1. Introduction

This chapter sets out what our Commission of Inquiry learned about child sexual abuse in institutional contexts. Understanding the nature, causes and effects of child sexual abuse helped us consider institutional failures and our recommendations to better prevent child sexual abuse in the future and respond appropriately to victim-survivors.

Our work was greatly informed by the Royal Commission into Institutional Responses to Child Sexual Abuse (‘National Royal Commission’) that ran from January 2013 to December 2017. The National Royal Commission drew on thousands of personal stories, hundreds of written accounts, dozens of hearings and an extensive program of research.1

Although the National Royal Commission provided an important foundation for our Commission of Inquiry, our task was to examine the Tasmanian context. To this end, we commissioned our own research and sought and received evidence from many sources about child sexual abuse in Tasmanian Government schools, hospitals, out of home care settings and the Ashley Youth Detention Centre.

We have no reason to believe that the nature, causes and effects of child sexual abuse in Tasmania differ substantially from the national experience, but there may be aspects of the Tasmanian context that require special consideration:

Tasmania is a small community. People are closely connected through school, work, marriage, partnership or friendship circles. That context of close connection intensifies the concern about reporting and about making allegations against people. This presents difficulties for those individuals on whom we rely to … [raise] concerns and [remain] vigilant about matters of child safety.2

Tasmania’s small population may also have implications for the availability of financial, human and other resources to address the risk of child sexual abuse.

We consider the specific Tasmanian context in more detail in Chapter 2 and throughout this report. In this chapter, we:

• briefly describe the different forms of child sexual abuse
• examine the factors that increase the risk of child sexual abuse occurring in an institutional context or compromise the ability or willingness of an institution to respond when it does occur
• describe the effects of child sexual abuse in institutional contexts on victim-survivors, their family members, communities and the broader society.

1. What is child sexual abuse?

As discussed in Chapter 1, our Commission of Inquiry has 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. Sexually abusive behaviours can include the [touching] of genitals, masturbation, oral sex, vaginal or anal penetration by a penis, finger or any other object, [touching] of breasts, voyeurism, exhibitionism, and exposing the child to or involving the child in pornography. It includes child grooming, which refers to actions deliberately undertaken with the aim of befriending and establishing an emotional connection with a child, to lower the child’s inhibitions in preparation for sexual activity with the child; and

Any related matters.3

We acknowledge the dynamics of child sexual abuse and that it may or may not be coercive. Professor Ben Mathews, Research Professor, Queensland University Technology School of Law, states:

Child sexual abuse can be inflicted by an adult, or by an older (and sometimes even a younger) child. It is inflicted in secret, and usually by an adult who is known to the child or a family member. It can be inflicted in circumstances where force or coercion is clearly apparent, but it can also be inflicted where such coercion is not as stark but where the victim is not developmentally capable of understanding the acts and/or where the child is in a position of physical, cognitive, emotional or psychological vulnerability such that consent is not freely given.4

This is recognised in the criminal law, which makes it clear that children below the age of 17 years in Tasmania cannot legally consent to sexual acts, except in very limited circumstances.5

1. Forms of child sexual abuse

The two most common forms of child sexual abuse reported by victim-survivors to the National Royal Commission were non-penetrative contact abuse and penetrative abuse.6 Non-penetrative contact abuse includes sexual touching of a child’s body or making a child touch the abuser’s body. These behaviours are described with terms including ‘molestation, indecent assault, [touching], sexual harassment and sexual assault’.7 Penetrative child sexual abuse refers to ‘the insertion of a penis, another body part or an object into the vagina (including labia and other genitalia), anus or mouth’.8 It may also be described as rape, sexual intercourse with a child or sexual assault.9

Other forms of child sexual abuse identified through research, and that we heard more about over the course of our Inquiry, include:

• violation of children and young people’s privacy, such as forcing a child to undress or watching them in a private space
• exposing children and young people to sexual acts and material
• child sexual exploitation (historically called child prostitution)
• production, consumption, dissemination and exchange of child sexual exploitation material (historically called pornography)
• forcing children to witness the sexual abuse of others.10

‘Grooming’ is a common strategy used by abusers to enable, facilitate and conceal their sexual abuse of a child or young person by acting to gain the trust of a child over time. Grooming can involve ‘psychological manipulation that is subtle, prolonged, calculated, controlling and premeditated’, with the ultimate purpose of making a child compliant with abuse.11 Abusers commonly use grooming to support them to gain access to the child or young person, initiate and maintain the abuse of that person, and conceal the abuse from others.12

Grooming behaviours can be difficult to identify because they are not necessarily overtly sexual and can be consistent with non-exploitative and even positive social behaviours.13 Grooming can be so effective that the child or young person believes they ‘consented’ to the sexual acts or even that they are in a ‘relationship’ with the abuser. Victim-survivors told us that at the time of their abuse they admired or even ‘loved’ their abuser.14 Leah Sallese gave evidence to our Inquiry that for a long time she understood sexual abuse by her teacher as an ‘affair’.15

Tiffany Skeggs told us that her abuser:

... fully groomed me to believe that I loved him and I had to protect him, that was my job. If I didn’t do that it would destroy his family, it would destroy me; he was very clear about the fact that I would lose the respect of everybody that ever knew me.16

Abusers may also direct grooming behaviours towards adults and other significant people in the child or young person’s life. The purpose of grooming others is to establish trust and cooperation that can facilitate the abuser’s access to the child and help the abuser avoid detection.

‘Institutional grooming’ refers to grooming children in an institutional context. It involves abusers exploiting the institutional environment to carry out the abuse and to evade detection.17 Abusers also groom people who work with children in institutions.18

Not everyone who breaches a professional boundary does so with an intent to groom. However, professional boundary breaches are a key warning sign for the risk of child sexual abuse.19 Abusers may also use professional boundary breaches to ‘test’ how resistant the organisational culture is to perpetration, with their boundary breaches becoming incrementally more serious with each breach they get away with.20

Previous research and inquiries into grooming and professional boundary breaches by child sexual abusers show that boundary breaches should be considered cumulatively. When multiple breaches are considered together, a pattern of behaviour consistent with grooming may be revealed. As separate incidents they can seem innocuous, and it can be easier for abusers to provide plausible excuses to explain the behaviour.21

1. Child sexual abusers

The National Royal Commission found there is no ‘typical profile’ of child sexual abusers. Child sexual abusers are diverse and cannot be easily identified based on factors such as age, gender, background or behaviours.22 However, it also sought to identify and understand characteristics that were frequently noted among abusers in institutional contexts. For example, abusers were frequently described as ‘charming, charismatic and popular’ when in public.23 Abusers who use the institution or organisation within which they work to abuse children commonly hold roles associated with positions of leadership, power and authority, such as roles in religious ministries or as teachers.24 Abusers in institutional settings may use techniques such as ‘coercion, favouritism, alienation, secrecy, and boundary violations’ to ‘groom’ or ‘entrap’ children and young people.25

Most victim-survivors who gave evidence to the National Royal Commission reported that their abusers were male.26 Evidence presented to our Inquiry reflected previous findings that adults who sexually abuse children in institutional settings are predominantly male.27 We did, however, hear about some female abusers.28 The National Royal Commission noted that while most adult abusers are male, most men do not sexually abuse children.29 However, there is clearly a relationship between gender and sexual abuse perpetration and victimisation. A 2023 Australian study found significant gender differences in victim-survivors of child sexual abuse: women reported ‘substantially more childhood sexual abuse’ than men.30 In addition, people who identified as gender diverse were found to be more likely to experience all types of child maltreatment.31

The National Royal Commission further identified several ‘risk factors’ that may contribute to the likelihood of a person becoming a sexual abuser of children.32 These risk factors include:

• adverse experiences in childhood (such as abuse and neglect)
• interpersonal, relationship and emotional difficulties
• distorted beliefs and thinking errors (such as deviant sexual interests or distorted attitudes about sex and/or children)
• indirect influences such as contextual or trigger factors.33

However, while such risk factors may appear at higher rates in child sexual abusers, they cannot be reliably used to determine the likelihood of abuse occurring: ‘There is no clear causal link that explains why a person becomes a perpetrator and no clear pathway to perpetration’.34

Only some abusers are preferentially sexually attracted to children.35 They may actively seek out institutional settings that increase their opportunities to sexually abuse children.36 Other abusers are opportunistic. They may only begin abusing children once they are in an institution where the culture and environment enable them to overcome their inhibitions.37

1. Harmful sexual behaviours

Harmful sexual behaviours are sexual behaviours displayed by children and young people that may:

• fall outside what is considered developmentally, socially and culturally expected
• cause harm to themselves or others
• occur face to face and/or via technology.38

When these behaviours involve another child or young person, they may include a lack of consent, reciprocity and mutuality, and involve the use of coercion, force or a misuse of power.39

Harmful sexual behaviours can include behaviours that are criminal. The effects of these behaviours on victim-survivors can be equal to those of adult-perpetrated child sexual abuse.40 However, the emotional and sexual development of children who have engaged in such behaviour is different from that of adults. The culpability that attaches to children’s behaviour, as well as prospects for rehabilitation, also differ from those of adults.41

Social and environmental factors that may influence children and young people’s propensity to engage in harmful sexual behaviours include ‘prior sexual, physical or emotional abuse, exposure to family violence, social difficulties, and exposure to and consumption of pornography’.42

The National Royal Commission reported that other children carried out just under one-quarter of the child sexual abuse reported to them.43

1. Characteristics of children associated with greater vulnerability to child sexual abuse

All children are potentially vulnerable to adult abusers because they depend on adults and lack comparative physical, social and legal power.44 Aspects of some institutional settings have implications for this vulnerability of children because they are separated from those who usually protect them. In addition, the power imbalance between adults and children can be heightened in some institutional contexts, ‘particularly those that are highly controlled, are isolated and exhibit hierarchical and authoritarian features’.45 It is important to note that, while several factors may increase a particular child’s vulnerability to sexual abuse, responsibility for abuse lies only with the abuser and the institution responsible for the child’s safety, never with the child.46

While all children are vulnerable, some children may be more at risk of sexual abuse at different times, based on certain characteristics or circumstances.47 Unfortunately, most children who have experienced sexual abuse have also experienced other types of maltreatment (exposure to domestic violence, emotional abuse, physical abuse and neglect).48 Other risk factors include gender, age and developmental stage, family characteristics and circumstances, and the child’s personal and physical characteristics.49 However, these risk factors do not mean a child will be abused, nor does the presence of protective factors ensure a child’s safety.50

Some groups of children are more vulnerable to sexual abuse due to being exposed to more of these risk factors. The National Royal Commission reported that, while Aboriginal children, children from culturally and linguistically diverse backgrounds and children with disability are ‘not inherently more vulnerable to sexual abuse’, they are at increased risk because, among other things, they are more likely to have sustained contact with institutions within which abusers have opportunities to abuse them.51 Aboriginal children, children from culturally and linguistically diverse backgrounds and children with disability were also shown to experience added challenges that affected their likelihood of disclosing or reporting sexual abuse.52

1. Risks of child sexual abuse in institutions

Child sexual abuse can occur within any institution. However, some institutional contexts and cultures enable sexual abuse more than others.53 This section focuses on the institutional factors that can increase the risk of abuse occurring in an institution, or an institution failing to identify or respond appropriately to child sexual abuse.

The National Royal Commission concluded that cultural, operational and environmental factors contribute to the likelihood of children being sexually abused and of abuse being identified, reported and responded to appropriately.54 It explained that:

• Institutional cultural factors include leadership and organisational culture, which shape assumptions, values, beliefs and norms.55
• Operational factors include governance, internal structure, day-to-day practices, the approach to implementing child safe policies and the recruitment, screening and training of staff and volunteers.
• Environmental factors include the characteristics of physical and online spaces that enable potential adult abusers and children with harmful sexual behaviours to access victims.56

Some of these factors are highlighted in Sections 3.1, 3.2 and 3.3, with particular reference to child sexual abuse in Tasmanian Government institutions.

1. Cultural factors

1. ‘Closed’ or ‘total’ institutions

There is generally a higher risk of child sexual abuse occurring in institutions that are less ‘open’ and therefore less accountable to the broader community.57 ‘Closed’ or ‘total’ institutions are those that exercise full control over a child’s day-to-day life. In these institutions, children are subject to strict rules and procedures, are entirely dependent on the institution, and are isolated from the outside world.58 Such institutions are often said to have the purpose of ‘reforming’ or ‘protecting’ children.

Because closed institutions are not common environments, they can become ‘alternative moral universes’—the cultural norms and rules are established and maintained wholly within the institution and are distinct from the norms and rules of general society.59 Closed institutions are also often hierarchical in nature, enforcing obedience to authority.60 Staff, volunteers, children and young people may therefore be less inclined or feel less able to report or act on abuse. We note in the real world that these factors exist on a continuum that result in some institutions being more closed than others.

1. Leadership

An institution’s leadership affects the risk of child sexual abuse. Leaders have decision-making power and so shape an institution’s culture and practices. Leaders influence the culture of their institutions through the people they hire and fire, the behaviours they reward or punish, the issues they prioritise, how they respond to crises, and the attitudes and behaviours they model.61

The way leaders work to prevent or respond to child sexual abuse can be distorted by things such as the often competing expectations to avoid public or political exposure, protect budgets and stakeholder confidence, maintain reputational standards and avoid litigation.62 Prioritising these factors can create a ‘damage control’ mindset that may lead to minimising or denying abuse, silencing victim-survivors, shifting risks elsewhere, or even, in extreme circumstances, actively concealing abuse.63

1. Trust and values

Some professions and institutions are highly trusted by the community. This can lead to a greater willingness to allow children to be unsupervised in their care, to be deferential and to second-guess suspicions or allegations of abuse when they arise.64 In the past, such institutions have included religious or spiritual organisations, elite sports organisations and medical practices.65 Children can find it harder to recognise abuse, or be discouraged from reporting abuse, when their family or community holds the institution, or the people in it, in high regard.66

In some settings, staff, volunteers and members can become ‘fused’ with the identity or ‘values’ of an institution. This may occur, for example, in relation to an elite school with a strong ‘brand’ and investment from alumni.67 People associated with an organisation may overidentify with it, and they may become defensive if they perceive that the organisation is under threat. They may take threats to the reputation of the institution personally, which can lead them to prioritise the institution’s reputation over the safety of children.68

1. Institutional culture and behavioural dynamics

Institutions comprise people who are conditioned by social norms and are susceptible to cognitive biases and psychological defences. Certain beliefs, behaviours and biases can influence a person’s ability and willingness to identify and respond to child sexual abuse.

Broad community attitudes also inform institutional norms, although it is possible for institutions to develop values and norms that depart from those held in the community, sometimes significantly.69 The views of people working in institutions are subject to various influences including:

• community attitudes about sexual abuse and the likelihood and frequency of it occurring
• attitudes about children’s rights
• attitudes about gender, race and sexual orientation.70

Researchers have found that psychological defences, called ‘techniques of neutralisation’, can stop people from feeling guilty about engaging in misconduct or for failing to intervene when they perceive a person’s behaviour as being wrong. In simple terms, these psychological defences can lead a person to:

• dismiss the capacity or humanity of a child or young person
• ignore the harm or distress a behaviour is causing
• believe they have no agency to change a situation
• believe they are doing ‘good’, or that the good they are doing outweighs the bad
• understand their failures—for example, to intervene in wrongdoing—as no worse than others’ failures.71

It is generally very difficult for people to overcome these behaviours. The most effective strategies for changing such behaviours involve creating a safe space to consider alternative perspectives and engage in critical self-reflection.72

Within institutions, these behaviours can become part of a larger dynamic, or ‘organisational culture’, that works against protecting children from harm.73 Organisational culture has been described as the ‘assumptions, values and beliefs, and norms that distinguish appropriate from inappropriate attitudes and behaviours in an organisation’.74 Organisational culture can be shaped through the messages and actions that are formally and informally communicated between staff and others in an institution, as well as by community attitudes.75

In the context of contemporary youth detention environments, the National Royal Commission identified the cultural characteristics of institutions that may increase the risk of child sexual abuse.76 These included:

• failing to prioritise children’s welfare and wellbeing77
• lack of voice—failing to provide children with the opportunity to communicate their views reflects a culture in which children are not listened to, and their views are not respected78
• disrespecting children79
• tolerating humiliating and degrading treatment of children—an institutional culture of dehumanising children can weaken the usual inhibitions or concerns of staff80
• engendering a strong sense of group allegiance—children are less likely to disclose abuse, and less likely to be believed, in institutions with strong group allegiance between adults81
• minimising the significance of harmful acts against children and young people.82

Research undertaken for the National Royal Commission found many barriers to identifying grooming or abusive behaviours in organisations. One barrier is the errors of reasoning that humans unconsciously employ daily. Errors of reasoning may contribute to the failure to notice or intervene in behaviours that indicate a risk of child sexual abuse.83 Three significant errors of reasoning identified in the research are:

• Confirmation bias—being more likely to notice evidence that supports pre-existing views and overlook evidence that challenges them. For example, being unwilling to characterise the behaviour of a well-liked colleague as grooming.84
• The representativeness heuristic—assessing people based on assumptions about the category they belong to, such as professionals working in children’s services. People tend to assume that employees of children’s services are there to act in the best interests of children, even when there is evidence to the contrary.85
• The availability heuristic—paying attention to a limited range of information, particularly first impressions and information that is ‘vivid, concrete, emotion-laden and recent’, rather than considering information that may lead to a different view. For example, forming a positive first impression of someone and thereafter disregarding small indicators of grooming behaviour.86

The authors of this research noted that overcoming errors of reasoning can be challenging, so organisations need to actively create environments that help identify and overcome them.87 In addition, dynamics in a workplace can affect a person’s willingness to take any action that may damage their relationships with their colleagues or superiors.88 In smaller communities, like Tasmania, these behavioural dynamics can extend from the workplace to the wider community; that is, people may fear they will lose their social relationships and standing if they act on a concern about a child or young person’s safety where that concern may place them in conflict with existing social hierarchies or consensus (for example, where an alleged abuser has an otherwise ‘good reputation’ within the community).89

Abusers often exploit the beliefs, behaviours and biases of individuals, communities and institutions, which allows them to sexually abuse children and young people freely.

1. Operational factors

The nature of the services or activities an institution engages in with children can increase the risk of abuse. Risk is generally greater in institutions where there is:

• a high degree of physical or intimate contact with children—for example, medical, disability and child care90
• a high degree of institutional control over the day-to-day lives of children or their living environment—for example, youth detention, out of home care, boarding schools or inpatient health care91
• a strong emotional or psychological connection between the child and the institution—for example, religious organisations or sporting clubs92
• regular unsupervised contact with children.93

In ‘closed’ or ‘total’ institutions, control over children is often achieved through strict rules and procedures, and children may depend entirely on the institution to provide care.94 Youth detention facilities and inpatient mental health services are such institutions.95

1. Management and governance

The management and governance structures of institutions can also affect the safety of children. For example, abuse can be difficult to report if there is a single manager in the hierarchy who is either the abuser or closely allied to them. Abuse can also be difficult to report where there is limited external scrutiny of the institution and its leadership.96 Conversely, where there is no clear responsibility for child safety within an organisation, abusers can easily go undetected.

1. Child safe policies and norms

The policies and practices of an organisation provide important practical protections against abuse, as well as signalling the importance of child safety to staff and volunteers.

There is a greater risk of harm to children occurring in institutions that do not have child-centred policies for preventing, detecting and responding to abuse.97 The absence of clear and appropriate policies creates ambiguity about appropriate standards of behaviour and makes it hard for staff and volunteers to know what to do if they have concerns about or receive disclosures of abuse.98 People are less likely to make complaints or disclosures if they do not understand or are not confident that such disclosures will be managed effectively through a transparent process that also respects confidentiality.99

Child safe policies will not be effective if they do not define and articulate the process for addressing sexual abuse, if they are impractical, if staff are not trained or resourced to implement them, and if they are not promoted, monitored or enforced.100

Most organisational policies will also require a degree of interpretation or judgment. For example, legitimate efforts to build rapport and demonstrate care towards children can be mistaken for grooming behaviours. Organisations need to consider the context of the behaviour and promote an open culture that encourages staff to seek advice about concerns.101 Safer organisations will generally describe in detail and explain discretions and ambiguities within policies and procedures, and support staff to use their judgment. Staff should feel safe to admit mistakes or breaches.102

Noncompliance can become normalised and accepted when institutions tolerate departures from otherwise robust policies—for example, by ignoring when teachers spend extra time with students unsupervised, or when staff have inappropriate non-sexual physical contact with children.103 The effectiveness of the best policies will also erode over time if institutions do not empower the children and young people in their care to speak up about safety concerns.104

In 2015, the then Tasmanian Commissioner for Children and Young People, Mark Morrissey, conducted a review into child safe organisations. This review directly engaged with children and young people. It found that many of the children felt they were not listened to by adults, did not understand what abusive behaviour was, and were unaware of their right to safety from all forms of abuse and about what behaviour is unacceptable.105

Research we commissioned confirmed that to feel safe, children and young people need to have ‘confidence in themselves as well as in adults’ and organisations’ efforts to keep them safe and respond when they have been harmed’.106 Without the confidence that institutions will act to keep them safe, children and young people reported being less likely to raise concerns, disclose abuse or seek assistance.107

Children are also less likely to experience institutions as safe if the institution is not inclusive or does not embrace diversity.108 Children who experience discrimination, whether relating to their culture/ethnicity, gender identity, sexual orientation, disability status, faith or other characteristics, are less inclined to report abuse because they may not feel confident they will be believed.109 This reluctance may be exacerbated if the institution also fails to embrace the diverse backgrounds and characteristics of its staff.110

There are links between patriarchal ‘macho’ culture and abuse. Research shows that abuse is more prevalent in institutions that normalise aggressive or sexualised behaviours as valid expressions of masculinity.111 Where institutions permit or require the routine use of force or violence (for example, threats, strip searching or restraints), staff can become desensitised. This makes it easier for them to minimise or tolerate harm against children in their care.112

In extreme cases, institutions can develop entrenched toxic behaviours involving ‘hazing’, bullying and overtly sexualised behaviours.113 There is also evidence that abusive or bullying behaviours between staff and volunteers can be mirrored between children in institutions.114

We talk about the elements of a child safe organisation and their implementation in Tasmania in Chapter 18.

1. Environmental factors

An institution’s physical environment can also increase the likelihood that a child or young person will be sexually abused. Abusers take advantage of spaces that are monitored infrequently.115 The risk that sexual abuse will occur in an institutional setting is therefore increased when that setting is enclosed, isolated, difficult to supervise or has limited options for entry and exit.116 In institutions such as schools, the physical design and layout can play a significant role in increasing or mitigating the risk that sexual abuse will occur by inhibiting or facilitating oversight, particularly in relation to higher risk spaces such as toilet blocks, professional offices or specialist classrooms.117 More open design including large windows, with fewer closed or hidden spaces, can allow increased lines of sight into and between spaces where children are expected to be, increasing opportunities for oversight and potentially decreasing the risk of abuse.118

Inappropriate residential placements in youth detention or out of home care—such as placing younger children with older children or those who have displayed concerning behaviour—can also significantly increase the risk of abuse.119 Inadequate adult supervision may enable children to display harmful sexual behaviours against others.120

Our Commission of Inquiry heard that children and young people in institutions are increasingly using online technology to engage with peers, people outside the institution, and staff and volunteers within the institution.121 Although there are many positive aspects to online communication, using this type of communication also comes with significant challenges relevant to keeping children safe.122 Abusers often use online environments, such as social networking sites and mobile phones, to groom children.123 Children and young people’s boundaries can be readily pushed by abusers online, who may progressively expose children and young people to intimate and sexualised messages and imagery.124 Technology can enable abusers to have ongoing contact with children out of physical sight.125

Online environments can also be difficult for parents, institutional leaders and staff to monitor.126 Mitigating the risk of abuse online relies on a nuanced understanding of how grooming works and when online contact is appropriate.127 Authorities such as the eSafety Commissioner are undertaking research and developing educational materials and resources for parents and children to support safe online engagement.128 Critically, in institutional contexts, children are better protected when they are aware of the rules for engagement through technology for adults in authority and are empowered to notify a parent or trusted adult if inappropriate contact occurs with a stranger or someone they know.129

1. The risk of child sexual abuse in particular institutions

This section provides an overview of the factors that increase the risk of child sexual abuse and compromise the ability of an institution to respond to abuse in hospitals, schools, detention centres and out of home care. In later chapters, we consider in depth how institutions in Tasmania that fall within these four categories have acted to prevent children from experiencing child sexual abuse and responded to children and adult victim-survivors.130

1. Hospitals and health institutions

Children in the care of any hospital are inherently vulnerable. Children in need of hospital-based medical care are often temporarily living away from their families and support networks, sometimes for long periods. Hospitals can be frightening and overwhelming places for children. Children who are admitted to hospital for extended periods due to illness or injury experience many of the features of a closed institution.

Risks of child sexual abuse are also present in health services more broadly. As the National Royal Commission observed, children and their parents often do not question a medical practitioner’s access to intimate parts of a child’s body because they ‘believe that a health practitioner is acting in pursuit of a higher purpose … and not out of personal sexual gratification’.131

In research we commissioned into the safety of children in Tasmanian institutions, researchers spoke to a range of children and young people who had spent time in hospital. These researchers found that children sometimes did not feel safe or confident in hospital and that they relied heavily on parents or carers to advocate for them.132 The often private one-on-one nature of medical care, where children and young people may not always have a parent present to advocate, places children in a vulnerable position.133 Health professionals can also abuse children and young people under the guise of medical treatment (including with medication or medical instruments), which can make it more difficult for patients and their families to recognise the behaviour as abusive.134

We report on what we found on preventing and responding to child sexual abuse in Tasmanian health services in Volume 6 and make recommendations for system-wide improvement.

1. Schools and educational institutions

In Tasmanian schools, as elsewhere in Australia, teachers and other staff step into the role of supervisors for children, in place of their parents, during school hours. On the whole, Department for Education, Children and Young People employees provide a safe and supportive learning environment for Tasmanian students. Schools are the most common institution with which children engage; most children attend school, and schools are generally the place children spend the most time outside their homes. Schools are not inherently a high-risk environment, but the large population of children in schools and the length of time they spend there means many concerning sexual incidents have occurred in state school systems.135

There is also increasing recognition that some factors in the school environment can expose children and young people to a greater risk of sexual abuse. These factors are ‘the amount of time children spend in school, the inherently hierarchical relationship between students and teachers (and other school staff), and the fact that children of different ages attend school together’.136 It is not feasible within a busy school environment for adults to have their eyes on every child all the time, and incidents of child sexual abuse can occur quickly and do not always occur behind closed doors.

In Volume 3, we examine in detail responses to child sexual abuse in Tasmanian government schools and make recommendations for systemic improvements.

1. Youth detention

While the risk of child sexual abuse is present in all residential institutions, youth detention centres ‘perhaps illustrate the highest level of risk’.137 As mentioned, detention centres are ‘closed’ institutions. The National Royal Commission identified specific characteristics as increasing the risk of child sexual abuse in youth detention:

• a culture of humiliating and degrading treatment of children, deprivation of liberty and invading children’s privacy
• a heightened power imbalance between staff and detained children, including the use of strict rules, isolation, discipline and punishment by staff
• young people detained in the centre having no say about their daily lives
• a culture that engenders strong group allegiance among staff, including management.138

Children and young people who are held in youth detention centres are more likely to have experienced past abuse or neglect. As noted in Section 2.4, past experiences of abuse and neglect have consistently been found to heighten children’s risk of experiencing child sexual abuse. Children in detention are also at a disproportionate risk of being involved with child safety services or to be in the care of the state in out of home care. They are therefore less likely to have a trusted adult to whom they can turn for help.139

Children in youth detention face several other barriers to disclosing abuse due to the characteristics of that institution.140 For example, cultural norms to not speak out or ‘snitch’ decrease the likelihood of children raising complaints, particularly where they are experiencing harm caused by another child or young person in detention.141

People who engage in sexual abuse in youth detention settings can include:

• youth workers and other custodial staff
• doctors, nurses, psychologists and other health professionals
• case managers, community, recreation and educational service providers
• chaplains and other religious personnel
• legal representatives
• people undertaking external inspection and complaint handling functions.142

There is also a high risk of young people in youth detention engaging in harmful sexual behaviours.143 These behaviours may be modelled on how adults or older children have behaved towards them outside and inside detention settings.144

We report on what we found in relation to Ashley Youth Detention Centre in Volume 5.

1. Out of home care

For the purposes of our Commission of Inquiry, out of home care means formal care that is arranged or provided by the Tasmanian Government for children and young people who cannot live safely at home. Out of home care includes foster care, kinship care, respite care, sibling group care, residential care, third-party guardianship and therapeutic services for children in care.145

Children in out of home care spend a lot of time alone with adults who are outside their usual family or social environment. As the National Royal Commission observed, the ‘very nature of out of home care involves adults having opportunities to be alone with children, primarily in home-based care but also in residential care settings, and to develop supportive relationships with those children’.146 Unfortunately, this means that in some instances sexual abuse will occur.

People who sexually abuse children in out of home care include adults within the out of home care system, such as foster carers, residential care workers or child safety officers; adults outside the out of home care system who have access to children and young people in care; and other children within the system, such as another young person in the care setting.147

Adults who sexually abuse children in out of home care are more likely to be male, charismatic, controlling and in positions of power.148 Abuse is often accompanied by grooming so children will trust the abuser and believe they have consented to the abuse.149 As discussed earlier in relation to health settings, abusers also engage in ‘institutional grooming’, whereby they manipulate other staff and communities into trusting them so their abusive behaviour is not suspected.150

Adults outside the out of home care system can pose a risk to children in out of home care through child exploitation. While child sexual exploitation occurs across the general population, there are adults who actively target children in out of home care, particularly in residential care, due to their increased vulnerability to grooming and abuse.151

Children who have engaged in harmful sexual behaviours are a significant concern in out of home care. Research suggests a strong correlation between young people living in residential settings and engaging in, or being subjected to, harmful sexual behaviours.152 Children in out of home care may be at greater risk of child sexual abuse by other children in their placement than by adult staff members.153

The National Royal Commission found that certain factors increase the risk that abusers will target a child or young person in out of home care. These factors generally relate to the vulnerability of the child in the eyes of the abuser and include the child’s:

• previous experience of abuse or neglect
• loss of connection to family and culture
• lack of understanding of what constitutes abuse.154

Female children and young people seem to be at greater risk of child sexual abuse in out of home care. However, the evidence is difficult to interpret because male children and young people are less likely to disclose abuse.155 Children with disability are about three times more likely than children who do not have a disability to experience sexual abuse in out of home care.156 The exposure of Aboriginal children and young people to the risk of institutional child sexual abuse is increased by being in out of home care. Also, when Aboriginal children are placed with non-Aboriginal families, they can experience disconnection from culture that can render them even more vulnerable to sexual abuse.157

In Volume 4, we examine in detail responses to child sexual abuse in Tasmania’s out of home care settings and make recommendations for reform.

1. The effects of child sexual abuse

This section examines the effects of child sexual abuse in institutional contexts on victim-survivors, as well as on their family members, communities and broader society. We also provide an overview of how institutional responses can reduce or aggravate the effects of child sexual abuse. In this section we draw on the work of the National Royal Commission and on what those affected by child sexual abuse in Tasmania told us.

1. Effects on victim-survivors

One victim-survivor told us:

People have asked me about, you know, the impact and stuff like that and I just want to say that I got to survive but I didn’t get to thrive. I will never get to know the person I could have been because of him … 158

Sexual abuse causes profound trauma. It adversely affects children and young people’s emotional and educational development, physical and mental health, the quality of their relationships, their connection to culture, and their sense of identity and wellbeing. These effects often continue into adulthood and can have lifelong consequences for a victim-survivor’s ability to work, raise a family, feel part of a community and enjoy intimacy.159 Trauma expert Bessel van der Kolk writes that traumatic experiences affect humans on multiple levels, leaving ‘traces on our minds and emotions, on our capacity for joy and intimacy, and even on our biology and immune systems’.160 He explains that:

Trauma, by definition, is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.161

The timeframe for experiencing the effects of child sexual abuse can vary. For some victim-survivors the effects are immediate and ongoing, for others they are temporary, while for others still they emerge later in life, when the trauma of the abuse is triggered by an event or different life stage.162

As the National Royal Commission observed, the factors that influence how a victim-survivor is affected by sexual abuse are complex, unique, profound, enduring and interconnected.163 Some of these factors include:

• the type, duration and frequency of the abuse
• the relationship of the abuser to the child
• the victim-survivor’s circumstances, experiences and characteristics
• the social, historical and institutional contexts of the abuse.164

A review of research findings prepared in 2017 for the National Royal Commission found that physical violence, penetration, prolonged/frequent abuse and grooming have all been associated with heightened detrimental effects for victims.165 Prior maltreatment and trauma, such as exposure to domestic violence and neglect, can also intensify the impacts of sexual abuse.166 Children with disability may experience particular and severe effects of abuse.167

Some victim-survivors experience cumulative or compounded trauma because of child sexual abuse and other forms of mistreatment and adverse life experiences, including heightened vulnerability due to intergenerational and collective trauma.168

Many victim-survivors who gave evidence to the National Royal Commission placed importance on the nature of their connection to the abuser and whether the abuser held a position of power over them.169 This power may arise from the abuser’s attributes, including their age, reputation, personality, professional expertise or role.170 If the abuser was a trusted person or another child, feelings of betrayal were exacerbated for many victim-survivors.171 One victim-survivor told us:

That man was my favourite person in the world. He was so funny and kind and I absolutely adored him … He broke my trust so much.172

The effects of sexual abuse may also be exacerbated if the abuse occurred in ‘closed’ institutions that heighten a child’s powerlessness and their capacity to remove themselves from the abuse, or to get support.173 Victim-survivors are often retraumatised by the way that abusers, and those with authority in the institutions where the abuse happened, respond to allegations of child sexual abuse.174

We heard from many victim-survivors about the effect that abusers had on their lives. For example, victim-survivor Robert Boost told us that:

… my whole life since the abuse or since that sort of 13, 14 year age, I have been running away from it and setting goals. So, initially I thought, you know, if I get a girlfriend, I will not feel this way anymore, and then for a moment everything’s good, and then sort of the tortoise and the hare: I run away and … the tortoise catches up.175

We commonly heard that victim-survivors have problems with mental health and substance use as a consequence of sexual abuse. For example, Erin (a pseudonym) gave the following evidence to our Inquiry:

… I went down a massive spiral … I started using ice, speed and smoking bongs. I drank a lot. This was my way of blocking things out and helping me forget … I’ve got PTSD, anxiety and depression. I struggle to trust males in particular. It impacts my relationships, which now impacts my children.176

We also heard about the distressing effects that sexual abuse had on victim-survivors’ own parenting as adults. For example, victim-survivor Alex (a pseudonym) stated:

I’ve got three kids. I won’t allow them to have sleepovers. I never bath my eldest child. I’m certainly on a hyperalert status all the time, especially in public. When I take my kids to the park I sit there and I can work out, you know, this child to that family, to this person to that person, and sadly this goes on and these people don’t wear red flags.177

The National Royal Commission noted that although child sexual abuse in any context has similar effects on victim-survivors, institutional settings can have specific impacts.178 These include distrust and fear of institutions and authority.179 Mr Boost told us of the effects of his abuse as a student:

I have developed a deep distrust of institutions because of the perpetrator. I never thought I’d get to a point that I’d trust another institution, even one like this Commission. However, I realised that it is important for me to give evidence to help me accept that this abuse has happened, to tell the community that it happened to me, and to move forward with my healing process.180

Mr Boost went on to describe how his abuse shaped his world view and led him to distrust those who held power and authority in society:

Through my life, I have come to understand that most people are decent and good-hearted, but there is still a large portion of sick and perverted people in society that will take advantage of vulnerable people. Because of this underground that I witnessed, I find it difficult to trust anyone … I do not like being under the power or control of another; it makes me feel uncomfortable to be in situations where there is a level of control over myself or my family. I try to avoid getting into that position.181

The National Royal Commission further found that the social and historical contexts in which child sexual abuse occurs can influence the way victims are affected. Community attitudes that children are inferior, lack of social awareness of child sexual abuse and the extent to which an institution is perceived to be a source of authority in the community can all exacerbate the impacts of sexual abuse on victim-survivors, as can gender stereotypes, racism and discriminatory attitudes to diverse sexual orientations.182

1. Effects on families and communities

Child sexual abuse can significantly affect the families of victim-survivors, others involved with the institution where the child sexual abuse occurred, religious and cultural groups (including Aboriginal communities) as well as broader society.183 The National Royal Commission found that people who are affected by the trauma of child sexual abuse in institutional contexts also includes children who witness the abuse, staff in the associated institution, whistleblowers and the family members of abusers.184

One mother of a victim-survivor said:

Sexual abuse doesn’t just affect the victim. It affects the whole family. They all had to process this and deal with this and try to keep [name redacted] safe, and I needed support. All she got was a phone number for [a sexual assault service] and a phone call begging her not to go to the media.185

Sexual abuse causes ‘cultural trauma’; that is, it affects the identity, cohesion and sense of safety of a community.186 The cultural trauma of child sexual abuse for Aboriginal communities is particularly pronounced because of the underlying ‘collective and intergenerational trauma’ caused by colonisation, dispossession, discrimination and the forced removal of children from their families.187

Parents, partners and siblings of victim-survivors have all reported ‘secondary traumatic stress’, including hypervigilance, insomnia, exhaustion and hopelessness, after the sexual abuse of a family member.188 For example, a parent of a victim-survivor said that:

It’s a fourth job for us. There are full-on email trails. Every time we make a complaint we have to revisit all the details and tell the whole story again. It’s traumatic. You should only have to tell your story once. They wear you down. They did it the first time she was abused, and they were successful, but this time, no.189

Sexual abuse also has an intergenerational effect. Children of victim-survivors may grow up in unstable environments where they are exposed to their parent’s trauma, mental illness and substance abuse. This increases the likelihood of victim-survivors’ children being placed in out of home care, continuing the pattern of institutionalisation across generations.190

A person who witnessed the sexual assault of her friend by a foster carer described to us the traumatic effect of being a witness in the criminal justice process in a case where the abuser was acquitted:

I lost hope. Later, in [the mid 2000s], when I was 16, I attempted suicide. In part, it was because I was extremely morally injured by the Tasmanian justice system. I couldn’t reconcile how to live in a world which was so unjust, and that unjustness was public, and enshrined into law in a power differential that seemed unquestionably sanctioned.191

Some whistleblowers told us about their experiences of trying to raise the alarm about institutional handling of complaints of child sexual abuse. Will Gordon, the whistleblower in relation to the Launceston General Hospital’s management of complaints about serial offender James Griffin, said:

I stand by my convictions in my pursuit for the abuse of children to not be hidden behind closed doors and for those who are vulnerable to find their voice to speak and heal. This has caused hardship within my social, personal, and professional life, and yet I have continued in my objective because of my moral principles … I now struggle to have trust in family, colleagues, acquaintances, and friends due to the stories of abuse I have heard since fighting for this.192

Alysha (a pseudonym), a whistleblower who exposed failings at Ashley Youth Detention Centre, where she worked, expressed her anguish at trying to improve the safety of detainees:

I had large boys crying to me and begging me to rescue them from the risk of sexual assault. The helplessness I felt, whilst telling them I would do all I could to ensure their safety—whilst knowing full well my recommendations would be undermined immediately—was soul destroying.193

1. Effects of institutional responses

How an institution responds to a child or young person who discloses abuse can either compound the distress and trauma they experience, or it can contribute to their healing and sense of justice. Inappropriate responses—including disbelief, hostility, or non-supportive and dismissive responses—can compound the negative effects of abuse and retraumatise a victim-survivor.194 The responses of other institutions, such as police, the justice system, support services and health services, are just as important as that of the institution where the abuse occurred.195

Inappropriate responses—including failing to act after a disclosure, enabling the abuser to remain in their position, and adopting an adversarial, delayed or overcomplicated approach to redressing the abuse—further compound the trauma of the abuse for victim-survivors.196 For example, one victim-survivor told us that:

To take a child who is already in a situation of powerlessness—and the powerlessness is extraordinary, particularly in a school environment—but to then be suddenly thrust into this world of police officers and court rooms and lawyers and cross-examination … I’ve had three, four psychiatric evaluations and they are brutal, you know? So, how do we do this process? How do we find ways that are supportive and not retraumatising?197

‘Institutional betrayal’ describes the experience of a victim-survivor who is harmed by a trusted and powerful institution on which they depend for their security and wellbeing.198 Institutional betrayal can refer to the failure of an institution to provide a safe environment for a victim-survivor, therefore putting that person at risk. It also refers to institutions that do not act once a disclosure of abuse is made, which can result in the continuation of abuse of the victim-survivor or other children.199 We identified a sense of institutional betrayal in many of the victim-survivors and staff in the out of home care system, youth detention, schools and hospitals. Tiffany Skeggs, who was abused by Mr Griffin, told us that many of his victim-survivors had lost trust in Tasmanian government institutions:

Even when I speak to people now, I struggle to tell them that they should come forward, and that they will be safe if they do. Because the reality at the moment is that it is not safe for them to do that … I have absolutely zero faith in referring them to any department, anywhere, in Tasmania.200

Victim-survivors reported to the National Royal Commission and to our Inquiry that being silenced or disbelieved after disclosure, punished, blamed for the abuse, or accused of lying, resulted in intense feelings of injustice, anger and shame.201 The shock of enforced silence is evident in this account:

One of the most demoralising things in my life was that after the perpetrator was acquitted, my friend and I were told that we couldn’t mention his name or tell the truth publicly, because if we did we’d be liable for defamation. This left us feeling extremely angry, demoralised and disillusioned.202

Victim-survivors emphasised the importance of being heard and believed, and the importance of associated institutions acknowledging and accepting responsibility for the harm caused.203 As one young person who participated in the research we commissioned said:

Children would kinda get depressed [if adults don’t protect them] because we’re told the teachers are there to look out for us but when they don’t help us, who are we supposed to turn to? … It makes you feel unsafe because you are all alone and you have to do it by yourself … You would feel horrible because there’s no-one you can trust.204

Victim-survivors reported to us that poor institutional responses to their disclosures of abuse had adversely affected their capacity to work, participate in society and to trust or engage with institutions in general. Some victim-survivors said they also avoided accessing services—including services to manage trauma related to the abuse they suffered—which further impeded their healing.

We also heard that victim-survivors faced ostracism after identifying or disclosing child sexual abuse. When abusers continued to be employed or otherwise supported by an organisation after an allegation of abuse was upheld, victim-survivors, their family members and supporters felt isolated and sometimes forced to leave their community.

We have been deeply affected by the accounts we have heard of the profound impacts of child sexual abuse. We have also seen the courage and resilience of many victim-survivors who are living with the effects of child sexual abuse and continuing to make positive and important contributions through their families, communities, careers and advocacy. We are deeply grateful to every victim-survivor of child sexual abuse in Tasmanian institutions who came forward to share their experience with us.

In the following four volumes (Volumes 3, 4, 5 and 6), we discuss the Tasmanian Government’s response to allegations of child sexual abuse in schools, out of home care, youth detention and health services, and make recommendations for reform. In Volume 7 we discuss the justice system’s response to child sexual abuse, before discussing system-wide reforms in Volume 8. We trust that the recommendations we propose in those volumes will assist in preventing institutional child sexual abuse and improve the lives of those who do experience such abuse.