The Sexually Seductive Patient: How Should Doctors React?
On my other threads on patient modesty and why doctors are hated, there is much concern and worry about sexually seductive doctors. Such concerns are warrented even though I am sure most doctors will treat patients professionally and keep to the professional and legal boundaries of behavior. However, physicians have their own concerns. One of their concerns is the behavior that the patient will bring into the office. There are the angry, disruptive and frankly belligerant patients. Medical students are taught to expect such patients and to react by trying to understand what is motivating these patients to these behaviors since such understanding may provide a therapeutic approach rather than the physician simply reflecting anger back to the patient. One of the more subtle and difficult patient behaviors for physicians to deal with is the sexually seductive patient. Such a patient, often a female relating to a male physician enters with the expression of obvious greater attention and interest with respect to the physician's personality and appearance than true concern about her own symptoms. Her actions may be sexually provocative. The patient may expose her body to the physician during the interview or exam to an extent which is clinically unnecessary. Female physicians are not free of seductive male patients.
Psychologists explain these patients' behavior as expressions of transference--where psychologic unmet needs are attempted to be met by engaging physicians who seem to resemble and reflect critical persons in the patients' emotional life. Of concern is the issue of counter-transference--where the physician may respond to this situation in a manner to support the physician's unmet needs based on the physician's emotional life. This can lead to physicians responding to the seductive patient in a manner beyond the professional boundaries of sexual attention.
How should physicians react to the seductive patient? Should they consider the patient has a psychologic or psychiatric problem in addition to their other disease and seek out evaluation, patient education and treatment for this disorder? Or should the doctor go ballistic and spell out the established rules of further behavior? Medical schools find that the need to educate students regarding how to deal with the seductive patient an important topic. I would like to read the views of my visitors on the subject of the seductive patient and what they think would be the very best approach to deal with the issue if it arises. One point I don't want to read from my visitors is that there is no such person as a sexually seductive patient or that the way patients behave is simply a reflection of the doctor's unprofessional behavior at the onset of the relationship. You have to be in medical practice yourself to see that this conclusion applied to all is not true! ..Maurice.
posted by Maurice Bernstein, M.D. @ 7:06:00 PM
22 comments
22 Comments:
Frankly, I am of the opinion that unless the patient is clearly distubed, honesty is the best policy, and that the best way for the physician to deal with it is "It may be that I am a prude, but I feel uncomfortable when...and I would appreciate it if...could be left out of our consultations from now on". This allows the patient to retain their dignity, and opens the door for a more productive doctor-patient relationship.
I am concerned, though, at your characterisation that this is usually a female patient/male doctor scenario. certainly this may well have been your experience, but when you contend such things I would like to see evidence. Valid research on this topic would account for such things as the different socialisation of men and women (for example the fact that women are taught to pay more attention to others than themsleves), the greater numbers of female patients and male doctors, and the likelihood that female doctors are not reporting what amounts to sexual harassment by their male patients. Can you provide pointers to such evidence, or is your assertion about female patients anecdotal?
The reason I harp on this point is because this post could equally have asked the question without the gender references, and that by casting aspersions on female patients you perpetuate the myth that male doctors should dictate how they behave when seeking healthcare.
Anonymous, you have presented valid arguments with regard to my posting. Yes, what I wrote were my assumptions and indeed at this point were anecdotal. However, our medical school is planning to cone down on the issue of the seductive patient to present to first and second year students (the school already deals with the "angry patient") and therefore we should be presenting to them something more than anecdotes if facts are available. Nevertheless, your points are well taken.
In general, how patients behave in a doctor-patient relationship is neither gender specific for the patient nor regarding the doctor.
By the way, we haven't even described homosexual attractions which are also possible but again I have no facts.
Let's see if we all can do a little research on the subject and present here some facts. ..Maurice.
Anonymous here again. I had a quick look through google scholar, and I could not find anything particularly about seductive patients, but I did find this which shows that actual sexual contact occurs more frequently in a male doctor/female patient scenario (when I say more frequently, I mean at a greater rate 10% of women and 4% of men reported contact with patients, and of the contacts reported male doc-female pt accounted for 89% of those where the patient's sex was reported). Unfortunately this can only say for certain that female patients, if they are the initiators, are more successful.
However, 56% of physicians said they received no education on patient sexual contact during residency, and those that had were very grateful for it, so kudos to you, Dr. B. for raising this important and underaddressed issue with your students.
Anonymous, thanks for the link to the article. Unfortunately, we don't know from the article who within the patient-doctor relationship was initially seduced by whom but regardless the survey does imply that even if the physician did not initiate the beginning of a sexual relationship, many physicians failed to bring it to an immediate stop. Also of interest from the survey results (from the early 1990s) was the large percentage of physicians who said they never had formal education and training regarding how to deal with sexuality if it would arise in the professional relationship. Since then perhaps there has been improvement in the statistics but perhaps not and that is why our school has this topic on its mind.
Again thanks.. and I think we should continue our research on this thread..there, hopefully, must be more facts available about the seductive patient issue. Also, what would be interesting would be to read from my non-USA visitors how the matter of sexual behavior in the doctor-patient relatonship is handled in other countries and other cultures. ..Maurice.
It is an interesting cultural note that the discussion of female patients coming on to doctors is refered to as seduction while the first poster refers to male patient's sexual overtures as "harrassment", while complaining about aspertions being cast females. It is normal human behavior for both genders to seek sexual contact with fertile members of the opposite sex and shouldn't automatically be considered an aspersion to refer to it--especially in a discussion where the focus is to understand rather than judge--or at least to understand before judging.
In my practice of psychiatry. I find encounter seduction often, for a variety of reasons. The most common is that it is part of the patients personality pathology in that it is the way that they relate to men routinely and are unaware that they are behaving seductively and have no intention of eliciting a sexual response. These people often have many stories to tell of "inappropriate" sexual advances by numerous men being unaware of how their behavior is viewed. I deal with these by carefully keeping my distance recognizing the huge potential for distortion by these patients.
It is also common--far too common to call it pathological--for women to behave seductively when dealing with male power figures as an unconscious strategy to get what they want when afraid or distressed. I consider it my job in this case just to not get pulled in to thinking it is about me, and usually deal with it initially non-verbally with pointed professionalism that cuts it off without confrontation. The big risk here is my distortion rather than theirs--thinking it is about me personally and getting foolishly flattered.
Then there are those who are overtly and consciously manipulatively using sex. Often narcotic seeking, occasionally with a history of sexual relationships with other physicians in the service of the same end. If get them out of my office and out of my practice without further delay. I once had one fondled my butt going down the hall to the waiting room. I had declined her request for speed due to suspicions of abuse and malingering, but scheduled another apt to assess further. When we got to the waiting room, I just said "I've changed my mind, I don't think we need to meet again." I had all the information that I needed at that point.
There are others: the ones that the doctor has unintentionally seduced in his efforts to provide support, the doctor-patient "lovesickness" of mutual transference-countertransference, and even simple loneliness and mutual attraction of people with common needs meeting, albeit in circumstances that ban acting on that attraction. But my management of them, are probably peculiar to the psychiatric setting.
I think all phsicians need a clear bright professional line of no consorting sexually with patients. Period. But other than that, there is not one stock response for all situations.
This largely comes down to matter of knowing oneself, and in situations making sure you're paying attention to your own reactions and behavior.
There is a wide range of reasonably normal human behavior, and my view is that within that range, some people are naturally seductive -- not naturally in the sense of literally being born with it in its complete expression, but really part of their overall personality. I find it more abnormal to see someone who is basically hostile, or expresses no emotion whatsoever.
As physicians we need to be able to go with the flow and not be distracted too much by these side issues. At least in theory, a physician should be able to interview, examine and treat a nudist and be able to focus on the medical issues. Maybe that's what we all need in our training -- trips to nudist colonies. If we can manage a naked woman, anesthetized on an operating table, why not when she's conscious?
When someone who is seductive is problematic is when they react adversely to a "failure" of their seduction, when it's seems clear that the visit has more to do with seduction than any legitimate medical need.
Greg, you write "If we can manage a naked woman, anesthetized on an operating table, why not when she's conscious?" Unfortunately, not all of my blog visitors, as expressed on the previous threads regarding patient modesty, would agree that doctors and other medical staff fully "manage" the issue of sexuality of a naked woman in the operating room. ..Maurice.
Nonetheless, naked women, naked men on operating tables happens all the time, and I would generally say that it doesn't generate much more than a nudist in a nudist resort.
As physicians we can hope that we have a more balanced attitude toward nudity than the general population. A balanced attitude doesn't mean we're neutered to sexual experiences. Birth, death, nudity, sexual intercourse -- these things are all part of the human condition and each has an aspect in medicine.
But we're human too, yet being a professional means that hopefully we have enough frontal lobe power to maintain a professional approach to whatever we encounter.
Sometimes a "seductive" patient is seeking reassurance and support in her anxiety and a message that your are committed--as her doctor. While reacting with excessive warmth clearly risks sending the wrong message, reacting by withdrawing may elicit even greater anxiety. Sometimes an explicit reassurance of professional attention will address the anxiety and ameliorate the behavior.
With regard to "harrassment" by male patients, female physicians need to accept the realities as they are and not how they would like them to be. Men are not used to paying women for intimate services unless they see prostitutes--and whether they do or not, the situation of paying a woman to get intimate with a man's body has unconscious implications of prostitution, generating sexual anxiety in the male that may be expressed in a variety of ways--including off color jokes or remarks that are a way of asking the doctor to laugh with them and diffuse the tension, to normalize the situation for them as a way of keeping it professional and removing the unconscious sexual implications by making it overt, and then laughing it off.
This is the first anonymous again. First of all I want to clarify my position on harassment -- given that in most circumstances it is defined as being ongoing unwelcome sexual attention, either male or female patients can easily be harassers -- my point was that society is more likely to label it harassment when it comes from a man than from a woman, not because it is any more harassing. Presumably this labelling distinction is as a result of the theory that women never want it and men always do, which I think we can all agree is fallacious. So let me be very clear, when I said "what essentially amounts to sexual harassment" I meant in any combination of genders.
To Greg P who thinks doctors have a "more balanced view of nudity than the general population" -- what is balanced? Isn't the concept of balance based on social norms? Doctors' view of nudity of their patients is often outside social norms, though in my (purely anecdotal) experience doctors often are not nearly so comfortable with their own nudity -- often to a point of being out of keeping with social norms in the other direction. I would ask you to put yourself in the shoes of your patients, who may see nudity as something best shared among equals (and reluctantly submit to nudity with their doctors for health reasons, or not) and then see whether your view feels "balanced". You may know more about physical bodies than many of us ever will, but people are more than bodies.
One thing that can confuse the issue is when the patient is in fact a nudist. They may be so used to being without clothing in front of others that they remove more clothing than the doctor expects. Even non-nudists may not have an issue with being without clothes in a medical setting.
There are those who want to remain as fully clothed as possible to those who think that they aren't getting a full exam if they are kept too fully clothed. Better communication from the doctor in the form of explaining what needs to be done and just how comfortable the patient is with exposure during an exam.
What I do not want to see happen is an over reaction to preserving patient modesty and then we all get exams that can't be as thorough.
MJ KC, I don't recall having a self-described nudist as a patient so I really don't know how they would react, however I doubt the patient's practice of nudism per se would hurt the functioning of the examination. We don't require the patient to be stripped naked for an effective physical exam. And as I have noted on other threads here, even a thorough dermatologic screening may be more accurately and completely performed by sequential draping and undraping of smaller segments of skin rather than having a patient stand nude and try to eyeball the whole body.(The source of that statement is the head of Dermatology Dept at my medical school.)
I don't think that preserving patient modesty is necessarily related to not performing a thorough physical exam. I think that the physician's need to rush through an exam because of time constraints is a more significant factor. ..Maurice.
If doctors have to rush through an exam because of limited time maybe they should see less patients each day, allow more time for each appointment. My doctor here in Australia is never running on time. The usual wait time is about 2 hours. I can understand there maybe an emergency occassionally, but every time, I doubt it. I think its more about money than thorough healthcare. At minimum $50 I dont want to be rushed out the door because they have placed each appointment only 10 minutes apart.
Whatever the circumstances, it's always the healthcare professional's responsibility to maintain appropriate boundaries. If s/he lacks the assertiveness and strength of character to do so, s/he should work on building those skills or find another job.
I agree with the comment that it is the physician's responsibility to maintain professional boundaries. But are there any responsibilities of behavior within the doctor-patient relationship for which the patient must maintain within the limits of their physical and mental capacity? ..Maurice.
I suppose that in theory, patients should also maintain appropriate boundaries. I imagine most do, just as most physicians also do. Remember, the provider is usually perceived as the person with higher status/power. The patient is responsible for sticking to the topic, although in psychology I get pretty used to seeing hidden agendas. the best course for providers is to make sure they guard their own boundaries. One of the other threads talked about a gynecologist finding that many patients were having "symptoms" merely because they needed to talk: essentially a mini counseling session. I would, for example, suggest that a provider would be well advised to do such counseling in a location other than where they have just performed a pelvic or other genital exam. Although not intended, counseling after an exam (and even more so before) is likely going to be viewed by the patient as two types of intimate behavior. This situation can get out of hand in an emotional patient of either gender and would require skillful management by the provider.
Someone touched on it earlier, as a male I know I find myself reacting more aggressive when I am embaressed or experienceing a lot of anxiety. In a medical setting where nudity and female providers I have never felt "seductive" but I struggle to manage amost a panic, I could see where this could manifiest itself as harrassment for some men. As stated, it could easily be some mens way of difusing the tension or reacting to what some may feel is controling or forcing them to be in a uncomfortable situation.
Doctor, I am anxiously awaiting your response to the post I submitted a few days ago referencing a female patient who undressed in the presence of her male surgeon. Is this question being avoided due to the sexes of the subjects?
Anonymous, I can't find your posting but in any event perhaps some of the recent postings about undressed patient who is being examined really belong discussed on my thread regarding patient modesty.
The thread really is about the issue as I described at the start of the thread: One of the more subtle and difficult patient behaviors for physicians to deal with is the sexually seductive patient. Such a patient, often a female relating to a male physician enters with the expression of obvious greater attention and interest with respect to the physician's personality and appearance than true concern about her own symptoms. Her actions may be sexually provocative. When a physician faces such a patient what are the considerations the physician must take and what should be the physician's response.
This is not some made-up situation..this does happen in doctors' offices and many doctors have these experiences. ..Maurice.
When physicians encounter a seductive patient, how do they usually handle the situation? Do they suggest the patient seek psychiatric help, or do they attempt to resolve the situation by talking with the patient in terms of what the root of the emotional problem is?
Anonymous from 10-15-07, beyond ignoring the seductive behavior if and when the observed behavior is over-interpreted by the physician as seductive, what happens next or what should happen next is really the basic question of this thread. If you read the previous comments, there are some valuable suggestions by the professionals and others who wrote them. Though I personally hoped there was some strict guideline which I could teach my med students, Maybe there will be only admonitions of what not to do. I await further discussion. ..Maurice.
I'm a patient's wife whose marriage has been ruined by a combination of an overly seductive patient and a female surgeon who obviously didn't have the ethical or mental awareness to keep it professional. Even though my husband would have surely found someone else to play with, I feel particularly "violated" by the fact that the "other woman" is a physician and was a his surgeon at the time. Yes, I know physicians are "human" too but I have to agree with Anonymous 9/07/07 comment: "If s/he lacks the assertiveness and strength of character to do so, s/he should work on building those skills or find another job." All of us have these opportunitie on a daily basis with everyone that we come in contact and it simply comes down to the fact that we are all conscious people making conscious decisions everyday and we MUST take responsibility for these actions and decisions. There needs to be some negative action taken against physicians that chose to VIOLATE the very personal and sometimes almost intimate "relationships" that they have with their patients. Patients also need to be handed off to other physicians when these types of situations arise. just because you are given an apple doesn't mean you need to eat it!
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