Abstract
In the 2000 annual report of the Royal Australian and New Zealand College of Psychiatrists, Jonathon Phillips [1] drew special attention to an issue that arguably poses the biggest challenge to the profession of psychiatry. Perhaps one of the most destructive, stigmatizing acts is the violation of boundaries in the context of therapy. I hardly need dwell on this point, noting simply that it is necessary to put our house in order. A project team supported by project officer has been charged with this task by General Council. Rhetoric is of no use. We need to take practical steps to clear up the problem. Each Fellow of the College will be charged $20 in the coming year to give us the means to proceed. I know many will say that boundary violations have nothing to do with them. That might be so at an individual level but we must respond collectively to the problem. (p.4)
It took the paradigm shifts in psychiatry that came to the fore in the 1980s for the profession to begin to change its conceptualization of many patients in the light of the emerging literature on the extent and severity of incest, child sexual abuse and other childhood traumas and deprivations. The traumatic antecedents of severe personality disorder, dissociative disorders and other syndromes encompassed within the rubric of complex posttraumatic stress disorder became a focus of increasing clinical awareness. The sleeper in all of this is the belated recognition that within the ranks of physicians, clergymen and other members of helping professions lie the same kind of dynamics that made widespread sexual abuse an endemic feature of all societies.
Physician sexual misconduct, an edited collection of 11 chapters by individuals extremely well qualified to make constructive contributions to understanding the complexity and seriousness of the issue, is timely. The book is divided into four sections containing chapters on forensic issues (e.g. Thomas Guthiel), clinical and regulatory issues (e.g. Elissa Benedek/David Wahl), physician education (e.g. Jerald Kay/Brenda Roman) and therapeutic and rehabilitative issues (e.g. Glen Gabbard).
Themes that emerge include the difficulty medicine has had in formulating clear approaches to sexual boundary issues and the lateness in appreciating the extent of harm experienced by patients whose sexual boundaries were violated by their doctor. As violations represent wilful unethical acts it is hard to construe them as being a facet of the spectrum of negligence. A number of writers grapple with the issue of litigation and victim compensation against a background where insurers now specially write policies to exclude coverage for damages arising as a consequence of what is quaintly termed ‘undue familiarity’, or if they do offer coverage, payouts are capped.
There is divergence of opinion regarding the usefulness and validity of typologies of physician abusers or the psychological profiles of victims (usually women). While there is acknowledgement that on occasion false allegations regarding sexual impropriety are made, it is not explored, nor does the volume examine the characteristics of the majority of victims who never institute a complaint.
The book is challenging and thought provoking and the text enhanced by many clinical vignettes. Many make forthright statements which demonstrate a robust diversity in perspectives, for example: Approximately half of the physicians charged with sexual misconduct are not amenable to rehabilitation, in my experience, because of severe character pathology, lack of motivation to change, and dishonesty. (Gabbard, p. 215.) Our experience indicates that the number of patients victimized, the sex of the victims, and the extent of sexual involvement (voyeuristic activity, fondling, oral or anal sex, intercourse, or extensive affairs) are not factors determining the acceptability of a physician returning to practice. Instead, assuming compliance with treatment, it is primarily the ability to establish a practice plan that protects the public that determines the viability of the physician returning to practice. (Abel & Osborn, pp.244–245.) We do not believe that sexual abuse of patients by members of the health care professions is going to go away, and we believe that few, if any perpetrators can be rehabilitated. (Wohlberg et al., p.202.)
This excellent and clearly written book addresses many issues central to Dr Phillips' concerns. It is hard to conceptualize a health professional who does not need to be familiar with all the topics covered before.