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THE SUBJECT of professional bound- of course, includes refraining from sexual As a result of the intense concern that
aries (and boundary violations) has re- involvement with patients. While sexual has been generated by sexual exploita
ceived a great deal of recent attention in contact is perhaps the most extreme tion in the physician-patient relation
the psychiatric literature.1-5 The empha- form of boundary violation, many other ship, much more research has accumu
sis on defining guidelines for professional physician behaviors may exploit the de lated on sexual boundary violations than
conduct has expanded beyond the con- pendency ofthe patient on the physician on nonsexual boundary violations.
fines of ethics committees and has and the inherent power differential. Hence, our discussion of professional
worked its way into licensing boards These include dual relationships, busi boundaries will begin with a consider
charged with disciplining physicians ness transactions, certain gifts and ser ation of sexual misconduct and progress
whose behaviorjeopardizes the well-be- vices, some forms of language use, some from there to an examination of other
ing of patients. The Massachusetts Board types of physical contact, time and du forms of professional boundary trans
of Registration in Medicine,6 for example, ration of appointments, location of ap gressions.
has recently issued detailed guidelines pointments, mishandling of fees, and mis
on such matters as self-disclosure, dual uses of the physical examination. The Sexual Boundary Violations
relationships, sexual relationships with transgressions of some of these bound Six studies813 have sought to deter
patients, and other professional bound- aries may at times be necessary and mine the prevalence of sexual miscon
aries to help define for the public and for helpful. For example, it would certainly duct in the physician-patient relation
the profession the parameters of pro- be appropriate to hold the hand of a ship (Table).
fessional conduct in the practice of psy- patient who reaches out to a physician A comparison of the US studies with
chotherapy by physicians. While spe- after losing a family member. One can the survey from the Netherlands and with
cialists in psychiatry have been debat- differentiate minor boundary crossings the studies from Canada suggest that the
ing the pros and cons of issuing such from devastating boundary violations problem is one that is not unique to US
guidelines, nonpsychiatric physicians that ruin professional careers and seri physicians and thatit occurs with roughly
have yet to involve themselves so ex- ously damage patients.3 Similarly, some the same frequency in the United States
tensively in similar discussions. In this problems arise from corrupt and unethi as in other countries where sexual mis
article, we will provide a conceptual cal physician behavior, while others arise conduct has been studied. The problem is
framework for discussion of professional from honest misunderstandings. not unique to medicine. Other professions
boundaries in the physician-patient re- Much of the medical profession's are also vulnerable, including other health
lationship and offer our view of mea increased interest in boundaries has de care professionals, the clergy, and the
sures the profession can take to prevent rived from the awareness of the dam law. Research aimed at psychologists, so
serious violations of these boundaries. aging effects of sexual misconduct. cial workers, and teachers reveals that
We will use instances from our own clini Examination of instances of physician- sexual exploitation is a pervasive prob
cal experiences or those of our trainees patient sexual relationships has revealed lem in fiduciary relationships.21416
to illustrate the relevant issues. that sexual exploitation is usually The studies listed in the Table must
WHAT ARE BOUNDARIES? preceded by a progressive series of non- be viewed as less than definitive be
sexual boundary violations, a phenom cause of the fundamental methodologi
Professional boundaries in medical enon generally described as the "slip cal problems inherent in questionnaire
practice are not well defined. In gen pery slope."2,3,7 In this regard, what surveys. These include low return rates,
eral, they are the parameters that de appear to be trivial violations may in raising the possibility that the sample is
scribe the limits of a fiduciary relation reality be considerably more serious by no means representative. Other prob
ship in which one person (a patient) en when viewed in the context of a con lems include the possibility that some
trusts his or her welfare to another (a tinuum. Attention to nonsexual bound practitioners might not answer the ques
physician), to whom a fee is paid for the ary issues may therefore be an effective tions honestly because they question the
provision of a service. Boundaries imply way to prevent sexual boundary trans anonymity of the method. Also, some
professional distance and respect, which, gressions. This approach is especially who have engaged in sexual misconduct
salient because it has become clear that may not return the questionnaire. On
many of the nonsexual boundary viola the other hand, other professionals who
From The Menninger Clinic, Topeka, Kan (Dr Gab- tions may in and of themselves cause have transgressed sexual boundaries
bard), and Department of Psychiatry, Harvard Medical harm to patients irrespective of the pos might feel the need to anonymously con
School, Boston, Mass (Dr Nadelson).
Reprint requests to The Menninger Clinic, PO Box sibility that they also may lead to sexual fess. In essence, we do not know the
829, Topeka, KS 66601-0829 (Dr Gabbard). involvement.1,3-5 true prevalence of sexual misconduct.
therapeutic purposes. lines do not apply legally outside the tact with a patient during a difficult de
3. Cases involving abuse of the physi employment context, the situation ofthe livery and capture the patient's fantasy
cal examination procedure (eg, a physi physician-patient relationship involves as a hero or rescuer.
cian who does a breast or pelvic exami a person in a less powerful position at These considerations lead us directly
nation when not indicated, or a physician risk for being subjected to harassing into an examination of why physician-
who does an appropriate examination in behavior by someone who is more pow patient sex is considered unethical. Sev
an inappropriate, erotized manner). erful, the classic paradigm of sexual ha eral reasons have emerged from case
4. Situations in which a physician asks rassment. It is important to note that law, from the deliberations ofethics com
a patient on a date during the initial there are gender differences in the per mittees and licensing boards, and from
visit to his or her office or to an emer ception of sexual harassment.23 While clinical work with patients who have
gency department. many male physicians may view sexual been exploited by their physicians. First,
5. Cases in which a long-standing phy comments as humorous, a female pa it is a breach of the trust that is funda
sician-patient relationship evolves into tient or health professional observing mental in a fiduciary relationship. Sec
an intense lovesickness or infatuation. such remarks is not as likely to view ond, it calls into question the physician's
6. Situations in which a rural general them in the same way. capacity for objective professionaljudg
practitioner who is the only physician in The second category in the New Zea ment. A third reason derives from the
town dates a patient because virtually land set of definitions, sexual transgres psychological state ofthe patient induced
anyone who is a potential romantic part sion, refers to inappropriate and sexu by the clinical situation. Patients rap
ner is also a patient. alized touching of a patient that stops idly develop feelings toward their phy
7. Cases in which patients are raped short of overt sexual relations. This cat sicians that have been called "transfer
or fondled (while awake or under anes egory would include such items as sexu ence." This involves the displacement of
thesia) in the operating room or office. alized kissing, touching of breasts or feelings derived from past relationships
physician encounters sexual arousal on repeat of early boundary violations that ed by sexually abused patients, particu
the patient's part while conducting a have left scars on the patient's psyche. larly the rescue fantasies they inspire in
physical? One female medical student One physician was charged with sexual physicians, who may gradually become
was examining an elderly male patient misconduct by a patient who insisted overinvolved in an effort to repair the
when she noticed that his penis was that he had had "genital contact" with damage from the past.
erect. She completed the examination her. The physician adamantly denied it. Another area of education that would