Physician Patient

Sexual Boundaries: The Conduct, the Code and the Consequences

Abstract

Health services professions agree that sexual relations between treating clinicians and their patients are harmful and should not be tolerated. Minnesota law and regulations encourage identification of offending clinicians in order to protect the public. Regulatory agencies such as the Minnesota Board of Medical Practice seek to stop licensed professionals from engaging in sexual behavior with patients and also, when feasible, to restore medical professionals to competent practice. The authors recommend individualized psychiatric assessment and therapy for physicians who violate professional standards.

The term “professional sexual misconduct,” often used to refer to physicians’ sexual boundary violations with patients, is somewhat of a misnomer because there is simply no professional justification for doctors or other clinicians to engage in sexual behavior with their patients. Sex between physicians and patients, including flirting and seductive talk, clearly undermines patient trust, violates the fiduciary responsibilities of physicians to patients, isolates physicians from their medical colleagues, and cripples the therapeutic power of the doctor-patient alliance. So the zero-tolerance standard for sexual misconduct is appropriate and in no way puritanical or prudish. The standard is based on a broad consensus that the medical profession, policymakers, and the professional licensing boards must be empowered to protect the public. Despite agreement about these standards, physician-patient sexual relationships continue to occur. Although their prevalence is not fully known, published surveys have indicated that 9% of doctors acknowledge having had sexual contact with patients in the past, and 23% of patients report past sexual contact with physicians.(1)

It is not believed that doctor-patient sex is on the rise in Minnesota, despite a lack of periodic, confidential surveys of Minnesota physicians about sexual involvement with their patients. Nonetheless, heightened public and professional awareness here and nationwide is leading to better identification of suspected cases.

The Slippery Slope

Doctors who serve as reviewers and consultants for the Minnesota Board of Medical Practice (BMP), which investigates such reports, note the slippery slope of how boundary crossings progress to boundary violations. Both physician and patient, knowingly or unknowingly, may allow a relationship to progress toward one that is inappropriate.(2) A “grooming sequence” ensues when patient and physician begin addressing each other by first name. The professional persona of the examining room fades at the door, physician self-disclosure turns into doctor revelations of personal and sexual feelings, office visits may be extended while the length of other patients’ visits is disregarded, and physician record keeping deteriorates for the patient with which the physician is involved. Physical contact begins with hugs and kisses on the cheek; the physician may discuss other patients with the special patient; they begin meeting at a restaurant outside the office; the physician stops charging the patient, and/or the patient’s bill mounts without discussion of it or attempts to collect on it; office visits for the special patient are moved to the end of the day; and dating begins.

It is not uncommon for the patient to wish to continue the “new” relationship. The patient at times will threaten to turn the doctor in to the medical board or notify his or her clinic authority if the doctor threatens to end the relationship, and very often the doctor becomes anxious about maintaining the secret. Most complaints to the BMP occur after it becomes clear to the patient that the doctor is unwilling or unable to sustain or terminate the relationship.

Such complaints are relatively rare. The Minnesota BMP, which regulates the state’s 18,000 physicians, reported that 20 (2%) of its 941 total complaints about physicians and other health care providers it oversees in fiscal year 2004 alleged that a licensee had engaged in sexual activity with a patient.(3) Complaints of sexual misconduct are automatically referred to and investigated by the Minnesota Attorney General’s office. Investigation into the complaint often involves the patient, doctor, doctor’s staff, and other parties. A doctor’s medical record also is carefully scrutinized.

Appeal to an Outside Authority

Most physicians encourage patients to inform them or their associates when grievances or questions arise about their care. However, approaching a doctor about sexual issues, especially when it involves the doctor’s own behavior, or when a patient-doctor relationship has already become sexual is not often a realistic option for patients or their families. Patients already feel exploited by the doctor, and they commonly believe that the doctor’s colleagues will not be receptive to their concerns. Patients who have discussed their experiences with representatives from the BMP or investigators from the attorney general’s office or during psychotherapy often report that they expect to be humiliated, put off, or bullied by the doctor because so much is at stake for the doctor.

Indeed, the doctor is responsible for the conduct of a doctor-patient relationship when sex occurs.(4) Thus, patients who perceive or experience unwelcome or invited sexual behavior from their doctor cannot in most cases work this out with the doctor. Moreover, when the patient does notify the doctor’s clinic or employer who determines that the patient’s complaint is credible, the doctor is often suspended from clinical practice and may be terminated as an employee.(5) Patients in such cases need special attention from the clinic to cope with their trauma and needs for care continuity. Doctors should immediately seek legal counsel and consult their professional liability insurance carrier, which may or may not indemnify sexual violations with patients.

To address the inherent imbalance of power in the doctor-patient relationship, Minnesota passed legislation in 1996 not only prohibiting physician conduct that is sexual or that may be reasonably interpreted by the patient as sexual and verbal behavior that is seductive or sexually demeaning to a patient, but also identifying the grounds by which a physician may lose his or her license to practice medicine.(6)

Initiating a Complaint

When a patient, the patient’s advocate, or another professional contacts the medical board alleging that a physician has exhibited inappropriate sexual behavior, talk, or innuendo, there is an assumption that the complaint has merit. Moreover, if the doctor has already been the subject of past complaints to and/or investigations by the BMP for any reason, the BMP will review the previous cases as well as the new complaint.

The professional literature reports that sexual abuse claims more often than not have a basis. But there are situations in which physicians may be falsely accused of substantial sexual boundary violations with patients. These may involve misinterpretation of remarks made in haste. Also, patients may be angry with or frightened by the doctor for reasons that are not immediately apparent. Frequently, such cases are associated with unpaid bills, a perception that the doctor is not sensitive to the patient’s concerns, and in some cases, the false belief that the doctor is in love with or desires to establish an intimate relationship with the patient.(7) For that reason, staff from the BMP and the attorney general’s office are trained to consider such situations and to not rush to judgment about the facts or presume that the doctor is guilty when they investigate a complaint.

In 5 states, sexual misconduct by professionals is now addressed under civil statute, and in 16 states, including Minnesota, sexual misconduct by health professionals is considered a criminal offense as well.(5)

Treatment and Accountability

There is no single diagnostic profile or set of psychiatric criteria to describe physicians who become involved in sexual relationships with their patients. In many cases, physicians—and sometimes patients who cross sexual boundaries—are using/abusing alcohol, illicit drugs, or prescription medications; have untreated mental disorders; or have a combination of these problems. The Minnesota Health Professional Services Program (HPSP) (www.hpsp.state.mn.us) provides monitoring for physicians who are seeking treatment for chemical dependency or mental health issues.(8) The HPSP monitors physicians and other licensees who have such diagnoses and are engaged in therapy or rehabilitation. Their treating physicians and other professionals submit periodic reports to HPSP, which report on a physician’s progress or compliance to the BMP.

A small number of sociopathic doctors sexually exploit patients simply because they believe they can get away with this behavior. These doctors are unlikely to pursue meaningful psychotherapy; and they may or may not tolerate being monitored by the BMP. Most offending physicians, however, realize that they have made poor choices and regret them. Carr contrasts the characteristics of physicians who can achieve rehabilitation with those who cannot. Among the disease and physician characteristics that Carr considers to be indicators of a positive prognosis for physicians who have committed sexual boundary violations are: having a substance-related disorder diagnosis, being able to be honest, being motivated/compliant, showing remorse, showing empathy for the victim (in this case, the former patient), insightfulness, having a recovery and peer support system in place, having an ongoing positive relationships with family and significant others, having recent identifiable psycho-social stressors, and having treatable mental disorders.(6) Bad prognosticators include: acting out despite sanctions or when under monitoring, refusing to end a sexual relationship, being profoundly self absorbed (narcissistic), being very dependent on the approval of others, refusing to allow or accept advice and support from peers and family, having pervasive boundary violations, and showing strong antisocial traits.

For most physicians, the ultimate goal of their treatment is rehabilitation and return to medical practice. To achieve this, they must be able to sustain safe and healthy doctor-patient relationships. Based on our experiences working with impaired physicians, we agree with Carr that most physicians who have committed a sexual boundary violation can be rehabilitated so that they can return to practice.(6) This may require different practice settings or degree of supervision. In some cases, career change may be necessary. For physicians in psychotherapy, treatment goals and strategies include an understanding of factors leading to doctor-patient boundary violations and rehearsing scenarios for alternative behaviors. Thus, part of the psychotherapy is an ongoing analysis of the physician’s skill and comfort maintaining appropriate professional boundaries with patients.

Nonetheless, the priority of the medical board is to protect the public from exploitative doctors. For that reason, the psychiatrist, counselor, or therapist working with a physician who has crossed boundaries should not offer guarantees of confidentiality if the problem behavior reoccurs. In this sense, the therapy model for treating these physicians is similar to that of military psychiatrists or occupational physicians who examine patients for work readiness and report to the employer if the subject is unfit for duty. This obligation can pose a conflict for the psychiatrist or therapist unless the treating doctor and the patient are each committed to the primary goal of public protection.

Summary

Physicians who cross sexual boundaries with patients place themselves in great peril. They risk tainting or destroying their professional reputations; damaging their health; and losing their jobs, contracts with payers, and hospital privileges. They jeopardize their financial security, bring shame to and conflict within their families, and may lose their license to practice medicine. Public awareness about the problem of sexual boundary violations by professionals is growing, as is disdain for all persons in fiduciary roles who engage in sex with those for whom they are responsible and over which they have power, whether they be wards, patients, or parishioners. The clergy scandals in the Catholic church highlight this growing public intolerance. Sexual misconduct is a serious black mark on a physician’s career. However, some physicians who demonstrate remorse, undergo therapy, and are willing to work with the Board of Medical Practice to regain the public trust can reclaim their careers.

The opinions expressed in this article are the author’s and do not represent positions of the Board Medical Practice or any other state agency.

Acknowledgement

The authors wish to thank Christina Rich, J.D., legal counsel for the Minnesota Medical Association, and Monica Feider, M.S.W., LICSW, HPSP Program Manager for their help in preparing this article.

Lee H. Beecher, M.D. is a psychiatrist in private practice in St. Louis Park, president of the Minnesota Physician-Patient Alliance, and a clinical associate professor of psychiatry at the University of Minnesota. Steven I. Altchuler, M.D., Ph. D. is co-chair of the Division of Tertiary Psychiatry and Psychology at Mayo Clinic in Rochester, MN, and serves as vice president of the Minnesota Board of Medical Practice.

Footnotes

Gartrell ND, Milliken N, Goodson WH, Thiemann S, Physician-patient sexual contact: prevalence and problems. West J Med 1992;157:139-143.
Simon RI. Therapist-patient sex. From boundary violations to sexual misconduct. Psychiatr Clin North Am. 1999;22:31-47.
Minnesota Board of Medical Practice. Report to the Minnesota Medical Association House of Delegates, September 2004
Beecher LH. Doctor-patient boundaries: road rules and red flags. Minn Healthcare News. 2005l3(2):28-30.
Carr GD. Professional sexual misconduct—an overview. J Miss State Med Assoc. 2003;44(9):283-300.5.
Minnesota Statutes, Chapter 147. Physician Practice Act.
Gutheil TG, Gabbard GO. Obstacles to the dynamic understanding of therapist-patient sexual relations. Am J Psychother. 1992;46(4):515-25 (1992).
Roberts K, Specker S. The health professional services program: an alternative for physicians with psychiatric disorders. Minn Med. 1999;82(10):54-6.

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