Introduction

The sexual exploitation of children and adolescents (SECA) is a fundamental violation of children's rights and a serious form of sexual victimization where sexual abuse and assault coexist with the economic exploitation of children (^{Estes & Weiner, 2002}). It is a type of childhood sexual victimization in which a person or group takes advantage of a situation of power imbalance to coerce, manipulate, or deceive a child or adolescent in exchange for something the victim may want or need, or in exchange for increased status or position in the social group (^{Beckett et al., 2017}). A key element in the definition of SECA refers to the child being used not only as a sexual object but also as a commercial object (^{Miller-Perrin & Wurtele, 2017}), which involves differences with respect to other forms of sexual victimization that must be taken into account in the intervention and treatment needs of the victims (^{Cole et al., 2016}).

Although SECA has been considered a practice linked to developing countries, either for the exploitation of minors within these countries or for their transport to developed countries to be sexually exploited there, it is now recognized as a problem in Europe as well (^{Benavente et al., 2021b}). Thus, recent studies have begun to analyze the phenomenon in Spain (see ^{Pereda et al., 2021}), which is both a country with minors who are sexually exploited within the region, and a transit and/or export country, according to reports by the ^{Observatorio de la Infancia [Childhood Observatory] (2017)} and other official sources of the Spanish state (Law 26/2015).

Due to the paucity of studies on SECA, victim identification remains difficult for professionals and society at large (^{Felner & DuBois, 2017}; ^{Marcus et al., 2012}). This difficulty is due in part to the hidden and clandestine nature in which sexual exploitation is often carried out, but also to the lack of a standardized and validated screening tool for use in settings where vulnerable children and adolescents are attended to, which severely hampers the capacity for early detection of victims in order to provide targeted care (^{Greenbaum & Crawford-Jakubiak, 2015}).

While the few studies that exist indicate that there are more girls than boys who are victims of SECA in Europe and that the average age is between 13 and 15 years, no young person is immune to sexual exploitation (^{Averdijk et al., 2020}). SECA occurs in all ethnic groups and at all socio-cultural levels (^{Berelowitz et al., 2012}), although the condition of unaccompanied migrant minor is an added risk to be assessed (^{Digidiki & Bhabha, 2018}). In turn, it has been found that having previous experiences of sexual victimization in childhood represents a high risk of exploitation (^{De Vries & Goggin, 2020}), as does having early and risky sexual relationships (^{Lalor & McElvaney, 2010}). Having had contact with the protection and/or juvenile justice system is another risk factor to consider, linked to previous experiences of victimization and lack of protection in the family of origin (^{Panlilio et al., 2019}). The consumption of alcohol and drugs is also a very relevant risk factor that additionally encourages the victim to remain in the situation of exploitation (^{Franchino-Olsen, 2021}). Running away and being in a situation of homelessness is an established risk factor (^{Klatt et al., 2014}). The exploiters are not just people that are unknown to the child but may also be members of the child's own family, professionals in the child's environment, or other caregivers (^{Beckett, 2011}; ^{Brayley et al., 2014}). The need for bonding and belonging leads many adolescents to be more influenced by their peers, “loverboys,” or even their own family members and to become involved in exploitative situations (^{Reed et al., 2019}).

In recent years, a number of screening tools have been developed to assist professionals in identifying children who are victims or at risk of SECA. Most have been developed in the United Kingdom and the USA and are based on a list of risk indicators or vulnerability factors related to SECA. The use of this type of tool facilitates decision making for professionals, establishing the level of intervention depending on whether the indicators suggest that the child is at risk of being sexually exploited or may actually be being sexually exploited (^{Brown et al., 2016}).

SECA constitutes a serious health problem for victims as they are exposed to an increased risk of injury, sexually transmitted infections, substance abuse, untreated chronic medical conditions, eating problems and malnutrition, post-traumatic stress disorder, depression, anxiety, and other mental health problems that can even lead to suicide or suicide attempts (^{Greenbaum & Crawford-Jakubiak, 2015}; ^{Lanctôt et al., 2020}). However, these young people have great difficulty in recognizing the abusive situations in which they find themselves, which makes the need even greater for the protection that must be provided to them by the professionals with whom they have contact (^{Stativa, 2000}). Studies indicate that most victims have been treated in health services at one time or another during their childhood, in addition to being in school, while they are being exploited (^{Greenbaum et al., 2018}). It is, therefore, crucial that health and education staff, as well as social service personnel, acquire a thorough understanding of the problem and are able to identify, intervene, and prevent SECA (^{Franklin & Smeaton, 2017}).

Development of the EDR-ESIA

Knowing the risk factors of SECA is essential for the early detection of cases and the development of prevention strategies (^{Franklin et al., 2018}). Thus, in response to the cases of exploitation that were made public in 2020 in Mallorca, which have led to the implementation of improvements in the detection of these cases and in the intervention with their victims, a tool was designed to detect the risk of sexual exploitation in children and adolescents. This tool has been named Eina de Detecció del Risc d'Explotació Sexual en la Infància i la Adolescència (EDR-ESIA).

It is an exploratory and brief instrument, as it is designed to be applied in services that have regular contact with minors, such as the health, education, and social services systems, where time is limited. Obviously, a more powerful test would have to be applied in a specialized screening context and would probably include many more items, but this would make it difficult to use among professionals who must perform early detection. This is not a diagnostic test for SECA, but an instrument capable of detecting possible SECA risk situations quickly and simply in standardized social, educational, and health services. Its role is to warn of cases in which high scores are obtained, initiating the process of examination and analysis to confirm whether a situation of exploitation is occurring.

To initiate the tool design process, a systematic review was conducted, complemented by a survey of the available instruments (^{Benavente et al., 2021b}). The initial validation method involved three phases of consultation: (1) a Delphi panel of experts, (2) a peer review, and (3) a final review by experts, as shown in Table 1.

Description of the EDR-ESIA

The final version of the EDR-ESIA tool consists of 88 items to be completed by the professional, collected from the reports, medical history, and/or records of the child, divided into four sections: (1) Identification of the child and the family (22 items), (2) SECA target indicators (13 items), (3) Risk indicators subdivided into (a) Significant risk indicators, (b) Medium risk indicators, (c) Other risk indicators with 12 items in each subcategory (up to 49 items in total indicators), and (4) Vulnerabilities of the child (17 items).

For use during the empirical validation phase, and to facilitate the professional's decision-making criteria, it has been considered to score only the 'SECA target indicators' included in Table 2.

To facilitate their completion, each of the risk indicator items are defined in the tool itself, and it is indicated how to score them according to the degree to which they are displayed. The score for each of these items is indicated as mild: 1; moderate: 2; severe: 3, with the final result being considered as the following score >9 points: established risk; 6-9 points: probable risk; 1-5 points: at professional discretion.

Sensitivity and specificity values were calculated by generating 507 different cases, using a simulation procedure of situations of sexual exploitation and borderline situations, with combinations of different situations. They were subjected to identification with the 13 target indicators. Only in cases where more than 9 points were obtained was the identification of SECA considered positive, corresponding to the highest levels of "established risk on the scale". These situations were also assessed with a gold standard constructed from the parallel identification as a case of SECA on three international reference scales, such that it was only considered that a true case of SECA had been identified when the identification was coincident among the three scales. These scales are ^{Basson's (2017)} Commercial Sexual Exploitation-Identification Tool (CSE-IT), ^{Clutton and Coles' (2007)} Sexual Exploitation Risk Assessment Framework (SERAF), and the ^{Kent and Medway Safeguarding Children Board (2017)} guidance.

Applying the criteria for interpreting diagnostic tests to the SECA situation, sensitivity has been defined as the probability of correctly classifying a person in a SECA situation, configuring the capacity of the scale to detect SECA (^{Pérez et al., 2021}). In the estimation performed, the probability is high, at 94.87%, taking as a reference the situation with more than 9 points, according to the threshold established above.

Specificity has been defined as the probability of correctly classifying a person who is not experiencing SECA (^{Trevethan, 2017}). That is, the probability for a person who is not in an SECA situation to obtain a negative result (equal to or lower than 9 points), leaving out situations that may determine the level of risk based on other investigations or expert professional judgment. In the estimate made, the probability is high, at 82.91%, although it is lower than that of sensitivity.

Predictive values have also been calculated as measures of discriminant capacity. The positive predictive value consists of the probability of being in an actual SECA situation if a positive result is obtained on the scale. The result is 86.62%. The negative predictive value is the probability that a person with a negative result on the scale (less than or equal to 9 points) is really in a no risk situation. In this case the probability is 93.27%.

Discussion

SECA is a problem that we have recently started to confront in Spain, similar to what has happened in the other European countries (^{Benavente et al., 2021}), for which professionals need tools and resources. There is a broad consensus on the need for early diagnosis of SECA for the effective protection of victims (^{Felner & DuBois, 2017}). Therefore, it is urgent to develop tools that increase the capacity for professional detection and for this to be done early, given the difficulties of handling and managing cases of SECA by professionals responsible for the care of minors in our country.

Although there are some instruments similar to the one presented in this article at the international level (^{Basson, 2017}; ^{Clutton & Coles, 2007}; ^{Kent and Medway Safeguarding Children Board, 2017}), these initiatives are scarce, they come from English-speaking countries, and there is no similar resource in the Spanish language to which professionals in our country can have access. Thus, the results of this first validation study of the EDR-ESIA tool, carried out in several phases and compared with the three most recognized international instruments in this field, show that Spanish professionals can have an instrument capable of predicting with a high degree of accuracy high-risk situations of SECA in children aged 11 years or older.

The EDR-ESIA is intended for application in primary care services in education, health, and social services. The use of a common tool is an important advance in this field that will provide professionals involved in the care of minors with a shared and accessible work instrument, with which the aim is to reduce the subjectivity component as much as possible. This common tool is intended to focus on situations that are not of great importance when presented in isolation, but that, when they occur together, constitute risks to which anyone in contact with children and adolescents must be vigilant.

The characteristics of the indicators considered allow us to conclude that there is no differential functioning in relation to different individuals in the same situation, since the descriptive language allows little room for distorted evaluations. Technically, these are observations by professionals of situations that can be described (^{Anguera et al., 2018}). The statements of the individuals analyzed are secondary, with respect to these observations, so the margin for distortion is almost negligible, i.e., if the situation can be documented, the indicator always works in the same way in different subjects. This facilitates and favors early detection and, therefore, more effective prevention work. However, it should be borne in mind that although obtaining a high score on the key indicators of the instrument indicates that the child is at probable risk of SECA, there is no certainty that this is the case. Conversely, low scores on the instrument's key indicators do not mean that the child is not at risk. In this sense, a low score may be due to a lack of collaboration or attention on the part of the professional who completes it, and therefore the scores do not necessarily reflect the real risk in all cases. The creation of a new instrument also involves training professionals in the particularities of SECA in Spain, making them aware of the importance of early detection of these situations and of its potential consequences for the young person, and also creating supervision mechanisms. SECA is a multicausal and complex problem that does not respond to simple solutions (^{Pereda et al., 2021}).

SECA is a problem on which much remains to be done in our country. Future studies in this area should include the perspective of the victims and the risk factors and motivations they allude to when they become involved in situations of exploitation, respecting ethical principles and the protection of children and adolescents (^{Pereda, 2019}). It is also worth assessing the effectiveness of the EDR-ESIA applied to a sample of professionals from different regions of Spain, and recognizing the existence of a problem that, as we are seeing, affects all the autonomous communities of our country.

Conclusions

The aim of the present study was to present the EDR-ESIA scale, developed to improve the detection of SECA risk situations in our country. The final scale, compared with the few current international instruments (^{Basson, 2017}; ^{Clutton & Coles, 2007}; Kent and Medway Safeguarding Children Board, 2017) and with the research carried out in this field (^{Armstrong, 2017}; ^{Brown et al., 2016}; ^{Felner & DuBois, 2017}), has been shown to include the most relevant indicators for the identification of SECA and to be easily applicable in the context of services in contact with minors. The EDR-ESIA scale represents a promising instrument that has good content validity, and is feasible, and operational for screening SECA situations in Spain. The tool fulfills the functions of assessing the risk of SECA, recording the recommended action according to the current risk assessment, and alerting the competent authorities to risk situations. Thus, it is a resource for Spanish professionals who detect a situation of vulnerability and/or risk in minors linked to possible situations of exploitation, and it represents a step forward with regards to an issue that we are beginning to tackle in our country and for which more research and studies are needed.