Since the time of Hippocrates, the doctor-patient relationship has been and remains a central part of health care and the practice of medicine. The relationship is based on trust, wherein the physician is expected to place patient’s welfare above his own self-interest. This relationship is built on the patient’s confidence in competence and integrity of the physician. In some instances, this trust is betrayed, resulting in sexual exploitation and mental distress. Cases of sexual misconduct by male doctors examining female patients have been reported in press and medical journals. It is hard to determine the true extent of the problem, but it would appear that 5-10% of all physicians have had a sexual contact with patients. This figure may be higher as many cases of sexual misconduct are not reported. Physicians from all specialties and backgrounds are involved. As a women’s health advocate, Dr Sherry points out that some doctors, especially male gynecologists, pediatricians, anesthesiologists and psychiatrists, have raped, fondled and molested patients of all ages. The Federation of State Medical Boards, USA categorizes sexual misconduct into two categories. “Sexual impropriety” can include watching a patient undress, examining their genital areas without gloves, or making inappropriate comments. “Sexual violations” occur when a physician engages in physical sexual contact with the patient (such as kissing, sexual intercourse, or touching any sexualized body part for purposes besides a medical exam), offers drugs in exchange for sexual acts. Study by DuBois and associates revealed that sexual misconduct is a common reasons for disciplinary action by medical boards; based on data from two groups of participants, Swiggare, Dewey, and Spickgard Ghulyan found that 35% to 36% of referrals were for sexual violations, with the remainder referred for sexual impropriety or sexual harassment. Effects on patients Sexual misconduct of a doctor is always harmful to the patient and detrimental to the hospital where the doctor works. James DuBois and associates reviewed 101cases of sexual violations and found that psychological sequel of sexual misconduct for patients include depression, anger, drug and alcohol abuse, trust issues, and posttraumatic stress symptoms; sexual misconduct includes much more than sexual intercourse with patients; it includes masturbating in the presence of patients, genital contact, and rape or sodomy. Frequently, patients who are abused start to avoid doctors altogether but some resort to seeing only female doctors. Many victims keep silent for fear they won’t be believed. Some develop trouble communicating with other close relationships: If a doctor betrayed them, is anyone trustworthy? In Pakistan, women generally prefer to seek consultation from a female doctor, especially when they have gynecological issues. Amale doctor conducting intimate examination of females is inconceivable. Female surgeon are given preference if the disease requires surgical intervention. In view of a dearth of female surgeons, they are often compelled to consult a male surgeon. In teaching hospitals, male students are not allowed to conduct delivery or intimate examination. The Pakistan Medical and Dental Council is a statutory regulatory authority that has been mandated to regulate the practice of medicine and dentistry in Pakistan. Amongst its various functions, the body oversees and regulates medical institutions and teaching hospitals, and also entertains complaints against medical practitioners on grounds of professional misconduct. According to its prescribed rules, doctors should normally ask permission from a patient before making a physical examination; for any intimate examination, the patient is entitled to ask for an attendant to be present. Any form of sexual advance on a patient with whom there exists a professional relationship is classified as professional misconduct. In addition, the doctor must not use his position to pursue a relationship of sexual or emotional nature with a patient. PMDC can deregister doctors who are convicted of infamous conduct. Crimes of unprofessional conduct remain unreported for various reasons. As Pakistani women are shy and inhibited, they are reluctant to report such crime. They fear that their spouse may react negatively and blame them. Most are unaware that PMDC is authorized to deal with such complaints yet others are too poor to file and pursue their claims. PMDC has been accused of protecting medical professionals instead of punishing them. Even the courts fail to redress their grievances on account of lengthy and tedious procedures, and conduct of lawyers is less than professional. Therefore cases of misconduct are rarely reported in print or electronic media. A casualty medical officer working at the Tehsil Headquarters Hospital Hazro was suspended and transferred to Lahore over the allegation of an indecent act’ with an unconscious female patient. Later, Deputy Commissioner Rana Akbar Hayat ordered a departmental inquiry. An inquiry, conducted by Assistant Commissioner Owais Tarrar, DHO Dr Javaid Chaudhry and a panel other officials, found the doctor guilty. Afew Pakistani doctors working abroad have been convicted of sexual misconduct. Dr Kamran Ali, Trainee GP from Pakistan was accused of sexually assaulting a woman while performing surgery, in another incident intimately touching a patient after she came in to discuss her anaemia. He was also accused of sexually assaulting three other women during consultations on matters such as acne medication and contraception pills. Another Pakistani doctor, Syed Bukhary, who moved to the UK with his wife faces being struck off after he was found guilty of groping a patient’s breasts whilst working at a hospital A&E unit. At the Medical Practitioners Tribunal Service in Manchester he was found guilty of all charges. He was accused of undertaking sexually motivated inappropriate examinations of a patient and attempted to pursue a sexual relationship with her by asking for her email address. Story of doctors who cause hurt that doesn’t heal A large number of cases have been reported in the Western media. In addition, professional journals have published cases of unprofessional conduct. Doctors benefit from a system where victims are often not believed, criminal charges are rare and doctor-dominated medical licensing boards tend to offer reintegration and a return to practice, the Atlanta Journal-Constitution (AJC) investigation reported. At a time when powerful men in business and politics are losing careers over sexual misconduct, American doctors remain a baffling exception. AJC also published a case of Dr. Richard Martin Roberts who is still allowed to see patients in Texas even though a medical board disciplinary panel in November 2017 found he repeatedly conducted unwarranted genital exams on young girls. The Medical Board of California put family physician Ramon Fakhoury on 35 months of probation after several patients alleged he had touched their genitals for no medical reason. Until he completes probation, he must have an attendant present when treating female patients. He did not admit to the allegations. (Courtesy of the San Bernardino County Sheriff’s Department) However recently, shocking reports about years of abuse by USA Gymnastics doctor Larry Nassar also surfaced, who is now serving what amounts to a life sentence. He was accused of abusing a number of female adolescents and women under the guise of medical treatment. He convinced the gymnasts that his vaginal “treatments” had a medical purpose. In another case Dr. Ricardo Cruciani, 63, admitted that he assaulted seven patients in 2016 while he was chairman of Drexel University’s neurology department and pleaded guilty to varying charges of indecent assault and harassment. He will serve seven years’ probation, register as a sex offender and will have to forfeit his medical license under his plea agreement. In handing down the sentence, Municipal Court Judge Gerard A. Kosinski said that Cruciani had imposed on his victims “a lifetime of pain.” Prevention: In order to prevent misconduct by male doctors, patients must insist on the presence of a medical chaperon; the attendant must be properly trained and should remain alert during the examination; ask the doctor why intimate examination is being performed; urge the doctor to explain the procedure in a way the patient can understand; most importantly choose a practitioner you trust and feel comfortable with. Inappropriate comments and sexual innuendo should be treated as warning signs, they should prompt termination of examination. In 94% of cases of sodomy and 88% of cases of rape, the abuse was preceded by inappropriate comments or touching of the victim. Cases of misconduct must be reported to the authorities concerned, including police. All these safety measures should be strictly applied during examination of small children, especially young girls. Presence of a parent is mandatory in such cases. Advice to the doctors Quite occasionally, we hear of allegations of sexual misconduct by female patients against male doctors. These are serious charges that can be devastating to the concerned doctor; in addition, they tarnish the image of the medical profession. Thus it is good to consider prophylactic and preemptive measures. 1. Never examine a female patient without a chaperon or a relative, preferably female, or spouse. 2. Explain clearly the nature of the examination or procedure in advance. 3. Clear instruction regarding undressing must be notified. 4. Do not examine if the patient refuses chaperon or another female to be present. The chaperon must closely watch the whole procedure. 5. Ensure privacy, arrange for appropriate dress such as gown, if called for, and drape adequately. All this is done with the help of a female assistant. 6. Important to note: Even while examining female minor patient, do not dispense with these measures. Many doctors feel that such allegations will not be made in case of small children. Always examine in presence of a guardian. 7. Avoid narrating inappropriate jokes with the patient. It is unprofessional and can be misconstrued. 8. Do not appear to be over friendly with the patient. 9. Do not exchange gifts with patients. 10. Do not be lax in collecting fees. This can be misconstrued. In some cases the allegations may be genuine. Undoubtedly, this is despicable behavior and such doctors do not deserve any sympathy. On the other hand, some cases may be perceived to be sexual misconduct, though it is unintended. Every effort must be made to avoid such situations by consciously following the preventive measures. Lastly there is a category of cases that are concocted and pre-planned with an idea of defaming or extorting money from the doctor. The writer is Chest specialist in San Francisco