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Although the so-called #MeToo movement got its start from allegations against Hollywood mogul Harvey Weinstein in late 2017, victims of sexual abuse -- in the church, in the locker room, in the workplace, and, yes, in the exam room -- had already begun to speak up and demand accountability.

And while media coverage has tended to focus on the individual perpetrators, it's clear that there is more to the problem than just a few "bad apples." In this new 麻豆传媒 series, we explore the background to sexual assault committed by physicians, and look at some of the systems that enable abuse and others that try to prevent it.

Last month, 17 women and its affiliated hospitals claiming they failed to intervene when Robert Hadden, MD, a former ob/gyn at New York-Presbyterian, sexually assaulted them during office visits.

Dozens of men filed last summer, alleging that former wrestling team doctor Richard Strauss, MD, sexually abused them while the administration ignored his misconduct.

Meanwhile, a George Tyndall, MD, the longtime campus gynecologist at the University of Southern California, after more than 200 women came forward alleging he assaulted them during their appointments.

All follow the , at Michigan State University, in which over 150 victims testified to being sexually abused by the former U.S.A. Gymnastics team doctor, many of whom had been minors at the time.

The Federation of State Medical Boards 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 outside an exam), offers drugs in exchange for sexual acts, masturbates in their presence, or encourages a patient to masturbate.

Tracing a Pattern

A 2017 analysis that examined instances where physicians in the U.S. had sexually abused patients found that all 101 cases involved physicians who were men, nearly all of whom were over the age of 39 (92%), working in private practice (94.1%), and had been born in the U.S. (84.2%), reported James DuBois, PhD, ScD, of Washington University in St. Louis, and colleagues in

Typically, most physicians in these cases (70%) were not board certified -- although three-quarters of those who were remained so while under investigation.

"One of the frustrating things about this is that there are a few things that are correlated with it, but in a sense, none of these are red flags," DuBois told 麻豆传媒, noting that the majority of physicians might have these same characteristics while never committing any sort of offense.

Abuse typically happened when physicians were alone with the patient (85.1%), and repeated abuse occurred in 96.0% of the cases.

"In terms of environment, this is also very challenging," DuBois said, recalling that in Nassar's case, many victims had their parents present in the room while the abuse occurred.

Using the LexisNexis law database, the researchers examined all cases recorded from 2008 to 2015. The database archives statutes and case judgments, and also provides access to medical board and regulatory documents. Women made up the vast majority of victims in this series (89.1%), in line with the proportion of involved in rape cases (90%).

In any situation in which a patient is required to undress or reveal a part of themselves to a physician, it may not be abundantly clear to the patient what is medically relevant for the procedure or exam, and what violates the standard of care, such as during an obstetrician appointment, said Paul Appelbaum, MD, of Columbia University in New York City, who is also a member of the Standing Committee on Ethics of the World Psychiatric Association and a former American Psychiatric Association president.

In cases where physicians are invested in satisfying their sexual impulses, this physical advantage puts them in a position in which they can blur the lines between what is appropriate behavior and what is not, he said.

Fundamentally, it is simple: a patient comes to an exam room because she is worried about her health and she turns to her doctor to provide her with a solution.

"That puts them in a dependent posture to the doctor, which on the patient side may contribute to their difficulty in saying no to a doctor's inappropriate physical advantage," Appelbaum told 麻豆传媒. "On the doctor side -- for that small minority of the profession that is so inclined -- expecting that dependency and vulnerability may actually encourage them."

Like in most sexual assault cases, it's possible that patients who have been violated will feel guilty that they either encouraged this behavior or allowed it to occur, said Appelbaum, which may inhibit reporting. Additionally, the abuse can lead to a post-traumatic stress disorder (PTSD)-like reaction, in which patients fear, distrust, or avoid the medical profession altogether.

"You may hear accounts of patients who have been through this and then don't go to a doctor again for years and years, or aren't willing to go to a gynecologist for an annual appointment because of the last time they went," Appelbaum said. "Or perhaps they aren't willing to see any physician again because they're concerned that abuse may occur."

"That's a very serious consequence, because potentially we have patient health and lives at stake as a result of the misbehavior," he added.

Under the Radar

In DuBois' study, the abuse more often than not lasted at least 2 years (58%), and nearly all cases involved multiple kinds of professional breaches (88%), suggesting that many incidents of sexual and medical violations went undetected before the physician was disciplined for his actions. Rarely was the person who reported the abuse a colleague of the physician or staff member at his practice (7.0%) -- typically the whistleblower in these cases was the patient (69.3%).

Marissa Hoechstetter, the only plaintiff to reveal her name in the Columbia case, began seeing the accused gynecologist in 2009 after a friend, who was Hadden's niece, recommended him.

Hoechstetter said Hadden often made inappropriate remarks -- like asking if she was having trouble with orgasms, or telling her husband that she looked "like a porn star" -- and performed prolonged breast exams without a cover. During their visits, they often talked about Hadden's niece, a detail that later became clear was a "grooming" tactic Hadden used in an attempt to build a false sense of comfort and trust, she said.

Grooming behaviors are common in physician offenders, who may "" to create an environment of forced intimacy and determine "if his target will protest," according to a landmark 2016 national investigation by Atlanta Journal-Constitution.

This may be one reason victims refrain from coming forward. Patients may also want to avoid bringing serious accusations against their physicians that will get them into trouble, Appelbaum said. But because of the doctor-patient dynamic, some patients might not even know they are being abused, he said.

Hoechstetter was pregnant with twins during most of her visits, and Hadden delivered her girls. It was a few months after they were born, during a post-op visit in stirrups, that Hoechstetter felt Hadden lick her vagina. During this exam, as well as the majority of her experiences with Hadden, there was no chaperone in the room.

Knowing the complications that can arise with twins, Hoechstetter said that during her appointments, she was primarily occupied with finding out how her girls -- who are now 7 years old -- had developed since their last visit. Pregnant and in stirrups for most of the exams, it's possible she physically could not see Hadden perform deviant acts under the premise that they were medically relevant procedures -- a possibility that still haunts her.

"I feel like he took advantage of me in a really vulnerable situation where I was looking for someone who I took to be an expert in a facility I took to be world-class care," she said. "I think he used that to his advantage to get away with this behavior."

The portion of physicians who commit sexual assault is small (the Atlanta Journal-Constitution investigation found 3,100 doctors accused of sexual misconduct since 1999), but since many of these doctors are repeat-offenders, they can likely abuse many patients, sometimes over the course of several years or decades.

As few women report their sexual assaults in general (only go to the police), the number of assaults in medicine is likely underestimated.

Even if patients do report their assault, the process can be confusing or inaccessible, and their reports could be filed in a vague or incomplete manner.

According to the study from DuBois' group, due to "rules shrouding disciplinary databases in secrecy," much of the data regarding physicians who commit sexual assault are lacking. This, paired with the longevity of most cases, also suggests that if disciplinary actions were taken toward physicians who abused patients, they did not always prevent them from continuing to practice.

In Hadden's, Tyndall's, Strauss's, and Nassar's cases, reports of abuse were traced back to the 1990s.

Part 2 of this series will explore the role of large institutions and how their reactions to physician sexual assault may contribute to a culture of silence.

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