Guidance on HSB for health practitioners

Last updated: 07 Apr 2020
Introduction

Most children display a range of healthy sexualised behaviours as they grow up. However some may display problematic or abusive sexualised behaviour. This is harmful to the children who display it as well as the people it's directed towards.

As a health practitioner, you should be able to distinguish normal sexual behaviour from sexual behaviours that are developmentally inappropriate, problematic and/or harmful.

You may need to reassure worried parents that their child is exploring their sexuality in a healthy way. However if a child is displaying harmful sexual behaviour (HSB) you need to provide them with appropriate advice and make referrals for relevant treatment and support

We've put together a guide to help health practitioners decide what kind of sexualised behaviour a child or young person is displaying and respond in the right way.

Watch: responding effectively to HSB disclosures and referrals

1. Gather information

Step one: gathering information

First, you need to gather as much information as possible so that you can work out whether a child is displaying healthy, problematic or harmful sexual behaviour.

Remember that for many children and parents this is a sensitive topic. Listen non-judgementally to what they are telling you.

You should consider:

  • The age of the child or young person who has displayed HSB. As children grow up they develop sexually. What is 'normal' sexual behaviour for a 15-year-old may be problematic or harmful for an eight-year-old. Consider the child's developmental ability as well as their chronological age.
  • The age of the other children or young people involved. If the children involved are the same age/developmental ability the behaviour may be considered 'normal'. But if the children are of different ages/developmental abilities, the behaviour might be problematic or harmful.

Indicators that behaviour is problematic or harmful

You should try to find out as much as possible about the behaviour that is being displayed. Children naturally explore and experiment with their sexuality as they grow up. If the behaviour seems to go beyond curiosity, for example if it is obsessive, this might indicate it is harmful.

You should also consider:

Is the behaviour unusual for that particular child or young person?
Children naturally explore and experiment with their sexuality as they grow up. If the behaviour seems to go beyond curiosity, for example if it is obsessive, this might indicate it is harmful. If a child's behaviour is out of character, it's important to take time to consider why the child is behaving unusually.

Have all the children or young people involved freely given consent?
If the behaviour involves coercion, intimidation or forcing others to take part, it should be considered harmful.

Are the other children or young people distressed?
If the behaviour is upsetting others, this indicates it is problematic.

Is there an imbalance of power?
If the child displaying the behaviour is in a more powerful position than the other children involved, this indicates it is problematic. This might happen if there are significant differences in age, size, power or developmental ability.

Is the behaviour excessive, degrading or threatening?
Excessive behaviour means behaviour that is obsessive, persistent, compulsive or has been going on for a long time . Any behaviour that involves force, coercion, bribery or threats is harmful.

Is the behaviour occurring in a public or private space?
If the behaviour is particularly secretive or is being carried out in private after intervention from adults, this may be cause for concern.

2. Assess the behaviour

Step two: assessing the behaviour

Sexualised behaviour should be seen as a continuum, ranging from 'normal' to 'inappropriate' and 'abusive' (Hackett, 2010).

Using the information you've gathered, consider where the child or young person's behaviour sits on the continuum:

Normal - Inappropriate - Problematic - Abusive - Violent

Normal behaviour 

  • Developmentally expected and socially acceptable behaviour.
  • Consensual, mutual and reciprocal.
  • Decision making is shared.

Inappropriate behaviour

  • Single instances of developmentally inappropriate sexual behaviour.
  • Behaviour that is socially acceptable within a peer group.
  • Generally consensual and reciprocal.
  • May involve an inappropriate context for behaviour that would otherwise be considered normal.

Problematic and concerning behaviour

  • Developmentally unusual and socially unexpected behaviour.
  • May be compulsive.
  • Consent may be unclear and the behaviour may not be reciprocal.
  • May involve an imbalance of power.
  • Doesn't have an overt element of victimisation.

Abusive behaviour

  • Intrusive behaviour.
  • May involve a misuse of power.
  • May have an element of victimisation.
  • May use coercion and force.
  • May include elements of expressive violence.
  • Informed consent has not been given (or the victim was not able to consent freely).

Violent behaviour

  • Physically violent sexual abuse.
  • Highly intrusive.
  • May involve instrumental violence which is physiologically and/or sexually arousing to the perpetrator.
  • May involve sadism.

Traffic light tool

The Brook Sexual behaviours traffic light tool can also help you work out whether a child's sexualised behaviour is appropriate.

The tool gives you information about which behaviours are considered 'green, amber or red' for the key developmental stages (ages 0-5, 5-9, 9-13 and 13-17).

It's best practice to cross reference between the Continuum and traffic lights tool to make sure your assessment of a child's behaviour is correct.

Guide for health professionals

We've created a quick printable guide to help health professionals remember how to recognise and respond to HSB.

> Download the quick guide (PDF)

3. Take action

Step three: taking action

Your response to a child displaying sexualised behaviours should vary depending on the child's age, stage of development and the type of behaviours being displayed. Consider where the young person's behaviour sits on the HSB continuum:

Normal - Inappropriate - Problematic - Abusive - Violent

HSB continuum

Your approach should focus on the needs of the child at all times.

Normal ("green") behaviours

It's healthy for children to be curious about their own and other people's bodies. The process of experimentation and exploration mean that children and young people will get it wrong from time to time but this may not indicate a serious concern.

How to respond

  • Listen to what children and young people have to say and respond calmly and non-judgementally.
  • Talk to parents about developmentally typical sexualised behaviours.
  • Explain how parents can positively reinforce messages about appropriate sexual behaviour and act to keep their children safe from abuse.
  • Signpost helpful resources such as our PANTS activity pack
  • Make sure young people know how to behave responsibly and safely. For example two 15-year-olds having consensual sex might benefit from a conversation about contraception and consent.
  • Remind children and young people they can contact Childline if they need confidential help and advice. Calls to 0800 1111 are free and children can also contact Childline online or get information and advice on the Childline website. You can download or order Childline posters and wallet cards to keep on display and give to children and young people.

Inappropriate, problematic or concerning ("amber") behaviours 

Although these behaviours are not abusive or violent, they should not be ignored. The child or young person will need support to help them change their behaviour and stop the behaviour escalating.

How to respond

  • Listen to what children and young people have to say and respond calmly and non-judgementally.
  • Follow your organisation's child protection procedures and make a report to the person responsible for child protection.
  • Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our trained professionals will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate.
  • Consider whether the child or young person needs therapeutic support and make referrals as appropriate.
  • If a child or young person needs confidential help and advice direct them to Childline. Calls to 0800 1111 are free and children can also contact Childline online or get information and advice on the Childline website. You can download or order Childline posters and wallet cards to keep on display and give to children and young people.

Abusive and violent ("red") behaviours 

Abusive and/or violent behaviours need immediate intervention and action. You should consider whether the child or young person displaying the behaviour is at risk and take the necessary action to protect them. You also need to take action to mitigate the risk their behaviour may pose to others.

How to respond

If a child is in immediate danger, call the police on 999.

If a child is not in immediate danger:

  • Follow your organisation's child protection procedures and make a report to the person responsible for child protection.
  • Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our trained professionals will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate.
  • Refer the child or young person for therapeutic support, for example from our Turn the Page service.
  • Direct children and young people to Childline if they would benefit from confidential advice and support. Calls to 0800 1111 are free and children can also contact Childline online or get information and advice on the Childline website. You can download or order Childline posters and wallet cards to keep on display and give to children and young people.

We've created a quick printable guide to help health professionals remember how to recognise and respond to HSB.

> Download the quick guide (PDF)

> Find out more about recognising and responding to abuse

Multi-agency response

As a health practitioner you might be involved in a multi-agency response to make sure the child or young person is receiving the right support.

> Find out more about improving multi-agency responses to HSB

> Find out more about direct work with children who display harmful sexual behaviour

If you're working with a child's school, you might find it helpful to take our online training on harmful sexual behaviour in schools.

Keeping records

Keeping records

It's important to keep detailed records about any sexualised behaviour you witness or are told about. This will make it easier to identify any changes or patterns in a child's behaviour that might be cause for concern.

It also helps ensure the child or young person gets the right support.

Make sure your record includes:

  • the child's age (date of birth) and stage of development
  • any specific vulnerabilities they have (for example if they have a disability or are in care) 
  • any other behavioural concerns
  • any other known incidents of sexualised behaviour
  • details of any incidents you have seen or been informed about
  • the child's view of what happened – in their own words if possible
  • the parents' view of what happened – how did they react and what support do they need?
  • information about any other factors which might be contributing to the behaviour
  • what action have you taken? (for example reported the incident to your organisation’s safeguarding lead)
  • what support have you provided to the child and their family?

Recording incidents

Make sure you record details of any incidents you have seen or been informed about. This should include:

  • date and time
  • what was happening before the incident took place?
  • specific details of the behaviour – avoid generalised terms such as 'inappropriate touch'
  • was there any power imbalance between the children involved 
  • did the behaviour appear spontaneous or premeditated?
  • was any coercion, force or secrecy involved?
  • was the behaviour consensual?
  • how did the other children involved react? (make sure the children are not named or identifiable in your record).
References and resources

References and resources

Hackett, S (2010). Children, young people and sexual violence. In Barter, C and Berridge, D (eds) Children behaving badly? exploring peer violence between children and young people. London: Blackwell Wiley.

Brook sexual behaviours traffic light tool

This interactive tool can help you work out whether a child's sexualised behaviour is considered 'green, amber or red'.

It helps you identify sexual behaviours for the each of the key developmental stages (ages 0-5, 5-9, 9-13 and 13-17).

It's best practice to cross reference between the Continuum and traffic lights tool to make sure your assessment of a child's behaviour is correct. And always make sure you take appropriate action after having assessed a child’s behaviour.

> Find out more about Brook's Sexual behaviours traffic light tool

Elearning

Our elearning courses can help develop your understanding of how to protect children from abuse:

> See our Harmful sexual behaviour in schools training

Support for children and young people

Childline provides information and advice for young people about healthy and unhealthy relationships

Further reading

> Look at our reading list on harmful sexual behaviour for the health sector

If you need more specific information, please contact our Information Service.

Related NSPCC resources

> Find out more about harmful sexual behaviour 

> Read our harmful sexual behaviour framework 

> Read our learning from case reviews briefing about harmful sexual behaviour 

> Read our research briefing about harmful sexual behaviour 

> Read our statistics briefing on HSB