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Awareness needed on real/false sexual harassment allegations by patients against doctors

27 Sep 2021

  • Local doctors suggest informed consent and mandatorily having a chaperone of the patient’s sex present during interaction
By Ruwan Laknath Jayakody There is a need for increased awareness regarding the possibility of patients making both real and false allegations of sexual harassment against doctors, a local concept paper on the issue noted. This was noted by A. Dayapala (attached to the District General Hospital, Negombo) and W.R.A.S. Rajapaksha in a concept paper on “Sexual harassment allegations against doctors: Facts and fiction” which was published in the Medico-Legal Journal of Sri Lanka 3 (1) in January 2016, which highlighted the need to prevent such incidents since it is vital to uphold the dignity of the profession and to safeguard the wellbeing of patients. The relationship between the doctor and the patient is unique, Dayapala and Rajapaksha explained, owing to the intimacy, confidentiality, and asymmetry of power that is involved. Therefore, having recognised the potential vulnerability of this relationship for abuse, professional codes of conduct for doctors in the form of medical ethics have been proposed, e.g. the Hippocratic Oath. With regard to conduct that is prohibited within the context of the doctor-patient relationship, C.A. Galletly’s “Crossing professional boundaries in medicine: The slippery slope to patient sexual exploitation” and the “Sexual misconduct in the practice of medicine” of the American Medical Association’s Council of Ethical and Judicial Affairs, includes zero tolerance for sexualised behaviours, as powerful authority figures such as doctors, exploiting the trust of patients to serve their own sexual gratification, is described as being akin to a parent abusing a child. In Sri Lanka, according to the Sri Lanka Medical Council’s (SLMC) “Guidelines on ethical conduct for medical and dental practitioners registered with the SLMC”, a doctor entering into an emotional or sexual relationship with a patient or with a member of the patient’s family, which would disrupt the patient’s family life or otherwise damage or causes distress to the patient or his/her family, is deemed serious professional misconduct. Allegations of sexual harassment However, Dayapala and Rajapaksha pointed out that in Sri Lanka, while from time to time, news items about the sexual harassment of patients by doctors are reported, irrespective of the truth of such allegations or the outcome of investigations into such, the doctor against whom the allegation has been levelled, and the profession as a whole, faces embarrassment, as Galletly observed, in the society, in hospitals, and even in their homes. On the other hand, as per C. Cohen, A.L. Kelian, R.A. Oliveira, G.J. Gobbetti, and E. Massad’s “Sexual harassment in the physician-patient interaction: Analysis of charges against doctors in the State of Sao Paulo”, the reported cases of such sexual harassment may only be the tip of the iceberg. Cohen et al. found that sexual harassment charges were mostly found in gynaecology and obstetrics (24.67%), followed by general surgery, paediatrics, cardiology, psychiatry, urology, and traumatology. According to the “Prosecution argues renowned forensic psychiatrist fit to stand trial on patient sexual abuse charges”, forensic practitioners too can also be vulnerable for such charges. For example, Dayapala and Rajapaksha observed that a forensic practitioner examining a hymen that is difficult in the forensic sense, using various examination techniques and for a long period, may give off a wrong impression to the patient or the guardian or an inexperienced chaperone.  Also, Dayapala and Rajapaksha explained that in a case of suspected wife battery, asking the female to expose the covered areas to look for other injuries too can lead to such misunderstanding. Another such instance of misunderstanding doctors actions is in the mortuary, where when a forensic practitioner, who is, as per W.U. Spitz’s “Asphyxia”, expected to detect hidden violence such as sexual assault, is attempting to do so, and a casual visitor or new post-mortem attendant witnesses the doctor paying undue attention to the genitalia of a young girl found dead due to hanging or poisoning. Hence, Dayapala and Rajapaksha added that all concerned parties and stakeholders must explore all possibilities to prevent such abuses at the hands of doctors. Possibility of misunderstanding It goes without a doubt, Dayapala and Rajapaksha mention, that if the offence is proven beyond reasonable doubt against a doctor, the most severe penalties that are legally possible, must be enforced against the abuser. However, Dayapala and Rajapaksha observed that it must be borne in mind that there is also ample room for false allegations to be made against doctors by patients, owing to a multifarious reasons. Such reasons, as Galletly, the Sexual Misconduct Claims Review Panel, and “Doctor’s possible defence: Alleged sex assaults were hallucinations” observed, include the misunderstanding of examination procedures, psychiatric disorders of patients, drug-induced hallucinations, and holding personal grudges against doctors. The misunderstanding of examination procedures can take place due to an incomplete explanation given by the doctor or the lack of an attempt being made by the doctor to explain to the patient the examination procedures. This aspect is also directly linked to, Dayapala and Rajapaksha noted, the issue of informed consent – where the patient and guardians of the patient are to be adequately educated about the line of thinking of the doctor in relation to the patient’s complaint. As Hamilton Baily noted in the “Demonstration of physical signs in clinical surgery”, medical students and medical practitioners have been taught that they have to first examine the healthy organ when a patient complains about something wrong in one of the paired organs. Therefore, it is understandable that when a doctor attempts to examine the right breast of a woman who is complaining about a lump in her left one, the said action could be misunderstood. Thus, Dayapala and Rajapaksha pointed out that almost all doctors have encountered patients who have attempted to show the “correct” side when the doctor started to examine the “wrong” side first. This same misinterpretation, Baily noted, can also arise when a doctor wants to examine the hip region, thinking of referred pain in a patient complaining of pain in the knee. A remedy to prevent such misunderstanding from arising and thereby false allegations, Dayapala and Rajapaksha explained, is the practice of informed consent. On drug-induced hallucinations being a reason for this situation, it is noted that while certain drugs (propofol – which is used to sedate patients, can trigger hallucinations that are sexual in nature when any stimulation to the chest, such as the removal of electrodes or the inflation and deflation of a blood pressure cuff occurs, or when the patient is asked to squeeze the doctor’s fingers; ketamine – which is used to induce and maintain general anaesthesia, can cause psychological manifestations varying in severity including pleasant dream like states, vivid imaginary hallucinations, and emergence delirium [an abnormal mental state that develops as a result of anaesthesia administration during the transition from unconsciousness to complete wakefulness]; diazepam – which can cause delusions which is the holding of false beliefs that cannot be changed by facts, and changes in sexual desire; and short duration sedatives such as midazolam – which can also induce emergence delirium and dreaming) have been reported to induce hallucinations. Some such hallucinations, Dayapala and Rajapaksha emphasised, are also of a sexual nature. The “Doctor’s possible defense: Alleged sex assaults were hallucinations” elaborated that though these side-effects are uncommon in modern medicine as per the medical literature, they have however resulted in false and career destroying allegations being made against medical practitioners. On how the psychiatric disorders of patients can play a role in this scenario, Dayapala and Rajapaksha stated that psychiatric disorders and borderline personalities (marked by an ongoing pattern of varying moods, self image, and behaviour) may also result in false allegations, while transference – a phenomenon where a person unconsciously transfers feelings and attitudes from a person or a situation in the past, onto a person or a situation in the present, can also result in such, whereby, at times, the unsuspecting doctor, P. Hughes and I. Kerr’s “Transference and countertransference in communication between doctor and patient”, can be a victim due to allegations arising from such psychological disorders in patients. When patients hold personal grudges against doctors such as due to unfulfilled ambitions like the failure to obtain a favourable report from the doctor for insurance purposes, such too can, the Sexual Misconduct Claims Review Panel noted, result in false sexual assault allegations. Therefore, in addition to the practice of obtaining informed consent in order to prevent false allegations being levelled under such circumstances, Dayapala and Rajapaksha added that it is a good ethical practice to insist that a chaperone of the same sex as the patient be present during the doctor-patient interaction.

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