Medical Students' Attitudes Toward Sexual Contact With Patients and Supervisors Antta H. Clayton, M.D. Ruth B. Weeks, M.D. W. Victor Re Vieweg, M.D.
We surveyed 297 medical students regarding their attitudes toward sexual relations between physicians andpatients andbetuieen physician supervisors andjunior colleagues. Significantly more female than male medical students would interuene in a situation involving sexual contact between a physician anda patient, andmale students would intereede significantly more often in thecircumstance ofsexual contact between a colleague andphysician superoisor. Four percent ofthestudents considered it acceptable tohave sexual relations with patients. Forty-two percent feit that sexual contact would be acceptable immediately after theprofessional relationship ended; 80% approved ofsexual contactwithex-patients after twoyears. The responses ofboth sexes indicated a naive understanding of theunequal power dynamics inherent in these types ofrelationships. We recommend specific discussions with medical students aboui thedynamics ofunequal relationships andsexual exploitation tohelp prepare them for some ofthedifficult ethical issues in medical training andpractice.
S
exual eontact between physician and patient and between physician-edueator and student (resident or medical student) is an area that has been addressed recently in the literature. Gartrell et al. (l) conducted a national survey of 1,423 praetieing psychiatrists and reported that 7.1% of the male and 3.1% of the female respondents aeknowledged sexual eontact with their patients. In another survey, Gartrell et al. (2) questioned From the Department of Behavioral Medicine and Psychiatry, University'of Virginia Health Sciences Center, Charlottesville, Virginia, where Dr. Clayton is an Assistant Professor Dr. Weeks is a Clinical Associate Professor, and Dr. Vieweg is a Professor of Psychiatry and Medicine. Address reprint requests to Dr. Clayton at University of Virginia, Health Seiences Center, Oepartment of Behavioral Medicine and Psychiatry, Blue Ridge Hospital, Drawer C, Charlottesville, VA 22901. Copyright © 1991 Academic Psychiatry.
"-, '
548 fourth-year psychiatrie residents and found that 0.9%aeknowledged having been sexually involved with patients, and 4.9% reported sexual eontaet with their psychiatrie edueators. Less than 1% of the residents reported that edueator-resident sexual contact had been addressed thoroughly in residency training, and only 12%felt adequately knowledgeable about patient-therapist sexual eontact. It was the authors' recommendation that curricula be developed "for both residents and faculty on the dynamics of sexual exploitation and the psychological eonsequenees of inequality" (2).The Ameriean Psychiatrie Association (APA) specifieally states that "sexual aetivity with a patient is unethieal" and "sexual involvement between a faculty member or supervisor and a trainee or student may be unethieal" (3).The Ameriean Medical Asso\ ( )I l \ 1J
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ciation (AMA) recently addressed exploitation of others by physicians in the Report of the Council on Ethica1 and [udicial Affairs (4). This report, approved by the AMA House of Delegates on December 4, 1990, states, "Sexual contact which occurs concurrent with the physician-patient relationship constitutes sexual misconduct. Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physician-patient relationship land] are unethical if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship" (see Tables 1 and Z), Sexual contact between trainees and teachers appears to be increasingly prevalent in and pertinent to psychology training programs. Pope et al. (5,6) described the results of anational survey of psychologists in which 10% of the respondents reported sexTADLE L Medical ethics especWly applicable to psychiaby The APA Ethies Committee states in the Principles of Medical Ethies With Annotations Especially Applicable to Psychiatry (1989Edition) that : 1) The patient may place his/her trust in his/her
psychiatrist knowing that the psychiatrist's ethies and professional responsibilities preclude hirn/her gratifying his/her own needs by exploiting the patient. This becomes particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrist. 2) Sexual aetivity with a patient is unethical. Sexual involvement with one's former patients generally exploits emotions deriving from treatment and therefore almost always is unethical. 3) Sexual involvement between a faculty member or supervisor and a trainee or student, in those situations in which an abuse of power can occur, often takes advantage of inequa1ities in the working relationship and may be unethical because: (a) any treatment of a patient being supervised may be deleteriously affected; (b) it may damage the trust relationship between teacher and student; and (c) teachers are important professional role models for their trainees and affect their trainees' future professional behavior.
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ual contact with educators as students. Of note was the finding that sexual involvement between faculty and students in psychology training programs appears to be increasing, with the concern that sexual contact between psychology educators and psychology graduate students may serve as a model for later exploitation of patients. Glaser and Thorpe (7) found that 22% of recent female doctorate recipients in clinical psychology had been sexually involved with their psychology educators. In the absence of data on the attitudes of medical students toward sexual contact with patients or supervisors/educators, we conducted a survey of medical students at a major university medical center about their attitudes toward sexual behavior with patients and between supervisor and trainee. This survey was done in April of 1987before TADLE 2. Sexual misrondud in the practice of mediane: Report of the American Medical Assodation Counci1 on Ethical and Judicial Affairll The AMA Council on Ethical and [udicial Affairs states that: 1) Sexual contact which occurs concurrent with
the physician-patient relationship constitutes sexual misconduct. Sexual or romantic interactions between physicians and patients detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician's objective judgment conceming the patient's health care, and ultimately may be detrimental to the patient's well-being. 2) U a physician has reason to believe that nonsexual contact with a patient may be perceived as or may lead to sexualcontact, then he or she should avoid the non-sexual contact . 3) At a minimum, a physician's ethical duties include terminating the physician-patient relationship before initiating a dating, romantic, or sexualrelationship with a patient. 4) Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physidan-patient relationship. Sexual or romantic relationships with former patients are unethical if the physidan uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship.
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the revision of the APA or AMA standards, at a time when there was little discussion about sexual contact with patients or facu1ty. It is of note that no formal ethics courses were taught at the medical school at the time of this survey. METHODS
The study involved the distribution of a brief, anonymous questionnaire to the medical students toward the end of the academic school year. Information was sought about age, sex,year in school, and previous courses
in ethics. There were questions regarding students' attitudes toward sexual relations between physiciansand patientsand toward sexual relations between physician supervisors and junior colleagues. Same questions involved a yes-or-no answer, while other questions provided choices including 1) ignoring a colleague's behavior, 2) talking directly with the colleague, 3) discussing it with the colleague's supervisor, 4) sharing this information with other colleagues, 5) reporting it to the local medical society chapter, 6) contacting the state board of medicine, or 7) another choice which could be written
TABLE 3. Attitudes questionnaire 1. Age:
_
2. Sex (circle one) : M F 30 Year in medical school (circle one): 1 2 3 4 40 Is there a course in ethics in your professional school program? Yes No If yes, please use a, b, c, or d below to fill in the blank next to how many hours per year your ethics course meets. Year Nurnber of hours (a, b, c, or d) a) 10 hours/year 1st b) 10-25 hours/year 2nd c) 25-50 hours/year 3rd d) >50 hours/year 4th 50 After you have completed your training and are in practice: a) If one of your patients told you in confidence that a colleague had had sexual relations with him/ her while he/she was a patient of your colleague, would you (circle any that apply): 1) decide the patient was fabricating/exaggerating 2) talk to the patient for full details 3) talk directly to your colleague about the accusation 4) talk with your colleague's supervisor 5) contact your local medical society chapter 6) report the situation to the state board of medicine 7)other ----,-----,_ b) If you knew one of your colleagues was having sexual relations with a supervisor would you (circle any that apply): 1) ignore it 2) talk with your colleague 3) talk with the supervisor involved 4) contact your local medical society chapter 5) report it to the state board of medicine 6)other _ 6. Would you consider it acceptable to (circle all that apply): a) have sexual relations with patients b) have sexual relations with ex-patients 1) as soon as the professional relationship ends 2) 3 months after the professional relationship ends 3) 1 year after the professional relationship ends 4) 2 years after the professional relationship ends 5) Some other time period (specify) _
" '
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Yes
No
Yes Yes Yes Yes Yes
No No No No No
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in by the student (see Table 3). The questionnaire was distributed directly to the first-year (n=118) and secondyear (n=114) students during a dass period, toward the end of academic year 1986-1987. Third-year (n=l23) and fourth-year (n=133) students received their questionnaire by mall. 5tudents were instructed to answer all questions anonymously. We cornpared the ages of male and female medical students using two-tailed unpaired t-tests. Chisquare tests were used in the rernainder of the analysis. RE5ULTS All first- and second-year students returned the questionnaire. Thirty-one (25.2%) of the third-year students and 34 (25.6%) of the fourth-year students returned the question-
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naire. The response by students in the clinical years was inadequate for a cornparison with students in the first and second years. Unless otherwise noted, we cornbined all students for the data analysis. Of the 297 respondents, 202 (68%) were rnen and 95 (32%) were wornen, reflecting the distribution of rnen and wornen at the school. There was no difference (t=0.966, p=0.355) in age between rnen (24.6±2.6 [SO] years) and wornen (24.2±4.4 years). The ages ranged frorn 20 to 37 years. We cornpared the responses of students of traditional age (±1 year) for their year in rnedical school (e.g., first year in rnedical school
We surveyed 297 medical students regarding their attitudes toward sexual relations between physicians andpatients andbetuieen physician supervisors andjunior colleagues. Significantly more female than male medical students would interuene in a situation involving sexual contact between a physician anda patient, andmale students would intereede significantly more often in thecircumstance ofsexual contact between a colleague andphysician superoisor. Four percent ofthestudents considered it acceptable tohave sexual relations with patients. Forty-two percent feit that sexual contact would be acceptable immediately after theprofessional relationship ended; 80% approved ofsexual contactwithex-patients after twoyears. The responses ofboth sexes indicated a naive understanding of theunequal power dynamics inherent in these types ofrelationships. We recommend specific discussions with medical students aboui thedynamics ofunequal relationships andsexual exploitation tohelp prepare them for some ofthedifficult ethical issues in medical training andpractice.
S
exual eontact between physician and patient and between physician-edueator and student (resident or medical student) is an area that has been addressed recently in the literature. Gartrell et al. (l) conducted a national survey of 1,423 praetieing psychiatrists and reported that 7.1% of the male and 3.1% of the female respondents aeknowledged sexual eontact with their patients. In another survey, Gartrell et al. (2) questioned From the Department of Behavioral Medicine and Psychiatry, University'of Virginia Health Sciences Center, Charlottesville, Virginia, where Dr. Clayton is an Assistant Professor Dr. Weeks is a Clinical Associate Professor, and Dr. Vieweg is a Professor of Psychiatry and Medicine. Address reprint requests to Dr. Clayton at University of Virginia, Health Seiences Center, Oepartment of Behavioral Medicine and Psychiatry, Blue Ridge Hospital, Drawer C, Charlottesville, VA 22901. Copyright © 1991 Academic Psychiatry.
"-, '
548 fourth-year psychiatrie residents and found that 0.9%aeknowledged having been sexually involved with patients, and 4.9% reported sexual eontaet with their psychiatrie edueators. Less than 1% of the residents reported that edueator-resident sexual contact had been addressed thoroughly in residency training, and only 12%felt adequately knowledgeable about patient-therapist sexual eontact. It was the authors' recommendation that curricula be developed "for both residents and faculty on the dynamics of sexual exploitation and the psychological eonsequenees of inequality" (2).The Ameriean Psychiatrie Association (APA) specifieally states that "sexual aetivity with a patient is unethieal" and "sexual involvement between a faculty member or supervisor and a trainee or student may be unethieal" (3).The Ameriean Medical Asso\ ( )I l \ 1J
', .
'\
I \ 11,/ F .' •
c, I
\ 1\ 11 1\ ' ," I
( I \ \ , ( J'.
ciation (AMA) recently addressed exploitation of others by physicians in the Report of the Council on Ethica1 and [udicial Affairs (4). This report, approved by the AMA House of Delegates on December 4, 1990, states, "Sexual contact which occurs concurrent with the physician-patient relationship constitutes sexual misconduct. Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physician-patient relationship land] are unethical if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship" (see Tables 1 and Z), Sexual contact between trainees and teachers appears to be increasingly prevalent in and pertinent to psychology training programs. Pope et al. (5,6) described the results of anational survey of psychologists in which 10% of the respondents reported sexTADLE L Medical ethics especWly applicable to psychiaby The APA Ethies Committee states in the Principles of Medical Ethies With Annotations Especially Applicable to Psychiatry (1989Edition) that : 1) The patient may place his/her trust in his/her
psychiatrist knowing that the psychiatrist's ethies and professional responsibilities preclude hirn/her gratifying his/her own needs by exploiting the patient. This becomes particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrist. 2) Sexual aetivity with a patient is unethical. Sexual involvement with one's former patients generally exploits emotions deriving from treatment and therefore almost always is unethical. 3) Sexual involvement between a faculty member or supervisor and a trainee or student, in those situations in which an abuse of power can occur, often takes advantage of inequa1ities in the working relationship and may be unethical because: (a) any treatment of a patient being supervised may be deleteriously affected; (b) it may damage the trust relationship between teacher and student; and (c) teachers are important professional role models for their trainees and affect their trainees' future professional behavior.
\( ";)t \ 1it [...... "
I I
"
I
l- 1
I,
"
ual contact with educators as students. Of note was the finding that sexual involvement between faculty and students in psychology training programs appears to be increasing, with the concern that sexual contact between psychology educators and psychology graduate students may serve as a model for later exploitation of patients. Glaser and Thorpe (7) found that 22% of recent female doctorate recipients in clinical psychology had been sexually involved with their psychology educators. In the absence of data on the attitudes of medical students toward sexual contact with patients or supervisors/educators, we conducted a survey of medical students at a major university medical center about their attitudes toward sexual behavior with patients and between supervisor and trainee. This survey was done in April of 1987before TADLE 2. Sexual misrondud in the practice of mediane: Report of the American Medical Assodation Counci1 on Ethical and Judicial Affairll The AMA Council on Ethical and [udicial Affairs states that: 1) Sexual contact which occurs concurrent with
the physician-patient relationship constitutes sexual misconduct. Sexual or romantic interactions between physicians and patients detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician's objective judgment conceming the patient's health care, and ultimately may be detrimental to the patient's well-being. 2) U a physician has reason to believe that nonsexual contact with a patient may be perceived as or may lead to sexualcontact, then he or she should avoid the non-sexual contact . 3) At a minimum, a physician's ethical duties include terminating the physician-patient relationship before initiating a dating, romantic, or sexualrelationship with a patient. 4) Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physidan-patient relationship. Sexual or romantic relationships with former patients are unethical if the physidan uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship.
:-- !
\ 11 1)I~ \ I '-, I! PI '\ 1'-, \ 111 11 PI '"'
the revision of the APA or AMA standards, at a time when there was little discussion about sexual contact with patients or facu1ty. It is of note that no formal ethics courses were taught at the medical school at the time of this survey. METHODS
The study involved the distribution of a brief, anonymous questionnaire to the medical students toward the end of the academic school year. Information was sought about age, sex,year in school, and previous courses
in ethics. There were questions regarding students' attitudes toward sexual relations between physiciansand patientsand toward sexual relations between physician supervisors and junior colleagues. Same questions involved a yes-or-no answer, while other questions provided choices including 1) ignoring a colleague's behavior, 2) talking directly with the colleague, 3) discussing it with the colleague's supervisor, 4) sharing this information with other colleagues, 5) reporting it to the local medical society chapter, 6) contacting the state board of medicine, or 7) another choice which could be written
TABLE 3. Attitudes questionnaire 1. Age:
_
2. Sex (circle one) : M F 30 Year in medical school (circle one): 1 2 3 4 40 Is there a course in ethics in your professional school program? Yes No If yes, please use a, b, c, or d below to fill in the blank next to how many hours per year your ethics course meets. Year Nurnber of hours (a, b, c, or d) a) 10 hours/year 1st b) 10-25 hours/year 2nd c) 25-50 hours/year 3rd d) >50 hours/year 4th 50 After you have completed your training and are in practice: a) If one of your patients told you in confidence that a colleague had had sexual relations with him/ her while he/she was a patient of your colleague, would you (circle any that apply): 1) decide the patient was fabricating/exaggerating 2) talk to the patient for full details 3) talk directly to your colleague about the accusation 4) talk with your colleague's supervisor 5) contact your local medical society chapter 6) report the situation to the state board of medicine 7)other ----,-----,_ b) If you knew one of your colleagues was having sexual relations with a supervisor would you (circle any that apply): 1) ignore it 2) talk with your colleague 3) talk with the supervisor involved 4) contact your local medical society chapter 5) report it to the state board of medicine 6)other _ 6. Would you consider it acceptable to (circle all that apply): a) have sexual relations with patients b) have sexual relations with ex-patients 1) as soon as the professional relationship ends 2) 3 months after the professional relationship ends 3) 1 year after the professional relationship ends 4) 2 years after the professional relationship ends 5) Some other time period (specify) _
" '
\ ( )I I \
Yes
No
Yes Yes Yes Yes Yes
No No No No No
f! , "
'\ I \ 1HI I, : • "I \I \ 11 I, I " "
I
( I \ '> 1\ r-,
in by the student (see Table 3). The questionnaire was distributed directly to the first-year (n=118) and secondyear (n=114) students during a dass period, toward the end of academic year 1986-1987. Third-year (n=l23) and fourth-year (n=133) students received their questionnaire by mall. 5tudents were instructed to answer all questions anonymously. We cornpared the ages of male and female medical students using two-tailed unpaired t-tests. Chisquare tests were used in the rernainder of the analysis. RE5ULTS All first- and second-year students returned the questionnaire. Thirty-one (25.2%) of the third-year students and 34 (25.6%) of the fourth-year students returned the question-
I'
!
naire. The response by students in the clinical years was inadequate for a cornparison with students in the first and second years. Unless otherwise noted, we cornbined all students for the data analysis. Of the 297 respondents, 202 (68%) were rnen and 95 (32%) were wornen, reflecting the distribution of rnen and wornen at the school. There was no difference (t=0.966, p=0.355) in age between rnen (24.6±2.6 [SO] years) and wornen (24.2±4.4 years). The ages ranged frorn 20 to 37 years. We cornpared the responses of students of traditional age (±1 year) for their year in rnedical school (e.g., first year in rnedical school
