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Introduction: There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed. Methods: From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data. Results: Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous. Discussion: Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.
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Trastornos Mentales , Servicios de Salud Mental , Humanos , Unión Europea , Trastornos Mentales/epidemiología , Psiquiatría Forense/métodos , Atención a la SaludRESUMEN
From the perspective of global societal crises, this paper discusses the long-term socio-political withdrawal of psychiatry into a self-defined position of therapy- and rehabilitation-oriented medicine with no responsibility for social, economic or political conditions. Global crises suggest mental health and overall resilience of the population as key societal resources. Only mental health and psychosocial resilience of people and societies worldwide will determine whether our answers to the current and future existential threats will be effective. This challenge requires a radical change of attitudes of both society and psychiatry. The rich expertise of psychiatry, e. g. on on how to balance autonomy and compulsion or regarding the interdependencies of cognition and human behaviour must contribute significantly to the socio-political debate and the fight against undesirable social or political developments.
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Psiquiatría , Humanos , Alemania , Salud Mental , PolíticasRESUMEN
BACKGROUND: The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence. METHOD: Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process. RESULTS: The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant. CONCLUSIONS: This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.
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Esquizofrenia , Humanos , Esquizofrenia/epidemiología , Esquizofrenia/diagnóstico , Estudios de Casos y Controles , Violencia/psicología , Trastornos de la Personalidad , Agresión/psicologíaRESUMEN
Background: Current evidence points towards a high prevalence of psychological distress in refugee populations, contrasting with a scarcity of resources and amplified by linguistic, institutional, financial, and cultural barriers. The objective of the study is to investigate the overall effectiveness and cost-effectiveness of a Stepped Care and Collaborative Model (SCCM) at reducing depressive symptoms in refugees, compared with the overall routine care practices within Germany's mental healthcare system (treatment-as-usual, TAU). Methods: A multicentre, clinician-blinded, randomised, controlled trial was conducted across seven university sites in Germany. Asylum seekers and refugees with relevant depressive symptoms with a Patient Health Questionnaires score of ≥ 5 and a Refugee Health Screener score of ≥ 12. Participants were randomly allocated to one of two treatment arms (SCCM or TAU) for an intervention period of three months between April 2018 and March 2020. In the SCCM, participants were allocated to interventions tailored to their symptom severity, including watchful waiting, peer-to-peer- or smartphone intervention, psychological group therapies or mental health expert treatment. The primary endpoint was defined as the change in depressive symptoms (Patient Health Questionnaire-9, PHQ-9) after 12 weeks. The secondary outcome was the change in Montgomery Åsberg Depression Rating Scale (MADRS) from baseline to post-intervention. Findings: The intention-to-treat sample included 584 participants who were randomized to the SCCM (n= 294) or TAU (n=290). Using a mixed-effects general linear model with time, and the interaction of time by randomisation group as fixed effects and study site as random effect, we found significant effects for time (p < .001) and time by group interaction (p < .05) for intention-to-treat and per-protocol analysis. Estimated marginal means of the PHQ-9 scores after 12 weeks were significantly lower in SCCM than in TAU (for intention-to-treat: PHQ-9 mean difference at T1 1.30, 95% CI 1.12 to 1.48, p < .001; Cohen's d=.23; baseline-adjusted PHQ-9 mean difference at T1 0.57, 95% CI 0.40 to 0.74, p < .001). Cost-effectiveness and net monetary benefit analyses provided evidence of cost-effectiveness for the primary outcome and quality-adjusted life years. Robustness of results were confirmed by sensitivity analyses. Interpretation: The SSCM resulted in a more effective and cost-effective reduction of depressive symptoms compared with TAU. Findings suggest a suitable model to provide mental health services in circumstances where resources are limited, particularly in the context of forced migration and pandemics. Funding: This project is funded by the Innovationsfond and German Ministry of Health [grant number 01VSF16061]. The present trial is registered under Clinical-Trials.gov under the registration number: NCT03109028. https://clinicaltrials.gov/ct2/show/NCT03109028.
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OBJECTIVE: Nationwide assessment of structural data and the frequency of use of coercive measures in forensic psychiatric hospitals in Germany. METHODS: Quantitative survey using a postal questionnaire on structural data and on the use of coercive measures in forensic psychiatric hospitals as part of the "ZIPHER" study. RESULTS: About one fourth of all forensic patients are affected by coercive measures, with seclusion (21.2â%) being way more often than mechanical restraint (3.2â%). This ratio contrasts with general psychiatric hospitals, where restraints are more common than seclusions. CONCLUSION: The results of the study reveal nationwide peculiarities in the use of coercive measures in forensic psychiatric hospitals. At the same time, it demonstrated the lack of general structural and process data of forensic hospitals in Germany.
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Psiquiatría Forense , Trastornos Mentales , Coerción , Alemania , Hospitales Psiquiátricos , Humanos , Trastornos Mentales/terapia , Aislamiento de Pacientes , Restricción FísicaRESUMEN
Background: Consent to treatment is a cornerstone of medical ethics and law. Nevertheless, very little empirical evidence is available to inform clinicians and policymakers regarding the capacities of forensic patients with schizophrenia spectrum disorders (SSDs) to make decisions about their treatment, with the risk of clinical and legal inertia, silent coercion, stigmatization, or ill-conceived reforms. Study Design: In this multinational study, we assessed and compared with treatment-related decisional capacities in forensic and non-forensic patients with SSD. 160 forensic and 139 non-forensic patients were used in Austria, Germany, Italy, Poland, and England. Their capacity to consent to treatment was assessed by means of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Multiple generalized linear regression models were used to identify the socio-demographic and clinical variables associated with MacCAT-T scores. Study Results: In total, 55 forensic (34.4%) and 58 non-forensic patients (41.7%) showed high treatment-related decisional capacity, defined as scoring ≥75% of the maximum scores for the understanding, appreciation and reasoning, and 2 for expressing a choice. Forensic patients showed differences in their capacity to consent to treatment across countries. Of all socio-demographic and clinical variables, only "social support" was directly relevant to policy. Conclusions: Forensic patients have treatment-related decisional capacities comparable with their non-forensic counterparts. Social contacts might provide a substantial contribution towards enhancing the decisional autonomy of both forensic and non-forensic patients, hence improving the overall quality and legitimacy of mental health care.
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OBJECTIVE: Neurocognitive impairment has been extensively studied in people with schizophrenia spectrum disorders and seems to be one of the major determinants of functional outcome in this clinical population. Data exploring the link between neuropsychological deficits and the risk of violence in schizophrenia has been more inconsistent. In this study, we analyse the differential predictive potential of neurocognition and social cognition to discriminate patients with schizophrenia spectrum disorders with and without a history of severe violence. METHODS: Overall, 398 (221 cases and 177 controls) patients were recruited in forensic and general psychiatric settings across five European countries and assessed using a standardized battery. RESULTS: Education and processing speed were the strongest discriminators between forensic and non-forensic patients, followed by emotion recognition. In particular, increased accuracy for anger recognition was the most distinctive feature of the forensic group. CONCLUSIONS: These results may have important clinical implications, suggesting potential enhancements of the assessment and treatment of patients with schizophrenia spectrum disorders with a history of violence, who may benefit from consideration of socio-cognitive skills commonly neglected in ordinary clinical practice.
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Esquizofrenia , Cognición , Humanos , Pruebas Neuropsicológicas , Esquizofrenia/complicaciones , Psicología del Esquizofrénico , Cognición Social , ViolenciaRESUMEN
BACKGROUND: Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors. METHODS: Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS: Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9). CONCLUSIONS: The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.
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Hospitales Psiquiátricos , Trastornos Mentales , Coerción , Humanos , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Aislamiento de Pacientes , Restricción FísicaRESUMEN
Research in mental health services in Germany is of increasing relevance. To this end, the recently founded "Mental Health Working Group" as part of the German Network of Health Services Research (DNVF) has written a discussion paper presenting key specifics, challenges, and goals of health service research in the field of mental health. Some research-relevant specifics in the area of mental health care, pragmatic challenges of research organization, ethical problems, and particular research topics in this field are presented and discussed critically.
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Investigación sobre Servicios de Salud , Servicios de Salud Mental , Alemania , HumanosRESUMEN
Background: The purpose of this systematic review is to systematically investigate which non-pharmacological interventions are effective in reducing violence risk among patients with schizophrenia spectrum disorders (SSD) in forensic settings. Methods: Six electronic data bases were searched. Two researchers independently screened 6,003 abstracts resulting in 143 potential papers. These were analyzed in detail by two independent researchers yielding 10 articles that could be used. Results: Of the 10 articles, four were non-randomized controlled trials, three were pre-post studies without controls, and one was observational. Only two studies applied a randomized controlled trial design. Cognitive behavioral treatment programs were investigated in three studies. A broad range of other interventions were studied. Often outcome measures were specific to each study and sample sizes were small. Frequently, important methodological information was missing from the papers. It was not possible to carry out a meta-analysis due to the heterogeneity of the study designs and outcome measures. Conclusion: Because of methodological limitations it is difficult to draw firm conclusions about the effectiveness of non-pharmacological interventions to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying better methods in terms of study design, sample sizes and outcome measures are urgently needed.
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BACKGROUND: In total numbers, Germany has faced the largest number of refugees and asylum seekers (RAS) in Europe in the past decade. Although a considerable proportion have experienced traumatic and stressful life events, there is no systematic review to date examining the prevalence of depressive symptoms and post-traumatic stress disorder (PTSD) symptoms in RAS in Germany. AIMS: To calculate the prevalence of depressive symptoms and PTSD symptoms in the general population of RAS living in Germany after the year 2000 and explore the impact of study- and participant-related characteristics on prevalence estimates. METHOD: We systematically searched PubMed, CINAHL, PsycINFO, PSYNDEX, Academic Search Complete, Science Direct and Web of Science from January 2000 to May 2020 to identify articles reporting prevalence of depressive symptoms and PTSD in RAS in Germany (PROSPERO registration number: CRD42020182796). RESULTS: In total, 31 different surveys met inclusion criteria with 20 surveys reporting prevalence estimates of depressive symptoms and 25 surveys symptoms of PTSD. Based on screening tools, the pooled prevalence estimate of PTSD symptoms was 29.9% (95% CI 20.8-38.7%) and of depressive symptoms 39.8% (95% CI 29.8-50.1%). Heterogeneity was large within and between subgroups. In multivariate meta-regressions on depressive symptoms, heterogeneity was largely explained by survey period, length of field period and study quality. CONCLUSIONS: Prevalence rates of depressive symptoms and PTSD symptoms in RAS are notably large. They exceed the prevalence in the general German population. As a result of high heterogeneity, however, pooled prevalence rates should be interpreted with caution.
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BACKGROUND: The purpose was to systematically investigate which pharmacological strategies are effective to reduce the risk of violence among patients with Schizophrenia Spectrum Disorders (SSD) in forensic settings. METHODS: For this systematic review six electronic data bases were searched. Two researchers independently screened the 6,003 abstracts resulting in 143 potential papers. These were then analyzed in detail by two independent researchers. Of these, 133 were excluded for various reasons leaving 10 articles in the present review. RESULTS: Of the 10 articles included, five were merely observational, and three were pre-post studies without controls. One study applied a matched case-control design and one was a non-randomized controlled trial. Clozapine was investigated most frequently, followed by olanzapine and risperidone. Often, outcome measures were specific to the study and sample sizes were small. Frequently, relevant methodological information was missing. Due to heterogeneous study designs and outcomes meta-analytic methods could not be applied. CONCLUSION: Due to substantial methodological limitations it is difficult to draw any firm conclusions about the most effective pharmacological strategies to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying more rigorous methods regarding case-definition, outcome measures, sample sizes, and study designs are urgently needed.
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This study explores the extent of sexual abuse of minors by members of the Catholic Church in Germany. It is the first comprehensive study to examine this extent in a European country. The goals of this study are as follows: (a) to analyze whether the extent and characteristics of sexual abuse in a European country are comparable to those in the United States and Australia and (b) how discrepancies can be explained. The personnel files of 38,156 Catholic Priests, deacons, and male members of religious orders in the authority of the German Bishops' Conference were analyzed. The study period lasted from 1946 to 2014. All 27 German dioceses took part in this study. A total of 4.4% of all clerics (N = 1,670) from 1946 to 2014 were alleged to have committed sexual abuse, and 3,677 children or adolescents were identified as victims. These results are similar to those from comparable studies in the United States. Sexual abuse of minors within the authority of the Catholic Church seems to be a worldwide phenomenon.
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Catolicismo , Abuso Sexual Infantil/estadística & datos numéricos , Clero/estadística & datos numéricos , Registros , Adolescente , Adulto , Anciano , Niño , Víctimas de Crimen/estadística & datos numéricos , Femenino , Alemania/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Encuestas y CuestionariosRESUMEN
INTRODUCTION: From 2014 to 2018, an interdisciplinary consortium of scientists investigated the extent and possible causes of the sexual abuse of children in the area of responsibility of the Catholic Church in Germany. The study bears the acronym MHG (Mannheimâ/âHeidelberg/Gießen) after the locations of the participating universities. The personnel file analysis identified 1670 Catholic clerics accused of sexual abuse of minors for the period from 1946 to 2014. For the Catholic Church specific conditions that favour the sexual abuse of minors could be identified. METHOD: A comparison of criminal records of accused clerics and perpetrators from other institutional contexts has been carried out. RESULT: Sexual offenses of priests are severe and the number of persons affected per convicted person is not less than that of perpetrators in other institutions; the duration of abuse by Catholic clerics is even significantly longer. Persons affected by sexual abuse in the context of the Catholic Church are significantly more often male. The Catholic Church has tried more extensively than other institutions to cover up accusations of sexual abuse of children or young people by clerics. CONCLUSION: Prevention concepts must take greater account of the specific conditions of sexual abuse in the Catholic Church.
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Catolicismo , Abuso Sexual Infantil , Adolescente , Niño , Clero , Alemania/epidemiología , Humanos , Masculino , MenoresRESUMEN
The treatment of people diagnosed with mental disorders who committed crimes differ greatly in countries around the world because of the long histories of criminal justice and psychiatry specific to each country. As a result, it is often difficult to grasp the specificities of each system. The main objective of this paper is to provide a narrative review of the interactions between the French mental health and judicial systems. Subsequently, we will discuss how the concept of forensic psychiatry does not yet exist in France and how it can be applied.
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Stress is a mind-body phenomenon, which affects both mental and physical health and is highly relevant to the health care system. Yet, knowledge on the costs of stress and related health problems in adolescence is missing. The present study addresses this gap by investigating direct health care costs in relation to stress, mental health problems and physical health in high school students. The sample comprised 284 pupils from four schools in Heidelberg (mean age 16.75 ± 0.64 years, 59.64% female). Self-reported health care utilization and medication intake within 1 month were translated into costs. We established correlative associations of the dichotomized overall costs (no vs. any) with stress, mental health problems and physical health within generalized structural equation models. In particular, mental health problems and physical health were examined as mediators of the association between stress and costs. An increase of stress by 1 SD corresponded increased chances for costs by OR 1.39 (Odds Ratio; 95% CI 0.13-0.53, p = 0.001). When mediators were analysed separately, both mental and physical health (problems) fully mediated the association. Yet, when examined together, only mental health problems acted as a mediator. Our results indicate the health economic relevance of stress-related mental health problems in high school students. The finding is meant to set the stage for further cost-of-illness studies of stress and related health problems, as well as economic evaluations. Longitudinal research is needed to allow conclusions on directionality.
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Costos de la Atención en Salud/estadística & datos numéricos , Trastornos Mentales/psicología , Salud Mental/economía , Estrés Psicológico/psicología , Estudiantes/psicología , Adolescente , Niño , Femenino , Alemania , Humanos , Masculino , Instituciones AcadémicasRESUMEN
The sudden arrival of culturally diverse asylum seekers and refugees into Germany has created a strong demand for recognizing and appropriately treating those suffering from mental health issues. Due to many systemic, organizational, cultural and socio-linguistic barriers, psychiatric treatment of refugees is posing a major challenge to Germany's mental health care system. Thus, there is a need for alternative models that allow for increased access to adequate, effective and efficient culturally sensitive mental health care services. Here, we describe the Mental Health in Refugees and Asylum Seekers (MEHIRA) project, a multicentre randomized controlled trial investigating a stepped collaborative care model (SCCM) for providing mental health treatment in this vulnerable population. The proposed SCCM aims to decrease the aforementioned barriers. Adult and adolescent participants will be screened for depressive symptoms and matched to appropriate psychological interventions, including group-level interventions (START intervention, Empowerment/Gender-sensitive/Peer to peer), and other innovative, digital treatment approaches (Smartphone application). The therapeutic effect of the SCCM will be compared to TAU (treatment-as-usual). All interventions have been designed to be culturally sensitive, and offered in two different languages: Arabic and Farsi. The outcome of this study may contribute significantly to future clinical and legal guidelines in developing parallel and efficient new structures of treatment. Collected data will inform primary and secondary mental health care providers with recommendations concerning the design and implementation of effective treatment models and programmes. Guidelines and recommendations may also potentially be adopted by other host countries, developing countries and also in humanitarian aid programmes.
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Asistencia Sanitaria Culturalmente Competente , Depresión/terapia , Servicios de Salud Mental/organización & administración , Psicoterapia , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Refugiados/psicología , Proyectos de Investigación , Trastornos por Estrés Postraumático/terapia , Adolescente , Adulto , Anciano , Depresión/diagnóstico , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto/métodos , Estudios Prospectivos , Trastornos por Estrés Postraumático/diagnóstico , Adulto JovenRESUMEN
BACKGROUND: The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant. METHODS: The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study. DISCUSSION: Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise. TRIAL REGISTRATION: Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.
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Trastornos Mentales/psicología , Violencia/psicología , Adulto , Agresión/psicología , Estudios de Casos y Controles , Vías Clínicas/normas , Europa (Continente) , Unión Europea , Femenino , Predicción , Psiquiatría Forense , Humanos , Masculino , Trastornos Mentales/terapia , Persona de Mediana Edad , Evaluación de Necesidades , Estudios Prospectivos , Trastornos Psicóticos/psicología , Factores de RiesgoRESUMEN
[This corrects the article DOI: 10.1371/journal.pone.0214056.].
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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.