed earlier than men (figure 1).

Figure 1. Proportion of participants younger than 16 years at first intercourse, by year of first intercourse.

Teenage pregnancy in Europe :

The incidence of teenage pregnancy across Europe varies considerably. The United Kingdom has the highest rate in Western Europe and is lower only than Bulgaria , Russia , and Ukraine in Europe as a whole. Throughout most of Western Europe, teenage birth rates fell during the 1970s, ’80s, and ’90s, but in the United Kingdom , rates have remained high-at or above the level of the early ’80s.

http://www.bmj.com/content/330/7491/590.full

Figure 2: showing teenage pregnancy in 6 European countries over a 25 year period.

The graph shows the trend over a twenty-five year period (1973-1995)

There is a sharp decline in the United Kingdom figures and then a near steady value in the late 70s and early 80s, before gradually reaching a crescendo in 1991 and then a sharp drop towards the end of the survey. The Netherland has the least and was fairly constant throughout the study period. Germany , France , Ireland ad Italy had fluctuating values, but generally, there was a decline towards the end of the study.

UNITED KINGDOM: In England and Wales , sex education is not compulsory in schools as parents can refuse their children take parting the lessons. The curriculum focuses on the reproductive system, foetal development and the physical and emotional changes of adolescence, while information about contraception and safe sex is discretionary and discussion about relationships is often neglected. Britain has one of the highest teenage pregnancy rate s in Europe and sex education is a heated issues I government and media reports. In 2000 study by the University of Brighton , many 14 to 15 year olds reported disappointment with the content of sex education lessons and felt that confidentiality prevents teenagers from asking teachers about contraception. In a 2008 study conducted by YouGov for channel 4 it was revealed that almost three in ten teenagers said they need more sex and relationships education.

In Scotland , the main sex education programme is Healthy respect, which focuses not only on the biological aspects of reproduction but also on relationships and emotions. Education about contraception and sexually transmitted diseases are included in the programme as a way of encouraging good sexual health. In response to a refusal bythe catholic school to commit to the programme, however, a separate sex education programme has been developed for use in those schools. Funded by the Scottish Government, the programme ‘Called to Love’ focuses on encourage children to delay sex until marriage and does not cover contraception and as such is a form of Abstinence-only sex education.

It is important to recognise that for some young women, particularly from certain ethnic or social groups, teenage pregnancy can be a positive life choice. Rates of teenage pregnancy within marriage are high, for example, in some South Asian ethnic groups in the United Kingdom . However, for many other young women, the costs of teenage pregnancy can be very high, particularly when linked with poverty. These risks include poorer outcomes for the children of teenage mothers as well as for the mothers themselves.

http://www.bmj.com/content/330/7491/590.full

Figure 3: showing the rate of teenage pregnancy in 17 European countries.

A sex survey by the World Health Organization concerning the habits of European teenagers in 2006 revealed that the birth rate among 15-19-year-olds in the UK was 27.8 births per 1,000 populations. The graph shows, the United States with the highest rate of teenage pregnancy and Switzerland with the least. The United Kingdom has the highest rate in Europe, which is clearly above the average value in Europe

FRANCE: In France , sex education has been part of school curricula since 1973. Schools are expected to provide 30 to 40 hours of sexual education and pass out condoms to students in grades eight and nine. In January,2000, the French government launched an information campaign on contraception with television and radio spots and the distribution of five million leaflets on contraception to high school students

GERMANY: In Germany , sex education has been part of school curricula since 1970. Since 1992 sex education is by law a government duty. It normally covers all subjects concerning the growing-up process, body change during puberty, emotions the biological process of reproduction, sexual activity, partnership, homosexuality, unwanted pregnancies and complications of abortion, the dangers of sexual violence, child abuse and sex-transmitted diseases, but sometimes also things like sex positions. Most schools offer courses on the correct usage of contraception.

A survey by the World Health Organization concerning the habits of European teenagers in 2006 revealed German teenagers about contraception. The birth rate among under 15- to 19-year-olds was very low- only 11.7 per 1000 population, compared to the UK’s 27.8 births per 1,000 population and – in first place -Bulgaria’s 39.0 per 1,000.

FINLAND: Sexual education is usually incorporated into various obligatory courses, mainly as part of biology lessons (in lower grades) and later in a course related to general health issues. The Population and Family Welfare Federation provide all 15-year-olds on introductory sexual package that includes an information brochure, a condom and to be most effective when a multifaceted approach is used, as the problem is multiple determined and multidimensional. The interventions

cartoon love story should not only focus on sexual factors and related on sequences, rather Interventions that are designed to reduce teen pregnancy appears they should include non sexual factors such as skills training, and personal development as well. Further, stakeholders including pregnant teens, parents, health sector, schools and churches should work together to devise programs that are practical, evidence based, culturally appropriated and acceptable to the target population.

Boostma writing on Sex Education: Preparing Instead of Prevention, surmise that the teenage pregnancy rates has been (one of) the Netherlands for years now. Asking the question if Netherlands are hardly sexual active or if the Dutch promote abstinence from sexual intercourse? He asserts that in the Netherlands , there is not one specific governmental programme for teenage sex education or contraception. There is however, a lot of information about sexuality and contraception that is coming from all directions.

Boostma believes that the Dutch approach attitude towards sexuality is one of tolerance, open mindedness and pragmatism and that studies from many countries that giving the message to young people ‘not to have sex’ are having the opposite effects. The same account for countries where the subject sex is more or less a taboo to talk about. The Dutch concluded that many young people will have sex anyway, so they should be prepared for sexuality than to be prevented from it. This preparing attitude is coming from different levels of the society:

The government through the National Health insurance pay for the contraception. Parents talk about sexuality and its consequence.

The Mass-media (Television, newspaper, magazines, radio) addresses sexuality and sexual health. Schools give sexuality talk/sex education. There many accessible services for sexuality and contraception. These and other factors result in a tolerant and pragmatic attitude towards sex make information and contraception accessible and explains the low rate teenage abortion or pregnancy.

Sexual heath in the Netherlands means preparation instead of prevention. This preparation means that young people are stimulated to become sexually autonomous and can make their own sensible discussions. Up till now, ‘the Dutch method’ has proven its effectiveness over and over again. Ian Sutherland, who was director in the Health department of Britain in the early 80’s co-authored a book, Health Education, perspective and Choices which dwells on the several choices available to people and the choices they make based on the information they have. The book analyses the different areas where choice is inevitable and the ideological basis for which certain choices should be made. Various authors contributed various topics on the theme Health education. The book first published in 1979 is invaluable as it coincide with the transition period of balancing health needs in Britain . The increased rate in teenage pregnancies and the consequence rise in abortion rates. It was also a period Britain was trying to establish formal curriculum on sex education. In an effort to include as much as possible, the authors referred extensively to a literature which begins with Plato. The authors tried to draw the readers’ attention to as many authorities as possible, and so made attempt at bringing together in one book the extensive libraries of ‘health’, ‘education’, and health education.

Crosby et al (2008) in a study titled, The Protective Value of Parental Sex Education: A clinical-based exploratory study of adolescent females compared the impact of sex education provided by parents to female adolescents against the same education provided by formal settings to female adolescent.

They sampled females aged 16-24 years, attending an adolescent medical clinic in urban area of the south were recruited prior to examination. Each patient completed an anonymous self administered questionnaire. Data from 110 respondents were analysed to compare those who indicating they had learned about each of 4 topics from parents to those not indicating learning about all 4 topics from a parent. The same process was repeated relative to learning about all 4 topics in a formal education setting.

The result showed that in controlled, multivariate analyses, adolescent not communicating with parent on all 4 topics were nearly 5 times more likely to report having sex partners in the past 3 months. Further, adolescents were 3.5 times more likely to have low self efficacy for condom use, 2.7 times more likely to ever using alcohol or drugs or sex and about 70% less likely to have ever talked about HIV prevention with a partner before engaging in sex. Differences relative to learning about all 4 topics in formal settings were not found out.

Looking at works done recently in the United Kingdom, (SHARE: Sexual Health And Relationships; Safe, Happy and Responsible) included 8400 pupils aged 13-15years in 25 secondary schools in east of Scotland (Wight et al,2002) Questionnaires was completed at base line and follow up done 2 years later. The intervention was a new 5-day teacher training programme plus a 20-session pack: 10sessions were delivered in the third year (at 13-14 years) of secondary school and 10 in the fourth year (at 14-15years). The primary outcome for the study was use of condoms at first intercourse. Similar proportions of both intervention and control groups used condom at first intercourse with less than 105 of pupils reporting first intercourse without condom. For all other behavioural outcomes (condom use after first intercourse, oral contraceptive use and unplanned pregnancy) there were no differences with the groups. However, as with Martiniuk’s study in Belize, published in this issue of the international journal of epidemiology, pupils in the intervention group were more knowledgeable than those in the control group.(Martiniuk,2003).

The Belize study was well designed in allowing for the clustered nature of samples both when calculating and the sample size and analyzing the data. Publishing the intra-cluster correlation will be good for planning future research.

However, there are a number of weaknesses with the randomized procedures discussed by the authors in their paper. The imbalance between groups in the number of classrooms could have been overcome by a block method rather than the simple coin toss employed here. (Schulz and Grimmes, 2002) There were considerable differences between groups at baseline in terms of gender and sexual experience. These data were not available to the researchers prior to the study starting. It may have been appropriate to allocate classes to intervention and control groups when the results from pre-test questionnaires were available. At this time an alternative randomization procedure such as stratification or minimization may have reduced the chances of imbalance between groups in the study (Pocock, 1984)

Anna Graham noted that the factor with the strongest influence preventing teenage pregnancy is educational opportunity. It is well-educated women who tend to delay childbearing. For women aged 20-24 years the longer a woman remains in school the less likely she is to have a child before the age of 20. Adolescents with little schooling are often twice as likely as those with more education to have baby before their 20th birthday. For example, 46% of young Columbian women with less than 7 years schooling have their first child by the age of 20, compared with 19% of those with more education. The contrast is even greater in Egyptian, where 51% of less educated women have their first birth before the age of 20 compared with 9% of better educated women. She noted that the link between lack of education and early childbearing is also strong among adolescents in the US . Some 58% of young American women who receive less than a high school education give birth by their 20th birthday, compared with 13% of young women who complete at least 12 years of schooling. The report from the Alan Guttmacher Institute, from which these data came, suggested that low level of education is not necessary a direct cause of early child bearing, however, the two characteristic of living in impoverished and rural environments. She further argued that when school is the main source of information about sexual matters, like the cross-sectional surveys in the UK , early and unprotected sexual intercourse is less likely, compared with when other sources such as friends and the media dominate.

She surmised that, the greatest impact to be made in reducing unwanted pregnancies and sexually transmitted infections is to increase the time spent in education by young women worldwide. She believes this form of intervention is likely to change the role of women in society empowering them to avoid the adverse consequences of sexual activity.

The author in her work tried to justify the need for a comprehensive education over and above the micro aspect of education-sex education. Believing that with increased time spent acquiring education, a women is more likely to avoid the bad aspect of sexual activity. She had looked into certain aspects of form of sex education and did not really weigh each on its own merit. She probably relied on her experience to draw a far reaching conclusion.

Boostma writing on Sex Education: Preparing Instead of Prevention, surmise that the teenage pregnancy rates has been (one of) the Netherlands for years now. Asking the question if Netherlands are hardly sexual active or if the Dutch promote abstinence from sexual intercourse? He asserts that in the Netherlands , there is not one specific governmental programme for teenage sex education or contraception. There is however, a lot of information about sexuality and contraception that is coming from all directions.

He believes that the Dutch approach attitude towards sexuality is one of tolerance, open mindedness and pragmatism and that studies from many countries that giving the message to young people ‘not to have sex’ are having the opposite effects. The same account for countries where the subject sex is more or less a taboo to talk about. The Dutch concluded that many young people will have sex anyway, so they should be prepared for sexuality than to be prevented from it. This preparing attitude is coming from different levels of the society. He noted that the government through the National Health insurance pay for the contraception. Also parents talk about sexuality and its consequence. The Mass-media (Television, newspaper, magazines, radio) addresses sexuality and sexual health. Schools give sexuality talk/sex education.There many accessible services for sexuality and contraception. These and other factors result in a tolerant and pragmatic attitude towards sex make information and contraception accessible and explain the low rate teenage abortion or pregnancy.

Sexual heath in the Netherlands means preparation instead of prevention. This preparation means that young people are stimulated to become sexually autonomous and can make their own sensible discussions. Up till now, ‘the Dutch method’ has proven its effectiveness over and over again. Perspective and choices which dwells on the several choices available to people and the choices they make based on the information they have is important in tackling the issue of teenage pregnancy. The different areas where choice is inevitable and the ideological basis for which certain choices should be made should essentially be based on informed choices.

Health authorities have proposed several methods of addressing Health education. This was very significant, particularly during the transition period of balancing health needs in Britain . The increased rate in teenage pregnancies and the consequence rise in abortion rates is significant, particularly going back to the period Britain was trying to establish formal curriculum on sex education.

Abortion seems to be on the increase in the United Kingdom , according to the office of national statistics in the United Kingdom , the proportion of conceptions terminated by abortion among under 20-year-olds increased slightly from 36 per cent in 1990 to 39 per cent in 2000. Over half (51 per cent) of all conceptions among under 16-year-olds resulted in a termination in 1990 and this increased slightly to 54 per cent in 2000. Legal abortion rates were highest in London and the West Midlands in 2000 and 2001?. Similarly, the data collected by the agency noted a corresponding decrease in conception rate, it noted that, “In 2000, the conception rate among females under 20 years was 63 per 1,000 females aged 15 to 19 years. This marks a decrease in conception rates over the last decade that mirrors a general decrease among females of all ages. The exception however has been among females aged 13 to 15 years. Rates of conceptions in this group have remained consistent at between 8 to 10 per 1,000 females from 1990 to 2000”. A likely consequence of abortion is decreased fertility and sexual infections, the agency equally noted a rise in sexual related infection within this time period, “Genital infection with chlamydia trachomatis if untreated, is associated with pelvic inflammatory disease (PID) in women and infertility. The diagnostic rate of genital chlamydia infection in females aged under 20 years old has increased since the mid-1990s. In 2001, the highest rates of diagnosed chlamydia seen in GUM clinics, were among 16- to 19-year-olds (1,035 per 100,000 females). Genital warts are the most commonly diagnosed viral STI. In 2001, 29 per cent of females diagnosed with genital warts were under 20 years of age, compared with only 10 per cent of males in the same age group. Rates of diagnosis among females aged 16 to 19 years increased by more than 15 per cent during the last decade and reached 680 per 100,000 females in 2001”.

Intervention in teenage pregnancy, need to among other things focus on improving contraceptive use, and initiate attitudinal changes and life style likely to prevent pregnancy and sexual transmission infection transmission. This should involve long-term services and interventions, which are tailored to addressing the major causes of teenage pregnancy. This should be spelt in information, which are clear and unambiguous and may involve ideas which the youths relate with. It should also be home grown, in that it should relate with the culture or practices inherent in the society.

This will start with identifying the risk group. There are certain categories among this age, which appear to be vulnerable. Vulnerability may be by choice or imposed due to social economic reasons or accessibility to health care, such as contraception use. Interpersonal skills development is vital in achieving this objective. Programmes and other educational facilities, which allow interpersonal development, should be explored, this will allow productive engagement. Clinic service for education and information, will also serve a vital role in checkmating the trend. As teenage will not only benefit, but the society will be better for it as well. Information dissemination is vital and there is the possibility of teenagers accessing this on their own, if encouraged to talk to health personnel or attend clinics for advice and education. Education in this sense should be all encompassing and structured to the need at hand. Constructive engagement and participation of all and sundry are vital.

Periodic review of methods is important in our ever changing world. Therefore, interventions should not just be in theory, but clear goals which are practicable should be outlined to follow the strategies mapped out. Outcomes envisaged, need to be weighed in relation to the input.

The delicate age, adolescence confers on teenage, makes it imperative, to address peer pressure and to make leaders of peer groups participatory in addressing the problems identified. All this need be done in an atmosphere of trust and confidentiality. It is often difficult to identify sexually active individuals, therefore, the scope of the intervention need be broad-based to cater for all and sundry. This can be achieved by recruiting experts or people trained in working with youths, who have enough experience to deal with the challenges teenage present.

Catherine et al 2003, working on reviews which looked at teenage pregnancy and interventional means of check in the scourge, surmised the intervention on socio-demographics, which addressed the various health, education and psycho-social needs of teenagers and their environment in tackling the problem.

They found out that, there is mixed evidence for the effectiveness of school-based and/or teacher-delivered sex education. They are of the opinion that, the best chance of interventions being successful in this setting is when they are multifactor and address a broad range of issues, including self esteem, vocational development, and access to services.

In the area of Clinic/primary care as an interventional means, they equally believe that, there is mixed evidence for the effectiveness of interventions that take place in a clinic/primary care setting alone, and that it will be beat, based on the literature search, that they are linked widely to other community and school services, and evaluated as part of a broader programme. They are of the view that, confidentiality is of utmost importance considering the age group. They also surmised that in the UK context, particularly on UK-specific services and settings, such as doctors who may be the first to see these individuals.

On Education and information dissemination, there is mixed evidence for the effectiveness of educational approaches. It was found out that, the more positive outcomes, have been found for education based approaches which link directly to services offered. This also includes a broad range of skills to help improve confidence and relationships among teenagers Vocational development may also be useful. It is said that, programmes should be long term, sustained across school years, and be in place before teenagers become sexually active.

It is also suggested that, there is the need to support young parents to continue their education to enhance educational and employment opportunity for parents, mother/child interaction, and social outcomes for children. Early educational interventions for disadvantaged children can improve long-term. The family is foremost in checking the trend and this is dependent on teenagers getting support from parents and families. Neglect has always been attributed as a cause of teenage pregnancy. This could be deliberate or due to pressure from social responsibilities from parents to support the family, often leading to children not getting enough or desired attention from their parents.

They further found out that, ‘community interventions should be developed with regard to local needs and existing services. There is some evidence that multi-factor interventions involving a degree of community activity or service may be effective at improving contraceptive use.’

On school-based clinics., it is noted that, although, more research is needed on these as the evidence covered by reviews here was methodologically weak, They may be effective as part of multi-factor programmes, but clinic-based healthcare programmes for teenage mothers and their children can improve their health outcomes, if taken as a priority at all stages. The media and the Internet are often seen as social agents which are often not properly utilised, either as a child educator and form of entertainment, but also as a means of redeeming the problem. The study noted that much work has not been done in the United Kingdom , but again, further work is needed here for the UK . Skills, meant to give self-esteem are vital. There is encouraging result for approaches that focus on these factors, particularly when they are part of a broad-ranging intervention. Peer education, is also important in addressing the core issues right from the onset.

Abstinence, as an interventional means has actually, not been fully found to be effective, as there are little or no evidence for the e

Introduction

This paper will consider some aspects of user and carer participation in theory and practice in relation to the case of a seventy two year old man named Harold.

Different Levels of Service User Participation

Service user participation is an integral part of social work practice and stems from the concept of the empowerment of service users.^[1] This ranges from consultation on an individual level…to user control and management of services (Carr, 2005, p.14). Service user participation is a principle that is quite often difficult to put into practice, although new initiatives such as Direct Payments which allow service users to choose and pay for the services they want go some way to alleviating this, in the case of a person such as Harold, who has complex needs, this is not always straightforward. There are power implications in the relationship between service users and social work professionals, and this makes it hard for service users to know whether their concerns are being taken seriously.^[2] This is even more problematic in situations where the person concerned does not appear to have any interest in what happens to them and this is discussed without reference to the service user as appears to be happening with Harold.

Harold has told his sons that he can’t be bothered to get washed or cook a meal… The sons have recently spoken with the day centre manager about their concerns regarding their father… he is spending most of his time in bed, and he is not eating regularly… he sometimes seems to be slightly confused and distant.

It is difficult to assess how far user participation might apply to Harold under these circumstances he no longer wants to attend the day centre and is not looking after himself so it is difficult to know whether he would be able to be involved at any real level in an assessment of his needs. This case does provide a dilemma for social workers on the one hand they have a duty of care, and also in terms of ethical practice, to take into account what the service user actually wants for him/herself. Service user participation often takes place in groups so that the service user does not feel overwhelmed by professional involvement, but this does not seem to be an option in Harold’s case. He sometimes gets confused and he also prefers to be on his own. If, on the other hand, the day centre manager and the other professionals (social worker, a Physiotherapist, Occupational Therapist, and a Community Psychiatric Nurse) involved with Harold take too much notice of the sons then they could be addressing their needs rather than Harold’s and it is difficult to see what level of service user participation would be applicable in Harold’s case.

An Approach to Service User Empowerment

Harold does not object to people coming to the house and perhaps user participation for Harold might best be achieved through the services of an advocate who could present Harold’s views in the best light. As a group older people can be disadvantaged and it is often forgotten that they are people who are as entitled to be treated with respect and consideration as are other groups. Since the 1960s there has been a growing movement in Britain which has come to be known as advocacy. Advocacy involves speaking on behalf of someone, it is an attempt to enable and empower people who might otherwise be disadvantaged. An advocate is there to promote the interests and views of the person they are speaking for. Dunning (2005) maintains that there are a number of stages in people’s lives (particularly those of older people) when advocacy should be a requirement, and especially if there is:

..a decline in physical and mental health, sensory impairment and the need for health and social services (Dunning, 2005, p.10).

This is a clear description of how things are in Harold’s case, he loses his way around the local shops and his GP has recently diagnosed that Harold has Parkinson’s Disease. Harold is becoming increasingly divorced from reality he acts as though his dead wife is still in the house with him and is unaware of the professional concern and considered involvement in his case. Under these circumstances it would seem clear that Harold is in need of someone who will act in his best interests and speak on his behalf if he is to have any control over his own future. An advocate would, hopefully, be able to establish what Harold should be asking for and what he might be entitled to in terms of services and support. Whether Harold would be empowered by knowing what is on offer is difficult to assess because of his tendency to become confused, but an advocate could make a case for the fact that Harold wants to stay in his own home and this would alleviate any fears he has of residential care. Quinn (2003) is of the opinion that information and advocacy are themselves services and can be the building blocks of …enabling older people to receive the services they require (Quinn, 2003, p.3). The team mentioned above have all received referrals for Harold, an advocate would try to elicit what Harold really wanted and convey this to the team so that his wishes are made known, and as far as possible, catered for. In this way an advocate would give Harold a voice and thereby empower him.

Factors that Promote and Limit Service User Involvement in Decision Making

Ongoing debate on the needs and rights of older people highlight the fact that while there has been a move to ensure individual’s rights to equality of service, older people may still face discrimination. Under these circumstances it is vital that factors relating to power imbalances between service users and professionals be acknowledged. It is only with this acknowledgement that the parties can then work together to at least lessen those factors that contribute to the marginalisation and exclusion of some service users (Carr, 2004). These factors might include a tendency of some professionals to ignore service users views or to at least misinterpret them so that rather than being enabled service user participation can result in service users feeling further disempowered. Institutional barriers need to be overcome, as does a continuing use of professional jargon which can also serve to exclude service users from the decision making process. Carr’s (2004) research found that service users often cited language gaps as a disempowering and exclusionary factor, however, once this was brought to light most professionals were more than happy to try to modify their language in order to encourage greater service user participation. Research tends to suggest, and Harold’s situation is a case in point, that greater and more effective service user participation cannot be achieved in a unitary way. There is a need for different models and levels of participation depending on the service user’s circumstances. Some service users will be so empowered by participation that they will go on to be involved in how services are delivered, still others are not able to be truly involved at any recognisable level without the intervention of a third person. Thus advocacy is an important element of lower levels of service user participation. An advocate can help to empower people in Harold’s situation because service users will then have someone who is impartial, who can inform them as to what is available in terms of services and support and who will promote their best interests among other professionals and make sure that their wishes are made known.

Harold, for example wishes to remain in his own home, he does not want to attend a day centre, neither does he want to go into residential care. Carr (2004) notes that the service user movement has been instrumental in promoting the rights of people’s entitlement to as ordinary way of life as is possible.

Working with Service Users and Carers in an Ethical and Anti-Oppressive Manner

Society often views old people as of little use because they no longer contribute to society in the same way as when they were younger and at the same time they are greater consumers of health and welfare services (Moore, 2002). Clearly it is not always easy working with older people because they may have multiple and complex needs, nevertheless under the 1998 Human Rights Act, they are entitled to be treated with dignity and local authorities have a duty to abide by the requirements of this Act. Any move to force a person like Harold to attend a day centre when he clearly does not want to is arguably not good practice. In order to deal with a person like Harold in an ethical and anti-oppressive manner it is vital that he is listened to. If his confusion makes this difficult then again, this is where the services of an advocate could play a vital role. An advocate would be able to see that Harold’s voice was heard they would also be able to express the concerns of his family. Harold may not be aware how concerned his sons are, he needs to be informed of their concerns but this does not mean that their concern for him should take precedence over his own desire not to attend day centres or to go into residential care. The professionals involved with Harold should not be persuaded by the arguments of his family because this could result in oppressive practice. Anti-oppressive and ethical practice has to consider the rights and needs of the service user as prior to the concerns of those close to him. Ethical and effective social work should involve a thorough assessment of Harold’s needs and a care package that takes his health and his wishes into account. It should be tailored to suit his individual needs and there should be room for changes and adjustments if the care package is not to become an imposition (Kerr et al, 2005). Where a person is not fully cognisant of what is happening then anti-oppressive practice should involve the use of an entirely independent advocate. This would be advisable in Harold’s case where there could be a conflict of interests between what his family wants for him and what he wants for himself, or what the care team may consider is best for him. An independent advocate would be the best way of ensuring that the team were consistently mindful of the need to engage in ethical and anti-oppressive practice. This is often achieved by those involved being reflective in their dealings with service users.

How Reflective Practice Informs Social Work Practice

In the contemporary climate social workers are often faced with a conflict of interests between bureaucratic requirements and targets and the needs of their clients. This is unfortunate because it negates the claim that effective social work is client centred, Schonn (1991) has argued that:

Professionals claim to contribute to social well-being, put their clients’ needs ahead of their own, and hold themselves accountable to standards of competence and morality. But both popular and scholarly critics accuse the professions of serving themselves at the expense of their clients, ignoring their obligation to public service, and failing to police themselves effectively (Schon, 1991:11-12).

When people reflect on what they are doing then they are more inclined to recognise people’s individual worth and therefore to act in an ethical manner, one that works towards the best interests of the client. Ruch (2002) maintains that reflexive practice results in a deeper understanding of a person’s self and the role it has in professional practice it makes them more open to new and different ways of working and thus it is now becoming an integral part of social work practice. In Harold’s case a reflexive practitioner may find it easier to balance the conflict of interests between Harold and his sons and with the help of an advocate empower Harold in his role as service user.

Bibliography

Carr, S. 2004 Has Service User Participation Made a Difference to Social Care Services? London, SCIE

Department of Health (2002b) Information Strategy for Older People (ISOP) in England. London: Department of Health

Dunning, A. 2005 Information, Advice and Advocacy for Older People York, Joseph Rowntree Foundation

http://www.assoc-optometrists.org/uploaded_files/nsf-olderpersons.pdf

Jordan, B (2000) Tough Love—Implementing New Labour’s Programme: social work and the third way (London: Sage).

Kerr, Gordon, Macdonald and Stalker 2005 Effective Social Work with Older People

Moore, S. 2002 3^rd Edition Social Welfare Alive Cheltenham, Nelson Thornes

Quinn, A., Snowling, A. and Denicolo, P. (2003) Older People’s Perspectives: Devising Information, Advice and Advocacy Services. York: Joseph Rowntree Foundation

Ruch, G. 2000 “Self and social work: Towards an integrated model of learning” Journal of Social Work Practice Volume 14, no. 2 November 1^st 2000

Schon, D. 1991 The Reflective Practitioner: How Professionals think in Action Ashgate Publishing, Avebury

www.scie.org.uk/publications/leadingpractice/files/scie_9%2520service%2520user.ppt+SERVICE+USER+PARTICIPATION& accessed 27/4/06

http://www.scie.org.uk/publications/positionpapers/pp03.asp Has Service User Participation Made a Difference to Social Care Services accessed 27/4/06

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Identify, using examples, how a professional social worker should work in such a way as to ensure user and carer participation.
Consider the practice issues for working anti-oppressively with users or carer’s who are either a frail elderly person and their carer.

A professional social worker must approach the elderly person as an individual and ensure that individual as opposed to generic needs are assessed. In practical terms this means that the approach taken is built upon a mix of professional pragmatism and textbook rules. This manner of approach also ensures that the social worker can approach the practice issues identified in an anti-oppressive and professional manner which promotes both user and carer participation. Certainly in terms of personal reflection, and from the writer’s perspective; as a white, middle class person, integrating the theory of how one is required to engage oneself anti-oppressively, in the capacity of social worker with the pragmatics of good social skills and an ability to put a user, such as a frail elderly person and their carer at ease is all the more important where there are differences between the practitioner and the service user in terms of age, race, religion and sex to name just a few examples. Therefore promoting user and carer participation and working anti oppressively with frail elderly users is by no means an easy task. Such a task requires an understanding of models of oppression. Models of oppression mainly relate to the ‘isms’ within society such as ageism, sexism, classism, racism and many others (Williams, (2002) 1), and in the context of this question perhaps ageism and its avoidance within a user/practitioner setting is the most relevant. The professional social worker must be aware that models of oppression must be understood and applied within carer/user settings in order to promote an ethical, participatory relationship between the two (Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (2006) 14). This is because as Beckett and Maynard ((2005) 46) observe, the social worker often deals with those groups within society who are the ‘least powerful’.

One classic example of this for the social worker in a practice situation could be at a juncture where a frail elderly person reaches a stage where their needs cannot be accommodated at home, and supported accommodation options for the elderly person may need to be discussed. In this instance ‘alone time’ spent between carer and the social worker and the user and the social worker can allow both to discuss the issues at hand frankly, and decide what the best way forward might be. This ensures that there is holistic user participation, as it is important that the needs of a frail elderly person are not entirely overshadowed by the input of the carer. This by no means implies that the carer should be ignored during a home visit, or should be excluded in any manner, but there will be times when it is appropriate for the frail elderly person (provided they are compos mentis) to express their viewpoint independently of those close to them (for example if they express a wish to have arrangements made for a will). This will also give the social worker an opportunity to have some time alone with the carer, which gives the carer an opportunity to raise concerns or to discuss issues which they would perhaps not feel comfortable raising in the presence of the person who they take care of. Of course, the user participation will be important once these discussions have taken place, because a frail elderly person cannot be placed into supported accommodation without their co-operation and consent. However, it is often beneficial, where a sensitive issue should as a move between home and supported accommodation is to be broached, that a carer and a professional social worker have an opportunity to discuss the needs of the ‘user’ of the services in a setting where these issues can be spoken of frankly. This does not mean that issues should be concealed from a user or from a carer, but often in terms of facilitating anti-oppressive practice issues it is appropriate to relate to both user and carer in different ways, and therefore it may be necessary to communicate with one or another (user and carer) separately.

In this context the issue of power within society and how it relates to social inequalities must be understood. The social worker is in quite a powerful position compared to an elderly and frail service user, and therefore a professional social worker is required to appreciate how their language must be employed as a strategy to engage the service user, and carer anti oppressively, and at the same time promoting participation.

To take stock of another example to illustrate this point, let us look at a scenario whereby an elderly person who is frail is hostile to interventions from a social worker. Here, the requirements for anti-oppressive techniques of care become all the more important. Difficult questions become apparent in this context. Some examples are as follows: What should one do whereby a frail elderly person has a carer who looks after their needs on a part time basis, and the social worker feels that there are issues of self neglect during episodes where the carer is not present? To take this example a little further, a scenario could arise where a frail elderly person, whose carer is not present, is being visited by a social worker. Let us imagine that the social worker wishes to gain entry to the house of the elderly frail person in order to assess their needs and the elderly person is suspicious and does not wish to allow the person in. How can language be employed in this setting to promote an ethical relationship based on anti-oppressive techniques in this scenario? A simple answer would be for the social worker firstly to explain who they are and why they wish to pay a visit to the elderly person, and secondly another strategy which could be employed would be to say to the service user (the elderly frail person); Can I come in for a Chat/some Tea?, rather then an overly formal explanation of why they are there for example ‘I have to speak to you to assess whether you are capable of looking after yourself’. This approach also empowers the service user, since they may feel more in control of the interaction, and they might also be more inclined to perceive the social worker on friendly terms.

To pose another critically important question here: how should a social worker in this above outlined scenario handle a conflict which arises between an elderly user and the state where an elderly person, who lacks capacity to make decisions for themselves is self-neglecting and will not co-operate with a social worker who encourages them to move into supported accommodation? Two models of intervention may be employed here by the social worker, to deal with the conflict. One is the state intervention model, which may involve sectioning the frail elderly person and removing them into the care of an institution, and alternatively the social worker can choose to employ more moderate interventions which involve living support from voluntary sector groups (Scottish Executive (2006) Section 1.3). Which one is best always depends upon the individual circumstances of the frail elderly person, and the judgement of the individual social worker^[1].

In this context, and to continue the reference to the particular example where a social worker wishes to gain entry to the house of a frail, elderly person for the purposes of assessing their needs, it is also important to remember that the social worker owes the frail elderly person some legal responsibilities. All social work practitioners, for example are required to adhere to the various codes of ethics which have been issued through the General Social Care Council, which was set up in 2001. Amongst other duties, each of the 84000 social workers and social worker students on the Social Care Register must submit to inspection by the Commission for Social Care Inspection, and are required to have their own copies of their codes of conduct; and also as of 2003, the Social Care Register requires that only registered social workers may describe themselves as social workers (to label oneself a social worker, and at the same time intending to deceive others in this respect is now a criminal offence) (www.gscc.org.uk). Another legal responsibility which the professional service user owes to the user and to the carer is the duty not to discriminate unnecessarily against a person on the grounds of their race, ethnicity, disability, and age to give just a few examples of areas which are protected by law by anti-discrimination legalisation. Research into what practice issues are important for services users including carers and the elderly which was carried out by the Cambridgeshire and Peterborough Mental Health Partnership NHS Trust suggests that the combating of discrimination and how it can lead to an oppressive relationship between service user and social worker is very important in social work practice (Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (2006) 14).

In terms of both user and carer participation, the issue of confidentiality is of the utmost importance. This builds trust between user and the social work practitioner and also may lead to a feeling of empowerment by the service user, who is in the context of this question a frail elderly person. To refer back to the first example used in this essay (where the issue of perhaps assessing the needs and views of both carer and an elderly frail person separately has been raised); where there are issues which are quite sensitive between a carer, and a frail elderly person, it is important that the confidence of both parties are respected by the social worker. It is also important to speak to each person on their terms. One classic example of this in the context of a frail elderly person, addressing the user firstly by using their formal title ‘Miss Jones’ for example or ‘Mrs Smith’, as opposed to the use of first names is potentially an important strategy to employ. It is often the case that there will be a large generational gap between the frail elderly person and the social worker, and this makes to concept of anti-oppressive techniques and participation techniques all the more important. Such a generational gap may make a frail elderly person perceive the social worker as more of a threat to them, and may perhaps convey to them the impression that the social worker has little understanding of their needs and view of the world. In this sense, also good case management and record keeping (often a legal requirement for social workers) will also facilitate user and carer participation, as well as anti-oppressive practices.

In conclusion therefore there are a plethora of practice issues which are pivotal in a scenario where a social worker is required to interact in a professional capacity with a frail elderly person and their carer. All of these issues are intersecting, related, and sometimes contingent upon each other. The requirements for user and carer participation and for an understanding of anti-oppressive techniques are therefore complex concepts which require a pragmatic approach, integrated with a theoretical approach on the part of the contemporary professional social worker. These arguments have been supported throughout the essay through a focus upon reflective and theoretical reasoning.

Bibliography
Books

Beckett, C. and Maynard, A. (2005) Values and Ethics in Social Work. Publisher: Sage Publications. Place of Publication: UK.

Articles

Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (2006) Strategy for Social Work and Social Care. Publisher: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust. Place of Publication: UK.

Scottish Executive (2006) The Need for Social Work Intervention. Publisher: Scottish Executive. Place of Publication: UK.

Williams, C. (2002) A Rationale for an Anti-Racist Entry Point to Anti-Oppressive Social Work in Mental Health Services Critical Social Work, 2002 Vol. 3, 1.

Website

<< http://www.gscc.org.uk/News+and+events/Media+releases/Put+social+care+centre+stage+in+social+exclusion+drive.htm >>.

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