Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation

The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.While some cases of sexual exploitation involve predatory doctors, many other cases represent the culmination of a series of boundary crossings (non-exploitative departures from usual practice). The deliberate move to reduce formality in medicine has increased the likelihood of boundary crossings and violations. There are also individual doctor risk factors; boundary violations appear more likely when doctors are under stress, with insufficient emotional support. Preventive strategies include continuing education about ethics and the management of professional boundaries, along with appropriate psychological support structures for doctors. Doctors are often involved in other professional relationships as teachers, supervisors and team leaders; inappropriate sexual behaviour in these relationships is harassment. Public pressure for more punitive responses is likely if the profession is not seen to be doing all it can to deal with these issues effectively, and to be cooperating with other responsible agencies.Cherrie A Galletl

Ethical Problems Regarding Sex between Therapist and Patient

The sexual exploitation of patients by their therapists has been a perennial thorn in the side of psychiatry. Surveys of therapists have revealed that 5–10% have engaged in sexual activity with patients, while about 40% of psychiatrists admit knowing at least one such colleague. Forensic psychiatrists are also subject to sexual misconduct, although the national organization, the American Academy of Psychiatry and the Law, has traditionally relied on the far larger American Psychiatric Association (APA) to adjudicate such charges against its members. An examination of the workings of a large APA District Branch Ethics Committee suggests that psychiatrists can successfully investigate, discipline, and deter unethical behavior by colleagues. Although due-process considerations impose certain limitations on ascertaining the veracity of some allegations of sexual abuse, the ethics committee remains a viable means to safeguard the standards of our profession

Physicians' Experiences with Patients Who Transgress Boundaries

BACKGROUND: Boundary violations have been discussed in the literature, but most studies report on physician transgressions of boundaries or sexual transgressions by patients. We studied the incidence of all types of boundary transgressions by patients and physicians' responses to these transgressions. METHODS: We surveyed 1,000 members of the Society of General Internal Medicine (SGIM) for the number of patient transgressions of boundaries which had occurred in the previous year. Categories were created by the investigators based on the literature. Physicians picked the most important transgression, and then were asked about their response to the transgression and its effect on the patient-physician relationship. Attitudinal questions addressed the likelihood of discharging patients who transgressed boundaries. The impact of demographic variables on the incidence of transgressions was analyzed using analysis of variance. RESULTS: Three hundred thirty (37.5%) randomly selected SGIM members responded to the survey. Almost three quarters of the respondents had patients who used their first name, while 43% encountered verbal abuse, 39% had patients who asked personal questions, 31% had patients who were overly affectionate, and 27% encountered patients who attempted to socialize. All other transgressions, including physical abuse and attempts at sexual contact, were uncommon. Only gender affected the incidence of transgressions; female physicians encountered more personal questions (P = .001), inappropriate affection (P < .005), and sexually explicit language (P < .05) than male physicians and responded more negatively to boundary transgressions. Respondents dealt with transgressions by discussion with the patient or colleagues or by ignoring the incident, but such transgressions generally had a negative impact on the relationship. Most physicians would discharge patients who engaged in physical abuse or attempts at sexual contact, but were more tolerant of verbal abuse and overly affectionate patients. CONCLUSIONS: Boundary transgressions by patients is common, but usually involves more minor infractions. Female physicians are more likely to encounter certain types of transgressions. The incidence and outcomes of such transgressions are important in assisting physicians to deal effectively with this issue