Table 2. Examples of Physician Sexual Misconduct 1,2
Sexual Impropriety
Sexual Violations
Neglecting to employ disrobing or draping practices respecting patient privacy or Deliberately watching patient dress or undress
Sexual intercourse, genital-to-genital contact
Performing intimate examination or consultation without clinical justification or appropriate consent Subjecting patient to intimate examination in presence of medical students or other parties without patient’s informed consent or informed consent withdrawn Examining or touching genital mucosal areas without the use of gloves (or with gloves without clinical justification) Making inappropriate gestures or comments about or to the patient, including but not limited to: • sexual comments about patient’s body or underclothing • sexualized or sexually demeaning comments to patient • criticizing patient’s sexual orientation • non-clinically-relevant comments during examination about potential sexual performance
Oral-to-genital contact
Oral-to-anal contact, genital-to-anal contact
Kissing in a romantic or sexual manner
Touching breasts, genitals, or any sexualized body part for any purpose other than appropriate examination or treatment or when the patient has refused/withdrawn consent
Using patient–physician relationship to solicit date/romantic relationship
Encouraging the patient to masturbate in the presence of physician*
Initiating conversation regarding physician’s sexual problems, preferences, or fantasies Masturbating by physician while patient is present Requesting details of sexual history, likes, or dislikes not indicated for type of examination or consultation Offering practice-related services, such as drugs, in exchange for sexual favors *The American College of Obstetricians and Gynecologists recognizes the value of physician-guided sexual health counseling in the proper clinical context by an appropriately trained provider. 1. Sexual Misconduct: ACOG Committee Opinion, Number 796. Obstet Gynecol. 2020;135(1):e43-e50. 2. Federation of State Medical Boards (FSMB). Report and Recommendations of the FSMB Workgroup on Physician Sexual Misconduct. 2020; http://www. fsmb.org/siteassets/advocacy/policies/report-of-workgroup-on-sexual-misconduct-adopted-version.pdf. Accessed November 10, 2021.
Severity further increases with physical contact that is explicitly sexual or reasonably interpreted as such. An example of a sexual violation might include performing an intimate exam without medical necessity or without obtaining informed consent. It might also involve any type of sexually- motivated physical contact with the patient. Sexual assault is any nonconsensual sexual act proscribed by federal, tribal, or state law. 13 Assault occurs through physical force, threats of force, coercion, manipulation, imposition of power, or circumstances where a person lacks the capacity to provide consent due to age or other circumstances. 1 Actions that constitute sexual assault range from sexual coercion to unwanted kissing, touching, or fondling to rape. 13 Grooming behaviors may not be misconduct but serve as precursors to more severe violations and include such actions as adjusting appointment timing to facilitate time alone with a particular patient, contacting the patient outside of clinic hours, or divulging personal information to a patient as a means to gain trust or to gauge whether an abuse opportunity exists. 1 Grooming behaviors should be taken seriously because severity of sexual misconduct tends to escalate: in one study of sexual violations by physicians, inappropriate comments or touching preceded 94% of cases of nonconsensual, non-penile anal or vaginal penetration and 88% of cases of rape. 6 It is important to understand that consent or seeming consent on the part of the patient does not alter the finding of a violation of the physician-patient relationship. 6 A sexual relationship concurrent with a treatment relationship is sexual misconduct. 25
Physical sexual contact between a physician and patient is a violation, whether or not the contact was initiated by the patient. 1 Data indicate that such encounters occur most frequently with patients whose mental health status make them vulnerable and are marked by considerable disparities in power, status, and emotional vulnerability. 17 Consider that the patient sees a physician because of a medical problem, and there may be implicit or explicit suggestion that continued care is contingent on willingness to accept sexual contact. Furthermore, treating as a patient a person with whom a physician has a current romantic or sexual relationship may violate the ethical proscription against treating family members. Physicians, therefore, must respect the inherent power differential and understand that sexual relationships with patients that are consensual or believed to be consensual breach one’s professional commitment to provide respectful, competent medical care. Relationships with Former Patients, Others in the Clinical Context The imperative to treat patients professionally does not stop when they leave a practice. It is also unethical to misuse the trust, knowledge, or influence from a professional relationship to pursue a sexual or romantic relationship with a former patient. 13 From a risk management standpoint, at minimum, if a sexual relationship is to be initiated with a patient or employee, the person must be referred elsewhere for medical care or dismissed as an employee. 26 Regardless, consent by the patient to sexual contact is not considered valid if it occurs
shortly after termination of the clinical context 1 and, in some circumstances, such relationships are never permitted. Some professional groups and disciplinary or licensing boards designate time limits for commencing a sexual relationship with a former patient following termination of a physician-patient relationship, but consensus is not complete. The American Psychiatric Association prohibits sexual activity with former patients, 27 and such relationships are viewed with grave concern by other professional associations because of the potential for undue influence and abuse of power. The American Association of Orthopaedic Surgeons (AAOS) acknowledges the variety of opinions and notes that ethical propriety depends on the nature and context of the former relationship. 14 Other professionals believe relationships with former patients are always unethical. 14 Importantly, some states prohibit dating a former patient no matter how much time has elapsed. 26 Questions that may come up are whether the termination of treatment was formally documented, whether the patient’s care was transferred to another provider, how long the treating relationship lasted, the time lapse since the physician-patient relationship ended, how much personal private information the patient confided, the nature of the patient’s health problem, and the degree of patient emotional dependence and vulnerability. 1 It is unacceptable and still considered sexual misconduct if one terminates a physician- patient relationship so that sexual contact can occur. 1
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