Sexual Abuse by Healthcare Workers
Won: 1st Place in AMSACON White Paper Competition
Authors: Mariam Jaza Murtaza, Reethika Ramalingam, Vaishnavi Shashidhar, Ruchitha Madhavan
Sexual abuse is the most abominable violation of the physician-patient relationship. A patient can be vulnerable to abuse by a doctor because of the dynamics of varying levels of trust, authority, and control. Therefore, there are specific boundaries that can shield the patient from abuse. However, the ignorance of these boundaries, combined with the patient’s lack of awareness, can lead to an alarming situation . The sexual violation includes sexual intercourse with a patient, masturbating in the presence of a patient, unwarranted genital contact, sodomy, and rape.
It is difficult to provide an accurate estimation of the frequency of sexual violations by healthcare workers due to many reasons. Most victims do not report the violation , and one study even concluded that only 1 in 10 victims report the violation . Even when the report is filed, it may so happen that the consequences are not implemented. A study done by Aza AbuDagga et al. found that 1% of physicians had been reported on account of sexual misconduct, but 70% of the physicians accused were not disciplined . Further available statistics approximate that 7.1% of all sanctions by the FSMB were for sexual misconduct , and a summary of disciplinary reviews by the AMA found 11% of cases involved sexual contact with patients. 
In the Indian situation, it has not been possible to find accurate statistics due to the lack of research on this topic. In 2010, a cornerstone study called “Is there an elephant in the room” was published by the Indian Journal of Medical ethics, which talked about the boundary violations – sexual and non-sexual by medical practitioners. This paper then influenced a group of healthcare professionals from all over the country and various backgrounds to form a document called “The Banglore Declaration” and submit it to the Medical Council of India (MCI). It requests the council to include a more detailed explanation of the boundaries of a doctor-patient relationship in the existing medical curriculum. The MCI did respond to include a foundation course in the curriculum implemented from the batch of 2019 .
This paper aims to highlight the current issue and elicit further discussion. It outlines the probable causes for the issue, including lack of awareness, inadequate communication & absence of precise guidelines. It explains each cause in depth and proposes policy-based solutions from a holistic perspective to prevent any such incidents that can harm a patient.
We categorised the problem into four main sub-issues:
1. Lack of awareness among patients
2. Obstacles in reporting
3. The Gap in communication between the doctor and patient
4. Inadequate sensitisation of doctors to boundary guidelines
Lack of awareness among patients:
During the examination, the patient lets down his/her guard, which makes them vulnerable, and some healthcare professionals exploit this vulnerability and sexually violate them. One of the reasons for patients being vulnerable to abuse is that they do not possess the medical knowledge of an examination, which leaves them unaware of being violated. For example, the two-finger test to determine the hymenal status are banned for determining rape while examining victims. However, the public is mostly unaware of this, which can be an area of vulnerability during the examination of assault victims.  This issue is not just confined to India, but a lack of awareness is prominent worldwide. To cite a few examples, A former New York-based gynaecologist Robert A. Hadden was charged for sexually abusing his patients under cover of medical examination. He abused many young girls and adult women over the 20 years of his practice, and all this came to light after the #metoo movement, where many women spoke up.  Another well-known case is Lawrence Gerard Nassar – the former USA Gymnastics national team doctor – who used his position to sexually abuse over 125 females, including underaged girls, during his career. He was only recently sentenced to 40 to 175 years in prison in 2018 . These examples show how predators can continue their abuse for long periods with no consequences due to their victims being unaware of the contents of an appropriate medical examination. It also shows that the healthcare system did not have proper precautions to ensure they were not enabling the abuse and that the reporting procedure was inadequate.
Obstacles in reporting:
Reporting of such incidents has a low rate due to multiple factors including shame, unaware about the abuse (ex. If the patient was under anaesthesia), fear of being accused of falseness (fear of not being believed), being complicit in the violation (ex. blackmail) or being uncertain about the abuse taking place (ex. If an ungloved breast exam was necessary).  Even if a patient realises the occurrence of his/her violation and musters up the courage to file a complaint against
the offender, by the time the police requisition could be arranged, most of the medical evidence could be lost or would not be collected, resulting in the acquittal of the accused.  Employers and administrators can sometimes even ignore reports of abuse and encourage resignations or suspensions rather than reporting the physician to law enforcement or the medical board to avoid criticism . There are situations where a violation would have occurred even in the presence of a chaperone. In such a situation, the chaperone that witnessed the crime would probably be afraid to report about the act if the abuser is already an influential authority figure or has a political background. As a result, these factors could lead to many cases left unreported and reported yet unresolved, which leads to the low justified statistic rate obtained in these cases.
The Gap in communication between the doctor and patient:
It is of great importance that the patient is explained the procedure of examination, and the consent of the same is taken. However, the communication skills of doctors tend to decline as they progress through their education and career. They begin to exhibit avoidance behaviours and discourage patients from voicing their opinions or questioning the diagnosis or examination. Doctors anticipate resistance by patients and sometimes omit explaining critical parts of the procedure . Sometimes doctors may even take on a parent’s role and decide what is best for their patients without involving them, thus being paternalistic . This communication gap, combined with the patient’s lack of knowledge, can create misunderstanding or actual violation by the doctor.
Inadequate sensitisation of doctors to boundary guidelines:
There is unawareness among the doctors about the official guidelines regarding sexual boundaries. The previous medical curriculum did not include educating the undergraduate medical students about the violations of patient boundaries and medical ethics in detail. The Medical Council of India(MCI) had laid out a new curriculum as part of its Vision 2015 to incorporate and sensitise the students to patient rights precisely . This has been implemented through the Competency-Based Medical Education (CBME) from the batch of 2019. Students look at various case studies to make them comfortable with the law and its aspects. There is a Foundation course for the first month, after which, the AETCOM (Attitude, Ethics, and Communication Module) will be conducted for the entire MBBS course . However, this method of patient sensitive teaching has not been provided for students of the current undergraduate batches of 2016-2018 and for the batches that have previously graduated. This creates a situation where the soon to be doctor student and the doctors are not entirely sure of what is appropriate for them. Therefore it is crucial to actively sensitise the medical fraternity to the guidelines regarding boundary violations.
Influence of the COVID-19 Pandemic:
The COVID-19 Pandemic can affect this issue in a few ways. Due to the pandemic, there is an air of uncertainty, and the population is in an anxious state.
A COVID-19 positive patient is confined in isolation either at home, COVID care centre, or a hospital. Being in isolation makes the patient more vulnerable to Abuse in all aspects discussed previously, and that reporting of violation becomes even more difficult. Given patients’ anxious state, violations during testing are sometimes not recognised, and perpetrators exploit this uncertain environment. Furthermore, it is difficult to identify the perpetrators since the personal protective equipment may cover them. An example of this would be a 24-year-old girl who was sexually violated during testing, as the lab worker took vaginal swabs to “confirm” whether she was COVID-19 positive . Another aspect is that with the growing use of telemedicine during the pandemic, there is a possibility where perpetrators can exploit the patient by asking for unnecessary acts by the patients.
Therefore, this aspect should be further looked at as we do not have the data to corroborate all the misuse possibilities.
1. To tackle the lack of awareness, we propose that all examining rooms display posters/ diagrammatic representation portraying what is considered medically necessary and which body parts must be examined for basic procedures. Patients must be informed that organisations in the hospitals function as redressal centres and are available for their help. This information must also be displayed in the major vernacular language of the state.
2. On 30th August 2018, the Ministry of health and family welfare notified the first “Charter of Patients” in India, which laid down seventeen rights of a patient [Appendix 1]. This charter must be incorporated as a part of the educational policy and must be taught from the school level.
3. “Charter of Patients” should be displayed at hospital entrances and OPD’s so that patients can familiarise themselves to their rights. These should be displayed in the required languages including the prominent vernacular languages of the state. This awareness can mitigate situations of both sexual violations as well as violence towards a healthcare worker.
4. Newly employed doctors should be oriented to the Guidelines for doctors on sexual boundaries – Version 3.4 published by the Indian Psychiatric Society (IPS) Task Force on Boundary Guidelines in 2016 and later adopted by the Medical Council of India in 2019. This could be done through a state-issued booklet or presentation, made mandatory by law. This provides a clear legal and ethical framework as to what is considered a sexual boundary violation. [Appendix 3] 5. Sex Education is an essential part of the school syllabus. It already forms a part of the curriculum in other countries, but since sex is considered a taboo in many Asian countries, this topic is not covered. It is imperative to understand that comprehensive sex education does not encourage kids to have sex, nor does it prevent the children from imbibing moral behavioural standards from their parents. A curriculum for sexual education can be originally formed, or any foreign syllabus can be adapted to Indian standards. These can be inculcated for high school students. Knowing what is expected will train the individuals to recognise and refuse unwanted sexual behaviour, but most importantly, it would teach them the concept of consent. It will also promote better sexual health among the reproductive population. Therefore, sex education must be incorporated in current education policy.
Thus, as a part of the medical community, it is our responsibility to ensure patients’ safety who trust us for their care. The physician-patient relationship has been on a downward trajectory of late due to the various problems discussed in this article’s depth. We believe that the implementation of these recommendations and policies would help curb such incidences and uphold our profession’s dignity.
1. In the United States of America, the Medical practice act ensures investigative power and imposes punitive measures on every State medical board. It allows the board to directly transfer a case to criminal jurisdictions instead of involving the police. Such a policy can be adopted in India to prevent the delay in reporting commonly due to police involvement and to help the victim in terms of fear of being shamed or judged. 
2. The Protection of Children from Sexual Offences Act 2012 (POCSO) should include the mandatory presence of a chaperone of the same sex as the patient (either family member or appointed individual) during the examination of minors (below 18 years of age) to ensure their safety. [Appendix 4]
3. Section 376 of IPC should be amended to include the rape of a man and the rape of a transgender man/woman. Sexual violation as sodomy should be considered as rape under section 376 IPC and not just as a violation of section 377 IPC. This will provide fair justice to male and transgender victims. [Appendix 5 & 6]
4. The Constitutional Rights allow victims to testify in a free and fair manner without any threat. The Witness protection scheme, 2018, provides for the witness’s protection based on threat assessment and protective measures. It is recommended that these be implemented strictly because, despite their existence, the Indian Justice system continues to reel on without them. 
5. The professional etiquette confers complete anonymity to the complaining doctor by the ethics committee. This must be extended to students as they are possible witnesses. [Appendix 2]
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1] “Charter of Patients” – https://nhrc.nic.in/document/charter-patient-rights 2] INDIAN MEDICAL COUNCIL (Professional Conduct, Etiquette and Ethics) Regulations, 2002
https://www.mciindia.org/documents/rulesAndRegulations/Ethics%20Regulations-2002.pdf 3] Guidelines for doctors on sexual boundaries – Version 3.4 – IPS Task Force on Boundary Guidelines http://www.indianjpsychiatry.org/documents/Guidelines.docx 4] Protection of Children from Sexual Offences Act 2012
https://wcd.nic.in/sites/default/files/POCSO%20Act%2C%202012.pdf 5] Section 376 IPC – https://indiankanoon.org/doc/1279834/
6] Section 377 IPC – https://indiankanoon.org/doc/1836974/