Healthcare professionals - supporting adults who present having experienced rape or sexual assault: clinical pathway

1. Introduction

1.1 What is the purpose of this guidance?

This clinical pathway and guidance is for healthcare professionals in Scotland working to support adults (16 years and over) who present having experienced rape or sexual assault. It outlines:

• The processes for supporting the immediate health and wellbeing of individuals
• The requirements for trauma-informed practice
• Guidance on how to assess and manage clinical risk, ongoing safety, and the provision of ongoing support and follow up
• Who can access self-referral FMEs
• The processes for collection of forensic evidence, if required
• The legal framework and policy context in Scotland
• The processes for providing evidence for criminal justice system purposes

Healthcare professionals should not make a judgement about whether the reported rape or sexual assault against a person did or did not take place. It follows that from a clinical, person-centred and trauma-informed perspective, that this pathway refers to a report of rape or sexual assault. Whether a rape or sexual assault has taken place is ultimately for a court to decide, if a police report is made a criminal case is subsequently brought forward.

1.2 Who should use this guidance?

This guidance should be used by NHS Health Boards and Integrated Joint Boards to inform the way in which services are structured and delivered locally. This guidance provides a minimum standard for service delivery, in line with the Health Board service specification^[2].

Responsibility for the delivery of healthcare and forensic medical services sits with NHS Health Boards.

1.3 How should this guidance be used?

This document is split into chapters, for ease of reference. Where possible, for all resources referenced or referred to within this document, a link to the document is provided. This pathway should be used as part of a holistic healthcare approach, which delivers a person-centred, trauma-informed service provided by an appropriately trained workforce. Anything defined in the guidance is a general description of the term and is not referring to a statutory definition of the term, unless otherwise specified.

1.4 Who is this guidance applicable to?

This guidance is designed to support the healthcare and FME of adults aged 16 and above who disclose recent rape or sexual assault.

For those under 16, please consult:

• National Guidance for Child Protection in Scotland (Scottish Government 2021)^[3]
• Standards of Service Provision and Quality Indicators for the Paediatric Medical Component of Child Protection Services in Scotland (Child Protection Managed Clinical Networks 2017)^[4]
• National Clinical Pathway for Children and Young People^[5]

There may be occasions, due to capacity, other additional needs or vulnerabilities where it is appropriate for a person aged 16 or over to have a joint examination with a paediatrician. This should be decided at an Inter-agency Referral Discussion (IRD). For further guidance on support for young people, please refer to section 2.4.

1.4.1 Delayed Disclosure

For those who disclose child sexual abuse in adulthood, the guidance below should be referred to:

• Working with Survivors of Childhood Sexual Abuse (Scottish Government 2008)^[6]
• The Psychological Therapies Matrix (2015) – A Guide to Delivering Evidence-Based Psychological Therapies in Scotland (NHS Education for Scotland 2015)^[7]
• Coping after a Traumatic Event (RCPCH 2016)^[8]
• Childhood Sexual Abuse – Information booklet for women survivors (Glasgow and Clyde Rape Crisis Centre 2016)^[9]
• Survivors UK^[10]

1.5 What other documents should be consulted?

The guidance is intended to supplement but does not replace existing national guidance and standards such as:

• Health and Social Care Standards: My Support, My Life (Scottish Government 2017)^[11]
• Standards for Healthcare and Forensic Medical Services for People who have experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults (Healthcare Improvement Scotland 2017)^[12]
• Indicators for Healthcare and Forensic Medical Services for People who have experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults (Healthcare Improvement Scotland 2020)^[13]
• Compendium of Healthcare Associated Infection Guidance (Health Protection Scotland, 2018)^[14]
• Recommendations from the Faculty of Forensic and Legal Medicine (Faculty of Forensic & Legal Medicine (FFLM), 2019), recognising that there are some important differences between the English and Scottish legal and justice systems^[15]
• Clinical Guidance: Emergency Contraception (Faculty of Sexual and Reproductive Health 2017)^[16]
• UK Guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure (British Association of Sexual Health and HIV (BASHH) 2021)^[17]
• Gender based violence, Domestic abuse - What health workers need to know (NHS Health Scotland 2019)^[18]
• Confidentiality: Reporting gunshot and knife wounds (General Medical Council 2018)^[19]

1.6 Who has developed the guidance?

The guidance has been developed by the Clinical Pathways Subgroup and approved by the Chief Medical Officer’s Taskforce for the Improvement of Services for Victims of Rape and Sexual Assault^[20].

A wide range of multi-agency professionals were members of the subgroup along with third sector organisations to represent the views of people with lived experience.

This document is currently held by the Chief Medical Officer’s (CMO) Taskforce Unit within the Scottish Government who are responsible for reviewing and updating it on behalf of the Taskforce. This version is an update to the guidance published in November 2020. However, each consecutive iteration should be retained for audit and control purposes. The most up to date version can be found on the CMO Taskforce website.

1.7 Review of the pathway

The November 2020 version of the pathway has been updated to take account of the introduction of self-referral FMEs in accordance with health board responsibilities under the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Act 2021, which commenced on 1 April 2022. The pathway will be updated to reflect any future changes that are relevant to the guidance included in this document.

This pathway contains references to legislation that are relevant to forensic medical services. This pathway does not supersede or alter any duties or requirements imposed by legislation or legal obligations and principles arising from case law determined by the courts (more applicable to criminal justice matters). Legislation may have been amended before this document is next reviewed and this should not be considered a comprehensive description of the law in this area. Case law may also have changed. If needed, independent advice should be obtained on the accuracy of any references to legislation or reference to any other legal obligations or descriptions of the law. If legal advice is required in relation to the provision of care, this should be sought through the normal Health Board process.

1.8 What terminology is used in the guidance?

Terminology in the pathway has been used to align with Healthcare Improvement Scotland’s Standards for Healthcare and Forensic Medical Services.

Wherever possible, generic terminology, which can be applied across all settings, has been used. The term ‘person’ or ‘people’ is used to refer to the person receiving care or support. This emphasises that people have the same rights to care, irrespective of their sex or other distinguishing characteristic.

Throughout this document, we have used the phrase ‘Sexual Offence Examiner’ (SOE) to refer to the clinician carrying out the FME. It is acknowledged that, depending on the specific circumstances or the wishes of the person who has experienced rape or sexual assault, it may be that there is only a requirement for a healthcare assessment and associated follow up and this may be done by a range of healthcare professionals.