Supporting children and young people who may have experienced child sexual abuse - clinical pathway: consultation analysis
An analysis of the responses to the consultation on the draft Clinical Pathway for healthcare professionals working to support children and young people who may have experienced child sexual abuse.
Section 6: Final Comments
|ID.||Consultation comment||Clinical pathways subgroup response|
|641R-N||[Our organisation] thinks that it would be helpful if an agile review of the pathway could be developed. We think this will be required as a result of the re-write of the Child Protection Guidance 2014 and the update of the GIRFEC National Practice Model. The development of a Scottish Barnahus will also impact on the clinical pathway for children in a very real and positive way.||The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
The Pathway is considered ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context.
|641N-H||It is essential that the pathway is informed by those who support children and young people with lived experience of sexual abuse and therefore we suggest that relevant organisations such as crisis centres, NSPCC, Barnados, SCLD, Zero Tolerance etc are adequately consulted. It would also be useful to know how this policy might link up with other protection policies such as the disclosure of female genital mutilation.||The Pathway has benefitted from third sector involvement.
The Pathway now includes information on Female Genital Mutilation.
|64ME-4||Tackling Child Sexual Abuse by Dr Sarah Nelson – is vital and essential reading for this arena. Most practitioners in the field have not read it and that should not be the case. Detailed study of this book is imperative. Dr Nelson is a former advisor to the Scottish Government. Center for Judicial Excellence – Fact Sheet||Noted.|
|641Z-W||Many children and young people feel they have consented to sexual activity and it is years later they realised what the grooming process was. There should always be a consideration of possible child protection for a child under 16 and under 18 with additional vulnerabilities||Noted.|
|641H-B||Important to cover sexting/sending and recivieing naked images as so common and is a criminal offence||The language in the Pathway is aligned with the draft revised National Child Protection Guidance, which is currently out for public consultation. It now includes cyber enabled abuse.|
|641U-R||There is a significant lack of resources within the NHS for children who have experienced trauma or sexual abuse/ assault. Currently in the area I work there are no resources for this purpose for under 12 year olds. There are resources from voluntary agencies for 12 years and over who have experienced sexual assault. These agencies also provide some support to family. They do not provide direct support to the child. There is limited resource from voluntary agencies to support other professionals working closely with a child on a consultation basis.||The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s). However, it is not prescriptive about how that should be done and cannot determine the allocation of resources.|
|6418-U||There are many other consultations and work streams (e.g. Joint Investigative Interview process, Barnahus Model, review of National Child Protection Guidance) recently or currently being undertaken. This can possibly cause some confusion and/or duplication of work. The documents/work streams should have clear links with each other, noting where pathways cross over or take precedence. It is unclear why this pathway is required – what led to it being developed? There is not a sense that the child is central to this process. To this end, the pathway needs to incorporate the UNCRC at least. It also doesn’t reflect the current and real practice of multi-agency/partnership working that already happens in child protection processes.||The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.|
|6412-N||In order to ensure the main aim of the document is met i.e. a “resource to outline the process for the healthcare response to disclosures by children and young people of sexual abuse of any kind” then front line clinicians (in this case dentists and their teams) should receive training on what to do when they receive a disclosure and how to act and react. This will have a pivotal effect on the rest of the pathway, and it is vial that this step is identified and included.||Advice received from the Children and Young People Expert Group and the Steering Group for the revised National Child Protection Guidance is that education, guidance and support on child protection is available from employers (or voluntary organisations/charities in the case of volunteers). The advice is that it is not necessary and may be unhelpful to duplicate material already available in this area.
Training for wider health professionals is out with the scope of the pathway.
|6416-S||Given the current focus on Female Genital Mutilation it may be helpful to make specific reference to this within the document as well.||The Pathway now includes information on Female Genital Mutilation.|
|6414-Q||Broadly, this is a helpful document. Nationally the resources should be available in every area to provide services to the highest standard and this pathway should be adopted so it is disappointing to note that the opening introduction states that it does not constrain NHS or Police Scotland – so it could just be ignored.||The Pathway is intended to describe best practice in line with current relevant legislation and guidance to assist practitioners in providing care and support to children and young people who have or may have experienced sexual abuse.|
|6413-P||We believe an EQIA should be carried out as we are concerned the clinical pathway does not adequately cover the needs of children and young people with disabilities. BAME, LGBTI, Disabled and looked after children will all have specific, intersectional and differing needs that are not covered in the pathway, e.g. the
child should be able to choose the sex of the practitioner carrying out their examination and there may be particular reasons why this might be important to a victim of sexual abuse. Also for some disabled children or young people it may be necessary to have specialist equipment such as a hoist.
We believe there needs to be overt reference to adopting a human rights based approach and to supported decision making as children and young people whohave been sexually abused need to know and understand their rights and be supported to make decisions about how they wish to proceed.The document also needs to make reference to some children and young people having a right to access independent advocacy and recognising how it cansupport them and make the process of disclosure and evidence gathering easier and smoother.
Any information produced needs to be accessible and easy to read and age appropriate for children and young people.
|An EQIA has been carried out on the Pathway.|
|64SM-J||Clear sections and good use of resources and links||Noted.|
|64SV-U||[Our organisation] would like to point out that children with disabilities and augmented communication are less likely to have access to victim support services. We would finally like to highlight that in reality there is a danger that children and young people with disability who experience abuse can be hidden in plain sight. That is why it is so important to make sure that information about children with disabilities and abuse is clearly and obviously included in the pathway||More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations/information sharing etc in the Pathway with hyperlinks to more detailed guidance if required.
The Adults with Incapacity Act and the Adult Support and Protection Act are now included within the pathway for consideration when appropriate. The limits to confidentiality when the person or others are considered to be at risk of ongoing harm are now included.
The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that although the young person is on the adult pathway, the requirements of public bodies related to corporate parenting and/or Getting It Right For Every Child (GIRFEC) must be considered.
|64SR-Q||Overall it reads very well and is a practical guide that people should find useful. Various sections of it are topical now but will become dated and need removed. Others will need to be updated as things change. Therefore important there is a 'live' version of the pathway owned by an organisation who update it regularly possibly annually.||The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.|
|64SY-X||The definition of the age of the child has raised some queries, specifically if it should be 18 if in full time education or with additional support needs or vulnerabilities. However 16 is the legal age limit for consensual sexual intercourse. From a medical perspective, current paediatric resources may be significantly stretched if aged over 16 included. Is there any information about numbers of 16-18 year olds seen annually currently by adult services?||The Pathway is applicable to the care of children and young people up to 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) who have disclosed sexual abuse of any kind.
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
||There is now more information and context in the Pathway on trauma informed care and adverse childhood experiences.|
|64SW-V||Overall I found the pathway straightforward and accessible. It is largely representative of practice in Angus but it is useful to have the pathway laid out clearly as it is here.||Noted.|
|64SB-7||Throughout the document, there are references to underage sexual activity and sexually harmful behaviour displayed by young people. As with other aspects of this guidance, neither of these issues receive sufficient attention for the reader to fully understand the context of these complex matters (which are not necessarily equivalent to child sexual abuse) and there is a danger that their inclusion serves to undermine the focus on child sexual abuse.||These issues are now addressed in more detail with reference to the relevant legislation.|
|64SJ-F||The pathway provides numerous sources of very important and critical information for practitioners. It may be useful to also provide information and weblinks to additional resources which would enable a self-assessment of services, particularly relating to whether the Getting it Right for Every Child practice model is being fully implemented and if the requirements of a ‘trauma informed’ service are being met. The Children and Young People (Scotland) Act 2014 define a child as someone who has not attained the age of 18. As included above re clarity of what legislation should be followed for 16-18 year olds, the Adult Support and Protection (Scotland) Act 2007 can be applied to over 16 year olds and if so these young people would not be considered under child protection processes. This needs to be clear for practitioners and suggest that the C&YP (Scotland) Act 2014 definition of a child be applied – up to 18 years old.||There is now more information and context in the Pathway on trauma informed care and adverse childhood experiences.
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation
|64SH-D||We believe that section 4 of the document, on which no consultation questions are asked, is key to ensuring that medical practitioners have an up-to-date, relevant understanding of CSA, which enables them to identify CSA and act in the best interests of those who have or may have experienced it. We would suggest the following amendments: 4.1 As noted above, we believe that the clinical pathway should be applicable to all children and young people up to the age of 18. 4.2 We believe that a simple, accessible definition of child sexual abuse would be most useful here. The WHO definition used does not offer a great deal of clarity and is not widely used in policy and practice around CSA in Scotland. It is very important for the definition to extend to subtypes of child sexual abuse, including child sexual exploitation, online child sexual abuse, grooming, and contact/non-contact abuse. Alternative definitions include: • Guidance for Child Protection (2014) (currently under review: “Sexual abuse is any act that involves the child in any activity for the sexual gratification of another person, whether or not it is claimed that the child either consented or assented. Sexual abuse involves forcing or enticing a child to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of indecent images or in watching sexual activities, using sexual language towards a child or encouraging children to behave in sexually inappropriate ways (see also section on child sexual exploitation).” • NSPCC definition (available in full at: https://learning.nspcc.org.uk/child-abuse-and-neglect/child-sexual-abuse/) which has been widely cited by other medical bodies (cf. https://www.rcoa.ac.uk/safeguarding/child-protection/child-sexual-abuse) It may be useful for this section to draw a distinction between children and young people, highlighting the differences in the most common forms of abuse within different age groups. The list of ways in which CSA may present (currently at Section 5.1) should be moved to 4.2, and retraction of a disclosure should be added. To avoid referring to children as perpetrators, the final bullet point should be rephrased to say “a child exhibiting unexpected, problematic or harmful sexual behaviour may have exhibit this behaviour due to their own experience of sexual abuse” We do not believe that the paragraph suggesting that the dynamics of child sexual abuse differ from adult sexual abuse is helpful or necessary. The information on the Sexual Offences Act should be included in Section 4.5 rather than 4.2. 4.3 and 4.4 Sections 4.3 and 4.4 should be amalgamated. The information in section 4.4, on the possible impact of ACES, should be rewritten to be clear that child sexual abuse is an established Adverse Childhood Experience, and that experiences of trauma can impact negatively on brain development, behaviours and mental health, whilst acknowledging that impact is very dependent on the individual circumstance of the child and crucially, the support they have around them. This should precede the information on trauma-informed services in 4.3, making explicit that the reason services must be trauma informed is to take cognisance of this possible effect, and to avoid anything which could be re-traumatising for the child/young person and create a space for recovery. 4.5 This section is titled ‘legal context’, but it may be more useful to frame this section explicitly in terms of what a medical practitioner is legally required to do in different situations, with the focus on practitioners’ actions rather than the full complexity of the law (references could of course be provided for those who wish to have a fuller legal understanding). The language in this section could be simplified and clarified: the term non-consensual activity should be replaced with sexual abuse to avoid undue complication for medical practitioners around the complexity of consent. So, for example, the second paragraph should read that information must be passed to police about any child or young person under 13 who has been engaged in any sexual activity, any child or young person who has disclosed any form of sexual abuse (including sexual exploitation), or where there is suspicion or concern that this child/young person may be experiencing abuse. Where a child/young person discloses any sexual activity with an adult, Child Protection processes should be followed. It is important to note that due to the grooming process, children and young people can be made to believe they have consented or are to blame for their abuse, or have been deceived into believing that it is not abuse. Professionals are still required to respond to instances where there has been an adult involved as a child protection concern, regardless of whether the child/young person can currently understand the situation as abusive or not. In cases where there has been reported or suspected sexual activity with another child/young person over 12, practitioners should exercise professional curiosity in terms of gauging children/young people’s understanding of consent and ‘free agreement’, and the circumstances surrounding the relationship between the young people. If it is disclosed or suspected that this relationship may be abusive, professionals should again use a child protection response. Where a child over 12 is disclosing consensual sexual activity with another child over 12, this should be closely monitored and appropriate supports offered.||The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
The definition of CSA from the draft revised National Child Protection Guidance (which is currently out for public consultation) is now included in the Pathway.
The UN Approach to Justice for Children outlines children’s rights in relation to the justice system. These rights apply both to children in conflict with the law and those who are victims of crimes. They are grounded in the United Nations Convention on the Rights of the Child (UNCRC) and its principles of:
Article 34 of the UNCRC requires that states protect children from all forms of sexual exploitation and sexual abuse. Ensuring that perpetrators of sexual abuse are successfully prosecuted is an important part of fulfilling those obligations and ensuring that robust evidence is collected, including via forensic medical examinations is essential. However, article 39 of the UNCRC also places an obligation on states to “promote physical and psychological recover and social reintegration of a child victim of any form of neglect, exploitation or abuse…” . The current consultation does not address this and instead focusses solely on the process of forensic medical examination. Whilst we understand that legislation on this issue is complex, we would prefer this clinical pathway to be considered as part of a holistic clinical pathway which also addressed the recovery and support needs of children who are victims of sexual abuse. Holistic support for children who experience sexual abuse We believe that children’s rights, particularly given the Scottish Government’s commitment to incorporation of the UNCRC into Scots law, would be better served by proposals which were grounded more firmly in children’s rights and drew on international best practice as demonstrated by the Barnahus model. The Scottish Government has committed to exploring the introduction of the Barnahus model of children’s centres, which provide a holistic and child-centred context for the investigation of sexual abuse and the continued recovery of child victims. We are disappointed that, despite reference to the Barnahus model in the introduction, this consultation places the proposals within current operational contexts and in particular, as outlined in the pathway illustration on page 14, continues to separate the health service from other agencies’ involvement. Finally, we are deeply concerned that the proposals do not include all children under the age of 18. The protective rights outlined by the UNCRC apply to all children up to age 18 and article 2 requires that states parties “respect and ensure the rights set forth in the present Convention to each child within their jurisdiction without discrimination of any kind” . On page 22 of the consultation document it is stated that article 1 allows the setting of a lower age of majority under law. Whilst this applies to empowerment rights, such as the right to vote or to instruct a solicitor, it is not the case that states may choose which children are entitled to protective rights, such as those in articles 34 and 36 of the UNCRC. The existence of the UNCRC is based on the premise that all children under the age of 18 have vulnerabilities, as a result of being a child, and therefore require additional protections to those provided by other human rights treaties. The protections proposed by this consultation should therefore be extended to all children under the age of 18 and we feel there would be a case for extending them beyond 18 for those with disabilities and other specific vulnerabilities. Recommendation We recommend that:
|The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation
The Pathway is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context.
|64ST-S||Main comments are that this document is too high level and discusses what should be done but there is nothing about how it should be implemented - is there an assumption that each Health Board follow this up with a local policy on implementation? If so them this should be added. Also there is nothing about resource / funding for the trauma informed services discussed in the document.||Local implementation of the Pathway is the responsibility of the local health boards.|
|64SU-T||Yes. This could have been really something. It really could have been - even in the same league with some of the best child protection systems on this planet but this, this right hear, is yet another Scottish Government failure like the Scottish independence bid was a failure because most of the politicians in government are failures. Due to a combination of inept and inconsistent law, politics before persons and the propagation of unverified theory this is going to lead to more harm than good. I am dismayed I can not support this. I would have loved to absolutely loved to. Trust me because right now Scotland's children in particulate are perhaps one of thee most endangered groups in North Western Europe in ways this government could not even begin to mentally process and still remain sain let alone comprehend over a consultation response. This governments obsession with abortion and targeting religious persons and the family unit is what is stop it from receiving the dire support from the public and international community that it needs in order to progress ! I have been both falsely accused in an incident of claim by police they then subsequently admitted too was false and also a victim to such abuse when I was younger as well. I do have sadly, lived experience of this sort of thing and its very hard to prove but sacrificing democratic legal protections designed to defend those falsely accused is far too great. I am just sorry to the children of Scotland for there Government loosing there independence, EU membership and futures were we could have advanced this nation to a just society for them. I want to say another thing one thing that really sticks out hear is the statement that being a victim of abuse could actually be a sign of that person being a child abuser - talk about victim blaming and being problematic Scottish Government ! This is an assumption based on the pet criminological theory that victims themselves could become perpetrators due to the abuse cycle certainly in so much as some cases even known to the author this certainly can be true but its not true in the majority cases. This theory is being more and more debunked by academics upon research that seems to show this is actually not water-tight after all as most victims are good people who have been victimised living very hard life's and while they may due to there experience go on to commit crime very few actually go on to commit the same crime that was committed to them out of sheer loathing of there abuser and not wanting to be anything like them.||Noted.|
|64SD-9||[Our organisation] note that there is little guidance or detail in the management of forensic samples. Further guidance on forensic sampling and sequence, including reference to the Recommendations for the Collection of Forensic Specimens from Complainants and Suspects (FFLM 2019) should be included. https://fflm.ac.uk/publications/recommendations-for-the-collection-of-forensic-specimens-from-complainants-and-suspects-3/ […] notes that there is a lack of supporting information or guidance on grooming and abuse perpetrated by children and young people - who may themselves be the victim of sexual abuse. This challenging presentation is often encountered in practice and there may be an opportunity for the Pathway to raise awareness of this, and provide guidance on management of disclosures of abuse by children and young people who are themselves victims.||The language in the Pathway is aligned with the draft revised National Child Protection Guidance. It now includes grooming and CSE.|
|64S7-V||General points Positive that it highlights the systemic aspects and different procedures and roles that people have. Positive that primary purpose is the health and wellbeing of the child in a holistic manner and secondary is collecting forensic evidence.||Noted.|
|64S4-S||No mention of the third sector or CAHMS, or other areas of support. May be embedded in support documents, but you'd need to go through and read every link, which people obviously might not do.||The third sector and requirement for support with mental health are now included in the Pathway.|
|64S4-S||Talks about non-recent disclosures, but no reference to the adult part of it. E.g if this is an adult who is presenting. The challenge is when an adult presents with a disclosure of non-recent abuse, it takes you back to being a child again, and you lose your sense of 'adult' experience and assertiveness. Maybe reference to some adult policies and procedures||This is covered in the Adult Clinical Pathway.|
|64S4-S||Is it intended as a procedural pathway, or to help people to work with children who have disclosed sexual abuse, or adults disclosing what happened to them as a child. It's a very medical model (although it is a clinical pathway) but suggest there should be a wider reach, as the medical model is not always the correct model. It references historical abuse because we are not good enough at finding ways to encourage them to come forward. This document doesn't take us any further, and we're stuck with CSA at the moment particularly around familial CSA, and we don't deal with it well enough at all.||Noted.|
|64S4-S||The pathway is based on disclosure, but we are aware that many child and young people we work with may never make a formal disclosure, even though we may have significant concerns about them. It felt to me that there is a small number of children and young people who would actually benefit from this. Sexual health services often work with people who have experienced sexual abuse, even if they don't make a disclosure, and they get that support. It should be broadened out.||Noted. However, the Pathway is intended to describe care and support within child protection procedures following a disclosure.|
|64S4-S||There's a real shift nationally towards different models and language (e.g Barnahus model), but this is not reflected in the document. E.g using 'management of health needs' rather than 'health and wellbeing'. There is an emphasis on 'doing to', and the person-centredness can get lost. Interagency child protection produces is a narrow chart.||The Pathway is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context.|
|64S4-S||The document might quickly be out of date, given ongoing work in relation to child protection guidance, joint investigative interviews, new health guidance etc.||The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.|
|64S4-S||The UNCRC and child right, not 'doing to' is not addressed.||The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.|
|64S4-S||It would be interesting to see the feedback from the CYP Expert Group, as it mentions in the document that feedback has been sought and changes made. What were their comments?||This has been incorporated into the updated Pathway.|
|64S4-S||Where does this sit alongside the principles and evidence base of the Barnahus? The children's rights, taking time, letting the child be at the centre, therapeutic way of working, trauma at the centre, relationship-building... all of this is missing in the pathway. This needs to be highlighted up front, and threaded throughout the document. Address the issue about whether the medical is being done for the child or for evidence-collection and court purposes. What are the priorities for health and the purpose of a medical intervention?||The Pathway is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context.|
|64MX-Q||Other agencies, collaborative and effective not sure. Doesn’t feel as collaborative. It is a clinical pathway, health focused. Quite process driven, more than just this bit – where is the bits about exploitation, needs to be identified, needs to be A&E, schools identifying those risk factors. There are several factors. Change it to pathways, multi-agency pathways as title? How children get to this point more quickly dependent on how we are identifying risk factors, sharing information – effective, people are sometimes reluctant to share information. Agencies can be defensive about sharing information. Feels multi-agency – doesn’t have that full collaborative, concerns full comprehensive agency, sharing of information. 1.5 Other documentation – supporting the signs guidance – sexual exploitation. References missing around exploitation in particular – some feedback to develop that a bit more. How we can work collaboratively. How does that work in terms of point of disclosure? Need for ongoing support and difficulty accessing, delays in examinations, healthcare in IRD. Pathways covers up to 16 years||The revised Pathway now makes clear that the care and support provided to Children and Young People who have experienced Child sexual abuse and non-abusing parent/carer(s) is multiagency and multi professional.|
[Our organisation] greatly welcome the creation of a specific care pathway for children and young people following sexual abuse. This is a critical development in supporting CYP’s highly distinct health and wellbeing needs, including their emotional health needs, to be met in the round following sexual abuse.
|The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.|
In section 5.2 – Clinical Pathway process/ IRD page 15
|The comment has been noted and the Pathway now contains reference to education attending IRDs when appropriate.|
|64MW-P||Child Sexual abuse should not be considered in isolation from all other forms of physical and emotional abuse and neglect. Therefore all services that provide a paediatric and forensic service must employ those who have a high level of skills in identification, assessment, and both multi-disciplinary and multiagency management of all forms of child maltreatment. 5 This should be clearly stated within the clinical pathway document.||Agree. The Pathway sits within the wider child protection context in Scotland which is now discussed in the document.|
|64MV-N||While welcoming the Scottish Government commitment to addressing the issues raised in the 2017 HMCIS report, we need to make sure that work to strengthen the clinical pathway for children and young people who have disclosed sexual abuse is considered within the developing work on the Barnahus approach, and takes full account of particular issues for children and young people around consent, the nature of child abuse and ACEs.||The Pathway is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context.
There is now more information and context in the Pathway on trauma informed care and adverse childhood experiences.
There is a problem
Thanks for your feedback