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How to protect patients in the pediatric office :

May 24, 2018

Although allegations of sexual misconduct against pediatricians are rare, some high-profile and widely publicized cases have raised the wariness and concern of caretakers, patients and pediatricians alike.

Medical professionals can be involved in sexual misconduct in many clinical situations. The AAP policy statement Protecting Children From Sexual Abuse by Health Care Providers (http://pediatrics.aappublications.org/content/128/2/407) defines pediatric sexual abuse as: “Engaging children in sexual activities they cannot understand or consent to, including genital or anal contact; exposing the child to exhibitionism, voyeurism, or sexually explicit material; using the child in pornography; and pandering the child for sex by others.”

Pediatricians may be vulnerable to allegations of misconduct from a wide variety of interactions: direct patient care, interactions with caretakers, caring for a large population of nonverbal patients, needing to discuss on a regular basis sexually sensitive issues with pre-adolescent and adolescent patients, and dealing with office personnel.

Part of regular and appropriate pediatric care involves examination of the genital and breast areas and may involve sexually explicit discussions with adolescent patients. Performing these duties in an appropriate and lawful way is the responsibility of every provider.

Pediatricians may need to examine sexually sensitive areas due to a medical complaint or as part of the routine well exam. In either case, it should be made clear to the patient and caretaker why the exam is being conducted and the extent of the exam. The patient should be draped appropriately to protect privacy, and optimally a caretaker or chaperone would be present during the examination. When sensitive, sexually oriented discussions are necessary with a young patient in private, consider having a chaperone present, if permissible by law and acceptable to the patient. (See AAP policy Use of Chaperones During the Physical Examination of the Pediatric Patient,http://pediatrics.aappublications.org/content/127/5/991.)

Physicians also should refrain from making comments that might be considered inappropriate. Remarks about attractive clothing or underwear, mentioning anatomic features not directly related to the concern at hand or remarking on specific social interactions all have been utilized against physicians in proceedings when misconduct has been alleged. Even when no abuse has occurred, these statements may indicate to patients or caretakers a cavalier attitude or may be construed as grooming behavior.

Some practices try to minimize risk by matching patients with providers of the same sex, but these interactions also can lead to allegations of wrongdoing when statements or actions by the provider are considered inappropriate or unnecessary. Explaining the reasons behind sexually sensitive examinations and specific questions can reassure the patient and caregiver. Providing caretaker or chaperone supervision benefits the patient and physician in these situations as well.

Pediatricians generally provide care through proxies, caretakers who accompany patients to the office and consent to evaluation and treatment for patients. Reasonable care should be used in assessing whether the individual accompanying the patient to the office can act as legal proxy. Failure to have appropriate consent can lead to allegations of inappropriate contact or even battery charges against providers.

Some states allow minors to consent for care that involves sexual or mental health. In this situation, a chaperone should be present during the assessment and examination. A similar situation arises with mature or emancipated minors.

Pediatricians also should avoid inappropriate comments or contact with caretakers. Some clinicians are physically demonstrative, hugging or squeezing a shoulder or hand of a worried parent. This is not specifically inappropriate; in some situations, it is a compassionate or needed reaction. Physicians, however, must be careful that these behaviors are not misconstrued as sexually suggestive touching.

Examining a toddler in a parent’s lap also is common and can lead to physical contact with the parent, which may be felt to be inappropriate. Discussing your exam and avoiding casual contact may be wise during these exams.

Romantic or sexual contact with parents or adult ex-patients may be problematic, as well. Physicians should be cognizant of the risks with these interactions, particularly when dealing with patients or parents who might have a mental health or developmental diagnosis. Though these relationships may not be criminal, they may cross ethical boundaries and can lead to complaints to state licensing boards.

Sexual misconduct allegations may affect your licensure and may result in criminal charges. Many of these offenses will not be covered by malpractice insurance, and providers may be responsible for paying for their own defense costs, which can run to tens of thousands of dollars.

Takeaway points

  • Sexual abuse by pediatricians is unethical, illegal, cannot be tolerated by fellow providers and must be reported.
  • Using chaperones during exams is a means to prevent sexual misconduct by providers, to document exam behaviors and can provide an extra level of protection if a false allegation is made against the clinician.
  • Providers should be respectful and judicious in their comments and physical interactions with patients’ caretakers.

Dr. Scibilia is a member of the AAP Committee on Medical Liability and Risk Management.

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