115. 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. Part 7 also 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.

116. The Inquiry identified that four factors all caused or contributed to the abuse and neglect of women and girls 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

117. 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 children, young people and adults were placed in State and / or faith-based institutions.

118. 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.

119. Women and girls 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 well-being and can reduce the risk of experiencing abuse and neglect. These factors are a combination of personal, parental, and environmental factors.

120. 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.

121. 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.

122. 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.

123. 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.

124. 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.

125. Most survivors of abuse and neglect in State and faith-based care had or experienced many of these factors, which heightened their risk of abuse and neglect. For women and girls, this meant that they were more susceptible to abuse and neglect if they were raised in poverty, were Māori, Pacific, Deaf, disabled, Takatāpui, Rainbow, MVPFAFF+, or experienced mental distress, or multiple combinations of these circumstances.

126. 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.

127. 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 that contributed to abuse and neglect in care

128. 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 women and girls in care.

129. In summary, institutional factors included:

• standards of care were inconsistent and routinely breached
• 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.

130. 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.

131. 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.

132. 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.

133. 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.

134. 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 care-related policies and regulation of the care system.

135. 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.

136. 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.

137. 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 the abuse and neglect of women and girls in care

138. 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.

139. Three of these factors had specific effects on women and girls in faith-based care – gendered roles and sexism in positions of authority, negative attitudes about sex and female sexuality, and religious beliefs being used to justify abuse and neglect in unmarried mothers’ homes.

Gendered roles and sexism in positions of authority

140. Historically churches have reflected the culture of the time in their approach to the status of women within their institutions, but they have also been conservative in their response to changing awareness of these issues.[129] Traditionally, formal religious roles were restricted to men in all Christian denominations.[130] Although early Christianity was notable for its respect for women, there is also a legacy of constraints on female leadership in the churches, despite frequent challenges from within.

141. Although there have been changes over time, in all eight faiths that the Inquiry investigated, clergy and religious leaders have been highly gendered, with control historically held by males.

142. There has been active involvement of women in various leadership roles within the Catholic Church. The Director of the National Professional Standards Office, the office that manages the investigation of all reports of sexual abuse against priests and religious, is a woman, and the Complaints Assessment Committee has female members and a female chair. Women have also held leadership roles within Catholic congregations – for example, Suzanne Aubert founded the Catholic order the Daughters of Our Lady of Compassion in 1892.

143. Despite the instances of female leadership, the Catholic hierarchy remained predominantly male-dominated throughout the Inquiry period. Only men were eligible for ordination under canon law and to hold positions of the highest authority within the Catholic governance structure, such as bishops, cardinals and the pope.

144. Women could be ordained in the mainstream Protestant denominations by the end of the 20th century, although in practice gaining full equality was difficult to achieve.[131] In the Anglican Church, the decision in 1976 to allow women to be ordained was controversial, and while there have been and are women who are bishops in the church, women are still underrepresented in the top roles.[132] In the Presbyterian Church, some women have achieved the highest office in the church, but historically women have struggled to be accepted by some parts of the denomination, especially at the evangelical end.[133] The Methodist Church can be viewed as more progressive, with the first woman ordained in Aotearoa New Zealand in 1958.[134]

145. Within The Salvation Army many officers are women. However, some have noted that historically the distribution of leadership in practice suggested that men held the true power, particularly in Aotearoa New Zealand where, in the past, great caution has been exercised in placing a woman over a man.[135]

146. In the Gloriavale community, those in the leadership roles of Overseeing Shepherd, Shepherds and Servants must be male. Roles are defined along biblical lines, emphasising men as decision-makers and breadwinners, with women in their places as mothers, running the household areas, and in later years, possibly as teachers in the early childhood centres caring for children. In Gloriavale, women’s scope of leadership was limited to ‘women’s work’ and ‘women’s issues’, primarily in the domestic sphere.[136] Māori survivor David Ready (Ngāti Porou) told the Inquiry:[137]

“From an early age, women are taught through formal education and observance of social structures, that they are worth less than men in the community.”[138]

147. Survivor Ms PP, who was born into the Plymouth Brethren Christian Church, told the Inquiry that the leadership “is a hierarchical male structure”, and as a woman “you are continually repressed and … you are expected to be subservient”.[139] NZ European survivor Mr UJ told the Inquiry that women were expected to fulfil their domestic duties as a wife and mother:

“The [Plymouth Brethren Christian Church] are a male-dominated culture and as such the women are expected to carry out a very narrow role. The expectation is that the women marry, bear children and look after the home. The husband has complete authority over the wife in all matters including marital relations”.[140]

148. The Plymouth Brethren Christian Church informed the Inquiry that women can serve as elders and that many do, with responsibilities that include providing advice to members and organising fundraising initiatives.[141] Despite this, the Inquiry found that women serving as elders were often limited to traditional gender roles, such as selecting a hymn to start each of the assembly meetings and setting the table for the Lord’s Supper (a meal celebrated each first day of the week by every member of the church).[142]

149. Research has previously highlighted that prescribed gender roles and the absolute authority of males within faith-based institutions contributes to the occurrence of abuse and neglect, and failed responses to abuse.[143] Patriarchal leadership structures result in what Susan Ross describes in relation to the Catholic Church as “unchecked, divinely sanctioned patriarchal power”.[144] These patriarchal hierarchies within faith-based institutions contribute to a culture where disclosing abuse is discouraged and victims are unsupported.[145]

150. The exercise of male power over women and children by men can limit freedom of thinking and response among those who are not in this position of power.[146] This constraint was particularly evident where survivors told the Inquiry that female staff, although they were not abusers themselves, did not act to intervene or report abuse by male clergy.[147] The power held by male abusers often meant their behaviours went unchecked.

Negative attitudes about female sexuality and sex led to abuse and neglect

151. Women and girls were subjected to interpersonal abuse motivated by sexism and negative attitudes about female sexuality. Much of this stemmed from a belief that women’s sexuality was something to be controlled and / or feared.

152. Christianity has historically encouraged sexual restraint outside of marriage.[148] A ‘proper’ Christian woman has been deemed one who remains a virgin until marriage so she is not “spoiled goods”.[149] In some Pacific communities, pregnancy outside of marriage is still associated with shame, although more broadly in Aotearoa New Zealand attitudes towards sex outside of wedlock shifted over the course of the Inquiry period.[150] The deep-rooted stigma associated with female sexuality drove various forms of abuse and neglect of women and girls across all the faith-based settings the Inquiry investigated.

153. Sexual abuse was often assumed to be avoidable if survivors behaved properly, and survivors were therefore assumed to be willing participants or otherwise responsible. The Christian emphasis on women’s and girls’ sexual purity as a virtue[151] led to a view that survivors of sexual abuse were at fault, or guilty of sin. Survivors sometimes blamed themselves or feared the consequences of reporting in case they were ‘tainted’ for what might be considered sex outside of wedlock rather than abuse, which created barriers to disclosure. NZ European survivor Ms QG told the Inquiry that at age 18 when she disclosed sexual abuse to her parish priest, he made her feel worthless and convinced her she needed to marry her abuser.[152] She was told “if I had engaged in sex in any form (whether forced or not) then I had no choice but to get married” and “it was God’s will that I marry him [her abuser]”.[153]

154. Victim-blaming was particularly evident in Gloriavale, where founder Hopeful Christian promoted the doctrine that girls and women could avoid sexual abuse by “not having a flirty nature, dressing modestly, and avoiding situations where they could be seen to be ‘leading on’ a male who was interested in sex”.[154] Survivors described being made to feel responsible for their own sexual abuse after reporting it. They described how Hopeful Christian would “remind members that men had a higher sex drive than women so it was up to women to prevent sexual assaults.”[155] They were to do this by “controlling their [the woman’s] behaviour, their location and their method of presentation in order to avoid provoking sexual reactions in men and boys”.[156] Current leader Howard Temple accepted that young women in the community may have felt that sexual assault was their fault as a result of these teachings.[157]

Religious beliefs were used to justify abuse and neglect in unmarried mothers’ homes

155. The Inquiry heard in the accounts of many survivors that people in positions of power and religious authority justified abuse using Christian beliefs. The association of suffering with salvation is found in aspects of Christian theology.[158] Suffering is thought to teach humility, and martyrdom – an extreme form of suffering – holds special status within the Christian tradition.[159] Often abusers used the biblical concepts of shame and humiliation, and the wider fear of religious punishment or repercussion to abuse and control women and girls in care.

156. The use of moral ‘reformation’ as a justification for abuse and neglect during pregnancy and childbirth was evident in the accounts of survivors of unmarried mothers’ homes.[160] The Anglican Church provided evidence to the Inquiry that these homes were established in the 19th century because of a perceived need to support unmarried mothers.[161] The Inquiry also saw literature to suggest that some unmarried mothers’ homes were established to impress Christian moral and spiritual values on unwed mothers.[162]

Societal factors that contributed to abuse and neglect in care

157. 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.

158. Sexism had a specific effect on women and girls. This is discussed below.

Sexism

159. During the Inquiry period, women and girls were considered less valuable than men and boys, and experienced gender-based discrimination. Negative views about female sin, immorality and perceived promiscuity led to female sexuality being feared and girls’ and women’s bodies as needing to be policed and controlled. Sexist attitudes and beliefs about traditional gender roles meant that women had limited and low-paid employment opportunities.

160. The discrimination arising from these sexist attitudes and beliefs was compounded by the racism experienced by Māori and Pacific women and girls. The Inquiry saw evidence that Māori girls and women were seen as lazy, unintelligent and hyper-sexual. The Inquiry also heard that the combination of sexism and ableism affected disabled girls and women, and girls and women experiencing mental distress, in care.

161. These societal attitudes contributed to women and girls being placed in State and faith-based care during the Inquiry period. Once in care, these attitudes and the consequent gender-based discrimination also contributed to women and girls being abused and neglected. The abuse and neglect they experienced was often specifically gendered.

Lessons identified and changes made

162. 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.

163. 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.

164. 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.

165. 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