PAEDO priests in Pennsylvania rinsed child victims with holy water and forced them to pose naked as Jesus, a harrowing report has found.
Over 300 priests have been accused of molesting 1,000 children since the 1940s, according to a grand jury which has also claimed a cover-up by senior church officials.
But the "real number" of abused children predator priests might be higher since some secret church records were lost and some victims never came forward, the grand jury said.
Among the accusations, it's claimed a priest raped a seven-year-old girl while he was visiting her in the hospital after she'd had her tonsils removed.
And another allegedly forced a nine-year-old boy to perform a sex act before rinsing out his mouth with holy water.
Attorney General Josh Shapiro also described alleged abuse by a group of Pittsburgh clergymen accused of ordering an altar boy to strip naked and pose as Christ on the cross while they photographed him.
It's also claimed Cardinal Donald Wuerl, now the archbishop of Washington DC, helped protect abusive priests when he was Pittsburgh's bishop from 1988 to 2006 - allegations he has disputed.
Here's what you need to know about the Pennsylvania dioceses sex abuse scandal...
What is a grand jury and what are they investigating?
In Pennsylvania, an Investigating Grand Jury is a tool that can be used by prosecutors to examine testimony and evidence to determine if criminal charges can be filed.
In this investigation, the grand jury heard from dozens of witnesses and reviewed more than a half-million pages of internal church documents.
These included reports by bishops to Vatican officials disclosing details of abuse by priests that they had not made public or reported to police.
The investigation covered six of Pennsylvania's eight dioceses - Allentown, Erie, Greensburg, Harrisburg, Pittsburgh and Scranton.
These areas represent about 1.7 million Catholics and the probe is the most extensive into Catholic clergy abuse by any state, according to BishopAccountability.org.
The Philadelphia archdiocese and the Johnstown-Altoona diocese were not included in the investigation because they have been the subject of three previous scathing grand jury probes.
The grand jury said they found credible evidence of sexual abuse against 301 predator priests, and over 1,000 child victims were identified.
But the final report noted that they believe the true number to be in the thousands.
What does the report say?
The grand jury concluded a string of Catholic bishops and other church leaders tried to shield the church from bad publicity and financial liability.
The report found most of the victims were boys, but there were girls too, and while some were teens, many were prepubescent.
The report said: "Some were manipulated with alcohol or pornography. Some were made to perform sex acts on their assailants, or were groped by them. Some were raped.
"But all of them were brushed aside, in every part of the state, by church leaders who preferred to protect the abusers and their institution above all."
The church failed to report accused clergy to police and used confidentiality agreements to silence victims, the report said.
It also sent abusive priests to so-called "treatment facilities," which "laundered" the priests and "permitted hundreds of known offenders to return to ministry," according to the report.
It's claimed the conspiracy of silence extended beyond church grounds as police or prosecutors sometimes did not investigate allegations out of deference to church officials or brushed off complaints as outside the statute of limitations, the grand jury said.
While the grand jury said dioceses have established internal processes and now seem to refer complaints to law enforcement more promptly, it suggested that important changes are still needed.
"Despite some institutional reform, individual leaders of the church have largely escaped public accountability," the grand jury wrote in the 900-page report.
"Priests were raping little boys and girls, and the men of God who were responsible for them not only did nothing; they hid it all."
Top church officials have mostly been protected and many, including some named in the report, have been promoted, the grand jury said.
It concluded that "it is too early to close the book on the Catholic Church sex scandal".
What happens now?
In nearly every case, prosecutors found the statute of limitations has run out, meaning that criminal charges cannot be filed.
In other cases, more than 100 of the accused priests are dead, and many others are retired, been dismissed from the priesthood or put on leave.
Authorities have charged just two, including a priest who has since pleaded guilty and Attorney General Josh Shapiro said the investigation is ongoing.
The report is still the subject of an ongoing legal battle, with redactions shielding the identities of some current and former clergy while the state Supreme Court weighs their arguments.
What have others said?
Diocese leaders responded Tuesday by expressing sorrow for the victims and stressed how they've changed.
They also unveiled for the first time a list of priests accused of some sort of sexual misconduct.
Bishop of the Diocese of Eerie, Lawrence Persico, said: "I want to express my sorrow and apologise directly to the victims of sexual abuse that occurred within the Diocese of Eerie.
"You have suffered in darkness for a very long time... You have experienced unimaginable behaviour by the very individuals who should have had the greatest interest in protecting you.
"You were betrayed by people holding themselves out as servants of God, teachers of children and leaders in the community."
Responding to claims he protected abusive priests, Cardinal Wuerl said: "As I have made clear throughout my more than 30 years as a bishop, the sexual abuse of children by some members of the Catholic Church is a terrible tragedy.
"And the Church can never express enough our deep sorrow and contrition for the abuse, and for the failure to respond promptly and completely."
Diocese of Erie Bishop Lawrence Persico has apologised after shocking report findings reveal hundreds of Roman Catholic priests in Pennsylvania molested more than 1,000 children
The Cardinal continued: "While I understand this report may be critical of some of my actions, I believe the report confirms that I acted with diligence, with concern for the victims and to prevent future acts of abuse.
"I sincerely hope that a just assessment of my actions, past and present, and my continuing commitment to the protection of children will dispel any notions otherwise made by this report."
James VanSickle of Pittsburgh, who testified he was sexually attacked in 1981 by a priest in the Eerie Diocese, called the report's release "a major victory to get our voice out there, to get our stories told."
Terry McKiernan of BishopAccountability.org said the report did a good job of highlighting the two crimes of church sex abuse scandals: the abuse of a child and the cover up by church officials that allows the abuse to continue.
He said: "One thing this is going to do is put pressure on prosecutors elsewhere to take a look at what's going on in their neck of the woods."
The Pennsylvania church sex abuse scandal: the most harrowing cases
In the Diocese of Greensburg, a priest impregnated a 17-year-old, forged the head pastor's signature on a marriage certificate, then divorced the girl months later. Despite having sex with a minor, fathering a child, being married and divorced, the priest was permitted to stay in ministry thanks to the diocese's efforts to find a "benevolent bishop" in another state willing to take him on.
Another priest, grooming his middle school students for sex, taught them how Mary had to "bite off the cord" and "lick" Jesus clean after he was born.
It took another 15 years, and numerous additional reports of abuse, before the diocese finally removed the priest from ministry.
A priest in the Diocese of Harrisburg abused five sisters in a single family, despite prior reports that were never acted on.
In addition to sex acts, the priest collected samples of the girls' urine, pubic hair, and menstrual blood. Eventually, his house was searched and his collection was found.
But the diocese remained unwilling to side with the children even in the face of multiple reports of abuse.
Years later, the abuser did admit what he had done, but by then it was too late.
In the Diocese of Pittsburgh, church officials dismissed an incident of abuse on the ground thats the 15-year-old had "pursued" the priest and "literally seduced" him into a relationship.
After the priest was arrested, the church submitted an evaluation on his behalf to the court. The evaluation acknowledged that the priest had admitted to "sado-masochistic" activities with several boys - but the sadomasochism was only "mild," and at least the priest was not "psychotic."
In the Allentown diocese, a priest admitted sexually molesting a boy and pleaded for help, according to documents, but was left in ministry for several more years.
What does the report mean for the Catholic Church in the US?
The report comes at a time of fresh scandal at the highest levels of the Catholic Church in the US as just last month Pope Francis stripped Cardinal Theodore McCarrick, 88, of his title.
The move came amid allegations that McCarrick had sexually abused boys and committed sexual misconduct with adult seminarians.
The report's findings echoed many earlier church investigations around the US which described widespread sexual abuse and church officials' concealment of it.
Previously, US bishops have acknowledged that more than 17,000 people nationwide have reported being molested by priests and others in the church.
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