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

2. Understanding and Responding to the Needs of People

This section:

• Focuses on the societal and cultural context of gender based violence, abuse and sexual violence
• Outlines the need for services that respond appropriately to the needs of people who have experienced rape sexual assault or child sexual abuse

Key points

• The term gender based violence is used to describe violence, predominantly against women and girls, in the context of gender inequality
• Those most at risk of domestic abuse are those with multiple vulnerabilities. Perpetrators can be adept at targeting people with vulnerabilities
• Services must be designed with the person at the centre, so that the physical environment and care pathway has due regard for the impact of trauma
• One of the challenges for the pathway is to provide age appropriate services. Services designed for older adults may not address the needs of young people

2.1 Gender Based Violence

Sexual violence can affect anyone in Scotland; it perpetuates inequality and prevents the achievement of potential, not only for those who directly experience it or those who fear it, but also their families, and communities (Scottish Government 2016).

The term ‘gender based violence’ is generically used to describe violence, predominantly against women and girls, in the context of gender inequality. Gender based violence encompasses:

• Domestic abuse including coercive control^[21]
• Rape and sexual assault
• Child sexual abuse
• Commercial sexual exploitation
• Sexual harassment and stalking
• Harmful traditions and practices

The roots of gender based violence are deeply embedded within societal and cultural attitudes towards women and in notions of how men and women should behave, particularly in relation to sexual matters (Health Scotland 2018).

These attitudes can have a significant impact on people who have been raped or sexually assaulted and can deter them from seeking help due to fear of judgment. Fear of judgement is particularly common among people who are vulnerable at that time, for example those with experience of the care system; people with learning and/or physical disabilities; people who experience gender based violence; those who have been victims of human trafficking and exploitation for the purpose of commercial sexual exploitation; those with experience of the criminal justice system; people who misuse drugs and/or alcohol; and those living with domestic abuse. These factors contribute to significant under reporting.

Sexual violence within relationships should always be considered within the wider context of domestic abuse. It is also important to understand the full dynamics of domestic abuse. The Domestic Abuse (Scotland) Act 2018 criminalises not only physical abuse but other forms of psychological abuse and coercive and controlling behaviour. This new offence brings clarity for victims so they can see explicitly that what their partner or ex-partner has done to them is wrong and can be dealt with under the law.

Anyone who is a partner or an ex-partner (spouse, civil partner or in an intimate relationship) can be affected by domestic abuse. Those most at risk of domestic abuse are those with multiple vulnerabilities. Perpetrators can be adept at targeting people with vulnerabilities. An assessment of ongoing risk should be undertaken with any individual experiencing intimate partner violence, including child protection issues (NHS Education for Scotland 2017). This is included in the digitised National Form within Cellma, and is to be performed as part of the health assessment.

Female Genital Mutilation (FGM) is an illegal practice and an extreme violation of human rights. FGM reflects deep-rooted inequality between the sexes and constitutes a severe form of discrimination against women and girls. Perpetrators of FGM may seek to justify their behaviour by referencing various socio-cultural factors, including fixed gender roles that perceive women and girls as gatekeepers of their family’s honour. FGM has been illegal in Scotland since 1985, when the Prohibition of Female Circumcision Act was passed. The Female Genital Mutilation (Protection and Guidance) (Scotland) Act 2020 was passed on 19 March 2020. Work on the implementation of the Act is now recommencing. The Act creates a new type of Protection Order for women and girls at risk of, or who have experienced, FGM, and for the general purpose of reducing the likelihood that FGM offences will occur. An application for an FGM Protection Order can be made by the person who has had, or who is at risk of FGM; by a relevant local authority, Police Scotland, or the Lord Advocate; or with the permission of the court by any other person (for example, a family member or a charity).

2.2 Responsive Services

A timely, person-centred multi-agency coordinated approach following rape or sexual assault can positively influence a person’s long term health, wellbeing and recovery, and supports continued engagement, as well as the collection of high quality evidence to support any criminal justice process.

For the person, sexual abuse can have both immediate and longer term impacts on their physical and mental health and wellbeing. Effects can vary and can include depression, anxiety, post-traumatic stress disorder, psychosis, alcohol and drug misuse, eating disorders, self-harm and suicide. Sexual abuse may also affect personal and professional attainment, and can worsen the impact of inequalities in women, the vulnerable and the disadvantaged (Department of Health 2012, Conaglen and Gallimore 2014).

2.3 Person-Centred, Trauma-Informed Services

In accordance with the Healthcare Improvement Scotland Standards^[22] and national service specification document^[23], services must be designed with the person at the centre, so that the physical environment and care pathway has due regard for the impact of trauma. Any staff in direct contact with the person should also have completed the NHS Education for Scotland (NES) training which incorporates the principles of the National Trauma Training Framework^[24]. The level of trauma training that staff working with people who have experienced rape and sexual assault will be expected to have is outlined in Appendix B. Health Boards are responsible for ensuring that their employees are trained to the appropriate level in accordance with the trauma training framework.

NES on-line training resources^[25] are available to help increase awareness, knowledge, capacity and capability among all sectors of the workforce to understand the impact of trauma and embed trauma-informed practice and responses. These are available for free and accessible to everyone in the Scottish workforce and include the key principles of safety, trust, choice, empowerment and collaboration. The importance of this approach is set out below.

First, it supports the recovery of those affected by trauma by providing them with a different experience of relationships, one in which they are offered safety rather than threat, choice rather than control, collaboration rather than coercion, and trust rather than betrayal. Each encounter provides an opportunity to reverse the association between trauma and relationships and is an important part of recovery.

Second, it minimises the barriers to receiving care, support and interventions that those affected by trauma can experience when memories of trauma are triggered by aspects of the service or interactions with staff. People affected by trauma can become highly sensitive to subtle (as well as obvious) reminders of their previous traumatic experiences and relationships. Such reminders and the distress that they may cause, is another reason why people affected by trauma may not engage with or drop out from the care, support and interventions that they need. Trauma-informed care allows workers and services to explicitly identify and adapt any aspects of their service that may trigger distress associated with trauma, in order to minimise it.

The Psychological Therapies Matrix^[26] recommends empowerment to help support a person’s recovery from the trauma they have experienced. The provision of services and the processes and policies which underpin them should all be viewed through a trauma-informed lens to ensure that the person is given choice and control over all aspects of their care. The person should be made to feel safe and that they can trust the people involved in providing their care.

Services should be alert to possible triggers. A trigger is a term commonly used to describe something that re-ignites the trauma response for a person and is highly personal to the individual’s experience. The response is a subconscious action by the brain to engage safety systems to protect them from further harm. They cannot control this response and may not even be aware what has caused it. Something which is identified as a trigger for one person may not affect someone else. Whilst no list can be exhaustive, the Health Board Service Specification seeks to highlight factors in the delivery of the service which may unintentionally trigger a trauma response (for example sights, smells, sounds or processes).

Useful Resources

NHS Education for Scotland (2017) Transforming Psychological Trauma: A knowledge and skills Framework for the Scottish Workforce^[27]

Rape Crisis Scotland (2017) I Just Froze^[28]

NHS Health Scotland (2018) Gender Based Violence^[29]

NHS Lanarkshire: Trauma and the Brain: Understanding Abuse Survivors Responses^[30]

2.4 Young People 16 and 17 Years Old

A young person aged 16 years is still developing emotionally, physically and sexually and their needs are therefore different from those of older adults. For young people aged 16 and 17, professional judgement should be used to decide whether the adult clinical pathway or the pathway for children and young people^[31] is most appropriate. In relation to a pathway for reporting rape or sexual assault, they should be considered potentially vulnerable based on age. The Adult Support and Protection (Scotland) Act 2007^[32] provides additional protection to adults at risk of harm or neglect. The Act defines 'adults at risk' as those (aged 16 years or over) who:

• Are unable to safeguard their own wellbeing, property, rights or other interests
• Are at risk of harm; and
• Are more vulnerable to being harmed because they are affected by disability, mental disorder, illness or physical or mental infirmity

An adult is at risk of harm if:

• Another person's conduct is causing (or is likely to cause) the adult to be harmed, or
• The adult is engaging (or is likely to engage) in conduct which causes (or is likely to cause) self-harm

The Act places a duty on local authorities to inquire into and investigate cases where it knows or suspects that an adult is at risk and that it might need to intervene to protect, among other things, the person’s wellbeing. A local authority has powers to visit and interview people, arrange medical examinations, examine records and apply for various types of protection orders. It must also consider if there is a need for advocacy and other services, such as help with medication, or support services.

The provisions of the Adults with Incapacity (Scotland) Act 2000^[33] may be relevant for some young people aged 16 and 17 years. The Act concerns the welfare of adults with special needs who are unable to make decisions for themselves or are not able to communicate. This Act provides the framework for other people (such as carers) to act on the behalf of people with incapacity. For further information on Adult Support and Protection, see section 6.1.

In addition, practitioners should be aware that a proportion of 16 and 17-year-old young people who present reporting rape or sexual assault may have been 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 criminal justice system. It is important to take account of the increased vulnerability of young people who have a history of abuse. This may include young people who experienced abuse from a young age which continued over many years and may have been perpetrated by someone close to them. 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, be subject to grooming or at risk of sexual exploitation.

Young people who have experience of the care system are at a significantly greater risk of being in this position. A young person with a history of sexual abuse will therefore need any new incident or report to be assessed within the context of a chronology of adverse childhood events. They will also need a comprehensive and holistic assessment of their needs to inform the offer/plan for trauma sensitive support post disclosure/reporting. Particular attention should be paid to considering any ongoing risks to their safety and assessing general wellbeing concerns. One of the additional challenges that can arise in relation to offering follow up in this group 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 being keen to protect their abuser, who they may consider their partner.

Other young adults who may be particularly vulnerable with regard to rape or sexual assault and where resistance to the offer of follow up support will need to be sensitively explored include:

• Those who have been trafficked and/or have been unaccompanied asylum seeking children
• Young people who have been victims of CSE and/or grooming and abuse in a coordinated way. This may be in part due to their age and a consequence of highly effective grooming, which can leave young people either believing that they are in a consensual relationship or in fear of the consequences of exposing their exploitation.

For these particularly vulnerable young people aged 16 and 17 years (and potentially up to 25 years if care experienced), although the young person is on the adult pathway, the requirements of public bodies related to corporate parenting and/or Getting it right for every child (GIRFEC) may be engaged.

For the purposes of this pathway, child sexual abuse is defined as an act that involves a child under sixteen (or up to 18 years of age for young people with vulnerabilities and additional support needs) in any activity for the sexual gratification of another. For those aged 16 and 17 who may be victims of sexual abuse, child protection procedures should be considered; and must be applied when there is concern about sexual exploitation or trafficking.

CSE is defined as a ‘form of child sexual abuse in which a person(s), of any age takes advantage of a power imbalance to force or entice a child into engaging in sexual activity in return for something received by the child and/or those perpetrating or facilitating the abuse.’

As with other forms of child sexual abuse, the presence of perceived consent does not undermine the abusive nature of the act. ‘Child’ in this context means child or young person up to age 18. A child or young person of either sex may be a victim. A child protection response is required, the manner of which will be determined following an Inter-agency Referral Discussion (IRD). ‘Disclosure’ is not a pre-requisite for a child protection investigation or IRD.

Where information is received by police, health or social work that a child may have been abused or neglected and/or is suffering or is likely to suffer significant harm, an IRD must be convened as soon as reasonably practical.

The IRD process may have to begin out with core hours, with a focus on immediate protective actions and interim safety planning. A comprehensive IRD must be completed as soon as practical. This should normally be on the next working day.

The IRD is the start of the formal process of information sharing, assessment, analysis and decision making following reported concern about abuse or neglect of a child or young person in relation to familial and non-familial concerns; and of siblings or other children within the same context.

IRDs are required to ensure coordinated inter-agency child protection processes up until the point a Child Protection Planning Meeting (CPPM) is held; or until a decision is made that a CPPM is not required. An IRD is not usually a one-off discussion. It is a series of discussions between representatives of each of the core agencies as to what the coordinated response should be - a process where it may be necessary to reconvene the IRD as enquiries progress to review strategies and evaluate outcomes.

The situation with regard to these young people may be complicated by:

• The fact that some will not regard themselves as particularly vulnerable
• The fact that some care experienced young people choose not to identify themselves as such

The key principles and components of the IRD are defined in the National Guidance for Child Protection in Scotland 2021^[34].

2.5 Corporate Parenting

The Children and Young People (Scotland) Act 2014^[35] (“the 2014 Act”; part 9 which relates to Corporate Parenting) came into effect on 1 April 2015. The Act names 26 public bodies^[36] and groups of bodies as corporate parents. Under the 2014 Act, Corporate Parents have a duty to promote the wellbeing of looked after children and care leavers to the age of 26.

The 2014 Act also inserts a new section 26A into the Children (Scotland) Act 1995. This section supports the provision of continuing care, meaning that a young person can remain in a foster care, residential care or equivalent placement until the age of 21. Corporate parenting duties for the 26 public bodies also apply to these young people.

The term corporate parenting is defined as: ‘An organisation’s performance of actions necessary to uphold the rights and safeguard the wellbeing of a looked after child or care leaver, and through which physical, emotional, spiritual, social and educational development is promoted’ (Statutory Guidance on Corporate Parenting, 2015).

Young people who have a corporate parent may form a disproportionately high proportion of young people age 16 and 17 on the adult pathway, due to their increased vulnerability. For these young people, and most others in the 16 and 17 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.

When required, the GIRFEC approach will provide a holistic assessment of support needs for the child or young person and a personalised support plan when the child or young person needs a range of extra support to be planned, delivered and coordinated. This plan will explain what should improve for the child or young person, the actions to be taken and why the plan has been created. The plan is managed by a 'lead professional'; someone with the right skills and experience to make sure the plan is managed properly. The child or young person and parent/carer(s) will know what information is being shared, with whom and for what purpose, and their views will be taken into account.

2.6 Older people

Circumstances that make children vulnerable to abuse can also apply to older people. Some older people will become dependent on others, creating a power imbalance that may be taken advantage of. Older people have the same human rights as everyone else and the impact of sexual abuse on an individual does not diminish as people get older.

The subjects of consent and capacity, including disability, are dealt with in section 7.