The proscription against sexual exploitation of patients by healers dates back at least to Hippocrates:

“Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons…”[i]

NCPHP has worked with physician and PA professional sexual misconduct (PSM) cases for most of our history. While PSM referrals to NCPHP cannot remain anonymous from the NC Medical Board, we are nonetheless interested in identifying an underlying treatable illness and thereby helping the participant demonstrate their medical practice safety to the Board. Unfortunately, the Federation of State Medical Boards’ position on PSM reflects a more legal and less clinical stance:

“In addressing the issue of whether sexual misconduct is a form of impairment, the committee does not view it as such, but instead, as a violation of the public's trust.”[ii]

Consistent with the literature, NCPHP has found that most physicians crossing boundaries with patients, in particular sexual boundaries, possess at least one of the following risk factors:

Narcissism: The attitude that “they know better” than peers or regulators is a consistent theme in PSM cases. The physician or PA can begin to believe that they will not harm patients, despite violating boundaries, because of their superior intellectual or emotional capabilities. Several NCPHP participants have said that their desire to be “all things to all people” was part of the self-deception leading to inappropriate behaviors with patients. Another physician (a psychiatrist) stated that he simply didn’t believe transference was a valid phenomenon. In fact, one study of 157 helping professionals assessed for allegations of sexual impropriety found a 9.5% incidence of narcissistic personality disorder.[iii] The doctor with a large dose of hubris may also be more at risk for feeling unrealistically invulnerable to the seductive or flirtatious patient.

Professional (and personal) isolation: The physician or PA who actively uses peer support is much less likely to begin the slide down the “slippery slope” of PSM. Professional organizations such as the AAOS advise consultation with a colleague when there are questions about boundaries.[iv]  The concept of peer supervision to assist with problematic patient interactions is well known and accepted in psychiatrists’ professional culture, but may be less so in surgical and other specialties. In contrast, the professional who is isolated by external circumstances or personal traits such as pathologic shame (or narcissism!) is more likely to fall into this trap.

Untreated psychiatric illness: In particular, physicians and PAs with untreated or undertreated bipolar spectrum disorders are at risk for professional sexual misconduct. In bipolar health care professionals, symptoms of poor judgment, poor insight, impulsivity, and hypersexuality can easily lead to professional misconduct, in much the same way that financial consequences are a risk for bipolar patients in general.

Personal stress or crises: Those who assess and treat professional sexual misconduct have long recognized that personal issues can predispose to PSM. Relationship problems such as divorce or marital difficulties, and even “good stresses” such as the birth of a child can pose a risk. Obviously, these events in and of themselves will not always cause boundary problems, but can combine with other factors to greatly increase the risk.

NCPHP stands ready to assist physicians concerned about sexual misconduct issues. As with all areas of physician health, primary and other forms of prevention are always preferable to dealing with active crises, so do not hesitate to use your colleagues, NCPHP and other resources for early consultation.