Celibacy, homosexuality in the priesthood, the infiltration into the priesthood of secular moral relativism, too much liberalism in the Church since Vatican II, damaging rollback of Vatican II reforms by conservative prelates—all have been suggested as causes for the crisis. This book, however, begins with the premise that, because the pattern of abuse and cover-up was so similar across the world, there is something fundamentally awry with Church traditions and power structures in relationship to sexuality and sexual abuse.

Specifically, in chapters on suffering and sadomasochism, bodies and gender, desire and sexuality, celibacy and homosexuality, the author concludes that aspects of the Catholic theology of sexuality set the stage for the abuse of minors and its cover-up. Frawley-O'Dea also analyzes the American bishops' lack of pastoral care and tendency towards clerical narcissism—the belief that the needs of the hierarchy represent the needs of the wider Church—as central factors in the scandal. She balances this criticism with a discussion of the backgrounds of the bishops presiding over the crisis and the challenges they faced in their relationships with the Pope and Vatican officials.

Drawing on twenty years of clinical experience, she imagines the dynamics of sexual abuse both from the victim's point of view and from the priest's, and she probes why the Church hierarchy, fellow priests, and lay people were silent for so long. Finally, Frawley-O'Dea examines factors internal to the Church and outside of it that drew this scandal into the public square and kept it there.