Crossing the Line: Sexual Boundary Violations by Physicians

| June 29, 2009 | 0 Comments

by Randy A. Sansone, MD, and Lori A. Sansone, MD

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2009;6(6):45–48

ABSTRACT

In this edition of The Interface, we review the literature related to sexual boundary violations by physicians. This literature consists of data from both disciplinary boards/agencies and anonymous surveys of physicians. Our findings indicate that disciplinary actions far under-represent the actual prevalence of self-reported physician boundary violations of patients. However, both prevalence rates represent a very small minority of practitioners. According to these findings, most self-reported boundary violations entail male physicians who are predominantly in the areas of family medicine, psychiatry, and obstetrics/gynecology.

Key words

boundaries, sexual relationships, physician/patient relationship

Introduction

In this edition of The Interface, we discuss the uneasy topic of sexual boundary violations by physicians. In our review of the literature, there is relatively scant empirical information in this area. However, in the following article, we present and summarize the available literature.

The Prevalence of Sexual Boundary Violations by Physicians

In the current literature, the available empirical data are based upon either disciplinary actions undertaken by state medical boards/federal agencies or self-report information that was obtained by investigators through anonymous surveys. Note that these sources of information are reliant upon either discovery or disclosure, which is likely to be conditionally determined. Therefore, as is the case with many other types of research, we are likely to be tapping into prevalence rates that may under-represent the genuine prevalence rate.

Disciplinary Reviews by State Medical Boards/Federal Agencies

There are four US studies of disciplinary actions of physicians by state medical boards/federal agencies. These offer some modest indication of the prevalence of sexual boundary violations by physicians. In the first study, Post[1] reviewed the disciplinary actions of the Office of Professional Medical Conduct for the State of New York from 1985 through 1989. During this time period, 68 physicians were disciplined for the sexual violation of patients. Given that the total number of physicians in the state at that time was “more than 40,000,” the rate of sexual boundary violations in this cohort was minimally 0.2 percent.

In the second US study, Enbom and Thomas[2] examined sexual misconduct complaints among 80 licensees who were under the jurisdiction of the Oregon Board of Medical Examiners between the years 1991 and 1995. Of these licensees, 77 were physicians. Given that 4,931 physicians were licensed by the state at that time, the prevalence rate of sexual misconduct complaints in this cohort was 1.6 percent. As for medical specialty, family medicine, psychiatry, and obstetrics/gynecology had the highest proportion of complaints.

In the third US study, Dehlendorf and Wolfe[3] examined a national database of disciplinary actions undertaken by both state medical boards and federal agencies. In this study, a total of 761 physicians were disciplined for sex-related offenses between the years 1981 and 1996; 75 percent of the allegations involved patients. The researchers examined the trends in the frequency of patient complaints and found that during this 15-year time period, the number of disciplined physicians increased. However, this finding may have been affected by a number of variables, including victims’ increasing willingness over the study period to report allegations. According to these data, 1994 was the year with the highest rate of physician disciplines for sex-related offenses, which affected 0.02 percent of all physicians in the country.

In the fourth US study, Morrison and Wickersham[4] examined the causes of physician disciplinary action undertaken by the Medical Board of California during a 19-month study period (October 1995–April 1997). In this study, 37 of the 104,000 physicians (0.04%) in the state underwent some type of action by the board for either inappropriate or actual sexual contact with patients. In comparison with the other types of offenses addressed by the board, those relating to sexual misconduct were fifth in frequency, preceded in order by negligence or incompetence (most common), inappropriate prescribing or drug possession, alcohol or other drug impairment, and fraud.

In addition to these data from US boards/agencies, there is one published British study on the disciplinary actions meted out to physicians. In this study, Donaldson5 examined the prevalence of “serious” disciplinary problems among the medical staff (N=1,274) of a large national health service workforce. Among this cohort, seven physicians (0.5%) were disciplined for “sexual overtones” in dealing with patients as well as staff. Donaldson described these specific physician behaviors as longstanding and repetitive in most cases.

Physician Surveys

In the area of sexual boundary violations by physicians, we encountered in our review of the literature a number of anonymous survey studies. Of these, only three explored such behaviors among physicians in the US. In the first of these studies, Kardener and colleagues examined the prevalence of sexual involvement between patients and four specialty groups of physicians who were members of the California Medical Society—family medicine, internal medicine, obstetrics/gynecology, and surgery.[6] The overall prevalence rate of sexual boundary violations in this 1973 cohort was 7.2 percent, with the highest rate being among family medicine physicians.

In a second US study, Gartrell and colleagues surveyed 10,000 physicians in the fields of family medicine, internal medicine, obstetrics/gynecology, and surgery—all who were members of the American Medical Association.[7] Of the 1,891 individuals who responded (a response rate of less than 20%), 9.3 percent acknowledged sexual contact with one or more patients. Interestingly, in this same sample, 94 percent of respondents opposed sexual contact with current patients, indicating that six percent were not opposed to such contact. Another perspective on these 1992 data is the following: Given a 20-percent response rate and a nine-percent prevalence rate, if the remaining 80 percent of nonrespondents reported no sexual contact with patients, the resulting overall rate would still be two percent.

In a third US study, Bayer, Coverdale, and Chiang[8] surveyed a randomized sample of 1,600 physicians in the American Medical Association in the specialties of internal medicine, family medicine, obstetrics/gynecology, and ophthalmology. Among the 787 respondents, 3.3 percent reported sexual contact with patients. In this 1996 study, there was no difference in prevalence rate among the medical specialties.

In addition to these US studies, several have been conducted in other countries. For example, in a Dutch study, Wilbers et al[9] surveyed over 700 physicians in two national professional societies—gynecology and otolaryngology. The researchers specifically elected otolaryngologists as a comparison group—i.e., a group that would not normally engage in any intimate examination of patients. Somewhat unexpectedly, 3.6 percent and 3.5 percent of gynecologists and otolaryngologists, respectively, reported sexual contact with patients (i.e., there was no statistically significant difference between the study groups).

In a 1995 study from the University of New Zealand, Coverdale et al[10] mailed an anonymous survey to 217 general practitioners. With a response rate of 86 percent (N=186), 3.8 percent of the sample reported having had sexual contact with a current patient.

In a 1996 Israeli study, Rubin and Dror[11] examined and compared the prevalence of sexual boundary violations between psychologists (n=96) and nonpsychiatric physicians (n=72). In exploring sexual contact with a past or current patient or supervisee, the researchers determined that the prevalence rates were 3.4 percent and 14.5 percent for psychologists and nonpsychiatric physicians, respectively.

In a final study from the Netherlands, Leusink and Mokkink[12] mailed anonymous surveys to a randomized sample of 1,250 general practitioners. With 977 respondents, the researchers experienced an 80-percent response rate. Among the respondents in this 2004 study, 32 (3.3%) reported sexual contact with a patient at some time in their careers and 11 of these (34%) acknowledged sexual contact with two or more patients.

Data Comparisons

Prevalence rates. Clearly, there is a notable difference between the percentage of physicians being disciplined by state and federal agencies (1.6% or less) and the self-reported rates of physician sexual contact with their patients (up to 14.5% in the Rubin and Dror study11) (Table 1). This vast divide is potentially wider, given the likelihood that a substantial number of physicians declined to participate in these survey studies because of fears of disclosure of boundary violations.

Another way to analyze these prevalence data is to combine all of the US self-report samples into a single sample. In doing so, a total of 257/3758 physicians reported sexual boundary violations with patients. This represents a prevalence rate of 6.8 percent. This mean prevalence rate is particularly interesting given the survey results of Coverdale et al,[13] who found that less than one percent of US physician respondents believed that sexual contact with patients is appropriate during consultation.[13] In addition, only three percent believed that sexual contact with current patients outside of consultation is appropriate.[13]

Specialty differences. In those studies that compared differences in rates among specialties, physicians most at risk for boundary violations with patients appear to be practitioners in the fields of family medicine, psychiatry, and obstetrics/gynecology,[2,6,7,14] although one study found no differences.[8] Perhaps the heightened risk in these specialties is explained by the patient/physician dyad’s greater likelihood of physical contact and/or psychological intimacy. However, in the study by Wilbers et al,[9] which was designed to explore these very hypothesized elements, the researchers found no differences in the prevalence rate of boundary violations between gynecologists and otolaryngologists.

Gender patterns. Note in Table 1 that the clear majority of boundary offenders are male. This may reflect the continuing male predominance in medicine and/or inherent gender differences in behavior.

Training backgrounds. The study by Enbom and Thomas[2] was the only investigation we encountered that examined the training backgrounds of physicians charged with boundary violations. In this study, osteopathic physicians were four times more likely to be disciplined for boundary violations with patients than allopathic physicians.[2] The veracity of this finding warrants further investigation. If confirmed by future data, what would explain these differences?

Conclusions

These data indicate that 1.6 percent or less of physicians are disciplined for sexual boundary violations with patients, yet on average, according to anonymous self-report surveys, nearly seven percent of respondents report a history of sexual relationships with patients. Most offenders are male (greater than 85%) and are likely to be in the fields of family medicine, psychiatry, and obstetrics/gynecology. While more research is needed, the study of sexual boundary violations by physicians with their patients is likely to remain a murky area. Indeed, such behaviors are clandestine, associated with substantial social stigma, and subject to punishment by licensing agencies. However, continued physician awareness and education will hopefully promote and reinforce appropriate professional boundaries with patients, which the overwhelming majority of physicians seem to manage without difficulty.

References

1. Post J. Medical discipline and licensing in the State of New York: a critical review. Bull N Y Acad Med. 1991;67:66–98.
2. Enbom JA, Thomas CD. Evaluation of sexual misconduct complaints: the Oregon Board of Medical Examiners, 1991-1995. Am J Obstet Gynecol. 1997;176:1340–1346.
3. Dehlendorf CE, Wolfe SM. Physicians disciplined for sex-related offenses. JAMA. 1998;279:1883–1888.
4. Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279:1889–1893.
5. Donaldson LJ. Doctors with problems in an NHS workforce. BMJ. 1994;308:1277–1282.
6. Kardener SH, Fuller M, Mensh IN. A survey of physicians’ attitudes and practices regarding erotic and non-erotic contact with patients. Am J Psychiatry. 1973;130:1077–1081.
7. Gartrell NK, Milliken N, Goodson WH 3rd, et al. Physician-patient sexual contact. Prevalence and problems. West J Med. 1992;157:139–143.
8. Bayer T, Coverdale J, Chiang E. A national survey of physicians’ behaviors regarding sexual contact with patients. South Med J. 1996;89:977–982.
9. Wilbers D, Veenstra G, van de Wiel HB, Weijmar Schultz WC. Sexual contact in the doctor-patient relationship in the Netherlands. BMJ. 1992;304:1531–1534.
10. Coverdale JH, Thomson AN, White GE. Social and sexual contact between general practitioners and patients in New Zealand: attitudes and prevalence. Br J Gen Pract. 1995;45:245–247.
11. Rubin SS, Dror O. Professional ethics of psychologists and physicians: morality, confidentiality, and sexuality in Israel. Ethics Behav. 1996;6:213–238.
12. Leusink PM, Mokkink HG. Sexual contact between general practitioner and patient in the Netherlands: prevalence and risk factors. Ned Tijdschr Geneeskd. 2004;148:778–782.
13. Coverdale J, Bayer T, Chiang E, et al. National survey on physicians’ attitudes toward social and sexual contact with patients. South Med J. 1994;87:1067–1071.
14. Enbom JA, Parshley P, Kollath J. A follow-up evaluation of sexual misconduct complaints: the Oregon Board of Medical Examiners, 1988 through 2002. Am J Obstet Gynecol. 2004;190:1642–1650.

Category: Past Articles, Primary Care, Psychiatry, Psychology, The Interface

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