Publication - Consultation analysis

Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis

An analysis of the responses to the consultation on the draft clinical pathway for healthcare professionals working to support adults who present having experienced rape or sexual assault.

Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis
Section 1: General comments on the pathway

Section 1: General comments on the pathway

Consultation comment Project group response
1 There is a good choice of services and consent is required at every stage. Noted.
2 a) I have had a look at the clinical pathway that has been suggested and find it to be an excellent proposal. One issue I would wish to highlight relates to Care Homes. Many Offenders are getting to an age where they will require to be looked after in care homes. Equally many people who have no history of disinhibited Sexual Behaviours can start to exhibit such behaviour as a consequence of aging. It means that people in care home can become victims of sexual offences, where the offender may or may not have capacity and equally the victim also may or may not have full capacity. All in all a pretty dreadful scenario but one which still needs to be fully investigated. As time goes by I suspect such incident are likely to increase in numbers and it may be worth giving some though to the best way to deal with them. The Clinical Pathways Subgroup acknowledges that residents in care homes may be vulnerable; however, a national clinical pathway is not designed to be tailored to individual circumstances. Individual care home providers are required to put measures in place to minimise risk to residents.
3 In summary says person can be supported by advocate or carer. Use of word advocate not helpful. Do they mean an advocacy worker? What do they mean by carer? Clarity would be helpful. Wording amended to 'the person is entitled to be accompanied during any such discussion by a supportive person of their choice, for example a friend or carer’.
4 We would stress the importance for all staff involved in the pathway to have undertaken trans awareness training. Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual offences examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards.
5 There are gaps between guidance given and what happens in practice, for example The Pathway states that a patient should be offered the facilities to wash, a change of clothes and something to eat. This would be of a huge benefit as a massive barrier to going through the process is the length of time from the incident to completing the examination, during which you are advised not to wash or eat, an additional benefit of offering the patient facilities to wash is it can assist a patient to be less triggered/distressed by the examination by not being left feeling “dirty”. The Clinical Pathways Subgroup decided that provision of facilities to wash and a change of clothes is related to the health board service specification, and is not in scope of a clinical pathway. A key aspect of the nationally agreed service model is that forensic medical examinations are carried out in fit-for-purpose environments that respect the privacy, dignity and personal care needs of the person. All NHS Boards have premises improvement plans designed to deliver on these standards. Each premise will have a treatment room, waiting room, showering and changing facilities, provision of tea / coffee / snack and an interview room. Scottish Government has provided funding to each NHS Board to achieve this.
6 There is a high level of responsibility for the forensic examiner. To achieve the highest quality of forensic evidence, it would be more appropriate if the clinician focused on their remit and left support work to someone who specialises in supporting patients. My suggestion would be that the support worker plays a part in the examination process by being there to provide support and explain things to the patient, allowing the clinician to focus on their role. The Clinical Pathways Subgroup acknowledges the suggestion and has updated the adult pathway to include a section outlining individual roles and responsibilities
7 The Pathway shows a limited understanding of trauma. However, it doesn’t succeed in guiding clinicians to reduce the risk of causing further trauma. It is positive that the pathway guides workers to be aware of the impact of trauma (2.2 P12) and barriers to reporting (2.1 p11) however it appears that there is not enough information given on either, which may result in workers overlooking other issues, and not taking into account the service/staff being a potential barrier. Workforce training is out of scope of the clinical pathway. It is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland to attend an accredited sexual offences forensic examination training course which is delivered through NHS Education for Scotland. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. This training has also been made available to nurses involved in providing care to victims of sexual crimes. NHS Education Scotland are currently working to deliver their “Essentials” training virtually with key elements scheduled for delivery in July. The clinical pathway now includes the required level of trauma training for key roles.
8 There is no guidance in the Pathway for clinicians supporting and improving outcomes for patients who present as negatively impacted by the trauma, just limited guidance on ways the trauma may impact them (e.g. the patient may be anxious, but no guidance is given on how clinicians should work with anxious patients) There is also no guidance on improving support for those who struggle to report, only statistics showing the high number of people who don't report (3.2.7 P17) Trauma informed training is available for all NHS Staff through NHS Education for Scotland and the clinical pathway now includes the required level of trauma training for key roles.
The clinical pathway outlines the immediate response to people who have already disclosed or reported rape or sexual assault. Work to address the issue of reporting is out of scope of the Clinical Pathways Subgroup, but is being considered by the wider Taskforce.
9 It has the potential to be person centred but depends really on the delivery by the personnel involved. The narrative makes clear what a trauma informed approach should look like, and that survivors should be given meaningful choice about who they engage with, e.g. whether they report to the Police, and whether they can access a female examiner, but the manner and approach of the people at key points within the pathway determine whether this is meaningfully done and that people don’t feel under pressure to report or engage. Workforce training, including detail on individual clinical practice, is out of scope of the national clinical pathway. Clinicians working in sexual offences examinations will be trained to provide trauma informed care. The clinical pathway now includes the required level of trauma training for key roles. Trauma informed training is available for all NHS Staff through NHS Education for Scotland.
10 The pathway has to be very clear about entitlement i.e. those with no recourse to public funds and/or insecure immigration status shouldn't be left out of the support. There are many services not Rape Crisis Centres who would not support survivors of sexual violence because of their immigration status in fact some may not even be eligible for secondary health care and may be susceptible to the prevailing policy and practice with regard to those with insecure immigration status. Currently, there are a number of police forces in England who would work with the Border Agency to deport women who are seeking safety from Violence because they may not have valid leave to remain. The pathway should acknowledge these situations and safeguard against the risk of survivors not coming forward because of their immigration status The Pathway is a healthcare pathway for Scotland and urgent clinical care is provided by NHS Scotland irrespective of immigration status.
11 At section 3.2 Social Factors, we suggest adding an additional paragraph highlighting the vulnerability of people with disabilities, particularly learning disabilities, to sexual abuse. There is considerable evidence that the prevalence of sexual abuse of people with learning disabilities is higher than the general population. Factors contributing to their vulnerability may include difficulties in understanding the context of abusive behaviour, resisting unwanted behaviour or communicating their experience to others, and wider stigma and marginalisation, leading to their being targeted by abusers. This section has now been removed from the revised version of the clinical pathway.
12 We note the specific consideration of evidence in section 3.2.5 regarding the LGBTI community and the observations around trans people, including that ‘LGBTI individuals are likely to face additional barriers to disclosure such as fear of judgement, stigmatisation and ‘outing’ of their sexual orientation or gender identity’. We also note the specific reference to the risk of sexual assault for trans prisoners (section 3.2.6). Noted.
13 In relation to people with disabilities, including learning disabilities and mental illness, it is important to be aware of the context of the UN Convention on the Rights of Persons with Disabilities, particularly the provisions of Article 12 - that in all aspects of life, persons with disabilities enjoy legal capacity on an equal basis with others, and that States must provide appropriate support to exercise their legal capacity; Article 13 - that States should ensure effective access to justice; and Article 16 - that States shall take all appropriate legislative, administrative etc. measures to protect persons with disabilities from exploitation, violence and abuse. This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
14 The examination form helps medical professionals and police officers identify victims as distressed vulnerable adults. There seems to be no attempt to identify sources of personal advocacy for the victim. If for example the victim is an adult of limited mental capacity, there seems to be no attempt or at least an option on the form to identify a named person. Issues not specifically related to health such as immediate food, housing and employment issues seem to go unaddressed. Identifying a 'named person' is addressed as part of the care of adults with incapacity (see section 6.4). Immediate needs will be assessed and appropriate referrals made. The type of services available will vary between NHS Boards but consistent principles will be applied. The options appraisal report 'Honouring the Lived Experience: Rape and Sexual Assault Victims Taskforce' contains further information on the approach taken.
15 Not enough focus on distress and choices The Pathway has been developed from a position of promoting trauma-informed practice and this is explicit throughout the document. Trauma-informed training is available for all NHS Staff through NHS Education for Scotland.
16 The pathway appears very clear and helpful, which provides specific focus on the person at the centre, their wellbeing and safety and provides clear guidance in terms of choice. Noted.
17 What is the ‘point of access’? Does this mean any health care service? The journey between point of access and disclosure assumes that services feel able to explore and encourage disclosures. Whilst there is routine enquiry training in some health care services around disclosure the focus is on domestic abuse often with closed questions about feeling safe with your current partner rather than wider risk. Many workers feel unsure and lacking in confidence about proactively exploring presentations and dealing with disclosure, including GP's who are often the gateway to other services. We have had numerous reports from survivors around their engagement with GPs and health professionals where the first response was to call the Police, without consent. We use point of access as engagement with healthcare services at or soon after disclosure.
Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup are to identify and support the training needs of sexual offences examiners. The trauma informed training needs of the wider health and social care workforce will be informed by the ‘Transforming Psychological Trauma: A Knowledge and Skills Framework for The Scottish Workforce’ strategy. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
18 Aside from having a forensic examination or not / choosing the gender of the examiner -what are their choices? – this could be clearer – can dates, times, places etc be options, choice about these aspects is frequently very limited and therefore the pathway possibly needs to be more explicit / upfront about which elements can attract a choice or the limitations of them The agreed national model is underpinned by published HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse which set out the requirements in terms of time and place that forensic medical examinations should be carried out. The standards are clear about the need to deliver an improved gender balance among the clinical professionals who provide these services. All NHS Boards have increased capacity to provide a forensically trained nurse during the forensic medical examination. An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
Choices of location and time of examination will vary depending on individual circumstances and service configuration in each Board. However, the available options should be discussed with individuals at the point of initial contact with the specialist service.
19 The analysis of Gender Based Violence (2.1 P11) is welcome. However there is no mention of organised or ritual abuse in the Pathway. Nor is there any mention of how perpetrators of sexual violence operate. The focus through-out is on the victim’s lifestyle etc. Encouraging professionals to consider the methods used by perpetrators instead would equip them with a more in-depth understanding of the patient’s needs, the impact of the trauma and the difficulties the patient may be experiencing Training of staff includes information on how perpetrators may groom and other wise identify victims.
20 It has the potential to be person centred but depends really on the delivery by the personnel involved. The narrative makes clear what a trauma informed approach should look like, and that survivors should be given meaningful choice about who they engage with, e.g. whether they report to the Police, and whether they can access a female examiner, but the manner and approach of the people at key points within the pathway determine whether this is meaningfully done and that people don’t feel under pressure to report or engage with the Police or specific services. Workforce training is out of scope of the clinical pathway. However, the Workforce and Training Subgroup have reviewed the “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland and are reassured that there is a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey.
21 It states that ‘pathway choices are offered and supported throughout with informed choice and consent’. This is a vital step and important for health boards to consider who is doing this. Even with the brief guidance at the back of this document it is highly unlikely that a GP/generic health worker would be able to meaningfully talk through with someone about the options around reporting to the Police and the criminal justice process. This requires criminal justice knowledge not just health care, and will not be adequately covered by the information on the justice process within this document. Hopefully the multiagency work would enable a next step which would then enable this, as opposed to assuming generic first responders have this. This is an ideal role for Rape Crisis Advocacy workers and the Rape Crisis Scotland Helpline who have the specialist support and criminal justice knowledge to support this process.
From there it notes that ‘trauma support is established’ but it is not clear what this means. Does this mean by doing the above that this is in place or that this is something separate. Important that health boards consider how this is done and by whom.
We agree that these are all key steps which should be in place, however these need to be meaningfully done in order for it to be fully person centred and trauma informed.
Information about the criminal justice process is included in the pathway document, as well as links to resources provided by Rape Crisis Scotland. The section on trauma support has been updated in the revised pathway.
22 On paper & in theory the pathway is person centred. However in practice the extent to which it is person-centred will hinge on staff training and approach. As an example - routine enquiry has been in place for considerable time and emphasises the person-centred nature of the approach & response to disclosures. Nevertheless we regularly hear from survivors that they feel 'shut down' or their experience minimised and that they feel sometimes that the staff member is asking because s/he has to and in fact is not overly keen on hearing & responding to the survivor's response.
In addition, it could give more emphasis to the centrality of the survivor being entirely in control of whether or not a police report is made. Again our experience is that staff often subtly (and sometimes not so subtly) 'encourage' a survivor to report.
Workforce training is out of scope of the clinical pathway. However, the Workforce and Training Subgroup have reviewed the “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland and are reassured that there is a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey.
23 The Pathway was judged to be excellent and would facilitate a person-centred response at the point of entering the pathway for forensic medical examination. Noted.
24 Although the Pathway is intended to be multiagency, the pathway could be strengthened by explicit reference to, and guidance for, alternative frontline services that could expect first disclosure e.g. primary care, accident and emergency, sexual health. Such an approach would underpin that the Pathway can be enacted in various settings and is not a specialist pathway solely for those presenting to forensic medical services. This Pathway is primarily a guide for professionals working in specialist forensic services. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
25 The recommended option for service delivery is a multi-agency coordinated service. This seems to focus more on the needs of the service than the needs of patients. It seems like a lazy way of improving services. The options appraisal event, responsible for making this decision supposedly was based around “honouring those with lived experience.” However of 51 participants only 5 were there in the capacity of service user. Additionally there was only 2 workers who support survivors in the voluntary sector. The majority of participants were NHS employees, or employees of other statutory services. The only representation of survivor’s voices in the presentation was a video of one service user, and a summary of a questionnaire completed by services users who use one service, not representative. It is claimed that this model of service delivery ensures organisations “can deliver the highest quality or care, treatment and support to survivors.” There is nothing to support this claim, in fact from experience, small independent specialised services provide the highest quality support, in line with person centred approach which is in danger of being lost in a multi-agency coordinated service. When a service tries to do everything they are sacrificing quality, as no service can specialize in everything. The outcomes from the options appraisal report were shared widely with stakeholders and feedback has been positive. All NHS Boards have set up multi-agency groups to oversee service improvement plans within their area. Local partnerships with small independent and third sector organisations are recognised as good practice and the Clinical Pathways Subgroup recognises quality of services that these partnerships provide.
26 The idea that it is possible to access a service for healthcare and or a forensic examination without being triggered doesn't show an understanding of trauma (2.2.1 p12.) The notion that a patient should be able to undergo any examination without feeling triggered undermines the Pathway rightly attempting to acknowledge the impact of trauma Wording in section 2.3 has been updated to be consistent with other documents around trauma triggers.
27 The pathway has given consideration to the sensitive circumstances under which an examination would be required and the potential for re-traumatising the patient. Noted.
28 It would be helpful if recognition could be given to accessibility issues that may prevent individuals from attending services both for examination and follow up service, this may include the cost of travel to individuals and access to travel. The new revised regional proposal which details a hub and spoke model of delivery may help with some of the accessibility issues by providing a service which limits travel for individuals. The implementation of the Pathway will be for local determination. The national model aims to deliver a multi-agency approach which is delivered as locally as possible, including forensic medical examinations and follow up care and support. All NHS Boards have local improvement plans in place to improve access to high quality care and support, including forensic medical examinations and through care.
29 Although it should perhaps reflect more information around the needs of the person with a learning disability in terms of reasonable adjustments / accessible information and how this could be supportive through the process. This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
30 The pathway would be strengthened if there was the opportunity within the pathway to gather feedback from survivors who may use any new services as a result of the pathway? Therefore any new resource should have a strong evaluation and feedback loop, to allow survivors to be part of the process. The Forensic Standards should also have some performance indicators that reflect feedback from survivors. The Healthcare Improvement Scotland Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse, Standard 1 (leadership and governance) outline that people should know how to provide feedback, including what to do if they wish to make a complaint or provide feedback about the service or facilities they have experienced. It is the responsibility for individual NHS Boards to offer this opportunity.
31 The pathway itself is person centred. Key to providing a person centred service, however, is the understanding of the individuals delivering the services within it. Training is vital to ensure understanding and a consistent level of service, irrespective of the point at which individuals enter the pathway and the first service provider they come into contact with. Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual offences examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
32 In theory the pathway has the potential to be person-centred but it depends on who is involved at the various stages. Survivors need to have choices about what route to take i.e. to report or not to report, to have a choice about what services they are referred on to etc. Survivors must be provided with the correct information to make informed choices in their own time. Noted.
33 On paper the pathway looks as though it has certainly been designed to be person-centred. As with any such guidance, being person-centred in practice will be dependent upon the appropriate resourcing being invested in training professionals and ensuring that the response services have the ability to deliver upon what is contained within the pathway. (E.g. the way in which the pathway is communicated, use of language, access to female examiners). Our feedback from women affected by sexual violence has noted that some report an experience very similar to the pathways document, whilst others feel that options were not explained and that the trauma they had recently been through was not responded to in a meaningful way. The pathway does indicate the approach to be taken and with the right resources could be embedded in a very person-centred way. Noted.
34 It has the potential to be person centred but depends really on the delivery by the personnel involved. The narrative makes clear what a trauma informed approach should look like, and that survivors should be given meaningful choice about who they engage with, e.g. whether they report to the Police, and whether they can access a female examiner, but the manner and approach of the people at key points within the pathway determine whether this is meaningfully done and that people don’t feel under pressure to report or engage with the Police or specific services. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
35 Delivery depends very much on the training, understanding and experience of the personnel involved. It also depends on whether the services and logistics are in place to ensure that there are female examiners available for everyone, that people do not have lengthy waits where they are unable to wash, and that their access needs are considered.
The biggest re-traumatiser and current barrier to forensic engagement which survivors consistently identify to us is the lack of female examiners. Having to wait unwashed for 12 hours to see a female examiner, or have immediate access to an examination by a male is not a meaningful choice and is one which will result in more traumatisation.
Additionally, a survivor has reported to our rape crisis centre that during her forensic examination she wasn't given any sexual health advice by the forensic physician and she was left to her means to get that advice and assistance. Survivors shouldn't have to ask for that advice and also some may not be aware that they can or need such advice particularly those from migrant backgrounds and those who are generally denied NHS services due to their immigration status.
The agreed national model is underpinned by published Healthcare which are clear about the need to deliver an improved gender balance within the clinical professionals who provide these services. An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
The provision of sexual health advice to victims is included explicitly in the Pathway.
36 I am a trans woman with lived experience of being a victim of sexual assault unfortunately and I can state for this failed SNP government right now that that pathway is not just not person centred it has the capacity to be completely reckless, selfish and lethal.

It is also prejudicial and ill informed.

A pathway that recommends even occasionally the murder of an unborn human child is a pathway not to justice or care but to injustice and harm it is not just the religious but medical experts of no religion with serious ethical objections based on the Hippocratic oath that share the same sentiment as well.

The government would do well to take those concerns into very careful consideration.
The Scottish Government believes all women in Scotland should have access to clinically safe and legal abortion services, within the limits that are currently set down in law, should they require it. It is our view that abortion care should be part of standard healthcare provisions, free from stigma. All persons should be supported and free to reach their own decision on whether or not to have an abortion.
37 The wishes of the individual are taken into consideration at every point and consent is sought before each intervention. Individuals can say no to any services offered. Noted.
38 There is no verification that treatment might have been offered. The victim is just identified as having suffered from trauma. This puts medical professionals and police in a position of immense power over the victim who consequently might be at threat from losing their house or job. Vulnerable adults in Scotland have no protection to stand up to the psychiatric drug therapy system. The form spells the end of a person's useful role in society. The Pathway outlines what treatment is available and which referrals to supportive agencies may be made.
The associated national form that will be completed by examiners has space where the treatment and support offered to a victim is noted.
39 Although the consultation paper refers to the longer-term consequences of sexual assault and rape, the clinical pathway focuses almost exclusively on management of disclosure of very recent trauma. Although it refers to The National Trauma Training Framework, the pathway lacks detail regarding people who delay disclosure, which is more frequent with the presentation overall and also in Mental Health/Addictions services where the initial presentation is usually seen with the long-term consequences of trauma. The clinical pathway is primarily for those who disclose acute rape or sexual assault. This has been highlighted further in the pathway document. Information has been added to the pathway introduction about sources of support for those who delay disclosure.
40 Up to a point --not enough emphasis on trauma
Very short-term approach taken --this should be made clearer;
some people don't disclose for many years; this should be recognised
The clinical pathway is primarily for those who disclose acute rape or sexual assault. This has been highlighted further in the pathway document. Information has been added to the pathway introduction about sources of support for those who delay disclosure.
41 We fully support the need for responsive and trauma informed services and welcome the level of understanding shown in the document in terms of the short and longer term impact of trauma on an individual and how services and responses can best meet their needs. Noted.
42 The pathway should reflect expectations on staff re: learning & development and knowledge of trauma, including how to manage it (e.g. grounding techniques). The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. This training is also available to nurses involved in the provision of care to victims of sexual crime.
The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and Local Authorities and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
43 The examples given in the response to q1 are also pertinent here e.g. it could be traumatising to feel one's experience has been minimised or that one is being held culpable to any degree for being raped or assaulted. The Clinical Pathways Subgroup agreed that there is a skill to asking clinically relevant questions in a non-judgemental way by framing the questions as relevant to health care. Practitioners will be supported to strike a balance between trauma-informed practice and clinical relevance as these skills are part of standard training provided by NHS Education for Scotland and maintained through personal development.
44 The pathway incorporates a range of trauma-conscious measures, including choice of sex of examiner, careful explanation and consent at each stage of the process as well as a range of additional necessary measures like limiting the number of people present, appropriate screening, etc. Noted.
45 An area for further consideration is the complex issue of transgender forensic examiners. This is a legal and sensitive area that must be clarified in terms of true options for the patient. E.g. Male and female victims almost universally prefer to be examined by a female examiner. If the FME has declared gender identity under the current proposals by SG this is not legally shareable but may be distressing to victims when they come face to face with a transgender individual in that environment. In the consultation on the draft Gender Recognition (Scotland) Bill, which closed in March 2020, the Scottish Government:
  • Referred to the general occupational requirement (GOR) exception in the Equality Act 2010.
  • Noted some suggestions that section 22 of the Gender Recognition Act 2004, on prohibition on disclosure of information, might make it harder to use the GOR exception.
  • Noted that the SG would consider if further exceptions need to be added to section 22 of the GRA and if guidance should be issued on section 22.
  • The draft Bill on which SG consulted did not make any changes to the Equality Act 2010.
  • That consultation was clear that further guidance from the UK Government on the operation of the single sex exceptions could be helpful.
  • On 1 April 2020 the Minister for Parliamentary Business informed Parliament that in light of the on-going impact of COVID-19, work on a number of planned government bills has been halted.
  • As a result, the Scottish Government will not bring forward a Bill to reform the gender recognition process before the next Scottish Parliamentary elections in May 2021.
  • SG will complete the work of analysing the responses to the consultation on the draft Bill.
  • However, no timetable can be provided at this stage as SG’s focus must be on dealing with the COVID-19 pandemic.
46 The key points supporting the pathway indicate that cognisance should be given to any cultural and individual health care needs in order to reduce any trauma; it would be helpful if this informed any training for both examiners and chaperones. The pathway refers to the offer of a psychosocial risk assessment to include the Safe Lives Risk Identification Checklist (RIC) where domestic abuse has been indicated, it may be helpful to know who would be responsible for sharing the information from the RIC with other agencies. This is important to reducing any further trauma to the individual if the assault has been perpetrated by an intimate partner. The person who is responsible for sharing the information is usually the clinician collecting the information. Local processes may vary, as in some NHS Boards this task will be delegated to another staff member during day time hours.
47 Within section 8.2.1 which details areas which may affect capacity or ability to consent reference is made to not using family members, friends or partners of the individual this should also be referred to in section 7.2.3. This section of the guidance refers to local pathways being in place for the use of interpretation services, reference should be made to ensuring that family/community members are not used as interpreters to minimize any additional trauma to the individual. Policies and procedures regarding use of interpreters are in place at NHS Board level.
48 The whole document does show an understanding of trauma but as discussed at 1, the pathway is an important means to an end but requires individuals operating the pathway and their practice to be fully trauma informed. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. The clinical pathway now includes the required level of trauma training for key roles.
This training is also available to nurses involved in the provision of care to victims of sexual crime.
The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
49 The pathway diagram, Page 24, also requires some further development as, in reality, this may be the only element of the document that busy professionals refer to. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
50 To deliver the pathway, the standards referred to in the standards document published in December 2017 in relation to leadership, training, female medical examiners and crucially facilities must be in place. Noted.
51 The content of the document makes this clear however, whether this becomes a reality very much depends on the people/organisations that the survivor has contact with. The professionals need to have had the appropriate training and have a deep understanding of the impact of sexual violence. Survivors need to be offered impartial support during the pathway. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. This training is also available to nurses involved in the provision of care to victims of sexual crime.
The Advanced Forensic Practice postgraduate course, accredited by the Faculty of Forensic & Legal Medicine and certified by the United Kingdom Association of Forensic Nurses Advanced Standards in Education and Training within forensic practice, currently being developed at Queen Margaret University will provide nurses and doctors with the opportunity to further develop their skills. Continued professional development for doctors can be accessed through NHS for Education Scotland.
The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
52 Having the choice of gender of the forensic examiner is key, in our experience survivors prefer female examiners. Forensic examinations must be carried out in a timely manner as long delays can cause further trauma. There should be a consistent provision across the whole of Scotland and this is a challenge in rural areas. To minimise delays, if survivors are offered the option to be examined by a male examiner and do this rather than waiting for a female examiner to be available, this is not a free choice and can lead to more traumatisation. Workforce planning is out of scope of the national clinical pathway. Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults.
Taskforce funding has been provided to NHS Education for Scotland to train more doctors to carry out forensic medical examinations, with a view to increasing the number of females who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service. An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on the gender balance in the workforce, has been approved and work to progress is currently underway.
53 Access to a female forensic examiner isn’t currently possible in our area and continues to be a difficulty for women going through forensic examinations. Workforce planning is out of scope of the national clinical pathway. Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults. Taskforce funding has been provided to NHS Education Scotland to train more doctors in sexual offence examinations with a view to increasing the number of female doctors who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on the gender balance in the workforce, has been approved and work to progress is currently underway.
54 We have mixed feedback from survivors. Some highlight excellent initial responses, with professionals being extremely supportive and taking everything at an individual’s pace. Others reported feeling rushed and the focus being heavily on reporting which made them feel as though their supporter “only cared about the law side”.

The following booklet was designed for professionals carers supporting people affected by CSA or child sexual exploitation - it's content may be helpful for some practitioners.
http://www.pkc.gov.uk/media/43394/Perth-and-Kinross-Trauma-Informed-Practice-Guidance-for-Practitioners-December-2018-/pdf/PK_Trauma_Informed_Practice_Guidance_for_Professionals_Dec_2018.pdf?m=636808067866230000
Careful use of person-centred, trauma-informed language is central to not re-traumatising the individual in the care of clinicians. Skilled training for nurses can be provided through the relevant Queen Margaret University postgraduate course in advanced forensic practice and via NHS Education for Scotland and the Faculty of Forensic and Legal Medicine in the case of medical practitioners.
55 Abortion is one of the most traumatic actions a woman can ever submit herself to, to recommend she kills an innocent child for the crimes of a criminal causes her more trauma on top of her rape not less. The Scottish Government believes all women in Scotland should have access to clinically safe and legal abortion services, within the limits that are currently set down in law, should they require it. It is our view that abortion care should be part of standard healthcare provisions, free from stigma. All persons should be supported and free to reach their own decision on whether or not to have an abortion.
56 The pathway is easy to navigate however the booklet is not. I would recommend an online version with hyperlinks making it easier and streamlined to navigate.
It’s important to be professional at all times, even when we don't know the answer or need clarification about process.
Further work on the national form has been carried out to make it more accessible.
The Quality Improvement Subgroup of the CMO Taskforce is currently working to introduce a national Clinical IT system for Forensic Medical Services in Scotland and following implementation, the National Form will be accessed electronically.
57 It’s a large document. Large documents put people off reading them. Perhaps a shortened version akin to the SIGN guidelines Scotland format would be of benefit. A summary diagram is available in section 4 of the Clinical Pathway.
58 The guidance is clear and concise. Noted.
59 I am sure the pathway is very easy for well-paid medical staff, police and social workers etc. to use. Noted.
60 We believe that the pathway should be interactive in format with each box in the flow chart having links to the relevant sections. For it to be useful to staff there needs to be a way of getting the relevant information and expectations at each stage. Hyperlinks have been added to the contents page and within the flow chart, references have been made to the relevant page numbers in the Pathway.
61 It's not clear what the point of access is - could it be any NHS service for example? Again the emphasis needs to be on training in dealing sensitively & appropriately with disclosures. Similarly the survivor having genuine choice in whether or not to report to police is crucial and will require staff to have knowledge of the CJS in practice as opposed simply to the helpful but very broad outline at the back of the document of what happens where & by when. Staff time to have these discussions is important - how will a GP deal with a disclosure during a 7 minute consultation for example?
We would suggest that an independent specialist trained advocate (eg as provided by the national advocacy project) would be a far better person to support a full and open discussion of a person's options and the implications of these.
As survivors may disclose to a range of practitioners, it is important that NHS Boards provide and publicise information about the criminal justice system.
The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
Individual Boards will develop their service models to ensure HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults are met.
62 The document is understandably lengthy and whilst this is not designed to be read cover to cover, it appears to have content in it that are not pertinent to a clinical pathway, such as summary background, etc (up to page 24). These would benefit from being reviewed, removing excess content and creating reference appendices to make it more user-friendly in the field.

Further, the document would benefit from diagrams and pathway flowcharts, etc in visual format being in the initial sections for ease of reference.
The Clinical Pathways Subgroup has reformatted the document in a way that is more user-friendly and removed some of the background information.
63 In the main, the pathway is easy to navigate however it was commented on that it was lengthy but relevant and some flowcharts may be helpful. A summary diagram is available in section 4 of the Clinical Pathway.
64 Depends who reads it and their level of understanding. A bullet point aide memoire might be helpful. A summary diagram is available in section 4 of the Clinical Pathway.
65 Survivors need to know how they access the pathway, this is unclear from form the document. The document suggests that it could be a GP or an NHS healthcare professional? This would mean that every GP/or NHS health professional would need to understand the pathway in detail, have in-depth Criminal Justice knowledge and understand the system. They would also require to have the appropriate training to deal with the disclosure sensitively and appropriately, listen to the survivor views and not apply pressure on them to report to the Police. The pathway must support survivors in an informed way and seek their consent for any action taken. This role would be well suited to a Rape Crisis Support & Advocacy Worker, they are specialist workers who have in-depth knowledge of the criminal justice process. This pathway describes the process a person should take through specialist forensic medical services. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
66 The steps outlined by the pathway are all appropriate and will be beneficial for survivors who have experienced sexual violence. However, for these to be carried out in way that is trauma informed and person-centred they need to be carried out in a meaningful way that improves the survivors experience and gives them choice. Noted.
67 The pathway feels unclear at the beginning. We are unclear about who or what is the point of access. Also, the pathway choices – we are not clear that this guide offers professionals the level of knowledge required to be in a position to provide people with accurate information about both health and criminal justice options. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
68 The role of Rape Crisis Advocacy workers would be meaningful at this stage and could form part of the ‘Trauma Support Established’ process. The role is there to ensure that individuals are fully aware of all options, what happens, when it happens etc. Noted.
69 Health boards would need to ensure that frontline practitioners are fully informed about the NHS Sexual Assault Service in their area. We have had a SARN service for a number of years but are aware of many healthcare professionals who do not know about the process. Promotion of this has recently been widely circulated again and this will need embedded in to all training. Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
70 As a remote and rural GP, I want to be assured that my patients who require forensic examination will have this performed not only as locally as possible (as specified in the document) but also by a professional whose evidence will stand scrutiny in court should this be required. GPs and other health professionals in my area strongly believe that people who have been assaulted should not be denied the services of a FME, and if none is available (as in my area) an FME should travel to the locality rather than the victim having to travel, whenever possible. The nationally agreed service model is focussed on the need to deliver a holistic and smooth pathway of care from forensic medical examinations to recovery. Individual Boards are responsible for ensuring that services are delivered as locally as possible to the necessary clinical and forensic standards.
The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. This training has also been made available to nurses involved in providing care to victims of sexual crimes.
The Advanced Forensic Practice postgraduate course, accredited by the Faculty of Forensic & Legal Medicine and certified by the United Kingdom Association of Forensic Nurses Advanced Standards in Education and Training within forensic practice, currently being developed at Queen Margaret University will provide nurses and doctors with the opportunity to further develop their skills in trauma informed practice and court skills. Continued professional development for doctors can be accessed through NHS for Education Scotland.
An initiative to develop the role of nurse sexual offence examiners in Scotland, aimed at building a multi-disciplinary workforce for the future, has been approved and work to progress it is currently underway.
71 Page 24: We recommend making it clearer that services can be offered without forensic examination, by linking the box covering “NHS assessment of sexual health risks and follow up arrangements” to the lower half of the adjacent box which covers emergency contraception, HIV and STI screening. The diagram has been amended in the revised pathway.
72 Long waiting times to be seen by support services, victims may believe they will be seen quickly Healthcare Improvement Scotland have developed standards and indicators which include waiting times -
http://www.healthcareimprovementscotland.org/our_work/standards_and_guidelines/stnds/sexual_assault_indicators.aspx. These waiting times may be considered during the development of a service specification, but are considered to be out of scope of the national clinical pathway.
73 There is a need to improve services for male victims of Childhood sexual abuse or sexual assault. While the consultation paper does acknowledge that male survivors have particular difficulty disclosing that they have been victims, there are no suggestions as to how male survivors can be supported to discuss their experiences. The Pathway outlines the immediate healthcare and forensic medical response to rape and sexual assault; improving the support for disclosure of historic child sexual abuse is considered by the Clinical Pathways Subgroup to be out of scope for this pathway. NHS Boards are best placed to reduce inequality of access to services in their local area and engage with partners to support all survivors of rape and sexual assault.
74 Support for people who disclose many years after the sexual abuse occurred. Access to services for psychological support essential; a flexible and choice-full approach required The Pathway outlines the immediate healthcare and forensic medical response to rape and sexual assault. Although there may be overlap in provision of support services, the Pathway does not aim to provide an outline of the national response for people who may disclose many years after having experienced abuse. The introduction has been amended to include information about support for those who disclose their experiences at a later date.
75 There is an assumption that NHS Boards will have a Sexual Assault service. In many small and Island boards this is unlikely to be a standalone service and maybe more of a virtual arrangement. The Taskforce recognises that small and island Boards will require a level of support from larger Boards within their region. There are collaborative models and support networks established already which provide forensic medical examination services for survivors and support to clinicians who are involved in providing treatment and care.
Regional Planning groups will continue to strengthen the systems they have in place to further improve service quality and to enhance peer support for professional staff involved in delivering treatment and care in remote and island communities.
76 The early evidence section reads like it would be conducted by health professionals. The initial evidence gathering by police (e.g. fingernail swabs) should also be reflected in the pathway at this point as well as in section 2. Police Scotland may gather evidence at the outset of the investigation using the early evidence kits. There may, however, also be circumstances where the health professional will use the early evidence kits to obtain evidence e.g. urine samples. Information on early evidence kits will be added to the guidance document for frontline practitioners.
77 It is not clear how the trauma support is established above and who is assisting the survivor to explore their options and choices. It could be interpreted that ‘trauma support established’ is in the manner of the health care worker such as the GP, and not something more robust and meaningful. Rape Crisis support & advocacy staff would be ideal for providing this, and the evidence noted in the evaluation below highlights how vital having this early access to specialist support and information is in navigating the justice process. The Rape Crisis national helpline, which is currently open 6pm to midnight provides timely access to this support and information and could also play a key role but is limited currently to 6pm to midnight. For both the Nation Advocacy Project and the national helpline there are some issues of capacity and additional funding would be required to ensure timeous specialist access.

Engaging with the criminal justice process can be a daunting one and having early access to support & advocacy can be ‘life changing’ (according to the evaluation of the Rape Crisis National Advocacy Project’. https://www.sccjr.ac.uk/publications/evaluation-of-the-rape-crisis-scotland-national-advocacy-project-final-report-2018/) Having the support & advocacy option highlighted prior to Police engagement would enable informed choice about engagement.

It is not clear about who would do the psychosocial needs assessment. Is this still the initial health care worker, or a further option? In the box at the bottom it references a number of agencies, but Rape Crisis, the only specialist national organisation working with survivors, is not listed amongst them, albeit listed later in the document. Health professionals can be wary of making referrals out with the NHS so without overt naming are unlikely to do so. The introduction to the document talks about multiagency and partnership, so this needs to be reflected in the pathway. Given the document is aimed at being used as required it may be when someone needs it they do not have time to read the whole document and will only refer to crucial key information so this should be listed here. Also it states ‘offer a choice of services’. This could mean give a leaflet with a number of organisations, but if many services have lengthy waiting lists this is not really a choice. Given p44 references immediately available there needs to be a review locally of what the capacity is to respond timeously.
Also currently the pathway notes either people want to report or they don't. There is a further option of intelligence sharing. Rape Crisis Scotland currently facilitates intelligence sharing with the Police through the online EPPIC system. Is this something which could be considered for those who do not feel ready/able to engage? This could be explored, or at least referenced. This is an issue for consideration with Police Scotland.
The Clinical Pathways subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
Detail of how the pathway is implemented will depend on local circumstances. The possibility of third party information sharing for those who do not wish to report to Police Scotland is included in current training.
Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. The Access to Services Task and Finish Group is looking at how people will contact self-referral services, as well as options for a national awareness raising campaign ahead of Bill commencement. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system. The adult clinical pathway will be updated to reflect any guidance / legislative changes that have a bearing on the pathway.
78 There is not an NHS Sexual Assault Service in every locality and there is no alternative outlined in the pathway for a survivor who wishes forensics to be taken but does not (at that point at any rate) want to report to police. In these circumstances there may need to be a separate pathway at that point of the current pathway. Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. Access to Services Task and Finish Group is looking at how people will contact self-referral services, as well as options for a national awareness raising campaign ahead of Bill commencement.
A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system. The detailed protocol will set out detailed and robust requirements for the retention of forensic evidence, including what is stored, where and how. Processes will be put in place to ensure that the corroboration and secure retention of any evidence obtained will be admissible in any future criminal proceeding.
The adult clinical pathway will be updated to reflect any guidance / legislative changes that have a bearing on the pathway.
79 It is astonishing that Rape Crisis type services are not specifically mentioned in the final box giving examples of follow-up care. As the national specialist service (and in many areas the only specialist service) for survivors of sexual violence this is a significant omission. Again the need for training is highlighted as staff need to know what services are in their locality, what they provide, any waiting list info, etc. Rape Crisis Scotland is referenced in Section 9 of the Pathway in relation to follow up care.
80 Although the Pathway is intended to be multiagency, the pathway could be strengthened by explicit reference to, and guidance for, alternative frontline services that could expect first disclosure e.g. primary care, accident and emergency, sexual health. Such an approach would underpin that the Pathway can be enacted in various settings and is not a specialist pathway solely for those presenting to forensic medical services. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources produced in November 2020.
81 section 7.2.1 about the psychological risk assessment - it would be helpful to have further guidance and a relevant tool to use at various stages of the pathway - as mentioned the safe lives is only applicable if domestic violence is suspected and as we understand this will be covered by the police so there is a risk of revisiting information already gathered by them if this is not shared. A relevant tool that could be used immediately by the FME service and something that could be used as follow up in care coordination would be helpful Noted - the national form has been revised to ensure the flow is improved and there is minimal duplication.
82 Child and adult protection are both covered within the document, but there is a gap regarding if the victim is a carer for an older adult/adult child with additional needs and thought given to ensure their safety and wellbeing whilst the person is engaged. Noted - 7.2.1 p46 under Assessment' a point has been added relating to the needs of other individuals the person cares for e.g. older adults.
83 More guidance could be given about the needs of people with a learning disability in terms of communication support This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
84 The document does not highlight the sensitivities around careful but overt statements when touching a patient. When rape or sexual assault has occurred and a person is traumatised, it would be appropriate to ensure you clearly state ‘I will now place my hand on your upper thigh’ or whatever is required, to ensure they are informed about appropriate touch at all times but in a sensitive and gentle way. Careful use of person-centred, trauma-informed language is central to not re-traumatising the individual in the care of clinicians. Skilled training for nurses can be provided through the relevant Queen Margaret University postgraduate course in advanced forensic practice and via NHS Education for Scotland and the Faculty of Forensic and Legal Medicine in the case of medical practitioners.
85 The document also refers to the Safe Lives Risk Indicator Checklist in terms of assessment of risk in domestic abuse circumstances. This should refer instead to the Safe Lives DASH suite of assessment tools for a fuller picture of risk. Noted – the DASH risk indicator checklist has been included.
86 Engaging with the criminal justice process can be a daunting and access to support and advocacy can be life changing so it would be beneficial to identify who will deliver the trauma informed support and explicitly mention how Third Sector Specialist agencies can assist, locally and nationally, including, in relation to support, advocacy, and help offered navigating the criminal justice system. We do however appreciate acknowledgement of the follow up care with a range of services including victim and advocacy agencies with a local determination. The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
87 The evidence base shows us that vulnerable groups are at greatest risk of assault and as such there should be a focus within the pathway to identify and support these groups e.g. people with learning and/or physical disability, Care Leavers, those suffering from modern slavery or trafficking, those working with commercial sexual exploitation , either formally or informally. These are groups we know are at increased risk and conversely also an underserved population. The pathway would benefit from additional guidance on how access can be increased for underserved groups.
Furthermore, it may be helpful to indicate within the box which provides detail on immediate risk if there is a safety issue in relation to domestic violence that the concerns are assessed and arrangements made at the initial disclosure.
Additional guidance has been added into the background section of the Pathway.
88 Although the pathway is primarily for health care professionals it may be the case that the initial disclosure or point of access may not be to someone in a healthcare professional, it may be helpful on ratification of the pathway that this is shared through the National Violence against Women network to ensure wider partners are familiar with the pathway. Noted.
89 Re Section 1.4 regarding inter-agency referral discussion, it may be helpful to expand on how long this discussion would take and how that would impact on the forensic examination being carried out. The timing and duration of the interagency referral discussion (IRD) is depending on the individual person.
All agencies involved in the interagency referral discussion (Police Scotland, Social Services and Health Services) are aware of the need to prioritise clinical and safety needs, while being aware of the need for timely forensic examination.
90 Reference to reasonable adjustments / accessible information and the use of an appropriate adult when supporting someone with a learning disability This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
91 Mandatory signposting or referral to a local rape crisis centre or mental health service. More communication with survivors at all parts of the process Choice in the process is crucial to a trauma-informed approach; therefore, the Clinical Pathways Subgroup does not support mandatory referrals other than those required as part of Adult Support and Protection measures. The Pathway includes enhanced follow up care for survivors with regard to coordination of healthcare needs.
92 There are gaps about where and who delivers certain aspects and how handover for example from one health board to another health board should take place. This feedback will be discussed with NHS Board Nominated Leads to establish the best way to ensure consistent practice in this area. NHS Board Nominated Leads will lead discussion within their multi-agency groups to determine how best to progress these issues within their local area.
93 The pathway does not specifically name an organisation who will be providing the trauma informed support but reads as though it would be a NHS worker such as a GP or health care worker. The pathway would be more meaningful and have a positive impact on survivors who have experienced sexual violence if the trauma informed support was provided by a Rape Crisis Support & Advocacy Worker. The workers are specialist and it is evidence based that the support they offer has beneficial outcomes for survivors affected by sexual violence. Rape Crisis is the only national organisation providing specialist support but is not specifically named in this part of the document. There would need to be additional funding to increase resources and capacity to expand the provision of the National Support & Advocacy Project. The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the Pathway in each NHS board area will depend on local circumstances.
94 As noted above, the inclusion of a pathway to a Rape Crisis Advocacy worker would address any gaps in knowledge which may occur. Furthermore, the option to have 1 consistent supporter throughout the process is advantageous. A role which exists from point of disclosure through to any court proceedings and post-court support if required. The decision to report can be incredibly daunting / overwhelming and national evaluation has evidenced the difference early engagement with this project can make.

We note that Rape Crisis is not listed in the follow up care section at the bottom. However, the national helpline and the centres working across Scotland are dedicated specialist services for individuals following rape or sexual assault. We work very closely with Police and NHS and part of this work has been establishing the SARN and supporting individuals to access forensics without the need to report. It would be appropriate therefore for Rape Crisis Services to be referred to on the pathway.
The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the Pathway in each NHS board area will depend on local circumstances.
95 It would also be positive to make reference to BME, LGBTi services in the follow up care represented in the flowchart. This is reflective of the wider guidance which recognises the additional barriers faced by individuals from these groups who have experienced sexual violence. NHS Boards are best placed to reduce barriers faced by groups in their local area and engage with partners to support all survivors of rape and sexual assault. Referral to specific local support services are the responsibility of individual NHS Boards and will be for local determination.
96 The architects of this work forgot to leave out the abortion part and place in the preserve human life from womb to tomb from cradle to grave part so, yes, there are indeed gaps.
Massive gaping grotesque gaps.
Noted.
97 Psychiatric assessment not included The Clinical Pathways Subgroup agreed that psychiatric assessment is not appropriate for every case and, therefore, this has not been included in the pathway.
98 BOT --research limited to recent disclosures Noted.
99 All of this is based on someone making the initial disclosure. Whilst the document talks about what trauma informed practice is it would be useful to include some very brief guidance about enabling and dealing with disclosure. The Pathway now includes guidance on dealing with the initial disclosure. Over time, the training needs of the wider health and social care workforce around trauma informed care will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy
100 It might also be helpful to include some research on the role and benefits of advocacy support through the criminal justice process. As well as the full document above there is a summary document here https://www.sccjr.ac.uk/wp-content/uploads/2018/01/RCS-NAP-Evaluation-Summary-Report_2018.pdf The Clinical Pathways subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the Pathway in each NHS board area will depend on local circumstances.
101 More could be said about the importance of and best practice in dealing with disclosure. The Pathway now includes guidance on dealing with the initial disclosure. Workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and Local Authorities and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
102 The benefits (as demonstrated through independent research) of specialist independent advocacy services could also be further highlighted. The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
103 As mentioned in The Scottish Centre for Crime and Justice Research (SCCJR) evaluation of Rape Crisis Scotland’s National Advocacy Project (NAP), the perceived imbalances in the criminal justice system, reflecting it’s adversarial nature and the perception that it protected the interests of the accused before that of the victim, means more work needs to be done prioritising the needs of the victim. The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
104 The document talks about trauma informed practice but does not outline what this looks like, some information about good practice in dealing with disclosures would be useful. The Evaluation Report commission by Rape Crisis Scotland regarding the National Advocacy Project would be pertinent here. The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
105 The pathway states on page 23 that the ‘recommended model of delivery is for multi-agency co-ordinated services’. However, following on from the comments above the pathway itself isn’t truly representative of this, and the importance of this may be missed by workers referring to the document at point of disclosure and looking at the flowchart only. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
106 We were informed that the National form was to be part of this consultation but it is missing from all documents. Noted.
107 long-term impact; effects of disclosure many years after events;
IUD latest research on its damaging impact
Noted.
108 Research regarding conviction and acquittal rates and the reasons for acquittals, in sexual offences cases. E.g. post-Trial focus groups. Noted.
109 Research in relation to the prevalence of sexual assault in people with learning disabilities and vulnerable persons - There are some articles available
Behind Closed Doors - Mencap 2001
Improving service responses for people with learning disabilities who have been sexually assaulted: An audit of forensic services.
British Journal of Learning Disabilities ( BR J LEARN DISABIL), Dec2017; 45(4): 238-245. (8p)
Responding to the needs of people with learning disabilities who have been raped: co-production in action
Olsen, Angela; Carter, Catherine.Tizard Learning Disability Review; Brighton Vol. 21, Iss. 1, (2016): 30-38.

The sexual abuse of adults with learning disabilities: Report of a second two-year incidence survey
Article in Journal of Applied Research in Intellectual Disabilities 8(1):3 - 24 • March 2010

Preventing rape and sexual assault of people with learning disabilities
Article in British journal of nursing (Mark Allen Publishing) 8(13):871-6 • July 1999
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant research and use of appropriate terminology.
110 There is a significant research gap within the prevalence of sexual violence among individuals who have a learning disability. While the guidance addresses socio-economic inequalities (race, sexuality, and gender), there is a significant omission of disability and, in particular, learning disability. It is important that the rights of people with a learning disability to enjoy and maintain healthy relationships, including sexual relationships, are also recognised.

In order that people with learning disabilities can enjoy safe relationships there is a need to provide equitable provision of sexual health and crisis services, in line with the rest of the population. Central to achieving this is ensuring the particular needs of people with learning disabilities are reflected in this guidance. This should include disabled women’s experiences of violence (including sexual violence) discussed in Boltzmann (2014) and the role institutionalisation has played in this.
In understanding people with learning disabilities’ exclusion and historic disempowerment, it is critical that particular focus is given to people with learning disabilities in this guidance. This focus should illustrate that rape and sexual assault does impact people with learning disabilities and that this is not a small scale issue.
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant research and use of appropriate terminology.
111 It is critical that those providing frontline crisis support understand the human rights of people with learning disabilities and the delicate balance between this and protection. This should help to ensure that professionals do not violate these rights through a culture of over protectionism.
  • The guidance should address the experience of people with learning disabilities with regard to sexual assault and rape
  • The guidance should reflect the importance of balancing rights and autonomy with protection. SCLD would welcome the opportunity to provide further advice on this and would recommend engagement with The Mental Welfare Commission
  • Expand and develop the section on informed consent and capacity. This expanded section should address challenges in communication between professionals and people with learning disabilities. For example, the framing effect.
  • Embed The Human Rights Act (1998) and the UN Convention on the Rights of Persons with Disabilities (2009) in the guidance.
Further Recommendations:
  • NHS Health Scotland to support the implementation of this guidance document with training on communication for frontline staff
  • Examine the potential to commission further research regarding the experience of people with learning disabilities regarding medical and victim support following sexual assault and rape.
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
112 There has been no research done or advertised in this consultation in regards the positive testimonies from rape victims whom have chosen to keep their child instead of terminating them and from those who have recommended to victims to keep their child.
There also seems to be missing research on why the need to declare who exactly is proposing this consultation and a letter contact address is so important when being transparent in a nation claiming to be a western democracy.
Noted.
113 Cannot comment wholly on the pathway without the form being supplied in tandem Noted.
114 Very good, clear and comprehensive document. Flow-charts for GPs, A&E and sexual health services may also be useful. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
115 There is some guidance in place already for some aspects of dealing with survivors of sexual assault and rape. For instance, there is guidance in place for frontline staff working with people with a history of Childhood sexual abuse. There is also recommended psychological treatments for different mental disorders, which are outlined in The Matrix (2015). This includes a section on treatments for trauma within the Adult Mental Health section.

In 2018, the Scottish Government published, Substance misuse services: delivery of psychological interventions, which outlines a need for trauma-informed approach to care within Addictions Services and different tiers of psychological interventions dependent on individual patient need.

The College recognises that work on The National Trauma Training Framework is ongoing. It would be advantageous to consider the recommendations from this in guidance for management of people who present with delayed disclosure of rape or sexual assault and longer-term consequences to Mental Health or Addictions services.
Links:
Guidance for frontline staff working with people with a history of Childhood sexual abuse - https://www2.gov.scot/Resource/Doc/218982/0058805.pdf

The Matrix - https://www.National Education Scotland.scot.nhs.uk/education-and-training/by-discipline/psychology/the-matrix-(2015)-a-guide-to-delivering-evidence-based-psychological-therapies-in-scotland.aspx

Substance misuse services: delivery of psychological interventions - https://www.gov.scot/publications/delivery-psychological-interventions-substance-misuse-services-scotland-report/pages/4/

The National Trauma Training Framework - https://www.National Education Scotland.scot.nhs.uk/education-and-training/by-discipline/psychology/multiprofessional-psychology/national-trauma-training-framework.aspx

Managing the impact of violence on mental health - https://www.rcpsych.ac.uk/pdf/PS01_2012.pdf

Coping after a traumatic event - https://www.rcpsych.ac.uk/mental-health/problems-disorders/coping-after-a-traumatic-event
The Clinical Pathways Subgroup have included appropriate references in the final pathway.
116 It is excellent that the document situates sexual assault firmly within the context of wider gender-based violence and recognises the societal inequalities that contribute to these issues. It is also welcome that the wider societal attitudes towards women and this type of crime impact on victims confidence and ability to seek help and report, the additional barriers faced by women who may be involved in prostitution or have substance use issues and the recognition of sexual violence in the context of relationships and the need to recognise ongoing risks. Noted.
117 You have not made any reference to convictions rates and the not proven verdict. I have recently started a campaign with Rape Crisis Scotland and think that it is important to explain the not proven verdict to all of those working with survivors who could come across and have to live with this verdict.
https://www.rapecrisisscotland.org.uk/not-proven/
This comment relates to judicial processes, which is out scope of a clinical pathway. Feedback will be shared with the wider Taskforce, in particular those developing further information on the not proven verdict. In the meantime, information on the not proven verdict is provided in the document 'Information and help after rape and sexual assault'.
118 The pathway references the importance of having evaluation structures in place and this will be vital in ensuring that the intentions of this work are being met and survivors’ voices and experiences are being valued and acted upon. Noted.
119 No but the pathway could usefully be made into an interactive resource with embedded links to more detail at each nodal point An interactive resource will be considered in the future.
120 Page 28 Section 7.1.3.1 – second bullet point / fourth line / ‘than’ should be removed

Page 40 Section 7.4.3 – ‘on’ should be ‘don’
Wording amended.
121 Consider how reasonable adjustments under the Equality Act 2010 can be referenced within the pathway
Enable Scotland have also produced some documentations

I have responded in areas in which I feel is my scope of practice in terms of supporting someone with a learning disability who may have experienced rape or sexual assault
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
122 I was a teenager during my experience of the pathways and I was not communicated with at all during the process, from reporting, to my forensic examination to the police investigation to the PF office all the way to the court and the final sentencing. 12 years on and I still don’t know the exact charges that were brought against my abuser. I was not offered any support, I was not referred to any mental health services, and I was not told what the process would actually entail or how long it would take. I feel that the process is not at all person centred or done in such a way that the survivor is actually cared for. The work of the Taskforce is to improve the service for the future and reduce the number of people who have similar experiences. The clinical pathway highlights the need for information to be given to survivors at every point in the pathway and requires people to be referred to services that they need when they require them.
123 Section 8.2- there is no mention of Power of Attorney (POA). It is possible that consent can be given or withheld by a POA who has welfare guardianship. It is also possible that the POA is the potential perpetrator or related to them. Something which sets out readily how the Forensic Physician does not need to pay heed if we believe the person is not acting in the interests of the person they are representing.

Page 49: 8.2: Paragraph 1- … the Forensic Physician should take account of the best interest of the patient… This may be absolutely what is intended, but the Adult with Incapacity Act refers to acting “to the benefit of the patient” rather than the “best interest” which is the terminology used in England.
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
124 I think the document could be shortened and more user-friendly. There is a one page flow diagram for full clinical and a psychosocial follow up in a wordy 50 page document. More flow charts and detailed diagrammatic pathways would be beneficial, though I appreciate this is not possible for every scenario. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
125 There doesn't appear to be any comment on training.
Are there Scottish standards for what the expected level of training /qualification for the various roles are?
The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. This training has also been made available to nurses involved in providing care to victims of sexual crimes.
The Advanced Forensic Practice postgraduate course, accredited by the Faculty of Forensic & Legal Medicine and certified by the United Kingdom Association of Forensic Nurses Advanced Standards in Education and Training within forensic practice, currently being developed at Queen Margaret University will provide nurses and doctors with the opportunity to further develop their skills.
Continued professional development for doctors can be accessed through NHS for Education Scotland.
126 The role of independent sexual violence adviser (ISVA) or equivalent - to provide support from the outset seems to have little inclusion. The Clinical Pathways subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
127 The role of patient feedback on guidelines and whether this is built into future role out doesn't seem to be included. The Healthcare Improvement Scotland Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse, Standard 1 (leadership and governance) notes that people should be informed about what to do if they wish to make a complaint or provide feedback about the service or facilities they have experienced. It is the responsibility for individual NHS Boards to meet this standard.
128 We welcome both the Pathways and Standards documents as major developments in the way victims of rape and sexual assault are treated when they come into contact with the NHS and, if fully implemented, will significantly improve their experience. Noted.
129 If implemented the major challenge will be to ensure that all NHS personnel receive training and are aware of the provisions of the pathway so that irrespective where and how they access services - GP, Accident & Emergency, health visitor etc. - they receive the appropriate, person centred response. The Pathway is person centred but a person centred service is reliant on the ability of individuals delivering it. The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland, has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
Wider workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
130 Evaluation of the pathway is vital, survivors’ voices should be considered and suggestions for improvement/development should be taken into account and implemented. The Healthcare Improvement Scotland Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse, Standard 1 (leadership and governance) notes that people should be informed about what to do if they wish to make a complaint or provide feedback about the service or facilities they have experienced. It is the responsibility for individual NHS Boards to meet this standard.
131 The flowchart on page 50 of the consultation document appears overly complex and potentially inaccurate and fails to adequately distinguish between examination and treatment.
Where a guardian or attorney has express authority to consent to medical examination (or treatment), and it is established that the adult does not have capacity to consent to the examination or treatment, that is the source in law for the doctor's authority to examine (or treat). If a flowchart is to be provided as a tool for medical professionals, then it should relate to forensic examination in the situation where such examination is necessary to establish whether criminal prosecution of a perpetrator is warranted, and if so to preserve and provide necessary evidence. The doctrine of necessity, expressly preserved in Part 5 of the 2000 Act, is potentially relevant if there is indeed urgency; as is the concept of assent, rather than consent – if necessary, communicated non-verbally.
The role of a guardian or attorney (including consideration of the scope of their powers), the use of certificates of incapacity, and the common law position in situations of emergency create a complicated system. The practical implications in forensic examination (as opposed to treatment), particularly in situations where examination may be urgent, require further consideration and clarification for the purposes of this guidance.
People with impairments of intellectual, mental and cognitive functioning are particularly vulnerable to sexual and other abuse. It is fundamental to concepts of justice and non-discrimination, reinforced by obligations under both human rights instruments referred to above, that they should be subject to no discriminatory obstacles in receiving the full protection of the criminal law, in practice as well as in theory. Potential offenders need to know that they are no less likely to face prosecution and conviction because they select victims with such impairments. The starting-point for section 8.2 of the consultation document must be to ensure that the foregoing requirements are fully achieved. A focus upon using an assessment of the existence of such impairments as a basis for failure to carry out essential forensic examinations, when such impairment may be the very reason for the suspected crime, is fundamentally inappropriate.
We suggest that this section of guidance should be further developed with the input of solicitors and practitioners with relevant expertise.
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
132 I am concerned that transgender women are being alluded to as a separate category than women in this action plan and that not enough support has been tailored to them in this despite the victim rate towards transgender women increasing - in fact within the LGBTI in Scotland it is transgender women whom are the most effected by rape and sexual violence by men and transmen in both the public and state sectors. Transgender women should be classed as women until
they stipulate their own identification of which they should not be judged for. While domestic violence, physical abuse and other forms of abuse are of course despicable actions and most criminal offences in Scotland there must be a clear distinction in the guidance between what is a sexual offence and what is an offence based on gender this difference should correspond to reality and will improve the public perception of those whom state they have been raped. A male punching a woman is disgusting of course but it is no penetrative rape. With the level of acquittals rising in Scotland as well one must also ask the government if it should now put in place measures to provide for those proven by a jury trial to have been falsely accused of this sort of crime for the damage and trauma they suffer there is also the issue within the document of proposing acquiring photographic evidence for the prosecution and defence for those effected by sexual violence now no agency or government department should ever make assumptions either way. It is not always possible to know that a victim is a lair or not or that a defendant is telling the truth or not without a jury trials verdict and even then there have been miscarriages of justice towards both the defence and the prosecution. I believe the Government in particular should steer well clear of judgement in its language regarding either side both for legal and moral reasons while not a criminal trial we have seen the folly of this in the civil trial of … at the Court of Session that ruled the defendants civil rights were grossly breached a breach regardless of criminal guilt or not that I warned MSPs seemed evident to me before it was concurred in court at Edinburgh now this disregard for the rights of the defence in that case is an issue which continues to cost this government very dearly to this day if there is anything as bad as rape it’s being falsely accused of rape. The state must not act on the assumption that the accused is guilty until proven innocent but innocent until proven guilty and any venture to capture evidence must be mindful of that fact. It is a very sad but true statement of which the author is only too well very painfully aware of it is the victim or in Scotland COPFS who must prove there allegation to a court and until that happens as much as I hate to admit it the state must assume there claims are unproven at best that of course does not mean those claiming to be victims which statistically are more often than not actually are telling the truth are automatic
liars and should not receive support and support in proving there allegations it simply means that the state must be mindful of the presumption of innocence a presumption that also applies to those being accused of making false allegations themselves actually. It is not the place of the NHS or even the police to declare a false allegation or declare a true allegation that is the remit of COPFS and criminal defence and it is the remit only of a judge or better still a jury of the Scottish people to verify if the allegation made by COPFS on behalf of the victim or a claim of innocence by the defence is true, false or unproven. I am concerned about the use of language in regards victims of rape under 16 as well a child is a child is a child and I find the notion in Scots law that a child 13+ but 15- can somehow give more consent than a child 12- very disturbing. It should be strongly stipulated in law and in practice that no matter the sexual orientation or gender of the person no person can give their consent to sexual activity with an adult 16+ in Scotland if they are below the age of 16.

Finally, there should be robust support given to those victim to s22 offences as defined under the Gender Recognition Act of 2004 and for those that do not have a GRC but are outed by the public or state. Outing in all its forms should be considered an act of violence towards woman. All points put forth by this consultation and by the responder for acceptance or rejection should only be accepted or rejected by the government if a majority of those living in Scotland agree to such actions by a majority via a direct democratic referendum.

In the event of a male police officer committing an act of sexual violence or outing a transgender person the pathway should take particular regard to the persons consent and work with their solicitor without crown direction or work only with CAAPD of COPFS without police contact. If an issue with CAAPD or COPFS ever arises then the pathway should work with the solicitor or make a direct application to work with the L-rd Advocate only. in the event of the victim ever being granted a ill of criminal letters then the pathway should work with the private prosecutor/or victim under their direction.
The Clinical Pathways Subgroup recognises that there are many vulnerabilities which may lead to a higher risk of assault. The adult clinical pathway outlines a high level national response to adults who present having experienced rape or sexual assault. Details on individual vulnerabilities are not provided in the pathway, as this is being addressed by changes to the training of staff, which will include more detail on particular needs of people at higher risk of assault.
Clinicians in this setting do not investigate allegations but take history from the individual at face value. The clinical pathway outlines how clinicians may support the collection of evidence to be used in the investigation, as well as assessing clinical need and offering appropriate assessment and treatment.
133 As a coal face GP, I am afraid that I did not find the pathway very informative or helpful. What I need is a single resource, which sounds like the “NHS Sexual Assault Service”. I have never previously heard of this service, so I would have appreciated the contact details. Generally, apart from standard good GP consulting, I would always cover Police and Rape Crisis Scotland, but I did not know that the NHS had any dedicated resource, over and above GUM / Sexual Health. The Honouring the lived experience: Rape and Sexual Assault Victims Taskforce options appraisal report recommended a service model based on local service provision with a regional centre of excellence.
The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
134 One of the challenges for the pathway is that a young person who has just turned 16 years of age is potentially viewed as having the same needs as an adult who may be in their 20’s, 30’s or much older A young person aged 16 years is still developing emotionally, physically and sexually and their needs are therefore different due to their age and continued status as a young person rather than an adult. In relation to a pathway for reporting rape and sexual assault this means that they should be considered vulnerable based on their age. In addition, practitioners should be aware that a proportion of 16/17/18 year old young people who present as having been affected by sexual assault or rape will have also been the victims of sexual abuse whilst they were under the age of 16 years. This may or may not have been reported and may or may not have progressed through the justice system. It is important to take account of the increased vulnerability of young people who have a history of abuse. This may vary from young people who experienced abuse from a young age, that continued over many years, usually perpetrated by someone close to them, and that these and other young people can continue to experience further abuse. Their early exposure to abuse means that many have an increased vulnerability to further abuse, including those where they may be groomed and subjected to environmental factors that may indicate sexual exploitation or a risk of this. It is known that our Looked After and Accommodated Young people are at a significantly greater risk of this. A young person with a history of sexual abuse will therefore need any new incident or report to be taken within the context of a chronology of adverse childhood events. They will also need attention paid to undertaking a comprehensive and holistic assessment of their needs informs the offer/plan for trauma sensitive support post disclosure/reporting. This will need particular attention paid to considering any ongoing risks to their safety and assessing for any general wellbeing concerns. One of the additional challenges that can arise in relation to offering follow up is that young people will at times not identify or recognise what they have experienced as abusive. Some will also be concerned about the potential consequences of sharing their experience, either fearing reprisals for themselves or keen to protect their abuser, who they may consider their partner. Resistance to the offer of follow up support will need to be sensitively explored, from a perspective of understanding that the issue of what constitutes abuse or consent can be confusing for a young person. Young people, who through time recognise that they were the victims of targeted and grooming and/or organised sexual abuse in a coordinated way, have shared that they initially did not recognise that were being exploited. This is in part due to their age and a consequence of highly effective grooming, which can leave young people believing that they are in a consensual relationship. The gap in information relates to young people aged 16-18 years (and potentially up to 25 years if care experienced) who may be particularly vulnerable for some reason. For these young people, requirement related to corporate parenting and/or Getting it Right for Every Child (GIRFEC) may be engaged although the young person is on the adult pathway. Young people who have a corporate parent may form a disproportionate high proportion of young people age 16-18 on the adult pathway, due to their increased vulnerability. For these young people, and most others in the 16-18 age group, it will be necessary to consider whether the GIRFEC approach should be used to provide support or augment support already in place for the young person.
In some cases, depending on the circumstances, an initial/interagency referral discussion (IRD) will be indicated.
The situation with regard to these young people may be complicated by
1) The fact that some will not regard themselves as particularly vulnerable
2) Some care experienced young people choose not to identify themselves as such.
The adult pathway should include some guidance on when these issues need to be considered, how to recognise young people who are particularly vulnerable and signposting on the practical steps which need to be taken
This language has been incorporated into the pathway to provide further guidance on when either the adult clinical pathway or the children and young people's clinical pathway should be used.

Contact

Email: CMOtaskforce.secretariat@gov.scot