Abstract
Christopher James Ryan, University of Sydney and Department of Psychiatry, Westmead Hospital, Sydney, Australia:
Should a trainee in psychiatry be permitted to have sexual relations with a psychiatrist who is not his current supervisor? I have argued that he should [1]. Clarke has provided a well-crafted rebuttal to this view, and is clear that he should not [2]. Both of us would agree, I am sure, that this is not the most important issue facing the nature of psychiatric supervision today [3]. In many ways, it is a side issue and a possible distraction, but it is nonetheless an important issue and one that holds out the promise of resolution by just the sort of debate Clarke and I are conducting.
Clarke attacks my paper on two fronts. First, he attempts to draw a parallel between the psychiatrist-trainee relationship and the teacher-pupil relationship. While we don't prohibit sexual relationships between other groups of differential power (e.g. doctors and nurses, executives and secretaries) the ‘structural power imbalance inherent’ in the teacher-pupil setting sets this type of relationship apart and argues for a special prohibition on sexual contact here. At first glance, this manoeuvre seems compelling. Clarke is right; normally, we do prohibit sexual contact between teachers and pupils. For my argument to stay afloat, I would need to demonstrate why the psychiatrist-trainee relationship differs from the teacher-pupil relationships we normally ban.
It turns out, however, that the psychiatrist-trainee relationship is importantly different from most teacher-pupil relationships in two ways. First, most teachers act as their pupil's supervisors and sexual relations in this setting are ill-advised. However, I have already argued that sexual contact within the supervisory relationship should be prohibited, so Clarke cannot (and does not) claim any advantage on that score. Second, our archetypal teacher-pupil relationship is conducted between adults and children. Think teacher-pupil and that's the sort of relationship that comes to mind. We do not allow sexual relationships between adults and children, but that is not because of the inherent power imbalance. Adults may not have sex with children because it is undeniable that children cannot consent to such relationships. Psychiatrists in training are, without exception, adults. Moreover, they are adults with considerable professional training and experience, who already hold a justifiably high standing within the community at large. Although it is clearly not Clarke's aim to infantalise trainees, there is a tendency for the process of training to do just that and it is vital to ensure that trainees are not compared to children in any way. If the teacher-pupil parallel is to be invoked in an attempt to suggest that the power differential should proscribe sexual contact, then only a very special sort of teacher-pupil relationship should be imagined. Specifically, it is one where the pupil is a mature adult and one where the teacher is not the pupil's supervisor. An example might be a relationship between a postgraduate student and a non-supervising lecturer of the faculty into which he is enrolled. While there will be some who will feel that this sort of relationship should be prohibited, I remain unconvinced that such a prohibition would not be an unjustified paternalistic incursion into the rights of the individuals involved. My reasons would be exactly the same as those I have used to defend psychiatrist-trainee relationships.
Clarke's second thrust involves a clever attempt to turn my own argument against me. Anderson and I had already argued that if there was not a strong prohibition upon sexual relationships between psychiatrists and patients, there would be, what Clarke terms, a loss of public trust in relationships between all future patients and their psychiatrists. If this trust were lost the efficacy of psychiatrist-patient relationships would suffer [1,4]. Surely, Clarke argues, the same is true here. If there is not a similar prohibition upon sexual relationships between psychiatrists and trainees, there will be a loss of trust in these relationships. If trainees and psychiatrists are allowed to embark on sexual relationships, it will follow that trainees will ‘avoid teaching and supervision, contribute little…learn little’ and ‘…be loath to develop the depth of relationship that would facilitate …development as a psychiatrist’.
Would Clarke's dire predictions really come to pass if the generally permissive policy I am advocating were enacted? In theory, the question would be open to empirical investigation, although in reality, of course, that study will never be done. In the end, we will need to rely on a common sense reckoning of the likelihood of a generally permissive policy destroying the essence of training. I, for one, do not feel that any of Clarke's soothsaying is likely prove accurate. Trainees are not like patients. Training is not therapy. If the predictions are deemed unlikely, Clarke's second thrust of attack is also neutralised.
To close, I return to my opening point. The bulk of problems faced by trainees during their years of training derive from sources far removed from that of the rights and wrongs of sexual relations with psychiatrists. In seeking solutions to these problems, we will do well to take acknowledgement of the autonomy of psychiatrists and trainees as an undisputed starting point.