Doctor-Patient Sex in ObGyn Care

I decided to reply to a comment that just came in about a post I wrote on doctor-patient sex in 2009 in a new post. The topic has drawn a lot of interest, and I didn't want the comment and my response to get buried in the past. Here's the comment from "Anonymous":

My obgyn has been pretty much my primary care physician for the last 12 years. He delivered my son 3 years ago. He has always had a great bed-side manner and made me me feel like I was the most important patient. I had always thought this was a great skill that he was able to make all his patients feel this way. As I look back over the years, comments about my looks, my sex life, and my job as a sex education teacher just seemed like a normal part of the visits. During my last yearly exam he asked me the normal question of what kind of birth control I was using. This question got me talking about the unsatisfactory sex life with my husband...maybe I shared too much and went into too much detail. He started talking about possible solutions that included medication for my husband, toys, positions, and finally said that I may need to get a boyfriend. We were kind of laughing about that. The conversation actually turned into me hitting on him and telling him about my sexual fantasies involving him and the exam table! Still, I really didn't think things had crossed the line. None of this conversation happened with me undressed, but rather after the physical exam. As I was leaving, he gave me a kind of one-armed hug and then turned my face to his and kissed me on the mouth. It was just a peck really, but it was obviously intentional. As he walked me out he told me that I could always call him after 5:00 at the office to speak to him directly.I could not get him off my mind all weekend. I have actually been attracted to him for years, but we have both been married at one time or another. I decided to call on Monday and just talk. We decided to meet on Wednesday at his office and had incredible sex on his office sofa. We have meet two other times over the past month. When we are together, I can't get enough of him. He says and does all the right things. He knows I would never leave my husband; and also knows that I really want to meet with him more often. He is really busy, which I understand, but I feel like I need him much more than he needs me. I have no desire to ruin this man's practice or hurt him in any way, but I feel a little "led on" in that he knew what I was looking for in a "boyfriend" when he volunteered for the job. Any thoughts?

Here's my response:

Dear Anonymous -

Thank you for your thoughtful, candid comment. In response to your closing question, I have a number of thoughts.

My focus in this blog is healthcare ethics, so that's the only dimension of the situation I'll comment on.

Your obgyn's capacity to make each of his patients feel special and important is something every physician should strive for. I can't tell whether in retrospect you believe his manner over the 12 years he's been your doctor was flirtatious and sexually inviting. Comments about looks, sex life, and your work as a sex educator could be an entirely appropriate part of obgyn care, but even if they were made with entirely professional intent (which is, in retrospect, uncertain), the intimacy of obgyn care has great capacity to elicit strong reactions, like the erotic fantasies you experienced. That's why the American College of Obstetricians and Gynecologists code of ethics is unambiguous about doctor-patient sex: "Sexual misconduct on the part of the obstetrician-gynecologist is an abuse of professional power and a violation of patient trust. Sexual contact or a romantic relationship between a physician and a current patient is always unethical."

Your comment that "I feel like I need him much more than he needs me" speaks to one of the dangers in sexual and romantic relationships between doctor-patient. The physician-patient relationship is asymmetrical. Physicians are in a position of "caring authority." That role can elicit what in psychiatry gets called "transference." The professional responsibility of the physician is to understand "transference" and manage both (a) the risks to patients and (b) our own reactions.

The fact that a patient might "hit" on the physician doesn't change a physician's ethical and clinical responsibility. Patients are entitled to express their feelings and fantasies, just as you describe. In a teaching session during my first year of residency a senior psychiatrist told of how a patient expressed a wish for romantic involvement. He responded "it won't be difficult for you to find a boyfriend if you want one, but it isn't so easy to find a good psychiatrist - that's the role you need me to be in."

The code of ethics for psychiatry differs from obgyn in an important detail. I put the key difference into bold italics: "the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical." The psychiatric profession has concluded, in my view correctly, that psychiatrists are responsible for continuing to act in a professionally responsible manner after treatment ends.

Your final comment that you "feel a little 'led on'" sounds realistic to the situation as you describe it. I'm concerned that you appear to be experiencing a sense of conflict and perhaps emerging hurt. I would encourage you to consider counselling to deal with the marital unhappiness you've experienced and the relationship that has emerged with your obgyn.

Again, thank you for your thoughtful and important comment!

Best

Jim