“First, Do No Harm” Part I
Introduction to a 3-part series on what healthcare systems need to consider related to sexual abuse of patients in the care of physicians and other healthcare providers.
“First, Do No Harm” is a minimum ethical requirement associated with the practice of modern medicine. It is not part of the original or modern versions of the Hippocratic oath, but the oath does contain language suggesting that the physician and their assistants should not cause physical or moral harm to a patient.1 This emphasis on “do no harm” is strongly tied to the physician-patient relationship characterized by a high level of trust where patients not only entrust their bodies to physicians but intimate information about their psyche. Here, patients experience a high degree of vulnerability while disparities in knowledge and power only add to the fragility of this relationship.2 However, there is no greater exploitation of that power than when a physician crosses the line and sexually abuses their patients. The result for patients goes far deeper than mistrust including psychological trauma such as depression, anger, drug and alcohol abuse, suicidal thoughts, post-traumatic stress symptoms, and an overall decrease in feelings of trust and safety. 3
Scope of Sexual Abuse in Medicine
Although most medical professionals deem this to be a rare but persistent problem, surveys of physicians from multiple specialties have yielded physician–patient sexual involvement rates of 3.3 to 9.8%.4 Similarly, researchers reviewing the National Practitioner Data Base (NPDB) have estimated the rate to be around 5-10% of all U.S. physician licensees5 and less than 1% for nurses.6 When looking at physician and nurse reports in the NPDB related to licensure actions and/or medical malpractice both are rare, 1% and 0.6% respectively. Additionally, in a recent publication examining sexual misconduct in the Canadian healthcare system, healthcare professionals outside of physicians and nurses committing sexual misconduct included social workers, psychologists, and counselors.3 Ultimately this shows that there is no single profile of professionals who perpetrate sexual misconduct. The true extent of sexual abuse by healthcare professionals is unknown partly due to the reality that most researchers estimate only 5-10% of patients who are subjected to sexual misconduct ever report the assault. This is not only due to common elements in sexual abuse by anyone including shame, shock, or feelings of disbelief but can also be contributed to the significant power imbalance between physicians and their patients as well as the complicated navigation of the regulatory system amongst healthcare and medical boards.4
Case Analysis Findings and Trends among Claims Data for Healthcare Institutions
Praesidium recently reviewed 100 legal cases of sexual abuse occurring in a healthcare setting (Table 1); 94 cases named a healthcare provider as the offender with the other cases naming other patients as assailants. Demographic analysis found that alleged offenders were predominantly male (98%) and in their late 40s (average age 48.9 years). Their interactions with victims most often took place in isolation (86%) and in a single occurrence (70%); however, they tended to have multiple victims (66%). The victims of these cases were predominantly female (78%) adults (71%) who reported these cases to authorities and criminal charges were often filed against the offender (70%).
Praesidium also investigated differences between alleged offenders with regard to professional roles. Alleged offenders were categorized by the following job titles/role: physicians (N=57), nurses (N=13), other allied health licensed providers (N=7), and patient care workers (N=17). As seen in the table below, nurses and other licensed allied health providers were grouped to allow for a more significant sample size. In this analysis, comparing physicians with all provider types, physicians made up the predominant role of alleged offenders (61%) and tended to have more incidents of repeated abuse (14% more) with victims (11% more with multiple victims); however, they faced fewer criminal charges (11% less). Interestingly, the differences between physician offender characteristics and other healthcare providers with a medical license who were alleged to be offenders didn’t vary as much as it did with non-licensed employees; the only exceptions to this involved characteristics around repeated abuse (24% less than physician offenders) and multiple victims (37% less). Additionally, this analysis showed that non-licensed employees who were identified as offenders in these cases tended to be younger (12 years), were more often interacting alone with patients (11% more), were less likely to engage in repeated abuse (16% less) and were less likely to abuse a minor (11% less). Non-licensed offenders were also more likely to face criminal charges (16%).
Table 1. Praesidium Review of Publicly Available Sexual Abuse Cases in a Healthcare Setting (n=100)
|All Provider (N=94) Case Review||Physicians (N=57) Case Review||Nurses and other licensed staff minus physicians (N=20) Case Review||Non-licensed employees (N=17) Case Review|
|% Male Offender||98%||100%||99%||94%|
|Average Age of Offender||48 years||46 years||45 years||36 years|
|Interactions with patients alone||86%||79%||95%||100%|
Additional findings of this analysis examined the type of healthcare settings (hospitals, academic settings, private clinics) and the legal ramifications for these entities. Due to the nature of the claims data used in this analysis, all healthcare entities were part of the suit with only 9 cases known to be dismissed (less than 10%). Conversely, 48 of the 94 cases (51%) had a disclosed settlement and monetary award associated with it (averaging $109M). This aligns with the current trends to not only hold individual offenders liable for abuse but the organizations they are employed by or work at as negligent and thus liable as well; strengthening the theory of the expansion of the physician-patient relationship to a more triad construct of the healthcare system.
Although this analysis has limitations, Praesidium believes that additional research of abuse cases in healthcare settings analyzed by offender role in patient care delivery may lead to critical information that will assist healthcare systems and medical licensing bodies to create additional safeguards for patients as well as reduce the healthcare system’s damage to its reputation and patient trust.
Prevention in Healthcare Settings
Praesidium has gained extensive knowledge on sexual abuse prevention over the last three decades while working with thousands of organizations using the Praesidium Safety Equation. The Praesidium Safety Equation® is a framework of eight organizational operations that allows an organization to identify where abuse could occur. Using current research and root cause analyses of thousands of cases of abuse across a diverse range of organizations, we have identified best practices in each operation and developed solutions to help organizations implement these practices. What Praesidium has learned is that abuse is not a random occurrence; it happens in predictable patterns and places.
Offenders need three things to abuse: access, privacy, and control. In the healthcare setting, opportunities for these three things are common and easily attainable. Despite these natural opportunities that may exist, there are a variety of ways healthcare systems can focus on limiting access, privacy, and control by implementing abuse risk management standards that keep patient safety as the top priority.
Over the next 3 articles, we will explore the opportunities that exist for healthcare systems to address healthcare provider sexual abuse of patients in their system using the Praesidium Safety Equation.
1Sioutis S, Reppas L, Bekos A, Limneos P, Saranteas T, Mavrogenis AF. The Hippocratic Oath: Analysis and Contemporary Meaning. Orthopedics. 2021 Sep-Oct;44(5):264-272. doi: 10.3928/01477447-20210819-08. Epub 2021 Sep 1. PMID: 34590941.
2Clemens V, Brähler E, Fegert JM. #patientstoo – Professional sexual misconduct by healthcare professionals towards patients: a representative study. Epidemiol Psychiatr Sci. 2021 Jun 21;30:e50. doi: 10.1017/S2045796021000378. PMID: 34402421; PMCID: PMC8220485.
3Martin, G.M., & Beaulieu, I. Sexual Misconduct: What Does a 20-Year Review of Cases in Quebec Reveal about the Characteristics of Professionals, Victims and the Disciplinary Process? Sexual Abuse 2023. https://doi.org/10.1177/10790632231170818.
4Chinmoy Gulrajani. Journal of the American Academy of Psychiatry and the Law Online May 2020, JAAPL.200014-20; DOI: https://doi.org/10.29158/JAAPL.200014-20
5Sindhu KK, Schaffer AC, Cohen IG, Allensworth RH, Adashi EY. Honoring the public trust: curbing the bane of physician sexual misconduct. J Law Biosci. 2022 Mar 29;9(1):lsac007. doi: 10.1093/jlb/lsac007. PMID: 35371518; PMCID: PMC8968028.
6AbuDagga, A, Wolfe, SM, Carome, M, Oshel, RE. Crossing the line: Sexual misconduct by nurses reported to the National Practitioner Data Bank. Public Health Nurs. 2019; 36: 109– 117. https://doi.org/10.1111/phn.12567