Health Letter, August 2019
By Azza AbuDagga, M.H.A., Ph.D.
Despite the #MeToo and #TimesUp movements reverberating across U.S. workplaces — from the entertainment and media industries to Congress — insufficient attention has been given to physician sexual abuse of patients.
Public Citizen’s Health Research Group discussed this important public health problem and offered recommendations to guard against it in a peer-reviewed Perspective article. The Perspective was published in the July issue of the Journal of General Internal Medicine.
Extent of physician sexual abuse
The Perspective discussed the findings from our 2016 study, which was the first to analyze physician reports in the National Practitioner Data Bank (NPDB) — a nationwide system for flagging potentially dangerous physicians. This analysis showed that only 1,039 physicians had adverse disciplinary licensing actions (taken by state medical boards), clinical-privileges sanctions (taken by hospitals or other health care organizations) or malpractice payments made on their behalf due to sexual misconduct from Jan. 1, 2003, to Sept. 30, 2013. Of those, 862 physicians had state disciplinary licensing actions because of sexual misconduct, totaling 974 such actions. Overall, these physicians accounted for fewer than 0.1% of all licensed U.S. physicians.
According to the above analysis, the U.S. rate of disciplinary actions for sexual misconduct is approximately 9.5 per 10,000 physicians per 10 years. In contrast, a 2011 analysis of disciplinary actions by medical licensing authorities in Canada from 2000 to 2009 found an approximate rate of disciplinary actions for sexual misconduct of 25.1 per 10,000 physicians per 10 years. Thus, the Canadian rate of disciplinary licensing action for sexual misconduct is 2.6 times higher than the U.S. rate. Neither analysis reported the proportions of sexual misconduct that involved patients. However, a 1998 Public Citizen analysis of medical board actions found that three-quarters of sex-related offenses (including sexual intercourse, rape, sexual molestation and sexual favors for drugs) by 567 U.S. physicians involved patients.
The Perspective pointed out that the difference in the rates of disciplinary actions for sexual misconduct by U.S. 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; there is no evidence that Canadian physicians are more prone to sexual misconduct than U.S. physicians.
Importantly, studies analyzing reports of disciplinary actions for physician sexual misconduct likely underestimate the scope of the problem. For example, a 1996 anonymous random national survey of U.S. physician members of the American Medical Association (response rate = 52%) showed that 3.4% of the respondents reported a history of personal sexual contact (genital-genital, oral-genital or anal-genital) with one or more patients.
Factors behind persistence of sexual abuse by physicians
Our Perspective highlighted several factors that can explain why sexual abuse of patients at the hands of their physicians is a persistent problem in the U.S. health care system. First, many of these cases are never reported by patient victims because they 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. 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. Even when they file complaints, victims can be further traumatized by the investigation and legal procedures, which may lead them to withdraw their complaints. Importantly, physicians often are unwilling to report their impaired or incompetent colleagues to relevant authorities, likely due to the absence of enforceable legal mandates for such reporting.
Second, according to a position statement by the Federation of State Medical Boards, many hospitals and health care organizations regularly ignore or circumvent reporting requirements for medical boards regarding impaired physicians.
Third, medical boards may not always act on complaints of physician sexual abuse of patients, especially when there is no material evidence or witnesses. Specifically, a 2006 federally funded 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 report showed that only 1.5% of the overall complaints to medical boards reached the formal hearing stage.
Additionally, there is evidence that even when medical boards discipline physicians for sexual abuse, those physicians often are permitted to continue to practice medicine afterwards. In fact, a 2016 nationwide investigation by the Atlanta Journal Constitution showed that more than one-half of physicians who were disciplined for sexually abusing patients or had other sex-related offenses were still licensed to practice.
Little information exists on the effectiveness of possible safeguards, such as counseling of sexually abusive physicians, to prevent recidivism and possible harm to future patients. Additionally, our 2016 NPDB analysis showed that medical boards did not discipline 70% of the physicians who had peer-review sanctions or had malpractice payments due to sexual misconduct.
Our Perspective called for replacing the term “sexual misconduct” currently used in the U.S. medical community with the term “sexual abuse” when referring to any physician conduct that involves any of the following behaviors: (a) sexual intercourse or other forms of physical sexual relations between the physician and a patient, (b) touching, of a sexual nature, of a patient by the physician, or (c) behavior or remarks of a sexual nature by the physician towards a patient. We adopted this characterization from a legal definition established by the Regulated Health Professions Act of Ontario.
We also emphasized that physician sexual abuse of patients should be classified as “never events”: No patient should ever experience any form of sexual abuse, or fear of being subjected to such behavior, by a physician. Therefore, we called on the medical community to implement a zero-tolerance policy against sexual abuse of patients, which has been adopted by other countries, including parts of Canada and New Zealand.
We noted that this standard must be coupled with regulatory, institutional and cultural changes to realize its promise and proposed the following recommendations for state medical boards:
- Educate the public about how to prevent, recognize and report physician sexual abuse;
- Discipline and report to authorities physicians who are found to have engaged in any form of sexual abuse of patients; and
- Disclose on their websites complete information concerning all disciplinary actions against sexually abusive physicians.
We proposed the following recommendations for the medical community including medical boards and health care organizations:
- Educate physicians about the enormity of sexual abuse of patients, how to avoid it and how to seek help if they are struggling with their boundaries with patients;
- Mandate reporting by physicians and other professionals of any witnessed or suspected abuse;
- Encourage and facilitate reporting by patients and their families of all forms of abuse by a physician;
- Investigate thoroughly each complaint of alleged physician sexual abuse of patients;
- Provide trained chaperones to act as “practice monitors” during body exams;
- Report physicians who were found to have engaged in abuse of patients to law enforcement authorities in all cases, not just when the victim is a child; and
- Establish and fund programs to provide subsidized psychological counseling for all victims.
Our Perspective concluded by asking each medical board, professional organization and health care institution to evaluate its current systems and procedures regarding physician sexual abuse and to take stronger comprehensive actions, including seeking legislation, to protect patients from all physicians who evade medical ethics, betray the trust of their patients and exploit the patient–physician relationship.