Guidelines Addressing Physician Sexual Abuse Long Past Due, Experts Say

Tara Haelle

May 21, 2019

Physicians' sexual abuse of patients is a substantial problem that the healthcare industry has neglected for too long, say authors of an article published online May 1 in the Journal of General Internal Medicine.

"We implore the medical community to begin a candid discussion of this problem and call for an explicit zero-tolerance standard against sexual abuse of patients by physicians," write Azza AbuDagga, PhD, MHA, a health services researcher at Health Research Group, Public Citizen, in Washington, DC, and colleagues.

"There should be a system change and a culture change, with multiple interventions to prevent this problem from happening," AbuDagga said in an interview. When it does happen, physicians and administrators have a responsibility to advocate for patients, to properly investigate cases, and to bring offending physicians to justice, including ending their practice.

"Practicing medicine is not a right, it's a privilege," AbuDagga said.

In their call to action, the authors outline the extent of the problem in the United States and issue recommendations for confronting and preventing physician sexual abuse through institutional and cultural change.

That process starts with acknowledging the problem, AbuDagga told Medscape Medical News. In the United States, the term "sexual abuse" does not occur in states' regulations of physicians, she and her coauthors note in their article. Instead, "sexual misconduct" is used, a term that "fails to connote the profound unethical nature of sexual relations between physicians and their patients," they write.

Despite the American Medical Association's 1991 statement on sexual misconduct, violations continue to occur without adequate consequences. It is thus clear that "more definitive action is needed to prevent physician sexual abuse of patients," the authors write. The Federation of State Medical Boards (FSMB) convened a work group to address the issue and update guidelines, AbuDagga told Medscape Medical News. The group's work resulted in publication last year of evidence-informed recommendations to prevent egregious ethical violations.

But guidelines alone are not enough, AbuDagga said. The issue has become more prominent in the #MeToo era, particularly after the case of Lawrence Nassar, the former USA Olympic gymnastics team physician who abused members of the team for years. However, the problem has existed — and has gone underreported — for years.

For example, the authors note that a review of the US National Practitioner Data Bank (NPDB) from 2003–2013 found that 863 physicians underwent state licensing disciplinary actions in response to their sexual misconduct. These individuals constitute fewer than 0.1% of all licensed physicians in the United States. Yet, in a 1996 anonymous random survey of members of the American Medical Association, 3.4% of respondents reported having had some form of sexual contact with at least one patient.

The authors also point out a suspicious disparity between the frequency of reports of physician sexual misconduct in Canada (25.1 per 10,000 physicians) in comparison with that of physicians in the United States (9.5 per 10,000 physicians).

"The difference in the rates of disciplinary actions for sexual misconduct by US and Canadian medical licensing authorities likely reflects more frequent detection and disciplining of physicians who commit sexual misconduct in Canada rather than more frequent sexual misconduct by Canadian physicians," the authors write.

Sexual assault by physicians has always been underreported, even more so than sexual assault in general, James M. DuBois, DSc, PhD, director of the Bioethics Research Center and professor of medical ethics and professionalism at Washington University School of Medicine in St. Louis, Missouri, told Medscape Medical News. DuBois led the FSMB work group that developed the recommendations regarding sexual abuse by physicians.

Reasons for Underreporting

Several factors explain how easily physicians can get away with sexually abusing their patients, AbuDagga said, starting with the nature of the physician-patient relationship.

"In no other profession can a professional tell a patient to undress and then examine them," she said. "And in many instances, patients may not know they're being sexually abused, because there are many different types of sexual abuse," she continued.

For example, a physician might ask inappropriate questions or conduct the exam in a sexual manner, stroking the patient or using other forms of touching that are not clinically necessary or appropriate but that the patient may not realize is inappropriate, even if it makes the patient feel uncomfortable.

"They may have a hunch that an exam they've undergone is not appropriate, but they don't know," AbuDagga said. She noted that family members were sometimes present during encounters in which Nassar abused patients.

In a 2017 review of 101 cases in which physicians engaged in abuse, researchers reported that inappropriate touching constituted a third (33%) of the cases, and sodomy accounted for nearly as many (31%). Other types of abuse included rape (16%), child molestation (14%) and "purportedly consensual sex" (7%). AbuDagga noted that consensual sex cannot exist within the context of the physician-patient relationship because of the inherent power imbalance, a factor that also contributes to underreporting.

"Patients may be shocked and consumed by feelings of disbelief, guilt or shame; may be fearful that they will not be believed due to the significant power imbalance between physicians and their patients; or may be unwilling to publicly disclose the abuse," AbuDagga and colleagues write. "Additionally, victims may not know how to navigate the regulatory system to seek redress for the harms of physician sexual abuse, such as filing a complaint with the state medical boards that licensed the physicians."

Then comes the secondary trauma from the investigation, the legal proceedings, and, often, the unwillingness of other healthcare providers to report their colleagues.

"The medical industry really regulates itself, and anytime an industry regulates itself, it gives people second chances," AbuDagga told Medscape Medical News. "People believe in the culture of redemption and are willing to give the physicians a chance, or a couple of chances or more," she said. "They believe in rehabilitation, and they're willing to let physicians go to therapy or put the physician on probation or give them a way out."

The current legal and regulatory environment makes it easy to do so.

Lack of Institutional and Regulatory Action

Many hospitals and healthcare organizations do not properly report physicians to medical boards when they violate ethical standards or engage in misconduct, the authors write. Even when they do, medical boards do not necessarily take action on cases involving sexual abuse, particularly if there is no material evidence or witnesses to corroborate the allegations.

"A 2006 report found that two-thirds of all complaints received by medical boards were closed either due to inadequate evidence to support the charges or because these cases were resolved informally, through a notice of concern or a similar communication with the involved physician," the authors write. They add that only 1.5% of all complaints to medical boards led to a hearing. Even when hearings are held, disciplined physicians often continue to practice medicine.

"It's frustrating, and it's time for action, because almost every other industry has acted," AbuDagga said in the interview. Congress, the entertainment industry, and other industries are establishing guidelines and implementing protections, but healthcare lags behind, she said.

Recommendations for Addressing Sexual Abuse

Two major steps that could help prevent sexual abuse are patient education and use of trained chaperones during exams, AbuDagga said. Patients should be made aware of what is and what is not appropriate. Chaperones who are trained specifically to recognize inappropriate behavior — and who aren't paid directly by the physician — are more likely to recognize it than untrained attendants or one of the physician's employees, she said.

Other recommendations AbuDagga and colleagues make include mandated reporting by physicians and other healthcare workers, with penalties for those who do not report sexual abuse; bystander training; and education of physicians "about the enormity of sexual abuse of patients" and how to avoid it or how to seek help in establishing and maintaining professional boundaries.

The authors advocate a zero-tolerance policy in which medical boards and healthcare institutions fully investigate all complaints, impose appropriate penalties, and include detailed information in physicians' public records if they've been disciplined for sexual misconduct.

DuBois expanded on what needs to happen in light of the recommendations from the FSMB work group.

"First, from the time medical students sit their step 1 board exam through medical practice, serious violations should be reported to a central agency, such as the NPDB, to enable tracking of past behavior, which is the strongest predictor of serious violations," DuBois told Medscape Medical News.

"Second, when behavior is reported, the behavior should be described in detail — we should never allow reporting of behaviors categorized as 'other' or 'not applicable.' "

In addition, patients who have been abused should be made aware of their options.

"Victims should be informed of their right to involve law enforcement and that only law enforcement can pursue criminal charges," DuBois said. "But many victims will prefer to work through boards rather than law enforcement. Boards can operate more quickly and privately."

AbuDagga and her colleagues also recommend that healthcare institutions and medical boards report all sexual encounters between a physician and patient to law enforcement, regardless of the patient's age, and establish counseling programs for victims of these violations.

"It's all about being transparent, having systems in place to protect patients from this problem, and having healthcare professionals advocate for patients and have bystander training," AbuDagga told Medscape Medical News. "Unfortunately, we're far from that."

The article was funded by the Public Citizen Foundation. The article's authors and DuBois have disclosed no relevant financial relationships.

J Gen Intern Med. Published online May 1, 2019. Abstract

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