Physician Characteristics Involved in Misconduct Sexual misconduct happens in all types of practice settings in all states. 1 Some reports indicate that greater numbers of reported allegations involve the fields of family medicine, psychiatry, internal medicine, and obstetrics and gynecology. 9,13 Sexual misconduct by physicians during labor and delivery has been reported in a large survey of U.S. and Canadian obstetric support personnel, who reported hearing use of sexually degrading language with laboring women or witnessing the performance of genital examinations or procedures without patient consent. 19 An investigation conducted by The Atlanta Journal-Constitution also found acts of physician sexual abuse in anesthesiology, ophthalmology, pediatrics, and radiology. 12 Encouragingly, there is some indication that education and awareness, the identification of high-risk practitioners, and the appropriate use of deterrence in the form of disciplinary action by state boards are useful in lowering the number of complaints. 13,20 A question is whether there are some commonalities of sexual misconduct in physician characteristics. Of 101 cases of sexual violations in medicine analyzed for physician and patient characteristics, practice settings, kinds of violations, and consequences to the perpetrator, the five most common characteristics of offenders were: 6
Physicians who molested children were more likely to commit sexual offenses such as exhibitionism or voyeurism with other patients than were physicians who engaged in other forms of sexual abuse. 6 Physicians who committed child molestation, nonconsensual, non-penile anal or vaginal penetration , and rape were much more likely to engage in inappropriate comments and touching with other patients than physicians who engaged in consensual sex. Personality disorders were suspected most frequently in cases of rape, and board certification was more common in cases of consensual sex with patients. 6 In another study, a chart review of 120 physicians monitored for boundary violations by a single Physician Health Program (PHP) in Colorado found that, compared to the general PHP population, more individuals with violations were men between 40 and 49 years of age, had been mandated for evaluation, and reported an abusive history. 21 Diagnoses varied, but mood disorders, adjustment disorder, and substance-use disorders were common (Figure 1). 21 Although certain physician characteristics (older, male, non-board-certified, in private practice) were associated with more deviations, these characteristics are also frequently shared by the vast majority of physicians who never commit any type of offense. Therefore, characteristics alone cannot and should not be used to infer that a physician is likely (or unlikely) to be an offender. Physician sexual misconduct is usually male to female but can happen to anyone of any age, racial or ethnic background, gender identity, or sexual orientation. Furthermore, reports of sexual boundary violations of patients by females do occur. 22 In most cases, misconduct happens more than once and when a physician is alone with a patient without a chaperone present. 6 However, some instances of misconduct take place with others present: 19% of cases of nonconsensual, non- penile anal or vaginal penetration occurred with a chaperone, parent, nurse, or other individual in the room with the patient and physician. 6
Ambulatory or office-based settings are at risk for boundary-violating behavior, perhaps because there is less scrutiny and oversight, and the physician is more often a sole authority. 23 Cases also have been publicized of physicians violating unconscious or otherwise compromised patients. 14 In any practice setting, including hospitals and emergency rooms, patients with special vulnerabilities for abuse include anesthetized patients, patients who do not speak English or whose immigration status make them less likely to report misconduct, minors, and Preventing sexual misconduct begins with preventing sexual harassment. The AMA Code of Medical Ethics Opinion 9.1.3 defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature.” 24 Sexual harassment of colleagues by physicians is an unethical abuse of power that interferes with work performance and appropriate professional advancement. The hostile environment created by harassment sets a culture in which professional boundary violations with patients become conceivable. A professional boundary is a term that encompasses respect for the personal bodily and psychological integrity and separateness of the patient. 25 A boundary crossing is a benign modification of the therapeutic relationship on behalf of the patient, such as accepting a hug or a gift of modest value from an appreciative patient. 25 Boundary crossings may differ across specialties and context, lack the motive of exploitation, and can usually be discussed and altered. In contrast, sexually-motivated contact with a patient is an absolute (i.e. black-and-white) boundary violation. One example of a boundary violation would be including a patient’s confidential clinical information in a published report without consent. Sexual misconduct with a patient is an extreme and egregious boundary violation. patients with limited mental capacity. Definitions and Kinds of Misconduct Physician sexual misconduct is defined by the FSMB as behavior that exploits the physician-patient relationship in a sexual way. 1 The behavior may be verbal or physical, occur in person or virtually, and may include expression of thoughts and feelings or gestures that are of a sexual nature or that a patient (or patient surrogate) may reasonably construe as sexual. 1 The FSMB further divides sexual misconduct into two categories: sexual impropriety and sexual violations. (Examples may include but are not limited those shown in Table 2). 1,13 Sexual misconduct behaviors exist along a continuum of escalating severity. Behaviors that constitute sexual impropriety might include inappropriate gestures or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. 1 Inappropriate language or gestures have the effect of embarrassing, shaming, and humiliating the patient. Such sexual impropriety can take place in person, but may also occur online, by mail, by phone call, and by text. 1
• Male physicians (100%) • Older than age 39 (92%) • Not board certified (70%)
• Practiced in nonacademic settings (94%) • Always examined patients alone (85%)
Primary forms of sexual violations were as follows: 6 • 33% inappropriate touching • 31% non-penile anal or vaginal penetration without consent • 16% rape • 14% child molestation • 7% consensual sex
Figure 1. Diagnoses Among Physicians with Boundary Violations 21
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