Professional Sexual Misconduct
27th Congress on Law and
Mental Health,
Werner Tschan MD
homepage : www.bsgp.ch
psychiatrist + psychotherapist FMH
Neuensteinerstr. 7
CH-4053 Basel
phone 0041-61-331-6113
tschankast@bluewin.ch
Boundaries
= according to Merriam-Webster’s
Collegiate Dictionary (1988): something (as a line, point, or plane) that
indicates or fixes a limit or extent.
Each doctor-patient relationship is defined by
boundaries. The professional relationship is considered as a fiduciary
relationship based on two main ethical principles, „do the best for your
patient“, and „do not harm your patient“. If a professional relationship turns
into a sexual one, the patient may be deeply violated. The breach of duty element, which defines the standard of care, assumes
that there is a line of competent practice below which no professional should
descend (Brown et al. 1998, p.527). Boundaries are defined by law, by state
of the art, personal limits, professional capacity, and also by culture and
gender. In any doctor-patient relationship, these boundaries guarantee space
where examinations, medical procedures and questions about intimate details can
be performed, which are unthinkable in private relationships. It is always the
professional who sets the limits therefore creating a structural power
imbalance in every doctor-patient relationship. Furthermore it is one the
professional’s first duties to maintain these boundaries intact. This should
never be the task of a patient or a client.
It may not be surprising that medicine has
traditionally dealt with boundaries - by creating ethical codes, among them the
Hippocratic oath, which is probably the most famous and which is over 2400
years old! Today numerous guidelines aim at the same.
Definition of PSM
Sexual
misconduct by professionals is an abuse of their professional power and
authority that arises from a special relationship that is inherently imbued
with trust (R. Simon 1995). Any sexual
behaviour during a professionally based relationship must be considered as
abuse of a fiduciary relationship. A professional relationship starts right
from the beginning, either when a patient arranges a consultation appointment,
or when a health care professional first sees a patient.
Three forms of PSM can be distinguished :
1. Sexual intercourse, either vaginal, anal, oral, or
masturbation
2. Sexual behaviour in a larger sense, like fondling,
watching touching genital zones
3. Verbal sexual behaviour like dating, sexually
coloured remarks, sexual insults
For post-treatment situations, we see a worldwide
tendency towards at least a two year period; in that time any sexual contacts
are forbidden. The problem of PSM cannot be dealt with just by operating
personal pathology models. The systemic view of the underlying problem clearly
shows that a sexual affair within a professional relationship always effects
the entire professional body, the health care system and society in general.
Therefore, there exists a duty to protect patients from unprofessional medical
doctors and other health care workers.
Three types of PSM-offenders can be differentiated,
according to treatment procedures:
1. Situationally impaired physicians due to personal
difficulties in their life, or professionals with weakened moral and ethical
views of their professional responsibilities and duties.
2. Impaired professionals due to an underlying
psychiatric or organic illness, e.g. psychopathic disorders, substance
dependency disorders, mood or psychotic disorders. Neurological disorders may
also be seen (e.g. Dementia).
3. Sex offenders with forensic deficits (paedophilia,
rapists, and other forms of deviant sexual behaviour)
Different forms of intervention are necessary for
these three types of professionals who violate boundaries. In general, any
rehabilitation program should be based on an assessment. An assessment is not a
finding of facts. A rehabilitation procedure can only be executed, if there is
a problem. Therefore, without the cooperation of accused professionals, no
treatment is possible. For sex offenders, whose treatment is mainly conducted
in prison, long lasting treatments are helpful. Practice re-entry for this type
of professional is in most cases not possible. In case of an underlying
disease, treatment comes first, and then a boundary training may be added. For
those who are situationally impaired, and for those with a lack in their
professional attitudes and behaviour, a boundary training may be sufficient.
Their licence should be temporarily withdrawn for the time of the
rehabilitation procedure. After practice re-entry, a monitoring is recommended
for a certain amount of time, e.g. 5 years in total (rehabilitation and
monitoring).
Psycho-Traumatology
Psycho-traumatolgy gives us a clear conceptual
framework, how the devastating effects of sexual abuse can be understood when
personal boundaries are violated. Also, not all patients after PSM suffer from
PTSD; nevertheless the trauma concept is applicable. Both boundary-crossing and
violation can lead to devastating effects on patients. A professional sexual
affair can not be regarded as harmless. The traumatic experience leads to the
core symptoms of PTSD:
·
reexperiencing the trauma (intrusion)
·
avoidance of reexperiencing
·
arousal symptoms
·
numbing
The answer of the professional bodies and authorities
The reaction in
Especially when sexual abuse occurs in the health care
system, the victims are even more hesitant to report it. There is no discussion
within the professional bodies about the underlying problems of PSM. In Europe,
even in case of severe sexual abuse, the licence is not withdrawn.
Professionals themselves minimize the effects on
victims and many still believe, „it is all loving“, or it is a private matter
between two people. The slippery slope concept clearly shows that the
progression towards sexual abuse is a premeditated behaviour. PSM does not just
occur by accident. Many victims do not get support from authorities or from
professional bodies. Only women’s self-help groups offer case-management and
advocating for victims. Treatment is often difficult to find for victims of
PSM. Either they are not believed by professionals themselves, or they are
blamed for being responsible. Still today we can see in trials that
professional experts blame victims for their borderline or seductive behaviour.
Canada, USA, Australia, New Zealand
These are the leading nations in handling PSM. About
ten years ago, Canada, Australia and New Zealand implemented a zero tolerance policy. For virtually all
of the twentieth century health professionals have been able to practice their
professions without fear of being sued due to sexual malpractice (Brown et al.
1998, pp. 525-577). Beginning in the mid-1960s, however, things shifted in a
new direction of recognizing professional duties. Discussions among
professional bodies and health authorities, cases of PSM brought to justice,
medical ethics discussions, and surveys among a variety of health care
professionals clearly showed that there is a considerable problem. Self
reported sexual contact with patients is as high as 15% for psychotherapists,
7.5% for physiotherapists, 4% for physicians (GP, gynaecologists, ear nose and
throat specialists). Consumer reports in Canada show a 1-10% of male and female
patients have complaints of improper conduct (British Columbia 1992) and 8% of
women have had at least one instance of sexual abuse or harassment by a
physician (Ontario 1991). The most recent and probably most reliable data come
from a consumer report in Ontario (1999), showing that 1% of the population
(110’000 persons) reported physical sexual abuse by health care professionals
in the past five years, and another 2% reported inappropriate professional
behaviour like sexual remarks, dating, watching undressing, fondling.
In the
It was only recently (June 2002) that for the first
time a Swiss general practitioner was condemned by a state criminal court due
to sexually abusing the dependency of his female patient. The court took into
consideration the true nature of the doctor-patient relationship by doing so.
There have been other cases in the past, which led to sentencing of medical
doctors, but always due to sexual abuse of unconscious patients or by violent
use of force (e.g. rape). The case mentioned went into appeal, therefore the
outcome is still unclear.
Boundary Training
The first step is a labelling and commitment process
by a professional: „I have a problem“. Rehabilitation only makes sense, if an
accused professional admits having some difficulties. The next step is an
enactment with a clear will to change in professional behaviour. Boundary
training is based on a forensic cognitive-behavioural treatment model. Each
individual training should be based on an assessment. The presenter has
developed a training program which is composed of 24 modules. The following
aspects, derived from general treatment concepts with sex offenders, are
covered and represent the mandatory part of the Boundary Training program:
·
acceptance of responsibility
·
planning the offence
·
deviant fantasies (premeditative thinking)
·
cognitive distortions
·
internal vs. external inhibitions
·
underlying
personal problems (e.g. sexual problems)
·
substance abuse
·
professional knowledge, skills and attitudes
·
relapse prevention
The main therapeutic focus is on the planning of the
abuse and related fantasies, and on the failure of internal and external
inhibitors. When this part is clearly understood, then the next step is to plan
a relapse prevention strategy. A non mandatory part may be covered by the
Boundary Training program as well:
·
personal
goals (both professional and private)
·
anger and stress management
·
personal work-life balance
The program is executed within a minimum of 20 to 30
double sessions and should be enlarged according to the needs of each
individual professional participant. Boundary Training is not a psychotherapeutic
treatment per se, but based more on psycho-educative intervention techniques.
Furthermore, the program uses the concept of change, described by Prochaska and
DiClemente (1992). How can we bring
professionals either at risk, or those who already have violated boundaries, to
undergo such a treatment program? Surely not by assuming, that they will do
that voluntarily. Boundary Training will only work, if it is part of a clear
concept of what should be done with professionals who sexually abuse their patients.
Internal investigations by professional bodies and self regulating procedures
in cases of PSM don’t work. This has become clear worldwide over the past
couple of years. The crisis the church is facing right now is based exactly on
the same misconception. Boundary Training only works if it is part of a
mandatory program implemented either by licensing boards, or by national or
state health care authorities.
The following modules are part of the Boundary
Training program :
0 introduction
1 counselling an offender-professional
2 doctor-patient relationship
3 boundaries
4 epidemiology
5 psycho-traumatology
6 resulting problems of victims of PSM
7 counselling victims
8 how does it begin?
9 masks
10 circle of abuse
11 own case presentation 1
12 Broken Boundaries (video)
13 20 steps
14 20 steps - interpretation
15 law and justice
16 offender-professional (video)
17 institution - consequences and reactions
18 burden of guilt - new beginning
19 relapse prevention
20 own circle of abuse
21 own case presentation 2
22 fantasies
23 responsibility
24 evaluation, end of program
Assisting professionals
In general, professionals first of all need training
and formation which includes these boundary aspects. Boundary training models should
therefore be integrated on a curricular basis for all health care
professionals. They need to come into a close contact with these questions
during their formation. The same aspects that are part of individual training
programs can be used for educational purposes. Professionals may also need
help, if they get into trouble. Professional bodies should therefore offer a
help line.
The concept of assisting physicians who are either at
risk or already have violated boundaries is based on a integrative three-pillar
model:
·
formation
·
consequences
·
help
Similar models can be used for a variety of other
professionals, both health care and non-health care, e.g. teachers, clergies,
etc. Keep in mind that boundary training is not a disciplinary means; rather it
helps professionals who get into trouble, or have already done so.
Open questions
In which situations are the authorities obliged to
withdraw the licence? In any form of sexual misconduct, or only in „serious“
ones? As we have seen from the slippery slope concept, each boundary crossing
may be a step towards sexual abuse. Therefore, withdrawal should be the general
rule in case of any sexual misconduct. German
criminal law §174c StGB declares that even the attempt by a professional
to achieve sexual contact with a patient is not acceptable, thus giving a clear
conceptual framework how to handle the limits. All medical guidelines worldwide
condemn any sexual relationship between professionals and their patients, no
matter whether it is sexual intercourse or any other form. This concept fits
with the empirical facts that the devastating effect of PSM is mainly derived
from a break in the fiduciary relationship between the professional and his
patient and not so much from the sexual intercourse per se.
The second point to discuss is, what should patients
know about policing of certain professionals? A future patient may be willing
to know whether a certain professional is suitable for him. The concept of
informed consent and patients’ autonomy may be helpful to demonstrate that an
open-book policy is necessary in the case of PSM.
Conclusion
PSM is a severe problem which no longer should be
neglected by forensic psychiatry, professional bodies or health care
authorities. PSM affects deeply all medical disciplines, not just psychiatry. A
concept how to handle PSM has to be developed by the European nations. There is
clear evidence that professionals need help themselves, either those at risk,
or those who have already violated boundaries. Psychiatry will play a crucial
role in handling PSM. Besides victim treatment after PSM, psychiatry
contributes in establishing support and treatment facilities for colleagues,
and in providing professional training and formation in that topic. The special
knowledge and treatment experience of forensic psychiatry is integrated into
the Boundary Training concept, which is one of many answers to the problem of
PSM.
http://www.
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advocateweb.org
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aerztegesundheit.de
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bsgp.ch
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