Sexual exploitation is considered to be one of the most serious ethical violations among the mental health professions and the clergy, and it is of increasing concern in other health professions as well. Sexual violations can be harmful to victims and their families, the careers and relationships of offenders, and the image of the health professions, especially when the professions are perceived as minimizing the seriousness of the problem (Edelwich & Brodsky, 1991; Gabbard, 1989; Gonsiorek, 1995; Rutter, 1989). Yet health and religious professionals and those who educate them have done relatively little to help their colleagues and students understand the importance of appropriate boundaries and the factors that place professionals at risk for boundary violations.

The Task Force was charged with "developing educational initiatives to include both professional training and continuing professional education" - Maryland Code Ann'd, Art. 41, §18-304(c)(3) (1993 Cum. Supp.).

FINDINGS

Need for Education

Recent attention to the problem of sexual exploitation by the professions has focused primarily on tighter ethical standards and more effective sanctions for offenders (Council on Ethical and Judicial Affairs, 1991) (1). However, it has become increasingly apparent that the issue is generally not addressed well in the education of students (Gartrell, Milliken, Goodson, Thiemann, & Lo, 1992). For example, in a study of 314 psychiatric residents in Canada, only 8.6% reported "thorough teaching" about the problem of patient-therapist sex and 21.3% reported no education at all in that area (Carr, Robinson, Stewart, & Kussin, 1991). Most of the teaching that exists in U.S. and Canadian psychiatric residency programs has begun within the last ten years. However, there is great diversity in content, format, and time devoted to this issue.

Most previous attempts to determine the extent of academic education on professional-client boundaries have involved retrospective surveys of graduate professionals and, therefore, cover a long and undifferentiated period of education. A recent study conducted in Maryland, that the Task Force helped design, asked students entering their fourth year of medical school about their educational experience in this area. Responses were received from 24% of the 126 U.S. and Canadian schools surveyed.

Required or elective education related to professional-client boundaries was reported from 67% of the medical schools. Required material tended to be taught in courses on ethics, behavioral sciences, human sexuality, or introduction to clinical practice. The teaching was considered to provide "a good basis for understanding professional-client boundaries" by students from 77% of the schools including such teaching. Ninety-three percent of the respondents felt that this area should be a part of the required medical curriculum.

Although these results are encouraging, it is clear that many schools either do not cover such material or teach it in a way that is not maximally effective. For example, several students suggested either that the discussion of individual cases in small groups would be more effective than lecture presentations or that the issue should be revisited during clinical phases of their education. Some students realized the need to address the balance between supportive and harmful expressions of intimacy or were sensitive to the dilemmas posed in closed systems, such as rural settings. The need for attention to student-teacher boundaries was also expressed. Resistance to the issue was reflected in comments such as, "Isn't this all just common sense?" or the conviction that the issue should have been taught "at home before medical school." One student insisted that "all that is needed is a review of laws and ordinances."

Areas of Need and Recent Advances

All in all, there are five settings, each with a different population, in which education about professional-client boundaries is important:

Pre-degree or Residency Training

Most of the established programs are aimed at those in mental health and related fields, although there is some evidence that the scope is beginning to broaden. One of the earliest attempts to formalize education of psychiatric residents in this area was the development of a videotape by the American Psychiatric Association (1986). The videotape is composed of a series of clinical vignettes and is accompanied by a study guide. An eight-week course for students in the mental health professions described by Bridges (1994) emphasizes the psychodynamics of professional-client relationships, using a number of poignant case examples. Pope, Sonne, and Holroyd (1993) recently published a book dedicated to teaching mental health professionals how to address sexual feelings in psychotherapy. A unique feature of the book is a long section of anecdotes and quotations from a number of noted therapists, each followed by a series of questions for discussion.

A resource guide on ethical development, recently published by the Association of American Medical Colleges, includes brief vignettes on student-teacher relationships and physician attraction to patients (Bickel, 1993). A book by Peterson (1992) presents an excellent discussion of professional-client boundaries and includes extensive case examples addressing a wide variety of sexual and nonsexual boundary issues in a number of professional settings.

Continuing and Institutional Education

Milgrom (1992) has written a training manual for facilitators conducting two-hour workshops on boundaries in professional relationships that can easily be adapted to a variety of settings. For example, Nugent and Plaut (Vice-Chair and Chair of the Maryland Task Force) expanded Milgrom's two-hour model into a full-day workshop for mental health professionals, with a major emphasis on prevention. In their expanded workshop design, Nugent and Plaut included an overview of relevant issues, such as the prevalence of the problem, the nature and dynamics of professional-client relationships, common responses of victims, issues in treatment and recovery, and options for redress. They also incorporated a systems model, based in part on White's (1986) work on organizational systems, for understanding factors at five levels--client, therapist, organizational setting, professional milieu, sociocultural environment--that may contribute to sexual exploitation. Nugent and Plaut also included a pre-post workshop questionnaire, self-assessments, and organizational action-planning exercises not included in Milgrom's two-hour workshop design. (Materials from the Nugent and Plaut workshop appear in Appendix A.)

A number of programs have been developed for use with clergy from many denominations (Houts, 1995). For example, the Center for the Prevention of Sexual and Domestic Violence in Seattle, Washington has developed a variety of educational resources, including the videos, Not in My Church and Not in My Congregation. These may be purchased from the Center and come with study guides and awareness brochures. The Center also offers a trainers' workshop on clergy misconduct, Sexual Abuse in the Ministerial Relationship, that emphasizes prevention and intervention. Denominations or organizations can request that the Center develop a specialized version of the training that is tailored to the group's specific needs. The Center grants continuing education units to participants who successfully complete the training. (See Appendix B for information on educational resources on clergy sexual misconduct.)

Another group that offers educational resources related to clergy sexual misconduct is the Interfaith Sexual Trauma Institute (ISTI) of Collegeville, Minnesota. According to The ISTI Sun (1995), the ISTI's first major project was to sponsor three national "discovery conferences" held in February and March 1995. These conferences, which drew 275 participants, were developed to "get a first-hand sampling of what is being done around the country, across denominations and, from the perspective of the participants, what needs to be done to address the issues of sexual abuse within religions."

Rehabilitation Education

Rehabilitation programs resulting from disciplinary action by licensing boards often include an educational component (Abel, Barrett, & Gardos, 1992; Plaut, 1995a; Pope, 1989a; Schoener & Gonsiorek, 1988). Frequently, an offender may be asked to complete a graduate level course in professional ethics. Such a requirement, although well intended, does not ensure either (a) that the course includes subject matter relevant to the offense in question or (b) that the professional has satisfactorily mastered relevant concepts. Because the subject of professional-client boundaries often has not been discussed at length during the normal education process, such a course may be the professional's first formal exposure to the topic.

Specialized Education

Canadian task forces established to study this problem in Ontario (Independent Task Force, 1991) and British Columbia (Committee on Physician Sexual Misconduct, 1992) concluded that all persons involved in hearing complaints should receive specialized training to increase their knowledge of and sensitivity to the complex issues involved. The depth and scope of the training will vary according to the role each individual plays, but at the very least, all must have a base of knowledge and an understanding of the issues and procedures involved in the hearing process.

Recommended Approach For Teaching Students About Sexual Exploitation: Focus on Clinical Boundaries

The defensiveness seen in the last three student comments reported in the discussion of responses to the student survey in the Need for Education section of this chapter is typical when the issue of professional-client boundaries is perceived as an absolute prohibition: "Thou shalt not have sex with thy patients." As necessary as that prohibition may be, it is more likely to be accepted if the student understands the unique features and dynamics of the professional-client relationship that make the client dependent and vulnerable and that can compromise the client's ability to give consent to sexual contact. These factors are often subtle, vary somewhat with the situation at hand, and involve nonsexual as well as sexual issues. Once these complex dynamics are understood, it is difficult to defend the position that the professional standards reflect common sense or that they necessarily extend naturally from moral standards presumed to have been taught in the home.

An optimum curriculum on clinical boundaries for students thus needs to cover three broad areas: (a) what constitutes appropriate professional boundaries and why, (b) what defines boundary violations and how they can be prevented, and (c) what roles health professionals may play in responding to a boundary violation.

An appreciation of appropriate boundaries must begin with the understanding that a certain level of closeness is not only acceptable but also sometimes desirable for clinical effectiveness. The clinician's warmth, caring, and even touch are often an integral part of the "laying on of hands" that is typically considered critical to effective patient care. At the same time, excessive or inappropriate closeness may compromise the professional's objectivity, confuse the client as to what appropriate boundaries are, and prevent the client from achieving the independence from the professional that is the ultimate goal of the helping relationship. Thus, an effective clinical relationship requires a balance between closeness and separateness (Kopp, 1976; Rogers, 1958). That balance may differ in various professional settings. For example, perceptions of appropriate boundaries for a radiologist, dentist, psychologist, physical therapist, gynecologist, or clinical supervisor may vary according to the circumstances.

The student must also learn that, by their very nature, the client's dependence on the professional and the trust that is necessary for a helping relationship impart a certain power to the professional that he or she has the responsibility not to abuse, sexually or otherwise (Feldman-Summers, 1989). Although either party may experience sexual feelings, the professional is always the one responsible for maintaining the boundaries. The power differential inherent in such relationships renders the patient vulnerable and thus unable to participate in such a relationship as a truly consenting person. Furthermore, the client's dependency may persist beyond the termination of a professional relationship, and the professional must be sensitive to that possibility as well.

It must also be understood that sexual attraction experienced by either the client or the clinician may be more symbolic than real. To varying degrees, any helping relationship is likely to involve elements of transference and countertransference. It is the professional's responsibility to consider the possibility that an apparent attraction may reflect unconscious representations of other relationships in the life of either party (Bridges, 1994).

Sexual contact is typically considered the most extreme and traumatic form of boundary violation. However, finding the balance between closeness and separateness can be most effectively accomplished by studying some of the more subtle nonsexual boundary issues (Gabbard & Nadelson, 1995). Under what conditions does a professional accept gifts or social invitations? To what extent are dual relationships (e.g., employment of or socializing with a client) acceptable? To what extent is touch between professional and client acceptable? Is it acceptable for the professional to disclose personal information to the client? Are there kinds of personal disclosure that are more or less appropriate? How does one manage the problem of dual relationships in relatively closed systems such as military settings, rural areas, or hospitals (Barnett & Yutzenka, 1994; White, 1986)? How are these considerations of boundary issues translated into ethical and legal standards for professional behavior?

Because boundary violations typically involve male offenders and female victims, one must also consider the role of cultural factors, such as men's attitudes toward women and the role they play in influencing how men relate to women in the professional setting. The Ontario Task Force (Independent Task Force, 1991) stressed that curricula on this topic must "reflect an understanding of the context in which sexual abuse by physicians occurs" (p. 37). Important issues that are part of that context include "gender socialization, sex roles, women's equality issues, [and] cultural variables" (p. 37).

Struggling with these issues helps students understand the importance and the complexities of boundary issues in a constructive way. The use of clinical vignettes, sessions with offenders or victim-survivors of sexual exploitation, or discussion of personal experiences with professional-client boundaries in small group sessions can be invaluable in exploring these subtle and complex issues.

A critically important aspect of the learning process is the modeling that students experience in their own relationships with their teachers, supervisors, and mentors (Conroe & Schank, 1989; Glaser & Thorpe, 1986; Jacobs, 1991; Plaut, 1993; Pope, 1989b). The boundaries between teachers and students are generally looser than those expected between provider and client in a clinical situation. A certain level of friendship and socializing is considered a constructive part of the mentoring relationship. Even here, however, the need for the teacher to evaluate and to guide the student requires a certain level of distance and objectivity. The teacher's ability to maintain that balance can help students prepare for their own roles as clinicians or teachers as they mature professionally.

Educating About Risk Factors and Warning Signs

Students and practitioners may be less likely to transgress clinical boundaries if they understand the dynamics of the professional-client relationship and are aware of factors that may place them at risk for exploiting clients. Educating students and professionals to be aware of risk factors--such as personal vulnerability related to a loss in one's life, isolation from professional peers, and an impoverished social network--and to seek consultation and support during times of increased risk may assist in prevention. Similarly, students and professionals should be taught to be aware of indicators of a potential problem, such as consistently looking forward to a certain client's arrival, fantasizing at length about a specific client, repeatedly extending a particular client's appointment time, or discussing with the client details of the professional's own personal life. Students and professionals should be made aware of such warning signs and encouraged to seek assistance before a critical boundary is crossed and before the situation gets out of control. Students and professionals must also learn how to respond appropriately to clients who make sexual advances toward them (Assey & Herbert, 1983).

RECOMMENDATIONS

Recommendation 1. Applicants for licensure or certification in the health professions must demonstrate knowledge of appropriate clinical boundaries and their importance in avoiding sexual exploitation of clients in order to be licensed or certified to practice in Maryland ⁽²⁾.

Currently, there is no standard that requires health professional curricula to include education on the topic of clinical boundaries and sexual exploitation. If the topic is covered at all, it is often included in an ethics course, rather than presented within the context of learning about clinical skills, one of which is understanding and managing clinical boundaries. Additionally, the decision to include information on sexual exploitation in any course is usually at the discretion of the particular faculty member developing the curriculum. The instructor may later change the course, another faculty member may take over the course and not include this topic, or the course may be eliminated altogether. Moreover, even if the topic is routinely covered in an ongoing course, the teaching approach may not be maximally effective.

Requiring knowledge of this topic as a prerequisite to receiving professional accreditation is the only way to guarantee that education about sexual exploitation will be included in curricula for students in the health professions. Therefore, questions about clinical boundary violations and sexual exploitation should be placed on examinations for licensure or certification, or a separate examination on this topic should be administered. The Task Force recommends that a set of questions covering issues related to sexual exploitation that would be common to all the health professions be developed and included on each health profession's licensing examination. In addition, each profession should also develop discipline-specific examination questions related to clinical boundaries and sexual exploitation.

Finally, the Task Force observes the distinction between one's having knowledge of a topic and actually conforming one's behavior to professional standards. The Task Force suggests that accreditation bodies consider ways to evaluate not only applicants' knowledge of this and related topics but also their clinical skills and behavior.

Recommendation 2. A cycle of continuing education emphasizing clinical boundaries in professional-client relationships should be designed and made available to the various health professions.

To renew their licenses to practice, most health professions are required to document a certain number of continuing education units (CEUs). Therefore, requiring continuing education is a particularly effective strategy for reaching those already licensed to practice.

The curriculum and materials developed should include the most current findings on clinical boundary violations and should be based on principles of adult and continuing education. The Task Force recommends that the curriculum focus not only on providing knowledge and information but also on sensitizing participants to the impact of sexual exploitation. For example, this could be done through videotaped or live presentations by clients who have been victimized and by practitioners who have exploited clients. Additionally, the Task Force recommends that the curriculum include opportunities for participants to apply insights and sensitivities gained to case examples or to discussions of their clinical work.

The Task Force notes that continuing education programs on sexual exploitation have generally been addressed to mental health professionals but that some other professions are also beginning to address this topic. The Task Force recommends that a curriculum be developed that includes a core section relevant to all health professions, with other sections customized to meet the educational needs of the various disciplines. (See Chapter 4 for additional recommendations on curriculum development and design.)

Recommendation 3. All health professional licensing or certification boards in Maryland should grant continuing education units on the topic of clinical boundaries and sexual exploitation and should require licensees to document that they have received such continuing education before they may renew their license to practice in Maryland.

Required continuing education as a condition for licensure renewal is an effective strategy for ensuring that all licensed health professionals have received education on this important topic. However, the Task Force recognizes that there may be some resistance to the requirement that all current licensees document such education and suggests that a two-tiered system could be implemented initially. In this two-level schema, new licensees would be required to demonstrate knowledge in this area as tested on the licensing examination. The requirement for currently licensed professionals to receive and document continuing education could be phased in over time.

Recommendation 4. All health and mental health institutions in Maryland should develop and implement, as part of their orientation and ongoing inservice training for employees, a program that provides a thorough explanation of the institution's policy on employee-patient sexual contact.

This recommendation is particularly important to ensure that unlicensed and noncertified health practitioners in health and mental health institutions also receive at least some education about client sexual exploitation. As part of new employees' orientation and ongoing inservice training, all employees in Maryland facilities should receive a thorough explanation of the organization's position concerning employee-patient sexual contact, the behavior expected of employees, and the consequences for violating the standard of expected behavior. The Task Force recommends that employees be given a copy of the policy, and that they be required to sign a statement indicating their understanding of the policy and the consequences for violating it. (See Chapter 4 for information on development of this training.)

Recommendation 5. Education included as part of the rehabilitation plan of a health professional who has been found guilty of sexually exploiting a client should be tailored to the specific needs of the professional seeking rehabilitation.

At times, a professional who sexually exploits a client has limited or erroneous knowledge about the nature and dynamics of the clinical relationship or lacks information about other important, related issues. One way to maximize the assurance that the professional in rehabilitation acquires knowledge to remediate specific learning deficiencies is to require that the offender undergo a board-sponsored and board-monitored tutorial experience designed to meet specific objectives relevant to the professional's individual situation. The Task Force recommends that such education be included in the rehabilitation plans for those who have sexually exploited clients. (See Chapter 7 for further discussion of rehabilitation for professionals who have sexually exploited clients.)

Recommendation 6. The law should require training on the dynamics of sexual misconduct for all professionals having a role in the investigation, prosecution, or disposition of licensing board complaints (e.g., board members, investigators, attorneys, and administrative law judges).

There is a significant variation in the levels of knowledge and sensitivity among various individuals with a role in investigating, prosecuting, and deciding complaints involving allegations of sexual exploitation. The Task Force recommends that a specialized training program be developed for all personnel involved in health profession licensing board complaints to enhance the knowledge and sensitivity with which they approach these cases. (See Chapter 4 for more information about curriculum development and Chapter 6, Enforcement: Licensure Discipline, Recommendation 6.)

Although the details of the schema presented here for educating health professionals may not translate exactly to the church or synagogue setting, it is recommended that religious organizations and institutions adapt the general direction and thrust of these recommendations for implementation in their particular settings.

NOTE

(1) Much of the information concerning the education of health professional students in this chapter previously appeared in Plaut, S. M., & Ginter, H. B. (1995). Sexual boundaries between health professionals and clients: A blueprint for education. SIECUS Report, 23(5), 3-5.

(2) Recommendations are numbered consecutively as they appear in the report but some are repeated in other chapters with their original number.

Abel, G. G., Barrett, D. H., & Gardos, P. S. (1992). Sexual misconduct by physicians. Journal of the Medical Association of Georgia, 81, 237-246.

American Psychiatric Association. (1986). Ethical concerns about sexual involvement between psychiatrists and patients (Videotape). Washington, DC: Author.

Assey, J. L., & Herbert, J. M. (1983). Who is the seductive patient? American Journal of Nursing, 4, 531-532.

Barnett, J. E., & Yutzenka, B. A. (1994). Nonsexual dual relationships in professional practice with special applications to rural and military communities. Independent Practitioner, 14, 243-248.

Bickel, J. (1993). Promoting medical students' ethical development. Washington, DC: Association of American Medical Colleges.

Bridges, N. A. (in press). Managing erotic and loving feelings in therapeutic relationships. Psychotherapy Practice and Research.

Bridges, N. A. (1994). Meaning and management of attraction: Neglected areas of psychotherapy training and practice. Psychotherapy, 31, 424-433.

Carr, M. L., Robinson, G. E., Stewart, D. E., & Kussin, D. (1991). A survey of psychiatric residents regarding resident-educator sexual contact. American Journal of Psychiatry, 148, 216-220.

Committee on Physician Sexual Misconduct. (1992). Report prepared for the College of Physicians and Surgeons of British Columbia. Vancouver, British Columbia, Canada: Author.

Conroe, R. M., & Schank, J. A. (1989). Sexual intimacy in clinical supervision: Unmasking the silence. In G. R. Schoener, J. C. Milgrom, J. C. Gonsiorek, E. T. Luepker, & R. M. Conroe (Eds.), Psychotherapists' sexual involvement with clients: Intervention and prevention (pp. 245-263). Minneapolis, MN: Walk-In Counseling Center.

Council on Ethical and Judicial Affairs, American Medical Association. (1991). Sexual misconduct in the practice of medicine. Journal of the American Medical Association, 266, 2741-2745.

Edelwich, J., & Brodsky, A. (1991). Sexual dilemmas for the helping professional (Revised and expanded edition). New York: Brunner/Mazel.

Feldman-Summers, S. (1989). Sexual contact in fiduciary relationships. In G. O. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 193-209). Washington, DC: American Psychiatric Press.

Gabbard, G. O. (Ed.). (1989). Sexual exploitation in professional relationships. Washington, DC: American Psychiatric Press.

Gabbard, G. O., & Nadelson, C. (1995). Professional boundaries in the doctor-patient relationship. Journal of the American Medical Association, 276, 1445-1459.

Gartrell, N. K., Milliken, N., Goodson III, W. H., Thiemann, S., & Lo, B. (1992). Physician-patient sexual contact: Prevalence and problems. The Western Journal of Medicine, 157, 139-143.

Glaser, R. D., & Thorpe, J. S. (1986). Unethical intimacy: A survey of sexual contact and advances between psychology educators and female graduate students. American Psychologist, 41, 43-51.

Gonsiorek, J. C. (Ed.). (1995). Breach of trust: Sexual exploitation by health care professionals and clergy. Thousand Oaks, CA: Sage.

Houts, D. C. (1995). Training for prevention of sexual misconduct by clergy. In J. C. Gonsiorek (Ed.), Breach of trust: Sexual exploitation by health care professionals and clergy (pp. 368-375). Thousand Oaks, CA: Sage.

Independent Task Force Commissioned by the College of Physicians and Surgeons of Ontario. (1991). The final report of the task force on sexual abuse of patients. Toronto, Ontario, Canada: Author.

Interfaith Sexual Trauma Institute (1995, September). Discovery conference participants advise ISTI board. The ISTI Sun, 1, 1-2.

Jacobs, C. (1991). Violations of the supervisory relationship: An ethical and educational blind spot. Social Work, 36, 130-135.

Kopp, S. B. (1976). If you meet the Buddha on the road, kill him! New York: Bantam.

Maryland Code Ann'd, Art. 41, §18-304(c)(4) (1993 Cum. Supp.).

Milgrom, J. H. (1992). Boundaries in professional relationships: A training manual. Minneapolis, MN: Walk-In Counseling Center.

Peterson, M. R. (1992). At personal risk: Boundary violations in professional relationships. New York: Norton.

Plaut, S. M. (1995a). Educational rehabilitation for boundary violations. Maryland Board of Physician Quality Assurance Newsletter.

Plaut, S. M. (1995b). Sex therapy after treatment by an exploitative therapist. In R. C. Rosen & S. R. Leiblum (Eds.), Case studies in sex therapy (pp. 264-278). New York: Guilford.

Plaut, S. M. (1993). Boundary issues in teacher-student relationships. Journal of Sex and Marital Therapy, 19, 210-219.

Plaut, S. M., & Foster, B. H. (1986). Roles of the health professional in cases involving sexual exploitation of patients. In A. W. Burgess & C. Hartman (Eds.), Sexual exploitation of clients by health professionals (pp. 5-25). Philadelphia: Praeger.

Pope, K. S. (1989a). Rehabilitation of therapists who have been sexually intimate with a patient. In G. O. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 129-136). Washington, DC: American Psychiatric Press.

Pope, K. S. (1989b). Teacher-student sexual intimacy. In G. O. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 163-176). Washington, DC: American Psychiatric Press.

Pope, K. S. (1994). Sexual involvement with therapists: Patient assessment, subsequent therapy, and forensics. Washington, DC: American Psychological Association.

Pope, K. S., Sonne, J. L., & Holroyd, J. (1993). Sexual feelings in psychotherapy: Explorations for therapists and therapists in training. Washington, DC: American Psychological Association.

Rogers, C. R. (1958, September). The characteristics of a helping relationship. Personnel and Guidance Journal, 6-16.

Rutter, P. (1989). Sex in the forbidden zone. New York: Fawcett Crest.

Schoener, G. R., & Gonsiorek, J. C. (1988). Assessment and development of rehabilitation plans for counselors who have sexually exploited their patients. Journal of Counseling and Development, 67, 227-232.

Stone, A. A. (1983). Sexual misconduct by psychiatrists: The ethical and clinical dilemma of confidentiality. American Journal of Psychiatry, 140, 195-197.

White, W. L. (1986). Incest in the organizational family. Bloomington, IL: The Lighthouse Training Institute.

Individuals seek treatment from a health professional because they need help. The nature of the professional-client relationship involves a power differential that places the client in a dependent and vulnerable position. In every instance, it is the health professional's responsibility, and never the client's, to maintain the boundaries of the clinical relationship. Nevertheless, in the same way that defensive driving can help to avoid accidents, an informed and educated health care consumer may be more likely to identify early warning signs of a potential boundary violation. To help inform and empower health care consumers, the Task Force was directed to "develop...initiatives for effective public education" - Maryldand Code Ann'd, Art. 41, §18-304(c)(4) (1993 Cum. Supp.).

FINDINGS

Many patients have limited knowledge or understanding of what constitutes appropriate treatment by a health care professional or of the power dynamics inherent in the professional-client relationship (Committee on Physician Sexual Misconduct, 1992). Additionally, in retrospect, some victimized clients have been able to identify early warning signs that the clinical boundaries were eroding before actual sexual contact occurred. Additionally, health care consumers are frequently unaware of the existence of licensing boards, and they are not informed about other avenues of redress and sources of support and information for clients who have been sexually exploited.

In Maryland, no reliable mechanism exists to educate the public on health care professional-sexual misconduct. The Medical and Chirurgical Faculty of Maryland, in conjunction with the Maryland Psychiatric Society, has developed a brochure entitled Medical Treatment NEVER includes SEXUAL CONTACT (see Appendix C); however, this brochure was intended for distribution to physicians, not consumers. Although it contains information helpful to consumers, its focus is on potential offending physicians.

The Treatment Exploitation Recovery Network (TERN), a self-help recovery group in Baltimore for survivors of sexual exploitation, developed a fact sheet (see Appendix D), written for an intended audience of both professionals and consumers. However, this fact sheet has not been widely disseminated to either group.

RECOMMENDATIONS

Recommendation 8. A brochure to educate health care consumers regarding health professional-client sexual exploitation should be developed.

The Task Force has developed a model informational brochure attached as Appendix E. Among other topics, the brochure contains a brief explanation of sexual exploitation, describes possible effects of such abuse, and lists actions that may be taken by the consumer if such abuse has taken place. Members of a self-help recovery group for survivors of sexual exploitation by health professionals reviewed and gave suggestions for the contents of the brochure. This brochure should be further refined as recommended in Chapter 4, Process for Developing and Disseminating Educational Curricula and Materials. (See also Recommendation 16 in Chapter 3, Organizational Education and Policy.)

Recommendation 9. Copies of the consumer education brochure should be distributed to health and mental health facilities and public libraries and should be made available to religious institutions throughout the State. These brochures should be displayed for clients or patients. Distribution to facilities should be funded and administered by the Department of Health and Mental Hygiene.

A volunteer survivor-run group such as TERN does not have the resources necessary for production and widespread dissemination of a public information brochure. To accomplish the goal of educating the public about sexual exploitation, the consumer education brochure must be distributed widely throughout the State. On the basis of its responsibility for the health interests of the people of Maryland, the Department of Health and Mental Hygiene (DHMH) is the most appropriate organization to undertake such a public education campaign.

Recommendation 10. Licensing boards should be required by Maryland law to include copies of the consumer education brochure in initial license or license renewal mailings to health professionals.

Requiring licensing boards to mail copies of the client education brochure to all licensees will facilitate wider dissemination of the consumer education brochure. At the same time, this strategy can also educate the professionals who receive it. Along with the mailing should come a strong encouragement or advisory to display the brochure in office or hospital waiting rooms.

Recommendation 11. Any health professional in Maryland learning from a client of an incident of alleged sexual exploitation should make available to the client a copy of the consumer education brochure.

Often, clients' first or early disclosure of sexual exploitation is to a health professional. By providing the consumer education brochure to any such client, the professional can help ensure that the client receives accurate information about sexual exploitation, its common effects on victims, and options available to the victimized client for information, support, and redress.

Recommendation 12. On receipt of a complaint of sexual exploitation, all licensing boards in Maryland should send a copy of the consumer education brochure to the complainant.

Clients who have been sexually exploited by a health professional need a variety of supports, one of which is information on common responses to sexual exploitation and possible actions one may take to seek redress.

Moreover, clients so victimized may lack confidence in licensing boards, which are sometimes perceived as protecting the professionals' and not necessarily the public's interest. By providing the educational brochure to complainants, licensing boards not only many offer needed information but also may engender increased confidence in the licensing board complaint process.

REFERENCE

Committee on Physician Sexual Misconduct. (1992). Report prepared for the College of Physicians and Surgeons of British Columbia. Vancouver, British Columbia, Canada: Author.

Maryland Code Ann'd, Art. 41, §18-304(c)(4) (1993 Cum. Supp.).

Governments, hospitals, religious denominations and organizations employ health care professionals who are or may be potential sexual exploitation offenders. As employers, such institutions carry responsibility for the direct, day-to-day oversight of health professionals and have the ability to administer immediate sanctions on occurrence of wrongdoing, such as demotion, suspension, or termination. Perhaps more important, employers have the opportunity to set institutional standards for professional practice, and to orient employees with respect to these standards, in an effort to minimize the incidence of unprofessional behavior.

Thus, institutions are part of the "public and private sectors" that encounter "problems and consequences associated with health professional-client sexual exploitation" - Maryland Code Ann'd, Art. 41, §18-304(c)(7) (1993 Cum. Supp.). The Task Force addressed itself to two major questions: (a) What roles do institutions play in preventing and intervening in incidents of sexual misconduct and (b) what roles should they play?

FINDINGS

The Task Force requested information from 130 institutions in the State of Maryland. These consisted of 24 governmental jurisdictions, 89 hospitals, 16 religious denominations, and one organization. Replies were received from 40 of these in the forms of policies, codes of conduct, and some procedures. A copy of the letter sent to institutions can be found in Appendix F.

The material submitted indicated that institutions have some awareness of the areas being addressed by the Task Force. However, there was little clarity or consistency as to how institutions set guidelines, train staff, or communicate with consumers. In addition, the words "sexual exploitation" tended not to be found in the material submitted. Descriptions were largely about "sexual harassment," with a focus on supervisor-employee relationships under equal employment opportunity laws. These findings reflect reports by investigators in other jurisdictions as well (e.g., Schoener, 1995).

At the same time, an increasing number of religious and educational institutions have been addressing the problem of sexual exploitation more directly in recent years. For example, the Episcopal Diocese of Maryland recently developed a set of policies and procedures (Diocese of Maryland, 1993), and a committee of faculty and students at the University of Maryland at Baltimore (a campus made up entirely of professional schools) has drafted guidelines on teacher-student boundaries, which is still under internal review as of this writing. These guidelines were based, in part, on similar guidelines developed in the Department of Psychology at the University of Maryland College Park. Educational initiatives developed for institutions in other states and for religious denominations are briefly reviewed in Chapter 1, Professional Education. These policies, as well as the nationwide experience with the problem of sexual harassment, should serve to guide other institutions in developing guidelines and policies that meet their specific needs.

Organizational consultants have been helpful in identifying institutional dynamics that can increase the risk of boundary violations in the professional setting. For example, White (1986) has described a process called "institutional closure" that is brought on when boundaries between an organization and the outside world are not sufficiently permeable. Employees need to have nurturance from sources outside the professional setting, and that nurturance can be represented by family life, religious activities, intimate relationships, hobbies, and so forth. When real or perceived demands within the institution prevent people from engaging in such activities, professional, social, and sexual activities tend to occur increasingly within the institutional setting. It is when such institutional closure occurs that sexually exploitative behaviors may be more likely to happen.

RECOMMENDATIONS

Because health care institutions have tended not to address employee-client sexual misconduct directly and because of the ability of institutions to reach employees directly with educational or other initiatives, the Task Force recommends the following:

These recommendations are modeled after Minnesota law (Minnesota Annotated Code § 148A.01-§ 148A.06) and are discussed more fully in Chapter 9.

DEVELOPING INSTITUTIONAL GUIDELINES

The remainder of this chapter outlines a series of considerations that may assist institutions in formulating guidelines and procedures designed to address the problem of sexual exploitation.

Definition of Sexual Misconduct

The following comprehensive definition has been developed by the Task Force, based on definitions that have been written into law in some states and in the application of ethical standards in various settings. Institutions may find this definition helpful in developing definitions that suit their specific needs.

Preventive Measures

Schoener (1995) has provided a comprehensive checklist of items that might be included in an institution's policy for addressing sexual misconduct. In general, four areas should be considered in fostering the prevention of sexual misconduct:

Addressing Allegations of Misconduct

Should an allegation of sexual misconduct be made, there must be a policy regarding its disposition. First, will it be handled within the institution, referred outside, or both? What are the advantages and disadvantages of internal versus external disposition (a) for the client, (b) for the provider, (c) for the institution, and (d) for the community? Any procedures for resolution should include the following considerations:

Clearly, these considerations should apply to any allegation of unprofessional behavior. However, such policies often tend to be excessively vague and inconsistently enforced. The need for such policies is highlighted by the problem of sexual misconduct, which in the past has been frequently misunderstood, ignored by the professional community, and left victims feeling isolated and betrayed, not only by the individual perpetrator but also by the perpetrator's professional colleagues. Clear and consistent policies and procedures will result not only in more appropriate responses to such allegations but also should serve as a deterrent by making the problem of sexual exploitation more of an open issue.

Organization Development

Like all organizations, health care and religious institutions are predicated on beliefs, attitudes, and values that shape the culture of the organization. These underlying structures are rarely examined and articulated. At times, they may reflect unconscious bias (e.g., gender or racial) that helps to create a culture that tacitly supports abuses of power such as sexual exploitation. Health, mental health, and religious organizations and professionals may assist in preventing sexual exploitation by carefully examining their organizational cultures and taking steps to eliminate any such biased theories, policies, or practices.

REFERENCES

Diocese of Maryland. (1993). Policies and procedures regarding clergy sexual misconduct. Baltimore: Author.

Maryland Code Ann'd, Art. 41, §18-304 (c)(7) (1993 Cum. Supp.).

Minnesota Annotated Code § 148A.01 - § 148A.06.

Schoener, G. R. (1995). Employer/supervisor liability and risk management: An administrator's view. In J. C. Gonsiorek (Ed.), The breach of trust: Sexual exploitation by health care professionals and clergy, (pp. 300-316). Newbury, CA: Sage.

White, W. L. (1986). Incest in the organizational family. Bloomington, IL: Lighthouse Training institute.

Educating health professionals, institutions, and the public will require the development and dissemination of a variety of education and training curricula and materials. The Task Force recommends that the Department of Health and Mental Hygiene ("DHMH") serve as the focal point for these activities.

DHMH, through its Secretary, "is responsible for the health interests of the people of [Maryland] and...supervises [a] generally the administration of the [State] laws" - Maryland Health General Article, §2-105 (b). Through its regulating boards, DHMH licenses all health are professionals and disciplines professionals who fail to act in accordance with professional standards. DHMH should take the lead in developing and disseminating state-of-the-art information, education, training, and materials to help prevent the problem's occurrence and to improve the quality and sensitivity of intervention in the State.

FINDINGS

There is need to develop and disseminate information, training, education, and materials that are intended for and directed to diverse populations in the State. An educational campaign of this magnitude requires extensive coordination, outreach to many professional communities and other groups of experts, and specialized knowledge and expertise both in the content area and in the design and delivery of curricula.

These efforts can best be accomplished by a central resource and clearinghouse. Using a central resource can also help to avoid costly duplication of effort and inconsistency of message and approach. DHMH is the most appropriate institution to assume this critically important role.

RECOMMENDATIONS

Recommendation 18. DHMH should gather existing training programs and related materials on professional-client boundary violations. DHMH should then convene a work group of experts--to include representatives of the health professions, the community of consumers and victim-survivors, the academic community, and others--whose task will be to review existing curricula and advise on the development of a model professional education curriculum for use in the State. Once developed, the curriculum should be disseminated throughout Maryland--to health and mental health facilities; colleges, universities, and other health practitioner training programs; law schools; professional associations; churches and synagogues, and other religious organizations.

Recommendation 19. All State-administered facilities should be required to offer the professional education program, with annual updates.

Recommendation 20. DHMH should develop and conduct the training required in Recommendation 6 (for all licensing board members, board administrators, investigators, and administrative law judges.) A work group--consisting of representatives of the health and other relevant professions; the community of consumers and victim-survivors; experts in adult and continuing education; and other groups as appropriate--should advise on the development of this training.

Recommendation 21. DHMH should develop consumer-oriented educational materials, such as brochures and fact sheets, on sexual boundary violations. The educational materials should be field-tested with consumers, including victim-survivors of sexual exploitation. These materials should be disseminated to health and mental health facilities and made available to religious organizations throughout the State. (See also Recommendation 9 in Chapter 2, Public Education.)

Recommendation 22. All curricula and educational materials should include, among other topics, information on the impact of sexual exploitation on associate victims, such as the families and colleagues of victims and perpetrators, and, in the case of clergy, congregants.

Recommendation 23. DHMH should serve as a central resource clearinghouse and provider of technical assistance to educational institutions; health, mental health, and related agencies; managed care organizations; consumer groups; professional associations; and others who seek assistance in developing and conducting educational programs to prevent or address client sexual exploitation by health professionals.

Recommendation 24. DHMH should make available the necessary human, fiscal, and material resources to accomplish the educational campaign recommended in this report.