Sexual misconduct by doctors: a problem that has not gone away

The medical profession has the opportunity to prevent further harm to patients and damage to public trust

Bismark and colleagues1 report the disappointing finding that health practitioners, particularly doctors, continue to be found guilty of sexual misconduct with patients. During 2011–2016, Australian regulators received more than 100 notifications of sexual misconduct by Australian doctors each year. As with other sexual crimes, it is likely that many victims do not make formal complaints; in this study, only 34% of notifications were made by affected patients.

Sexual misconduct notification rates were higher for men than women, for practitioners over 45 years of age, and for practitioners in regional or rural locations.1 In a recent American study, factors associated with sexual misconduct included personal stress, overuse of alcohol or drugs, working in solo practice, and having trained outside the United States.2

Bismark and colleagues found that sexual relationship notification rates (per practitioner‐year) were highest for psychiatrists, psychologists, and general practitioners, specialties generally involving longer term one‐to‐one therapeutic relationships.1 Complaints about non‐sexual misconduct are also more frequent for mental health practitioners (psychiatrists and psychologists), particularly complaints concerning professional ethics, communication skills, and practising while impaired.3

In this issue of the MJA, Millbank and colleagues4 compare definitions of when professional obligations to former patients end. The Australian Psychological Society has determined that a sexual relationship with a client or someone closely related to a client is not permissible for at least two years after the end of therapy, and then only after the psychologist has consulted a senior colleague. The Medical Board of Australia provides clear guidelines, including a range of factors to be considered in deciding whether a sexual relationship with a former patient is unethical, but does not set a specific time period.5

In recent years, community recognition of the prevalence of sexual abuse by people in positions of relative power has increased. The Royal Commission into Institutional Responses to Child Sexual Abuse6 found that thousands of children had been sexually abused in Australia over several decades. Some cases of sexual misconduct by doctors also involve children, but more commonly involve women who are vulnerable because of the authority of the doctor from whom they seek help.

In the United States, the Atlanta Journal‐Constitution newspaper has campaigned for greater recognition of misconduct by physicians,7 with parallels to the Boston Globe investigations that led to national recognition of widespread sexual abuse of children by Catholic clergy. The investigative team collected more than 3500 cases of doctors disciplined for sexual misconduct and reported that serial offenders were often permitted to return to practice.

In Australia, the most serious cases of misconduct (sexual and non‐sexual) by health practitioners are referred to disciplinary tribunals. A review of tribunal decisions during 2010–2017 found that sanctions for doctors were generally less severe than for other health practitioners, partly because doctors more frequently had legal representation. Forty‐nine of 62 doctors found guilty of sexual misconduct (79%) were removed from practice: 30 were deregistered and 19 suspended.8 Bismark and colleagues1 report that one in six practitioners with sexual misconduct notifications were the subjects of more than one notification over six years. This is concerning, as it suggests that these practitioners have not altered the behaviour leading to such notifications.

As noted by Bismark and her co‐authors,1 unprofessional behaviour by some doctors has been well described. The question is, what to do about it? In late 2015, the Royal Australasian College of Surgeons (RACS) introduced a comprehensive Action Plan on Discrimination, Bullying and Sexual Harassment in the Practice of Surgery, with three components: cultural change and leadership, education, and complaints management. Annual reports document progress, and priorities are set each year.9

The RACS action plan focuses on workplace behaviour. A similar model could be adopted for groups such as GPs and psychiatrists, who require particular expertise in negotiating professional boundaries with patients. Such a plan should include doctors trained overseas, rural practitioners, and those who do not belong to Australasian specialty colleges.

In March 2020, the Australian Health Practitioner Regulation Agency raised the threshold for mandatory notifications to the presence of substantial risk of harm to the public, so that doctors affected by personal stressors or losses, depression, or drug and alcohol misuse can now seek help more comfortably.10 Health services that provide confidential care for doctors have been established.11 Colleagues, friends, and medical defence organisations can also provide advice and support for doctors who find themselves on the slippery slope of waning professional boundaries.12 These difficulties sometimes arise when managing a patient with a severe, complex personality disorder, and advice from a psychiatrist colleague can be helpful.

The Australian Psychological Society code13 stipulates that a psychologist should discuss potential sexual relationships with former patients with a senior colleague, but the practitioner would probably consult someone they believe to be sympathetic to their wishes. For medical practitioners, it might be useful to designate senior practitioners available for confidential consultations regarding professional conduct.

Churches and other institutions were subject to considerable negative publicity before they dealt with unacceptable behaviour in their organisations. The medical profession has the opportunity now to address the problem of abusive or exploitative behaviour by a small minority of doctors, to prevent further harm to patients and damage to public trust.