Chapter 24 To become a doctor, one has to unlearn many cultural taboos. Doctor–patient encounters present situations of unusual intimacy, which might in other circumstances be connected with sexual attraction, and patients are both emotionally and physically vulnerable. It has always been recognised that this can lead to risky situations. The Hippocratic oath included the following: ‘Into as many houses as I enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice, especially from sexual acts both upon women’s bodies and upon men’s, both of the free and of slaves.’ Rules about what constitutes inappropriate ‘sexualised’ behaviour have become clearer over recent years and include: Each of these areas has its own investigative procedures and sanctions. The prevalence of sexual boundary violation among doctors is extremely difficult to establish, but mainly USA-based surveys and disciplinary findings suggest it is not uncommon. Doctors who break boundaries are more likely to be male and older, sometimes in powerful senior positions. The specialities most likely to be involved are general practice, psychiatry and obstetrics and gynaecology (see Boxes 24.1 and 24.2). Clifford Ayling worked in Kent as a GP and part-time clinical assistant in obstetrics and gynaecology, and also did family planning sessions. In 1998 he was arrested and charged with indecent assault of patients and was found guilty on 12 counts, for which he was imprisoned and struck off by the GMC in 1999. The incidents were generally of inappropriate touching or examination of women’s breasts or genitals. There had been complaints for many years, which were not responded to effectively. The defence was that these were justified examinations, if old-fashionedly thorough. The inquiry particularly recommended further advice on the use of chaperones and guidance on responding to ‘sexualised behaviour’ (Department of Health, 2004). The Kerr/Haslam Inquiry, Department of Health (2005) While the serial predator with psychopathic personality hits the headlines, ‘single victim’ cases are more common. A doctor may be convinced he is in love or that the emotional relationship will be therapeutic. An awareness of general vulnerability is most useful. Most obviously, vulnerable patients are the most powerless – such as children, the learning disabled and the mentally ill. However, it is easy to think in opposed stereotypes: the patient as innocent young female victim of a predatory and deceitful male doctor, or the foolish young doctor falling prey to a seductive woman who has demanded a late home visit. These situations certainly arise, but there are also more nuances, and many exceptions (see Box 24.3). Same-sex incidents can occur, and a patient may well have previous experience of sexual abuse, making her or him vulnerable.
Violation of Professional Boundaries
OVERVIEW
Introduction
Rules and regulations
Are there risky (or at-risk) doctors?
Box 24.1 Case study: Clifford Ayling, General Practitioner
Box 24.2 Case study: William Kerr, Consultant Psychiatrist
Concerns were raised throughout his career…The allegations were of unscheduled domiciliary visits, or appointments being arranged for the end of clinics when there would be few nursing staff around. William Kerr would then allegedly expose himself and ‘invite’ patients to perform sexual acts (often of masturbation or oral sex) upon him, sometimes suggesting that this was part of their treatment. A number of patients also alleged that full sexual intercourse took place. A number of women described William Kerr’s ability to make them comply with his wishes, leaving them confused and guilty about their own actions and afraid to complain…prior to 1983, of the 30 concerns alleged to have been raised about William Kerr all but one fell on deaf ears.
Are there risky (or at-risk) patients?
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