Publication - Consultation analysis

Supporting children and young people who may have experienced child sexual abuse - clinical pathway: consultation analysis

Published: 10 December 2020
Directorate: Chief Medical Officer Directorate
Topic: Children and families, Health and social care
ISBN: 9781800042537

An analysis of the responses to the consultation on the draft Clinical Pathway for healthcare professionals working to support children and young people who may have experienced child sexual abuse.

Supporting documents

Section 1: Introduction

Do you believe the pathway would improve and standardise services for children who have disclosed sexual abuse and their families?
Yes	35	61.40%
No	12	20.05%
Not Answered	10	17.54%

ID.	Consultation comment	Clinical pathways subgroup group response
Comments
641E-8	This pathway is aligned to our current procedures in [our area]. However, a standardised pathway will ensure procedures are consistent nationwide.	Noted
64ME-4	The Pathway will not improve the system because the system itself is not fit for purpose – and this is so for a number of reasons. If you have experienced a Joint Interview, and the lead up to it, you will know that it is not in any way child friendly. It is intimidating and does not in any way take into account the needs of a younger child in particular, the primary need being to first establish a relationship of TRUST. Basically what the JII asks of children is for them to immediately trust a total stranger with information they feel scared and confused about – information that they are barely able to process or understand themselves – in an alien environment into which they are thrust with very little warning or preparation. It is fundamentally inept and borders on being barbaric. It is essential to bear in mind that many sexual abusers embed threats in the mind of the child victims in order to silence them. How then can a child disclose to complete strangers in the context of a Joint Investigative Interview any concrete information while believing that it would result in a terrible fate befalling them or someone they truly trust. The Barnahus model offers a far more child sensitive approach where time and care is taken to build a rapport of trust with the child in a safe and comfortable environment, which happens over a period of time and is not a rushed, stressed, invasive experience – as are some JI’s in Scotland. The Barnahus model was referred to in a positive way in the Evidence and Procedure Reviews that took place in recent years, and yet I see no sign that this has been taken forward into the Scottish System of child protection.	The Pathway is intended to describe best clinical practice in line with current relevant legislation and guidance. The Pathway is not intended to change the IRD or Joint Investigative Interview process or to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s). The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64ME- 4	My daughter experienced a JI when she was 4 years old. We had to go to [a] Police Station and sit in the entrance where two large intimidating men stood behind the desk. It was an entirely unfamiliar setting for my daughter, and I felt it was unpleasant and potentially alienating. Then the social worker and police officer arrived and said we had to go somewhere else, which was the […] Hospital. We had to drive there and provide a lift to the Social worker who was evidently very stressed and came across as being agitated. When we got there, it looked like an abandoned hospital. The context felt unfriendly and was bordering on eerie. My daughter tried to make conversation with the police officer and had obviously taken a liking to her, but still had to cope with the JI with the stressed Social worker who gave off no sense of calm or an appropriate level of warmth. Then my daughter had to go in to a white room, with nothing in it but two chairs, a table and a fake flower in a vase on the table. I felt that it was much more akin to a prison cell. There was nothing about the environment that was conducive to confiding, neither was the manner in which the whole run up had been handled. This kind of situation and treatment is not going to make a child feel safe or trusting	Thank you for sharing your family’s experience with us. Ensuring that children and young people’s voices are heard, listened to and acted on are very important points. The Pathway promotes consistent, child centred and trauma informed care. Hearing the views and experiences of children and young people, and their families is key to this work and to driving improvements in all aspects of care and support. The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is not intended to change the IRD or Joint Investigative Interview process or to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64ME- 4	All the material on CSA repeatedly states how difficult it is for children to disclose sexual abuse. It is incredible to think that in this day and age this kind of approach of JI is still used for children under 12. It might be suitable for children over 12, but I doubt even that. It is also well known that it can take children years to disclose. A recent NSPCC study states that it takes on average 7 years for a child to disclose – longer if they are younger. And of course, this cannot take into account the numbers of children who never disclose. None of this is taken in to account when the Joint services look at a case with younger children. It appears that no account is taken of behavioural and verbal clues from a child that could aid an assessment of risk. My daughter had a second JI – which came after a sudden disclosure to a boy on a play date, {…]”. The second JI was conducted in a better way. It took place at her school, but there was no warning and it came as a shock to her. She was so frightened she was not able to say anything much. […]. I would have thought that given the context in which my daughter had confided this would have led to it being taken very seriously. After the second JI my daughter told me she had been too frightened to say anything because she “didn’t know what would happen next”. Then six years old, she was a couple of years older than at the first JI. Given how difficult it is for children to disclose it was remarkable she was able to say anything at all…The social worker’s discounting of her statement I believe contributed to the Sheriff’s final judgement which found in favour of her father. This means unsupervised access has already begun, and that unsupervised residential access is likely to begin quite soon. She is showing considerable distress before and after these events	Thank you for sharing your family’s experience with us. Ensuring that children and young people’s voices are heard, listened to and acted on are very important points. The Pathway promotes consistent, child centred and trauma informed care. Hearing the views and experiences of children and young people, and their families is key to this work and to driving improvements in all aspects of care and support. The Pathway is intended to describe best practice in line with current relevant legislation and guidance. The Pathway is not intended to change the IRD or Joint Investigative Interview process or to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
641N-H	We think it is essential that the pathway is underpinned by both GIRFEC and the UNCRC, that the service design is adequately shaped by lived experience and that the language and terminology used are clear, concise and really explicit. It is vital that children are supported throughout the process and that expectations around disclosure and subsequent actions are accurate. We believe that equality impact assessments need to be conducted as soon as possible.	The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation. Impact assessments on the Pathway have been carried out and informed revision of the initial draft.
641Z-W	My only concern is the timescale for forensic examination as we have had circumstances where a delay has been an issue both for the child and in gathering evidence. Facilities like the Meadows in Larbert, Stirlingshire provide a non threatening holistic environment	The Pathway indicates appropriate timescales for examinations to be performed in line with the relevant standards. These are contained in the NHS Healthcare Improvement Scotland Standards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards). Boards will work to deliver examination in line with these standards and, where appropriate, collaborate on a regional basis to meet them.
641T-Q	Yes - promotes consistent, child centred, trauma informed care.	Noted.
6418-U	Firstly, it is not clear what, if any, pathways this replaces. We are unclear as to whether there is a need for this or why this is required. There are no core/minimum standards contained within the pathway. Core/minimum standards would allow for reporting and measuring of services in a consistent manner.	The pathway is underpinned by the HIS standards for healthcare and forensic medical services and corresponding quality indicators (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards). A consistent reporting mechanism of service performance is being developed by the QI subgroup.
6418-U	There are no clear timescales set out for any stages of the process, however under the section for IRD, the pathway refers to ‘within 24 hours’. The pathway should be aligned with the Police Scotland SOP and National Child Protection Guidance in relation to timescales for IRDs. It should also acknowledge local multi-agency IRD procedures.	The pathway refers to the timescales set out in the HIS quality indicators, which reflects the MCN Quality Standards and the need to reduce undue delay, in line with the principles of putting the child’s best interest first.
6418-U	Consideration should be given to highlighting the importance of Education being consulted or be part of IRDs.	Guidance on the specific operation of IRDs has been developed nationally and has been included in the new National Child Protection Guidance which is currently out for public consultation.
641K-E	The pathway should, if well-resourced throughout Scotland, provide a standardised, consistent approach to how clinical services respond to children who have disclosed sexual abuse.	Noted
6412-N	It will so long as the pathway is clear for all healthcare practitioners to use. For dentists, this needs to be a user-friendly resource where disclosure of sexual abuse is not a regular occurrence. When it is disclosed, this pathway must be in a format that is easily accessible by all members of the dental team who may receive the disclosure. Primary care dentistry is busy during clinical hours and referring to a long document is not practical, particularly when staff will not be using this pathway regularly. A dental specific version or supplementary dental guide would be useful. “It is not intended for this resource to be read cover to cover, rather, this resource is split into a number of chapters for easy access”. In the current form this will be of little use to dental teams (except for the flow chart) as it is too much like a report than a toolkit or pathway. Alongside this should be an easy to use tool for practitioners who need to apply some of this pathway in their practices. Some of it can be read as a background document but as a useful tool it needs an accompanying streamlined document.	Advice received from the Children and Young People Expert Group and the Steering Group for the revised National Child Protection Guidance is that education, guidance and support on child protection is available from employers (or voluntary organisations/charities in the case of volunteers). The advice is that it is not necessary and may be unhelpful to duplicate material already available in this area.
6414-Q	Shetland NHS use Paediatricians in Aberdeen for forensic medicals in sexual abuse cases and this paper does not acknowledge differing pattern of service provision nor does it emphasise that despite rurality and distance all children in Scotland have a right to a good service.	The clinical pathway aims to provide an outline of national consistency across Scotland, recognising necessary variation in local implementation.
64S9-X	I feel that the document is not specific enough in clarifying the roles and responsibilities of each organisation and could be widely interpreted across organisations rather than its purpose to standardise and improve the approach. It is too generic in its detail.	We have attempted to address the balance of describing best practice in line with current relevant legislation and guidance while allowing flexibility to take account of local multi-agency procedures. The revised Pathway now includes a section on the roles and responsibilities of the professionals involved.
63SV-U	[Our] believes that consideration needs to be given to children with disability/complex needs as they have an increased risk of harm; I. May access respite - Separated from family II. Dependent on others III. Non-verbal communication IV. Exposed to a wider range of carers V. Rely on others for communication VI. Not aware of personal safety	More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations/information sharing etc. in the Pathway with hyperlinks to more detailed guidance if required. The Adults with Incapacity Act and the Adult Support and Protection Act are now included within the Pathway for consideration when appropriate. The limits to confidentiality when the person or others are considered to be at risk of ongoing harm are now included. The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that 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) must be considered.
64SE-A	[Our] welcome the introduction of the pathway to standardise services for children or young people who have disclosed sexual abuse. Current inconsistencies across the country may adversely affect child protection procedures, partnership working and service provisions. Ultimately, it is hoped the pathway will provide positive outcomes for children and young people and promote effective partnership working. We believe the role of [our] in child protection is already well defined; the introduction of the pathway for children and young people outlines the responsibilities of all professional bodies and should determine the bespoke care, information and support package a child or young person should receive.	Noted
64SN-K	Inclusion of recovery response and service commissioning - patchy at best across the country.	Noted. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64SB-7	The introduction of the Clinical Pathway has the potential to improve and standardise the services and supports children and their families receive where medical examinations are required due to experience of sexual abuse. In order for the potential of these improvements to be fully realised, further development of some areas of the Clinical Pathway is required. In particular, improvements could be made by: Clearly integrating and embedding the Barnahus concepts throughout the Clinical Pathway, in particular, the three core principles of placing the best interests of the child at the centre of practice and decision-making; ensuring children’s right to be heard and to receive adequate information at all times; and avoiding delay in protection, assistance and justice processes. (6) Currently, beyond the initial mention of Barnahus on page 7, there is little evidence of how the approach and concepts are reflected in the Clinical Pathway, and what this means for the way practitioners should operate. Reflecting clear recognition of the vulnerability of all children, and their rights and entitlements to sensitive, trauma informed and holistic responses when receiving services as part of the Clinical Pathway. Regardless of the inconsistency in some areas of the Scottish legal system concerning the definition of a child, the UNCRC (which the Scottish Government is committed to incorporating into domestic law) is clear that anyone under the age of 18 is a child, and is entitled to have their rights upheld as such. This is also reflected in Girfec, which is in place for all children up to the age of 18. Furthermore, in recognition of the additional needs and vulnerabilities faced by children and young people with care experience, and the responsibility of the state to safeguard their rights and promote their wellbeing, Part 9: Corporate Parenting of the Children and Young People (Scotland) Act 2014, requires Scottish Ministers, NHS health boards, and a range of other public sector bodies to pay particular attention to meeting the needs and listening to the views of these children and young people in all areas of their services. Young people to whom the state is a corporate parent are entitled to additional support up to the age of 26. Their needs, and how these are taken into account in the Clinical Pathway, requires explicit clarification. Providing greater clarity about how the Clinical Pathway is integrated within the wider multi-agency child protection system, in line with the Girfec approach. This is largely missing from the Clinical Pathway currently, and the shared responsibilities of all practitioners in responding to child sexual abuse, and the mechanisms through which partners work together, requires significant attention.	The Pathway is intended to describe best clinical practice in line with current relevant legislation and guidance. The Pathway is not intended to change the IRD or Joint Investigative Interview process or to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s). The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation. The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that 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) must be considered.
64SZ-Y	Whilst we are very supportive of the intention, and have been part of both the Task Force and the Clinical Pathways group what is missing from this pathway in its current format is the clear outline of the importance of support & advocacy which should be made available to the child &/or family throughout their engagement to enable them to make informed choices, to be able to access the support they need following disclosure and to enable recovery. Whilst the Barnahus model is referenced, what is missing from the body of the text is the importance of and need for young person centred support. This is clearly articulated in the adult pathway but missing from here. What was clearly demonstrated in the NSPCC research ‘Right to Recover’ into the experiences of children and young people who disclose https://learning.nspcc.org.uk/media/1128/right-to-recover-sexual-abuse-west-scotland.pdf was that for many there was little support provided once any immediate child protection concerns were addressed. This document will do little to clarify that this needs to change. On page 17 paragraph 2 for example it references having a child’s plan and says ‘The Child’s Plan (GIRFEC) may include access to ongoing therapeutic support for the child and their family members / carers post examination, but also in the months and years following disclosure of Child Sexual Abuse (CSA). In many parts of Scotland this is just not available and this needs to change. This should be stressed as something which is fundamental. Earlier in the document there are references to ACES and the impact of trauma on children, and on their parents, but without looking at the support needs as something which is not optional this will not change.	Noted. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64SH-D	The pathway as drafted would, if fully implemented, improve standards and services for children who have disclosed sexual abuse and their families. However, we believe that the focus on children who have disclosed sexual abuse is too narrow, and restricts the impact that this pathway could have. We believe that the document should cover clinical pathways for all children and young people who have or may have experienced sexual abuse. In focussing on children who have disclosed child sexual abuse, this document potentially misses an important opportunity to engage medical professionals in wider discussions about child sexual abuse; increasing their understanding of this type of abuse, their ability to identify signs and indicators, and therefore their ability to engage child protection processes at an earlier stage. This will impact on the support and protection the child or young person will receive. In our experience, very few children and young people will independently make a verbal disclosure of sexual abuse. Some are unable to do so due to age, developmental stage or disability; others do not feel able to disclose due to fear, shame or not recognising what they are experiencing as abuse. Recent research from the University of Bedfordshire (https://www.beds.ac.uk/ic/recently-completed-projects/making-noise) also identifies a number of situations where children and young people think they have made a disclosure, but this is not picked up as such by those around them. By limiting the focus to young people who disclose, many victims will be missed. At present, the pathway puts the onus onto the child by focussing on disclosure. The Scottish Government’s wider child protection work encourages us to see child protection as everyone’s business, while the current focus of this pathway relies on children to protect themselves by focussing on disclosure. The document does detail (in Section 5.1) a range of ways in which sexual abuse in children may present. We believe that this should be highlighted much earlier in the document, with medical professionals encouraged to look out for and identify these signs in all the children and young people they work with. This approach is particularly important as this pathway is for use by a broad spectrum of medical professionals. While those conducting a forensic examination, for example, may not be in a position to spot indicators of potential sexual abuse, others who have more regular or ongoing contact with children and young people such as GPs, health visitors, school nurses and LAC nurses, would be well placed to identify patterns and possible indicators. These might include recurrent STIs/UTIs, multiple pregnancies, terminations and use of emergency contraception, missed medical appointments or children regularly being under the influence of alcohol. They are also well placed to support the child before, during and after any eventual disclosure or child protection response. This document could be used to increase their understanding of the background risks and indicators for child sexual abuse.	The Pathway has been updated to refer to a disclosure or an initial concern. The Pathway has been updated to clarify that the scope is for children and young people who may have experienced sexual abuse There is now a section on child sexual abuse earlier in the Pathway. Revised National Child Protection Guidance will be published in 2021 and we have not replicated material from the draft of that guidance.
64SH-D	To best support medical practitioners through situations where they have reason to believe that a child or young person they work with may have experienced or be experiencing sexual abuse, we recommend that three pathways should be developed alongside one another to support medical practitioners: One for children/young people who are experiencing abuse currently (and therefore require an immediate response); another for children who have reported abuse that is not current or non-recent; and a final pathway where there is suspicion or concern of abuse. We do not believe that one pathway for those who have experienced child sexual abuse is sufficient, as this does not take sufficient cognisance of different experiences and the different situations children and young people may be in. In some circumstances, the pathway could and should be used as a basis for discussion between the medical practitioner and the child about what will happen next, and what the child should expect at different points in the process. It is therefore important that the pathway accurately reflects the different processes in different situations, to avoid children being given inaccurate information. It is also important that the response is based on the need of the child/young person and their individual circumstances; one response will not fit for all children and young people. Within the pathways for children currently experiencing abuse, or where there are concerns this is the case, distinctions in the pathway should be drawn where a child is at immediate risk and where there is ongoing but less immediate risk. For example, while a child who is being abused when visiting relatives every other weekend may require a Child Protection response, a child returning home from the medical appointment with the perpetrator of their abuse may also require a response from emergency services. We do not believe that all sections of the pathway as drafted would be required or appropriate for a child/young person who has disclosed non-recent or non-current sexual abuse, and therefore recommend that a parallel pathway is developed for this situation. Coordinating pathways should therefore be developed for children and young people who have disclosed ongoing abuse; children and young people who have disclosed non-current abuse; and children and young people where sexual abuse is suspected.	The Pathway has been written to take account of various scenarios and explicitly addresses degrees of urgency required in child protection responses. We feel a single comprehensive pathway is preferable and easier for practitioners than multiple pathways addressing different scenarios.
64ST-S	The document is too high level - there is not enough practical information within it - how is to be implemented, what resource is there is provide the trauma informed care that is discussed.	The Pathway is aligned with current National Child Protection Guidance and has flexibility to take account of local multi-agency IRD procedures. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s). Training and education was offered to all health professionals at roadshow events prior to implementation of the resource.
64SU-T	I can not in all good faith support this in its current form because it is self defeating in its aims to save the life's of Scotland's children by promoting the murdering of unborn children itself via recommending the use of abortion in cases were minors have been raped. A babe should not be burnt at the stake for the crimes of a rapist ! Secondly, I can not support this because the laws in regards the age of sexual consent, age of marriage and age of majority are not in communion with one set standardised age and therefore there is a blatant inconsistent statement being made hear by the Scottish state to its society regarding when a child is a child and when an adult is an adult and therefore when free consent can be counted as valid or not counted as valid and therefore when rape actually occurs or does not occur until these issues are resolved as to make the lines in Scots law more consistent the pathway will fail both victims and those accused falsely in terms of actual objective reality as apposed to just Scottish Government legal dictate. Since this nations age of consent is 16 this pathway and its consultation should have focused exclusively on alleged victims who are 15 and below. This response will therefore be concerned with those alleged to have been raped 15 below and no higher. Thirdly, the pathway is limited in scope and in power even if one accepts all propositions including yes, even the abortion it actually does not have all the top qualities that should be present within it that are found in other systems in other nations, of which there children live in an even more protected child friendly environment than in Scotland. However, I do note that those nations have a higher human rights index score than Scotland. The system will not therefore make as big a contribution to ending the abuse of children in this country as it could have done - abuse that I am not surprised has increased dramatically and that will only continue to climb at an alarming rate in Scotland regardless of previous the two points made. Outlawing the proscription of abortion should be the first and foremost move in stopping the abuse of minors in Scotland I believe followed by standardising the age of consent in which a person can exercise all there liberties to one national standardised age then redesigning this pathway to include more advanced measures to combat the sexual abuse of minors. This will leave no more blurred lines anymore to be had in regards maturity, learning difficulty or arguments around positions of trust for example or other claims such as inequality under the law due to characteristics that may lead to legal challenges by an alleged victim themselves of when the pathway is entitled to regard them as an alleged victim or allegedly not a victim by way of there given consent being or not being counted as valid by another as apposed to the person who actually gave there consent maintaining or not maintain they freely gave it and this will mean the Scottish state can regard any infraction of one set national age limit as child rape despite the under age persons opinion or not with full public support immediately allowing more robust credible prosecutions of any adult for breaching that national statutory standard of which will be then applicable to all regardless of who they are. Currently for all intents and purposes for most liberties the age is 18 but actually having sex and even voting to decide the destiny of the entire nation is 16 still horrifying is the ability of 12 year olds to consent to or refuse medical treatment until death occurs or life chances increase - a child under the national age of consent should have there health always attended to regardless of there consent therefore there life's saved the question of them giving or not giving there consent to treatment should not come into it - this state of affairs is absolutely ridicules. This needs to be changed to 18 for all rights and freedoms that would mean the right to: Refuse medical treatment. Marry. Have Sex. Vote. And all other freedoms. Be made18. Today's Scottish youth are far to immature to be granted any rights at any age younger than this whatsoever. Whatever position the Scottish Government takes on age though it must at least not be ambivalent. An adult is a consenting adult for all actions in all circumstances in a democracy no matter what those are or are not unless of course that adult is not an adult but a child that is under the one consistent national age limit, or an adult that says no, does not give consent, is unconscious, deemed severely incapacitated in mind, misinformed as to the nature of the act, coerced, blackmailed, significantly intoxicated or otherwise drugged as to be stupified. Once the national age limit for all rights and freedoms is consistent at 18 then this pathway may deal with incidences and only incidences were children have been alleged to have been raped with force, presumption of there consent, or by so called 'freely giving there consent'' to a person who has reached the national age limit or above. Until then, this pathway should focused on those 15 and below as to maintain credibility.	There is a legal right in Scotland to clinically safe and legal abortion services. People should be supported and free to reach their own decision on whether or not to have an abortion. A child within the content of this clinical pathway has been defined as a person up to the age of 16. This is in line with clinical practice and reflects similar arrangements in paediatric services nationally. The CYPEG recognise that a ‘child’ is defined differently in various pieces of legislation, and have taken cognisance of the reasons for this differential. An additional appendix on the age of a child has been included.
64SD-9	[Our organisation] believes that the pathway supports the delivery of a consistent healthcare response to disclosure by children and young people of sexual abuse.	Noted
64SP-N	Those children and young persons who are the victims of sexual abuse need to have confidence in the way that they are handled following such allegations. The pathway seeks to improve and standardise services. The standard of service should be child-centric and not affected by where they live or to whom they disclose. The pathway may do much to support provision of confidence, transparency and support for the child. Paragraph 1.2 of the document notes that the pathway and guidance are to be used by healthcare professionals in Scotland. We suggest that others, including those working with children and young people such as teachers and social workers, also need to be aware of and understand the pathway. Publicity and awareness raising may be required to fully achieve the aims of the pathway.	The remit of the Pathway now covers local authority staff including teachers, Police and third sector. There will also in 2021 be revised National Child Protection Guidance to support these groups of staff.
64SQ-P	It is helpful to have a pathway that provides clarity and consistency. However, the pathway would be strengthened if it reflected more explicitly, the engagement with relevant partners at all stages. This includes effective engagement with children, young people and their families	The Pathway now includes the organisations and individuals involved in its development. Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway.
64SK-G	It has the potential to improve services but standardisation relies on a consideration of the wider supports that are available... eg page 10 talks about emotional and mental health support which varies greatly across Scotland	The clinical pathway aims to provide an outline of national consistency across Scotland, recognising necessary variation in local implementation.
64S6-U	Geography, has challenges (Dumfries). Police have to transfer consumables to Wishaw or Glasgow, challenges for us. Argyll – major issues children and adult, 4 hours to drive to Glasgow. Inverness, 4 local authorities, child need joint medical from Shetland or Orkney – Aberdeen or Glasgow. Occasions where there is an overnight stay. Should be doctor to patient not patient to doctor. Impact on the child. Fife – surrounded by 3 NHS authorities 4 in total. Tayport have to drive to Edinburgh, Kincardine again go to Edinburgh. Due to medical networks. 3 hour journey potentially. Aberdeen – Grampian. Elgin – we are now through NHS Boards to Inverness 35 miles, which use to be Aberdeen 70 miles do likewise for children as we now do for adults. Doctors would need to agree to that. Police and social work can normally stay local for interview, and we have the kit (laptop with camera and microphone). Wherever is closer to them. Child will still have to travel for the examination. Implement pathways and services aren’t ready that’s when we meet bumps. Don’t meet expectations of victims. We are not doing what we will say we are going to do. If we implement a pathway we need to be ready, speak to others and that could dissuade others of reporting. Implementation of pathways would encourage reporting, cant services pathway have gaps initial positivity will become negative. Not doing the right thing. How are we going to promote the pathway in some way, schools, TV etc. pamphlets in GPs. Not going to have knowledge unless involved.	The Pathway is aligned with current National Child Protection Guidance and has flexibility to take account of local multi-agency procedures. The Pathway is not intended to address the variances between local provision of services and the need to travel to access small volume specialist services. It does make clear that the best interests of the child or young person should be the main consideration in all decision making.
64S4-S	GIRFEC should unpin this and be the starting point, especially if moving towards Barnahus. All the additional parts about the pace, the ways of working, and the team around the child. Without that, the pathway doesn't take into account current ways of thinking and working, and can't change anything. The values and language are trying to be there, but they are not exposed enough.	The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. The Pathway is intended to describe best clinical practice in line with current relevant legislation and guidance. The Pathway is not intended to change the IRD or Joint Investigative Interview process or to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context.
64S4-S	Question the added value of this, other than as a useful reference document. It reads as though the Taskforce has decided there should be a clinical pathway, and therefore there is a clinical pathway. But what is the added value?	The Pathway is intended to describe best practice in line with current relevant legislation and guidance to assist practitioners in providing care and support to children and young people who have or may have experienced sexual abuse.
64S4-S	What is the document intending to change and what is it responding to? It's not driving to change anything, as it doesn't reflect the new practice.	The Pathway is intended to describe best practice in line with current relevant legislation and guidance to assist practitioners in providing care and support to children and young people who have or may have experienced sexual abuse.
64S4-S	We are putting the onus and the responsibility on the child to actively disclose, and to have that responsibility. We should be keeping them safe, not expecting them to have to disclose, and people can be affected with a wider experience of sexual abuse within a familial setting (where an older sibling is disclose to protect a younger sibling who is at risk).	The Pathway notes the healthcare response that should be provided for a child or young person following disclosure of sexual abuse or for a child or young person where, through other interactions, there are indications that sexual abuse has occurred.
64S4-S	There is a loss of control--everyone knows what has happened, and once it is over young people can get dumped or left. With all of the feeling of the process, having the loss of control, fall-out between family, without support, and feeling like they are not believed. This is where wellbeing is not at the centre, and the wellbeing indicators are not discussed	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64MC-2	The inequalities experienced by those with care experience is well documented and understood, thus the need for a root and branch review of care which will conclude 2020. In Scotland there has been progress but there remain significant gaps between the legislation, policy and the implementation in practice. There are many, but one example which highlights this gap is continuing care – the evidence from those with care experience, the paid and unpaid workforce alongside data analysis has highlighted that this progressive legislation is not being implemented. The lack of continued support has a devastating impact on the lives of young people: homelessness, lack of emotional and financial support, resultant placement moves all highlight the fundamental lack of Corporate Parenting duties being implemented. As well as immediate day-to-day improvements to the lives of infants, children, young people and families experiencing the ‘care system’, [our] team is building a detailed understanding of the bridges and barriers to change (e.g. resources, culture, geography, provision etc.) in every context. [Our organisation] aims to identify and deliver lasting change in the care system and leave a legacy that will transform the wellbeing of children and young people […] There are some extremely successful stories of people who have experienced care as an infant, child and or young person and we don’t want to continue painting the picture of stigma of those who have experienced care. However, what we do need is to change the picture, so that it is no longer relevant. Our response to this consultation is another step towards that. [Our organisation] fully backs the purpose and implementation of the clinical pathway, agreeing that it would improve and standardise services, though recognises that this opportunity for improvement has not realised its potential as it currently stands.	Noted These findings in the reports of the Independent Care Review 2020 have been taken into account in the Pathway.
64MC-2	[Our organisation] strongly urges that care experienced people play an integral part in the final content, taking the journey of care into account in each of the key areas; covering a range of ages and input within this, and in general are fully considered when looking at the content and outcomes.	Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway. The reports of the Independent Care Review 2020 and the needs of care experience children and young people are referenced in the Pathway.
64MC-2	[Our organisation] welcomes the recognition of the importance of having a workforce across agencies all working to an approach of trauma informed care as a part of the pathway and recommends that this extends beyond the workforce, incorporating carers and families (including corporate parents).	Noted
64MC-2	[Our organisation] has a number of key areas being worked on just now, that will provide a very useful resource that will tie into this work; with findings not produced anywhere else to date. We would therefore request that the production of the final pathway document either takes into account [our] timings to allow for these key findings to play a part in the final document or alternatively, for there to be a planned review of the pathway in 12 months, that will allow for the findings to feed into this.	The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MC-2	[Our organisation] urges that the age parameters reflect other areas of Scottish legislation: young people to whom the state is a corporate parent are entitled to additional support up to the age of 26; this must be reflected in the pathway. Scotland should act to protect our infants, children and young people at risk, working to help those at the heart of the trauma, bringing all relevant people and organisations together to act in the best interest of the victim, gaining the best outcome	The duties of corporate parents are discussed in the Pathway. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MV-N	We welcome the Chief Medical Officer's commitment to developing consistent, person centred, trauma informed healthcare and forensic medical services and access to recovery for anyone who has experienced rape or sexual assault in Scotland. The 2017 HMCIS report found major issues in the support available for those who have experienced rape or sexual assault in Scotland, and it was right that swift action was taken to address this. However, in the introduction to the document it is stated that this guidance is intended to support the implementation of the outcomes of the Options Appraisal of the Taskforce (Honouring the Lived Experience). This recommended the option of Multi-Agency Centre with co-ordinated services for adults, children and young people who have experienced sexual assault and rape (acute and historic). It is also stated that these recommendations “are intended to be in line with the Barnahus concept”. However, the Barnahus concept, as set out in the International Barnahus Quality Standards (see https://www.childrenatrisk.eu/promise/standards/) is for multi agency and holistic services for “all children who are victims and/or witnesses of violence regardless the form of violence have equal access to the service and are offered a multi-disciplinary response” (standard 3). It is not clear how the option identified by the Options Appraisal process for all-age service for people who have experienced sexual assault and rape (acute and historic) can be reconciled with the Barnahus approach of multi-agency services for children who have experienced or witnessed violence, whether sexual violence or physical or emotional violence. Given that the Scottish Government has repeatedly stated said that Barnahus is its preferred direction of travel for supporting child victims and witness of crime, ensuring that they get the best support and can give the best evidence, we are uncertain as to how these two very different approaches can be reconciled. We recognize the work that has been done on the pathway, but there is a danger that if services are designed to address the needs of only some of the children who require Barnahus– those who have experienced sexual abuse – these services will not in practice be aligned with the requirements of the International Barnahus Quality Standards . The Scottish Government has now launched a process to develop Barnahus Standards for Scotland, which we hope and expect will set out how a Barnahus response will meet the needs of all children and young people who have experienced or witnessed, sexual, physical or emotional abuse and violence. These Barnahu standards must be cross cutting; covering justice, child protection, health and recovery. This should ensure forensic pathways for children and young people are aligned with the holistic, child-centred model of an accepted barnahus model, with the appropriate infrastructure to house it. Therefore the process of standards development will need to be completed before the pathway is finalised and rolled out. We acknowledge that the desire to bring about positive change has led to action on the issues raised in the 2017 HMCIS report across various departments, but this action has had the unintended consequence of creating different and increasingly conflicting timescales of work. We recognize that there is urgency in addressing the complex challenge of seeking to achieve an improved response to adult victims of rape and sexual assult. However we would stress that their needs are many ways significantly different to those of children and young people. Work to secure a child-centred, consistent, trauma sensitive and recovery focussed response for children and young people, including the clinical pathway. must therefore be undertaken within the Barnahus standards development process.	The Pathway is intended to describe best clinical practice in line with current relevant legislation and guidance. The Pathway is not intended to change the IRD or Joint Investigative Interview process or to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
Are there any key areas of research missing, or any general amendments you would suggest?
64HR-C	There should be recognition that in some areas the reference to IRDs is taken to mean Initial Referral Discussion, which is specific to the initial tripartite discussion which takes place between the Police, Social Work and Health. This becomes an important distinction at para 5.3 as the Police use their Interagency Referral Discussion(s) in plural whereas other partners see the Initial Referral Discussion as a singular one off discussion about making decisions about how to proceed with the case.	The definition and role of interagency referral discussions has been expanded in line with the draft revised National Child Protection Guidance which seeks to encourage greater consistency across Scotland and is currently out for public consultation.
64H6-G	More clarity on the statement (used twice) that "the dynamics of child sexual abuse differ from those of adult sexual abuse." - seems to suggest that adults don't experience sexual abuse/violence from people known to them, which they overwhelmingly do.	Noted
64ME- 4	– younger children may not know the names of body parts and therefore use infantile language to describe acts or body parts. The lack of awareness of this – especially in the court system means that from a Sheriff’s point of view a communication from a child may be vague or “non-sensical”. In one case a child described how her daddy had put a needle up her bottom. This was not a description of what actually happened, but rather a description of the sensation. Younger children do not understand what abuse is and it may be that they have had it described as or are able to understand it as a game they don’t like. This is why, especially in the case of younger children, time and trust are two absolutely vital components for helping a child to disclose – not half an hour in a room like a cell with total strangers. The JI process informs what happens in a court room when an abusive parent is seeking a judgement that allows unsupervised access with a child he or she has abused. It is therefore absolutely vital to enable and comprehend every element of the disclosure of children. Fundamentally this takes time. It should only be conducted in the knowledge that it is a process. The failure to acknowledge and work with this is a systematic flaw in the inadequate system that exists. It fundamentally gives no time at all in the relative scale of the length of time children need in order to disclose enough of what has happened to them. To quote from Dr Sarah Nelson’s book “Tackling Child Sexual Abuse”, “ Interviewing problems with ABE The formalisation of, and regulation around, interviewing of children, in prescribed official settings through Memorandum of Good Practice interviews, can be very valuable in court if carried out sensitively after building children’s confidence and trust. The ABE (Achieving Best Evidence) phased interview approach centrally includes building rapport with the child, creating a child-centred environment and providing a free narrative phase, for the child to give a non-chronological account in his or her own words. But researchers have found that in practice many such interviews have been conducted in a flawed and unhelpful way for children. That includes the interview environment not being conducive for establishing rapport, not taking into account the child’s age or trauma levels, inappropriate questioning, failure to account for confusion and memory problems, and frequent failure to build initial rapport (Westcott and Kynan, 2006; Robinson, 2008).There is also an inherent problem about the importance given to a child’s free narrative in these interviews. This is a well-intentioned response to repeated claims that interviewers had been influencing children with suggestive questions. But sexual abuse is precisely a subject which most children feel constrained, ashamed or humiliated to talk about freely in the first place, most of all about the nature of degrading sexual acts committed on them. If they cannot be prompted by gentle yes-no questions, for example ‘I wonder if perhaps this happened to you?’(without, of course, suggesting who the perpetrator was), many will not reveal much through free narrative. This problem is a classic example of defensive responses and reactions to the backlash, which do not actually fit well with children’s own feelings, difficulties and reactions. Many interviews also still place stressed children in unnatural settings, with unfamiliar people. It has left the considerable and the greatest problem, that of aggressive defence cross-examination in court, untouched. It has responded to older social assumptions about the unreliability and untruthfulness of children, and to attempts to protect staff from accusations of poor practice. While gaining disclosures of child sexual abuse from children can be considerably improved, there needs to be far more emphasis on gaining other sources of evidence”	The remit of the Pathway does not include the training of police officers, social workers, court staff and officials including lawyers, sheriffs and judges, or any other agencies involved in the court system.
64ME-4	There is little or no understanding about the sophistication of abusers. There is little or no understanding of the fact that they can look and sound like ordinary people and can come across plausibly and very personably. In contacting MOSAC (Mother of Sexually Abused Children) what they have said is “9 times out of 10 the abuser will get access” and “the system is stacked against you”. From my own and others' experience I believe that what I was told is true. Events of the past four years have taught me that the functioning of the systems that are supposed to protect children are inadequate and that there are many areas of malfunction. On the subject of gathering material from a child who has been showing signs that he or she has been exposed to sexualised behaviour from an adult, I feel very strongly that the formal systems within the police and social work department do not have the time and expertise to engage with a child in the ways that lead to adequate assessment of the child’s situation. My own daughter was referred by the GP to CALMS, but contact with that agency was prevented by her father, so she never got any professional help.	Thank you for sharing your family’s experience with us. Ensuring that children and young people’s voices are heard, listened to and acted on are very important points. The Pathway promotes consistent, child centred and trauma informed care. Hearing the views and experiences of children and young people, and their families is key to this work and to driving improvements in all aspects of care and support. The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse. The revised National Child Protection provides guidance on wider child protection issues and ultimately some issues are for a court to decide.
64ME-4	It is well known that a child is more likely to disclose to the primary carer than anyone else. This is confirmed by the NSPCC study. A child’s instinct is, correctly, to turn to a trusted parent or care giver. Why then does the child protection system expect a young child to be able to disclose to a complete stranger in an unfamiliar environment, without any time to build up a sense of trust?	The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse. The revised National Child Protection provides guidance on wider child protection issues.
64ME-4	A major subject that is not understood or recognised about perpetrators is what the abuse can consist of. The abuse can begin with fun games eg. A puppet game/ a dragon game/ dog game and later be led into something else, which can confuse the child so that he or she might well perceive this as still being part of the game. Deliberately confusing explanations and stories are told to the child so that they will struggle to be able to understand or describe what has happened to them. For example, common descriptions of semen refer to “milk”, and many cases contain this signature description which is either misunderstood or ignored by the authorities. There is a kind of grooming that ‘normalises’ a certain kind of touch that involves private body parts. A perpetrator might even urinate on the child as preparation for subsequent ejaculation. There was a case thrown out of court because the court could not understand why a perpetrator would urinate on a child – or how it would be cleaned up. Urinating on a child can be considered to be a signature or hallmark of certain cases and is found in a significant number of cases and yet courts do not take it into account as being credible, or as being related to sexual abuse. Courts appear to lack the understanding of how perpetrators function. Psychologists may grasp the factors in cases where gross physical violence has been proved. However, the activities of other sexual abusers and damage to children created by a significant percentage of them is often outside their perception and understanding	The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse. The revised National Child Protection provides guidance on wider child protection issues and ultimately some issues are for a court to decide.
64ME-4	Dr Richard Whitecross’s study on Domestic Violence has led to further instruction and training on Domestic Violence in the court system. With regard to sexual abuse of children, highly advanced training is required for police, social workers, the courts and all other agencies that are involved. (NB: Sadly recent cases have demonstrated that despite this courts still cannot recognise Domestic Abuse and will give either equal parental rights or access to a demonstrably abusive parent.)	The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse. The revised National Child Protection provides guidance on wider child protection issues. The remit of the Pathway does not include the training of police officers, social workers, court staff and officials including lawyers, sheriffs and judges, or any other agencies involved in the court system. However, the Child Protection Committees (CPCs), which were established in each local authority in Scotland in 1991, are the key local bodies for developing, implementing and improving child protection strategy across and between agencies, bodies and the local community. Protecting Children and Young People: Child Protection Committee and Chief Officer Responsibilities (Scottish Government 2019). CPCs should have an overview of the training needs of all practitioners involved in child protection activity. This includes practitioners with a particular responsibility for protecting children, such as Lead Professionals, named persons or other designated health and education practitioners, Police, Social Workers and other practitioners undertaking child protection investigations or working with complex cases.
64ME-4	A film was made about a study of the links between CSA and postnatal depression: http://safetosay.co.uk/resources/ (Please watch the whole film – available on request). A specially trained social worker worked with a group of women who had postnatal depression. In the work they did it emerged that all the women had suffered CSA. None had disclosed it before. At a screening of this same film a social worker asked if every social worker should have the specialist training that the key worker in the film had. The answer should be glaringly obvious	The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse. The revised National Child Protection provides guidance on wider child protection issues. The remit of the Pathway does not include the training of police officers, social workers, court staff, or any other agencies involved in the court system. The Child Protection Committees (CPCs), which were established in each local authority in Scotland in 1991, are the key local bodies for developing, implementing and improving child protection strategy across and between agencies, bodies and the local community. Protecting Children and Young People: Child Protection Committee and Chief Officer Responsibilities (Scottish Government 2019). CPCs should have an overview of the training needs of all practitioners involved in child protection activity. This includes practitioners with a particular responsibility for protecting children, such as Lead Professionals, named persons or other designated health and education practitioners, Police, Social Workers and other practitioners undertaking child protection investigations or working with complex cases.
64ME-4	We can only guess at the number of undisclosed cases of child sex abuse in our society. Everything we know points to the likelihood that the number is significantly greater than current statistics show	Noted
64ME-4	Dr Sarah Nelson is a former Scottish Government Advisor. It is very worrying to note that her book “Tackling Child Sexual Abuse” had neither been read or heard of by the police I dealt with, the social workers, the court or any of the lawyers I dealt with. Even the senior QC I consulted who was known to be the top Family Law QC in Scotland had not heard of or read the book. This is a very damning fact. The only people that were aware of her work were certain Senior police that I spoke to. There is much absolutely essential detail in Dr Nelson’s book, which has been available since 2016, and yet none of it appears to have been adopted or acted on	The remit of the Pathway does not include the training of police officers, social workers, court staff, or any other agencies involved in the court system. The Child Protection Committees (CPCs), which were established in each local authority in Scotland in 1991, are the key local bodies for developing, implementing and improving child protection strategy across and between agencies, bodies and the local community. Protecting Children and Young People: Child Protection Committee and Chief Officer Responsibilities (Scottish Government 2019). CPCs should have an overview of the training needs of all practitioners involved in child protection activity. This includes practitioners with a particular responsibility for protecting children, such as Lead Professionals, named persons or other designated health and education practitioners, Police, Social Workers and other practitioners undertaking child protection investigations or working with complex cases.
64ME- 4	Scottish head of the NSPCC in a BBC article of 2018 made a call for a “Children’s house” – I believe a reference to the Barnehus model. Again, this call has not been acted on by the Scottish government	There is a Scottish Government commitment to develop Scottish standards for the Barnahus concept, forming a framework for a child-centred approach to delivering justice, care and recovery for children who have experienced trauma.
64ME-4	CSA is still not well enough understood by the key people who make judgements about the lives of affected children and their carers. There are a number of threats that seem to be in common use in cases of CSA: eg, that children will be dangled from a great height to instil the fear of death in them, they are told that mummy will be killed/ run over, they are told they will be killed/ thrown in a fire (see the book Strong Mothers by Anne Peake and Marion Fletcher). The fear and terror instilled in children is so severe that it can take years to unlock – which is why a JI in a stark room with a total stranger is highly likely to be completely useless. My belief is that JI’s as they exist now should be scrapped altogether and replaced with a system which understands the true plight of the child, and the work force in the area needs to be educated with properly detailed understanding of the significance of each developmental stage of children. Appropriate responses in interaction with children, taking into account the developmental stage involved, is essential. It is crucial to have a detailed understanding of characteristics of perpetrators and the way they are likely to behave in order to ensure that a child behaves in the ways that they want them to. At present what knowledge is employed is severely deficient. A stark example of the deficit was shown by the social worker who asked the question about training at the film screening. The ability of courts and workers in the field to understand and protect children who have been sexually abused is very compromised by their lack of knowledge and understanding.	The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse and therefore this is out with the scope of the pathway.
64ME-4	The Scottish Government should follow the example of the Center for Judicial Excellence in America and do research and provide a fact sheet such as the one I will attach in my covering email. Here is an example of the content: 23. Can mental health professional investigators determine if a child has been sexually abused? Fact: No. Investigation of child sexual abuse allegations is a specialty field, and very few evaluators, mediators or social workers are experts in this field. Alleged perpetrators can find that the process of psychological evaluation sometimes works to their advantage. “Psychological evaluators cannot distinguish reliably between incest offenders and non-offenders...” Clinical evaluation is especially poor at predicting future sexual offenses against children, scoring only slightly better than chance in assessing which men would re-offend and which would not.” Psychological testing fared no better than clinical evaluation in predicting future sexual offenses against children. 51 “...[N]or is there a valid psychological test or profile that can conclusively determine whether an accuser, an accused, or a child is telling the truth about an allegation.”5 At the same time, psychological testing of the mother who brings the allegation of child sexual abuse to the attention of the court is often used to discredit her reports. She may be described by the evaluator as angry or bitter about the divorce, hyper-vigilant, or paranoid. Such evaluations rarely take into account the normative psychological responses of mothers whose children have been sexually abused. This particular section highlights the problematic nature of the evaluation of the so-called experts in the field and their ability to make effective evaluations. This should be considered, researched and highlighted in relation to how to process information from “experts”. In addition to this it should be recognised by the Scottish government that CSA is a specialised field and should not be dealt with by ordinary Sheriffs who have no training or detailed knowledge of the matters, as they will easily miss and misunderstand the common hall marks and signposts in such cases. CSA cases should be dealt with by specially trained Sheriffs who have in depth knowledge of child development and the psychology and common behaviours of perpetrators. What we have now is the equivalent of a GP performing brain surgery. I would not want that and I don’t know anyone that would. As well as the need for specifically trained Sheriffs we should ensure that judgements about protecting children are not made by one person alone. There needs to be a system where one person’s personal bias cannot affect the outcome of a child’s life. This happens all too often and there is no adequate system of checks and balances to prevent this.	The Pathway is intended to support the clinical care of Children and Young People who have experienced child sexual abuse and therefore this is out with the scope of the pathway.
641N-H	We believe that more work needs to be in done in terms of supporting children and young people with additional needs and learning disabilities, care experienced children and others who may be at risk – managing risk and promoting healthy relationships should be a priority. Supporting mental and emotional well being needs to be a priority throughout and there needs to be a clear definition and framework around trauma informed practice. Thought also needs to be given to supporting (non-abusive) family members or carers as they will be key to supporting the child or young person throughout the process and in recovery.	The Pathway now contains more material on these areas.
641Z-W	More information about support when reporting and following a report as this will be vital. There should be more about involvement of the third sector	The Pathway now contains a section on ongoing care and support for Children and Young People who have experienced Child sexual abuse and non-abusing parent/carer(s).
641H-B	Making and distributing of incident images - it is a form of sexual abuse - and would be useful to include this e.g. sending naked pictures/sexting. Would be useful to have guidance on what to do when this is reported	This issue is covered in the revised National Guidance on Child Protection which is currently the subject of consultation, but the Pathway does now make mention of the use of electronic media in child abuse.
641T-Q	The pathway structures how to immediately respond to a disclosure of sexual abuse however following this fails to address follow up or recovery from the event to ensure consistent and standardised care for all children.	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
641K-E	Our consultation group were unable to identify any missing research that would further inform the pathway	Noted.
6412-N	The clinical pathway assumes that all healthcare practitioners know exactly what to do when they receive a disclosure. Whilst some healthcare professionals may receive training in receiving a disclosure, dentists are unlikely to have received the same training. Whilst they have their professional training, this is an area across the UK that is not covered in depth. It would be helpful in ensuring that in order to follow the pathway, that healthcare professionals including dentists and their teams are equipped to receive the disclosure in the first place.	Advice received from the Children and Young People Expert Group and the Steering Group for the revised National Child Protection Guidance is that education, guidance and support on child protection is available from employers (or voluntary organisations/charities in the case of volunteers). The advice is that it is not necessary and may be unhelpful to duplicate material already available in this area.
6416-S	Albeit the document is targeted at Health professionals it would be appropriate to include more reference to the multi-agency nature of child protection at all stages from prevention through to intervention and support thereafter.	The Pathway now has more emphasis on the multiagency nature of child protection procedures.
6414-Q	Document well linked to research and guidance.	Noted
64SM-J	Age pathway applies to: Education colleagues raised an issue about the definition of the age of the child and wondered if it should be 18 if in full time education. However the caveat of additional support needs or vulnerabilities may be more appropriate. 16 is the legal age limit for consensual sexual intercourse and itmakes sense that this is the cut off . Vulnerable 16-18 year olds may not be in full time education. From a service perspective, current paediatric resources maybe significantly stretched if age over 16 included. Is there any information about numbers of 16-18 year olds seen annually currently by adult services?	The Pathway is applicable to the care of children and young people up to 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) who have disclosed sexual abuse of any kind. The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area.
64SM-J	There is a large discrepancy between the number of sexual offences against children and the number of people proceeded against for sexual crimes every year although two tables in section 2 not directly comparable. Is there any new research or analysis which should be aware as to the reasons behind this and what can we do from a health prospective to improve these numbers (better forensic collection, documentation, etc.) How many convictions are recorded as a result of the prosecutions? Recent media coverage of rapes in England and Wales note only about 1.5 % end in prosecution. An overview of this type of data would also be useful if patients request this as part of informed consent. In section 6.1 3 iii – it is mentioned that the likelihood of obtaining positive forensic results decrease exponentially with time. It would be helpful if we had some actual Scottish figures regarding how often there is a positive result and the actual rate of positive results correlated with time the sample was taken after the assault. I am not aware how often a positive result is obtained and could not inform families accurately if they ask. Regarding acute abuse in Medical Section 6 “Examination should occur as soon as possible to obtain forensic evidence. Guidelines indicate that likelihood of obtaining positive forensics decreases exponentially with time. This is also true for documentation of injuries as the genital area heals extremely quickly”. It would be useful to have clearer information about research about how quickly forensic evidence such as semen and DNA disappears and how quickly genital injuries disappear in order to plan medical timing and service provision of paediatric examination services out of hours including weekends. Agree that medicals out of hours outside 8-8 may not be in the best interest of the young person.	It is acknowledged that accurate information on the incidence of child sexual abuse is not available and the table has now been removed from the Pathway. The Pathway is aligned to the NHS Healthcare Improvement Scotland Standards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards).
64SM-J	In section 5.2 (IRD) – they mention consent for medical examination is part of that process. However, consent is taken at the time of the medical examination, not before. It is appropriate to consider who will give consent at that stage in case in the rare instance that a warrant or CPO is needed but it needs to be clear that the consent will be taken by the doctors at the medical.	Now explicit in the Pathway
64SV-U	[Our organisation] recommends adding information relating specifically to children with disabilities/complex needs and should be highlighted clearly. We specifically recommend adding/highlighting a link to the national guidance found in Child Protection Scotland: Protecting Disabled Children from Abuse and Neglect, May 2014	Now included in the Pathway
64SE-A	From the figures provided from Police Scotland it is evident that the number of sexual offences recorded against children has increased year on year and notably between 2013 and 2018 there has been an approximate 29% increase. It would be helpful if a comparison could be made between these and statistics with the number of children and young people who have benefited from support service or a support/care plan when a disclosure of sexual abuse has been made.	This information can be obtained from NHS Healthcare Improvement Scotland Standards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards), which include statistical figures on: 4.1 Percentage of people who received a psychosocial risk assessment at the time of the examination. 4.2 Percentage of people who were referred to all required services identified during a psychosocial risk assessment. 4.3 Percentage of people who were referred to: a) sexual health services b) a relevant third sector support organisation c) mental health services, or d) their GP. 4.4 Percentage of cases where initial follow-up contact was made by the forensic medical service within 72 hours of the end of the examination.
64SY-X	There is a large discrepancy between the number of sexual offences against children and the number of people proceeded against for sexual crimes every year, although the tables in section 2 are not directly comparable. Is there any new research or analysis of which we should be aware as to the reasons behind this and what we can do from a health perspective to improve these numbers (better forensic collection, documentation, etc.)How many convictions are recorded as a result of the prosecutions?.	The table has now been removed from the Pathway.
64SY-X	Section 5.2 (IRD) Consent for medical examination as part of that process. However, consent is taken at the time of the medical examination, not before. Where a Child Protection Order or Warrant is required, it is appropriate to consider who will give consent to a medical examination. However, consent will be taken by the doctors at the time of the medical. The paediatrician involved in the planning discussion (IRD) should take responsibility for taking the medical assessment forward – this is not always realistic since certain areas do not have capacity for paediatricians to take part in IRD’s, given the numbers and short timescales (held within 24h). A medical representative should attend all IRD’s and then information shared in order that a medical examination can be arranged	The Pathway is aligned with current National Child Protection Guidance and has flexibility to take account of local multi-agency IRD procedures. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SY-X	Section 6.1 3 iii “the likelihood of obtaining positive forensics decrease exponentially with time”. It would be helpful if we had actual figures regarding how often there is a positive result and the actual rate of positive results correlated with time the sample was taken after the assault. This information would be helpful in order to inform families accurately if they ask.	Information on the correlation between the results of forensic samples and time of examination is not currently available.
64SY-X	Although ideally the victim should be able to request the gender of the examiner, at present this may not always be an option, and families may want to know how much decreased likelihood of positive sample collection is there if they wait a further 24 hours in order to have a preferred gender. “Examination should occur as soon as possible to obtain forensic evidence. Guidelines indicate that likelihood of obtaining positive forensics decreases exponentially with time. This is also true for documentation of injuries as the genital area heals extremely quickly”. It would be useful to have clearer information from research as to how quickly forensic evidence such as semen and DNA disappears and how quickly genital injuries disappear in order to plan medical timing and service provision of paediatric examination services out of hours including weekends. We agree that medicals out of hours outside 8-8 may not be in the best interest of the young person	Information on the correlation between the results of forensic samples and time of examination is not currently available.
64SY-X	Section 6.7 “Reports should be produced within four weeks, as per MCN Standards of Service Provision and Quality Indicators for the Paediatric Medical Component of Child Protection Services in Scotland and should include a clear summary of findings, interpretation of these findings in light of current evidence and a clear final opinion. Good practice is that the joint forensic report should be written and agreed by the paediatrician and Forensic Medical Examiner”. Four weeks is a long time to wait for the outcome of the medical report – it would be good for decision making for the child if a summary of the findings could be available sooner, for example one week, with full report in 4 weeks. Locally, the paediatrician will send a letter to the GP, social work, and police which is usually available a week after the examination.	Flexibility to support this practice is now included in the Pathway.
64SN-K	Research into other legal systems and their experience of supporting families/victims without the need for corroboration.	The Pathway is written in the expectation that the requirement for corroboration will continue.
64SW-V	No, the pathway gives a broad overview of research/policy context whilst remaining a straightforward and accessible document.	Noted.
64SB-7	To strengthen the Clinical Pathway, the following additions are recommended: To reflect the commitment to taking a rights-based approach, include reference to the UNCRC in Section 1.5 The inclusion of the Additional Notes for Practitioners: Protecting Disabled Children from Abuse and Neglect supplementary document to the National Guidance for Child Protection in Scotland is a necessary addition to Section 1.5. Research suggests that children affected by disability are 3 to 4 times more likely to be abused than non-disabled children, and that children with communication impairments, learning disabilities and sensory impairments are particularly vulnerable. (7) In terms of Section 2, the difficulty in estimating the prevalence of child sexual abuse is recognised. Useful additions to the data referenced include: o The NSPCC estimate that 7 of every 8 children who experience sexual abuse do not come to the attention of statutory services. (8) o Reference to increased prevalence for children affected by disabilities, as noted above. o Findings from the 2015 survey by FRA, the European Union Agency for Fundamental Rights, reports that 18% of women in the UK said that they experienced sexual violence before the age of 15, by adult perpetrators. (9) (7) Scottish Government (2014) National Guidance for Child Protection in Scotland. Additional Notes for Practitioners: Protecting Disabled Children from Abuse and Neglect. Edinburgh: Scottish Government (8) Galloway, S., Love, R. & Wales, A (2017) The Right to Recover: Therapeutic services for children & young people following sexual abuse - An overview of provision in the West of Scotland. NSPCC (9) FRA (2015) Violence against women: and EU-wide survey. Main results. Luxembourg: European Union	The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation. The guidance on abuse of disabled children is now included in the Pathway. It is acknowledged that accurate information on the incidence of child sexual abuse is not available and has been removed from the Pathway.
64SJ-F	The pathway is very clear and comprehensive. Practitioners are referred to the document ‘Delivering a Healthy Future - An Action Framework for Children and Young People’s Health in Scotland’ (Scottish Executive, 2007) regarding age appropriate environments of care. This publication is 12 years old and it may be beneficial to cite a more recent reference relating to this item. Pages 5 and 21- Amendment of date: Child Protection Guidance for Health Professionals. The Scottish Government, Edinburgh 2013 (not 2012). This is correctly documented in page 17 and elsewhere in the pathway document. Page 6- 1.7 heading should read: who has developed the Guidance? Additionally, were young people consulted and involved? It’s not clear from reading this if their voices have been heard	We consider the 2007 document to be relevant and clear on this point. Corrections now made. Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway.
64SZ-Y	The term child sexual abuse is used throughout this document. Generally this term is used where abuse has been over a period of time and is by an adult/older person. This term would not generally be used for example if we were talking about the rape of a 14 year old by her boyfriend. We would reconsider whether the sexual assault of a child or young person is a better fit if we are looking to improve the responses across the board, and to acknowledge within the text the differing nature of how children and young people might experience sexual violence and the differences in service responses and design. What was really clear in earlier workshops RCS have been at re responses was that children are not a homogenous group and that the needs of young children and teenagers are quite different in service delivery. This we believe needs acknowledged here. It may be referenced in some of the linked documents but it requires a more central focus. Non contact sexual abuse such as Image based sexual abuse is not mentioned. Whilst the driver for this work has been forensic provision if the aim is to look holistically at best practice in responding to sexual violence disclosures, including non contact abuse, then the law and context around image based and cyber enabled crime should be included. See recent research on the impact with recommendations https://www.dur.ac.uk/resources/law/ShatteringLivesandMythsFINALJuly2019.pdf	The language in the Pathway is aligned with the draft revised National Child Protection Guidance which is currently the subject of consultation. It now includes cyber enabled abuse.
64SF-B	Views of child, young person	Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway.
64SA-6	I would suggest there be more proactive information rather than reactive. From previous research there is a higher rate of adults than children disclose sexual abuse and I feel there should be more education and support for children to encourage disclosures when young in order for early intervention rather than victims having to live with this into adulthood.	The Pathway is intended to support practitioners caring for a child once a disclosure / concern has been raised that CSA has taken place.
64SH-D	We believe that this pathway should apply to all children and young people under 18. We believe this for the following reasons: At present, the guidance includes 16 and 17 year olds who have a particular vulnerability. We would argue that having experienced child sexual abuse is in itself a vulnerability and it is therefore logical that all under-18s are responded to via this pathway. All victims deserve access to a compassionate, trauma-informed, person-centred pathway; in our experience, young people aged 16 and 17 struggle to receive this through adult services and often feel unable to engage with adult processes. The UNCRC, which will shortly be incorporated in Scotland, defines a child as under 18 years old. Legislation and guidance that has recently been developed in this area, of which we are aware, is moving to a definition of a child as under 18. This includes: the Scottish Government definition of Child Sexual Exploitation and the Human Trafficking and Exploitation (Scotland) Act 2015. We understand that the current review of the National Guidance on Child Protection (2014) is likely to recommend amending the definition of a child to all those under 18. Bringing the pathway into line with this would help to future-proof it, and prevent guidance having to be changed in future to keep pace with these developments. We cannot identify any unintended consequences of including all 16/17 year olds in the pathway, but can think of many 16/17 year olds we have worked with who would have benefited enormously from a more child/young person-friendly process. In order to incorporate a range of learning styles, alongside the existing reports referenced in the document, links could be included to the following videos: Tyler’s Story, a short film by Seen and Heard documenting a young man’s journey to and through disclosure within a health care setting (https://www.seenandheard.org.uk/) Making Noise, a short animation sharing the voices of children and young people who have experienced sexual abuse and their experience of disclosure and service provision (https://www.beds.ac.uk/ic/recently-completed-projects/making-noise)	The Pathway is applicable to the care of children and young people up to 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) who have disclosed sexual abuse of any kind. The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64ST-S	How you do support young people that don't want the police/ SW involved. The document makes an assumption that all sexual abuse cases go to IRD which is not the case - how do we support the young people who disclose and want support but the disclosure does not need to go to IRD?	The Pathway is intended for cases which do involve police and social work. If a child presents to the health service reporting sexual abuse or assault, in most cases this would be reported to other agencies and an IRD held. It is difficult to imagine circumstances where this would not happen but in that case then the health needs of the child or young person would be addressed.
64SU-T	Children who have been alleged to have been raped should not be given abortifacients to end any human life in anyway whatsoever however they should be given the morning after pill to prevent life from occurring in the first place within certain circumstances, this can actually be done and I would highly recommend this. To summarise a new Catholic Law as of 25/2/2019 does permit the morning after pill as an act of mercy to child rape victims within three full days since the sexual assault against them took place and under the following nine conditions: 1 - The morning after pill is used by the girl between the time of assault say 3:00am in the Monday morning to 3:00am Tuesday the next morning. 2 -Or The Morning after pill is used rom 3:00am the Tuesday morning to 3:00am the Wednesday morning by the girl. 3 - Or finally the morning after pill is used from 3:00am the Wednesday morning to 3:00am the Thursday Morning. That means the girl can use the pill within a full 72 hours and providing the other conditions below are met its use can not be regarded as an abortion. Those otherf conditions are as follows: I - The girl is not suspected of being prior pregnant since the day of the assault. II - The girl has been indeed been sexually assaulted. III - The girl has not yet ovulated She must pass three tests also: A) The girls leutinizing hormone (LH) level must not be spiked. B) The girl must not be within her fertile period in regards her menstrual cycle. C) The intent of the girl must be to use the morning after pill as an emergency contraceptive and not as an abortifacient. If the morning after pill is used by her in any other way outside of this ritual then it is not a life defensive procedure of a child but murder of the other child or an attempt therefore in her womb. Thus should not be entertained physicians. I would support the pathway then if under the condition that it was to employ the procedure detailed above	Noted
64SU-T	When an alleged rape of a minor has been reported all social work and police activity with regards to the associated child protection processes should be recorded by an active video device within a secularly locked compartment within a Barhanus such as CCTV in terms of the child and within a Police Station as concerns the adult - no other person but members of the court service should be able to open that compartment when interviewing the accuser or accused. In terms of the CCTV recording it should store all recording of the victim or accused within the Barnhanus or Police Station for three days forcing the Crown to either prosecute or let the detained go upon evidence if no prosecution is commenced then the recorded interviews should be allowed to automatically rewrite themselves if there is reason to prosecute or if accused or accuser has a complaint against the Crown, Police or Defence of unfair treatment then the Scottish Court Service should allow the interview to be saved by which ever side needs it to be saved for there interests. The only other persons that should be able to access it are the prosecutor fiscal and defence solicitor once given clearance by the Scottish Court Service to do so and only if the child, child's guardian or crown decide to take the matter to a criminal court. Over the three days that the CCTV is retained the Crown Police and Defence must be able to view the recordings to examine them. Ideally a prosecutor fiscal and a defence solicitor should be able to examine and cross examine the child within a Barahus in the sight of a judge and jury this protects an alleged victim from being cheated of the justice due to them by deliberate malpractice or otherwise incompetent practice & any adult who is allegedly falsely accused by being deliberately set up by the child being coached or the adult themselves being coerced into giving a false confession. If any engagement or questioning of the accused or accuser by the prosecution or defence should occur out with those areas then the accuser and accused should continue to be able to record the approach of any such civil servant of the crown or agent of the defence and keep the recording for evidential purposes. If it is ceased and destroyed without a warrant then it should be a crime. All civil service personnel and agents of the defence should as well be able to use cameras and I would say the civil service or the crown should be obliged to carry recording devices unless within a private citizens property without a warrant. However if the authorities are investigating a claim of child sexual abuse recording should occur without need of a warrant in respect of private property between 2019 - 2021.	These areas relating to the investigation are out with the remit of the Pathway.
64SU-T	The decision to prosecute or not to prosecute should always remain with the crown first the child's guardian(s) second as the child is far too young to make any such decision on this matter themselves whatsoever unless it is a historic case and the child is then an adult. Keeping the Crown in primacy in this decision making process will enable the crown to act if they believe the child is being abused by the parent	As per 29(2)(e) and 48(5) of the Scotland Act 1998 detailed below, the statutory provisions confirm that the Lord Advocate is the independent head of the system of criminal prosecution. There are no plans to change these.’ 48 (5): Any decision of the Lord Advocate in his capacity as head of the systems of criminal prosecution and investigation of deaths in Scotland shall continue to be taken by him independently of any other person. 29(1): An Act of the Scottish Parliament is not law so far as any provision of the Act is outside the legislative competence of the Parliament. (2) A provision is outside that competence so far as any of the following paragraphs apply— (e) it would remove the Lord Advocate from his position as head of the systems of criminal prosecution and investigation of deaths in Scotland
64SU-T	All medical support and health care management should not be recorded in any audio video format unless the alleged victim or alleged victims guardian requests or otherwise consents in writing to an offer to. The defence and prosecution should have access to material & forensic evidence collected by the medical services if the child who has been allegedly raped agrees in writing or there guardian agrees in writing. If the alleged victim or alleged victims guardian does not agree to any both of these sides accessing the material for cross examination purposes then the accusation should not proceed to a court of law at all. If evidence to prove guilt is damaged or lost by the defence the defence should be held in contempt of the court and/or perhaps be removed from the Law Society of Scotland if the prosecution damages or looses evidence of the defence that would suggest innocence then case must be dismissed.	Consent for examination is addressed in the Pathway. The other issues here are out with the remit of the Pathway.
64SU-T	GIRFEC should be completely removed from the pathway all together and if it must be implemented it must be observant of the UK Supreme Court Judgement UKSC 2015/0216 known as 'The Christian Institute and others (Appellants) v The Lord Advocate (Respondent) (Scotland)' respectively.	Reference to GIRFEC in the Pathway remains appropriate.
64SU-T	Information sharing should always be mindful of s22 of the Gender Recognition Act 2004 and be done with the transgender child's written consent only if children are able to ever transition in the future. This should be the case in regards transgender children who have not applied, are applying or have got a GRC - a transgender child even today should never be outed by having there gender designated at birth shared with other so called "colleagues" against there written consent if this does happen then the individual within the pathway who has outed them should be prosecuted for breach of that section. If outing happens by a person within the pathway in regards the accused without the accused persons written consent then the public servant themselves should be prosecuted under the same section of the gender recognition act as well with a mandatory three years imprisonment if found guilty by a jury of 15 in each scenario.	Noted.
64SU-T	Police should lead and decide in any criminal investigation independent of the IRD and not on the dependency of the agreement of just the social work or medical services however in regards the alleged victims treatment including forensic evidence collection by doctors and preservation of evidence given by the alleged victim to the medical services voluntary the medical services should take the lead in accordance to the Hippocratic oath. Any forensic medical evidence not of the accused but of the accuser such as there blood or other material collected by police-doctors should be only handled in accordance to the wishes of the accuser or accusers guardian. In short a police-doctors duty in respect of issues pertaining to the accuser should be to the Hippocratic oath over Scots law. The only incidence a police doctor should have any duty in regards the accused under the Hippocratic oath is in matters separate from securing material for there conviction but only pertaining to saving there life, for exsample, if the accused suddenly takes a seizure.	These matters are out with the remit of the Pathway.
64SU-T	The IRD should be adaptable to work with the RMP or other law enforcement agencies including HMRC and The UK Border Force if it must be implemented. It should also be able to work against any person from the inside under direction of those or other agencies of CAAPD or other superior division of law enforcement. It must always and only be used in accordance to Scots law. If there a jurisdictional issues then the law of Scotland should prevail if the alleged incident is said to have occurred in Scotland unless it has been alleged to have occurred by a member of the UK Armed Forces in which case UK military law should take precedence however the court marital must be held within Scotland. If in the event a member of CAAPD is accused then the L-rd advocate should take the lead if in the event a L-rd advocate is accused then the alleged victims guardian should be granted a bill of criminal letters.	Issues of jurisdiction for various police forces are out with the remit of the Pathway.
64SU-T	There should be no actions based on unsubstantiated concerns of another but only upon an allegation by a child, the child's guardian or were a doctor believes physical injury to the infants body would suggest sexual violence has occurred once there is collaborative evidence also. The apparatus should not degrade parents as ''Supposedly trustworthy adults' either, as most parents in Scotland are good and trustworthy the anti-parental disdain and hatred behind that statement in fact is the kind of tactic once employed […] in order to eliminate the family unit and encourage full state control of the infants view of the world and there own personal world in order to aligned them with the view of the state as warned about when judgement was delivered against the Named Person Scheme by the UKSC when it decreed: " There is an inextricable link between the protection of the family and the protection of fundamental freedoms in liberal democracies... Different upbringing produce different people. The first thing that a totalitarian regime tries to do is to get at the children, to distance them from the subversive, varied influences of their families, and indoctrinate them in their rulers' view of the world. Within limits, families must be left to bring up their children in their own way. " (UK Supreme Court judgement on the Named Person, para. 73) Unless of course a parent has sexually abused there child then I would be the first to recommend the child pit themselves against them and certainly not to trust them if they value there own survival. However there is a great presumption of guilty being placed upon parents by the state stating that they are 'supposedly'' trustworthy. That's actually creepy. Who is automatically ore trustworthy than the parents then ? […] That statement is outrageous - the parents of Scotland are awed an apology ! I fear that more likely actually that the Scottish State could launch an unsubstantiated concern of sexual, emotional or negligent abuse or coach a child to the same simply to effect the attempt at state control of a child as warned about in the Supreme Court Judgement previously cited above. Especially if there is a monitory, political or other incentive for the state to do so such as trafficking children mostly from working class, immigrant or religious backgrounds to middle to upper class families or so called more ‘providing politically correct families’ to ensure the so called future wellbeing of that child. If a religious family brings there child up in there faith to regard gay marriage as ''incorrect'' or if a gay family brings there child up to regard gay marriage as 'correct'' will those cases be seen as child abuse by the state and grounds for intervention ? In a democracy both cases should never be used as grounds for removal ! Also the inherent unjustified and prejudicial suspicion towards young working class single mothers with large families in the consideration of environments so called more likely than not to be conducive to child rape being punted by some feminist academics who look down at such women that stay in the home instead of competing in business is an outrageous slander as well. This apparatus if it go's forward should not therefore be solely focused on households either as there is no one "type of person" from one "type of place" that can be said to be or not to be a child rapist, child rape can be committed by anyone, anywhere. To believe or put anything else forward as infallible is totally naive.	The comments are out with the remit of the Pathway.
64SU-T	The current seems data to suggests that rape of minors is indeed mostly done by a genetic man in a position of power & trust or otherwise known to them which yes includes in a lot of cases the father of a household - such statements do not always make a rule though and I think such sweeping interpretations held as infallible fact have more to do with an irrational ideological hatred of a perceived so called patriarchy from the far left feminist bridge than actual scientifically verified data especially when that data is limited in scope in so far as it has not been derived and can not be derived from all worldwide child abuse incidents as to detect or otherwise investigate every incidence in Scotland let alone internationally is an impossible task to do so in the first place. The current limited data from the United Nations and Vatican City State gathered independent of each other does seem to actually collaborate the assertion of the Scottish Government made upon its own limited data on this point as well in that it is genetic men who seem to be the main perpetrators and genetic girls &transgirls that seem to be the main victims however what the data does not state is who the "Father" or "Other male figure" in each case involving a family home studied actually was. Was the attacker the genetic man who co -conceived his genetic daughter or trans daughter ? Or the genetic mother or trans mothers new genetic male partner […] for example ? Was it a gay father ? Or gay fathers lover ? A transman or trasnmans genetic male or transmalelover ? And if men are more likely than woman to commit these acts especially to little girls and trans girls does that mean there more safer in a lesbian family or a trans lesbian family than in a family with two male partners or one with a mum and with a dad or trans dad and trans mother or even one trans parent and none trans? Who knows Scottish Government ? We can only speculate and speculation is not good enough. The data from domestic cases seems to show that the most likely candidate is actually step brothers and step fathers. It maybe that such conclusions based on such data will be replaced actually as cases are always occurring plus more and more cases are now starting to show that child abuse may actually be being committed more commonly and has been more commonly carried out by genetic men not in family homes but in secular state institutions such as care homes, the third sector, and religious organisations - case in point the ongoing Scottish Child Abuse Inquiry of which I have provided intelligence too. So the temptation hear is to label all genetic fathers more likely than others to rape there little girls or trans girls or indeed the little girls or trans girls of others when that may not actually be the case. However, I do give way to the Scottish Governments point that regardless of who the male actually is it does seem to be males that carry out the abuse ore so than women or transwomen this has been independently verified and the authors own project, […] into this issue has also found the same those who harmed me when I was younger were all males - it seems to be committed more so by men from a middle class to upper class background that are in power, holding authority and positions of trust such as the police, army, and political institutions as well as churches, synagogues and mosques. I am there for worried at this systems configuration being classist and primary focused on families of the poor or working class. Some of the biggest child molesters in the U.K. also had a string of letters after there name Scottish Government. Therefore it is little girls and little trans girls from poor, immigrant and working class backgrounds under the so called trust of professional genetic men outside of there families that need empowered, emancipated and embraced. There also could be the added fact though that the reason most of the data suggests genetic males is because no serious worldwide study of the sexual abuse of children by genetic women has ever been conducted. In fact while the author is neither a defence solicitor or procurator fiscal it is my current understanding that there is little to no recognition in Scots law that a genetic female can be a child sexual predator or that one even exists as most of the laws governing this area only recognise penetrative acts by the sex organ of heterosexual men, trans men with a penis or transwomen without a vagina. If say a genetic women was to sexually abuse her child by penetration using an instrument the genetic female could be prosecuted for common law assault yes but the genetic male, transmale with a penis or a transwomen without a vagina can be prosecuted for child rape right off the bat - if that is true then that is not right. There is actually an inherent prejudice against men, transwomen without vaginas transmen with penis due to an assumption by the public at least that genetic women are not capable of such acts as well and that little boys or little transboys with a penis or little transgirls without vaginas may not by implication be real victims of a real rape if a genetic woman should rape them. That is clearly an injustice and is akin to the case of when homosexual persons if raped by another man had to have there attacker prosecuted under assault laws while heterosexual woman who were raped were given the chance to prosecute there rapists under rape laws. What's interesting is that the data tends to show that genetic women are more predisposed to being traffickers and suppliers of children to genetic male rapists especially for monitory gain or to impress a potential mate. The current data seems to show that genetic male pedophiles and genetic female traffickers maybe more likely than not not to be gay or straight but bisexual. However making such data an infallible guide maybe erroneous as well because clearly not all bisexual people male or female are pedophiles or rapists. Its very important then to remember that rapists and child sex abusers no matter what gender or sexuality they are - are very few in number compared to the entire population in Scotland and while they may be gay or straight male or female they do not represent all members of the gender or sexuality they are a member of. Arguments around what gender or sexuality is least likely or not least likely are essentially futile to be honest.	The Pathway aims to respond to victims of CSA, regardless of who the alleged perpetrator may be.
64SU-T	Children who have been allegedly raped or are allegedly at sever threat of it can not afford to have those responsible for there safety be partisan, pick and choose whom they protect or prosecute for any reason. Equality in the law in this area must always be paramount or the result could be a dead child. I don't believe Scotland's authorities are capable of such none partisan operating right now. For example while the system pledges to believe all children in there accusation I think we would quickly find it turns cynical if a child was to accuse any prominent member of the government example. In fact a response was given to the adult pathway by the author and free speech was heavily redacted in a partisan way under fears of "liability" being placed upon the Government if it was fully published due to it mentioning high profile organisations, vulnerable minority groups and what should happen IF certain actions ever took place. I must be making an impact after all. The inability to be impartial and be prepared to talk about let alone hold to account the governments own persons in positions of power and trust as well as the public is as self evident as it is hypocritical. While adults may accept that, it can not be allowed to be accepted in the case of children unless of course the Governments stability is placed more important than believing a child may have been possibly raped. If the system really is credible and willing to dispense justice based solely on establish fact or to not pursue if no evidence is established then It does not matter if it's an accusation against a head of one of the four governments of the UK, the author or a poor person on the street it must be investigated and either prosecuted or the falsely accused exonerated without fear or favour. The state must also be ready to jail an adult or place in a child's detention centre a child false accuser, if they are a member of the government or public and the false allegation is against a member of the public or government but there allegation should first be established by a court as false and as even a false accuser deserves to be regarded as innocent until proven guilty first the only person that should deem an allegation false in regards an accuser without needing to prove its first false is the accuseds defence solicitor. Such as the prerogative of defence solicitors. Anything else is just a mockery of the justice due to victims and the falsely accused.	These comments are out with the remit of the Pathway.
64SU-T	Above all, the primary objective of the system even more so than prosecuting the alleged rapist of the child must be to save the life of the child. You can not save a child from harm or have them testify against there alleged attacker if they have already been buried Scottish Government. Therefore I am in favour of this system being medically centred. PEPs should be issued to children who have been alleged to have been raped.	The Pathway is focussed on the delivery of consistent care and support to Children and Young People who have experienced child sexual abuse.
64SD-9	[Our organisation] notes that the Pathway is intended to supplement existing national guidance and standards. [Our organisation] welcome the high level summary of the clinical pathway which retains the Interagency Referral Discussion as the core response expected by statutory agencies of disclosure of sexual abuse by a child or young person.	Noted.
64SP-N	We note that the document refers to children and young people making ‘disclosures’ of sexual abuse. From a legal perspective, it would be more appropriate to use the term ‘allegations’, reflecting the fact that these procedures will be taking place at an early stage of investigations, and it will not yet have been established whether a sexual assault has occurred. There is no specific reference to how this resource should be introduced to those healthcare professionals who will be working in relation to the pathway. We would be interested to know how this will be incorporated into the training and education of healthcare professionals and those working in other relevant fields	We note the point about the most appropriate terminology from a legal perspective. In the pathway we now refer to a disclosure or an initial concern. The terminology in the Pathway is aligned with the National Guidance for Child Protection in Scotland 2014. Training and education was offered to all health professionals at roadshow events prior to implementation of the resource.
64SQ-P	The aim of the pathway as set out in para 1.1 is “a resource to outline the process for the healthcare response to disclosures by children and young people of sexual abuse of any kind”. We found very limited mention of child sexual exploitation as a form of sexual abuse and suggest including reference and links to research on this.	More information on CSE has been added.
64SK-G	Page 6 1.7--were young people consulted and involved? I'm not clear from reading this if their voices have been heard	Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway.
64S6-U	Consent – parents being suspects. Children over 13 can give own consent. Under 13 – parent in the room when the parent is in the room. Cases where the child is over 13 and the consultant still wants to contact parents. Agency cannot override parent’s decision. In our area, consent lies with paediatrician not the police and we use warrants.	Guidance on obtaining consent for an examination under various circumstances is included in the Pathway with references for further information if required by health staff.
64S3-R	The pathway needs to be anchored more in wider child protection guidance and winder discussions on supporting child and young people in Scotland	The Pathway now contains more information and background on the wider child protection context in Scotland.
64S3-R	Need to ensure that the pathway is tied into the revised integrated national guidance for child protection and be aligned with the UN Convention on the Rights of the Child. All children under the age of 18 should be considered as part of the pathway, rather than 16, in line with new guidance. It should be explicitly stated that child protection may be considered for young people up to age 18, and this is legally linked to ongoing work in relation to CSE	The pathway is applicable to the care of children and young people up to 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) who have disclosed sexual abuse of any kind. The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64S3-R	For young people aged 16-18, referenced in section 5.1, it should be recommended that adult support and protection may need equally need to be considered. It would also be good to see a reference to onward involvement in adult services for this age group. For 16-18 year old young people with learning disabilities, for example, adult support and protection may be working as part of the pathway (as the disclosure will likely be made in this context). The use of 'vulnerability' should be aligned to wider discussion on supported decision-making and a rights-based approach.	The Pathway now includes reference to adult support and protection measures.
64S3-R	The section on legislation needs to be expanded in relation to corporate parenting duties, in particularly given that health boards are statutory corporate parents	The Pathway has been revised to include information on corporate parenting.
64S3-R	Additional information on how the pathway relates to regional and local models would be helpful, especially if the child protection procedures cross different localities, where regional centres are used. Need to be clear about the interface that the pathway will be implemented through and wider governance arrangements	The Pathway is aligned with current National Child Protection Guidance and has flexibility to take account of local multi-agency IRD procedures. It is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation when the revised National Child Protection Guidance is implemented. The reports of the Independent Care Review 2020 and the needs of care experienced children and young people are referenced in the Pathway.
64S4-S	The pathway does not reflect current practice and where practice is moving towards, both in principles and practice	The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area. The Pathway is aligned with current National Child Protection Guidance and has flexibility to take account of local multi-agency IRD procedures. It is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation when the revised National Child Protection Guidance is implemented. The reports of the Independent Care Review 2020 and the needs of care experienced children and young people are referenced in the Pathway.
64S4-S	Who is going to use this, and pick it up? Is it organised as a document that will be picked up and used by many agencies, or will a clinical pathway only be used by one agency?	The Pathway is primarily intended for the health service but may, on occasion, be relevant to police, social work, Crown Office and Procurator Fiscal Service and third sector.
64S4-S	Is the updated guidance on health professionals referenced, and if so what is the purpose of an additional clinical pathway?	The Pathway is a clinical pathway intended to support the delivery of consistent high quality clinical care across Scotland and it is set within current legislation, guidance and clinical practice in this area.
64MC-2	Input from Care experienced people In person Care experienced people have often been subjected to many different forms of abusive behaviour, before entering care (and sometimes during care) creating a lasting impact on their lives. Where this is the experience of the young people our systems need to enable options and not hurdles. To expand upon our point 1: There is much evidence to back the high percentages of people who have experienced care having been subjected to sexual abuse, with an understanding that we do not have figures that reflect reality, due to the nature of the matter, but we are aware of the issue at large . You need look no further than The Scottish Child Abuse Inquiry and the current work it is undertaking to gauge the size of the problem [Our organisation] therefore asks that the final pathway has significant and meaningful input from people who have experienced care as the experts, alongside people from the field of working with people who are in care or have been so; allowing there to be the opportunity for us to get this right, increasing the likelihood in the future of people to come forward where they are subject to sexual abuse. We have the opportunity to gain insight and understanding how to best ensure the pathway works for and with people who are in our ‘care system’. To expand upon our point 3, the [our organisation] urges that our findings, due to be published summer 2020 play an integral part to the final shape of the clinical pathway (timeline detailed in our ‘Journey’ report ).	The points about care experience people is important. Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway.
64MC-2	[Or organisation] is having the opportunity to find out and collate lived experience and wisdom of people from across Scotland. That means actively listening to the voices of children and young people in care, care leavers – young and old – and families and carers. It is their experiences and voices that is giving clarity and focus on what matters in this complex and challenging task. These findings are generating a picture we have never had the opportunity to explore to this level until now. [Our organisation] does not want to hold up the launch of the pathway but is of the belief that the findings of the work being undertaken since early 2017 should play a fundamental part to the final shape of the document. Were this not to be possible, we would ask for a 12 month review on the document, allowing for these to be added at a later date.	Engagement in this area with Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s) is challenging and we have benefitted from the experience of Children 1^st’s involvement in developing the Pathway. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MC-2	[Our organisation] recognises that it may not be beneficial to have a full listing stating who the pathway is for. However, [our organisation] believes that there needs to be a broader listing than is currently provided and that Corporate Parents are part of this: In 2015, 24 groups of bodies and public bodies were named as Corporate Parents with legal duties to deliver on to people who have experienced care as an infant, child and or young person. With the implementation of these changes, [our organisation] urges that there is communication with The Corporate Parenting Board so that the changes can play an important part in their knowledge and understanding of what options are available. Corporate parenting responsibilities are set out as: (1) It is the duty of every corporate parent, in so far as consistent with the proper exercise of its other functions — (a) to be alert to matters which, or which might, adversely affect the wellbeing of children and young people to whom this Part applies, (b) to assess the needs of those children and young people for services and support it provides, (c) to promote the interests of those children and young people, (d) to seek to provide those children and young people with opportunities to participate in activities designed to promote their wellbeing, (e) to take such action as it considers appropriate to help those children and young people— (i) to access opportunities it provides in pursuance of paragraph (d), (ii) to make use of services, and access support, which it provides, and (f) to take such other action as it considers appropriate for the purposes of improving the way in which it exercises its functions in relation to those children and young people. [Our organisation] recommends that this become part of pathway and considered throughout the document and any role out for the changes, for example. Without this there is a risk / chance of good practice not being shared where needed	Communication with Corporate Parents was part of the communications strategy when the Pathway and various other Taskforce documents were launched.
64MM-C	5.2 Interagency referral discussion - consideration should also be given to any other child who may have been affected or who may still be at risk, rather than only children living within the same household.	An important point but out with the scope of this pathway.
64M5-M	The title of the document is ‘Clinical Pathway for Children and Young People who have disclosed sexual abuse’. However, within the text the document is variously referred to as ‘clinical pathway’ ‘clinical pathway and guidance’ and ‘guidance’. Whilst we acknowledge that this is not our area of expertise, our understanding is that clinical pathways are multi-disciplinary plans of care to support the implementation of guidelines and protocols. We wonder if it might be confusing, in a health context, to be referred to as a ‘clinical pathway’ and as ‘guidance’? In a more general sense, we note that the pathway is to be used by NHS Boards, LAs and IJBs (pg. 5; Section 1.2). We would respectfully suggest that the title ‘Clinical Pathway’ may make the document feel less relevant to core partner agencies. Whilst ‘Clinical Pathway’ is a familiar concept in health settings, we note that this term most commonly relates to hospital based interventions and plans. It may be helpful to consider re-naming the document ‘Collaborative Care Pathway’ in order to increase its relevance to core partner agencies, as well as the wider multi-disciplinary health team. A ‘Collaborative Care’ pathway perhaps better describes the necessity of health working in collaboration with other core services, to ensure the child’s emotional health needs are central to the response at every stage of their journey, to ensure improved health and wellbeing outcomes, as well as justice outcomes. We note the longstanding, expert consensus about the need for multi-agency services working in close collaboration around the child and family, if not co-located, to ensure that the child’s emotional wellbeing and recovery needs are at the very heart of a caring response to child victims of sexual assault and abuse (including National Co-ordinating Networking Board; HMICS Strategic overview; ‘SARC plus’ model under consideration in CMO Taskforce). We would wish to see this fundamental principle more clearly articulated in the introduction and throughout the pathway. We would query the age group of children and young people that the pathway is applicable to. We are aware that a child is defined differently in different legal contexts in Scotland, and that the HIS Standards define a child as under the age of 16, except in cases where the child is deemed vulnerable. Given the moves towards implementation of UNCRC in Scotland, it would seem wise to future-proof the pathway, in line with the UNCRC definition of a child. It is also our understanding that the revised National Child Protection Guidance, which is currently being drafted by the Scottish Government, will define a child as a person up to the age of 18. We would strongly support close collaboration in the drafting of and consultation around these two essential documents.	The Pathway now has more information on the wider child protection context in Scotland and multiagency procedures as well as emotional wellbeing and recovery needs. On reflection we will keep the title of Clinical Pathway but take the point on this and have detailed the purpose of the document in section 1. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MW-P	The consultation document makes reference to The Children and Young People Expert Group which provided advice on tailoring recommendations to children and young people and states that the recommendations are intended to be in line with the Barnahus concept. As this is not the case we would suggest that the Barnahus is explained as follows: The Barnahus model was adopted in order to create a specific legal system that responds to the special needs of children about whom there is a suspicion that they have been subjected to violence or abuse. The Barnahus (which literally means Children's House) is a child-friendly, interdisciplinary and multi-agency centre for child victims and witnesses where children could be interviewed and medically examined for forensic purposes, comprehensively assessed and receive all relevant therapeutic services from appropriate professionals. These are: criminal investigation, collaboration/protection, physical health and mental health. Moreover, the Barnahus is a place at which the social services, the police, the public prosecutor's office, forensic medicine, paediatrics and child and adolescent psychology can confer and collaborate, particularly in the initial stages of the preliminary investigation and the social investigation. In addition to this, we would highlight that the work of the CYP expert group is wide and encompasses more topics than the Barnahus model of care alone	The Pathway is not intended to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64MW-P	In discussing the prevalence of child sexual abuse, the pathway presents figures on the numbers of these offences recorded by Police and the number of people prosecuted for sexual crimes against children. [Our organisation] believes this reads to the suggestion that the new pathway is being implemented to increase prosecution in these crimes. Instead the pathway should aim to standardize care and develop minimum standards to ensure that all victims of abuse are provided with better care and offset at least some of the trauma associated with abuse. In response to this we would suggest the inclusion of the numbers of examinations that are undertaken by health boards for child victims of sexual abuse however, robust national data is not currently collected (We do understand that a pilot for an ISD national dataset is forthcoming)	The figures in the Pathway are provided for context only. The primary aim of the Pathway is to promote the delivery of consistent high quality care and support to Children and Young People who have experienced child sexual abuse and their non-abusing parent/carer(s).
64MV-N	As stated above, further work should be done to reconcile this document with the Scottish Government commitment to Barnahus, making sure that the pathway work becomes part of the wider Barnahus standards development process. This should include the process of gathering evidence that will need to underpin Barnahus development work.	The Pathway is not intended to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
Do you have any further general comments on the pathway document?
64HR-C	Does the health service not have any responsibility for providing victims of sexual abuse with details of what supports may be available to them either, via CAMHS - regarding any thoughts of suicidal ideation as a result of their trauma, or third sector supports which may assist the child or young person in dealing with the aftermath of their abuse? The Aims of the Clinical Pathway as outlined at paragraph 3 specifies that, 'services...are able to promote health, wellbeing and recovery' but there is little by way of content around how the pathway links to wellbeing and recovery.	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
6417-T	The NHS England Strategic Direction appendix describes 'Lifelong care for victims', recognition of the long term effects of CSA is crucial.	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64ME-4	The pathway is only a repetition of known facts that have been generally accepted for quite some time. It does not take in to account, or implement, changes that will actually make a difference to the children in most need. In fact, the pathway is grossly inadequate. I know that one of the main criticisms of the Barnehus model is that it can interfere with the quality of evidence collected, but through rigorous research and analysis there is no reason why proper systems could not be put in place to ensure that questions or conversations are of the necessary quality. Most importantly there is the need for a system which gives the child time, a sense of safety and an opportunity to trust another adult in whom they can confide. I believe that use of the Barnehus system provides a more accurate indicator if sexual abuse has taken place and as I understand it, the statistics back that up	The Pathway is not intended to introduce a Barnahus model or facility to Scotland. However, it is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64ME- 4	From Dr Sarah Nelson’s blog: Most children and young people do not disclose of their own accord; or not in ways that adults can understand; or only anonymously; or only in very sympathetic and protective circumstances. (Crisma et al 2004; McElvaney 2013). Most adults, including teachers, do not know, or are nervous of asking, or believe they should not ask. Perpetrators do not tell. Social work and children’s hearing statistics show identification of CSA has been consistently falling- the figures are tiny- even though at the same time reports to police of sexual crimes against children, including online crimes, keep rising (Nelson 2016b). A recent Scottish study (Marryat & Frank 2019), using Growing up in Scotland study statistics to draw conclusions about Scottish children affected by ACES, did not even consider CSA, since there were ‘too few cases to include’ (sic). Yet the questions used, the environment of the GUS surveys and the respondents chosen would have meant that GUS surveys have been very unlikely to reveal sexual abuse. In addition to all these difficulties we have the phenomenon of children being taken away from their mothers when, after a court case which the father has won, the children continue to disclose what has happened to them ie. Instead of anyone actually making an effort to listen to the children, they are taken away from their mothers by the court and may be put into the care of their fathers. One of the number of mothers to whom this happened said she felt the court wanted to “punish” her as the court concluded that she and the other mothers were prompting their children to speak about abuse. This is utterly horrifying when potentially valid disclosures are being made by the children and are not investigated by the authorities. This constitutes further abuse of the child by the state. It is essential that the child is not written off at this stage, particularly given the deficit in the current system. I am personally referring to Scottish cases – the link below is American but the same applies: https://centerforjudicialexcellence.org/2019/07/31/a-gendered-trap-when-mothers-allege-child-abuse-by-fathers-the-mothers-often-lose-custody-study-shows/ This happens in Scotland and I have been warned by my solicitor that if I do not comply with the wishes of the court, or if my daughter continues to disclose of her own accord there is a risk she will be taken away from me.	The pathway has been updated to not only cover disclosures by children, but to also be applicable when a concern has been raised that a child may have experienced sexual abuse.
64ME- 4	What I know is what my daughter disclosed to me. What I know is that she feels scared to be with her father on her own. If she decides to say anything more to anyone besides myself I risk having her taken away from me – and there is no mechanism for her to have her feelings or opinions heard. Even though the website for the Children’s Commissioner for Scotland says Article 12 of the UNCRC says that every child “has the right to be listened to and taken seriously”. It says, “children and young people have the human right to have opinions and for these opinions to matter. It says that the opinions of children and young people should be considered when people make decisions about things that involve them, and they shouldn’t be dismissed out of hand on the ground of age”. Article 12 is not upheld in Scotland. No one has listened to my daughter’s opinion. No one has taken her views. There is no mechanism through which she can have her voice heard. […]my daughter HAS an opinion and that opinion HAS NOT been heard and has effectively been prohibited. If she does speak now she risks being taken away. Some mechanism needs to be installed IMMEDIATELY to ensure that the voice of the child is heard and so that Article 12 is properly implemented and active in Scotland.	Thank you for sharing your family’s experience with us. Ensuring that children and young people’s voices are heard, listened to and acted on are very important points. The Pathway promotes consistent, child centred and trauma informed care. Hearing the views and experiences of children and young people, and their families is key to this work and to driving improvements in all aspects of care and support. The Scottish Government have indicated their intention to incorporate the UNCRC in to Scots law and have introduced the Bill to Parliament.
641N-H	It is vital that we approach the disclosure process with believing the child from the outset.	This point is emphasised in the Pathway.
641Z-W	The places to refer to are Stop it Now or Rape Crisis on your main page. Stop it Now work with offenders so that is giving the wrong message to children and young people about who to call. Survivors of childhood abuse do not feel rape crisis is relevant in many cases. To ensure safety and appropriate safeguarding this page should highlight the specialist sexual abuse organisations funded by the survivor policy team.	Noted
64MW-P	The philosophy of this clinical pathway should be underpinned by the principles set out in the United Nations Convention on the Rights of the Child (UNCRC) and the European Convention on Human Rights (ECHR). This emphasises the child as an individual, as part of a family, and part of a community who has rights which should be recognised and upheld. Article 4 (protection of rights): governments have a responsibility to take all available measures to make sure children’s rights are respected, protected and fulfilled. Article 12 (respect for the views of the child): when adults are making decisions that affect children, children have the right to say what they think should happen and have their opinions taken into account. Article 16 (right to privacy): children have the right to privacy. Article 19 (protection from all forms of violence) states that all children have a right to be protected from ‘all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child.’ Article 24 (health and health services): every child has the right to the best possible health and to medical care and information. Article 39 (rehabilitation): children who have been neglected, abused or exploited should receive special help to physically and psychologically recover and reintegrate into society Article 34 (sexual exploitation): governments should protect children from all forms of sexual exploitation and abuse	The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
6412-N	As per question 1. the pathway needs to be a useful tool for practitioners and there needs to be a short separate document that is easy to use particularly for dental practices. It is likely that dental practices will be undertaking only the first two stages on the flowchart and also the management of healthcare need if appropriate and relevant to the patient’s oral health. It is unlikely that dentists will perform a medical examination in the context of this pathway so something that is profession specific would be helpful.	Advice received from the Children and Young People Expert Group and the Steering Group for the revised National Child Protection Guidance is that education, guidance and support on child protection is available from employers (or voluntary organisations/charities in the case of volunteers). The advice is that it is not necessary and may be unhelpful to duplicate material already available in this area.
6416-S	The document is straightforward, clearly written and informative. The outcome that children and young people get appropriate and timely access to health care and to emotional, mental health and social support is welcome although it does not set out standards or details and, as above, fails to include sufficient reference to partner agencies including social work, education and police appropriately. The document balances the child and young person’s needs and the requirements for criminal prosecution. Information sharing between agencies has been impacted following GDPR with a rise in actual and perceived difficulties so it would be helpful if the document linked to any new Scottish Government guidance in relation to information sharing. The inclusion of trauma informed services and ACEs is appropriate but would benefit from more contextual information. The diagram on page 14 is helpful but not entirely accurate as it fails to include Education or Third Sector partners.	The Pathway covers the journey of care and support for the child or young person, from initial concern through to their onward recovery. It describes the requirement for close working between the NHS, social work services, police and the third sector to ensure the provision of a holistic healthcare response.
6414-Q	The principles are sound, but the introduction is not strong enough on emphasising the need for a clear pathway to be adopted in the best interest of children and young people.	The introduction has been enhanced to make clear the aims of the Pathway.
64S9-X	It does not seem to place the child or young person at the heart of the process and is systems focused without recourse to consideration of the wellbeing and mental health of the child or young person and their family.	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64SX-W	The document is for health practitioners and focuses - rightly - on the role and function of forensic medical examinations. These will be necessary when there is evidence of contact sexual abuse. However the document has a wider role in relation to how health care professionals should respond to sexual abuse disclosures more generally. There are gaps in how the document conceptualises sexual abuse that would be relevant to identification of - and responses to - sexual abuse in health settings (particularly sexual health settings for instance). Lack of reference to abuse online or more nuanced discussion of sexual abuse perpetrated by peers / harmful sexual behaviour are particular weaknesses. These are addressed in particular sections later in our response	The Pathway is intended to describe best clinical practice in line with current relevant legislation and guidance. The language in the Pathway is now aligned with the draft revised National Child Protection Guidance and it now refers to cyber enabled abuse. However, as the Pathway is intended to support the delivery of care and support to Children and Young People who have experienced child sexual abuse and their non-abusing parent/carer(s) it does not attempt to cover these wider issues.
64SM-J	The format is user friendly and the links to other documents are helpful and makes this a good resource for further training / CPD for clinicians. Use of diagrams was helpful in IRD section. It might have been better if the consultation questions mirrored the sections of the document exactly.	Noted.
64SV-U	[Our organisation] believes that the section 4.3 Trauma-Informed Services – would benefit from a section on children with disabilities including impact of non-verbal disclosure, relying on others to recognise / identify potential signs of sexual abuse etc. It is worth noting at this point that there is a lack of research, information and statistics on abuse of children with disabilities. Across the whole pathway [our organisation] recognises the complexity of recognising the signs that a child / young person has been abused. That is why we feel that this is a specific opportunity for the pathway, clinical process and medical examination to advise, support and inform professionals and heighten awareness of the signs of abuse to children and young people with disabilities.	The Pathway refers to the draft revised National Child Protection Guidance which covers this area in more depth. However, as the Pathway is intended to support the delivery of care and support to children and young people who have experienced sexual abuse and non-abusing parent/carer(s)following disclosure it does not attempt to cover wider issues of recognising abuse that are covered in the revised guidance. More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations / information sharing etc. in the Pathway with hyperlinks to more detailed guidance if required. The Adults with Incapacity Act and the Adult Support and Protection Act are now included within the pathway for consideration when appropriate. The limits to confidentiality when the person or others are considered to be at risk of ongoing harm are now included. The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that 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) must be considered.
64SE-A	The pathway to be a success will require multi-agency tiers of national and local support. Police Scotland acknowledge effective sharing of information and engagement between professional bodies is essential for the identification of risk; assessments; investigations and service provision to children and young people who have disclosed sexual abuse. It would be helpful to establish if there will be a formal approach built in the pathway process to obtain feedback and identify good practice or areas of improvement.	The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SW-V	Well presented, straightforward and accessible as notes above.	Noted.
64SB-7	In order to be as useful as possible to practitioners, the Clinical Pathway document may benefit from clarifying the purpose of document, and that the stated purpose fully aligns with the contents of the document. The statement of purpose in Section 1.1 is noted as ‘a resource to outline the process for the healthcare response to disclosures by children and young people of sexual abuse of any kind’. However, this is not clearly reflected in the document. Rather than guidance about responding to disclosures, the document provides a detailed account of the process for undertaking medical examinations of children, where such examination is required under child protection procedures. Throughout the document, introductory or summary information is provided on a range of areas related to the purpose of the document (such as disclosures, indicators of sexual abuse, adverse childhood experiences, as well as legislation, policy and procedures), however this information appears cursory, and its place and purpose in the document is unclear. If the document is partly intended as a signposting document to more detailed information, this should be clear, and the expected practice implications of such signposting for those using the Clinical Pathway must be identified	The Pathway now has more information on the role of health and the medical examination of children and young people. This is included within a description of the wider child protection context in Scotland and the processes of IRD, JII and, in broad terms, what ongoing support to aid recovery should be available to victims and families.
64SJ-F	The pathway appears robust and comprehensive. It’s a timely, useful resource; which is clear and focused on raising standards to promote a consistency of approach. Additionally the focus on ‘trauma informed’ service provision is important. The gap for the 16-18 year olds and the arrangements to support staff who work in health care practices to be aware of the signs of sexual abuse/cultural issues arranged marriages that are abusive. The LAAC are highlighted it is the hidden that seek help in clinic settings. Staff need ongoing education and support from a strategic level to identify. Clear guidance would be beneficial when considering which legislation or policy applies to a young person aged 16-18 years as this can be dependent on a young person’s individual circumstances and could therefore be managed differently nationally	The Pathway is intended to describe best practice in line with current relevant legislation and guidance and so covers up to age 16 (18 years for those with vulnerabilities or additional needs). The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SF-B	I am surprised that there were no public health school nurses or health visitors involved in the consultative group. While initial forensic examination and clinical assessment does not directly involve these professional groups, their clear remit within the child protection process and development of child centred practice and often continued support of these children and young people would make their contribution notably worthwhile.	Noted
64SA-6	This is a useful document as a health professional using trauma informed care on a daily basis.	Noted.
64SH-D	Throughout our response we have noted specific suggestions on improving the structure and clarity of the document, but overall we have a concern that the pathway document is not easy to follow, and at times the information presented seems so complex that we are concerned this may cause readers to disengage. In particular, we note that while the document is not intended to be read from cover to cover, separate sections can be difficult to understand without reference to other content. The structural device of hyperlinking to different documents within the text also gives the impression that further reading is necessary to fully understand the issues. Medical professionals working with children and young people are likely to come into contact with those who have experienced or are experiencing sexual abuse. It is therefore vital that the information in the pathway is presented in an accessible way, which empowers professionals to take a proactive, supporting and responsive role. We believe that the document would be improved by child sexual abuse being presented as an issue with which medical professionals will routinely engage, rather than as a complex legal issue. We believe that this could be achieved by ensuring that throughout the document the focus is on the child, and what the medical practitioner can/should do alongside the child to support them through this pathway. The document could be strengthened throughout by increasing the focus on the child/young person’s own agency and rights within this process. The list of other documents in Section 1.5 could usefully include information on children’s rights, and in Section 1.7 it would be helpful to mention what work, if any, has been done with children and young people as part of the process of developing the pathway.	We have restructured the document to make it easier to read and changed the format of references and suggestions for further reading.
64ST-S	The key issue that is missing is resource - currently there are huge waiting lists for all services that provide support for sexual abuse victims (children and adults). The idea of providing trauma informed care and support for children in this position is great but is not sustainable with current resource.	Resources are out with the scope of the Pathway.
64SU-T	Another aspect of concern is the MAPPA program that any system like this would most likely take input from including list 99 or s142 of the Education Act 195. Now MAPPA and list 99 are great tools to protect children and fight crime if the persons being monitored have been found guilty by a jury of 15 in Scotland of a crime against children but they are potential infringements on UK, EU and UN human rights legislation when they list people in secret, potentially without notification, and without due process and trial - despite there review policy. The people being monitored in secret could be innocent in fact are so presumed such until trial and conviction. I believe also in regards list 99 or the barred list there is scope to exclude people fro working with children simply for being disabled with a mental health issue. Are there a majority of LGBT persons on MAPPA or s142 lists ? None-White people ? Or political or religious suspects for example ? We only have the government & law enforcement word that they maybe not and unless one adores the idea of abandoning democracy by having there authorities unquestioned that word is not good enough unless it is able to be verified by the electorate objectively. There is also potentially a risk of disability discrimination with this planned system hear as well while the author firmly believes the age of consent should be 18 for all genders and all sexualities in line with the recommendation of both Vatican City State and the United Nations if Scotland is going to maintain its historic 16 year old age of consent law (Which the author used to support as well as 17) then it must be equal to all.	These comments are out with the remit of the Pathway.
64SU-T	The author being learning disabled is aware that disabled people are sexual persons as much as anybody else and unless we are severely lacking in our capacity, coerced, forced, drugged, misinformed, duped, have our consent assumed or are otherwise unconscious simply having a learning disability or mental health disability in and of itself for that matter does not automatically invalidate our consent if it has been freely given at 16. One must be careful then that we the disabled are not unduly denied our human right to seek, give or receive mutually consented to sex and found a family nor that those at 18+ that are not disabled who have consented to sex with people like us at 16 are prosecuted. The disabled are entitled to a states legal age of consent to marry and found a family as well. Having a learning difficulty or mental health issues does not automatically mean us giving our consent is any less valid than that of a person from the enabled community without such issues. If a carer or parent or civil servant must decide if the giving of consent by a disabled person at 16 or any age above is valid or not or if flirtation between a 16 year old disabled or mentally ill person and a 18+ year old enabled person is appropriate or not then that person should have a very good firm basis too ever intrude in that persons private sex life and declare the free giving by that person as being not free or invalid. I am also rather insulted by the assertion that 16 year old disabled persons who have been allegedly raped should be treated as alleged child rape victims compared to enabled alleged victims of rape of the same age who would be seen as adults - they maybe victims and may require assistance from the state certainly but they should still be treated as adults as much as there enabled counter parts even if they have indeed been raped by their consent being regarded as invalid due to sever incapacity.	The Pathway emphasises the need for individualised care and support if concerns are raised about potential abuse.
64SU-T	Having a learning, maturity or mental health issue and being raped in any way does not make one a child that has been raped if they are 16 it makes them a disabled, mentally ill or immature adult that has been raped and they should be treated as an adult victim like all other adult victims all be it with there disability taken into consideration if this nation is maintaining a 16 year old age of consent. As stated there are also issues regarding the lack of capacity issue and prejudice in regards justice that I am concerned about. For example a person charged with looking after the disabled persons interests could decide that the disabled person is capable of heterosexual sex but not homosexual sex, can comprehend being there genetic gender but not transitioning into another gender under the context of stating the disabled person can understand certain things but not others. Not only would that be a discriminatory act towards that disabled person but if a charge of rape against there gay partner was to be raised by there carer then there partner could be accused of such not for raping the person but simply for having the wrong type of consented to sex. Or for another, if a disabled person is incapable of giving consent at all and therefore sex with them even if they verbalise a yes is rape on part of the enabled person does that also mean the disabled person if they commit a sex crime are incapable of being held responsible or punished for there actions because clearly if they can't comprehend as to there rights they can't comprehend as to there responsibilities either. Now the states way of getting round this is to state that the person can comprehend to one thing but not the other therefore they can't comprehend when there having sex but can when there raping somebody and true yes a rapists could attempt to argue they can't comprehend raping somebody but they can sex but that can not be the case they either both in both cases can not comprehend to the reception or commission of an action good or bad or they can. Finally again, if a disabled persons, mentally ill persons or immature persons consent or withholding of it can be disregarded as either invalid or valid by the state and not the person in regards sex at 16 compared to there enabled counter parts what is stopping the state from disregarding the wishes of the disabled 16 year old alleged victim in regards there decision to keep a resulting possibly disabled child compared to the enabled alleged victims whom would have there consent to keep there healthy child respected ? The state itself ? Yes, humanity did that one and it lead to the eugenics program.	The Pathway emphasises the need for individualised care and support when concerns are raised about potential abuse. Some of these comments are out with the remit of the Pathway
64SU-T	I am worried that if a child or disabled person is allegedly raped that the state will override any girls choice to keep her child on the mere basis of her age or incapacity thus activate an abortion. This would be and should be unacceptable to all Scottish Catholics especially those who support no sex until marriage.	There is a legal right in Scotland to clinically safe and legal abortion services, within the limits that are currently set down in law, should this be required. People should be supported and free to reach their own decision on whether or not to have an abortion.
64SU-T	In short while no civilised person including the author would ever condone raping a disabled person and certainly if that disabled person is under 16 or 16+ and says no or does not give consent or has there consent presumed that should be enough to protect and prosecute, a concern to protect a disabled person at 16 when that 16 year old gives there consent could be used to discriminate and deprive that person of there liberties upon prejudicial grounds liberties that don't belong to the state but to them. A capable adults consent must never be assumed and if it is withheld or given it should be respected even if they are disabled. Some religions may take objection to welfare concerns around intended spouses at 16 being prevented from marrying due to concerns around disability as well as the disabled spouses themselves. There are a lot of enabled persons out there whom may wish to regard the disabled persons giving of consent as not given or invalid simply because there interest is not in the presence or absence of capacity but because they do not believe people with disabilities should be marrying or procreating at all simply because they are disabled. That is why the author strongly recommends the age of consent be raised to 18 for every gender and every sexuality for every person for everything including marriage as to avoid issues such as the described which require more complex considerations both on a moral and legal level in order to be just.	The Pathway emphasises the need for individualised care and support when concerns are raised about potential abuse. Some of these comments are out with the remit of the Pathway.
64SQ-P	We found the document referred to as both a resource and guidance. It will be important to clarify the status of the document and for this to be used consistently throughout to avoid confusion.	The Pathway has been revised to describe the document as guidance. The purpose of the pathway is to ensure a consistent approach to the provision of healthcare and forensic medical examination services for children and young people who may have experienced sexual abuse. It is intended to complement existing guidance, standards and legislation. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64SQ-P	We welcome the emphasis on trauma informed practice and alignment to the National Trauma Training Framework.	Noted.
64SQ-P	We suggest that Child Protection Committees be added to those who should use this resource	The comment has been noted and Child Protection Committees have been included as professionals who should use the guidance.
64SQ-P	We suggest the document strengthen links to the national guidance for child protection in Scotland and the work being developed in respect of the Barnahus model	The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation. It is ‘Barnahus ready’ in that it could align with future development of a Barnahus model in the Scottish legal and child protection context. The Pathway promotes consistency in Scotland across a number of areas covered by the European Barnahus Quality Standards: focussing on the best-interests of the child or young person, the right to be heard and receive information and avoiding undue delay multidisciplinary and interagency collaboration age appropriate facilities interagency case management medical examination the provision of ongoing support and therapeutic services for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64S1-P	[Our organisation] outlines the need for the pathway: To include children and young people with learning disabilities in the context of the pathway To reframe the aims of the pathway To support the disclosure of children and young people with learning disabilities To ensure children and young people with learning disabilities understand their options through the provision of accessible information and advocacy To ensure a whole person approach to medical examinations.	More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations / information sharing etc in the Pathway with hyperlinks to more detailed guidance if required. The Adults with Incapacity Act and the Adult Support and Protection Act are now included within the pathway for consideration when appropriate. The limits to confidentiality when the person or others are considered to be at risk of ongoing harm are now included. The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that 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) must be considered.
64S6-U	Feedback from people using the pathway. Lived experience. Ongoing for adult pathway, implement a way forward we need to get the feedback via support services. Appropriate services for children. Half a year from CAMHS for children. Information sharing is important. Consent	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64S3-R	The document is accessible and easy to read, although we understand this is a clinical pathway and the language is not necessarily a shared language. The heading are clear, the intentions of the pathway are made explicit, and the links are useful	Noted.
64S3-R	The document should be a 'live' document and be continuously updated to keep pace with national development, especially given the development of new integrated guidance documents and national integrated child protection models, with GIRFEC at the centre. Additional guidance on self-referral for over 16s should also be added when it is available	The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64S4-S	The child should be at the centre of the document and they're not. No mention of the team around the child.	The purpose of the Pathway is to ensure a consistent approach to the provision of healthcare and forensic medical examination services for children and young people who may have experienced sexual abuse. It is intended to complement existing guidance, standards and legislation. The Taskforce vision is for consistent, person-centred, trauma-informed healthcare and forensic medical services and access to recovery for anyone who has experienced rape, sexual assault, or child sexual abuse in Scotland. The Pathway now has further information on how the GIRFEC approach can be used to support victims. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
64S4-S	Not much in relation to health, wellbeing and recovery. Not much of a focus on recovery given that it needs to be trauma-informed, and the onward referral and support system is not gone into detail--not just about referring, but everyone's responsibility.	The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64S4-S	There are already pathways to deal with disclosure for a multi-agency response, and these are linked in the pathway document. Do you really need another document just because you're a consultant? Also guidance references documents for forensic and legal aspects, as these procedures are already there. GMC has guidance for the involvement of health and the role of paediatrics. Why do we need a clinical pathway in the first place?	The Pathway is intended to assist practitioners by describing best practice in line with current relevant legislation and guidance with all the relevant information in one document.
64S4-S	The pathway is not doing everything it could be, but is more than just a clinical document. Need something equally concise and detailed, but set within GIRFEC.	The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64MC-2	[Our organisation] is supportive of the pathway and welcomes work taking place. However it must reflect the needs of children and young people who are in ‘the care system’, have experienced care, and the people and organisations who work in the area; without this, the pathway will not reflect the needs of the country. o To take into account Part 9: Corporate Parenting of the Children and Young People (Scotland) Act 2014 , we would ask the age to be reviewed. Young people to whom the state is a corporate parent are entitled to additional support up to the age of 26. [Our organisation] would expect the pathway to sit in line with this legislation. o[Our organisation] recommends that the pathway is looked at from a well-being approach, rather than a rights-based approach; this ties into the trauma informed care model to be used. o[Our organisation] highlights that there are no specific arrangements listed for written consent where a child is looked after away from home. [Our organisation] would ask this to be considered and improved for the final documentation. o[Our organisation] notes that the approach takes into account an agency approach. [Our organisation] would, however, ask that there is more clarity to the wider agency approach, and that this is reflected in the process and any final flow charts, etc. Currently this does not reach the potential it offers, and does not reflect the expectations and responsibilities that should be within the document. o In addition to the above point, the [our organisation] would ask that there is training and guidance made available for a broad range of agencies who will feed into the pathway. o Aftercare should always be designed around the needs of the person leaving care, supporting them to lead a fulfilling life, for as long as they need it. Therefore there should be no barriers to this and as much support in place to enable this. o The key message comes from someone who shared their story with [our organisation] in the hope of delivering change: “Listen to us. Stop making decisions about us without asking us.”	The Pathway now has further information on how the GIRFEC approach can be used to support Children and Young People who have experienced child sexual abuse. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation. It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation. The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that 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) must be considered.
64MM-C	From a stance of Violence Against Women and Girls: Page 10 - the statement made regarding the difference between adult sexual abuse and child sexual abuse, needs to be looked at again as it implies that adults may not experience sexual abuse at the hands of someone they trust (www.rapecrisisscotland/help-facts/)	The Pathway has been revised to provide more clarity.
64MY-R	Overall in agreement with the document. 1. Purpose is clear and supports consistency in practice and access to support. 2. It should provide a useful reference and resource for all agencies.	Noted.

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Section 1: Introduction

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