Addressing Sexual Boundaries: Guidelines for State Medical Boards

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January 11, 2006

Lisa Robin
Vice President, Leadership and Legislative Services
Federation of State Medical Boards

P.O. Box 619850

Dallas, TX  75261-9850

Dear Ms. Robin:

Thank you for asking the American Academy of Physician Assistants (AAPA) to comment on the Federation’s draft policy, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.” As you are aware, the AAPA is the national professional society for physician assistants (PAs). In this capacity the Academy represents over 58,000 physician assistants in the United States.

The Academy recognizes the importance of the Federation’s role in providing guidance to medical boards through policy documents such as the proposed guidelines. We also applaud the Federation’s desire to seek input from the Academy and other professional societies prior to consideration of the Guidelines at the Federation’s House of Delegates.

We would like to offer two general comments and follow with a few very technical suggestions.

To begin, the Guidelines as drafted are consistent with the spirit of Academy policy and we endorse their content. The Academy’s Guidelines for Ethical conduct for the Physician Assistant Profession state:

“It is unethical for physician assistants to become sexually involved with patients. It also may be unethical for PAs to become sexually involved with former patients or key third parties. Key third parties are individuals who have influence over the patient. These might include spouses or partners, parents, guardians or surrogates.

Such relationships generally are unethical because of the PA’s position of authority and the inherent imbalance of knowledge, expertise and status. Issues such as dependence, trust, transference, and inequalities of power may lead to increased vulnerability on the part of the current or former patients or key third parties.”1 

The Academy, as stated above, believes that sexual contact with patients or key third parties is unethical. Unethical behavior by health care providers should be grounds for discipline by the licensing agency. This is supported in AAPA Policy. The Academy’s Guidelines for State Regulation of Physician Assistants state,

"The American Academy of Physician Assistants strongly endorses the authority of designated state regulatory agencies, in accordance with due process, to discipline physician assistants who have committed acts in violation of state law. Disciplinary actions may include, but are not limited to, suspension or revocation of a license or approval to practice. In general, the basic offenses are similar for all health professions and the language used to specify violations and disciplinary measures for physician assistants should be similar to that used for physicians."2

Our second general comment relates to the document’s focus on physicians. Of course this is reasonable. The primary function of a state medical board is to regulate the practice of physicians. This is a document of the Federation of State Medical Boards, whose stated mission is to “improve the quality, safety and integrity of health care through high standards for physician licensure and practice.” However, many medical boards also regulate physician assistants, podiatrists, and a wide variety of other health professionals. Physician assistants are regulated by 57 of the Federation’s 70 member boards. We would note that the issue of sexual boundary violations is important to all board licensees.

The document interchanges the use of the term “physician” and “licensee.” We believe that all of the provisions and requirements for physician licensees, as applicable, should also apply to and be imposed on PA licensees. 

What follows are specific suggestions for the content of the text.

Line 20

We question the use of the term “guidelines” here. We believe that document does not call for the board to use “guidelines,” but rather to assure sufficient statutory authority, adopt rules, and methodically follow a legal and regulatory framework. One way to address this would be to change the sentence to state, “As state medical boards are required to respond to an increasing number of complaints, it becomes imperative that medical boards assure a sufficient statutory framework and adopt regulations and legal procedures for dealing with sexual boundary issues and take measures to educate their licensees about sexual boundary issues.”

Line 48

Earlier in the document the Guidelines state, “Sexual behavior between a physician and a patient is never diagnostic or therapeutic.” Yet line 48 requires that the behavior exploits the physician-patient relationship to be deemed misconduct. We believe the document would be strengthened if the sentence ended after the word “board.” It then would say, “Categories of behavior described as sexual misconduct are not hierarchal as both types are the basis for disciplinary action by a state medical board.”

Lines 69-70

This section defines "sexual impropriety."  Section 7 includes in the definition, "performing an intimate examination or consultation without clinical justification and without explaining to the patient the need for such examination or consultation except when the examination or consultation is pertinent to the issue of sexual function or dysfunction."

We would hold that there is no instance in which it is appropriate to perform any examination without clinical justification and without explaining to the patient the need for such examination or consultation, even when relevant to an issue of sexual function or dysfunction. We suggest that the section be amended to end after line 69. It would then read, “performing an intimate examination or consultation without clinical justification and without explaining to the patient the need for such examination.”

Lines 215-216

The introduction to the document recognizes that “sexual addiction” is not recognized as a disease. Thus we would suggest that the term be removed from these lines.

Line 291

This section implies that the patient’s treating practitioner can “describe the physician’s rehabilitative potential and risk for recidivism.” It is unclear how the patient’s treatment provider could or should be called upon to render an opinion on the physician’s treatment or future. We would suggest that this language be stricken from the draft.

Line 318

The section on discipline states that when determining disciplinary action the board should consider the offender’s “existence of social support systems.” It is unclear to us why this is relevant and we recommend that this either be clarified or removed.

Thank you for the opportunity to comment on the proposed Guidelines for Sexual Boundaries. We would be happy to provide additional information upon your request.

Sincerely,

Ann Davis, PA-C

Director of State Government Affairs

 

1. Guidelines for Ethical Conduct. American Academy of Physician Assistants. 2005-2006 Policy Manual. Alexandria, VA.

2. Guidelines for State Regulation of Physician Assistants. American Academy of Physician Assistants. 2005-2006 Policy Manual. Alexandria, VA.