Canadian Medical Association Journal 1996; 154: 643-649
The second part of this article appears in the Apr. 1, 1996, issue.
Paper reprints of the full text may be obtained from: Dr. Gail Robinson, Department of Psychiatry, Toronto Hospital, 8EN-231, 200 Elizabeth St., Toronto ON M5G 2C4; fax 416 340-4198
Abstract
Introduction
Physician-patient sexual misconduct
Teacher-learner mistreatment
and harassment
Conclusion
References
Top of document
Introduction
Health care professionals, licensing bodies, governments and the community are paying increasing attention to the negative consequences of sexual misconduct by physicians. Task forces established by the colleges of physicians and surgeons in Ontario[1] and British Columbia[2] have recommended changes in medical training for physicians at all levels, from undergraduates to practising physicians, to increase the understanding of appropriate interactions and behaviours between patients and physicians. They have recommended that such training include how to set and enforce boundaries for appropriate treatment; how to give care and comfort, including touching, in an appropriate, nonsexual manner; and how to recognize signs in one's own behaviour that violations of the boundary with a patient may occur.[1] In 1993, 2 years after the release of its task force's report, the College of Physicians and Surgeons of Ontario hosted a conference for educators to promote interest in developing courses in this area.
Most physicians now practising received little if any such training when they were students. Furthermore, most medical students and residents are not receiving adequate training in the principles of ethical practice and the prevention of sexual exploitation of patients.[3,4] In addition, many investigators have noted that teachers may be responsible for mistreatment of and boundary violations vis-à-vis learners (students, residents, interns and other trainees).[5-8] Not only can this behaviour have an adverse effect on education, there is now evidence of an association between teacher-learner mistreatment, misconduct or harassment and later misconduct by physicians who were abused as students.[9,10] Again, there is inadequate education about this problem during training.[11] To reduce the abuse of patients or students, health care professionals should know the definitions, causes, consequences and warning signs of physician-patient sexual misconduct and teacher-learner mistreatment and harassment.
At the University of Toronto a committee chaired by the director of postgraduate programs in medicine and strongly supported by the dean of medicine was established to ensure that all undergraduate and postgraduate students received adequate education about appropriate physician-patient and teacher-learner boundaries. A course concerning physician-patient sexual misconduct and teacher-learner mistreatment and harassment, designed by us, was offered as a faculty development seminar to the directors of all postgraduate and undergraduate education programs in the Faculty of Medicine. The directors were then required to ensure that their faculty be instructed in this area and that teaching on this topic be included in their undergraduate and postgraduate curricula. Such teaching has now been instituted in most programs including psychiatry, family and community medicine, pediatrics, obstetrics and gynecology, anesthesia, surgery, medicine and various subspecialties of these areas.
The program includes a didactic and an experiential component. The didactic portion consists of lectures that review the causes and consequences of sexual misconduct by physicians and mistreatment and harassment of learners by teachers as well as relationships after termination of treatment. We focus on the behaviour of physicians and educators because it is their responsibility to remain professional despite any invitations, seduction or harassment on the part of patients or learners. In the faculty development seminar, the president of the College of Physicians and Surgeons of Ontario also discussed the college's complaint and discipline procedures.
This article consists of the content of the didactic portion of the curriculum. The goal of this component is to ensure that all students and educators in the Faculty of Medicine can demonstrate knowledge of the ethical issues involved in physician-patient sexual misconduct and in teacher-learner mistreatment and harassment. A subsequent article, to appear in the Apr. 1 issue of CMAJ, describes the experiential component and the evaluation of the curriculum.
Top of document
Physician-patient sexual misconduct
Studies of the frequency of sexual misconduct by physicians have suffered uniformly from poor response rates. Therefore, rather than stir up controversy about the accurate prevalence of such misconduct, the lectures focus on the behaviour and its potential to cause harm.
The definition of sexual misconduct established by the appropriate provincial regulating body may help physicians appreciate the seriousness of sexually abusing a patient. We use the following definition of sexual abuse from the Ontario Regulated Health Professions Act.[12]
Sexual intercourse or other forms of physical sexual relations between the member [of the College of Physicians and Surgeons of Ontario] and the patient; touching of a sexual nature, of the patient by the member; or behaviour or remarks of a sexual nature by the member towards the patient. Touching, behaviour and remarks that are of a clinical nature appropriate to the service provided do not constitute sexual abuse of a patient by a member.
To further clarify the definition, we list the following activities that may be included under this definition: sexual intercourse, masturbation, genital-to-genital contact, oral-genital contact, inappropriate touching of a patient including touching the patient's genitals without wearing gloves, kissing the patient, any behaviour demeaning to a patient or demonstrating a lack of respect for a patient's privacy such as watching a patient undress, sexual comments about a patient's underwear, discussions of the physician's sexual fantasies and requests to date a patient. Because physicians often fear that such rules mean that they will be chastised for mere friendliness or giving a patient a reassuring touch, we emphasize that only truly inappropriate behaviour falls under "sexual abuse."
There are elements of the physician-patient relationship that increase the potential for sexual abuse.[13,14] The patient usually comes to the physician because he or she is suffering and needs help. The patient may be anxious about symptoms or emotional problems and may feel frightened and vulnerable. He or she perceives the physician as a wise and knowledgeable person who holds the answer to the patient's problems. The physician receives the patient's trust and respect merely by virtue of his or her position. Because patients usually do not know the correct way to carry out physical examinations or psychologic treatments, they rely on the physician to ensure that they are subject to legitimate procedures, carried out ethically. This inequality between the patient and the physician is increased by the fact that the physician has the opportunity to find out everything about the patient's personal life without divulging anything about his or her own. The power differential may be accentuated when the physician is male and the patient female, since, in our society, greater power is generally accorded to men than to women.[15]
Data from surveys of physicians have shown that almost 90% of offenders are men.[16] Gabbard[17] has described four motivations of offenders: psychosis, predatory psychopathy and paraphilia, "lovesickness" and masochistic surrender. Another category -- involving an uninformed, naïve physician who lacks knowledge of ethical standards or an understanding of professional boundaries -- has also been described (Table 1).[18] Offenders are not limited to any one type of practice but can be found in all specialties.[19]
The patient may be vulnerable as a result of the power differential in the relationship, the patient's inherent trust in the physician and the patient's presenting symptoms, fears and concerns.[13,19] The patient may also develop a transference reaction to the physician. In transference, feelings about people in the patient's previous life experience are attached to the physician. The patient may, for example, see the physician as an idealized parent-like figure who deserves his or her admiration, love and obedience.
Patients may have various reasons for wanting an intimate relationship with a physician.[20,21] The patient may believe that he or she will acquire importance and an enhanced sense of self-worth by establishing a relationship with someone with a high social standing. Seductive, dependent or histrionic behaviour may be part of a patient's usual method of dealing with authority figures. Patients with a history of sexual abuse may be especially vulnerable to abuse by a physician because they may have difficulty understanding or establishing appropriate boundaries. As well, the physician may know that these patients have learned to keep secrets and tend to blame themselves when things go wrong. Because of the imbalance in the relationship, the vulnerability of the patient, the possibility of a transference reaction and, hence, the potential for exploitation in a physician-patient relationship, it is the physician's responsibility to refrain from unethical behaviour, even when the patient appears to consent to or initiate an intimate relationship.
Such abuse has many possible consequences for victims.[22] Patients' presenting problems are often ignored and, indeed, complicated as a result of abuse. Abused patients may find it difficult to trust other physicians in the future, and they often avoid physical examinations or therapy for many years. Since the abusive physician may have been kind, helpful or even loving in some ways, the patient may have confused, ambivalent and protective feelings toward the physician. Patients often erroneously blame themselves for abuse and feel guilty and ashamed. The secrecy in which abuse takes place often tends to lead to isolation and loneliness. Patients may experience anxiety, depression, repressed anger or suicidal ideation, any of which may lead to treatment in hospital. They may have somatic complaints or suffer from post-traumatic stress disorder; they may have amnesia concerning some events and intrusive thoughts and memories of others. Sexual misconduct may also have consequences for the physician, his or her relatives and other patients, the community and the profession (Table 2).[23]
Several provincial medical governing bodies have set guidelines concerning relationships with patients after termination of treatment. Although these guidelines differ, most state that it is unethical to terminate treatment in order to start a relationship. The power differentials and possible transference and countertransference in any physician-patient relationship do not end merely because the professional relationship is over. In addition, the patient may be left without a physician to deal with his or her original problems.[24]
The guidelines of the College of Physicians and Surgeons of Ontario state that there should be an interval of at least 1 year between the ending of a physician-patient relationship and the initiation of a personal, intimate relationship.[25] The 1-year ban on a personal relationship diminishes the likelihood that the professional relationship will be terminated for this purpose. As well, it minimizes the possibility that the information the patient gives or the care that he or she receives are affected by the patient's fantasies of a potential future relationship with the physician. It also decreases the risk that transference and countertransference will lead to a wish for a relationship.
In the case of psychotherapeutic relationships, established not only by psychiatrists but by physicians offering any type of psychotherapy, the College of Physicians and Surgeons of Ontario states that there should be a lifetime ban on sexual involvement.[25] This prohibition takes into account the strength and enduring qualities of transference and power differentials, which do not end merely because the therapy is terminated. The lifetime ban also ensures that the patient remains free to return to the therapist should he or she need help in the future. Although other provinces do not have clear guidelines, it is advisable for physicians to avoid intimate relationships with patients after termination of treatment because of the inherent dangers.
Top of document
Teacher-learner mistreatment
and harassment
Mistreatment and harassment are defined in various ways, cover a wide range of behaviour and are subject to varying perceptions, depending on one's age, sex, background and attitudes. We use the definition established by the Ontario Ministry of Education and Training: "One or a series of vexatious comments or conduct related to one or more of the prohibited grounds of the [Ontario Ministry of Education and Training] Code that is known, or might reasonably be known, to be unwelcome or unwanted, offensive, intimidating, hostile, or inappropriate."26 Examples include gestures, remarks, jokes, taunting, innuendo, display of offensive materials, offensive graffiti, threats, verbal or physical assault, imposition of academic penalties, hazing, stalking, shunning or exclusion related to one of the prohibited grounds, such as sex, race, marital status or sexual orientation.[26] The ministry also defines other forms of mistreatment, such as discrimination, creation of a negative environment and sexual and systemic harassment, and it provides examples of these.[26]
Harassing behaviour may include sexist remarks about a learner's appearance, behaviour or career choice; sexually offensive stories or jokes; or unwanted flirting, staring, sexual innuendo, questions, rumours or touching that may or may not proceed to sexual intercourse. Mistreatment and harassment may or may not be associated with academic rewards or threats of academic reprisals.[5,6,27-29]
The role of the unequal power between a supervisor and trainee is central to mistreatment and harassment. In US law, two forms of harassment are recognized: quid pro quo (sex is an explicit condition of obtaining, retaining or having the benefit of employment) and a hostile, intimidating or offensive work environment (this is judged from the perspective of a reasonable woman, since, the courts have found, conduct that many men do not consider objectionable may offend many women).[29] It is easier to establish explicit criteria for harassment involving physical acts than for other behaviour.[29]
The professional setting for physicians is particularly prone to boundary violations. It is emotionally charged, often involving life-and-death matters. Patients are often seen partially clothed or naked. The sleep deprivation, fatigue and close contact between teachers and learners that typically accompany clinical education may lead to intimacy or mistreatment.[29] Blurred boundaries may result in confusion about whether the supervisor is a teacher or a friend. The student's objectivity may be weakened by loneliness or by his or her caring for, admiration of or gratitude toward his or her teacher. The power and authority of the teacher may prove an added attraction or may make the student less likely to resist mistreatment or advances. A review by Gordon, Labby and Levinson[29] emphasizes the unequal power in teacher-learner relationships. Teachers can open or close doors to learners' careers through grades, recommendations and referrals. As well, medical teachers may be prone to burnout, mid-life crises, family problems and marital difficulties that may increase the risk that a friend or mentor relationship with a student may progress to a sexual one.[29]
In one survey of 581 senior students at 10 US medical schools, 91% had had a teacher make negative comments about their suitability for a medical career, 86.7% reported that they had been subjected to public humiliation, 55% (mainly women) had been sexually harassed, 53.5% had had someone else take credit for their work, 34.8% had been threatened with unfair grades, [26].4% had been threatened with physical harm and 3.4% reported no mistreatment.[6] In a recent study conducted at the University of Toronto, 345 medical students in the first and fourth year of training were surveyed.[5] Of these students, 71% reported at least one occurrence of verbal, emotional, physical or sexual abuse during medical school; as well, 46% of women and 19% of men reported having been sexually harassed. A 1990 survey by the American Association of Medical Colleges found that 60% of female medical graduates experienced sexual harassment or discrimination in medical school, but 90% of those affected did not report the behaviour or complain about it because they feared reprisals or because they felt that reporting would be ineffective.[30] In a recent study involving 133 internal-medicine residents, 73% of the women reported that they had been sexually harassed, most of them during medical school.[7] Nonphysical harassment was three times more frequent than physical harassment among the students affected. Two studies of psychiatric residency programs showed that approximately 5% of residents had engaged in "consensual" sexual relationships with educators.[8,11]
Learners may be harassed and mistreated by attending physicians, other physicians, residents, nurses or patients.[5-7,30] Male attending physicians and residents are the harassers most frequently identified.[7,29,30] According to one report, many of the offenders are men, their behaviour tends to be repeated and to involve many female learners over time, and they tend to be either older professionals who abuse power and prestige or younger teachers who underestimate their influence on learners.[29] However, teachers of either sex may harass or mistreat learners of the opposite sex or the same sex.
At least two studies have shown that many trainees who became sexually involved with their teachers felt coerced to some degree at the outset of the relationship and that the sense of coercion increased with time.[8,11,28] This was particularly clear in situations in which the student wished to break off the relationship while still being supervised by the teacher. Many trainees felt that sexual relationships with teachers created ethical and personal problems and had a negative effect on their career plans and on their relations with other teachers.[8,11,28] They were concerned that the teacher with whom they were having the relationship could be involved in evaluating, promoting or recommending them for future training or employment. These types of concerns have led the American Medical Association's Committee on Ethical Affairs to recommend that university policies on sexual conduct should specifically address "consensual" relationships and should caution professors about the unequal power between teachers and students and the risk of coercion or exploitation.[31] Several Canadian universities are examining or addressing these issues.
Trainees report that mistreatment and harassment impair their well-being and emotional development and compromise the learning environment. Learners may suffer guilt, shame, doubt, confusion or disruption of home life during or after mistreatment and harassment. Even when the behaviour is free of malice, it may leave the trainee feeling demeaned or intimidated.[5,6,27-29] There have been reports that students avoided certain teachers, dropped out of training, changed specialties, schools or career plans and were deterred from seeking leadership positions as a result of mistreatment and harassment.[5,6,27-29] Harassment may interfere with learning opportunities and discussions and may have a negative effect on evaluation and advancement. As well, it is poor professional role modelling and may impair patient care. There is now evidence that students who were themselves abused during training are more likely to abuse patients in their subsequent careers than are students who were not abused.[5,6,9,10] As well, an increase in cynical attitudes among trainees, a decrease in humanitarian values and a deleterious effect on individual students, teacher-learner relationships in general and the entire profession have been reported.[5,6,27-29]
These behaviours are likely to be reduced when the university or academic centre has strong policies on mistreatment and harassment of students and trainees and has powerful and accessible coordinators in charge of programs.[7,8,27,29,31] Training of students and teachers should be conducted in order to heighten awareness and establish community standards.[7,8,31] Trainees should also be taught responses to harassment and mistreatment that they can use at the time to stop the behaviour. They should also be encouraged to seek help if the unwanted behaviour persists.[7] Although some universities have established clear protocols for a fair, unbiased investigation of complaints, reporting by students is often limited by the belief that complaining will cause an inevitable negative backlash that will affect their subsequent careers.[7,8,31] Although specific complaints should remain confidential, publicizing the actions taken may serve as a deterrent.
Top of document
Conclusion
Physician-patient sexual misconduct and teacher-
learner mistreatment and harassment can have serious negative consequences. Although health care professionals, educators and the public are increasingly aware of the dangers of these activities, few comprehensive teaching programs have been developed. This article, which reviews the didactic portion of a curriculum in widespread use at the Faculty of Medicine of the University of Toronto, is only a starting point for the educational process required to familiarize professionals with these topics. We strongly recommend that lectures containing the preceding information be combined with an experiential component in which participants can discuss the practical applications of these issues. This experiential component, as well as an evaluation of the curriculum, will be discussed in Part 2 of this article.
The development of this course was supported in part by the Ontario Ministry of Health's Wife Assault and Sexual Assault Grants Program for the Education of Health Professionals.