Research has shown that somewhere between 1% and 12% of physicians report sexual contact with patients. However, more interesting is that up to 80% of doctors report a sexual attraction to their patients. The issue here is not whether a doctor feels a sexual attraction to a patient, but how the doctor behaves relative to the experience.
What every chiropractor should know…
I recently spoke on the topic of sexual misconduct in the ornate grand ballroom of the former Playboy Towers at the annual meeting of the Federation of Chiropractic Licensing Boards in Chicago. Dr. Linda Steele Denham was the gracious emcee for the mixed crowd of about 75, and before Dr. Denham introduced me she said, Before we start, I have a joke I want to tell. Have you heard about those Wonder Bras? They’re just a really big thing, but down in the South we have these new bras called the Denominational Bras. First there’s the Methodist Bra. It uplifts the downtrodden. Then there’s the Catholic bra that covers the masses; and finally there’s the Baptist Bra that makes a mountain out of a molehill.
Most of the audience laughed uproariously, but there were some who seemed to recoil at Linda’s joke. As I took the podium, I informed the audience that they were the victims of a set-up. Linda told me previously she had considered telling that joke during the introduction, but had second thoughts when she became aware of the subject matter of my discussion. I encouraged Linda to tell the joke anyway, since I felt it could well illustrate a basic premise of the sexual boundary subject. Some participants may have found that joke funny; some may have been a bit put off or even offended by it. There were approximately 75 people in that room who all witnessed the same event. . . but they all experienced it in an entirely different way.
The doctor has to consider this in the context of providing services in their offices. it’s easy for a doctor to be jocular with their patients and think they’re just being themselves, performing their normal daily routine with patients, not recognizing that different patients may perceive the doctors. behavior in different ways. These patients are constantly aware of the physical presentation of the doctor, and their minds are continually evaluating what the doctor says, the mannerisms of the doctor, and the way the doctor touches and handles them. Consider the following statement of the Hippocratic Oath from more than 2,500 years ago:
Whatever house I may visit, I will come for the benefit of the sick and remain free of all intentional injustice, of all mischief, and in particular of sexual relationships with both female and male persons; be they free or be they slaves. While I find slavery abhorrent, it is interesting to note that even 2,500 years ago, professional boundaries were considered applicable to all classes of people regardless of their social standing when providing for their health care needs.
Professional Boundaries Defined
Before we can determine whether or not there is violation of a boundary we first have to define what a boundary is. Dr. Pamela Staples, a clinical psychologist in Minnesota provided a succinct definition of a boundary. She stated “”A personal boundary is defined as the place where you and I begin and end. If we were to describe a boundary using a biological analogy, we could characterize it as being much like a cell wall that allows selective entry and exit; a semi-permeable membrane that carefully and selectively allows some things in, while keeping others out. In this case, the determination of what is allowed in depends largely on the person’s own choices. These boundaries are different for each person largely because of their life experience. Typically boundaries are dynamic and adaptable, and can often be renegotiated as the relationship changes and progresses over time. This is fine as long as these boundaries are never renegotiated to the point of violation.
Research has shown that somewhere between 1% and 12% of physicians report sexual contact with patients. However, more interesting is that up to 80% of doctors report a sexual attraction to their patients. While some may find this statistic troubling, we should not expect that because a person becomes a licensee or a doctor of any kind, that they’re suddenly going to be able to control millions of years of developmental evolution of hormones. We all have hormones and are subject to a normal physiological process intended for the propagation of the species. The issue is not whether or not the doctor experiences or feels a sexual attraction to a patient. The issue is how the doctor behaves relative to the experience. Recently, some other statistics have arisen as a result of more research into the subject matter. In 1995, the Minnesota Board of Medical Practice (MBMP) assembled a task force on sexual misconduct, drawing experts from all over the country.
They found that of adults experiencing violations, 90% are women and 75% committing them are men. Of all these types of violations, it was found that the most obsessive behavior typically occurs between a female patient and a female doctor . . . and that these may result in a type of obsession that may well promote stalking situations. Sexual boundary transgressions are not always clearly black or white. For all intents and purposes, they exist on a continuum from mild to severe, and the doctor may have difficulty in making the distinction between appropriate behavior and inappropriate behavior. Each person may have a different set of responses to different situations. For example, some people may judge a relationship between a doctor and a patient as acceptable if it ultimately resulted in a legitimate relationship or perhaps even a marriage.
Additionally you will find varying opinions as to whether or not a doctor should treat a member of their own family; resulting in engaging in what should be a true doctor-patient relationship as well as their familial relationship. I point these two examples out to show that there are situations that illustrate a gray area in our thinking and in societal standard. However, in the more traditional sense, sexual relationships between physicians and patients are almost always damaging to the patient. Damage includes, but is not limited to sexual dysfunction, anxiety disorders, depression, increased risk of suicide and dissociative behavior–where patients tend to regress from society, friends, family and even themselves. (I shudder to think of the emotional impact of a patient committing suicide because a doctor engaged in a personal relationship with a patient that ultimately failed? Yet, according to this report, there are several citations of this happening.)
This continuum of conduct can be viewed in the context of boundary crossovers. Boundary violations, and sexual misconduct This may well result from a number of factors which we’ll discuss shortly. However, it is probably prudent here, to attempt some definition of these terms.
There is a gray area of clinical decisions where the best course of action is not readily apparent. A decision to deviate from an established boundary, a Boundary crossing may enhance the therapeutic alliance, especially if properly examined within therapy.
Frick gives examples of boundary crossings as appointment changes, extension of payments, small gifts to the therapist, or requests (from the client) for disclosure of bits of personal information (by the therapist). (Frick 1994) Boundary crossings may be trivial. The danger may arise if there is an increase in the frequency and severity of crossings. (Simon, 1995)
Boundary crossings can be distinguished from Boundary violations. Boundary violations are characterized by a reversal of roles, secrecy, the creation of a double bind for the client and the indulgence of personal privilege by the professional. (Peterson, 1992) Often, the first step down that slippery slope is excessive personal disclosure by the professional. There is a confusion of the professionals needs with the client’s needs and the use of rationalization to justify the behavior. (Schoener, 1989) The professional may fantasize that love, in and of itself, will be curative. Frequently, there may be re-enactment of incestuous involvements from the client’s past. (Gabbard, 1991) A professional boundary violation is a disruption of the expected social, physical and psychological boundaries that separate doctors from patients. Some of the violations may be very subtle–so subtle that the patient is not aware of them, and in fact the doctor may not even be aware of them. Others are, of course, quite severe.
Sexual misconduct by professionals . . . means the use of the power, influence, and/or knowledge inherent in one’s profession in order to meet one’s own sexual needs. The most extreme types of sexual misconduct involve actual sexual contact, intercourse, and rape. It could be the action of an overt predator, or it could be the action of a more cunning predator who carefully manipulates over time to seduce. It could be the lovesick, one time offender who yields to temptation.
In a very general sense, boundary violations can be divided into two major categories, each with their own respective etiology, and each with a different likelihood of successful resolution. These categories are predatory and non-predatory. Non-predatory violations are violations that are typically not related to intent. It was not the doctor’s original intention to transform his or her attraction of a patient into an active pursuit. It may be more likely that such pursuit is based on the naïveté of the doctor, the vulnerability (based on mitigating life factors) of the doctor, or insensitivity on the part of the doctor. It is believed that these doctors are more capable of being rehabilitated with education and some sort of rehabilitative therapy.
This should be distinguished from a predatory practitioner. Predatory practitioners generally engage in violations which are related to intent. The doctor has the clear intention of actively pursuing some type of relationship with this particular patient or pursuing some form of relationship which results in sexual gratification for the doctor. The prognosis for the true predator is said to be extremely poor. This belief is consistent with not only the research performed by the MBMP, but other agencies across the country. We typically find that these people are incapable or rarely capable of being educated to the point of being able to function in a manner safe for the patient.
25 STEPS TO NAVIGATE THE SLIPPERY SLOPE OF SEXUAL BOUNDARIES
Manage the Relationship!
a. Handle any problems to mutual satisfaction immediately! (don’t give the patient time to stew over the issue.)
b. Handle any boundary infringements the same way. Address them directly with the patient.
Establish the proper safe environment for the patient.
a. Tell the patient what you are going to do and what you expect of them
b. Acquire the patient’s permission (freely given) before proceeding.
c. Invite the patient to have a third party present, particularly during certain sensitive procedures.
a. Record immediately, any issues that have come up between you and patients. If a patient flirts, sends cards or gifts, etc. record the event, how you handled it, other professionals you may have sought assistance/advice from, etc. You may also consider keeping such material, should you later need to defend yourself against a complaint.
Improve communications with patients.
a. Regarding the performance of procedures.
b. Regarding office procedures.
c. Regarding financial obligations.
d. Regarding relationships with third party payors
e. Regarding relationships with other advocates such as attorney’s or other providers.
Improve responsibility toward practice.
a. Provide reports on time.
b. Properly file and manage patient records.
c. Forward requested records in a timely manner.
d. Handle disgruntled patient concerns immediately.
Develop written policies and procedures.
a. Include fees, hours, boundary issues, etc.
b. Have patients sign; keep one in chart and give one to patient.
Establish a Pre-touch thinking process.
a. Is this procedure necessary?
b. Am I the right person to do this?
c. Should someone else be in the room?
d. Would I do this if this patient were not attractive to me?
e. Has the patient been given a proper explanation?
f. Has the patient been given adequate opportunity and the proper atmosphere in which to decline?
Continue to improve interpersonal skills.
Develop awareness of personal attitudes and behaviors.
Continue to educate yourself in this subject matter.
Do not violate the patient’s trust. Put the patient’s welfare ahead of your own needs. Leave your personal agenda on the other side of the door.
Do not sexualize the relationship, even if your patient expects or demands that you do.
Avoid flirtations, off color jokes, or sexual innuendos.
Ask female staff and patients about your behavior. An anonymous questionnaire can be verym effective for accomplishing this.
Get help from a supervisor, colleague, or other professional if you find yourself attracted to a patient. DON’T DISCOUNT THIS ONE. If you begin to find yourself fantasizing about a patient, YOU NEED HELP RIGHT AWAY! Believing you can handle it by yourself may be the costliest mistake you ever make. Just discussing it with another professional tends to diffuse the situation right away.
Recognize patient’s limits.
Recognize your own limits. Seek guidance, particularly if you feeling vulnerable due to personal situations.
Don’t use patronizing language. Use honey only for significant other, and girl for a female child.
Be careful in complimenting patients. Don’t compliment a patient’s clothing when they are lying on the table with your hands on them. (Ask yourself if what you are saying sounds like a pick-up line at a singles bar. Also ask if you would feel comfortable saying what you are saying if the patient’s significant other was in the room with you.)
Treat all patients equally, regardless of age, gender or attractiveness. Be particularly careful of extending special considerations that you wouldn’t ordinarily give to anyone else.
Pay attention to where your eyes are wandering.
In this day and age, doctors should reconsider their propensity to hug (or kiss) patients.
Let your patients adjust their own clothing.
Establish, in writing (for yourself) a cooling off period. This is a period of time following the last clinical contact in which you would allow yourself to engage in any social or other contact with a patient. Different disciplines have already done this in their laws, and a common period of time is two years. This period of time will serve to mitigate the power differential that exists between the doctor and the patient, and therefore the doctor’s ability to exploit their position. Putting this in writing gives the doctor a written personal standard upon which they can draw, if they begin to feel attracted to a patient.
Again…handle any problems or misunderstandings of any nature immediately, and document all situations, particularly those involving unusual patient behavior.
Three Contributors to Boundary Violations
Generally speaking, the elements influencing the reporting of boundaries violations can be classified into three general categories: those that are societal in nature, those that are patient-related, and those that are doctor-related. Those that are societal in nature tend to permeate the others and are often difficult to distinguish. However, the most elemental contributor, and that which is fundamental to the presence of a professional boundary (and the resultant need to maintain its integrity) is power. I submit to you that the very characteristic that makes the doctor an effective healer may also be his or hers downfall.
That characteristic is POWER: the power differential that exists between the doctor and the patient, not only makes the doctor capable of establishing a compliant relationship with the patient, but opens the relationship up to potential exploitation. We have to recognize and understand that society ascribes additional power to certain types of professions. The doctor’s power comes from having knowledge, and the trust of the patient. As an example of this, what other professions (other than health care or healing professions) can ask someone to go into another room and tell them to take their clothes off and have them unquestioningly comply with the request? How do you think you’d react if your grocer told you to take your clothes off? Or your auto mechanic? they’re certainly not going to get away with that. There are, however, other societal contributors. Some of these are:
A. Today’s recognition of high levels of sexual abuse. (Experts believe that one out of three women, and one out of every four to five men has been sexually abused before the age of eighteen.)
B. Higher patient awareness of improper behavior.
C. Willingness to speak out and protest.
D. The sexual revolution
E. The Women’s Movement.
F. Self help improvement trends.
G. Consumer activism.
H. A more litigious society.
I. Power shifts.
J. Public campaigns against rape.
K. Increased fairness in the process; less humiliation to the complainant.
L. Greater knowledge of how to file complaints.
The second element, are those contributors ascribed largely to the patient. When a patient presents to your office, they are inherently in a heightened state of vulnerability. Typically they enter in a lot of pain and the doctor is seen as having the solution to the problem. They are seen as having this solution by virtue of their knowledge, experience and training. Moreover, while the patient’s needs are certainly physical, potential psychological elements cannot always be ruled out. In addition to that doctors, (and particularly chiropractors) are often able to provide things that are not received in the home such as touch, warmth, concern, caring and validation.
Demographic statistics remind us time and time again that the doctor-patient mix elicits a higher concentration of female over male patients. While you may speculate as to why this is so, lets accept for the purposes of this discussion that this is accurate. Chiropractic is a profession, that by its very nature, places its practitioners at greater risk of exposure. A patient comes to us in a great deal of need and pain looking to the doctor as the solution to their problems. It may be the first time in years this patient has been touched in a way that makes them feel good. It may be that this patient has a terrible relationship at home with their spouse, their children are teenagers who cannot stand their parents, their dog is chewing up the carpet, things aren’t going so well at work and the car is about to blow a transmission.
These pressures may either cause or contribute to the physical and psychological pain experience they are having. They enter the doctor’s office for care and the doctor asks them to take their clothes off and then what does the doctor do? He or she puts their hands on the patient in a way that is loving, caring, nurturing, comforting, warm, giving and validating. This is a formula that is easily seductive . . . and I don’t mean seductive in the sexual sense. I mean physically and emotionally seductive to the patient … a combination fraught with danger.
The powerful doctor/vulnerable-patient relationship mirrors the traditional roles of the pursuer and the pursued in a conventional relationship. As a result, physical force and/or weapons are not necessary in this kind of violation. The doctor’s capacity for abuse is woven into the fabric of the patient’s trust. In addition, the population of patients who have become victims of professional abuse, tend to have a statistical predisposition to previous abuse.
All too often patients are unwilling to share information with the doctor of previous abuse (whether as an adult or child) perhaps by a husband, someone in their family, or someone otherwise trusted by them. This is a critical piece of information necessary for a doctor’s knowledge base to be able to properly manage that patient relationship. I’m not suggesting that because the doctor is not informed of the patients history of abuse that this should mitigate the doctor’s responsibility.
I am saying that when doctors evaluate patients they acquire a certain amount of knowledge regarding that patient and from that knowledge they derive a determination of how they’re going to manage the case and its attendant relationships. If the doctor is unaware of a history of abuse, s/he is missing a core piece of information necessary to appropriate case management, and critical to the appropriate management of a vulnerable relationship. Finally, while this can be considered either a patient’s contributor or a doctor’s contributor, it should be pointed out that from the time of Hippocrates and Aesculapius the delivery of health care which necessarily included the doctor-patient relationship, was inviolable. There was simply no forum for a patient to question or second guess their doctor.
This is no longer true and the transformation of the doctor/patient relationship creates an upheaval for both the doctors and the patients with casualties mounting on both sides. We have patients who are not getting necessary needed care, and doctors who are losing their licenses and their reputations. Finally, there are the elements which pertain primarily to the doctors. The factors affecting a doctor’s predisposition for overstepping professional boundaries include naïveté, inadequate training in professional boundary issues, and inadequate training in touch, sexuality and women’s issues. Currently, some of the colleges are developing courses and workshops specifically devoted to the area of touch and women’s issues.
Other factors may include insensitivity to a patient’s subtle signals, a lack of knowledge about their responsibility, and the concentration of chiropractors in isolated solo practices. This may be changing to some degree, and while this should not be construed as a defense of the managed care system, we should recognize that one of the side effects of the managed care system is that many of the isolated solo practices are disappearing. This places doctors in a larger network, with greater resources to draw upon if they become aware that a problem is developing. Another contributing factor is the doctor’s personal stress or difficulties.
A doctor may find things aren’t going so well; money is not coming in, there may be difficulties with their spouse, maybe they’re divorcing or having problems with their children–all of these things tend to play a role in the psychological architecture of a doctor. Their state of mind may place them on the fence of good judgment. But add a high level of stress and anxiety to the mix, they may give in to bad judgment, effectively relinquishing control of their behavior. It is also possible that a doctor may not be intellectually sophisticated enough to be aware of the force and effect of their own power. If you’re a student, you have no power and everybody is telling you what to do, how to do it, and when to do it.
However, this trend reverses as you enter the role of a doctor. At some point you become licensed to practice and you suddenly have a level of power inconsistent with your knowledge of how to properly harness and manage it. First the doctor gets the white jacket then s/he realizes his/her power, then s/he becomes comfortable with their power. This can be a particularly treacherous time in the development of a doctor’s psychological profile. If becoming comfortable with their power includes losing awareness of its potential for abuse, the doctor becomes dangerous, and the public is at great risk.
Finally, a doctor may fail to recognize when crossing the slippery slope. As pointed out earlier, there is a vast continuum between the early stage boundary crossing and the later stage boundary violation or sexual misconduct. The battle lines are not always clearly drawn (at least in the mind of the doctor) and the path is usually insidious. The course of behavior may start with simple things such as something said, (a little joke or little innuendo shared with the patient.) It may be something a little off-color like the joke mentioned earlier. Adding to the confusion may be that it’s the patient who tells the joke, or engaged in innuendo.
The doctor may suddenly believe they have free license for their interactions. They may not be thinking about this on a conscious level, but the next time the patient comes in the doctor is ready with a joke of their own. This may be followed by other risky behavior such as scheduling this patient as the last patient of the day with increasing frequency, or scheduling the patient when there are no other staff members around. Typically, this subtle (or not so subtle) behavior will be accompanied with well developed and convincing rationalization. The doctor may not even be aware of why he or she is doing these things.
Who is the Responsible Party?
I recently had the privilege of giving a presentation on this subject matter in Salt Lake City, Utah. I drew upon the ambiance of the beautiful snow-covered mountains to provide an analogy in answer to this question. Those, who have challenged the powder, know that the up-slope skier has the responsibility of avoiding collisions with those who are down-slope. Why? The reason is they have the most knowledge about everyone’s proximate relationships to each other and their environment.
Therefore, they have the greatest opportunity to manage the terrain safely. Additionally, the down-slope skier does not have knowledge of anything other than what is directly in front of them, and can’t be expected to be responsible for those behind them. Likewise, from a legal standpoint, the person who had the greatest chance to avoid conflict, may be saddled with most or all of the responsibility should such conflict arise and result in harm. However, when it comes to professional boundaries, it has traditionally been held that the doctor is always responsible for maintaining appropriate boundaries, and little weight is given to the participation or provocation by the patient.
Courts around the country have held that doctors are responsible because patients are not in a position to give consent for sex. This seems to derive from the fact that the unequal distribution of power makes opportunities for sexual exploitation more possible than in other relationships.
Prevention rather than cure?
As doctors of chiropractic, we have been raised on the concept of prevention being superior to cure. With that in mind, I would like to offer 25 suggestions made by a number of practitioners and other experts in the field about things that might be done that may serve to prevent the doctor from becoming a statistic. Although this list may be significant, I would take the position that while you may not wish to embrace all of these ideas, the more you use, the more protected you and your patients will be. And lest you think the entirety of this article is devoted to self-protection, I would point out that anything which protects the doctor serves first, to protect the patient’s
This article is based upon a speech delivered by Dr. Larry Spicer to the 63rd Annual Congress of the Federation of Chiropractic Licensing Boards at the Regal Knickerbocker Hotel in Chicago, Illinois, April 20, 1996.
NOTE: Please call Chiropractic Economics for a copy of the references to this article, 904-285-6020.”
Larry A. Spicer, DC, of Eagan, Minnesota, is a 1985 graduate of Pasadena College of Chiropractic. Dr. Spicer’s career spans 27 years in the health care industry, including practicing, teaching, consulting and writing. He is currently the Executive Director of the Minnesota Board of Chiropractic Examiners; a member of the Federation of Chiropractic Licensing Boards; a member of the Japan Chiropractic Research Association and the Sacro-Occipital Research Society. He previously served as assistant professor, and faculty clinician, as well as an instructor in the regular and post graduate departments of Northwestern College of Chiropractic. Dr. Spicer has been teaching radiation physics and radiation technology for more than 19 years, and was honored with a Certificate of World Leadership, and included in the first edition of International Leaders in Achievement, 1987.