TAMPA, FLA. (FRONTLINE MEDICAL NEWS) – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.

“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD , of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.

While not discounting psychiatrists who themselves have psychiatric pathology that leads them to sexual boundary violations, Dr. Gabbard recounted numerous cases in which violators slowly became entangled in a sexual relationship with good intentions. He recited cases in which sexual contact was initiated to address loneliness in a patient threatening suicide, to accommodate patients who identify sex as a means to fill a psychological void, or, not least common, when mutual and overpowering “lovesickness” led to what the offending therapist considered a fated romance.

These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.

Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.

Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.

One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.

In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.

“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.

Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.

Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.

Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”

Dr. Gabbard reported no relevant conflicts of interest.