More than 300 "predator" priests in Pennsylvania are accused of abusing more than 1,000 children across seven decades, a grand jury said in a devastating report that decried a systematic cover-up by the Catholic Church.
It is thought to be the single most comprehensive report to date into abuse in the US church, since The Boston Globe first exposed paedophile priests in Massachusetts in 2002.
But while the report led to charges against two priests, one of whom has pleaded guilty, the majority of those responsible are dead and the vast majority of crimes happened too long ago to prosecute, officials said.
The two-year investigation by a grand jury into all but two Pennsylvania dioceses turned up dozens of witnesses and half a million pages of church records containing "credible allegations against over three hundred predator priests".
More than 1,000 child victims were identifiable, but the "real number" was "in the thousands," the grand jury estimated, given those children whose records were lost or who were afraid to ever come forward.
Victims were often traumatised for life, driven to drugs, alcohol and suicide, the grand jury said. The only recourse was to recommend changes to the law and expose what had happened to make sure such widespread abuse was never repeated.
Warning: Graphic content
One cleric raped a seven-year-old girl in hospital after she had her tonsils out, the report said.
Another child drank juice, only to wake up the next morning in pain and unable to remember what had happened.
A priest forced a nine-year-old boy to perform a sex act, then rinsed out his mouth with holy water to "purify him".
Another priest abused five sisters from the same family, including one from the age of 18 months to 12 years.
When the youngest victim of the family told her parents in 1992, a police search of the priest's home found underwear, plastic containers of pubic hairs, vials of urine and sexually suggestive photographs of young girls.
The church ignored credible allegations against him for years, and the priest died awaiting trial, Pennsylvania's Attorney General Josh Shapiro said.
"The pattern was abuse, deny and cover up," Mr Shapiro said.
"As a direct consequence of the systematic cover-up by senior church officials almost every instance of child sexual abuse we found is too old to be prosecuted."
So far only two new priests are being charged with crimes that fall within the statute of limitations. One pleaded guilty earlier this month, prosecutors said.
The other allegedly assaulted two boys, one of them for eight years starting from the age of eight. His alleged crimes continued until 2010.
The grand jury called for changes in the law that would scrap the statute of limitations for child sex abuse, give victims more time to file civil lawsuits and tighten legislation compelling people to report abuse they find out about.
"Despite some institutional reform, individual leaders of the church have largely escaped public accountability," the report said.
"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. For decades."
Church elders were instead promoted and predator priests allowed to remain in ministries for ten, 20 even 40 years after leaders learned of their crimes as the list of victims got longer and longer, Mr Shapiro said.
Between 5,700 and 10,000 Catholic priests have been accused of sexual abuse in the United States, but only a few hundred have been tried, convicted, and sentenced for their crimes, according to the watchdog Bishop Accountability.
Since the abuse crisis became public in the 2000s, the US church has spent more than $3 billion in settlements, according to Bishop Accountability.
The group has documented settlements for 5,679 alleged victims of Catholic clergy -- only a third of 15,235 allegations that bishops say they have received through 2009. One estimate suggests up there were 100,000 US victims.
The Boston Globe won a Pulitzer Prize in 2003 for work by its investigative team exposing sexual abuse in the Catholic Church. That story was turned into Oscar-winning Hollywood movie, 'Spotlight,' starring Michael Keaton.
Faced with a growing number of cases worldwide and repeated criticism over the church's response, Pope Francis in 2013 brought in new legislation covering child sex abuse and pornography and sentences of up to 12 years for priests.
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