What Is Professional Sexual Misconduct?

Health care providers are becoming more and more aware of sexual misconduct on the part of professionals. The profession of occupational therapy is not immune from this phenomenon. The National Board for Certification in Occupational Therapy, Inc. (NBCOT) is in agreement regarding the potential for harm or abuse to the recipients of occupational therapy services.

Professional sexual misconduct is defined by Richard Irons (Irons, 1) as "the overt or covert expression of erotic or romantic thoughts, feelings, or gestures by the professional toward the patient, that are sexual or may be reasonably construed by the patient as sexual." Sexual misconduct includes a broad range of behaviors including, but not limited to, nudity, kissing, spanking, and sexual suggestions or innuendoes.

Can It Happen In OT?

Could sexual misconduct happen in OT? Consider the following:

• The personal nature of OT services - such as working with patients with performance deficits in dressing, toileting and bathing;
• Situational vulnerability in the environments in which OTs practice - for example, patient's bedrooms (as in nursing homes), or in patient's homes (as with home health agencies);
• Vulnerability of persons receiving OT services - such as children, individuals with physical limitations, or individuals with psychosocial problems.

Principle 7 of NBCOT's Candidate/Certificant Code of Conduct states "Certificants shall not engage in conduct with recipients of occupational therapy, fieldwork students, or colleagues that violates appropriate professional boundaries and that does, or reasonably could be expected to, result in harm to recipients of occupational therapy services, fieldwork students or colleagues. Examples of this conduct include, but are not limited to, sexual exploitation or misconduct, inappropriate physical contact, financial exploitation, intrusion into the personal affairs of the recipient of occupational therapy services, fieldwork students or colleagues, and inappropriate self-disclosure."

Since beginning its disciplinary action program in 1987, NBCOT has received 31 complaints containing allegations related to sexual misconduct by an occupational therapist or occupational therapy assistant.

Why Is Sex Between Therapist And Patient Considered Exploitation?

By its nature, the therapeutic relationship is unequal. Patients make themselves vulnerable by sharing intimate details of their lives with their occupational therapist and/or occupational therapy assistant. Patients invest trust and authority in occupational therapy personnel, relying on the professional's judgment for help. Patients often view their therapists as powerful, parental figures, and patients may interact with the professional in a child-like way. Many patients admire and idealize their therapists and often experience sexual attraction or romantic feelings toward them.

Competent, ethical occupational therapy personnel recognize that these patient responses are normal, but they also realize that the power imbalance between professional and patient negates the possibility of an equal, consenting relationship. Occupational therapy personnel who encourage patients to act on these feelings abuse their responsibility to help the patient. Such manipulation is a violation of the patient's trust and a form of sexual abuse, whether or not the patient consents or even initiates the sexual contact.

Many people believe that the power dynamics in the therapeutic relationship so closely resemble those in the parent-child dyad that sex between professional and patient is psychologically equivalent to incest. For this and other reasons, several states have criminalized sexual exploitation of patients as a form of statutory rape.

How Common Is Therapist-Patient Sexual Contact?

Members of major health professions have conducted research on the incidence of sexual contact with patients by professionals. Studies have shown (Schoener, et al, 39) that 1% to 17% of professionals, in confidential self-reports, admitted to sexual contact with at least one patient. Some researchers believe that the actual incidence may be higher. It is interesting to note that among the professions which have been studied for the incidence of sexual contact, several are female-dominated professions.

Who Exploits, Who is Exploited?

Although the most common pattern involves a male professional and a female patient, abuse can occur between a professional and a patient of the same sex, or between a female professional and a male patient. Eighty percent of offenders exploit more than one patient.

What Effect Does This Exploitation Have On Victims?

Most victims suffer severe negative effects. Common reactions include:

• Isolation
• Confusion about the abuse, about the perpetrator, and about one's role in the abusive relationship
• Loss or lessening of ability to trust
• Feelings of guilt or shame
• Anger/rage
• Anxiety and panic
• Severe mood swings
• Depression
• Suicidal feelings
• Sexual problems
• Cognitive problems, such as difficulty concentrating and intrusive thoughts about the abuse
• Reluctance to seek help from another professional

Danger Signals!

The following behaviors are often indicators that a sexual boundary violation may be occurring:

• Increased or inappropriate self-disclosure on the part of the professional
• Longer appointments or appointment at the end of the day
• Change of location (meeting at a restaurant or bar)
• Introduction of alcohol or misuse of drugs in treatment
• Suggestive or seductive statements, "dirty jokes", or other verbally demeaning behavior
• Professional intruding into the patient's personal life (phone calls at home, social engagements)
• Excessive or intrusive focus on sexuality
• Request for secrecyInappropriate physical contactNudityErotic/sexual contact
• What Can Victims/Survivors Do If They Are Sexually Exploited?

Get out of the therapy immediatelyRecognize that they are not at faultTalk with other survivors of professional-patient sexual exploitation and/or other types of sexual abuse; join a support groupReport offender to agency where treatment is providedReport offender to NBCOT and/or the state regulatory boardFile a civil (malpractice suit)File a criminal complaint

What Can Professionals Do?

• Articulate strict prohibitions against professional-patient sexual involvement
• Report offending colleagues to appropriate boards, and advocate stricter discipline for offenders
• Receive education on professional-patient sexual exploitation
• Advocate including such training in academic and continuing education programs
• Work with other professionals, consumer-advocates, and survivors to reduce the degree of re-traumatization involved in reporting and in litigation

Selected Bibliography

Gabbard, G. (ed), Sexual Exploitation in Professional Relationships. Washington, D.C.: American Psychiatric Press, Inc., 1989.

Irons, Richard, The Sexually Exploitive Professional: An Addiction Sensitive Model for Assessment. 2nd Monograph of the Annual Conference on Addiction: Prevention, Recognition and Treatment, November, 1991.

Noel, B. and Watterson, K., You Must Be Dreaming. New York, N.Y.: Poseidon Press, 1992.

Pope, K. and Bouhoutsos, J., Sexual Intimacy Between Therapists and Patients. New York, N.Y.: Praeger, 1986.

Rutter, P., Sex in the Forbidden Zone. Los Angeles, CA.: Jeremy P. Tarcher, Inc., 1989.

Schoener, G. et al., Psychotherapists' Sexual Involvement with Clients: Intervention and Prevention. Minneapolis, MN: Walk-In Counseling Center, 1990.

Walker, E. and Young, P. A Killing Cure. New York, NY: Henry Holt, 1986.

Some information adapted with permission of Cathy Nugent, Treatment Exploitation Recovery Resource Associates, 2403 Guilford Avenue, Baltimore, Maryland.

(Revised 11/2006)