A.3: Common themes

39. Over the course of the Inquiry’s work, similar failings, problems, concerns and harms emerged. These have been grouped together into six common topics, experiences and themes:

common experiences and the impact of child sexual abuse on victims and survivors;
perpetrator behaviours;
institutional or organisational failures;
the role of the internet in facilitating abuse;
wider societal issues; and
the criminal justice system.

40. These common themes are distilled from the Inquiry’s investigations, some of which stretched back over many years and others which were more contemporary. These subjects are important because they reveal similarities in impact, behaviour, practice and culture that together illustrate the very real challenges that victims and survivors have experienced over the years and, in some contexts, continue to face. These findings go to the very core of the Inquiry’s work and demonstrate how the breadth of the Terms of Reference has enabled the Inquiry to identify common features and parallels across a wide range of institutional and individual responses without necessitating an examination of each and every institution that cares for children.

41. A separate theme relating to criminal justice has been included because, throughout the duration of the Inquiry, witnesses and participants in the Truth Project have expressed concerns about the criminal justice system’s efficiency and effectiveness.

Common experiences and the impact of child sexual abuse on victims and survivors

42. The impact of child sexual abuse cannot be overstated because many victims and survivors have experienced harm that has permeated many aspects of their lives. As the accounts set out in Victims and Survivors’ Voices and the Inquiry’s investigation reports reveal:

effects of the child sexual abuse, both physical and emotional, were profound and lifelong;
education, employment and career prospects were often irreparably damaged;
stable, secure and long-term relationships were hard to achieve;
sexual intimacy was often difficult;
children who were ‘groomed’ through use of alcohol and drugs often acquired a long-term dependency or addiction;
some victims and survivors were driven to self-harming behaviours by shame, guilt and embarrassment, and some were so affected that they tried to take their own lives;
many victims and survivors of child sexual abuse that occurred in a religious context reported that it had led to a loss of faith or a loss of trust in a religious organisation; and
some people from ethnic minority communities were either ostracised or chose to leave their family or local community after their child sexual abuse became known.

43. While each victim and survivor inevitably experienced sexual abuse that varied in its nature and in the settings and circumstances in which it was perpetrated, there were common features:

child sexual abuse was often preceded or accompanied by threats, violence, cruelty and neglect;
there was excessive corporal punishment in some institutions, including in Roman Catholic and other schools which the Inquiry examined, custodial institutions and child migrant placements, which was often used as a means in itself of obtaining sexual gratification;
many children experiencing sexual abuse in a ‘closed environment’ were captive victims with little scope for reporting abuse to a trusted adult;
many did not disclose sexual abuse for fear of reprisals;
victims received grudging and unsympathetic responses to disclosure;
in many settings, compassion was extended to perpetrators but not to victims, with religious organisations in particular often displaying callous indifference to victims;
abuse often involved deliberate humiliation of children;
children in custodial institutions are amongst the most vulnerable in society;
adult survivors of sexual abuse in custodial institutions in the 1960s described some of the worst abuse the Inquiry heard;
the use of pain compliance on those aged 18 years or younger in custodial institutions was, and is, a form of physical abuse which contributed to a violent atmosphere in which sexual abuse thrived;
children with disabilities were particularly vulnerable to sexual abuse; and
issues with communication could make disclosing abuse more difficult, for example for non-verbal children or those with limited speech.

Perpetrator behaviours

44. The Inquiry has identified similarities in the ways perpetrators targeted and groomed their victims and committed sexual abuse:

many perpetrators sexually abused more than one child, their offending spanned years, if not decades;
isolating children from their carers and families in order to commit sexual abuse, for example taking them away for unsupervised trips and holidays, particularly those involving overnight stays;
threatening or committing violence against a child to secure compliance with sexual abuse;
some perpetrators were seen as sadistic and predatory by victims;
identifying vulnerable children who were less likely to have the capacity or capability to complain or protest, including singling out children with disabilities who were unable to communicate what had happened to them;
adopting a ruse: for example, perpetrators in a position of authority conducted medical examinations when unqualified to do so in order to sexually abuse a child;
befriending the child’s family and carers in order to gain access to the child and eliminate suspicion about the perpetrator’s motives – for example, manipulating the situation so that the perpetrator gained access to children alone in their bedrooms;
plying the child with alcohol, drugs, gifts and affection to create a false impression that the perpetrator was genuinely fond of the child;
in religious settings, perpetrators were able to shelter behind the moral standing of the institution to deflect allegations, inhibit investigations and belittle survivors;
posing as friends in online activity with children with the intention of securing indecent images of the child or meeting the child for the purpose of committing sexual abuse in person;
children in poorer countries (although not limited to those places) were encouraged to live stream sexual abuse for payment – in some instances, perpetrators in England and in Wales offered to pay for the child’s education as a means of persuading families to make their children available for such purposes; and
some perpetrators in England and in Wales deliberately targeted countries where they believed they could sexually abuse children without fear of detection or prosecution by the authorities.

Institutional or organisational failures

45. The breadth of the Inquiry’s work demonstrated many common failures and issues across a diverse range of institutional or organisational settings. These can be grouped into broad themes:

failures of leadership;
a lack of concern for the child’s welfare; and
inadequate, and sometimes wholly absent, child protection arrangements, with particular problems faced by those in residential care and foster care.

46. Where an allegation was reported to an institution, there were sometimes failures to respond appropriately, with allegations being ignored and not reported to the statutory agencies and records not being kept. Weaknesses in inspection and audit arrangements and redress schemes were also identified, along with the challenges posed by the growth in online-facilitated child sexual abuse.

Leadership, deference and accountability

Institutions prioritised their own reputations, and those of individuals within them, above the protection of children.
There were examples in the past of deeply flawed central and local government policies and practices which put political priorities before the welfare of children.
Those who worked in statutory agencies in senior positions often showed deference to persons of prominence, such as councillors, Members of Parliament and leading clergy, when faced with investigating allegations of sexual abuse.
Some councillors who were alerted to child sexual abuse ignored the abuse if it was politically inconvenient for them to acknowledge its existence.
Political and sometimes personal allegiances meant that decision-making by councillors in individual cases was poor, prioritising the interests of staff over the welfare of children when allegations of child sexual abuse were made.
Adherence to a particular grouping, often of long standing, led to an abuse of power and lack of accountability, and compromised child protection. This was particularly evident in religious organisations and political parties.
Elected members, governors and senior people in many of the institutions studied by the Inquiry were rarely held accountable for the sexual abuse of children which occurred on their watch, sometimes over decades.
In the religious settings examined, deference and obedience could prevent or inhibit reporting of allegations and contribute to the abuse of power by those exercising religious leadership or authority.
Power imbalances were exploited in some settings, including children’s homes and custodial institutions, where some staff treated children as ‘undeserving’ and not worthy of protection from sexual abuse.
Victims of child sexual exploitation were frequently seen by police and other professionals as making a choice – such as to be ‘child prostitutes’ who ‘consented’ to their own abuse – and so their needs were not prioritised and the criminality was not addressed.
Victim-blaming language was in evidence in almost every institution and was largely unchallenged. In many cases, the Inquiry concluded that there were underlying problems with values and attitudes of those charged with the protection of children.

Children’s welfare

In some areas, the treatment by staff of children in care who were from ethnic minority communities was racist, hostile and abusive. It showed little sensitivity to particular cultural needs such as diet, hair care and clothing.
Across some institutions there was little recognition of the heightened vulnerability of children with disabilities to being sexually abused.
In some settings, the external physical environment presented opportunities for sexual abuse which institutions did not monitor or supervise. This included where extensive grounds and outbuildings were frequently misused for sexual activity with children.
For years, harmful sexual behaviour amongst children took place in residential homes and schools and was left unchecked through a failure by staff to understand its potentially harmful effects.
Harmful sexual behaviour was often seen as ‘teenage experimentation’ without any victim, despite being accompanied on many occasions by bullying and coercion, frequently of younger children.

Systems and processes

Most religious organisations examined in the Inquiry’s investigation into child protection in religious organisations and settings had inadequate child protection policies and procedures in place. In some, there were none at all.
Those in leadership and senior positions assumed responsibility for determining how the institution should respond to an allegation of abuse when lacking the competence to do so.
There was a tendency in some institutions to move alleged perpetrators from one workplace to another without investigating the allegations or reporting the allegations to the authorities.
Across some religious institutions and schools, there was a reluctance to refer allegations to the statutory agencies.
Many institutions knowingly retained in their employment adults who posed a risk to children. They allowed adults who were suspected of child sexual abuse to leave their employment and sexually offend elsewhere, without alerting any known employers.
Within some local authorities, trade unions appeared to prioritise their members’ individual interests over the protection of children. They were sometimes supported in this by elected members, who failed to take decisions to dismiss individuals who were later convicted.
Too often, people classed as ‘volunteers’ were allowed open access to children in care without any vetting, thus creating opportunities for potential child abusers.

Residential care and foster care

There is a national shortage of suitable residential placements for children who are at risk of, or have experienced, child sexual exploitation.
Children placed alongside much older children in various settings were left exposed to abuse, with little staff or carer supervision.
Some children’s homes were not a safe environment for children. Staff were threatening and violent, physical abuse was commonplace and children were frightened.
Children should have been nurtured, cared for and protected, but some councils and other care providers exposed them to sexual abuse perpetrated primarily by predatory residential staff and foster carers.
In some instances, a sexualised culture existed in residential homes, with staff behaving inappropriately towards children, which paved the way for sexual abuse.
Residential care in the 1970s and 1980s carried little priority with senior managers, even when they were made aware of escalating numbers of allegations of sexual abuse.
Some children’s homes where sexual abuse had been rife should have been closed sooner than they were.
Standards of conduct and child protection procedures were frequently put in place, but staff were rarely trained in their use and action was not taken against those who did not comply. Staff ignored these requirements with impunity.
In the 1980s, there was evidence of failures to vet foster carers properly for their suitability to look after children and failures to carry out criminal records checks.
When allegations of sexual abuse were made about foster carers, some councils were too willing to take the side of the foster carer and disbelieve the children.
The use of unregulated placements for older children in care placed some of them at heightened risk of sexual abuse, particularly of child sexual exploitation.

Responses of institutions to allegations

In close-knit communities and hierarchical institutions – such as educational facilities run by monastic orders, boarding and residential schools, and custodial institutions – normal scrutiny from parents, friends and visitors was restricted.
Complaints of abuse made by children were rarely listened to or responded to with empathy, concern or action. They were dismissed out of hand without investigation.
Some institutions went to extreme lengths to avoid contact with, or investigation by, the statutory agencies when allegations of abuse were made and parents were not always informed.
Some institutions sought to excuse or explain perpetrators’ behaviour by spurious reference to ‘the standards of the day’.
The statutory agencies did not always share intelligence and other information about perpetrators with other agencies and organisations.

Data collection and records

At institutional and national level, poor data collection has led to an incomplete picture of the nature and scale of child sexual abuse and exploitation. Many institutions, including religious institutions and schools, kept no records of allegations of abuse and actions taken. This is one of the reasons that the true scale of sexual abuse of children is likely to be much greater in all settings than has been uncovered by evidence to the Inquiry.
Records were often incomplete. Some were lost or destroyed, including in some cases through deliberate action, thereby concealing potentially criminal activity. This included personnel records of alleged and known abusers.
The introduction of document retention policies has improved the availability of records, but access to records by victims is generally a long, complex and often unsatisfactory process.
The police and social services did not record the ethnicity of victims and alleged perpetrators, as evidenced in the case studies included in the Child Sexual Exploitation by Organised Networks Investigation Report.

Review, audit and inspection

The Office for Standards in Education, Children’s Services and Skills (Ofsted) and other inspectorates, particularly the Social Services Inspectorate, on occasions did not do enough to identify the serious weaknesses in the protection of children in some of the care and educational settings the Inquiry examined. The Independent Schools Inspectorate also had a mixed record in their scrutiny of institutions where sexual abuse of children was taking place.
Over several years, there were too few multi-agency safeguarding inspections, as opposed to single-agency inspections. These could have provided a more holistic view of the strengths and weaknesses of child protection within an institution, from a range of professional perspectives.
Many institutions commissioned external reviews of their child protection systems. These reviews identified weaknesses and left those in charge in no doubt that children were at risk of sexual abuse, or that it had already occurred. These findings and recommendations were infrequently acted upon fully or at all.

Apologies, support and redress

The avenues for redress which the Inquiry examined did not often provide remedies which satisfied the need for accountability and reparations for victims and survivors of child sexual abuse.
In order to obtain a legal remedy, victims and survivors often had to resort to civil litigation, some of which spanned over a decade.
In civil proceedings, the imposition of a time limit led to injustice for many child sexual abuse victims, for whom it could take years before they felt able to discuss their abuse. This time limit continues to pose problems in current civil claims.
Inadequate provision of support and counselling for those who experienced sexual abuse remains a serious concern for victims and survivors. This is particularly the case for children, for whom few specialist resources exist and a much more child-centred approach is required.
The quality and authenticity of apologies from institutions was extremely variable and frequently added to the trauma experienced by victims.
Historically, some insurers confirmed that they required institutions not to make apologies or offer support of any kind to victims, for fear of this being interpreted as an admission of liability. If institutions did make apologies in these circumstances, they risked invalidating their insurance.

The internet

The number of child victims of online-facilitated sexual abuse and the true scale of offending are likely to be far higher than the reported cases.
Some of this offending involves levels of depravity, such as the rape and violent abuse of babies and toddlers, on an unprecedented scale.
Internet companies failed to demonstrate that they knew the scale of underage internet use.
The live streaming of abuse affects children all over the world, including in the UK, the majority of whom are girls aged between seven and 13 years.
Industry witnesses repeatedly asserted their companies’ commitment to preventing child sexual abuse, but their responses at times seemed reactive and intended to counteract adverse media reporting and reputational damage.
The internet, while bringing great benefits to society, has also been a vehicle to capitalise on opportunities to commit child sexual abuse through the production and distribution of indecent images of children, grooming and the live streaming of abuse.
There are often challenges for parents and carers in understanding and tackling online harms to their children, particularly given the speed of technological developments.
The trade in indecent imagery and live streaming the sexual abuse of children and babies has proliferated to industrial scales and represents a threat to children around the world.

Wider societal issues

Child sexual abuse and exploitation has been, and still is, under-reported.
Some parents of some sexually abused children seemed reluctant to accept the possibility that sexual abuse had taken place because the institution associated with the perpetrator was trusted and respected, as were the perpetrators themselves.
Where the parents were closely associated with an institution, such as a school, on occasions their allegiance to that institution was a more powerful influence than the welfare of their children, even in circumstances where they suspected or were told that the abuse had occurred.
Child sexual abuse has often been met with embarrassment and fear, leading to a culture of silence when confronted with the reality of that abuse.
Many in the general public, as well as in the police and other statutory agencies, did not believe children’s reports of sexual abuse.
Sometimes children were considered to be responsible for the sexual abuse that occurred because they had made so-called ‘lifestyle’ choices.
Awareness of the scale and scope of child sexual abuse tends to be underestimated throughout society and more needs to be done to increase awareness across England and Wales.
The trafficking of children for the purposes of child sexual abuse and exploitation is a growing concern.

The criminal justice system

For some years, the criminal law perpetuated myths about children. It was not until 1988 that the uncorroborated evidence of a child was admissible in evidence.
On occasions, police forces failed to investigate allegations of child sexual abuse properly, or at all. Allegations were not always treated seriously.
Links between perpetrators were not always explored during police investigations, so the full picture of child sexual abuse was not identified.
Hierarchical structures in police forces prevented officers from raising concerns about failures to investigate properly.
On some occasions, officers expressed prejudicial views about children, particularly about children in the care of the local authority. Officers often ignored the children’s complaints and the children were forced to remain in the place where the sexual abuse had taken place.
Young people, particularly those experiencing sexual exploitation, were sometimes arrested by the police and criminalised for offences arising from their exploitation, while the expoiters remained at liberty to continue offending.
Intelligence opportunities were lost when some police forces failed to interview missing children thoroughly when they returned or were brought home.
The data collected by criminal justice agencies did not identify the scale and extent of child sexual exploitation by networks. In the areas under scrutiny, data collection was generally poor, so the authorities could not identify cases for investigation.
Some police forces had merged analyses of child sexual exploitation with child criminal exploitation, leading to potential failures to distinguish sexual expoitation cases from other crimes.
Disruption tactics to prevent perpetrators from committing sexual offences against children were underused and poorly recorded, leaving police forces without reliable data to assess the effectiveness of such tactics.
Undue deference has from time to time been shown to people of prominence by prosecution authorities, particularly in relation to politicians. Some people of prominence were not prosecuted in court, sometimes despite the weight of evidence.
On occasions, the police or the Crown Prosecution Service wrongly concluded that there was insufficient evidence to prosecute for offences relating to child sexual abuse, on the basis of an assessment of the child’s evidence that could not be justified.
Delays in investigations and criminal proceedings appeared to be endemic within the system such that adult survivors of child sexual abuse had to wait years before their case was finalised.
Compensation for victims of child sexual abuse was unlikely to come from a convicted defendant. It was not always easy to access or secure payments from the Criminal Injuries Compensation Scheme. Some restrictions on claims (for example, time limits) disadvantaged some applicants whose applications were rejected on these grounds.

Child sexual abuse today

47. Many of the failures described above were prevalent over several decades. More recently, some of the failures have been mitigated, in part, by improvements in prevention, identification, detection and public awareness. Other threats have also emerged, which are addressed in Part J.

48. One of those threats is the reported growth of incidents of child sexual abuse and exploitation worldwide. This Inquiry is one of a number that have been, or are in the process of being, conducted across the globe, including in Australia and the Republic of Ireland.

49. There are two specific global issues, however, which the Inquiry notes have had a deleterious impact on responses to child sexual abuse.

49.1. The first is the response to the global financial crisis from 2008 onwards, which led to significant reductions in funding of public services. These services are central to effective responses to child sexual abuse, and include the police, children’s social care, the Crown Prosecution Service, health and education. The financial crisis also directly affected the voluntary and charity sectors, which mainly rely on funding from public services, via the commissioning process and direct grants. At the same time, the demand for children’s social care has increased significantly. A National Audit Office report in 2018 noted that local authorities’ spending power had fallen by 28.6 percent since 2010. However, between 2010 and 2020, child protection referrals increased by 125 percent and the number of looked after children increased by 24 percent.

49.2. The second global issue is the COVID-19 pandemic. There is clear evidence from national and international organisations of the increase in child sexual abuse (and increased domestic abuse) which has taken place since March 2020. This is generally attributed to stress on families from several different sources, such as financial pressures, school closures and stay-at-home requirements. There has also been an increase in online child sexual abuse during the pandemic. Statutory services, particularly those with a protective role such as social workers and district nurses, have also been affected, with the restrictions in contact with children and adults. Virtual visits and doorstep visits have had to take the place of in-person visits for much of the time, to prevent the spread of the virus. This is very likely to have led to an incomplete picture of risk to children, as well as presenting ethical challenges to many child protection professionals. A relaxing of COVID-19 restrictions should not, however, be taken to indicate that there will be a consequential reduction in the scale of offending or risk of harm to children. As set out in Part B of this report, the prevalence of child sexual abuse continues to rise.

50. This report is structured thematically and builds on the entirety of the Inquiry’s work, including previously published reports. It seeks to draw together what the Inquiry has learned and, unlike previous reports, it is focussed on the future and the ways in which institutions and organisations can and must improve in order to keep children safe. Footnotes are provided to assist the reader in identifying where further information might be found. While inevitably institution or investigation-specific, the footnotes refer to the Inquiry’s previous conclusions at the time of the relevant investigation to illustrate the issues covered in this report. These examples are not exhaustive and so should be read in conjunction with the Inquiry’s previous publications.

The Report of the Independent Inquiry into Child Sexual Abuse

Final report