Sexual Boundary Violations

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Sexual Boundary Violations

• Robert S. Crausman, MD, MMS

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Sexual Misconduct by Physicians

• Physician Impairment
• Adversely affects public welfare
• Exploits the physician-patient relationship
• All Medical Boards
• All States
• All Specialties

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Boundary Violations

• Sexual relationships with a patient are wrong
• Enough said?

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Report on Sexual Boundary Issues by the Ad Hoc
Committee on Physician Impairment,FSMB April 1996

• Although a mental disorder may be the basis
• Sexual misconduct is not caused by
  physician/mental impairment
• DSM IV does not recognize sexual addiction

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Physician sexual misconduct is

• Wrong
• Behavior that exploits the physician-patient
  relationship in a sexual way.
• Nondiagnostic and nontherapeutic
• Verbal or physical
• Expressions of thoughts or feelings or gestures
  that are sexual or reasonably construed as such

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Sexual violation may include...

• Sex, initiated by physician or patient
• Kissing in a romantic or sexual manner
• Touching any sexualized body part for any purpose
  other than appropriate examination or treatment
• Offering practice related services such as drugs
  in exchange for sex

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Sexual impropriety includes

• Disrobing or draping practices that reflect a
  lack of respect for patient privacy including
  deliberately watching
• Subjecting a patient to an intimate examination
  in the presence of students or others without
  explicit consent
• Examination of genitals without the use of gloves
• Examining the patient intimately without consent

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Sexual impropriety includes

• Inappropriate comments about or to the patient
  including those about underclothing, sexualized
  or sexually demeaning comments, criticizing
  sexual orientation, commenting about potential
  sexual performance except when the consultation
  is pertinent to the issue of sexual function,
  requesting details of sexual history, likes or
  dislikes when not clinically indicated
• Conversation regarding the sexual problems,
  preferences or fantasies of the physician

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What does the AMA say?

• A physicians ethical duties include terminating
  the physician-patient relationship before
  initiating a dating, romantic, or sexual
  relationship with the patient
• A relationship with a former patient is unethical
  if it uses or exploits trust, knowledge,
  emotions, or influence derived from the previous
  professional relationship

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What doesnt the AMA say?

• A clearly stated length of time that should pass
  between the termination of the physician-patient
  relationship and the initiation of a romantic or
  sexual relationship.

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Warning signs for Docs

• Specialness
• Intense attraction
• Behavior changes during visits
• Violating clinical norms
• Professional isolation
• Excessive disclosure
• Danner, C. Boundaries and the patient physician
  relationship. Behavioral medicine briefs issue 24
  Sep 2002.

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Even without overt sexual contact

• The failure to render needed therapy
• Failure to refer hanging on
• Unhealthy dependency
• Confusing the patient about what is therapy and
  what is personal
• Breach of trust
• Interference in family relationships
• Psychological distress
• Schoner, G. boundary violations in the
  professional relationship. Available at
  www.advocateweb.org

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Gray areas

• Gifts
• Friendships
• Employees
• Social gatherings
• Special events

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Does physician specialty matter?

• Psychiatrist
• Primary care physician
• Urgent care physician
• Consultant
• Cross covering physician

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Guidelines for State Boards

• Should have the authority to investigate
  allegations of sexual misconduct
• Should intervene when there is a reasonable
  probability of sexual misconduct
• Should have the authority to order comprehensive
  evaluation

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Patient sensitivity

• Cases are unique
• Individual evaluation
• Proper procedures for dealing with victims with
  sensitivity
• Female investigators interview female victims
• Special training
• Support persons present
• Opportunities to appear before Board or
  subcommittees
• Confidentiality

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Patterns of behavior

• Isolated case or pattern of behavior?
• Most represent a pattern
• Pattern predatory behavior

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Comprehensive psychiatric evaluation

• Expertise with physician boundary cases
• Independent
• Former sexual misconduct offenders should not
  perform evaluations
• Release of all information to the board

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Hearings/considerations

• Patient harm
• Severity
• Culpability
• Psychotherapeutic relationship
• Age of patient minor
• Frequency of behavior
• Number of patients
• Duration
• Evaluation/assessment results

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Monitoring

• Supervision in workplace by supervisory physician
• Chaperones
• Periodic on site review
• Practice limitations
• No pelvic/breast examinations
• No opposite sex examinations
• Regular reports and interviews

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RI BMLD

• We have disciplined 23 physicians for sexual
  misconduct over the past decade.
• 22 were male and 1 was a female doctor.
• we investigate the facts and circumstances around
  the physician-patient relationship, and obtain an
  independent multidisciplinary psychiatric
  assessment of the physician.
• gt90 percent admit to the relationship.

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Disagreement amongst experts