99. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes the factors that the Inquiry identified as having caused or contributed to the abuse and neglect of children, young people and adults in State and faith-based care. In addition, Part 7 identifies the lessons learned and the changes made to prevent and respond to abuse and neglect. Part 7 concludes by setting out findings relating to:

• breaches of relevant standards
• factors that caused or contributed to abuse and neglect in care
• fault
• lessons learned.

100. The Inquiry identified that four factors all caused or contributed to the abuse and neglect of Takatāpui, Rainbow and MVPFAFF+ survivors in in State and faith-based care. These included:

• factors relating to the people at the centre of abuse and neglect
• institutional factors
• structural and systemic factors
• societal factors.

The people at the centre of abuse and neglect

101. During the Inquiry period, many whānau and communities needed support to care for their children, young people and adults at home or within their community. Without this support, many Takatāpui, Rainbow and MVPFAFF+ children, young people and adults were placed in State and / or faith-based institutions.

102. People placed in care needed support, strong protection and to be safeguarded against abuse and neglect. Instead, many were placed in care facilities with institutional environments and practices that heightened the risk of abuse and neglect.

103. Takatāpui, Rainbow and MVPFAFF+ children, young people and adults in State and faith-based care were diverse, with diverse care and support needs. Although each person in care was unique, every person needed support, strong protection, and safeguarding. Strong protection refers to a set of internationally-recognised factors that contribute to resilience because they promote healthy development and wellbeing and can reduce the risk of experiencing abuse and neglect. These factors are a combination of personal, parental, and environmental factors.

104. The rights guaranteed in te Tiriti o Waitangi reinforce many protective factors. For example, connection to whakapapa, whānau, hapū and iwi are taonga protected by te Tiriti o Waitangi.

105. Had these rights been upheld during the Inquiry period – such as the right to tino rangatiratanga over kāinga, and the right to continue to live in accordance with indigenous traditions and worldview guaranteed by the principle of options – these rights would have been amplified protective factors for tamariki, rangatahi, and pakeke Māori, reducing entry into care and the risk of abuse and neglect in care.

106. Human rights recognise that children, young people, adults, people with disabilities and Māori as indigenous to Aotearoa New Zealand are distinct groups that also require special measures, particularly protective measures. In care settings, this means special protection measures like comprehensive standards of care needed to be in place. During the Inquiry period, the lack of special protections or measures for people in care were factors that contributed to abuse and neglect.

107. Many of the personal circumstances that made it more likely a child, young person or adult would enter care often became the factors for why they were more susceptible to, or at an increased risk of, abuse and neglect in care. These factors were underpinned by societal attitudes, like discrimination based on racism, ableism, disablism, sexism, homophobia, transphobia and negative stereotypes about children and young people, poverty and welfare dependency.

108. These factors included:

• being raised in poverty and experiencing deprivation
• being disabled with unmet needs
• being Māori and racially targeted
• being Pacific and racially targeted
• being Deaf with unmet needs
• experiencing mental distress with unmet needs
• being Takatāpui, Rainbow, MVPFAFF+, gender diverse or transgender and being targeted
• if a person had experienced significant or multiple adverse childhood events before entering care
• having a deferential attitude to people in positions of authority, including faith leaders and medical professionals
• other reasons such as age or gender.

109. For Takatāpui, Rainbow and MVPFAFF+ people in care, this meant that they were more susceptible to abuse and neglect if they were also raised in poverty, were Māori, Pacific, Deaf, disabled, and/or experienced mental distress, and/or had multiple combinations of these circumstances.

110. Abusers were a key factor that contributed to abuse and neglect in care. Abusers misused their positions of power and control over people in care to inflict at times extreme and violent abuse, or to neglect people in their care. Abusers sometimes took calculated steps to conceal their actions which allowed them to continue, at times, acting with impunity.

111. Many staff and carers who witnessed abuse and neglect, or were told about it, did nothing. Some bystanders did complain or raise concerns, but often with limited success.

Institutional, structural and systemic factors contributed to abuse and neglect

112.    Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes the institutional, structural and systemic factors that contributed to abuse and neglect in care during the Inquiry period. Most of these factors did not have a significantly different effect on Takatāpui, Rainbow and MVPFAFF+ survivors.

113. In summary, institutional factors included:

• standards of care were inconsistent and routinely breached
• poor or absent vetting exposed people in care to abusers
• inadequate recruitment, training and resourcing contributed to abuse and neglect
• complaints processes were absent or easily undermined, with few records kept
• senior State and faith leaders prioritised the reputations of institutions and abusers over people in care
• oversight and monitoring was ineffective
• rights guaranteed under te Tiriti o Waitangi and human rights were largely absent
• people in care were dehumanised and denied dignity › people in care were isolated from whānau, kainga, communities and advocates › there was little accountability for abuse and neglect.

114. The Inquiry examined the responsibility of the State in respect of the abuse and neglect in care during the Inquiry period. The State was ultimately responsible for safeguarding all people in care, regardless of the care setting, and preventing and responding to abuse and neglect. It was the State, for the most part, who decided who should and must enter care, what type of care and how long for, how people were to be treated in care, and how and to what extent abusers and those who contributed to abuse and neglect in care would be held to account.

115. The State failed to uphold all of its responsibilities for the care system, which contributed to abuse and neglect. This section sets out the following failures:

• the State did not give effect to te Tiriti o Waitangi or fulfil its human rights obligations
• legislative and policy settings were discriminatory and ignored people’s rights
• this discriminatory approach reflected a lack of diverse leadership
• people in care had limited input into State decision-making
• the State’s attempts to address institutional discrimination fell short
• the State did not ensure that people in care were safeguarded from abuse and neglect
• the State lost sight of its core regulatory, enforcement and funding functions
• the State’s highest-level decision-makers rarely took accountability for abuse and neglect in their care.

116. During the Inquiry period, the rights guaranteed to Māori in te Tiriti o Waitangi were largely absent in care settings. Similarly, human rights protections were largely absent from care settings for most of the Inquiry period. Many children, young people and adults in State and faith-based care were isolated from their whānau, kāinga and communities.

117. Inadequate standards of care, failure to implement existing standards, and breaches of standards contributed to different forms of serious abuse and neglect across all care settings. People in care were regularly dehumanised and denied human dignity. These failures resulted in inappropriate and unsafe care placements, and a one-size fits-all regimented approach to care.

118. Throughout the Inquiry period, government agencies held multiple and conflicting roles in care. Agencies often designed their own standards and policies, regulated some care providers, owned and operated care facilities, delivered care, employed staff, oversaw and monitored their own services, and advised the State on carerelated policies and regulation of the care system.

119. This concentration of power, where an agency could be responsible for all aspects of a situation from decision-making to service provision to monitoring, decreased accountability and increased the risk of abuse. Many staff and carers in government agencies were under-resourced, or had too many duties, leading to some of them having to ‘cut corners’ or not being able to carry out some of their duties.

120. Where there were complaints processes in place, these were ineffective and easily undermined. People in care faced barriers to making complaints and were often not believed and called liars or troublemakers if they did raise concerns. When there were concerns or complaints about abuse, it was often treated as an employment issue or as a sin to be forgiven, rather as criminal behaviour that needed to be investigated and the perpetrator held to account. Senior leaders or managers often prioritised institutional reputations, and abusers’ reputations and future careers over the safety of people in their care. Abusers were often shifted to other residences or institutions.

121. Unlawful and serious breaches of standards of care were rarely reported to NZ Police. Senior leaders and managers often failed to report abuse or neglect to NZ Police. In some cases, they took deliberate steps to defer or avoid reporting and following through with other accountability steps, such as dismissal under employment laws. Other measures taken by senior leaders and manager included denying they abuse happened, blaming complainants for the abuse, taking a litigious response to complaints, or entering confidential settlements with abusers.

Faith-specific factors that contributed to abuse and neglect

122. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes the faith-specific factors that contributed to the abuse and neglect of children, young people and adults during the Inquiry period in faith-based care. These factors included:

• the misuse of religious power
• the moral authority and status of faith leaders and the access this power, authority and status gave them
• gendered roles and sexism in positions of authority
• negative attitudes about sex and repression of sexuality
• racism and ableism based on religious concepts
• the interpretation of sexual abuse through the lens of sin and forgiveness
• harmful use of religious beliefs and practices.

123. Two of these factors converged to have specific effects on Takatāpui, Rainbow and MVPFAFF+ survivors in faith-based care – negative attitudes about sex and repression of sexuality, and the harmful use of religious beliefs and practices.

124. The Inquiry’s summary report on survivors’ experiences of abuse and neglect in faith-based care has more detail on the factors that that were specific to faith-based care settings.

Negative attitudes about diverse sexual orientations and gender identities

125.  Negative perceptions of homosexuality created barriers to reporting. Pākehā survivor Craig Hoyle described the homophobia and transphobia present within the Plymouth Brethren Christian Church. Craig explained there was “zero tolerance for diversity of sexuality or gender identity” within the Plymouth Brethren Christian Church, and that “homophobic and transphobic slurs were commonplace”. [90] Craig explained that “anyone who deviated from cisgender heterosexuality was seen as a pervert, demon-possessed, or mentally unwell” [91] and was subjected to harmful labels and put-downs.

126. The Plymouth Brethren Christian Church’s belief that homosexuality is inconsistent with the teachings of the Bible, coupled with a belief that a person’s sexuality can be changed, led to attempts to ‘correct’ or ‘manage’ the sexuality of congregants through conversion practices.[92] NZ European survivor Mr UJ explained that within the Plymouth Brethren Christian Church, “there is no tolerance for alternative sexual and or gender identification ... conversion therapy is imposed.”[93]

127. One survivor said:

“What contributed to the historic abuse and neglect of Rainbow communities in care? Disconnections with whānau and family that were caused by church attitudes and teachings relating to homosexuality – these disconnections contributed to the high incidence of Rainbow people going into care and being abused.”[94]

128. Negative attitudes about homosexuality also created barriers to reporting sexual abuse among male survivors who were not Takatāpui, Rainbow and MVPFAFF+. A survivor described the hypocrisy of the anti-homosexual sentiment of Catholic teachings compared to his experience of sexual abuse by male clergy.[95] Research has highlighted that boys who are sexually abused by another male can experience shame and stigma associated with homophobia and fear of being viewed as a homosexual.[96]

Societal factors that contributed to abuse and neglect in care

129. The Inquiry heard that discriminatory societal attitudes including racism, ableism, disablism, audism, sexism, homophobia, transphobia, negative attitudes towards children and young people, and discrimination against people experiencing poverty contributed to abuse and neglect in State and faith-based care.

130.Some of these societal factors – homophobia, biphobia, transphobia and other forms of discrimination against people with diverse sexualities or gender identities – had a specific effect on Takatāpui, Rainbow and MVPFAFF+ survivors. This is discussed below.

Homophobia, biphobia, transphobia and other forms of discrimination against people with diverse sexualities or gender identities

131. During the Inquiry period, homophobic attitudes led to the abuse and neglect of children, young people and adults in care, including verbal abuse, conversion practices and shock treatment. Attitudes that connected homosexuality with mental illness and criminality were especially harmful:

“What contributed to the historic abuse and neglect of Rainbow communities in care? [The] link between criminalisation of homosexuality and colonisation – countries in the commonwealth had higher likelihood to criminalise homosexuality than others.”[97]

132. The Inquiry saw evidence of strongly homophobic attitudes in both State and faith-based care, particularly the idea that homosexuality was sinful, morally wrong and needed to be cured or treated. Survivors of faith-based care described a general culture of homophobia in most of the faiths the Inquiry investigated.[98]

133. In 1963, the principal of Fareham House in Pae-Tū-Mōkai Featherston listed lesbianism as a problem that needed to be prevented:

“Unless it is equipped at the same level as the other places, then Fareham House cannot be regarded as a Training Centre for seriously delinquent girls, otherwise the vandalism, destruction, abscondings, Lesbianism and other sexual aberrations, will continue because there are no means available to prevent them.”[99]

134. The perception of homosexuality as sexually deviant contributed to abuse and neglect being minimised or ignored. A former staff member at Epuni Boys’ Home in Te Awa Kairangi ki Tai Lower Hutt acknowledged that staff were far more concerned with same-sex activity between boys in the home than with the potential for them to be sexually abused by staff.[100]Complaints of sexual abuse where the abuser was the same gender were sometimes characterised as a “homosexual experience” or “homosexual relationship” rather than as abuse, even where it was clear that the survivor could not legally consent or where the abuser was in a position of power.[101]

135. As one survivor told the Inquiry:

“What contributed to the historic abuse and neglect of Rainbow communities in care? Ignorance, bigotry, homophobia, fear, racism, misogyny and general disinformation about gender and sexuality. White fucking supremacy!”[102]

Lessons identified and changes made

136. During the Inquiry period, the State attempted to make some changes to address problems identified in different care settings and to prevent and respond to abuse and neglect in State and faith-based care.

137. Most changes were specific to certain care settings. These changes included the creation of new legislation, policy, rules, standards and practices to prevent and respond to abuse and neglect in care as well as subsequent tweaks to these regulations, as new lessons were learned. Several of these changes had a positive impact on people in care, while some had intentions that were not achieved in practice.

138. Legislative and policy changes can largely be seen as a good faith attempt by the State to address lessons identified and to respond to and mitigate abuse and neglect in care. With hindsight, much more abuse and neglect could have been prevented if changes had been applied consistently across all settings and implemented differently. The changes often reflected discrete elements of a lesson, which limited their potential impact for preventing and responding to abuse and neglect in care.

139. Implementation repeatedly frustrated successful change. Common failures of implementation included funding and resourcing constraints, and lack of diversity in leadership positions, policy design and service delivery. 

Footnotes

[90] Witness statement of Craig Hoyle (14 July, page 12).
[91] Witness statement of Craig Hoyle (14 July, page 12).
[92] 91 Royal Commission of Inquiry into Abuse in Care, Internal notes from the Inquiry’s meeting with representatives of the Plymouth Brethren Christian Church (29 November 2022, page 13).
[93]Witness statement of Mr UJ (7 July, para 3.16).
[94]Moyle, P, “As a kid, I always knew who I was”: Voice of Takatāpui, Rainbow and MVPFAFF+ survivors, An independent research report to the Abuse in Care Royal Commission of Inquiry (Te Whāriki Manawāhine Research, July 2023, page 42).
[95]Victim Impact Report of a survivor who wishes to remain anonymous (11 September 2019, page 1).
[96]Easton, SD, Saltzman, LY & Willis, D G, “Would you tell under circumstances like that?”: Barriers to disclosure of child sexual abuse for men,” Psychology of Men & Masculinity, Volume 15, No 4 (2014, page 461).
[97]Moyle, P, “As a kid, I always knew who I was”: Voice of Takatāpui, Rainbow and MVPFAFF+ survivors, An independent research report to the Abuse in Care Royal Commission of Inquiry (Te Whāriki Manawāhine Research, July 2023, page 47).
[98]Private session of a survivor who wishes to remain anonymous (17 February 2021, page 5); Private session of Ms SP (17 August 2021, page 13); Witness statements of Kevin Lundon (21 April 2021, page 7); Rodney Anderson (20 September 2021, paras 45–54); Joshua Denny (8 July 2021, paras 22–34); Andrew Adams (30 May 2022, page 2.34).
[99]Annual Report from E Naylor, principal of Fareham House, to the Superintendent of Child Welfare (28 March 1963, page 1).
[100]Witness statement of Gary Hermansson to Crown Law (8 May 2007, paras 73–74).
[101]Letter from DM Burrows, social worker, to the director, Palmerston North District Office, Department of Social Welfare, Recommendation for continued involvement (14 June 1976, pages 6–7); Letter from CA Havill, social worker, to the Area Welfare Office, Tokoroa District Office, Department of Social Welfare, Recommendation for discharge (12 May 1982, page 2).
[102]Moyle, P, “As a kid, I always knew who I was”: Voice of Takatāpui, Rainbow and MVPFAFF+ survivors, An independent research report to the Abuse in Care Royal Commission of Inquiry (Te Whāriki Manawāhine Research, July 2023, page 47).