- Patients, doctors – colleagues and trainees victimised
The sexual abuse of patients and the sexual harassment of colleagues and trainees in the medical profession are aspects that should be considered seriously.
These matters were raised in an opinion piece on ‘Can we be complacent about sexual misconduct in the medical profession?’ which was authored by R. Monaragala and published in the Sri Lanka Journal of Psychiatry’s 15th Volume’s First Issue, this month.
“Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief, and in particular of sexual relationships with both female and male persons, be they free or slaves” – the Hippocratic Oath (4th Century Before Christ).
The sexual relationship between teacher and student, employer and employee, subordinate and superior, or therapist and client, irrespective of the consensuality, will inevitably be sexual misconduct as there is a breach of trust and a power imbalance (K. Zelas’s ‘Sex and the doctor-patient relationship’). Similarly, if a doctor concurs sexually with their patient, it is ethically transgressional due to the breach of trust and the power imbalance (a New Zealand-based study and R.M. Cullen’s ‘Arguments for zero tolerance of sexual contact between doctors and patients’). In Sri Lanka, sexual harassment is a criminal offence under Section 345 of the Penal Code Ordinance (Assault or use of criminal force to a woman with the intent to outrage her modesty), and occasionally, sexual misconduct committed by a doctor can be legally contested as sexual harassment (S. Ost’s ‘Breaching the sexual boundaries in the doctor-patient relationship: Should English law recognise fiduciary duties?’). Thus, sexual misconduct ensues serious legal implications and impacts on the profession.
Defining sexual misconduct
Any behaviour that exploits the doctor-patient relationship in a sexual way (verbally, physically, virtually, or any behaviour involving the expression of thoughts, feelings, or gestures that are sexual) or if a patient or surrogate (the patient’s immediate family member or bystander) reasonably construes such as sexual, is an act of sexual misconduct (R.V. Capule’s ‘Physician sexual misconduct’ and K.K. Sindhu, A.C. Schaffer, I.G. Cohen, R.H. Allensworth, and E.Y. Adashi’s ‘Honouring the public trust: Curbing the bane of physician sexual misconduct’). In addition, ‘gift giving’, special treatment, the sharing of personal information or other acts or expressions that are meant to gain a patient’s trust and acquiescence to subsequent abuse, are subtle forms of sexual misconduct.
Sexual misconduct and the breach of ethical principles
The unique relationship between the doctor and patient serves as a basis for the provision of medical care (R. Kaba and P. Sooriakumaran’s ‘The evolution of the doctor-patient relationship’). This relationship typifies inequality (i.e., imbalance of power) as the patient has to depend on and be bestowed upon the knowledge and expertise of the doctor for their health-related status. In other words, the patient is deemed to trust the doctor. Beneficence, non-maleficence, and autonomy are three ethical principles intricately associated with trust (i.e., in addition to the power balance and consent), and hence, if a doctor engages sexually with a patient, these ethical principles will inevitably be violated regardless of the consensuality.
Sexual contact with former patients
The Council on Ethical and Judicial Affairs of the American Medical Association (AMA), proscribes sexual or romantic relationships with former patients (Sexual misconduct in the practice of medicine). However, the ethical codes to determine the propriety of sexual relationships with former patients differ across various governing bodies for professional conduct (V. Clemens, E. Brähler, and J.M. Fegert’s ‘Patients too – Professional sexual misconduct by healthcare professionals towards patients?: A representative study’), and are based upon the maturity and decision-making capacity of the patient, the amount of time that has elapsed since the cessation of the therapeutic relationship, the nature and intensity of the service, and most importantly, the potential for the physician to exploit the trust, knowledge and dependence that developed during the professional relationship (‘The patient – physician relationship’ and L.E. Ferris’s ‘Patient protection laws and the issue of consensual sexual relationships with physicians’).
The definition of sexual misconduct extends to the relationship between a doctor and family members or others who are involved in the treatment and welfare of a patient (e.g., a mother seeking medical advice from her child’s physician). Family members or others directly involved with the patients should be considered as patients too, and hence, all ethical principles applied to patients will be applied to them as well (G.E. Skipper and S. Schenthal’s ‘Sexual misconduct by professionals: A new paradigm of understanding’).
Prevalence of sexual encounters with patients
A high number of doctors decline to take part in self-reported surveys on the prevalence of doctor-patient sexual encounters/relationships (R.A. Sansone and L.A. Sansone’s ‘Crossing the line: Sexual boundary violations by physicians’). United States-based studies conducted in 1973 (S.H. Kardener, M. Fuller, and I.N. Mensh’s ‘A survey of physicians’ attitudes and practices regarding erotic and non-erotic contact with patients’), 1992 (N.K. Gartrell, N. Milliken, W.H. Goodson, S. Thiemann and B. Lo’s ‘Physician-patient sexual contact – Prevalence and problems’) and 1996 (T. Bayer, J. Coverdale, and E. Chiang’s ‘A national survey of physicians’ behaviours regarding sexual contact with patients’), portray the prevalence rates of doctor-patient sexual contacts as 7.2%, 9.3%, and 3.3%, respectively. In a Netherlands-based study, 3.6% of gynaecologists and 3.5% of otolaryngologists (a healthcare specialist who treats conditions affecting the ears, nose, and throat) reported sexual contact with patients. In Israel, 14.5% of doctors admitted sexual engagements with patients. In New Zealand, 3.8% of general practitioners reported sexual contact with a patient. In another Netherlands-based study of a randomised sample of 1,250 general practitioners, of whom 977 responded, 3.3% admitted to having a sexual relationship with a patient, and out of them, 34% had at least two or more sexual engagements. Among the cases disciplined by the State medical boards due to sexual misconduct, male doctors, gynaecologists, and psychiatrists were overrepresented (a Canadian study, M. Favero, V. Gomes, A.D. Campo, D. Moreira, and V. Sousa-Gomes’s ‘Sexual violence perpetrated by health professionals’, an Australian study, an American study, and N. Mulvihill’s ‘Professional authority and sexual coercion: A paradigmatic case study of doctor abuse’). Furthermore, most of the accused were over 39-years of age and had repeatedly been involved with multiple patients for over a year (an American study and J.M. DuBois, H.A. Walsh, J.T. Chibnall, E.E. Anderson, M.R. Eggers, M. Fowose and H. Ziobrowski ‘Sexual violation of patients by physicians: A mixed-methods, exploratory analysis of 101 cases’.
However, C. Kamau-Mitchell, K.B. Waleed, and M.M. Gallagher’s ‘Global meta-analysis of physicians’ experiences of workplace sexual harassment by patients’, found a pooled prevalence of 45.13% out of 18,803 physicians from several specialities (e.g. internal medicine and surgery), having ever experienced sexual harassment by patients.
Complications
Incidents and the severity of harm to victims of sexual misconduct by health professionals have been a matter of opinion and often, objectively immeasurable (M.S. Rapp’s ‘Sexual misconduct’). Nevertheless, in 90% of the cases of sexual encounters with health related caregivers, it was perceived negatively, and in some, lasting psychological repercussions were observed (J. Bouhoutsos, J. Holroyd, H. Lerman, B.R. Forer, and M. Greenberg’s ‘Sexual intimacy between psychotherapists and patients’, A.W. Burgess’s ‘Physician sexual misconduct and patient’s responses’ and J.L. Alpert and A.L. Steinberg’s ‘Sexual boundary violations: A century of violations and a time to analyse’). Depression, post-traumatic stress disorder, multiple disruptions to significant relationships and daily functioning, mistrust and intractable anger outbursts were some of the psychological repercussions that victims underwent following sexual misconduct (M. Halter, H. Brown and J. Stone’s ‘Sexual boundary violations by health professionals – An overview of the published empirical literature’). Furthermore, victims manifested emotional injury as feelings of exploitation and betrayal, impairing future relationships with other doctors and health staffers. The harm is not only confined to the victimised patient but also to the doctor who transgressed due to the consequent reputational damage, financial losses, the revocation of the licence to practise, and occasionally being subjected to criminal charges and eventual imprisonment. Such misdemeanours will also harm the medical profession at large due to the degradation of the perceived legitimacy of the profession each time such misdemeanours are committed by doctors.
Attributing factors of sexual misconduct
Attributable factors that can lead to sexual misconduct can be explicated in terms of the characteristics of the doctor and the patient and the nature of the medical speciality.
Apart from being of an older age and the male sex, attitudes (such as consensual sexual relationship with patients is permissible, patient seduces and initiates into sex, sexual relationship is therapeutic, and feeling positive after the act) (another Netherlands based study and G.O. Gabbard’s ‘Transference and countertransference in psychotherapy in therapists charged with sexual misconduct’), personality disorders (mixed, and narcissistic personality with antisocial features) (A.J.R. Finlayson, M.S. Dietrich, R. Neufeld, H. Roback, and P.R. Martin’s ‘Restoring professionalism: The physician fitness for duty evaluation’), life-related difficulties and life-related transitions (e.g., marital and family problems, midlife or late midlife stage of life crisis and burnout), health conditions that interfere with judgement, hypomanic episodes (T. Fahy and N. Fisher’s ‘Sexual contact between doctors and patients’), alcohol and/or substance abuse disorders and paraphilias were depicted as characteristics of doctors who are involved sexually with patients. Explicably, an unconscious process known as counter transference (i.e., idealising the patient as a lover) is psychoanalytically implicated in seeding the sexual or romantic drives in doctors towards patients.
Characteristically, victimised patients were demographically in the younger ages (which includes minors) and females, diagnosed with personality disorders (e.g., borderline, dependent, and submissive personalities that make patients oblivious to differentiating between social and professional boundaries), have a history of sexual abuse, have a history of sexual contact with a professional, and have more ordinary adverse life circumstances (e.g., loneliness). From a psychoanalytical perspective, the patient can go through an unconscious process known as ‘idealising transference’, where the patient can feel bonded to a professional through their disclosure, which can turn to dependency, in turn blurring the lines of what is and is not appropriate behaviour, and desensitising the victim from the warning signs of abuse and exploitation.
Any specialty that involves prolonged contact with patients, particularly in psychiatry and gynaecology, increases the liability for sexual misconduct (another Netherlands-based study). Further, the provision of intimate information, and medical procedures that allow for violating the bodily integrity enhance the trust and respect in the caring doctor, which paves the way towards dependence and intimacy in the doctor-patient relationship that might lead to an eventual sexual misdemeanour. Moreover, in an intimate and dependent relationship, the needs and fantasies will increase while weakening the objectivity and control necessary to preserve the professional boundary.
Prevention of sexual misconduct
Many doctors were not educated or had a standard education on sexual misconduct during their medical student period (a United Kingdom [UK]-based study). Moreover, some doctors who committed such violations were ignorant of professional standards (G.E. Robinson and D.E. Stewart’s ‘A curriculum on physician-patient sexual misconduct and teacher-learner mistreatment, Part 1: Content’). Hence, as a primary preventive measure, incorporating topics on professional ethics and sexual misconduct in the medical education curriculum and as a major component of the continuous medical education programmes is suggested (Robinson et al.’s ‘curriculum, Part 2: Teaching method and H. Dekker, J.W. Snoek, J. Schönrock-Adema, T.v.d. Molen, and J. Cohen-Schotanus’s ‘Medical students’ and teachers’ perceptions of sexual misconduct in the student-teacher relationship’). Further, the early recognition of disruptive behaviour and providing formal peer feedback will enable the doctor to understand and correct the misconduct, thereby preventing recidivism. In addition, the risk associated with workplace settings should be deliberated, particularly where patients are alone with individual healthcare professionals, especially during examinations with lots of physical contact, examinations of intimate body zones and long-lasting treatment relationships characterised by high intimacy, and in situations where patients might feel unsafe or uncomfortable. Seemingly, assessing patients in the presence of a chaperone would be the best preventive measure in these vulnerable workplace settings, yet, the aforementioned American study revealed that 19% of cases of sodomy occurred in the presence of a chaperone, parent, or nurse. Thus, this underscores the importance of chaperones being trained on how to respect privacy while providing appropriate oversight, and how to speak up when behaviour appears to be inappropriate.
Finally, to prevent patients from falling victim to sexual misconduct, they should be empowered when dealing with situations that are routinely experienced as disempowering, which can be achieved by raising public awareness to recognise and stand against the unprofessional practices of doctors.
Conclusion and recommendations
A doctor concurring sexually with a patient is a serious professional misconduct that can give rise to dire repercussions for the patient, the doctor, and the medical fraternity. Moreover, although statistically the prevalence of such a transgression is not high on the surface, it should be seriously cogitated, as there can be many unreported subtle incidences, particularly among psychiatrists, gynaecologists, and general practitioners.
Without indulging in emergent erotic feelings, one should fathom the limits of the professional relationship, and if overwhelming, these feelings should be brought into conscious awareness and modified cognitively, failing which, the patient should be handed over to a colleague (G.A. Golden and M. Brennan’s ‘Managing erotic feelings in the physician-patient relationship’). If the patient directly expresses sexual feelings or overtures, he/she should be made aware that the relationship is professional and consists of strict limitations or if the expressions are more indirect, the same message should be made implicit by being more formal with the patient. Every healthcare provider should be able to recognise inappropriate behaviours and not act inappropriately due to their emotional attraction to patients; hence, in addition to professional ethics, topics on emotional regulation, transference, and countertransference should be taught in medical schools, postgraduate training and in courses meant for professional development.
The Sri Lanka Medical Council (in the Guidelines on Ethical Conduct for Medical and Dental Practitioners Registered with the SLMC states that "It is essential that doctors have a nurse or chaperone, especially when examining patients of the opposite sex" and that doctors "must not use [their] professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to him/her"), in concert with academic bodies of all medical specialties should conduct awareness raising programmes for the medical fraternity and the general public regarding professional ethics and boundary related violations, thereby creating a culture that imposes on sexual misconduct. In addition, academic bodies of various medical specialities should implement formal ethical committees to conduct peer feedback to help doctors reflect upon their potential misconduct and restore professional etiquette. Yet, doctor-patient sexual relationships could occur despite professional ethical prohibitions; hence, as a deterrent, the SLMC and the other relevant legal bodies should adhere to the zero tolerance of such serious professional misconduct and observe strict punitive actions.
The medical profession is known to be at a critical juncture not only in terms of abuse against patients but also in relation to the sexual harassment of colleagues and trainees. The UK and American health authorities have even implemented programmes such as ‘active bystander training’ to empower potential victims to stand against it.