Sexual Ethics and Professional Standards

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The Hippocratic oath gives early expression to a general prohibition against professionals taking advantage of the vulnerability of clients or patients and their families to enter into sexual relations: "Whatever house I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves" (Verhey, p. 72). The prohibition was reiterated for mental-health professionals by Sigmund Freud (Schoener et al.). From these roots grows a general prohibition against professional-client sexual relations, including relations between teacher and student, supervisor and supervised, clergy and parishioner, therapist and client, and physician and patient. In some professions, the taboo has been so strong that sexuality is the problem professionals "don't talk about" (Rassieur) or "the problem with no name" (Davidson).

Yet some famous therapists (e.g., Carl Jung) have been notorious for having sexual relations with their clients (Schoener et al.). Studies of various professions indicate a rate of sexual contact between professionals and clients or patients of between 5 and 11 percent (Schoener et al.; Bonavoglia). The phenomenon has become sufficiently widespread to be called a "national disgrace" (Pope and Bouhoutsos) and an "epidemic" (Rutter).

In the ten years following the publication of Betrayal (Freeman and Roy), which described one woman's successful lawsuit over sexual misconduct by a psychiatrist, over $7 million was paid out in legal claims. In the face of revelations of misconduct, professional societies began to insert clear prohibitions into their codes: "sexual intimacies with clients are unethical" (American Psychological Association); "the social worker should under no circumstances engage in sexual activities with clients" (National Association of Social Workers); "sexual relations between analyst and patient are antithetic to treatment and unacceptable under any circumstance" (American Psychoanalytic Association). Even in the controversial field of sex therapy, direct sexual contact between therapist and client is discouraged; sexual surrogates are used instead (Masters et al.).

Several jurisdictions have enacted laws making it a felony for a psychotherapist (including clergy) to have sexual contact with a client, and at least one holds the therapist's employer liable if the employer knew or should have known of a history of sexual abuse (Bonavoglia; for statutes, see Schoener et al.). Sexual contact is variously defined, but generally includes not only sexual intercourse but also intimate touching and other sexualizing of the relationship.

The prohibition against professional-client sexual contact rests on three foundations: the likelihood of great harm from the sexual contact, the responsibility of the professional to work for the good of the client, and the vulnerability of the client and the power gap between client and professional, which raises questions even in the absence of demonstrable harm.

There is growing consensus that significant harm is done to patients or clients who enter sexual relations with professionals in whom they have vested trust: "[T]he balance of the empirical findings is heavily weighted in the direction of serious harm resulting to almost all patients sexually involved with their therapists" (Pope and Bouhoutsos, p.63). A few therapists have argued for the beneficial effects of sexual relations between therapist and client (Shepard; Schoener et al.), but their data have been challenged (Pope and Bouhoutsos; Schoener et al.). Studies of women who have had sexual relations with their gynecologists, psychotherapists, and clergy all point to deleterious consequences including loss of trust, poor self-concept, loss of confidence in one's judgment, and difficulty establishing subsequent relationships (Pope and Bouhoutsos). Several commentators have noted the similarities to incest because of the power of the professional and have argued that the consequences are as deleterious as those of incest (e.g., Fortune, 1989). Others note that women who enter relations with therapists often have a history of sexual abuse, and thus are being revictimized (Rutter; Pope and Bouhoutsos).

Sexual contact between professional and client thus subverts the legitimate goal of the profession—the healing or making whole of one who is wounded and vulnerable (Verhey). There is both exploitation of the client for benefit of the professional and a failure to provide the services implied by the professional role.

However, harm and failure to help are not the only ethical issues at stake. Several commentators argue that the power of the professional is morally relevant (Lebacqz; Lebacqz and Barton). Professionals may hold several types of power: Asclepian power—the power of professional training; charismatic power—the power of personal magnetism and authority; social power—the power of the role and its authority (Brody). By contrast, the client lacks the power of the role and of its associated training. In addition, female clients facing male professionals generally lack the social power that men have in a sexist context (Lebacqz; Lebacqz and Barton). Clients are vulnerable.

The vulnerability of clients and the power of professionals mean that professionals can take advantage of clients. Sexual relations between professional and client are therefore an abuse of professional power—an illegitimate use of that power for the professional's own ends instead of for the ends of healing the client (Lebacqz and Barton; Schoener et al.; Rutter; Fortune, 1989).

Moreover, the vulnerability of patients or clients and the power gap between client and professional may compromise the freedom needed to give truly informed consent for sexual intimacies (Pope and Bouhoutsos; Lebacqz and Barton). The psychotherapeutic notion of transference (redirecting childhood feelings toward a new object) suggests a special vulnerability that may literally paralyze patients, making them unable to resist a therapist's advances (Freeman and Roy). Noting special vulnerabilities in the sexual arena, Karen Lebacqz and Ronald Barton (1991) propose that sexual intimacies differ from other acts to which patients, clients, and parishioners might continue to consent.

Some argue that vulnerability does not end when therapy ends and that there should be a prohibition on posttherapy sexual contact (Schoener et al.; Rutter). John C. Gonsiorek and Laura S. Brown proposed that sexual relations posttherapy should never be permitted where there was significant transference or where the client was severely disturbed, but might be permitted after two years with former clients who were not disturbed and showed little transference (Gonsiorek and Brown). Such a proposal raises difficult issues regarding who would make this judgment, but it reflects a clear principle that the base for determining whether sexual relations are permissible is the relative power and vulnerability of professional and client. Sexual contact might not be wrong where the power gap is minimized. Although few codes of professional ethics address the posttherapy issue, in 1993, the American Psychiatric Association explicitly addressed it: "Sexual activity with a current or former patient is unethical" (APA).

In a similar vein, Lebacqz and Barton (1991) argue that romantic or sexual relations might be acceptable under circumstances where the power of professional and client is relatively equal and the relationship is under public scrutiny—for example, when clergy date parishioners with whom they are not involved in a pastoral counseling relationship and members of the church are informed.

All commentators agree, however, that "sexualizing … therapy is a betrayal of a trusting relationship" (Pope and Bouhoutsos, p. 54) and that no sexual relationship should be permitted where there is a counseling or therapeutic relationship involved (Pope and Bouhoutsos; Fortune, 1989; Rutter). The professional-client relationship that involves psychotherapy or particular vulnerability on the part of the client is a "forbidden zone" for sexuality (Rutter).

Professional-client sexual contact must be addressed on institutional, not just personal, levels. Professional societies and supporting organizations such as churches are complicit when they fail to punish offenders, try to cover up the problem, blame the victim, and otherwise minimize the issue (Fortune, 1989; Bonavoglia). Underreporting is a significant issue: 65 percent of therapists in one study had seen clients who were sexually abused by a previous therapist; they judged that abuse harmful in 87 percent of cases but reported it in only 8 percent (Schoener et al.). Peter Rutter acknowledges the reluctance of men to blow the whistle on each other (Rutter). Gary Richard Schoener notes that the professional literature "documents more in the way of inaction than of active and creative study leading toward solutions" (Schoener et al.). Professional misconduct damages the profession and institutions as well as individuals (Fortune, 1989). Lack of internal regulation within the professions has led some U.S. state legislatures (e.g., Minnesota) to pass laws that hold institutions as well as individuals responsible for sexual misconduct of professionals (Lebacqz and Barton).

Underlying social and cultural patterns—sexism, the eroticization of domination, and the maldistribution of power in society—are causal factors (Lebacqz and Barton; Rutter). Since Phyllis Chesler's early feminist exposé of therapy in Women and Madness (1972), feminists have paid attention to the ways in which traditional therapy often reinforces passive and self-destructive behaviors for women, including behaviors that would make women likely victims of sexual abuse. Dynamics of sexual contact cannot be understood without recognizing sex-role patterning and power imbalances in the general culture (Schoener et al.; Lebacqz and Barton; Brown and Bohn,). Evidence indicates, for example, that male clients may not experience the sexualizing of relationships to be as harmful as female clients do (Pope and Bouhoutsos). Such gender differences may reflect social patterning of male and female sexuality, in which men gain and women lose power when entering a sexual relationship. There is also evidence that women therapists do not engage in sexual contact with clients as frequently as male therapists do, and that they judge it more harmful (Schoener et al.).

The traditional prohibition against sexual contact between professionals and their clients continues to be reaf-firmed in spite of arguments and practices to the contrary. An adequate ethical framework requires attention not only to professional responsibility, harm, and power imbalances but also to institutional structures and to cultural dynamics of sexuality and power.

karen lebacqz (1995)

bibliography revised

SEE ALSO: Coercion; Confidentiality; Epidemics; Medicine, Profession of; Nursing, Profession of; Profession and Professional Ethics; Sexual Behavior, Social Control of; Sexual Ethics; Sexual Identity; Sexuality, Legal Approaches to; Public Health Law


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