DÄ internationalArchive22/2019Sexual Abuse at the Hands of Catholic Clergy

Original article

Sexual Abuse at the Hands of Catholic Clergy

A retrospective cohort study of its extent and health consequences for affected minors (The MHG Study)

Dtsch Arztebl Int 2019; 116: 389-96. DOI: 10.3238/arztebl.2019.0389

Dreßing, H; Dölling, D; Hermann, D; Kruse, A; Schmitt, E; Bannenberg, B; Hoell, A; Voss, E; Salize, H J

Background: When cases of sexual abuse within the Catholic Church became known, the German Bishops’ Conference (Deutsche Bischofskonferenz, DBK) commissioned a study by an interdisciplinary consortium to determine the frequency of sexual abuse by Catholic clergy in Germany (the MHG study).

Methods: Qualitative and quantitative research methods were used and the subject matter of the study was analyzed in seven component projects. To determine the frequency of sexual abuse, 38 156 personnel files of Catholic clergy from the period 1946 to 2014 were studied, and the epidemiologic findings of these evaluations are presented.

Results: 1670 persons belonging to the Catholic clergy who were accused of sexual abuse of minors were identified from their personnel files, corresponding to 4.4% of the clergy overall. 3677 victims of sexual abuse could be linked to the accused persons; 62.8% of them were male, and 66.7% were under 14 years old when the abuse took place. The mean duration of the abuse in individual cases was 1.3 years. “Hands-on” abuses (i.e., abuses involving bodily contact) occurred in more than 80% of cases. Many of the affected persons suffered serious consequences for their health and social functioning. The ones most commonly reported were anxiety, depression, mistrust, sexual problems, and difficulties with interpersonal contact.

Conclusion: The figures reported here should be considered a lower bound to the actual frequency of sexual abuse. Asymmetrical power relationships in a closed system such as the Catholic Church can facilitate sexual abuse. Physicians play an important role in the diagnosis and treatment of the victims of sexual abuse, in the diagnosis and treatment of persons inclined to commit abuses and actual abusers, and in the development and implementation of preventive strategies.

LNSLNS

Sexual abuse of children is a global problem with high prevalence rates of 18% in girls and 7.6% in boys (1). The use of dissimilar inclusion criteria und survey methods has resulted in higher or lower reported lifetime prevalence rates (2). The effects of sexual abuse offenses can be significant and comprise direct and indirect as well as short-term and long-term consequences. The younger the age at which the sexual abuse occurred, the higher the likelihood of a poor state of health (3). Numerous studies have shown an increased prevalence or a greater severity of posttraumatic stress disorder in victims of sexual child abuse (4). Other potential consequences of abuse offenses experienced as a child include anxiety disorders, depression, suicidal behavior, sleep disorders, and eating disorders (5). In addition, studies reported an association between sexual abuse and later substance abuse as well as self-injurious behavior as elements of maladaptive coping strategies (6).

Sexual child abuse most frequently occurs in families, followed by institutions (7). Systematic research into the prevalence of sexual abuse in an institutional setting is worldwide primarily available for the Catholic Church (8). Although some structures and dynamics regarded as risk factors for sexual abuse are unique to the institutions of the Catholic Church (9), insights into abuse events in the Catholic Church can be held as exemplary for how sexual abuse is dealt with in other institutions. Comparable data on the prevalence of sexual victimization of children in, for example, the Protestant Church or other institutions have not yet become available (10). The aim of this study is to work out how the insights from the MHG Study can be translated into clinical practice.

Methods

This study reports epidemiological data obtained by analyzing personnel records of clergy. All during the analysis period from 1946 to 2014 active or retired clergy as well as minor victims of sexual abuse were included in this study. The clergy comprised Catholic priests (“diocesan priests“), full-time deacons and priests within religious orders who are governed by “Gestellungsverträge” (a contract conferring a form of stipend), i.e. priests within Catholic orders who, temporarily or permanently, exercise functions of priests within the area for which the German Bishops’ Conference is responsible. A detailed description of the methodology is provided in the eMethods section.

Results

Accused clergy

Information about allegations of sexual abuse of minors was found for altogether 1670 persons. This corresponds to 4.4% of persons in the study population. The share among diocesan priests was 5.1%, among full-time deacons 1.0% and among priests within religious orders who were governed by “Gestellungsverträge” 2.1% (Table 1). The difference between the shares of accused diocesan priests and accused deacons was statistically significant (χ= 78.6607; p<0.0001).

Number of accused clergy
Number of accused clergy
Table 1
Number of accused clergy

For 1485 accused persons (88.9%), information about their age at the time of the alleged first abuse offense was available. The mean age was 42.6 years (SD = 11.4 years, 95% confidence interval [CI]: [42.0; 43.1]), with a range of 20 to 82 years.

In 472 of the accused clergy (28.3%), evidence of sexual abuse of at least two minors aged 13 years or younger and of abuse occurrences over a period of more than six months was identified. At the time of the first offense, these 472 clergy were significantly younger (aged between 20 and 39 years) compared to those not showing this constellation (χ2 = 14.284; p<0.001. According to the personnel records, a criminal complaint was filed in 38.3% of cases. A separate analysis of the criminal files found that 67.1% of criminal proceedings were discontinued, largely because of limitation. Only in one of the cases with final judgment made by a court, the person charged was acquitted.

During the analysis period, the number of accused clergy peaked in the 1960s to 1980s, but new first accusation were noted up to the end of the analysis period in 2014. At the same time, it should be noted that the absolute number of clergy has significantly declined in recent years.

Affected persons

Altogether 3677 sexually abused minors could be linked to the accused persons. In 706 (42.3%) of the 1670 accused, evidence of alleged sexual abuse offenses involving more than one minor was identified (“accused persons with multiple allegations“). For 902 accused clergy (54.0%), evidence of a single abused minor in each case was found (“accused persons with one allegation“). In 62 accused persons (3.6%), the number of affected persons in each case could not be determined.

The mean number of victims of abuse among all accused persons was 2.5 (SD = 3.5 affected persons; 95% CI: [2.4; 2.7]). Among the 706 accused persons with multiple allegations, the mean number of affected persons per accused person was 4.7 (SD = 4.5 affected persons; 95% CI: [4.4; 5.0]).

Of the 3677 sexually abused persons identified in total, 2309 were male (62.8%) and 1284 female (34.9%). For 84 affected persons (2.3%), no information about their sex was available.

For 2847 affected persons (77.4%), data on the age at the time of first sexual abuse was available; the mean age was 12.0 years (SD = 3.1 years; 95% CI: [11.9; 12.2]). Two-thirds of those affected were aged 13 years or younger at the time of first sexual abuse (n = 1899; 66.7%) (Table 2). There was no difference with regard to the sex ratio of one-third female to two-thirds male affected persons between the two age groups.

Age of affected persons at the time of first sexual abuse
Age of affected persons at the time of first sexual abuse
Table 2
Age of affected persons at the time of first sexual abuse

For 2993 affected persons (81.4%), information were available about the year the abuse started and the year it ended or about the fact that a single abuse event occurred. From these data, an estimate of the duration of the abuse period was calculated. The calculated mean duration of individual abuse courses was 1.3 years (SD = 2.3 years; 95% CI: [1.3; 1.5]).

Abusive acts

In 3388 affected persons (92.1%), information about the type of abusive act was available (Table 3). Here, multiple responses were allowed. In at least 582 cases, the abusive act was genital or manual penetration (15.8% of all affected persons or 17.2% of affected persons with information about the type). In 1360 cases, some kind of masturbation act occurred (37.0% of all affected persons or 40.1% of affected persons with information about the type).

Type and number of abusive acts (multiple items allowed)
Type and number of abusive acts (multiple items allowed)
Table 3
Type and number of abusive acts (multiple items allowed)

Consequences of the abusive acts

Table 4 shows the range of potential health consequences. In at least 244 affected persons (6.6% of all affected persons or 23.7% of affected persons with information about health consequences), the clustering of items indicates a symptom pattern in line with posttraumatic stress disorder. Because no standardized survey and documentation of the findings was carried out in the context of this study, it was not possible to establish a valid clinical diagnosis.

Health problems of affected persons (multiple items allowed)
Health problems of affected persons (multiple items allowed)
Table 4
Health problems of affected persons (multiple items allowed)

In 890 affected persons (24.3%), information about problems in social functioning was available. The documented problems included relationship problems (53.1%), sex-life problems (43.0%), career problems (34.2%), problems related to social participation (32.5%).

In addition, it was noted that 144 affected persons (3.9%) left the church. At least 626 affected persons (17.0%) received psychiatric or psychotherapeutic treatment for consequences of the abusive acts. Given the non-standardized nature of the documentation, it can be assumed that the actual treatment prevalence is higher.

For 348 affected persons (9.5%), information about the severity of the consequences of the abusive act on health and social functioning was available, but no standardized criteria were used for severity classification. In the majority of cases, the consequences of the offence were assessed as severe (Table 5).

Severity of health-related or social consequences of abuse
Severity of health-related or social consequences of abuse
Table 5
Severity of health-related or social consequences of abuse

Discussion

There were methodological limitations with regard to standardization, validity, and reliability of the data. It can be assumed that the full extent of the sexual abuse offenses by clergy was not captured. Not all sexual abuse offenses were documented and an unknown number of personnel records were no longer available or no longer complete when the study began. On the one hand, this results in an underestimation of the number of accused clergy and minor victims of sexual abuse. On the other hand, there was a multitude of missing information on individual aspects in the data sheets which were recorded as such. All information was shared in anonymized form with the research consortium for analysis; consequently, the assessments of the investigators could not be reviewed. Since the personnel records were analyzed by review teams of the dioceses, neither a conflict of interest, nor incomplete sharing of the available information can be excluded. It is not possible to provide a quantitative estimation of this bias. A point to note here is that in 50% of abuse cases considered as plausible by the Catholic Church itself, no corresponding information was found in the personnel records or other documents. Despite of this limitation, we were able to analyze a very large sample and an abundance of so far unknown empirical data was compiled.

The figure of 1670 clergy accused of sexual abuse of minors as well as the figure of 3677 affected persons allegedly abused by these accused persons during the period from 1946 to 2014 should be regarded as lower estimates of the actual sexual abuse that has happened. While it cannot be excluded that some clergy have been wrongly accused, it can be assumed, based on the insights from research into unreported abuse cases, that a lower number of potentially wrong accusations is more than offset by a significantly higher number of undiscovered cases (11). A recent review has shown that studies on the frequency of false allegations do not allow robust prevalence estimates and that the vast majority of accusations is true (12). The insights from the MHG study can help to establish professional access for the health system to dealing with sexual abuse in an institutional setting (13). Besides general mechanisms promoting sexual abuse in institutions (for example, asymmetrical power relations or a closed system), high-risk constellations specific to the Catholic Church should also be taken into consideration. These include the abuse of clerical power, restrictive Catholic sexual morals, a problematic attitude toward homosexuality and a problematic way of dealing with celibacy and secrecy of confession (14). Whether there are specific risk constellations for child sexual abuse in the Protestant Church or other institutions, has as yet not been studied comprehensively. Striking is the—compared to other institutions—very high share of abused boys in the area of responsibility of the Catholic Church. This raises questions regarding the significance of Catholic sexual morals and the Catholic Church’s statements on homosexuality. Doctors should have an understanding of general and specific risk constellations for the problem of institutional sexual abuse of children, as they can be contacts for affected persons, for persons inclined to commit sexual abuse, and for perpetrators. In addition, medical expertise may be needed in prevention programs or with interventions directly aimed at protecting a child at risk.

In the group of the affected persons, the results of our study show a wide range of adverse effects on health and social functioning. However, in the absence of a control group, it cannot be proven that the experienced sexual abuse caused the health and social problems of the affected persons. Because the information was not obtained from medical or psychological reports, but personnel records of clergy, no diagnoses according to ICD-10 (ICD, International Statistical Classification of Diseases and Related Health Problems) could be established. However, in contrast to the German general population where a recent study found a prevalence of depression of only 6.4% (15), the fraction of depressed persons—if this information was available—among victims of sexual abuse and among the entire group of affected persons was 42.4% and 11.9%, respectively. Likewise, a considerably higher prevalence of symptoms of posttraumatic stress disorder was found in the group of affected persons. This amounted to 23.7% of the affected persons with corresponding information and to 6.6% in the entire group of affected persons. For the German general population, a prevalence of posttraumatic stress disorder of 2.9% was reported (16). It is noteworthy that in the records analyzed in our study information about health-related and social consequences of the abuse was documented for only just under one-third of the affected persons. However, it cannot be deduced from this that there were no negative consequences, but only that no corresponding information was available.

Children and adolescents in closed institutional systems are frequently victims of sexualized violence (17, 18). It is an important responsibility of physicians to be aware of the possibility that a patient could suffer from consequences of abuse and to detect and diagnose potential traumatic events by taking a careful medical history and to initiate further steps, if necessary.

There are a variety of ways how a physician obtains information about the fact that an act of sexual abuse had occurred. This information can, for example, be provided by the child itself or its caregivers. It is also conceivable that a physician suspects sexual abuse because of unspecific symptoms in a minor. Examples of such unspecific symptoms in children include anxiety, aggressiveness, drop in achievements at school, withdrawal tendencies, or psychosomatic symptoms (7). Under certain circumstances, information about sexual abuse can be made available to a physician anonymously. In cases where there is strong suspicion of sexual abuse, a safe environment should be provided as an emergency measure. The individual treatment requirements should then be immediately assessed by a child and adolescent psychiatrist (7). It should, however, be remembered that many affected persons do not, or only decades later, report that they were sexually abused, while suffering from a variety of mental and physical symptoms after the traumatic event(s). Therefore, the possibility that a patient experienced sexual abuse in the context of the Catholic Church should be considered in adults too and, in case of unclear etiology, it should be cautiously explored. Here, the physician can first point out that the present symptoms can be caused in some patients by experiences of abuse. Subject to the response of the patient, potential abuse situations can then be explored by asking biographical questions. The art of medical interviewing lies in ability to obtain specific information, while keeping in mind a potential reactualization of posttraumatic symptoms and avoiding to provoke false memories by asking suggestive questions.

With regard to the accused clergy, one should be aware that physicians may come into professional contact with this group of persons too; potentially at a time when the clergy is only inclined to commit an offense, but has not yet committed it. Here, prevention can set in: For example, physicians may detect potential high-risk constellations early when taking a comprehensive sexual history and then initiate specific sex therapy interventions. Here, the prevention network “Kein Täter werden“ (Don’t offend) is a suitable contact. Physicians are advised to always see themselves in the diagnosis, intervention, and prevention of cases of sexual abuse as a partner in an interdisciplinary team and to involve the justice system, government agencies, and counselling services, too.

Because of the methodology used in our study, it is in the majority of cases not possible to reliably diagnose the accused clergy; therefore, extreme caution is advised when considering the motivation and typology of the offender. In clinical practice, it can be helpful to assume a continuum of offenders and persons inclined to commit an offense. This continuum extends from a fixed type with pedophilic preference disorder to regressive offenders or persons inclined to commit an offense who, for example, have immature or narcissistic personality problems.

The Catholic Church has now responded in all dioceses to the abuse scandal by implementing prevention and protection plans. However, there is significant heterogeneity in their implementation. Until now, the preventive work has been lacking a focus on the specific risk constellations of sexual abuse by clergy (19). If evaluation studies were conducted, they mainly found an effect of the respective intervention program in favor of the intervention group (20). An evaluation of the prevention activities by the Church which satisfies scientific criteria still needs to be performed.

Prevalences of accused clergy comparable with the 4.4% in the MHG study were found in the US (4%) and Australia (7%) (Table 6).

Overview of selected study findings
Overview of selected study findings
Table 6
Overview of selected study findings

The similar prevalences highlight the fact that sexual abuse by Catholic clergy is a global phenomenon which needs to be addressed by the reginal healthcare systems.

Funding

The study was funded by the German Bishops’ Conference and the Association of German Dioceses (VDD, Verband der Diözesen Deutschlands).

Conflict of interest statement
All authors received study support and reimbursement of travel expenses from the VDD and the German Bishops’ Conference.

Manuscript received on 12 December 2018; revised version accepted on 28 March 2019

Translated from the original German by Ralf Thoene, MD.

Corresponding author
Prof. Dr. med. Harald Dreßing

Zentralinstitut für Seelische Gesundheit,

Medizinische Fakultät Mannheim,

Universität Heidelberg, J 5, 68159 Mannheim, Germany

harald.dressing@zi-mannheim.de

Cite this as:
Dreßing H, Dölling D, Hermann D, Kruse A, Schmitt E, Bannenberg B, Hoell A,
Voss E, Salize HJ: Sexual abuse at the hands of Catholic clergy—a retrospective cohort study of its extent and health consequences for affected minors (the MHG Study).
Dtsch Arztebl Int 2019; 116: 389–96. DOI: 10.3238/arztebl.2019.0389

Supplementary material
eMethods:
www.aerzteblatt-international.de/19m0389

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Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University:
Prof. Dr. med. Harald Dreßing, Andreas Hoell, Dr. phil. Elke Voss, Prof. Dr. sc. hum. Hans Joachim Salize
Institute of Criminology, Heidelberg University, Heidelberg:
Prof. Dr. iur. Dieter Dölling, Prof. Dr. phil. Dieter Hermann
Institute of Gerontology, Heidelberg University, Heidelberg:
Prof. Dr. phil. Dr. h.c. Dipl.-Psych. Andreas Kruse, Prof. Dr. phil. Dipl.-Psych. Eric Schmitt
University of Gießen, Gießen: Prof. Dr. iur. Britta Bannenberg
Key messages
Number of accused clergy
Number of accused clergy
Table 1
Number of accused clergy
Age of affected persons at the time of first sexual abuse
Age of affected persons at the time of first sexual abuse
Table 2
Age of affected persons at the time of first sexual abuse
Type and number of abusive acts (multiple items allowed)
Type and number of abusive acts (multiple items allowed)
Table 3
Type and number of abusive acts (multiple items allowed)
Health problems of affected persons (multiple items allowed)
Health problems of affected persons (multiple items allowed)
Table 4
Health problems of affected persons (multiple items allowed)
Severity of health-related or social consequences of abuse
Severity of health-related or social consequences of abuse
Table 5
Severity of health-related or social consequences of abuse
Overview of selected study findings
Overview of selected study findings
Table 6
Overview of selected study findings
1.Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermanns-Kranenburg MJ: A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat 2011; 16: 79–101 CrossRef MEDLINE
2.Moody G, Cannings-John R, Hood K, Kemp A, Robling M: Establishing the international prevalence of self-reported child maltreatment: a systematic review by maltreatment type and gender. MC Public Health 2018; 10: 1164–8 CrossRef MEDLINE PubMed Central
3.Irish L, Kobayashi I, Delahanty DL: Long-term physical health consequences of childhood sexual abuse: a meta-analytic review. J Pediatr Psychol 2010; 35: 450–46 CrossRef MEDLINE PubMed Central
4.Cantón-Cortés D, Cantón J: Coping with child sexual abuse among college students and post-traumatic stress disorder: the role of continuity of abuse and relationship with the perpetrator. Child Abuse Negl 2010; 34: 496–506 CrossRef MEDLINE
5.Paolucci EO, Genuis ML, Violato C: A meta-analysis of the published research on the effects of child sexual abuse. J Psychol 2001; 135: 17–36 CrossRef MEDLINE
6.Yates TM, Carlson EA, Egeland B: A prospective study of child maltreatment and self injurious behavior in a community sample. Dev Psychopathol 2008; 20: 651–67 CrossRef MEDLINE
7.Dressing H, Dölling D, Hermann D, et al.: Sexueller Missbrauch von Kindern. PSYCHup2date 2018; 12: 79–94 CrossRef
8.Dressing H, Dölling D, Hermann D, et al.: Sexual abuse of minors within the catholic church and other institutions: a literature review. Neuropsychiatrie 2017; 31: 45–55 CrossRef MEDLINE
9.Dressing H, Bannenberg B, Dölling D, et al.: Sexueller Missbrauch Minderjähriger durch katholische Priester, Diakone und Männliche Ordensangehörige im Bereich der Deutschen Bischofskonferenz. Nervenheilkunde 2015; 34: 531–5 CrossRef
10.Jud A, Rassenhofer M, Witt A, Münzer A, FegertJM: EXPERTISE Häufigkeitsangaben zum sexuellen Missbrauch Internationale Einordnung, Bewertung der Kenntnislage: www.beauftragter-missbrauch.de/fileadmin/Content/pdf . (last accessed on 8 March 2019).
11.Horten B, Dölling D, Hermann D, et al.: Sexueller Missbrauch an Kindern – Entwicklungen im Hell- und Dunkelfeld seit 1953 und Implikationen für das Gesundheitswesen [Sexual abuse of minors: development in light field statistics and dark field research since 1953 and implications for the health care system]. Gesundheitswesen 2018; 80: 1042–7 CrossRef MEDLINE
12.O´Donohue W, Cummings C, Willis B: The frequency of false allegations of child sexual abuse: a critical review. J Child Sex Abus 2018; 27: 459–75 CrossRef MEDLINE
13.Fegert JM, Jud A, Plener PL: Kinder- und Betroffenenschutz in der Medizin. Nervenheilkunde 2013; 32: 834–840 CrossRef
14.MHG Forschungsprojekt: Sexueller Missbrauch an Minderjährigen durch katholische Priester, Diakone und männliche Ordensangehörige im Bereich der Deutschen Bischofskonferenz (2018): www.zi-mannheim.de/fileadmin/user_upload/downloads/forschung/forschungsverbuende/MHG-Studie-gesamt.pdf (last accessed on 30 October 2018).
15.Luck T, Then FS, Engel C, et al.: Die Prävalenz aktueller depressiver Symptomatik in einer urbanen Erwachsenenpopulation. Psychiatr Prax 2017; 44: 148–53 CrossRef MEDLINE
16.Glaesmer H, Matern B, Rief W: Traumatisierung und posttraumatische Belastungsstörungen. Auswirkungen von Art und Anzahl traumatischer Erfahrungen. Nervenarzt 2015; 86: 800–6 CrossRef MEDLINE
17.Terry KJ: Sexual Offenses and Offenders. Belmont: Wadsworth 2013.
18.Bundschuh C: Expertise im Rahmen des Projekts „Sexuelle Gewalt gegen Mädchen und Jungen in Institutionen“. Nationaler und Internationaler Forschungsstand. Deutsches Jugendinstitut e. V. (ed.), 2010.
19.Dressing H, Dölling D, Hermann D, et al.: Wie aktiv ist die katholische Kirche in der Prävention des sexuellen Missbrauchs? Erste Ergebnisse der MHG Studie. Psychiatr Prax 2017; 45: 103–5 CrossRef MEDLINE
20.Walsh K, Zwi K, Woolfenden S, Shlonsky A: School-based education programs for the prevention of child sexual abuse: a cochrane systematic review and meta-analysis. Res Soc Work Pract 2015; 28: 1–23 CrossRef
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