Child welfare workers’ understanding of gender, sexual orientation and sexual health in assessments of youths with a problematic substance use

ABSTRACT

The use of alcohol or illicit substances by youths may be related to sexual motives and experiences. Accordingly, child welfare workers need to address young people’s sexuality in their investigative work. In this study, we have examined the significance of different social categories, namely gender and sexual orientation, when child welfare workers assess young people with a substance use and their related sexual health. Fifteen child welfare workers were recruited through a strategic sampling to participate in semi-structured interviews, which were analysed using thematic content analysis. The results consist of three sub-themes: Sexually vulnerable girls; Boys as perpetrators; and Unseen LGBTQ+ youth. Together, these sub-themes constitute an overarching theme where the heterosexual matrix appears to be the interpretative framework when investigating a problematic substance use. The suggested implications for practice include education in sexual and reproductive health and rights for child welfare workers aiming to achieve an equitable assessment process for all youth with a problematic substance use.

ABSTRAKT

Ungas substansanvändning kan ibland relateras till sexuella motiv och erfarenheter. Det är därför av vikt att socialsekreterare adresserar dylika frågor i barnavårdsutredningar som är fokuserade på ungas eventuella missbruksproblematik. I denna studie har vi därför undersökt hur olika sociala kategorier – kön och sexuell läggning – relateras till ungas sexuella hälsa, men också hur det får betydelse i utredningar av unga med missbruk. Femton socialsekreterare har intervjuats med stöd av en semi-strukturerad intervjuguide, vartefter resultatet analyserats med hjälp av en tematisk innehållsanalys. Det slutgiltiga resultatet ledde fram till tre sub-teman: sexuellt sårbara tjejer; killar som förövare; osynliga HBTQ+ -ungdomar. Dessa tre teman bildar tillsammans ett övergripande tema; den heterosexuella matrisen fungerar som tolkningsram i utredningsarbete av ungas substansmissbruk. Implikationer för praktiken innefattar bland annat utbildning i sexuell och reproduktiv hälsa och rättigheter (SRHR) för socialsekreterare inom den sociala barnavården i syfte att säkerställa jämlika utredningsprocesser för alla unga med substansmissbruk.

KEYWORDS:

• Child welfare
• gender
• sexual health
• sexual orientation
• substance use

NYCKELORD:

• Kön
• sexuell hälsa
• sexuell läggning
• social barnavård
• substansanvändning

Background

Young people with a problematic substance use are in many respects a heterogeneous group with different motives, experiences and consequences related to their substance use (Hunt, 2006). There are strong connections between substance use and a range of sexual experiences and risks. For instance, intoxication can function as a means for enabling or evoking specific enjoyable sexual experiences, but it can also lead to loss of control and risky situations (see Coleman & Cater, 2005; Lindroth & Löfgren-Mårtenson, 2013; Parent et al., 2021; Tokle et al., 2023). If individuals with a substance use are not given the opportunity to talk about sexual issues, they risk missing out on developing harm-reductive strategies and learning how to handle the risks of relapse connected to their sexual health and behaviours (Lindroth & Löfgren-Mårtenson, 2013; Svensson & Skårner, 2014). Problematic substance use may, but does not necessarily, imply clinical dependence. Determining when, how, and why alcohol or illicit substance use has transitioned to problematic use is thus difficult. Therefore, in this study, we have not relied on a strict definition of the term ‘problematic substance use’. Instead, we allowed the interviewed social workers to define this, departing from their professional knowledge and experiences.

An assessment context provides a unique opportunity for child welfare workers to engage in conversations with young people about what a problematic substance use means for them, and how it affects their sexual life. In addition, the assessment context provides young people an opportunity to receive support related to their overall health and well-being, including aspects of their sexual health, both within the assessment process and through continued support interventions within the child welfare system. However, child welfare workers have been shown not to see sexuality issues or sexual and reproductive health and rights (SRHR) as an important part of the assessment of a young person with a suspected substance use problem (Björkas et al., forthcoming). Instead, they interpreted questions related to sexual health based on areas of knowledge that are already traditionally consolidated within child welfare. This was manifested in, for example, how young people’s substance use most often tended to be understood based on the negative effects of intoxication (e.g. sexual victimisation or sexual abuse) rather than intentional or meaningful in terms of sexual feelings or behaviours (Björkas et al., forthcoming).

SRHR has been a neglected subject in social work education, and consequently, perspectives on sexual pleasure and healthy sexual practice are often absent within social work (Areskoug-Josefsson et al., 2019; McCave et al., 2014), including in child welfare practices (Björkas et al., forthcoming; Combs et al., 2022; Riad & Forden, 2021). At the same time, previous research has shown how young people in the child welfare system have a poorer sexual health compared to the general youth population (Fernández-García et al., 2022; Schindele & Lindroth, 2021; Winter et al., 2016). Previous studies have also shown that gender tends to be used to classify the needs of social work interventions; namely, girls are seen as vulnerable and their sexual behaviours are often problematised, whereas boys’ sexual behaviours seldom are addressed (Östberg, 2010; Pettersson & Andersson Vogel, 2023; Schlytter, 1999). However, little is known about how child welfare caseworkers understand the meaning of gender or sexual orientation in assessments of young people with problematic substance use and their sexual health. Therefore, in this paper, we explore these connections.

Child welfare assessments in Sweden

In Sweden, there is a mandatory reporting requirement, meaning that professionals who have concerns about children or young people (0–17 years) are obligated to report this to the child welfare services (14 ch. 1 § Social Services Act). This obligation stems from the child welfare system’s orientation towards initiating early therapeutic interventions to anticipate and prevent harm (Östberg, 2010). This includes harm sprung from parental shortcomings (e.g. neglect) as well as the experiences or behaviours of young individuals (e.g. victimisation, problematic substance use, or criminal behaviours) (National Board of Health and Welfare, 2023). In Sweden, the legal age for buying alcohol is 18, and all use of narcotics is prohibited. Because of this, an early debut of alcohol use, an extensive alcohol consumption, as well as any form of narcotics use among young people also tend to lead to reports to the social services.

A child welfare assessment is initiated when a problematic substance use is suspected, if an ongoing support intervention is deemed insufficient/unsuccessful or if there is a need for a decision on compulsory care. During the assessment, the responsible child welfare worker typically meets with the young person individually, as well as together with their parents, to discuss the topic(s) of worry. The social worker also gathers complementary information about the young person from school, healthcare services or counselling services. This process may take a maximum of four months, but since the social services generally have a very high influx of cases, it is not uncommon for a young person to only have a few meetings with their social worker during this period. An assessment is complete when the social worker has either closed the case, or identified further support needs and matched them with suggestions for appropriate support measures (Björkas et al., forthcoming; National Board of Health and Welfare, 2023).

The national SRHR strategy suggests that these welfare assessments (as well as any related outpatient treatment or community care) should address SRHR needs (Public Health Agency of Sweden, 2020, 2023). However, the Social Services Act (SFS, 2021, p. 453) is not explicit on these issues; it does not address sexual health and rights, even if it states that promoting the well-being of young people is a central mission of the child welfare system. Similarly, general objectives regarding young people’s right to good health are expressed in the legislation on compulsory care for children and youth, namely the Care of Young Persons (Special Provisions) Act (SFS, 1990, p. 52), but again, there are no explicit statements about sexual health for young people. On the other hand, in the legislative history of the Care of Young Persons Act, it is stated that the sexual behaviour of young people could be grounds for justifying compulsory care, for instance, if a young person engages in prostitution or performs at sex clubs (Prop., 1989/90:28 1989). This suggests that the child welfare services, at least in some cases, are expected to relate to sexuality issues in their assessment work.

In a Swedish context, it is more common for girls than boys to be subject to an assessment within the child welfare services. Research has suggested that reports of concern regarding girls are more often connected to stereotypical notions: girls are considered vulnerable and in need of protection from others to avoid being harmed, whereas boys are attributed agency for their externalised as well as norm-breaking behaviours (Kalin et al., 2022; Östberg, 2010). Thus, for the child welfare services, girls’ sexual practises and experiences have been important in the assessments of their vulnerability and needs, while boys’ only seems to be of importance when they are suspected of sexual abuse (Östberg, 2010; Pettersson & Andersson Vogel, 2023). Although assessments of girls are initiated to a greater extent, boys are more frequently referred for substance use treatment through the child welfare services (Anderberg & Dahlberg, 2018). Girls are referred to the health and medical services or, alternatively, must seek support on their own, to a greater extent than boys. This poses a dilemma as girls tend to have more severe substance use problems than boys, which is related to the fact that girls often wait significantly longer for access to substance use treatment (Richert et al., 2020).

More extensive substance use among youths tends to involve a greater risk of sexual risk-taking behaviours (Strandberg et al., 2019), but also, an increased vulnerability to sexual violence (Stefansen et al., 2021). In addition to gendered differences, research has shown that it is more common among LGBTQ + people to use substances to handle stress caused by internalised heterosexism, which in turn increases their risk of developing substance use problems (Huynh et al., 2022; Marshal et al., 2008). We have not been able to find research explaining when and, if so, how substance use among LGBTQ + youth might influence child welfare workers’ assessments, neither in relation to decisions to initiate assessments nor in the design of support interventions. Nonetheless, research has described how LGBTQ + youth often experience marginalisation and discrimination in contact with various parts of the child welfare system (Kaasbøll et al., 2022).

Aim

The child welfare caseworkers’ understanding and handling of social categories in assessments are important as this lays the foundation for possible recommendations about further support needs, as well as access to health support, related to young persons’ illicit substance use and their sexuality. Therefore, the present study aims to explore whether and how child welfare workers base their assessments of young people with illicit substance use problem and their sexual health on different social categories, mainly gender and sexual orientation.

Method

Design and sampling

This study is based on interviews with 15 child welfare workers experienced in doing assessments of young people under 18 with a problematic substance use. The informants were recruited via strategic selection. Unit managers in geographically dispersed Swedish municipalities of different sizes were contacted, with the aim of collecting a wide range of experiences among child welfare workers and group leaders. In connection to this, interested social workers were encouraged to get in touch for more information about what a participation in this study would entail. Due to limited feedback from potential participants, the first author also spread information about the study through acquaintances within different child welfare offices. In this recruitment process, we aimed for people of different gender, age, and work experience. Nevertheless, the final sample consisted of 14 women and 1 man, probably because child welfare services is a female-dominated work area in Sweden. The informants were between 30 and 67 years of age and had varying lengths of experience in assessments within the child welfare services (between 2 and 25 years). They worked at local child welfare offices in seven different-sized municipalities, including both rural areas and bigger cities, with between 10 and 360 000 inhabitants.

The interviews, were held online over video conference programs, conducted between February 2022 and March 2023 and lasted between 1 and 1.5 hours. The interview guide covered background information and the following areas: (a) the boundaries of responsibility in assessment of young people with a problematic substance use, (b) knowledge of sexual health and sexuality, (c) the ability to identify needs for care, (d) confidential conversations, (e) integrity, and (f) operational support within the child welfare system.

Analysis

The interviews were analysed using thematic content analysis, inspired by Braun and Clarke (2006), and the analysis was performed through six different steps. First, the first author transcribed all interviews verbatim. Thereafter, the transcripts were read through, and meaning units were identified in several rounds of coding and re-coding. To ensure a shared understanding of the coding, two interviews were closely examined within the author group, which confirmed a consensus on the initial codes. The subsequent analysis involved the first author revisiting the coding scheme to categorise relevant codes in subthemes and themes. This process involved moving between the original coding and the three levels of thematisation as various analytical patterns emerged over time. All authors then agreed on the final thematisation.

The identified codes were used to construct three different sub-themes – Sexually vulnerable girls; Boys as perpetrators; Unseen LGBTQ + youth – framed by a main theme; The heterosexual matrix as an interpretative framework for evaluating problematic substance use. The quotes used are mainly chosen because they represent consistency and tensions within the three sub-themes. Since the analysis was conducted inductively, the theoretical concepts the heterosexual matrix (Butler, 1990; 1993) as well as testimonial and hermeneutical injustice (Fricker, 2007) will be presented and applied in the discussion section. No clear patterns related to the social workers’ personal characteristics (age, years of experience, size of the municipality where they worked) emerged. Consequently, these factors have not been further explored.

Ethical considerations

All informants received written and verbal information about the study, including information about the possibility to withdraw their participation. They also received information about the first author’s specific role – as a Ph.D. student and as a concurrent child welfare worker – because he was the researcher conducting all interviews. The aim of this transparency was to mitigate any potential power imbalances that otherwise could have risen in the interview situation. None of the informants expressed any concerns about the dual role of the first author. Instead, many stated that it was beneficial to meet a researcher well-versed in the daily operations and challenges of the child welfare services. The study received approval from the Swedish Ethical Review Authority (2021-05820-01).

Results

Sexually vulnerable girls

The social workers highlighted that girls with a problematic substance use are often situated in a vulnerable life situation, usually because of concurrent neuropsychiatric difficulties or mental illnesses. They reiterated that reports of concern regarding girls with problematic substance use often includes a specific concern about sexual vulnerability, and they stressed the importance of including questions about sexuality in assessment interviews with most girls. However, these questions mostly seem to focus on the psychosocial aspects of problematic substance use, for example, how girls handle the presence of boys in risky environments such as parties, hotel rooms or on the streets. Discussing physiological aspects of substance use, such as acute substance craving and its connection to sexual health issues with girls was not as common, even though these aspects were attributed to a higher risk of girls being exposed to sexual violence. The social workers also reflected on how young individuals who are deeply entrenched in their substance use lack the capacity to reflect on sexuality issues, particularly during acute substance cravings or while under the influence of substances.

One of the informants, Emma, emphasised how she had experienced the investigation context as an opportunity for enabling vulnerable girls to, often for the first time, reflect on their past sexual experiences together with an adult:

Well, not that they would admit that they have been subjected to [sexual] abuse, but I think that it is a defence, that it is very difficult to realize that you have been subjected to abuse. So, if you bring up, for example, that it was stated in a report that they were in an environment that was inappropriate, eh, and where it also emerged that they had sex in some way, when you bring it up, it can be very much … Like, yes, but laughing: ‘Yes, but so what? What does it matter?’ I also get the feeling that they are testing the reaction, that they want to see my reaction, ‘Is it okay or isn’t it okay?’ That they don’t know if they have been subjected to abuse, but they want to see if I react to it. (Emma)

Emma's statement demonstrates how the social workers managed the temporal constraints within the investigative context by utilising the assessment interview as a form of intervention in itself. However, like other informants, Emma mainly utilised these opportunities to address issues of victimisation concerning sexual violence. In some instances, they also emphasised the risk of contracting sexually transmitted infections (STIs) or an unplanned pregnancy, but they did not use these investigations to encourage discussions about substance use and associated sexual experiences and encounters. In other words, the social workers did not give significance to young girls having a different view of themselves, their sexuality, or their sexual experiences than the social workers’.

While the informants primarily focused on discussing the risks of sexual exploitation, this does not necessarily imply that they believed that they, or the child welfare system, was responsible for working with girls presumed to be victims. They repeatedly emphasised a clear responsibility to support girls who were victims of sexual violence by filing a police report, but did not necessarily view it as their role to investigate these issues any further or to delve into other sexuality related issues. Most of the social workers argued that addressing the victimisation of sexual violence should fall under the purview of treatment elsewhere, such as within child and adolescent psychiatry. This was attributed to girls’ general psychosocial state, putting them in vulnerable situations, and to that experiences of sexual violence can lead to more severe psychosocial and psychiatric consequences. This line of reasoning also presented a dilemma as girls with problematic substance use often had limited access to psychiatric interventions. The social workers explained this by pointing out that the healthcare system often argue that problematic substance use hinder psychological assessment and treatment:

I also know that then they will not be allowed to enter anywhere else, because as long as there is a problematic substance use, that is what becomes so complex for them. If there is a problematic substance use, the health and medical services do not want to take them on, frankly speaking. You have to work with it [the problematic substance use] first. And that’s what I mean: what function does the behaviour serve? Is it based on an abuse that you have this behaviour or do you have this behaviour because you … (Linda)

Linda’s statement, like Emma’s, shows yet another strategy that several of the informants employed to address the presumed care needs of vulnerable girls. Despite expressing occasional doubts about whether the child welfare system actually have the competence needed to handle issues of sexual vulnerability, they still referred the girls with problematic substance use for further interventions within the system. This was often stated as being necessary due to the girls’ reported vulnerability. However, the social workers often also tried to direct these girls to a third community agency in addition to the child welfare system and the child and adolescent psychiatry, namely the youth clinic. Many of the informants saw the youth clinic (a sexual health clinic for young people) as the primary community agency for engaging in discussions with young people regarding various aspects of their sexuality, including sexual victimisation. Therefore, the social workers believed that referring girls would ensure they would receive the right support in the right place, while also safeguarding girls’ sexual integrity in relation to the child welfare system.

Boys as perpetrators

Regarding boys with a problematic substance use, the social workers stated that the police was the primary outsider agency that reported sexuality-related cases, most often cases of boys as perpetrators of sexual violence. Again, they described a division between the physiological and psychosocial aspects of problematic substance use and related sexual experiences. Most informants tended to associate boys’ substance use with a manifestation of boys’ sexual violence, and a few included boys’ inability to manage their consumption of violent pornography in their reasoning. However, boys’ potential exposure to sexual violence and other types of sexual vulnerability was rarely mentioned in the reports of concern received by the social services:

We don’t hear very much about boys’ destructive relationships based on the fact that they are vulnerable. Erm. And when it comes to the boys, it’s probably more, yes, reports about [boys being] suspected [for] rape and so on, and it often involves narcotics. (Vanja)

While issues of sexual vulnerability and victimisation were a risk factor attributed mainly to girls, both in incoming reports of concern from others (e.g. the police) and in their own subsequent assessment work, a few social workers emphasised how boys can be subjected to sexual violence. Some had even handled such cases, although they did not specifically connect this to boys with a problematic substance use. Some reasoned that in many cases, societal norms likely hinder boys’ own understanding of their vulnerability:

I think it’s deeply ingrained in society as a whole: ‘Boys will be boys, and they’re not vulnerable, they take what they want, they … .’ I don’t think people consider boys’ sexuality to be problematic in the same way as girls. And that’s also something we need to work on! I think boys might sometimes do things that they’re not comfortable with afterwards, and boys, I don’t generally think that fathers are good at talking to their sons. (Jonna)

Although the social workers primarily focused on boys’ delinquent behaviours, there were a few accounts of how they took advantage of the opportunities within the assessment to address different sexual experiences among boys. Some asked the boys if they had done anything under the influence of drugs that they regretted later, but they rarely asked questions about ambiguous, or positive, sexual experiences. Consequently, they put a greater responsibility on boys, compared to girls, to raise any concerns about their sexual health and sexuality.

The social workers predominant focus on boys’ violent behaviours sometimes resulted in interventions, since this is a central area of responsibility for the child welfare services:

For example, we have a great programme called [name of the intervention] that works extensively with criminality, and I had a boy who was convicted of a sexual, well, a sexual offense and had other criminal tendencies, and then I included [in the assignment] the task of talking about sex and consent and respecting others’ bodies and so on. Well, they weren’t used to working with that [within the intervention], but it’s also a crime, and they were not opposed to addressing it. (Matilda)

Adapting existing treatment to include sexuality-related issues was achieved by Matilda, but this required the question of sexuality to have already been raised in the assessment concerning a specific boy. Overall, sexuality was seldomly mentioned in the reports of concern leading up to social work investigations of boys, and it was uncommon for the social workers to raise it in their subsequent investigative work. Thus, Matilda's example highlights an exception.

Unseen LGBTQ + youth

A recurring theme when investigating young people’s challenges and associated support needs related to a problematic substance use was their gender identity. That is, there was a prevailing distinction between cis-gendered boys and girls. Many informants problematised this, but few had any concrete solutions for how to grant an equal assessment process. Nelly was an exception:

I usually think like this: before making a decision, uh, reporting a concern, reporting to the police, whatever you’re going to do, we sit down, we change the gender. Like, we switch parents, and we get the class aspect involved. We change, erm, ethnicity … If you come to the conclusion, would we have done the same if this was a doctor’s kid? Or vice versa? To see our own prejudices. And if it happens, that we think that this is how we would handle it regardless, yes, then it’s right, then that’s what we have to do. (Nelly)

Accordingly, the quote above could be interpreted as proposing a strategy for conducting equal assessments, even though it does not ensure equitable investigative practices. This lack of equitable strategies that acknowledge non-heterosexual and gender diverse youth with problematic substance use was described by some informants. It was seen as complex and requiring knowledge that most social workers lacked. Olivia was one of the few informants who highlighted the vulnerable living conditions of LGBTQ + youth. She pondered on how this might contribute to the development of substance use problems:

If we take sexuality, for example, if you think, that I feel that I’m falling in love with the same gender, sort of. The fact that you start to follow those paths is not what makes you, perhaps, that you suddenly start abusing because you are in love with the same sex. It’s what happens around you. How to identify with others. You may feel alone, you may feel left out, you may feel, um, different, abnormal – all these thoughts! (Olivia)

Olivia also talked about how her knowledge of LGBTQ + people’s living conditions was largely acquired outside of her work. In contrast, two other informants talked about how their local social work office had become LGBTQ certified. This was a somewhat two-sided experience because this initiative was not tailored to the organisational means of the child welfare services:

We became LGBTQ certified while I was working there. If it was four or six half working days to talk about LGBTQ issues, history, and so on. It wasn’t bad by any means, although it did, it took a lot of work, but it was a great idea. However, time was not spent talking about sexuality among young people in general. It’s a bit strange! We come across more, or maybe you didn’t ask the question, but I can assume that we come across more heterosexual young people than we come across LGBTQ young people […] and yet the educational investment is directed towards LGBTQ, uh, and the one does not actually exclude the other. (Nils)

Nils’s reasoning suggest that the gender identity and sexual orientation of young people have become an increasingly visible issues in society, reflecting a growing need for knowledge within the child welfare system as well. However, Nils primarily found that the education efforts within his workplace had entailed a rather general perspective on subjects such as LGBTQ + history and the structural life conditions of LGBTQ + individuals. Indeed, these efforts involved discussions on what a professional approach to this target group might look like, but did not make any clear connections between LGBTQ + issues and topics that were otherwise considered particularly relevant to the child welfare services. For instance, these efforts did not address the potential links between the life conditions of LGBTQ + youth and problematic substance use, similar to what Olivia reasoned about above. Thus, Nils’s description illuminates an overall lack of knowledge of sexuality issues within child welfare services, regardless of clients’ genders or sexual orientations. Overall, the informants, including those working in LGBTQ-certified offices, lacked LGBTQ + affirmative strategies in their assessments of young people’s problematic substance use. When having this competence, it often relied on knowledge and experiences of individual child welfare workers, drawn from contexts outside the formal child welfare system.

Discussion

When exploring how child welfare workers assess sexual health among young people with a problematic substance use, and whether, and if so how, gender and sexual orientation was addressed, three sub-themes emerged: (1) Sexually vulnerable girls, where girls’ sexual health and rights are understood in relation to antisocial traits, risk exposure, and related support needs; (2) Boys as perpetrators, where boys’ sexual health and rights are made invisible in the shadow of violent behaviours; and (3) Unseen LGBTQ + youth, where the lack of knowledge about LGBTQ + youth is articulated and thus making investigative work complex. The three sub-themes can be summarised under an overarching theme: The heterosexual matrix as an interpretative framework when investigating a problematic substance use.

The result shows that the social workers focus on cis-girls and cis-boys, with an emphasis on victimisation and perpetration of violence in heterosexual relationships. That social workers often discussed aspects of sexual violence is not surprising, as extensive substance use often correlates with sexual (ill) health, such as experiences of victimisation (Frøyland et al., 2023). However, the interviews revealed a relatively one-sided analysis in which girls were primarily attributed antisocial behaviours. Social workers believed these behaviours could either put girls in danger or expose them to exploitation or sexual assault. This aligns with previous research on assessments in child welfare, where girls have not only been seen as vulnerable but repeatedly described as irresponsible for their own lives (Östberg, 2010). Consequently, girls are judged to need support via the public sector because they are considered as lacking the ability to protect themselves from further victimisation (Grim & Persdotter, 2021; Östberg, 2010). In contrast, boys tend to be attributed agency in the assessments; they are seen as competent enough to be responsible for their own behaviours and life situations (Grim & Persdotter, 2021; Östberg, 2010). Thus, boys’ potential experiences of victimisation often become invisible unless they disclose them voluntarily or if their victimisation becomes apparent to the case workers in some other way. Boys’ victimisation often occurs in heavily intoxicated and tumultuous situations, and they tend to describe the issue of guilt in violent situations as complex, making it difficult for them to voluntarily disclose or even understand that they carry experiences of victimisation (Stefansen et al., 2021). Therefore, addressing boys with experiences of violence requires the social worker to have an awareness of the heterosexual matrix, that is the social hierarchy dividing humans into groups of stereotypical men or women, who can only find wholeness when they are heterosexually united with each other (Butler, 1990; 1993).

That informants focus on sexual health in terms of violence could be understood in light of the globally acknowledged issue of gender-based violence (Starrs et al., 2018). There are valid reasons for child welfare workers to concentrate on addressing girls’ vulnerability to sexual violence. However, relying on structural explanatory models or prevalence also presents challenges when trying to understand individual youths’ life situations. For example, that the informants repeatedly described how girls with a problematic substance use tend to lack the ability to see and understand their own living conditions suggests that the assessments are characterised by testimonial injustice – ‘wherein a speaker receives an unfair deficit of credibility from a hearer owing to prejudice on the hearer’s part’ (Fricker, 2007, p. 1). Indeed, the informants incorporate a significant structural understanding of gender-based violence. At the same time, they often seem to allow their own perceptions of young girls’ potential vulnerability to take precedence over the girls’ own statements on diverse sexual experiences.

Boys’ experiences of violence and their sexual health needs appears to be a question of hermeneutical injustice. This type of injustice is defined as ‘the injustice of having some significant area of one’s social experience obscured from collective understanding owing to hermeneutical marginalization’ (Fricker, 2007, p. 158). Failing to see boys’ sexual health needs can be related to social workers’ lack of in-depth knowledge about how boys’ experiences of sexual violence tend to manifest. This is particularly noteworthy because boys encounter professionals focusing on SRHR to a significantly lesser extent compared to girls, e.g. as boys do not perceive themselves as a designated target group for youth clinics (Pettersson & Baroudi, 2023). Consequently, child welfare workers have a unique opportunity to address boys’ sexual health as well as their different sexual experiences, including matters of sexual violence.

The results show that social workers’ understanding of problematic substance use, on the one hand, and sexuality and violence, on the other hand, was connected to youths’ binary gender identities. Not all youth align with traditional gendered repertoires, and understanding LGBTQ + youth needs appeared to be difficult. It was sometimes even seen as beyond the scope of knowledge within the child welfare services. Interestingly, even the ‘LGBTQ certification’ received by the child welfare offices where some of the informants worked did not cover the specific challenges of LGBTQ + youth concerning problematic substance use and sexual health. This raises questions about what kind of knowledge these certifications can, or should, provide (see, e.g. Smolle & Espvall, 2021). Similar to the perception of heterosexual boys’ experiences of violence, the connection between problematic substance use and non-binary gender identities or non-heterosexual orientations appears to be yet another aspect of hermeneutical injustice within the child welfare system – LGBTQ + youth appears to be unseen. This finding echoes a general lack of basic knowledge within social services on the health and living conditions of LGBTQ + youth (see, e.g. Kaasbøll et al., 2022; Lindroth et al., 2024).

The national SRHR strategy outlines that work with young people should not only focus on violence but also include aspects such as STIs, unplanned pregnancies, and sexual safety online (Public Health Agency of Sweden, 2020). Such issues were brought up by some informants, often reformulated to become inquiries about violence (e.g. girls being ‘unknowingly’ exploited to send nude pictures) or referred to as healthcare issues. As healthcare issues, they could be seen as the responsibility of other societal agents (e.g. testing for STIs or an unplanned pregnancy at a youth clinic as well as treating trauma within the child and adolescent psychiatry), not the child welfare service. Accordingly, implications for practice include raising social workers’ knowledge regarding SRHR and problematic substance use, as well as incorporating intersectional perspectives (e.g. gender and sexual orientation) to enable well-targeted assessment processes. A greater understanding of SRHR among social workers could potentially stimulate more in-depth discussions between professionals regarding responsibilities and possibilities to address youths’ substance use and sexual health beyond the limiting perspective of gender, and gender-based violence. In such educational endeavours, we consider it essential to include young people as co-creators (Hall, 2020).

Study strengths and limitations

The findings provide insights into experiences among a selection of child welfare workers, and they may be transferable to settings that have similar social work assessments and views on youth sexuality. To the best of our knowledge, research concerning whether and how social workers base their assessments of young people with substance use problem and their sexual health on different social categories has been lacking. In light of this, comparable studies are also lacking. However, the results seem to align with previous research on assessment processes (not specifically concerning problematic substance use or sexuality) within the child welfare services, where the heterosexual matrix constitutes the protruding interpretive framework (see e.g. Östberg, 2010; Pettersson & Andersson Vogel, 2023).

Conclusion

Considering the known connections between problematic substance use and sexual ill health, it was surprising that the interviewed social workers did not specifically address this when conducting child welfare investigations. The findings revealed that the heterosexual matrix functions as an interpretative framework, that is; child welfare workers adhered to normative perceptions of cis-gendered and heterosexual youths in their assessments. Understanding and dealing with young people who do not conform to societal norms of gender and sexual orientation, such as LGBTQ + youth, was described as complex due to lack of basic knowledge of how these norms may relate to the sexual health and life situations of young people.

Declaration of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Swedish Research Council for Health, Working Life and Welfare.

Notes on contributors

Robin Björkas

Robin Björkas is a MSc in sexology. Björkas divides his time between PhD studies in social work at Malmö university, Sweden, and his work as a child welfare caseworker at the municipality of Gotland, Sweden. His research interests involve issues related to child welfare services, youths and SRHR.

Torkel Richert

Torkel Richert is a PhD in social work and holds a position as associate professor at the Department of Social Work at Malmö University, Sweden. Richert’s research concerns drug markets and drug policy, social work, treatment, and harm reduction services in the field of addiction, everyday life, vulnerability, and risks for people who use drugs, as well as drug addiction and affected family members. Richert works as a teacher and course manager on the bachelor’s and master’s programs in social work and on the master’s program in sexology at Malmö University.

Malin Lindroth

Malin Lindroth is a PhD in health and society, and associate professor in health and society, orientation in sexology and sexuality studies at Malmø university, Malmø Sweden and associate professor, orientation health promotion at OsloMet, Oslo, Norway. Her research is on different aspects of sexual and reproductive health and rights, SRHR, and she teaches in with various master's courses in sexual health.