Clinical pathway for children and young people who have disclosed sexual abuse: consultation

4. Context

4.1 Who is a Child?

A child can be defined differently in different legal contexts (see Appendix A).

This clinical pathway is applicable to the care of children less than 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs e.g. looked after and accommodated)

4.2 Sexual Abuse

The World Health Organisation, in association with the International Society for the Prevention of Child Abuse and Neglect, defines child sexual abuse in general terms as:

the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violate the laws or social taboos of society

The dynamics of child sexual abuse differ from those of adult sexual abuse. It is more likely for a child to experience sexual abuse at the hands of a family member or another supposedly trustworthy adult.

With childhood sexual abuse children are often too young to know how to express what is happening and seek out help. Disclosure tends to be a process rather than a single episode and is often initiated following a physical complaint or a change in behaviour.

Children can be sexually abused by adults or other children who are – by virtue of their age or stage of development in a position of responsibility, trust, or power over the victim.

The Sexual Offences (Scotland) Act 2009 outlines types of offences against younger children (up to 12 years of age) and older children aged 13-15. Although engaging in sexual activity under the age of 16 is illegal, the law draws a distinction between consensual and non-consensual conduct with older children, and in these circumstances a risk assessment to establish and respond to child protection concerns is appropriate. Inter-agency discussion will help to establish how best to proceed in individual cases. (Underage sexual activity: identifying child protection concerns).

4.3 Trauma–Informed Services

4.3.1 Trauma–Informed, Child and Family Centred Care

Trauma informed practice takes into account the impact that sexual violence may have on a child or young person and their family. It seeks to ensure that their experience of trauma is not repeated or triggered during the examination or journey through care. It offers a very different relational experience from child sexual abuse; one which may help to start the healing process rather than hinder it.

Principles of trauma informed practice:

• Realise the prevalence of trauma.
• Recognise the impact of trauma.
• Respond using trauma informed principles, both personally and as an organisation.
• Resist re-traumatisation through offering choice and collaboration, power and control, safety and trust.

4.4 Understanding the Impact of Adverse Childhood Experiences

The dynamics of child sexual abuse differ from those of adult sexual abuse.

When children are exposed to adverse and stressful experiences, it can have a long-lasting impact on their ability to think, interact with others and on their learning. When not properly treated, child sexual abuse can result in a lifetime of Post Traumatic Stress Disorder (PTSD), depression and anxiety.

Useful resources

NHS Education Scotland (2017): Transforming Psychological Trauma: A knowledge and skills Framework for the Scottish Workforce

NHS Health Scotland (2018): Gender Based Violence

NHS Lanarkshire: Trauma and the Brain: Understanding Abuse Survivors Responses

NHS Education Scotland (2018): Opening Doors: Trauma Informed Practice for the Workforce https://vimeo.com/274703693

NHS Health Scotland (2018): Adverse Childhood Experiences (ACEs)

4.5 Legal Context

This pathway outlines the response of professionals when they have become aware of concerns or allegations of possible sexual abuse of children. As such they have a duty to respond by considering the safety of the child and other children who may be at risk, as their primary concern, within a child protection context.

Children under the age of 13 cannot consent to sexual activity so concerns must be passed on in accordance with local child protection procedures. Cases where children aged 13 to 15 years have disclosed non-consensual activity must also be passed on.

Where young people aged 13 to 15 years are involved in consensual sexual activity it may be necessary to share information to ascertain if this activity is truly consensual and ensure the child is not a victim of exploitation or grooming.

All those working with children and young people should follow their organisation’s child protection policies and procedures. A child protection response should still consider the views and wishes of the child.

It is crucial that paediatricians and other professionals involved in care of children who have disclosed sexual abuse have an understanding of the legal frameworks that inform these processes. More detail of the legal context is provided in Appendix B.