Healthcare professionals - supporting children and young people who may have experienced child sexual abuse: clinical pathway

2 Child Sexual Abuse (CSA)

2.1 Definition of CSA

Within this pathway, child sexual abuse (CSA) is defined as an act that involves a child less than 16 years of age in any activity for the sexual gratification of another person, whether or not it is claimed that the child consented. A child or young person of either sex may be a victim. Sexual abuse involves forcing or enticing a child to take part in sexual activities, whether or not the child is aware of what is happening (National Child Protection Guidance 2021). For those who may be victims of sexual offences aged 16-17, see section 3 of the pathway.

There are situations between young people under 16 that may not require child protection processes to be used, but where immediate support is needed in relation to sexual risks, development and relationships. This may be addressed either on a single agency or multi-agency basis, depending on needs and circumstances. Child protection concerns arise when the impact of under-age sexual activity could cause significant harm.

With child sexual abuse, children are often too young to know how to express what is happening or how to seek help. The identification of concerns or disclosure tends to be a process rather than a single episode and is often initiated following a medical 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 child. Online technology and the internet can be vectors of non-contact activity which can lead to contact sexual abuse.

As young people grow and develop, they are influenced by a whole range of environments and people outside their family including in school or college, in their local community, in their peer groups and/or online. Children and young people may encounter risk in any of these environments. Sometimes the different contexts are inter-related and can mean that children and young people may encounter multiple risks.

There are various circumstances within which abuse can occur which is why health professionals also have a role, with partners, in the response to extra-familial forms of abuse. Contextual safeguarding looks at how we can best understand these risks, engage with children and young people and help to keep them safe.

Some groups of young people may be particularly vulnerable with regard to rape, sexual assault or CSA, and resistance to the offer of follow up support will need to be sensitively explored. These include those who have been trafficked and/or are an unaccompanied asylum seeker, or who have been victims of child sexual exploitation and/or grooming and abuse in a coordinated way. Reluctance to accept help and support may be 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, professional judgement may determine that it is more appropriate for the young person to follow the adult clinical pathway. However, the requirements in relation to GIRFEC must still be considered and child protection procedures must be followed for victims of child sexual exploitation or trafficking who are aged 16 and 17.

The Sexual Offences (Scotland) Act 2009^[11] (2009 Act) outlines types of offences against younger children (under the age of 13) and older children (aged 13-15). In all cases of suspected child sexual abuse there should be an Inter-agency Referral Discussion (IRD) (see Section 6.2).

Younger children

Children under the age of 13 cannot consent to sexual activity so in every case in which a child of that age is subjected to sexual activity it is very likely that a criminal offence has been committed. Accordingly, concerns must be raised in accordance with local child protection procedures.

Older children

If a child aged between 13 and 15 years has been subjected to non-consensual sexual activity then, in accordance with the law in relation to adults, it is very likely that a criminal offence has been committed due to the absence of consent. Cases in which children aged between 13 and 15 years have disclosed non-consensual activity must also follow child protection procedures.

If a child aged between 13 and 15 years engages in apparently consensual sexual activity with a person aged 16 or older it is likely that a criminal offence has been committed by the person aged 16 or older. For example, if a male aged 16 or older penetrates the vagina, anus or mouth of a 13-15-year-old female with his penis with her consent he commits an offence in terms of section 28 of the 2009 Act. In these circumstances, it may be necessary to share information to ascertain if the child is a victim of exploitation or grooming. There will be many circumstances in which consensual sexual conduct involving a child aged 13-15 should be investigated by the police and subsequently prosecuted.

Other children, aged between 13 and 15 who engage in sexual activity with one another both commit a criminal offence in terms of section 37 of the 2009 Act if: a) the activity involves penile penetration of the vagina, anus or mouth or touching of the vagina, anus or penis with the mouth; and b) both parties consent to the activity. Again, depending on the particular circumstances it may be necessary to share information to determine if one or both of the children are being, or have been, exploited.

2.2 Young people 16 and 17 years old

Within this pathway, child sexual abuse is defined as an act that involves a child under sixteen (or up to 18^th birthday 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 have experienced sexual abuse, child protection procedures should be considered, and must be applied when there is concern about sexual exploitation or trafficking.

There may be multiple reasons for considering a young person aged 16 or 17 to be vulnerable or have additional support needs. Children with communication impairments, behavioural disorders, learning disabilities and sensory impairments may be additionally vulnerable to abuse and neglect. The most common forms of abuse experienced by disabled children are neglect and emotional abuse, although they may experience multiple abuses including sexual abuse. Disclosing abuse can be more difficult for children who have a communication impairment, and this can be more problematic if a perpetrator is also in a trusted role.

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 is most appropriate. The National Guidance for Child Protection in Scotland includes young people up to 18 years within the definition of ‘child’ and therefore consideration must also be given as to whether an IRD is required. In doing so, consideration should be given to the person’s capacity and whether there is a need for adult support and protection measures to be put in place.

Not all young people aged 16 and 17 years interpret abuse as abuse. Some are at heightened risk because of vulnerabilities, effective grooming and/or because of fear of the consequences of speaking out. They may fear reprisals for themselves or someone close to them or be keen to protect their abuser, who they may consider to be their partner. In addition, health professionals should be aware that a proportion of 16 and 17-year-old young people who present reporting rape or sexual assault may have experienced 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 an early age which continued over many years and may have been perpetrated by someone close to them.

2.2.1 Adult support and protection

The provisions of the Adults with Incapacity (Scotland) Act 2000^[12] may be relevant to some young people aged 16 and 17.

Under the Adult Support and Protection (Scotland) Act 2007^[13] (“the 2007 Act”), an ‘adult at risk’ is someone aged 16 or over who is unable to safeguard their own wellbeing, property, rights or other interests, is at risk of harm and because they are affected by disability, mental disorder, illness or physical or mental infirmity, is more vulnerable to being harmed than adults who are not so affected.

The 2007 Act provides that an adult is at risk of harm (for the purposes of the 2007 Act) if another person’s conduct is causing (or is likely to cause) that adult harm, or the adult is engaging (or is likely to engage in) conduct which causes (or is likely to cause) self-harm. The provisions of the 2007 Act are in place to support and protect any adults who are at risk of harm.

The 2007 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 2007 Act concerns the welfare of adults (for the purposes of this pathway, young people aged 16 and 17) with special needs who are unable to make decisions for themselves or are not able to communicate. The 2007 Act provides the framework for other people (such as carers) to act on the behalf of people with incapacity. Further information on Adult Support and Protection, can be found in the adult clinical pathway.

2.3 Child Sexual Exploitation

Child Sexual Exploitation (CSE) is defined within the National Guidance for Child Protection in Scotland 2021 as a ‘form of child sexual abuse in which a person or persons of any age take 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.’

The victim may have been sexually exploited even if the sexual activity appears consensual. CSE does not always involve physical contact. It can also occur using technology. As with other forms of child sexual abuse, the presence of perceived consent does not excuse or mitigate the abusive nature of the act. ‘Child’ in this context means child or young person up to their 18^th birthday. A child or young person of either sex may be a victim. A child protection response is required, the nature of which will be determined following an Inter-agency Referral Discussion (IRD). ‘Disclosure’ is not a pre-requisite for a child protection investigation: the clinician(s) may have concerns about abuse and exploitation necessitating an IRD (see section 6.1). Children who are trafficked across borders or within the UK may be sexually abused.