Te taitōkai i roto i ngā pūnaha taurima
Sexual abuse in care

116. Sexual abuse can be understood in many ways and according to different standards. The Inquiry has considered the definitions used by international organisations as well as legal standards to inform its understanding of sexual abuse. It should be noted that the Inquiry’s consideration of sexual abuse is broader than actions required to constitute a crime.

117. The World Health Organization defines sexual violence as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting including but not limited to home and work”.[163]

118. It is important to consider consent within a definition of sexual abuse. Consent is reflected in the above definition through the terms ‘unwanted’ and ‘coercion’. Consent is a crucial part of determining sexual abuse or assault between adults. However, it is not a factor in defining the inappropriateness of sexual activity involving children, as children cannot consent to sexual activity.

119. After taking victim perspectives and legal definitions into consideration, the Australian Royal Commission into Institutional Responses to Child Sexual Abuse defined child sexual abuse as “any act which exposes a child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards”.[164]

120. As outlined in the Inquiry’s interim report, Stolen Lives, Marked Souls, the word ‘rape’ is commonly used in Aotearoa New Zealand to describe non-consensual penetrative intercourse of any person by a male.[165] In legal terms,[166] ‘rape’ in Aotearoa New Zealand is a gendered offence that requires the penetration of female genitalia by a penis.[167] Survivors used the term rape to describe various forms of sexual assault, by different genders. The World Health Organisation understands rape more broadly as “physically forced or otherwise coerced penetration – even if slight – of the vulva or anus, using a penis, other body parts or an object”.[168]

121. This Inquiry has taken experiences of sexual abuse, legal definitions and te ao Māori perspectives. The Inquiry acknowledges that sexual abuse from an ao Māori perspective violates a person’s tapu, their whakapapa and their mana tipuna. The Inquiry considers that sexual abuse is any act which exposes a person to, or involves a person in, any non-consensual sexual activity or sexual process or content where a person is under the age of 16 or is unable to give consent or is unable to understand the sexual activity.

122. Sexual abuse was identified in many care settings. Survivors were subjected to grooming, inappropriate touching, inappropriate conversations about sex and masturbation, sexual assault, rape, being forced to perform sexual acts on others (including peers, themselves or the abuser), and combinations of these types of abuse. Survivors also witnessed (by seeing or hearing) the sexual abuse of others and, in some cases, were forced to do so. Some survivors spoke about instances of what seemed like organised sexual abuse.

123. Survivors told the Inquiry they were sexually abused and raped by caregivers,[169] staff,[170] peers or other residents,[171] police officers,[172] medical practitioners,[173] teachers,[174] nurses,[175] nuns,[176] priests and religious ministers,[177] other religious leaders such as Christian Brothers or Brothers of St John of God,[178] and other adults who were given access to them.[179] In most instances of sexual abuse reported by survivors, perpetrators were male. This is consistent with other research including the Australian Inquiry into Child Sexual Abuse.[180]

124. Some survivors experienced one incident of sexual abuse; others experienced multiple incidents during their time in care. For many survivors, sexual abuse started the day they arrived in care, and continued for many years. In some settings, sexual abuse was described as habitual and ongoing, and an entrenched part of the culture and environment.

125. The Inquiry heard from many survivors who described being repeatedly targeted by the same or different abusers. In some settings, survivors explained that once it was known they had been sexually abused, other staff or caregivers targeted them too. Mr AU, who shared his experience in the Inquiry's interim report Stolen Lives, Marked Souls, tells how he was targeted by the brothers once they learnt he had been abused by his stepfather before arriving at the orphanage.[181]

126. The Inquiry is aware that specific groups of survivors placed in positions of vulnerability were targeted by abusers. For example, the Inquiry heard how a cleaner at Tokanui Psychiatric Hospital located south of Te Awamutu would sexually abuse a young man with cerebral palsy who was unable to communicate through speech or movement. This cleaner would suck the boy’s penis into a high-powered vacuum cleaner. This sexual abuse co-occurred with psychological and emotional abuse as this cleaner would laugh about the abuse with other members of staff.[182]

127. Disabled people who lived in institutions often relied on others for a great deal of intimate care. This placed them into a position of vulnerability that led to targeted sexual abuse. Disabled people were also subjected to abuse that interfered with their sexual capacity and reproductive systems, including sterilisation and abortions without their personal consent.

Te whakawaiwai
Grooming

128. Grooming involves incremental acts by an abuser which increase in intensity to gain access to a victim / survivor as well as to initiate, maintain and conceal abuse. Grooming can involve or co-occur with other abuse, such as manipulation or spiritual abuse, as is especially evident in pastoral care contexts.

129. For many survivors, sexual abuse often began with some form of grooming, where relationships of trust were developed with survivors, and sometimes their whānau, before the abuse occurred.[183] The Australian Royal Commission into Institutional Responses to Child Sexual Abuse stated that grooming is:

“designed to establish an emotional connection and build trust to gain access to the victim and to initiate, maintain and conceal sexual abuse. In this respect, grooming can involve psychological manipulation that is subtle, prolonged, calculated, controlling and premeditated. The process is often gradual and intended to make the child feel comfortable, acquiesce to abusive behaviour, and maintain the secrecy of the abuse.”[184]

130. While initial stages of grooming can appear innocent, later stages tend to be more overt in the abuser’s attempt to desensitise the victim / survivor to sexual activity.[185] Grooming involves an unequal power dynamic between abusers and victim / survivors, whereby abusers hold a lot of influence over and within the lives of those they target.

131. Often, abusers put themselves in situations that made children more accessible through regular and unsupervised contact. This was particularly the case for religious leaders, who were widely respected within communities and by survivors’ families. For example, one survivor was sexually abused by a school counsellor, a Marist brother, at the Catholic St Bernard’s College. He explained how the school counsellor would ask him questions about sex and took photos of him under the guise of capturing results of his new gym routine:

“The way he gained my trust was to show me photos of another guy a couple of years older than me, ah, who I really looked up to … He arranged a sheet as a backdrop and up went the tripod. It was time to strip down to my undies, which I did … Then the question ‘fuck it, why don’t you take off your underwear and celebrate your manliness, be a man’.”[186]

132. The Inquiry heard from survivors that abusers would, give them drugs or alcohol, or expose them to pornography[187] or inappropriate sexual instruction in order to create the opportunity to perpetrate sexual abuse.[188] Sometimes survivors were given ‘treats’ or ‘privileges’ such as more recreational time, lollies, money, drugs, alcohol or tobacco to groom them or keep them quiet.[189] Sometimes abusers would help them or show kindness when the survivor was being bullied.[190] Some survivors reported that their abusers would threaten them to keep them quiet, including being threatened with never being released from care.[191]

Te whakariterite taitōkai
Organised sexual abuse

133. The Inquiry uses the term ‘organised sexual abuse’ to mean any occurrence of sexual abuse where “multiple victims have been exploited by multiple abusers acting in concert”.[192]

134. Several survivors spoke about instances of organised sexual abuse. One survivor told the Inquiry he had heard of boys from Epuni Boys’ Home being “prostituted out” – driven to a Catholic facility in vans where clergy walked “around the van to look at the boys inside and select who they would take” to sexually abuse.[193] The Catholic Church’s National Office for Professional Standards told the Inquiry it had worked alongside a person who had reported this abuse and they had undertaken an investigation which has since been completed. They told the Inquiry it had not been able to identify which Catholic institution this allegation could have been referring to. The Inquiry is unaware as to whether the Catholic Church reported this to NZ Police.

135. Another survivor who went through Ōwairaka Boys’ Home also told the Inquiry there was ‘prostitution’ of the boys by staff – he described guards driving boys to homes in the community and being offered ‘extra privileges’ if they had sex with women:

“This didn’t happen once or twice; this happened on a regular basis and it wasn’t with the same lady but with different ladies at different houses they were using the boys for. These trips happened more than once and were facilitated by the guards. I saw money being given from the older people to the guards on these trips.”[194]

136. The Inquiry also received evidence from survivors about organised sexual abuse. This included evidence from Cooper Legal about a deceased woman they had represented. This survivor was placed into Glendenning Children’s Homes in Ōtepoti Dunedin from age 13 to 14 years old. There, she described being subjected to severe sexual abuse, including being “passed around a ring of paedophiles who she recalled were parishioners of the local Presbyterian Church”.[195] These individuals raped and sodomised her, often when she was made to visit them for meals or after church services. She also described being raped and “fondled” by two staff members from the orphanage.[196]

He whakatewhatewhanga i ngā whakapaenga mō te taitōkai nahanaha o ngā tamariki i ngā pūnaha ā-Kawanatanga
Investigation into allegations of organised sexual abuse of children in State care settings

137. In its early stages, the Inquiry received allegations about organised child sexual abuse or a “paedophile ring” by former central government politicians in social welfare settings in the Horowhenua area in the 1980s.

138. The Inquiry began a separate and confidential investigation into the allegations because of a concern that survivors and witnesses may not come forward to the Inquiry out of fear of retribution, or that there would be a “cover up” if alleged abusers became aware of the investigation.

139. The scope of the investigation later broadened to include all allegations of organised abuse of children and young people in State care by people in public positions of power and influence.

140. The investigation considered seven broad allegations:

• The transportation of children and young people from social welfare residences and institutions and other State care residences and institutions in the Horowhenua area to private locations in the Horowhenua and Te Whanganui-a-Tara Wellington regions. It is alleged at the private locations theywere sexually abused by former central government politicians and prominent public servants
• Missing children and young people from social welfare residences and institutions in the Horowhenua region had been buried under trees or dumped in a lake
• Groups of men being brought into the Kimberley Centre (a psychopaedic hospital near Taitoko Levin) to sexually abuse non-speaking girls in care
• Abuse of children and young people in care by former central government politicians in Tāmaki Makaurau Auckland
• Abuse of children and young people in care at a Tāmaki Makaurau Auckland brothel
• Abuse of young people in care working as underage sex workers in Te Whanganui-a-Tara Wellington and Ōtepoti Dunedin by prominent public servants, and
• An allegation that police officers had abused girls who had run away from their care placement before returning them to care.

141. The investigation was challenging. The investigation team conducted witness interviews throughout Aotearoa New Zealand with people who had registered with the Inquiry, but also with others who had not. Care was taken in approaching potential witnesses directly to obtain sensitive information, and significant time was spent building trust with these potential witnesses. Often, several meetings or interviews would be held with witnesses before they felt comfortable sharing aspects of their experiences that were relevant to these matters. Other investigation methods were also used, including research of historical records and notices issued under section 20 of the Inquiries Act to NZ Police, Oranga Tamariki and the Ministry of Social Development requesting relevant information.

142. The Inquiry located one witness with first-hand direct evidence of such organised abuse of children and young people in social welfare care settings. Most witnesses spoke to the Inquiry of hearing about organised abuse from others, which was sometimes second or third-hand information. Attempts to corroborate the information from people named to the Inquiry as being survivors of such abuse were unsuccessful. Many of the leads that were followed up did not result in evidence of organised abuse. Several people named by others as survivors or as having relevant information had died or were too unwell to speak to the Inquiry, and some were unable to be located. In other instances, the information provided indicated that organised abuse may have occurred, but no survivors could be identified.

143. Another key difficulty was that some people who may have held relevant information did not want to provide a witness statement or survivor account to the Inquiry because they were fearful of repercussions due to the powerful position formerly or still held by their alleged abuser. This included beliefs that NZ Police were aware of the paedophile rings at the time and had not investigated them.  It was clear that some people did not trust the Inquiry’s processes, including its ability to protect the confidentiality and safety of individuals who shared information. The Inquiry acknowledges that there were and will continue to be many barriers for survivors to disclose abuse. Those barriers can be exacerbated where the abuser has an actual or perceived position of power over the victim.

144. Ultimately none of the allegations of organised group abuse in State care settings described above were able to be substantiated by direct evidence.

145. The Inquiry did receive direct information from two survivors who alleged they had been sexually abused by different individual former central government politicians. One of the allegations was referred to NZ Police in June 2023. NZ Police provided an update to the Inquiry in November 2023, indicating that progress has been hindered by challenges in locating evidence.

146.  The Inquiry did receive direct eye-witness evidence from NZ European survivor Mr EI who said he witnessed the repeated rape and sexual violation of several non-speaking children at the Kimberley Centre near Taitoko Levin in the early 1960s by a group of members of the public who were regularly granted entry after paying the nursing staff.[197] Mr EI said:

“I was woken up by the same woman and taken over to this other room. When we arrived, there were girls and boys there around my age. There were also several adult men and women. There was a girl laying on a bed with no clothes on. The bed looked like an old-fashioned hospital bed. It was on wheels. Her legs were spread apart, with her feet up on things that looked like crutches or braces. They looked like restraints. One of the men got up and had sexual intercourse with her, while we watched. Two other girls were sexually interfered with. They were sexually touched by hand by the adults, while me and this other boy were made to watch. This happened for about an hour. After, I was made to go and wipe down the girls’ private parts and the adults left.”[198]

147. While the evidence that the Inquiry received is deeply suspicious, the Inquiry is unable to make a finding that organised abuse of children and young people in State care occurred by groups of people in public positions of influence.

Te taitōkai aropā
Peer-on-peer sexual abuse

148. Peer-on-peer sexual abuse is similarly complex to peer-on-peer physical abuse and occurs for many reasons. These can include coercion by staff or caregivers and learned behaviours. It is important to note that while some children inflict sexual behaviours on peers because they themselves have been abused, this does not mean that all people who have experienced sexual abuse will inflict the same behaviours on others.

149. The Inquiry heard sexual abuse by peers was common across care settings, particularly where survivors had been in abusive environments previously. For children, this was often when they were placed in close contact with older peers, unsupervised. For example, Deaf survivors said that many students at special schools experienced peer-on-peer sexual abuse, often from older students.[199]

150. Peer-on-peer sexual abuse commonly occurred in the context of wider bullying and in situations where physical abuse and violence was present, including initiations into residences and as part of kingpin hierarchies. Allison Campbell, who was an IHC worker from the 1980s to the 2000s, told the Inquiry that she thought “there was a culture of violence, including sexual violence, at Campbell Park School, Oamaru. This is my impression based on my dealings with people who came out of Campbell Park. All had no self-esteem, were violent, unhappy and very troubled.”[200]

151. Sometimes peer-on-peer sexual abuse was directed, where children were told to perform sexual acts on others by adults.[201]

152. Survivors also reported that peer-on-peer sexual abuse occurred while they were in hospital settings, particularly psychiatric hospitals. NZ European survivor Christina Ramage was admitted to care when she was 15 years old. She was raped multiple times at Carrington Hospital in Tāmaki Makaurau Auckland by staff members in the 1970s, and sexually abused by other patients there. The Inquiry heard from her and other survivors[202] that sexual abuse between patients was common.[203]

Te tūkinotanga ā-kaikiri me te whakahapa ahurea i roto i te pūnaha taurima
Racial abuse and cultural neglect in care

153. Racial abuse and cultural neglect are discriminatory types of abuse that target or impact core components of an individual’s identity involving their ethnicity or culture. While the experiences that survivors shared showed that these were distinct forms of abuse, they were also often interrelated.

154. The Inquiry refers to ethnicity, rather than race, as the central, self-described characteristic that is attacked through racial abuse.

155. The Inquiry defines racial abuse as any instance of abuse that includes hostility, contempt, ridicule, hurtful or offensive actions on the grounds of a person’s skin colour, race, or ethnic or national origins. As such, it is a type of abuse that manifests through other more broadly experienced types such as verbal, physical or sexual abuse, but provides another ‘layer’ to these actions that victims experience differently depending on their identity (and often the identity of the abuser).[204]

156. Racial abuse differs from the concept of ‘racism’. Not everyone can experience racism. Racism is intrinsically tied to and backed by power, ideology, and disparities, and is reinforced by the dominant culture, institutions and worldviews of a society.[205]

157. For survivors, abusers did not always discriminate based on the specific ethnicity of those they were abusing; often it was out of colourism, or an underlying prejudice towards those with dark skin (which is itself based in colonial and racist ideologies). Samoan survivor David Williams (aka John Williams), who was placed in care when he was 11 years old, told the Inquiry:

“The thing is, no matter where you went, if you had brown skin, you were going to get abused. Physically or sexually or both. Occasionally one of the white boys would, but he would have to be a real bad bugger. If you were brown you were going to get done no matter what.”[206]

158. Culture encompasses the ideas, beliefs, behaviour, knowledge, laws, customs, language, and habits of a particular group or society; this is not exclusive to racial or ethnic groups. Many different groups of people fit within the scope of ‘culture’, including those based on religion, spirituality, disability, age and gender.

159. In the Inquiry’s interim report He Purapura Ora, he Māra Tipu – From Redress to Puretumu Torowhānui, the Inquiry defined cultural neglect as:

• Disconnection from culture, language, whakapapa or identity as a result of being placed in care institutions where a survivor’s own culture is not recognised or where their cultural connections are actively discouraged.
• Misidentification of ethnicity or cultural identity by a care institution denying a survivor knowledge of their culture, language, whakapapa or identity.[207]

160. In addition to this definition, it is the Inquiry's view that cultural neglect occurs when only the culture belonging to the most dominant, powerful group in society is upheld within institutions. Throughout the Inquiry period, this was typically an ableist, Pākehā, Christian culture.

161. Racial abuse and cultural neglect are closely related. However, they are distinct in that racial abuse involves an intent to harm someone based on their ethnicity or skin colour, while cultural neglect is about an absence of connection to culture. Both can be the product of the same structural prejudice toward non-Pākehā ethnicities (or in the case of Deaf communities, non-hearing people) and systemically embedded in institutions. They can also appear in the same instance of abuse; for example, racially motivated punishment for using te reo Māori can lead to a survivor becoming distanced from te reo Māori.

162. Because of the way in which they target collective characteristics within identities, racial abuse and cultural neglect not only impact individuals, but “[strike] at the very identity and soul of the people it is aimed at; it attacks their sense of self-esteem, it attacks their connectedness to their family and community”.[208]

163. This Inquiry has focused on the racial abuse experienced by Māori and Pacific survivors, and cultural neglect experienced by Māori, Pacific and Deaf survivors. It is important to recognise that survivors experienced these forms of abuse intersectionally – that is, depending on their identities, they could have experienced multiple instances of this abuse, targeting multiple aspects of their identity. Many survivors had a shared whakapapa to Māori and Pacific cultures, which meant most experienced abuse and neglect that corresponded to either or both parts of their cultural identity.

Ngā wheako tūkinotanga ā-kaikiri me te whakahapa ahurea o te Māori
Māori experiences of racial abuse and cultural neglect

164. Common across most Māori survivor experiences was recognition that the care settings they entered were inherently racist and did not support their connection to their culture. They commonly experienced overt, targeted abuse based on their ethnicity and culture. This is indicative of systemic racism.[209]

165. Māori survivors recall enduring racial abuse in many different forms and within many different contexts. Many were punished for simply saying or doing anything Māori.[210] Survivors often recalled experiencing racist verbal abuse and ridicule from staff who would mock their Māori heritage and whānau. English, Māori survivor Rexene Landy (Tahawai) told the Inquiry about her time at a Catholic orphanage:

“We knew it was wrong to be Māori. You had made a terrible error and Jesus did not love you. He did not love you, dirty little natives. That was what the sisters made sure we knew. I remember thinking of killing myself so that I could go to Jesus and apologise to him for being Māori.”[211]

166. Some survivors reported co-occurrence of racial abuse with other forms of abuse, including physical and sexual abuse where abusers expressed racist sentiments while abusing or as justification for abuse.[212] Survivor Hone Tipene said that at Wesleydale Boys’ Home, Tāmaki Makaurau Auckland, a staff member abused him: “[He] called me names such as ‘black nigger’, ‘black ass’ and would say things like ‘you think you are a big man’ before he beat me up.”[213]

Te whakaparaunga me te motunga o ngā here ki te ahurea Māori
Denial and disconnection from taha Māori

167. Māori have their own distinct ideas, beliefs, behaviours, knowledge and customs that shape how they perceive and interact with the world and those around them. Although Māoritanga is a term used to describe Māori culture, there is no ‘universal’ Māori identity – iwi have distinct, histories and identities that shape their kawa, their reo, their perspectives and their responses to issues.[214]

168. Nonetheless, there are certain shared histories, values and beliefs held by Māori from different whānau, hapū and iwi that govern the way in which they might approach an issue or interact with others. For many Māori, whakapapa is an important gateway to remaining connected to te ao Māori.

169. For others, their sense of belonging and ability to identify as Māori came through their immersion in te ao Māori, tikanga and their reo.[215] Unfortunately, the process of colonisation and removal of practices and structures that would support access to Māori beliefs, values and customs has meant that some survivors who whakapapa Māori did not have the same sense of belonging and connection as their counterparts. This was a situation created for many Māori through their time in care, as a continuation of colonisation.

170. Māori survivors spoke at length about being severed from their taha Māori, including their mātauranga, tikanga, reo Māori, and crucially, their connection to whakapapa, whānau, hapū and iwi. Survivors told the Inquiry about the immense mamae, whakamā and loss that separation had caused. Some described feeling like they had had their identities ‘stolen’ or ‘stripped’ from them.[216] This was an abuse that occurred for more than just the individual in care, as survivors spoke about how this disconnection and cultural loss resonated throughout their whānau and whakapapa intergenerationally.[217]

171. In some cases, the denial of cultural needs of Māori survivors was experienced via the explicit banning of Māori customs. Māori survivor Leena Kalpus (Ngāti Wairere, Tainui) explained that she wasn’t allowed to speak te reo and was punished for “doing anything considered Māori at the Presbyterian North Haven home.”[218]

172. In other cases, care settings failed to support and provide access to cultural knowledge (matauranga Māori), tikanga, and an environment that could nurture cultural identity – many institutions failed to provide survivors with any link to te ao Māori, including their whakapapa.[219] Survivors shared how they were not given any opportunity to learn about important Māori values and concepts including whanaungatanga,[220] mana, wairua and papakāinga (a Māori village or community settlement). During their placement, they missed out on many cultural lessons,[221] which made some feel confused, stupid, useless and not Māori.[222] This impacted their ability to maintain a positive connection to their Māori identity and sense of self; Māori survivors shared that they felt uncomfortable around other Māori because they never spent time on a marae.[223]

173. The Inquiry also heard of instances where care facilities disregarded Māori culture and beliefs with their culturally insensitive decisions. For instance, in mental health settings, access to traditional healing and tohunga were not available to some survivors as it was seen as an invalid practice.[224]

174. Māori survivor Mr OL (Ngāi Tai ki Tāmaki, Ngāti Kohua, Ngāti Tupaia, Ngāti Tanewai) was adopted at birth. He spoke about being matakite, a Māori term for an experience of heightened spiritual or intuitive connection. It can include seeing, hearing, smelling, tasting and feeling things that cannot be perceived by other. He said this was not considered when he was later diagnosed as having a mental illness that required treatment.[225] Māori survivor Mr IA (Ngāti Raukawa, Ngāti Toa Rangatira) shared how when he was young, he had experienced a form of mākutu (witchcraft, black magic, sorcery).[226] He was sent to a psychiatric hospital for treatment at 12 years old. While he was there, Māori healers would visit him but the hospital would not acknowledge them or include them in his treatment.[227] He shared that it was the Māori healers that had helped him with that experience rather than the treatment he had received from the psychiatric hospital.[228]

Ngā wheako tūkinotanga ā-kaikiri me te whakahapa ahurea o ngā uri Pasifika
Pacific experiences of racial, cultural abuse and neglect

175. Pacific survivors told the Inquiry about they experienced racial abuse and cultural neglect, including the denial of access to knowledge of their specific cultural identities, the denial of opportunities to learn about their specific culture or to practise or speak their specific cultural customs and languages; and the denial of access to, and knowledge of their kainga (family). Many Pacific survivors that came forward to the Inquiry also had whakapapa Māori, meaning they often experienced multiple and compounding forms of racial abuse and cultural neglect and were often denied access to multiple cultural identities and their associated knowledge, languages and customs.

176. Pacific survivors experienced verbal taunts and racist name calling that made them too embarrassed to identify with or share their culture. Cook Island Māori survivor Jovander Terry shared how he was fluent in Cook Island Māori prior to entering into care. However, after the racist name-calling experienced by peers and staff at a boy’s home,[229] he chose not to speak his language. Other institutions dissuaded Pacific survivors from speaking their specific language by using corporal punishment if they were caught doing so.[230]

177. Derogatory statements were also made in survivors’ records, which they discovered years later upon receiving them. Samoan survivor Fa’amoana Luafutu found comments that disparaged his family and held negative views towards Pacific Island migrants, such as:

“This 12-year-old boy comes from a family who have not settled into European ways readily and cling to a Samoan language and dress. If the parents would take a greater interest in English, then they would have been able to assist their boy to a far greater extent.”[231]

178. A Māori and Niuean survivor who was placed in care when he was 12 years old shared how one staff member wrote in his notes that he was not productive as a member of the work group and suggested he should go back to the islands where his present way of life could be acceptable.[232]

179. Pacific survivors of institutional residential care reflected on how residential facilities and homes were not set-up to provide for them culturally in the first place. Fa’amoana Luafutu, for instance, said that Kohitere Boys’ Training Centre, Taitoko Levin, “had no function to meet the needs of a Samoan like me”.[233] Similarly, Tokelauan and Māori survivor Mr TH said that “there was no cultural support at Epuni”.[234]

180. For Pacific survivors with disability or mental health conditions, institutions did not provide for a connection to culture, including within therapeutic processes.[235] Samoan survivor, Lusi Faiva, with cerebral palsy who described the lack of opportunities she had to learn about and participate in her culture during her time at the Kimberley Centre near Taitoko Levin:

“(No) one ever talked to me about my Samoan heritage … I felt like people didn’t know or care about my Samoan culture. Even if they did there was no recognition, interest or inclusion. There was no respect or effort to recognise me for who I am. Even I didn’t know.”[236]

Te whakaparaunga me motunga o ngā here ki te kāinga
Denial and disconnection from kainga

181. For some survivors, cultural neglect was primarily experienced through being disconnected from kainga, as these were the people who could provide them with the cultural shelter they needed or desired. When Pacific survivors entered care, family contact and relationships were limited, not maintained consistently, or severed. This significantly impacted their future wellbeing, sense of self, identity, and connections to their culture, language, kainga, and other people.

182. Associate Professor Folasāitu Dr Apaula Julia Ioane explained cultural safety further, saying “safety is not just about the absence of threat, it is the presence of connection”.[237] At a practical level, cultural safety means ensuring Pacific children, young people, and adults can maintain connection, or be connected, to their cultures, families, and communities while in care. The Honourable Luamanuvao Dame Winnie Laban stated that it also means ensuring carers and institutions “have an understanding and a respect for our culture, for our history, for our values”, which might include pronouncing Pacific names correctly or ensuring that communication and engagement with Pacific families is done appropriately.[238]

183. Dr Sam Manuela explained: “In instances where survivors were placed into the care of others, these then became substitutes for family. However, the vā [the “space between” that holds people and things together] that exists between family members does not have the same meaning as the vā between a person and unfamiliar others.”[239] For many, maintaining a connection to kainga is critical to their wellbeing and is a crucial link to culture, cultural heritage, language and identity.

184. Survivors have shared how they were not allowed to see their family while they were in care. In the rare instances when they were allowed to see them, it was only for a short visit over a holiday.[240] For some survivors, the brief time they could see their families pained them because they knew they could not see them for long.[241]

185. Other survivors were not told that they had family they could contact and connect with. Samoan survivor David Crichton shared that the social welfare residences and institutions he stayed in held the contact details for his extended Samoan family, but never facilitated that connection or told him about them.[242] Cook Islands and Māori survivor Anau Jr (Ngāpuhi), who was placed in care at 12 years old, was denied the ability to connect to his family as the social welfare residences and institutions did not try to contact his immediate and extended family while he was in care.[243]

186. Some survivors were denied their connection to their kainga because the State failed to correctly identify and support their ethnicity while they were in care. The Inquiry has heard of instances where survivors were made to believe that they were Māori but only found out later in life that they were Cook Island Māori,[244] or learned they were Samoan after they had requested their records from the Ministry of Social Development.[245]

187. The denial of access and knowledge of kainga was acknowledged by Oranga Tamariki at the Inquiry’s State Institutional Response Hearing, where it was conceded that “children were severed from families, [and] children were severed from their extended families”.[246]

Te tautuhi tuakiri hē me ngā ngoikoretanga raraunga
Ethnic misidentification and data deficiencies

188. Several survivors of care settings discussed how their ethnicity was misidentified and misrecorded by care staff, or not recorded at all. This primarily affected individuals from Māori, Pacific and mixed ethnicity backgrounds. Such errors could follow survivors throughout their time in care and contribute to wider cultural neglect, as care staff did not to recognise all or part of their cultural heritage.

189. Two Department of Statistics documents from the 1980s outline the systemic issues that led to flawed ethnicity recording policies and contributed to staff incorrectly following revised policies that were intended to mitigate these issues.[247] Oranga Tamariki has acknowledged that data on ethnicity was not kept prior to 2001, and that this has contributed to an incomplete picture of who was in care throughout this time.[248] The Ministry of Health has made similar acknowledgments.[249]

190. Faith-based organisations have made limited concessions about ethnicity recording failures. The Anglican Church admitted there has been poor record keeping of ethnicity within its institutions, but said that there has “never been an obligation to record ethnicity data about our members in the past.”[250] Representatives from Presbyterian Support Central stated that their lack of ethnicity recording was a failure and “a poor part of our service”.[251]

191. Pacific survivors reported incorrect ethnicity recording across settings including State[252] and faith-based care,[253] faith-based schools[254] and psychiatric care.[255] For example, Mr TH received some of his files and saw that sometimes he had been recorded as only Māori and not Tokelauan.[256] Samoan survivor David Crichton was mislabelled as Māori upon entry into the care of Presbyterian Support Services as an infant, an error that followed him through his time into social welfare residences and institutions and then adulthood.[257] Due to thinking he was Māori, David missed out on the opportunity to connect with his Samoan culture and aiga, a neglect which he feels was the worst aspect of his time in care.[258] Cook Islands Māori survivor Te Pare Meihana described how “with the flick of a pen”, her ethnicity was changed to Māori to make her easier to adopt out to a Māori family.[259]

192. Māori in care were also subjected to incorrect and incomplete ethnicity recording, often due to flawed processes failing to record mixed-ethnicity individuals, or because institutions neglected to record at all. Māori survivor Ms AF (Ngāti Tahinga / Ngāti Ira) described how after her birth, her doctor and social workers colluded to have her ethnicity changed to ‘European’ on her birth certificate, to make her ‘more adoptable’; her adoptive mother had specifically asked for a white baby. She said that, “in doing so, they stole my whakapapa and my whenua from me and my descendants.”[260]

Ngā wheako whakahapa ahurea o te hunga Turi
Deaf experiences of cultural neglect

193. Deaf survivors, including tāngata Turi Māori, told the Inquiry that Deaf culture was neglected and actively discouraged in special schools for the Deaf and in mainstream education settings. This was partly due to Audism. Audism is a negative and prejudiced attitude towards anyone who can’t hear or speak and sees Deafness as a disability.[261] This meant that students were not supported to choose their means of communication and instead were forced to learn oralism.

194. Dating back to the 19th century, oralism was introduced as an official State policy for Deaf education and was enforced in specialist deaf schools, deaf units, and in mainstream education. Oralism refers to educating Deaf students to produce oral language using lip reading, mimicking mouth shapes, using breathing patterns and vocal exercises of speech.[262]

195. Deaf survivors were forced to adopt oralist methods of communication, including lip reading and vocalisation,[263] and were prevented from using communication methods that were relevant to them, such as Sign Language, which was banned in education at a National level by the Department of Education until 1979.[264] To prevent the use of Sign Language, survivors were physically punished; their ears were twisted[265] or they were physically strapped.[266] Some were hit over their ears while wearing hearing aids.[267]

196. Survivors shared how they were forced to speak.[268] A student who attended Sumner School for the Deaf from 1979 to 1984 recalls their hands being tied to their chair so they could not use them to communicate.[269] Others during that time (and earlier) used their Sign Language secretly and taught it to Deaf students.[270] Tāngata Turi Māori survivor Mr JU (Ngāti Porou) who was a student at St Dominic’s Catholic Deaf Centre in Papaioea, Palmerston North, in the 1960s shared how he and other Deaf children would hide among the trees so they could sign to each other. They were punished if they got caught.[271]

197. In mainstream school environments from the 1960s to the 1980s, all lessons were conducted verbally. Deaf children were expected to lip read and copy the teachers lip patterns. They were also encouraged to speak. These communication barriers meant that teachers would focus on the hearing children.[272] Deaf survivors also experienced bullying in mainstream schools.[273] Some explained that in some education settings they experienced linguistic and cultural neglect because there were no Deaf teachers or hearing staff with adequate understanding of either Sign Language or Deaf culture.[274]

198. The use of Sign Language was banned throughout Aotearoa New Zealand until 1979 and therefore prohibited by some schools that were specifically set up for Deaf education,[275] for example St Dominic’s Catholic Deaf Centre in Papaioea Palmerston North,[276] Sumner School for the Deaf in Ōtautahi Christchurch,[277] and Van Asch College in Ōtautahi Christchurch and Kelston School for the Deaf in Tāmaki Makaurau Auckland.[278]

199. The Inquiry heard of Deaf survivors being ridiculed when they tried to use facial expressions while signing. Facial expressions are a crucial part of communication for Deaf people.[279]

200. Tāngata Turi Māori were barred from signing along with other students in deaf schools, and there was no access to te reo Māori.[280] The Inquiry heard how tāngata Turi Māori who attended residential deaf schools grew up without access to, or an understanding their Deaf and Māori identities.[281]

201. Deaf survivors shared how the lack of knowledge and access to Sign Language and Deaf culture occurred in settings beyond education, which exacerbated their experience of abuse and neglect. In hospitals, Deaf survivors were misdiagnosed because no effort was made to use an interpreter to ask the survivor directly how they felt and explain what was happening to them.[282] The survivor was left out of the decision-making process.

202. The suppression and denial of their language and culture made it difficult for Deaf children to understand and report other forms of abuse experienced in these settings.

Te tūkinotanga me te whakahapa ā-wairua, ā-whakapono hoki i roto i te pūnaha taurima
Spiritual and religious abuse and neglect in care

203. Spiritual and religious abuse and neglect are closely related forms of abuse that interfere with the spiritual wellbeing, wairua, or religious beliefs of individuals, or use these elements to further other abusive aims.

204. Spiritual abuse has numerous definitions in academic and faith-based literature. The Inquiry uses spiritual abuse as an umbrella term to refer to any instance of abuse where an abuser uses spirituality to gain power and control over a victim or has the result of harming the spiritual wellbeing of an individual. Spiritual abuse can co-occur with or enable physical, sexual or emotional abuse, and can intensify the impacts of that abuse by giving it a spiritual dimension, for example, feeling guilty or ‘sinful’ after sexual abuse.

205. Spiritual abuse should be understood as being broader than abuse experienced within the bounds of Christianity or the church. Other culturally specific beliefs and practices of ‘spirituality’ could be manipulated for, or the target of, abuse. These could result in someone being disconnected from cultural and spiritual wellbeing. Although this has a strong crossover with cultural neglect, the Inquiry heard from survivors who shared their experience of abuse within their whānau[283] and abuse by others who share their culture[284] which impacted their attempts to reconnect to anything related to their culture, practices and beliefs.[285]

206. Spiritual neglect refers to the failure of a care setting to cater to the spiritual wellbeing of people in care. This can be through failure to provide access or acknowledgement of an individual’s unique spiritual beliefs or expressions (in this sense, it also has a strong connection to cultural neglect).

207. Religious abuse is defined by the Inquiry as “using faith or church beliefs and teachings (including prayer, scriptures and deference to God) to perpetrate abuse and harm, and to discourage disclosure of that abuse and harm”.[286] Religious abuse has also been characterised as the use of religious philosophies and practices to manipulate, control and abuse another; and can occur when someone misuses their position of religious power to dominate or manipulate.[287]

208. Spiritual and religious abuse occurred through different actions, and alongside many other forms of abuse. These included spiritual leaders using their position and teaching to groom survivors for sexual abuse; psychologically abusing and dehumanising individuals using religious teachings and describing them as morally corrupt or sinful; imposing beliefs or religious practices on those in care; and undermining faith (possibly resulting from the betrayal of belief systems due to the actions of abusers). These forms of spiritual abuse are noted in international literature.[288]

209. Religious abuse was extremely prominent as a part of clerical sexual abuse within churches, as power dynamics of relationships between religious leaders and those in their care were central to this abuse.[289] The Inquiry heard how religious leaders were not only powerful, but also trusted and respected by whānau and communities, which allowed them to have unique access to children, young people and adults. This enabled abuse to occur, and intensified barriers to reporting. This status, combined with the importance of obedience in faith-based care settings, often made it difficult for survivors to identify abuse or question the abusive behaviour. In some cases, abusers used their status and ‘closeness to God’ as a means or silencing survivors.

210. Examples of abuse involving religious teaching often featured a religious leader or staff member using their teaching or mentoring to groom victims, and sometimes to justify or explain the abuse.[290] Survivor Vincent Reidy, who was abused by a Catholic priest, told the Inquiry that:

“spiritual trauma is worse than psychological, emotional or physical abuse, because being attacked by clergy, the priest holds a powerful position, because a priest is closer to God. Abuse discounted all the sureties of life that I had been brought up to take for granted.”[291]

211. Religious teachings were used in faith-based schools, orphanages and residences as a part of creating institutional environments of fear, where children were told to be afraid of eternal damnation as punishment for wrongdoing.[292] Strict religious practices such as early morning prayer were imposed, with harsh punishments for those who didn’t comply.[293] Similarly, survivors from some faiths told the Inquiry that religious teachings about separation from society were used to keep members obedient to leadership out of fear that they would be cut off from their friends and family in the community.[294]

212. Many survivors from faith-based schools, orphanages, residences and unmarried mothers’ homes told the Inquiry that staff saw them as morally corrupt. These survivors were abused using spiritualised language that framed them as intrinsically sinful. This framing was used to justify further physical, sexual and psychological abuse and neglect.[295] Survivors who were Māori,[296] disabled[297] or Takatāpui, Rainbow and MVPFAFF+[298] were also described as evil or sinful for having these identity traits, and were subject to further abuse seemingly justified through religious beliefs.

213. Discrimination against Takatāpui, Rainbow and MVPFAFF+ people, as well as conversion practices were primarily experienced in a pastoral care context. Mr UB, a Māori (Ngāi Tahu) and Tongan fakaleitī, survived two instances of conversion therapy, one that was initiated by the church and the other that was initiated by his school.[299]

214. Conversion practices are discussed in further detail in the following section, Medical abuse and neglect in care.

Te tūkinotanga me te whakahapa ā-rongoā i roto i te pūnaha taurima
Medical abuse and neglect in care

215. Medical abuse is a broad term capturing many abusive actions involving the improper application of medical treatment and practices, the misuse of medicine or medical equipment for purposes other than treating illness, or the medicalisation of issues that were not related to illness. It can include instances of treatment without informed consent, as well as instances of medical trials or experimental treatment. Medical abuse occurred in most care settings, including social welfare settings, disability and mental health settings, health camps, and faith-based settings particularly unmarried mothers’ homes.[300]

216. Often, different types of abuse would co-occur when medical resources were misused. For example, survivor Mr OW described how he was held down and strapped to a bed with dog-like collars at Porirua Hospital in the late 1960s before receiving electric shocks to his testicles.[301] He told the Inquiry “the staff thought it was funny to do it”.[302]

217. Staff across care settings and institutions sometimes used medical treatment and medications as tools to control and punish children, young people and adults in care, including aversion techniques involving electric shocks and painful injections of medication. This was particularly common in psychiatric and psychopaedic institutions and social welfare residences and institutions.

218. Many survivors, particularly those who were in disability and mental health settings, spoke about receiving treatment without giving informed consent. The Inquiry acknowledges there were instances where treatment without informed consent was legal and an accepted practice. This section of the Inquiry’s report, focuses and reflects on survivors’ experiences where they received treatment that they did not give informed consent to and that they describe as abusive and traumatic.

219. The denial of reproductive rights is another form of medical abuse that survivors, particularly women and girls, experienced in care. This was carried out through the administration of contraception, sterilisations and abortions. Contraception refers to drugs, devices and techniques used to prevent pregnancy. Sterilisations are procedures that render a person unable to reproduce. Abortions are procedures that terminate pregnancy. The Inquiry found there was often a lack of informed consent around these procedures. In some cases, these procedures were forced on survivors.

Te whakahau i te kai rongoā ki te whakahaere, ki te aupēhi rānei i te tangata
Forced medications to manage or control people

220. Medication was used to control, subdue or ‘manage’ people’s behaviours while they were in care settings, often for the benefit of staff. ‘Overmedicalisation’ refers to the inappropriate application of medical analysis or diagnosis to non-medical situations, as well as the use of unnecessary treatments, which applies to many instances of medical abuse the Inquiry has heard about.[303]

221. The Inquiry heard evidence of medication being used in an experimental nature in psychopaedic and psychiatric settings. Former staff have used the term ‘medical experiments’ to describe the kind of trials that took place in these settings.[304]

222. Dr Enys Delmage, consultant in adolescent forensic psychiatry, told the Inquiry that caution should be exercised when “passing judgment on historical prescribing practices”. He said clinicians in those days “would not have had the benefit of decades of research and innovation that followed”.[305]

223. At the Inquiry’s State Institutional Response Hearing, Ministry of Health Chief Executive and Director-General of Health, Dr Diana Sarfati publicly acknowledged that:

“Much of the nature and standard of care and treatment provided in historical psychiatric or psychopaedic institutions would be unacceptable today and are now, rightly, reviewed as neglect or abuse.”[306]

224. Dr Mhairi Duff, deputy clinical director at the Mason Clinic, said that although prescribing practices have improved “there is still an overreliance on medication with a powerfully sedating side effect within mental health”.[307] Expanding on this, she said:

“If you run a medical model you’re going to get medical interventions high in the hierarchy of choices and a relative downgrading of the value of non-medication interventions.”[308]

225. Survivors often used the term ‘guinea pig’ to describe how they felt being given different medications, typically without their informed consent. Samoan survivor Leota Scanlon, who was placed in Lake Alice Child and Adolescent Unit at 13 years old, described how he “just felt like a guinea pig there” as “the staff spent their time figuring out what drug worked best to settle us down and to shut us up”.[309]

226. Chemical restraint is a type of restraint where medication is used to control a person’s behaviour, typically to sedate, subdue and encourage compliance. Chemical restraints can be proactive and used to stop an anticipated behaviour occurring. When it is used in this way it is called overmedicalisation, as a regular dose of medication is being given to maintain control over the behaviour. At other times, medication is used reactively to control or curb unwanted behaviour. The Inquiry has heard evidence of chemical restraint being used in care settings such as disability and mental health settings, as well as social welfare residences and institutions.

227. Dr Martyn Matthews described how the use of medication as a means of behavioural control could develop in psychopaedic institutions that lacked staff, had little or no staff training or had a highly institutionalised practice:

“This is an international problem and is one of the major contributing factors to the continuing overmedication of people with a learning disability. Within the records reviewed for this report, there was clear evidence of PRN [as the circumstances arise] antipsychotic and hypnotic medication being used for behavioural control.”[310]

228. Dr Matthews explained that “many of the challenging or ‘problem’ behaviours seen in care settings were a direct result of the living environment and poor quality of support and treatment that were received.”[311]

229. Survivor Robert Shannon (8 years old) was placed in an adult ward at Palmerston North Hospital for eight months in the early 1960s.He told the Inquiry he was sedated throughout his time at the hospital, and that it:

“Was only necessary because I was not in an appropriate facility and I was not receiving any treatment for my condition [paediatric behavioural challenges later diagnosed as Childhood Behavioural Disorder].”[312]

230. In a letter to a charge nurse at Alice Child and Adolescent Unit, Rangitikei, Dr Pugmire refers to both paraldehyde and Largactil (the brand name for antipsychotic medication, chlorpromazine) as “tranquilizers”.[313] Not only was this kind of medication used as a chemical restraint in care, but paraldehyde injections were often used as tools to inflict aversive punishment.

231. Medical abuse in the form of chemical restraint and over-medicalisation enabled other types of abuse to occur, particularly sexual abuse. Sexual abuse sometimes occurred while survivors were physically or chemically restrained (including being heavily medicated) in settings such as psychiatric hospitals.[314] Survivors spoke about how they were intentionally taken advantage of while in these states.

232. The Inquiry has also been told about punitive medicating. Dr Olive Webb, clinical psychologist specialising in intellectual disabilities and autism spectrum disorder, gave an example of the ward doctor at Sunnyside Hospital in Ōtautahi Christchurch who increased a patient’s medication as punishment. The patient had broken the antenna on his car in retaliation for something he had said that upset her.[315]

233. Contraceptives were used to control girls’ and women’s bodies. For example, injections of Depo-Provera for example were used to ‘manage’ menstruation, by limiting the care that could have been required from staff, and to decrease the likelihood of pregnancy.[316]

234. An amendment to the Mental Health Act 1969 in 1977 gave medical superintendents, or employees acting at the superintendent’s direction, authority to administer any contraceptive to “mentally subnormal” females under care of the relevant hospital.[317] In the same year, the Contraception, Sterilisation, and Abortion Act 1977 was enacted, allowing parents, guardians, people with custody of any female, or medical practitioners in the course of treatment to administer contraceptives to “mentally subnormal” females if it was in their best interests.[318]

235. The Inquiry is also aware of non-therapeutic sterilisation of males. Māori survivor Walton James Ngatai-Mathieson (Ngāti Porou) told the Inquiry he received contraceptive medication at Lake Alice without his consent. He shared that he was given a blue pill which he understood was to make sure he couldn’t get anyone pregnant. He referred to this pill as the “kill cocker”.[319]

236. Dr Olive Webb told the Inquiry that she witnessed male patients receiving Melleril, which had the ‘advantage’ of producing erectile dysfunction, and said it was seen as a way of controlling the men’s sexual behaviour. Dr Webb explained that this thinking was a carryover from the eugenic beliefs of people such as Truby King who set up the psychopaedic hospitals to segregate inferior breeding stock.[320]

Ngā whakahaunga arotake hauora me ngā pokanga
Forced medical examinations and procedures

237. The Inquiry heard of procedures and examinations taking place without survivors’ informed consent. For example, many girls, sometimes even under 5 years old, were subjected to forced vaginal examinations. This mostly occurred in social welfare residences and institutions, but also in unmarried mothers’ homes, and health camps.

238. The Inquiry also heard of occasions where children were subjected to vaginal examinations to see if they had been sexually abused, even when there was no alleged abuse. Forced vaginal examinations were a routine practice upon entry into social welfare residences and institutions, and also occurred when girls returned from holiday or leave. Examinations occurred in an uncaring and often degrading way. The Inquiry heard of many survivors being traumatised by these procedures, and that some medical staff used the procedures as an opportunity to sexually abuse those in their care.

239. Forced internal examinations at girls’ homes were not compulsory. However, girls were locked in secure units until they agreed to undergo a test. The tests were given to girls even if they were not sexually active. Testing took place upon entry and return if a girl had run away. Survivors saw forced medical examinations as a punishment.[321]

240. The Auckland Committee on Racism and Discrimination, in their 1978 investigation into children’s homes, found that the method and manner of testing for sexually transmitted infections, particularly at Bollard Girls' Home, Tāmaki Makaurau Auckland, constituted “degrading”[322] treatment or punishment under article 7 of the International Covenant on Civil and Political Rights that states: “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation.”[323]

241. The Inquiry also heard about contraceptive procedures such as the insertion of intrauterine devices and sterilisation surgeries such as tubal ligation, being performed on survivors in institutional care, particularly larger-scale disability and mental health institutions.[324]

242. Most of the evidence the Inquiry reviewed surrounding sterilisation related to the sterilisation of women. The Inquiry heard from survivors who were sterilised while in institutional care,[325] family members who questioned the consent processes surrounding their loved ones’ sterilisations,[326] and disability sector workers who confirmed that sterilisations historically occurred in institutions.[327]

243. Mark Benjamin, the former chief executive of Standards and Monitoring Services in Aotearoa New Zealand, told the Inquiry that from his personal observations it was unlikely people who were sterilised would have gone through “a process of making an informed choice about these procedures”.[328]

244. The Inquiry also heard of forced and unconsented abortions happening in disability, mental health, and social welfare settings. Family members and other patients described women they were in care with or women they were related to who were in care, being forced into abortions without their knowledge and consent.[329] Mostly, the Inquiry heard of women who realised during or after that the procedure they had undergone was an abortion. The Inquiry also heard that some of their pregnancies were a result of sexual abuse occurring in care.[330]

245. Survivor Christina Ramage became pregnant after being raped by a psychiatrist while in the care of Carrington Hospital’s psychiatric ward, Park House in Tāmaki Makaurau Auckland, and was given an abortion without her knowledge or consent:

“A few months later, after the psychiatrist raped me, I was taken by a nurse to a room that was normally always locked. This room had lots of shiny things. I was told to get on the bed and I recall there being a nurse at my side and one behind me. I assumed I was there to get some sort of examination. Suddenly, everything went dark. I'm not sure whether this was because I had a mask over my face or if they had given me gas. The next thing I knew, I was awake. I can't guarantee the exact words, but the nurse beside me said something along the lines of, 'It's okay, you haven't got a baby anymore’.”[331]

246. Non-consensual abortion, sterilisation and contraception for disabled people prevented their inclusion and participation in the mutual support and interdependence of parenthood. Rather than respect their difference and diversity, the care system devalued their human potential as parents and denied them that opportunity.

He whakawhiunga, he aupēhinga te whakamahinga o ngā tukanga kaupare
Aversion techniques to punish and control

247. Aversion therapy is a form of behaviour therapy where undesirable behaviour is matched with an unpleasant (aversive) stimulus and delivered in a measured, controlled way.[332] As unpleasant feelings or sensations become associated with that behaviour, the goal is for the behaviour to decrease or stop. Aversion therapy has been the focus of debate for many years among educators, medical professionals and practitioners.[333] Its use remains controversial on ethical grounds and because of concerns about its effectiveness and safety.[334]

248. The Inquiry has seen some evidence of aversion techniques being used on children, young people and adults across different care settings in an attempt by staff to reduce behaviours they viewed as ‘problematic’ or challenging. This was often done through the delivery of uncomfortable, sometimes intolerable medical stimulus such as electric shocks delivered through ECT machines and painful injections. Survivor Mr JJ said that he was given electric shocks on 12 occasions in one day after accidentally breaking a pot at Lake Alice Child and Adolescent Unit.[335] The Inquiry refers to these as aversive techniques, rather than therapy, as they represented medical abuse as a form of punishment and control.

249. The effects of medical abuse, such as electric shocks, could enable subsequent abuse to occur. As discussed in the Inquiry’s interim report Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit, several survivors suspected they were raped while heavily sedated or unconscious after ECT.[336] Survivor Malcolm Richards, said he had no idea how long he had been unconscious after ECT, but he “came to back in the cell with a sore, sticky rectum" and believed he had been raped.[337]

250. The Inquiry has seen evidence of paraldehyde injections being used as aversive punishment. Paraldehyde is a hypnotic and sedative with anti-convulsant (anti-seizure) effects, known to have an extremely offensive taste and smell.[338] Administration by way of injection is understood to be extremely painful.[339] Following administration, people report being unable to use the part of the body that received the injection over a long period, until the effects have worn off.[340]

251. Medical abuse in the form of aversion techniques also commonly occurred consequently to children, young people and adults in care who were impacted by other types of abuse and neglect. Caroline Arrell, a former worker at two large-scale disability and mental health institutions, Tokanui Psychiatric Hospital near Te Awamutu and the Kimberley Centre near Taitoko Levin, said young residents’ ‘challenging behaviour’ was overwhelmingly caused by emotional and physical neglect and a lack of stimulus:

“I believe [residents] as demonstrated in their behaviour, were also responding to a wide variety of abuse. I believe that they were behaving in perfectly understandable ways in very abnormal environments.”[341]

Te whakapanoni hemahematanga i ngā mahi taurima hinengaro
Conversion practices in psychiatric care

252. Conversion practices, also referred to as ‘conversion therapy’, is an umbrella term used to describe a range of interventions based on the shared belief that a person's sexual orientation or gender identity and expression can and should be changed. Those with diverse sexualities and genders continue to experience profound prejudice in Aotearoa New Zealand. Homosexuality was illegal until 1986 and was pathologised and classified as a mental illness that many medical professionals believed could and should be treated,[342] commonly through conversion practices. The conversion practices survivors were subjected to varied between psychiatric settings and faith-based settings.

253. Such views meant that members of the Takatāpui, Rainbow and MVPFAFF+ communities have experienced conversion practices, typically through harmful aversion techniques, while in State and faith-based care settings (most commonly in institutional psychiatric settings).

254. Survivors explained that once they disclosed their sexuality to staff members or medical professionals in psychiatric settings, attempts were sometimes made by these institutions to convert them to heterosexuality. The Inquiry found that in psychiatric settings, the most common conversion practice experienced by survivors was being subjected to aversion techniques in the form of electric shocks. Survivors talked about the traumatising experience of receiving ‘treatments’ to ‘fix’ or ‘cure’ them, sometimes without their informed consent. [343]

255. This form of medical abuse typically co-occurred with other types of abuse, particularly psychological and emotional abuse, such as homophobic name-calling.

Te whakahapanga ā-rongoā
Medical neglect

256. Medical neglect means the failure to provide or allow for adequate medical care that could be needed by children, young people and adults in any care setting. This includes injuries and illnesses being left unnoticed, untreated or caregivers or staff withholding access to medical treatment for any length of time.[344] Family members told the Inquiry that they brought injuries to the attention of staff, but they remained untreated.

257. Medical neglect itself could lead to other harmful experiences in care or after leaving care. For example, former IHC staff member Allison Campbell, who had extensive contact with various disability settings from 1980 to 2002 told the Inquiry that dental care in larger-scale disability institutions, such as psychopaedic hospitals, was so bad that when people moved into smaller group homes, many had to have “their teeth pulled out”.[345]

258. The Inquiry heard of instances from most care settings where survivors suffered physical injuries and ailments, including loss of consciousness, broken bones or infections because of other types of abuse experienced in care, but were denied or unable to access medical help.[346] In some cases, the medical treatment they did receive was inadequate.

Te whakataratahinga i te pūnaha taurima
Solitary confinement in care

259. ‘Solitary confinement’ is an umbrella term the Inquiry uses to refer to any practice in care that involved forcibly isolating children and adults for any period. This covers similar procedures that were known by different names across settings, including isolation, solitary confinement, secure, and seclusion. For most survivors being placed in solitary confinement was traumatising. In some settings, these practices were pervasive.[347]

260. The use of solitary confinement was widespread in social welfare residences and institutions, including boys and girls homes, faith-based residences and children’s homes,[348] psychiatric care, psychopaedic care, special schools and Gloriavale Christian Community. Some survivors discuss similar practices in their foster homes as well.[349] Solitary confinement involved locking children, young people and adults into confined spaces, sometimes for extended periods. The nature of rooms varied between settings, although they were usually small and bare. Occasionally, survivors reported being placed in a location such as a box or cupboard.[350]

261. Policies surrounding solitary confinement varied between settings. The Residential Social Workers Manual from 1975 stated that placement into ‘secure’ should be seen as a “temporary, emergency measure”, but that it should also be used as punishment, for the protection of the child’s interests or those of the community or institution, and directly on admission, where necessary.[351] This policy was further formalised in 1986, and punishment was removed as a valid reason for placement in solitary confinement.[352]

262. The use of ‘seclusion’ is currently legal under the Mental Health (Compulsory Assessment and Treatment Act) 1992,[353] and had been in widespread use within psychiatric and disability institutions in the decades before this.[354]

263. The damaging effects of these practices have been acknowledged by the State. During the Inquiry’s State Institutional Response Hearing, Oranga Tamariki recognised that the practice of solitary confinement was inhumane,[355] and the Ministry of Health and Whaikaha both acknowledged there was inappropriate use of seclusion and restraint in psychopaedic settings. The Ministry of Health acknowledged there was inappropriate use of seclusion and restraint in psychiatric settings.[356]

264. The Ministry of Health acknowledged that ‘seclusion’ has no therapeutic use, but they also stated that “in certain circumstances it is unfortunately a necessity”.[357]

265. Solitary confinement was often used in many social welfare residences and institutions and disability and mental health institutions as a means to contain, control and manage behaviour, and punish perceived bad behaviour, particularly for running away.[358] The Inquiry heard that while in solitary confinement, survivors were sometimes subjected to psychological abuse and neglect, and physical neglect. They were often deprived of basic needs such as access to food, water and toilets, as well as human contact, education, and activities.

266. Across all State residences, children and young people, sometimes as young as 8 years old, were locked in small cells that were cold, dark, and unhygienic, with access to only a bed and toilet. The Inquiry heard survivor evidence alleging they were held in solitary confinement for days, weeks, or sometimes months.[359] This also occurred in Borstals run by the Department of Justice. Māori and Pākehā survivor John Baxter (Taranaki iwi, Whakatōhea), who said he was held in solitary confinement for three months at Waikeria Borstal told the Inquiry:

“Solitary confinement was used as a punishment at Waikeria and was one of the hardest things to cope with. Most inmates lasted about two hours before they began to panic and started to beg in hell to be let out, banging on the door as they called. This could go on for several hours before there was the sound of a scuffle and things went quiet or subsided into a measurable whine. This made me feel as if the walls in my cell had begun to shrink in on me. A couple of times I thought I would start kicking the door and screaming too. Only the fear of being beaten up [by the guards] stopped the feeling of panic rising.”[360]

267. Solitary confinement could co-occur with and enable many other forms of abuse. In some cases, staff in social welfare residences and institutions took advantage of solitary confinement to sexually and physically abuse survivors.[361] Pākehā survivor Alison Pascoe shared how she was placed in solitary confinement at Kingseat Hospital in Karaka when she was 9 years old, as punishment for trying to run away from the severe abuse she was suffering. She described being held in solitary confinement and how the staff member Sister Noble tried to make her drink her own urine and eat her own faeces.[362]

268. In disability and mental health settings, some survivors were locked in areas with limited or no access to toilets, showers or water. Survivors often had no choice but to soil themselves.[363] At times they were also restrained manually or with devices, or medications that rendered them immobile or limited their ability to think and act. Residents could be held in ‘seclusion’ for hours, days and sometimes weeks. The Inquiry heard that in some institutions, being locked in rooms was a nightly routine.[364]

269. Solitary confinement was also experienced by survivors in faith-based care. Some survivors described the nuns using solitary confinement as a form of punishment at Mount Magdala, a Catholic home for “women and girls experiencing disadvantage” and Marycrest,[365] a Catholic training school.[366] Survivors of Anglican children’s homes described being locked in closets and rooms as punishment.[367] Survivor Mr NP was placed in care when he was 2 years old. He told the Inquiry about a cupboard under the stairs where children would be locked in at the Anglican All Saints children’s home – the children called it their ‘jail’ or ‘cell’.[368] The cupboard had no light or seat, and children were not allowed a meal while they were locked in.[369] Once Mr NP spent at least 24 hours in there.[370]

270. Solitary confinement was sometimes used as a form of punishment at Gloriavale Christian Community. Survivor Ms PM told the Inquiry that people would be put in a hut / flat if they did anything that the Gloriavale elders viewed as seriously wrong: “You would be in in isolation for three or four weeks until you had, in the eyes of the Elders, repented for your sin.”[371]

Te tūkinotanga-ā-pūtea, ā-ohaoha anō hoki i te pūnaha taurima
Financial abuse and forced labour in care

271. Financial abuse and forced labour occurred in some State and faith-based settings. The Inquiry defines financial abuse as any action that interferes with someone’s money or belongings without their consent or without proper purpose, as well as their ability to access or acquire these things for themselves. This includes theft, extortion, manipulation and coercion.

272. Forced labour is closely related to financial abuse, as it involves making people work against their will, often through threats or force,[372] sometimes for no pay, and sometimes for the economic benefit of others. Forced labour could involve a range of circumstances, from having to do excessive chores to working exceedingly long hours in businesses connected to a State or faith-based institution where the person was in care.

273. Staff and caregivers stole personal possessions and money from those in their care, or exerted control over how they managed or used their money. Survivors spoke about payment being withheld for labour they had completed,[373] or being coerced, sometimes violently, into labour such as farm work and unreasonable housework.[374]

274. Survivors spoke of being forced to work without any personal reward, often in severe conditions and subjected to psychological and physical abuse.[375] From a Māori worldview, this reflects the status and position of taurekareka or enslavement, which was believed to represent the lowest status within Māori society. When someone is enslaved, they lose the ability to enact their rangatiratanga and be self-determining over decisions about what they do, when and how they do it, and for whom they do it.

275. The term taurekareka can be literally translated as ‘slave’. However, it is also used to describe someone of low status, or who is shameful, disgraceful, and dishonourable. The whakamā associated with being forced into a position of taurekareka was extreme, as it epitomised the degrading of a person’s position in their community and society, and their sense of self-worth.

276. In foster homes, it was common for survivors to be forced to engage in physical labour, particularly farm work, housework, and caring for or raising other children, often at the expense of their own education. Survivors’ work in this context was over and beyond what would be considered everyday chores or tasks that most families would expect children to complete. Survivors were often punished, with physical and psychological abuse, if they did not complete the tasks and work they were forced to do. Survivor Denise Cordes shared how she and her siblings felt like ‘little slaves’ in their 1980s foster home, saying that their foster parents: “made us do a lot of chores and would punish us if things didn’t get done.”[376]

277. In faith-based care, women and girls in unmarried mothers’ homes were forced to work, often while heavily pregnant, including cleaning and providing food for residents of other wings at the hospital. The Inquiry heard evidence of women at St Mary’s Home for Unwed Mothers (Anglican) being forced to pay board through their sickness benefits and to work as domestics.[377] Survivors from other faith-based orphanages, children’s homes and residences described extensive work and chores, both inside the residences and in gardens or on farms.[378]

278. Survivors from other faiths have also described various ways they were financially abused through restrictive and exploitative employment conditions, and through losing control of their financial independence. Many survivors from Gloriavale Christian Community reported arduous labour within the community with no pay. Male survivors worked extreme hours from their childhood years onwards, up to 16-hour shifts as teenagers, with no time off for injuries.[379] Female survivors reported similar experiences working in the community kitchens and laundries, practices that have been ruled by the Employment Court to be examples of forced labour (under appeal).[380]

279. In disability settings across the Inquiry’s review period, financial abuse was experienced through the exploitation of residents in sheltered workshops, where they were made to work for minimal to no pay,[381] and with no worker’s rights.[382] Under the Disabled Persons Employment Promotion Act 1960 disabled people could be employed in sheltered workshops that were excluded from having to meet labour legislation covering pay and other conditions.[383] Survivors and their whānau also told the Inquiry that financial abuse occurred in disability and mental health settings through the theft of personal possessions, including staff members stealing survivor’s personal allowances.[384] This abuse contributed to the devaluation of disabled people by reinforcing social and economic disadvantage.

Te whakahapa ā-mātauranga i roto i te pūnaha taurima
Educational neglect in care

280. Education can include school curriculum as well as teaching those in care basic and necessary life skills. Some examples include health education, where girls are taught about menstruation, or teaching Deaf students to ‘speak’ at the expense of curriculum learning. The Inquiry’s definition of educational neglect is the omission of any of these educational and life skills required to live a full and meaningful life. This contrasts with Oranga Tamariki’s definition which only focuses on allowing truancy, failure to enrol in education or inattention to education needs.[385]

281. Educational neglect occurred across settings, including State[386] and faith-based residential care,[387] foster care,[388] special residential educational settings, and mainstream educational settings such as day schools and faith-based private or State integrated boarding schools.[389] Educational neglect could occur with varying severity, ranging from poor resourcing,[390] lack of engagement from teachers[391] and narrow curriculums to a complete lack of any kind of meaningful education while in care.[392]

282. Survivors from social welfare residences and institutions said that when they were in care education was minimal or non-existent.[393] Survivors from some foster placements discussed how their foster families forced them to work, rather than attend school.[394]

283. Throughout these care settings, both Māori and Pacific survivors reported that they were often disregarded and ignored by teachers, streamed into classes with easier work, or outright racially abused.[395] They were also punished more frequently and more severely for perceived misbehaviour than their Pākehā counterparts. During the Inquiry’s State Institutional Response Hearing, Chief Executive and Secretary for Education Iona Holsted acknowledged that the education system’s expectations of Māori and Pacific children and young people, were ‘too low’, which had harmed these groups and contributed to poor educational outcomes over generations.[396] Ms Holsted acknowledged that the system had not sufficiently valued Māori cultural understanding and had failed to respond to Māori identity, language and culture needs.[397]

284. A Deaf survivor told the Inquiry that when they were a student in the 1970s, teachers in mainstream classrooms forgot they had a Deaf student and taught lessons with their back turned to the class[398] or without their mouth visible when they spoke – making it difficult for the Deaf student to lip-read.[399] Some survivors who were students during the 1960s and 1970s described their experiences in mainstream and special schools as frustrating because of the breakdown in communication that would occur between themselves and other students and staff.[400]

285. Deaf and blind survivors experienced educational neglect in special residential education settings and mainstream schools.[401] Educational neglect contributes to, or could even represent, more general forms of cultural neglect for Deaf survivors.[402]

286. The Inquiry heard that in psychopaedic institutions such as the Kimberley Centre near Taitoko Levin and the Templeton Centre located near Ōtautahi Christchurch, survivors experienced serious educational neglect in the form of limited or no access to education, and / or poor quality of education.[403]

287. The Inquiry heard that access to education was an issue in various mental health settings, particularly among survivors who were young when they entered.[404] Survivors and former staff members told the Inquiry there was often no opportunity for individuals to access any form of schooling, even if they wanted to pursue or maintain education.[405] In many cases, people in disability and mental health care settings did not receive sex education[406] or education about “personal relationships, or intimacy and sexuality”.[407]

288. Survivors told the Inquiry about educational neglect in faith-based care.[408] Survivors also spoke about educational neglect in care homes where they sometimes experienced poor education and little encouragement. For example, one survivor said she was only the second girl from St Andrew’s Home for Girls (Anglican) to get School Certificate and said her potential wasn’t encouraged by staff.[409]

Te whakataunga o ngā momo tūkinotanga me ngā whakahapa i te pūnaha taurima
Conclusion on the different types of abuse and neglect in care

289. Survivors told the Inquiry about a wide range of abuse and neglect that they experienced in State and faith-based care in Aotearoa New Zealand. For many, care was abusive from the very start, as the process of entering care was often discriminatory, involving the disruption of attachments and the start of institutionalisation. From there, survivors experienced:

• psychological and emotional abuse and neglect
• physical abuse and neglect
• sexual abuse
• racial abuse and cultural neglect
• spiritual and religious abuse and neglect
• medical abuse and neglect
• solitary confinement
• financial and economic abuse and forced labour
• educational neglect.

290. These forms of abuse and neglect were often experienced concurrently, with instances involving traits or dynamics from many types of abuse. Every instance of abuse had a component that was psychological. Abuse was also experienced cumulatively for many survivors, with repeated instances adding up to greater effect over time. This kind of cumulative abuse came to define many settings as systemically abusive.

291. Much of the abuse discussed by survivors from all groups, and across all settings, involved dehumanisation of those within care, which indicated a destructive and callous disregard for those in care across the entire system.

292. Often, dehumanisation in care reflected structural discrimination or prejudice that exists in the wider society of Aotearoa New Zealand. This included factors such as racism, sexism, disablism, classism, and discrimination against sexual or gender minorities. This meant that while all survivors who suffered abuse were dehumanised in some way, survivor groups such as Māori, Pacific Peoples, Deaf, disabled people, Takatāpui, Rainbow and MVPFAFF+ and women / girls experienced targeted, identity-specific abuse and neglect. Harm experienced along these ideological lines reflected the purpose of State and faith-based care institutions, which was not care, but control; it further reinforced the viewpoint of those in power that these identities were in some way defective.

Footnotes

[163] Krug, EG, World report on violence and health (World Health Organization, 2002, page 149).