Betrayal of Trust

Betrayal of Trust
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Betrayal
OF TRUST:
Sex and Power in
Professional
Relationships
JOEL FRIEDMAN and
MARCIA MOBILIA BOUMIL
Westport, Connecticut
RRAEGER London
Library of Congress Cataloging-in-Publication Data
Friedman, Joel.
Betrayal of trust : sex and power in professional relationships /
Joel Friedman and Marcia Mobilia Boumil.
p. cm.
Includes bibliographical references and index.
ISBN 0-275-95029-8 (alk. paper)
1. Sexual abuse victimsUnited States. 2. Sexually abused
patientsUnited States. 3. Professional employeesUnited States
Sexual behavior. 4. Professional ethicsUnited States. 5. Sexual
ethicsUnited States. I. Boumil, Marcia Mobilia. II. Title.
HV6592.F75 1995
362.88'3'0973dc20 94-28004
British Library Cataloguing in Publication Data is available.
Copyright 1995 by Joel Friedman and Marcia Mobilia Boumil
All rights reserved. No portion of this book may be
reproduced, by any process or technique, without the
express written consent of the publisher.
Library of Congress Catalog Card Number: 94-28004
ISBN: 0-275-95029-8
First published in 1995
Praeger Publishers, 88 Post Road West, Westport, CT 06881
An imprint of Greenwood Publishing Group, Inc.
Printed in the United States of America
The paper used in this book complies with the

Permanent Paper Standard issued by the National
Information Standards Organization (Z39.48-1984).
10 9 8 7 6 5 4 3 2 1
Contents
Preface vii
Introduction ix
Chapter 1 Sexual Intimacy in Professional Relationships 1

Chapter 2 Sexual Exploitation in the Mental Health
Professions: The Paradigm 11
Chapter 3 Sex and Power in Other Professional Relationships 27
Chapter 4 Early Warning Signs: The Prelude to Exploitation 45
Chapter 5 Filing a Complaint Against Your Therapist: The
Mental Health Paradigm Revisited 61
Chapter 6 Bringing Your Therapist to Court: The Costs and
Benefits of Private Lawsuits 79
Chapter 7 Legal Recourse for Sexual Exploitation by Other
Professionals: The Emerging Law 91
Chapter 8 Overcoming the Psychological Effects of
Exploitation 109
vi Contents
Chapter 9 Sex After Termination: The Nature of Consensual
Relations, the Residue of Power, and the
Unresolved Issues 119
Afterword 131
Bibliography 135
Index 139
Preface
For decades people have put themselves in the hands of professionals,

doctors, lawyers, clergy, educators, or others, with an unequivocal faith
and trust that would not allow them to question even the competence,
and certainly not the ethics, of their practices. They rarely questioned
the advice; they did what they were told, and they were grateful for the
privilege of doing so. Indeed, the professions were cloaked with a dig-
nity and respect only deserved by and accorded to those of high honor
and unquestionable character.
Today the realities are different. Each week the newspapers report the
alleged wrongdoing of another trusted professional. Television shows
regularly document these abuses and so today we have come to expect,
and even demand, information, answers, and choices from the profes-
sionals who serve us. We routinely avail ourselves of second opinions
in order to be sure that we can trust what we are told. Informed consent
has become an expectation and not just an ideal.
Those of us who engage professionals are also quick to hold them
accountable when something goes awry. Our despair over a poor result
is as often voiced in the courts as it is in the privacy of our homes. And
all too often, we are justified.
That, however, is not the end of the story. We have also come to
viii Preface
recognize that the same professionals whom, only a short time ago, we
thought we could entrust with our bodies and our souls, we now know
may be capable not only of error or neglect, but also of intentional
wrongdoing. Some have purposefully taken advantage of our naive trust,
and that trust has been betrayed. And what is worse is that we were
probably aware a generation ago of these same types of violations and
were afraid to speak out.
Violations of trust by professional providers can occur in a number
of ways. One of the most obvious is when they too often recommend
services that are not in our best interests. Instead such services may
yield an economic advantage to them, or perhaps an opportunity to ex-
periment with our bodies at our expense. But a violation with even more
serious consequences to the individual is the one that this book ad-
dresses: sexual exploitation. This occurs when a trusted professional
uses his powers of persuasion and position to coerce an unsuspecting
victim into sexual activity with him. Whether a victim consents because
she is frightened of his power or persuaded by his supposed virtue, it is
a clear professional violation and betrayal of our trust.
A generation ago the victims of sexual exploitation, mostly women,
were usually afraid to speak out. And when they did, few people lis-
tened. But today the social climate has changed and women are willing,
indeed encouraged, to stand up for their rights, speak out when they are
violated, and pursue remedies against their abusers. This book is in-
tended to inform, support, and encourage that end: to help victims antici-
pate and identify abusive situations, to promote awareness of their rights
and recourse, and to assist them with the personal growth that can ac-
company their recovery from a betrayal of trust.
Joel Friedman
Marcia Mobilia Boumil
Introduction
It is currently estimated that one-third of all money awarded for medical

malpractice is for damages for sexual misconduct. Indeed, sexual exploi-
tation by professionals (defined as sexual contact with a trusted profes-
sional: doctor, lawyer, teacher, clergyman, or other, who is engaged to
provide professional services) has come to be recognized as a problem
of great magnitude in recent years. The sheer numbers of cases that have
been reported, to say nothing of the vast majority which doubtless re-
main hidden, make it a problem of scandalous proportion.
Although both men and women can be victimized by professionals
who are supposed to serve them, because of the dynamics of male/fe-
male relationships, as well as the usual hierarchy of greater status and
position of men, the vast majority of victims are women. The great
number of reported cases has made it possible to examine, ponder, and
theorize about what makes so many women vulnerable to this kind of
victimization. On the other hand, it has been much more difficult to
understand what leads these men to jeopardize their status, power, and
position and even their livelihood by engaging in sexually exploitative
behavior.
Careful examination of the life stories, and specifically the underlying
motivations, of both victims and perpetrators involved in a variety of
x Introduction
sexual and other abusive relationships has led us to understand the fun-
damental aspects of male/female interactions that help set the stage for
abusive or exploitative relationships when an opportunity arises. Of
course, not all men take advantage of such opportunities, and presum-
ably the great majority do not. But the interplay of what men and
women look for in each other, what, in particular, attracts them to one
another and how they express their attraction, gives insight into why
"professional exploitation" is so prevalent. The following case of a
bright, young corporate associate, whom we will call "Ginny," and her
psychotherapist, whom we call Dr. Steven L., illustrates this point. As
Ginny related to us first:
I was 27 years old and had gotten an M.B.A. from an Ivy

League university 3 years earlier. I was working for a Fortune 500
company as a marketing analyst. The hours were long; the money
was great and the people were terrific. Even my social life was as
good as it had ever been. But still something wasn't right in my
life. In fact, I had known for years that I suffered from a depression
of sortsone that I never quite understood. For years I had substi-
tuted studies and work and "community" service for a satisfying
personal life. This job was perfect. I could completely immerse
myself in my work, even doing extra things for the people around
me, and nobody would ever know the difference, except me, when
I arrived home each day to find my only stable companionmy
cat.
After many years of avoiding this problem I knew it was time
to come to terms with it and figure out what was going on with
me. I came upon Dr. Steven L. quite by accident. His office was
actually across the border in another state. I got him from a referral
agency and my first priority was that my visits to him would be
confidential.
Steve tells us that he distinctly remembers Ginny's first visit. He said:
I recall that Ginny came into my practice at a difficult time in my

life. The patient I saw just before her was a woman who always
seemed to be angry and complaining and for whom no amount of
work seemed to have any effect. After her I spent a few minutes
on the phone with my wife trying to figure out where the money
would come from to replace the roof and pay for our daughter's
Introduction xi
tuition. It was one of our typical brief but annoying interactions

that usually left me cold. When Ginny came in I immediately no-
ticed how young and sparkling she was. As she began to speak I
found myself really paying attention to her. I was actually "pres-
ent" in the sessioncompletely, for the first time in a long time.
She was particularly concerned that our sessions would be private
and confidential and she accepted my assurance with an openness
and naivete that were very refreshing.
Ginny recalls:
For me our first few meetings were uneventful. Dr. L. was a

man of about fiftyish, tall, attractive, and well-groomed. He was
polite in his manner and exceedingly patient. I noticed this particu-
larly as time went on and we started getting into things that were
really hard for me to talk about. He would keep me focused and
he always seemed interested and attentive.
As Ginny tried to sort out her initial feelings of attraction to Steve, she
commented:
There was something so comforting about just being there with a

man who cared about what was going on with me. I was grateful
for his willingness to listen to me, even if I had to pay for it. I was
surprised at how close to him I began to feel and sometimes I
would even ask him little personal things about himself. Usually
he wouldn't respond directly, but one time I thought I could see
him strugglinglike maybe he wanted to tell me more. At some
point during this time he asked me to call him "Steve." At first it
was difficult but after a while it seemed quite natural. I realized
how special it made me feel and how I began to have other feelings
about him as well.
Steve continued:
I began to look forward to my sessions with Ginny. They were

usually in the early evening, yet she always looked fresh and alert.
She talked readily and often carried the sessions, making my work
easier. When I offered an insight or a suggestion, she was always
willing to consider it. She expressed gratitude for my help and she
Xll Introduction
never failed to pay her bill on time. I felt recognized, youthful, and
effective in my work with her. All this was happening and we
hadn't even gotten into her story yet. I knew that I had great influ-
ence over this woman.
Ginny recalled:
After about a month we got into the subject of when my first

prolonged feelings of sadness began and I ended up describing my
parents' divorce. I was an only child and my father left when I
was 11 years old. My mother was devastated and had so little
emotional support to give me. In fact, most of the time she relied
on my strength, even just to get up in the morning. She needed so
much and I had so little to give.
Ginny related this sadly, as though taking care of her mother were some-
how her responsibility.
I think it was during this discussion that the powerful reality of

Steve as a man, probably as a father himself and as a "healer"
overcame me. He, of course, would have understood how Mom
and I felt. He, of course, would have thought about my needs. And
he, of course, never would have left.
Steve also remembered this incident vividly:
As time went on and Ginny began to tell me some of the things

that were going on with her I could sense her longing to be loved
and cared for. Her parents had given her little and it was amazing
how well she had met her own needs. She was not, however, hid-
ing them from me and the more she shared the more important to
her I felt. The rest of my life had become really routine, but my
sessions with Ginny were differentthey were alive. A couple of
times I requested that she do little things for no particular reason
perhaps come earlier and wait in the waiting room or change her
perfume. Whatever I asked, she just did itwithout hesitation. I
loved it.
When asked to describe her sexual attraction to Steve, Ginny recalls:

Introduction xiii
I can't quite describe it. First I saw him as the perfect father, and
yet the quality in him that really captured me wasn't fatherlike at
all: he seemed so smart, so worldly and so strong, and yet so sensi-
tive and caringthe perfect mate.
Ginny described a particular meeting when her feelings for Steve

reached a peak:
For weeks we had been talking about really important events in

my life that I had never talked about to anyone. I discovered feel-
ings that were deeply buried that I never even knew existed. Then
one time Steve asked me about something so incredibly powerful
for me that I just couldn't answer him. I opened my mouth, but
nothing came out. So we just sat there, the two of us together, and
the silence seemed to last forever. And through it all, all that I
could think about was that I wanted him to touch me, hold me,
and tell me that he'd never leave.
Steve recalled that session only too well:
Ginny was really very upset. She spoke slowly, tears gently flow-
ing from her eyes, and then at one point she got tongue-tied and
could only utter a helpless sigh. My mind raced ahead and as she
spoke I found myself paying attention not to her words but to the
smell of her scent, the sheen of her hair, and, of all things, the
sexy turn of her ankle within the revealing sandal. I was overcome
by desire, knowing I could have her whenever I wanted. This was
the feeling I wanted to retrievewhat I thought I needed so I could
feel whole again.
Ginny continued in a very deliberate tone:
When I finally looked up at him, it almost seemed like he, too,

was mesmerized. I couldn't quite tell if he was unable to find the
right words, or if he was just being patient, but he didn't say any-
thing either. It was so hard to tell what was going on with him
because of his calm manner, but at times it seemed like he really
did care about meas though somehow I really mattered. I
couldn't take my eyes off him. For me there was so much "energy"
XIV Introduction
in the room that I wished we could have made love right then and
there.
In an instant Steve faced a defining moment in his life which he de-

scribed this way:
Our eyes remained locked and I knew Ginny was very vulnerable.
I knew she would do whatever I asked of her. I also knew that I
felt strong and whole again and that having her sexually would be
wonderful for me. I even thought of how it would also allow Ginny
to confront and work through her fears of abandonment. I reached
across to her and began to gently wipe the tears from her face and
my hands groped to feel the softness she willingly offered. I asked
Ginny to come back that night after I had finished with my last
patient. She eagerly agreed.
What you have just read is not a scene out of a romance novel; in
fact, there is absolutely nothing romantic about it. It is not about love;
it is really not even about sex. It is about power and exploitation. It is
about what happens when an unethical professional encounters a psy-
chologically vulnerable patient, client, student, or other and decides to
use her trust in him, primarily engendered by his power and position, to
his own advantagewith little regard to the consequences for her. It is
about the nature of these professionals who deceive themselves and
those who rely on them, and the contexts which provide fertile ground
for this deception to occur. And this book is not just about psychothera-
pistsalthough the mental health professions provide the paradigm for
professional exploitation. It is also about teachers, lawyers, doctors, and
even the clergy who use their position to abuse those who come to trust
them most. Our intention is not to titillate but to educate so that both
potential victims and abusers alike will know how exploitation happens,
why it happens, and what to do to prevent it. We will also provide some
suggestions about how to remedy the damage that has already been done
to thousands of unsuspecting victims.
Betrayal of Trust
Chapter 1
Sexual Intimacy in Professional

Relationships
In recent years there has been an ever increasing awareness that various
forms of sexual violence perpetrated primarily against women are oc-
curring at an alarming rate. It is currently estimated that as many as one
in three women is a victim of sexual abuse by a relative whom she
knows and trusts. Rape is thought to occur somewhere in the United
States every 30 seconds, more often than not committed by an offender
who is known to the victim. Even sexual harassment is currently esti-
mated to affect nearly 70 percent of American women, both in the
school and on the job.
Today there is a growing awareness that there is yet another form of
sexual violence, also primarily affecting women: sexual exploitation.
Also sometimes referred to as "professional incest," sexual exploitation
is perpetrated by professionals against the patients, clients, students, and
others to whom they provide services. In the most common circum-
stance a female patient, client, or student seeks out the services of a
professional man, and during the course of the professional relationship,
he engages her in sexual activity. While, of course, the offenders are
not always men nor are the victims always women, in most instances
this is, in fact, the case. For the purposes of clarity this book will, there-
2 Betrayal of Trust
fore, generally refer to men and women, respectively, as perpetrators

and victims of sexual exploitation.
Why, exactly, are sexual liaisons within professional relationships ex-
ploitative? There are two major ways in which women become victim-
ized by these relationships. In the first, a victim is led to believe that
this is an opportunity to share in an intimate relationship with a man
whom, because of his power and position, she has come to respect, trust,
and admire. Often he presents himself as a kind and caring professional,
attentive to the needs of an unsuspecting female client, patient, or stu-
dent and seeking to be helpful in whatever way his profession offers. At
the same time, he is powerful and revered, a figure whose judgment one
might otherwise never question. Often a victim becomes mesmerized by
the thought that such an awesome person is interested, really interested,
in her!
So what is wrong with that? In the great majority of cases, the inten-
tions of the professional who approaches his clients, patients, students,
and others in this manner are insincere. They are not based upon genuine
interest in the individual; they are based upon the man's desire to use
the relationship for his own sexual gratification: in short, to "exploit"
her. And that's what's wrong.
Lynne was approached by Dr. S., her gynecologist, whom she saw
regularly for various matters as they developed over the years. She
admired his wisdom and professional position and appreciated his
kind bedside manner. When Dr. S. indicated at one point that he
had a personal interest in Lynne, she felt honored that such an
important man would be interested in her. He quickly engaged her
in a sexual relationship with him which lasted only a few months.
After that, his interest seemed to evaporate and he terminated the
relationship abruptly.
Because of the nature of the relationship, the professional is often able

to know where and how victims are vulnerable and to use the knowledge
gained through the professional relationship to manipulate a victim in a
manner that takes advantage of those vulnerabilities. If he is successful,
she may willingly consent to a sexual relationship with him, only to be
used, abused, and "dumped" when his needs are gratified and he no
longer wants her. Her needs are rarely considered except to the extent
that they are used to manipulate her.
In the second situation, the professional may or may not purport to
Sexual Intimacy 3
have a genuine interest in his victim, but instead uses the professional
relationship to coerce her, often subtly, to participate in a relationship
with him. In these cases, the victim "consents" to the relationship, but
her consent stems from fear that the professional services will be termi-
nated if she does not acquiesce to his sexual desire.
Kerry was referred by a friend to Attorney Jacobs when her mar-

riage fell apart. He had the reputation of getting great results and
Kerry was desperately afraid of losing custody of her son. From
the beginning, Jacobs was reassuring about her position and made
her feel good about herself at a time when she was feeling lonely
and rejected. Kerry found herself looking forward to their meetings
and was even pleased when his subtle remarks flattered her. She
was taken by surprise, however, when he made his first sexual
advance toward her. A part of her was clearly attracted to him;
another part was skeptical about why he showed such interest in
her; and yet another part was afraid to rock the boat with him
because so much was at stake.
In most cases the sexual relationship that results is short-lived; it lasts

until the professional man gets what he wants from it or gets tired of it,
and then it ends abruptly. The incidence of this form of professional
misconduct is alarming, and the consequences to the victims are often
tragic.
The reality of sexual exploitation as an increasing social problem has
generated a number of difficult questions. Indeed, it has been widely
debated whether the various professions should assume an active role in
determining whether, and under what circumstances, their members may
engage in sexual or other relationships with the individuals they serve.
On one side of the equation are two adults who may desire a consensual
sexual relationship with one another. The law views this as a fundamen-
tal right of privacy and is loath to interfere with people engaging in
mutually agreeable conduct with one another (so long as it is neither
illegal nor immoral). Indeed, the law strongly protects this constitutional
provision that people have a right to freedom of association. Yet on the
other side of the equation is the professions' recognition that their mem-
bers, merely by virtue of their power and position, can exert undue in-
fluence over the individuals they serve. What appears to be a consensual
relationship is so fraught with an inherent imbalance of power and op-
portunity for undue influence that it can cause patient, clients, and stu-
4 Betrayal of Trust
dents seemingly voluntarily to consent to such relationships without

knowing that they are actually being exploited. And when the relation-
ship runs its course and the professional moves on to someone else, the
effects on the exploited individual are often so devastating that the law
and the professions themselves are finding it necessary to step in and
take responsibility: in short, preventing unsuspecting individuals from
becoming victims of this type of abuse.
The various professions have dealt with the problem of sexual exploi-
tation in different ways. The mental health professions, by far, have
been most aggressive as it has become evident that the prevalence of
sexual exploitation is enormous in that field. Indeed, the high incidence
and seriousness of the consequences have led to the coining of the
phrase "therapist-patient sex syndrome," indicating the magnitude of the
professions' concern about the problem. The reason that sexual exploita-
tion is so significant in mental health is well understood. The mental
health professional is engaged to analyze, understand, and influence the
patient's psychological and emotional state. The therapist's work re-
quires that he act so as to elicit and sustain a deep sense of trust from
his patient. If he is successful, this results in her willingness to expose
to him psychological weaknesses and points of vulnerability.
In working with a mental health professional patients are encouraged
to discuss parts of their lives that include intimate thoughts and feelings
not generally shared with other people. The very process of doing so is
likely to stimulate feelings of intimacy toward the therapist, particularly
if he acts (as he should) in a manner that is kind, caring, and attentive.
This scenario sets up a clear and direct opportunity for the mental health
professional, who is often dealing with emotionally needy patients, to
use the information that he has gathered during the therapy to manipu-
late them through their vulnerabilities: if he believes that a victim is
insecure, he can become the perfect father; if he believes that she has
poor self-esteem, he can promote a better self-image. The feelings of
intimacy and attraction, which have physical as well as emotional com-
ponents, are encouraged to develop during the therapy. They are sup-
posed to be used as part of the healing process. If, instead, they are used
to establish a sexual relationship, whether or not the therapist has a
malicious motive, the harm that can be caused is often devastating. This
is sexual exploitation.
Gynecology is another profession in which there exists the opportu-
nity for sexual exploitation. As with mental health professionals, women
discuss highly intimate matters with their gynecologists. They may dis-
Sexual Intimacy 5
cuss sexual function and dysfunction. They may discuss their marriage
or other intimate relationships. As part of a routine examination, the
woman allows the gynecologist to touch and even manipulate her genital
areas. Even when there is no intent of either party to "sexualize" the
relationship, it is often the case that a woman feels an intimate connec-
tion to her gynecologist. As a result, he has a great opportunity, similar
to the psychotherapist's, to take advantage of that intimacy to urge sex-
ual contact.
While there are the similarities indicated between therapists and gyne-
cologists, the analogy goes only so far. Indeed, there are also important
differences. Gynecologists do not routinely treat individuals who are
mentally or emotionally compromised, in a current state of upset, or
otherwise particularly vulnerable to psychological manipulation. More-
over, gynecologists do not necessarily have the expertise to recognize
when and how a particular patient can be exploited. Time constraints
and short and infrequent contacts usually limit the chances of strong,
intimate feelings that require time and exposure to develop and usually
occur gradually. So while some of the same factors may give gynecolo-
gists some special access to their patients, they do not squarely fall
within the mental health paradigm, as significant differences make the
analogy imperfect.
In recent years the occurrence of sexual exploitation and its negative
consequences have also been observed within the legal profession. The
incidence and severity have been less well documented, but sexual ex-
ploitation by lawyers is now clearly recognized and the profession is
taking measures to protect potential victims from being harmed. To date,
at least eleven states have ethical provisions in their codes of conduct
which, in most circumstances, prohibit lawyers from engaging in sexual
conduct with clients whom they represent. In addition, the states of Cali-
fornia and Oregon have recently adopted rules that forbid sexual contact
between lawyers and clients, at least to the extent that such relationships
impair the lawyer's ability to represent the client adequately. New York
has a similar provision applicable only to divorce lawyers. In creating
these rules, the California Bar Association specifically acknowledged
that attorneys can seriously harm their clients by engaging in a sexual
relationship with them while providing their legal services. A number
of other states (Illinois, for example) appear to be moving in the same
direction, although specific rules have not been created as this book goes
to press.
There are two common circumstances that give rise to clients' becom-
6 Betrayal of Trust
ing sexually involved with their lawyers. In one, the client is emotion-
ally vulnerable, perhaps going through a divorce. She feels lonely and
rejected and looks to the lawyer not only to handle the legal matter but
to help her through this difficult time. Not unlike what she expects from
a therapist, she wants someone to listen, to sympathize, and to solve the
problem. A lawyer who successfully fills this role will doubtless gain
her admiration and respect and may win her sexual interest if he is intent
upon doing so.
In an alternative circumstance the client may or may not be emotion-
ally vulnerable when she engages the services of a lawyer to represent
her. But after the professional relationship begins, a predatory lawyer
attempts to use his power and position to cajole or coerce sexual favors.
The client may believe that her acquiescence is beneficial or necessary
for her case to be handled competently. She may feel trapped, not realiz-
ing that the lawyer can be fired. She may rationalize that it's okay, that
it has nothing to do with her legal problem, or that it is worth putting
up with to have her case go well.
Once again the analogy between lawyers and therapists is imperfect.
Like gynecologists, lawyers do not always deal with emotionally vulner-
able clients. And even when they do, they also do not necessarily know
how to manipulate that vulnerability. The opportunity for intimacy is
less certain, particularly if the legal matter concerns a purely economic
transaction like a business deal or real estate matter. In those cases in
which the lawyer (e.g., the divorce lawyer) does play the role of emo-
tional caretaker, however, the opportunity for exploitation is signifi-
cantly increased.
Teaching is yet another profession which has recently been forced to
acknowledge that sexual exploitation is a significant problem. In fact,
numerous colleges and universities have recently adopted policies that
forbid faculty members to engage in sexual relationships with students
whom they teach or supervise in any capacity. Once again, if mental
health is the paradigm, these two professions have both common threads
and important differences. Students, in general, do not present them-
selves with the same emotional vulnerability that a patient of psycho-
therapy might. Nevertheless, their lack of maturity can be just as disarm-
ing. It is not unusual for students to idolize teachers, and to follow their
lead, simply assuming that their motives are pure. In a very real sense,
students look to teachers as they look to their parents, and they expect
their well-being to be protected in the same way. It is largely on that
Sexual Intimacy 7
basis that faculty members are precluded from engaging in sexual con-
duct with students.
Still other professions have explored the ramifications of sexual ex-
ploitation within their own ranks and considered the need for regulation.
In each case, the mental health profession is likely to be used as the
paradigm. Each time, as the analogy to such a different profession be-
comes more imperfect, the argument for regulation becomes less com-
pelling. But despite the differences between the mental health profes-
sions and the others, in most cases the basic and fundamental ingredients
are shared: a difference in power and stature within the relationship and
a fiduciary expectation that the professional will act in the best interests
of the individual who trusts his intentions.
What about the clergy (but not those who are engaged in pastoral or
spiritual counseling, as they function much as therapists do)? A clergy-
man is looked up to as a symbol of the deity or salvation. Does this
perception affect how a parishioner might react to a sexual advance?
Does the expectation of the clergy's fiduciary obligation to do no wrong
affect a judgment about whether, in fact, such an advance is appropriate?
The reality is that yet another group of professionals, the clergy, has a
significant ability to exert undue influence over those whom they serve,
and under such circumstances the potential for exploitation is very real.
Finally, consider the remaining health professionals: doctors, dentists,
chiropractors, and others. They do not necessarily deal with emotionally
compromised individuals. They are not presenting themselves as a ser-
vant of God. And the individuals they serve are not usually impression-
able youth. Again, as we move away from the mental health paradigm,
the opportunity for exploitation is less obvious, but nonetheless still
present. Many of the basic elements still exist, and a vulnerable individ-
ual can be hurt just as badly. But it is also true that mutual, meaningful,
and enduring relationships can also develop out of these encounters, so
it becomes more and more difficult to regulate behavior as the indicia
of danger become less apparent.
The mental health professions have dealt with the problem of sexual
exploitation in a clear and decisive manner. Psychiatrists, psychologists,
and social workers each have their own codes of ethics which separately
but distinctly condemn sexual contact between therapists and patients
under all circumstances. During the course of the professional relation-
ship the codes decree that it is absolutely unethical for any such mental
health worker to suggest, agree to, or participate in sexual contact of
8 Betrayal of Trust
any kind with a patient or client. Even after the professional relationship
ends, there are many in the field who believe that a subsequent sexual
relationship between therapist and patient would still be exploitative be-
cause of the "timeless" nature of the clinical relationship. In fact, there
is presently an ongoing debate about whether therapists ever can ethi-
cally engage in sexual relations with their former patients. The nature
of this controversy as it pertains to the mental health and other profes-
sions will be explored in Chapter 9.
Sexual exploitation within professional relationships sometimes has
been referred to as "professional incest." Although it is not incestuous
in any traditional sense, it is nevertheless a descriptive characterization
for a number of reasons. First, the perpetrators are individuals in whom
the victims have placed their trust. As in parent/child relationships, the
professional may be like a parent in the eyes of a child: powerful and
caring, worthy of trust, and certain to never betray that trust. Like a
parent, the professional is viewed as more competent than they and en-
dowed with the expectation that the superior knowledge and skill would
be used in their best interest. Indeed, many of us have been taught that
the doctor can do no wrong and we maintain this faith, never dreaming
that a revered and respected professional could actually have feet of
clay. Many people tend to stereotype professionals, equating education
and status with character and goodwill, and may be blind to the reality
that professionals have human frailties.
When Kerry's chiropractor began to touch her in a sexual way

while purporting to treat her back problem, she assumed that it
was part of the treatment. When his sexual advances became more
obvious, she had a sense that a man who was engaged to perform
this type of service should not be acting in this way, particularly
during treatment. However, she knew him to be a "doctor" and
trusted that he would not behave inappropriately during an office
visit.
Another reason that sexual exploitation by professionals resembles

incest is that the consequences to victims are remarkably similar to the
effects observed in incest survivors. Women who are abused by some-
one whom they know and trust demonstrate distinct symptoms which
usually are not present in victims of violence who did not know the
offenders. They usually view their own participation as voluntary and
therefore are likely to experience feelings of shame and guilt about hav-
Sexual Intimacy 9
ing consented to the sexual conduct. They may feel anger at the perpe-
trator, but the anger is also turned inward to themselves, often leading
to self-doubt and depression. As a result, they frequently demonstrate
severely lowered self-esteem, social isolation, and sometimes self-de-
structive behavior, including suicide.
Michelle was sexually exploited by her divorce lawyer when she

was going through her second divorce. At the time she was emo-
tionally distraught and he was very supportive, attending not only
to her case but also her well-being. After she exposed the exploita-
tion, many of her family and friends, although kind to her, treated
her as though it was simply another affair that she agreed to out
of poor judgment. In fact, she had demonstrated less-than-ideal
judgment in the past, but this was not such a case.
What about the responsibility of the client, patient, or student who

willingly consents to the sexual relationship with a professional whom
she engages, perhaps even initiating it? The professions consider sexual
misconduct involving a patient, client, or student to be the responsibility
of the professionalregardless of whether or not he actually initiated
the sexual behavior, or whether there exists an appearance of consent.
This is because "true" consent is thought not to exist. What appears
disguised as consent is too often impaired judgment resulting from igno-
rance, deception, or psychological manipulation of the client, patient, or
student's vulnerabilities. Judy's experience illustrates this point.
Judy sought the help of a psychologist after many years of suffer-

ing from recurrent episodes of depression. She was a single mother
of twin girls and held a full-time job to support them. She was
herself an only child with few family ties. After just a few sessions,
Judy started looking forward to her sessions and to sharing her life
with Dr. T., who was the only person who she felt could under-
stand the stresses of single parenthood. Two months into the ther-
apy, Judy had become quite attached to Dr. T., and he professed a
strong attraction toward her. He told her that although he was a
married man, he was actually quite lonely and would really enjoy
a sexual relationship with her. Judy had become so dependent upon
Dr. T. that being "special" to him was an opportunity that she felt
she couldn't pass up. She knew, of course, that a sexual relation-
ship with a married man was improper and was unlikely ever to
10 Betrayal of Trust
amount to anything, but it felt right for her at the time, and it gave
her temporary relief from the depression which had plagued her
for so long.
The statistics indicating the incidence of sexual exploitation by pro-

fessionals are still being compiled. Data from the mental health profes-
sions indicate that as many as 10 to 12 percent of male therapists sexu-
ally exploit patients at some point in their career. Many do it often and
repeatedly. Of those patients who are abused in this way, as many as 90
percent suffer serious consequences. Statistics on the incidence of sexual
exploitation in other professions are still being gathered. In Massachu-
setts, for example, one researcher found that one-third of the money paid
out in medical malpractice lawsuits was to compensate patients for injur-
ies due to sexual misconduct by doctors. Both the justice system and
the professions themselves are alarmed by the severity of this problem.
"Conspiracies of silence" and the protectionism of "old boy networks"
are giving way to efforts at finding solutions that both protect victims
and preserve the dignity of the professions.
Chapter 2
Sexual Exploitation in the Mental

Health Professions: The Paradigm
CASE STUDY: KKISTEN
It's been nearly 2 years since my relationship with Carl ended. He was
a therapist that I went to see when my marriage to my second husband
was in trouble. I was 31 and about to get divorced again. Everybody
tried to tell me that it wasn't my faultbut I knew that I was responsi-
ble for a lot of it. Carl, Dr. M, that is, was recommended to me by
another woman at work, who thought he was just great with relationship
problems and self-esteem, and I thought that was just what I needed. I
still had some hope of working out the trouble with Dan, my second
husband, and this therapist sounded great.
It's hard to remember exactly how I felt about him in the beginning.
He was an attractive man in his mid-forties, soft-spoken and incredibly
sure about himself. I think that's what I liked most. He obviously felt
good about himself and I was sure he could teach me to feel the same
about myself. At first I saw him once a week, but after just a few weeks
it was like I couldn't make it through unless I saw him, so I started
making up excuses to need appointments more often. It's hard to de-
scribe what it was about him that was so alluring. As I look back I think
it was just that he was willing to listen to me. For the first time in my
life, someone would actually let me talkand sit there, patiently, and
listen to me. I grew up in a large, overburdened family. My parents
didn't have much to give by the time I came along, and if I just wanted
to get heard, I had to be quicker and louder than everyone else. And
here was this manhe would let me take as long as I needed and he
would still be there, listening. At the beginning I mostly talked about
Dan. I talked a lot about being hurt, but I also tried to talk about how
deeply I cared about Dan. But if I ever thought this man was going to
help me keep my marriage together, I was dreaming. He had his own
agenda, and as I look back at it, it was there from the beginning. Every
time I would talk about maybe trying to work things out with Dan, he
would tell me that I deserved better and that I needed to "move on"
with my life. Sometimes I would end up feeling worse, but somehow
before I left I would always feel like I had to come backlike it would
be just another failure if I couldn't even be a good patient. Besides, I so
much wanted Carl to like me.
The hardest part of this story is to tell you how I felt about Carl. I
know I felt a very strong connection to him, probably because I got to
tell him about things that nobody else ever cared enough to hear about,
even the men I was married to. Dan really was a good man, and I think
that if we could have gotten him to come to therapy, there would have
been a real chance to work things out. Carl never even suggested it.
Instead it always seemed that in order to be a good patient, I had to
"move on," which meant away from Dan. I really wanted to work things
out, but Dan was angry and didn't make it easy for me to question
Carl's advice. Carl, on the other hand, showed me that men could be
kind and gentle and still be strong. What I realize now is that Carl
actually taught me that men can be kind and gentle if that's what they
think it takes to get what they want.
I had been seeing Carl for several months, starting once a week, but
scheduling more sessions when I wanted to see him or if I was really
upset, when his approach seemed to change. Instead of letting me talk
about whatever was on my mind, he started being more active and di-
rect, asking me about how I felt about how things were going, and about
him. He began to make really explicit comments about memy dress,
my hair, my makeup, and even my bodyand also discussed some
things about himself. I was so hungry for attention that I just soaked it
Sexual Exploitation 13
up and went back for more. I felt special to Carl and looked forward to
seeing him. Then one day it just happened.
I called him on a Monday morning to report that Dan had been very
nasty to me and had decided to move out. I asked if he could squeeze
in an "emergency" appointment. He was very accommodating and sug-
gested that I come by at the end of the day since he had no other free
time. When I arrived he seemed to be anticipating my arrival and
greeted me warmly. I can remember how sweet he smelled as though
he had just freshly showered. At the time I didn't think it was strange
because I was consumed by what was going on in my life. He started
by saying that he was glad that I could "reach out" to him in a crisis. I
wasn't there for even 5 minutes when I fell apart and started to cry. Dan
had left and I needed someone to care. Carl came over to me, put both
arms around me, and led me over to his couch. For several minutes he
just held me, but I couldn't stop crying. Then the next thing I knew, he
was stroking my shoulders and as I relaxed he began to caress my
breasts, making me feel wonderfully warm and safe. The contrast be-
tween how cruel Dan had been and how this man was treating me was
stark and overwhelming. I was swept away.
When I stopped crying Carl talked to me in a voice that went right
through me. He said that I was feeling rejected and lonely and that he
knew what I needed. His touch, his calm and controlled manner, and his
seemingly deep concern about me were what I felt I needed. There was
no question in my mind that he knew what was right, and it seemed so
fortuitous that he would be there and willing to give it to me. I was
feeling like a carefree child, almost as though in a trance, and Carl
seemed strong, caring, and protective. When he started to undress me I
offered no resistance. I did whatever he told me to do, gave him what
he wanted, and felt grateful to be able to repay his kindness.
For the next five-and-one-half months Carl would schedule end-of-
the-day appointments for me twice a week. After about a month, things
began to change once again. He would barely take the time to greet me
before he would start getting undressed. His softness disappeared. He
paid much less attention to my needs. After sex he would no longer talk
about how special I was to him, but instead would tell me why sex with
him was good for me and that it was part of my treatment. He continued
to bill me at his regular hourly rate.
Between sessions, when I wasn't with Carl my feelings for him and
what was going on were not always positive. On the one hand, I would
say to myself, "Why not?" He was willing and nice and being with him
seemed to improve the way I felt about myself. On the other hand, the
"talking therapy" part of this relationship effectively stopped. Instead of
my talking about what was going on with me, we would have sex and
only talk about why it was so therapeutic for me. Sometimes it seemed
wildly exciting; at other times it seemed cold and mechanical. It's diffi-
cult to explain, but a part of me felt safe and valued and another part
felt like I was being used. The more confused I was the more attached
to Carl I got. This was my escape from loneliness and another failed
relationship. I was afraid to say "no." I was afraid to stop. I was pretty
sure that if I didn't agree to sex, that would be the end of our relation-
ship, and I wasn't strong enough to give that up. Ultimately it wasn't
my choice.
As abruptly as this relationship began, it ended. One day Carl simply
announced that his wife was complaining that he was getting home too
late and he no longer had time for this aspect of my therapy, which he
felt I no longer needed since I was "cured." I left obediently and became
very, very depressed.
My ability to function was instantly disrupted. I spent the next three
months in my apartment, mostly in bed. I couldn't go to work and even-
tually lost my job. I can't quite describe the level of my despair, but,
basically, I didn't see any reason to go on living. This was worse than
my divorce. I felt completely rejected and couldn't imagine ever being
interested in anything again. Fortunately my best friend, Sarah, stood by
me through all of it. She brought me food, talked to me, and literally
kept me alive. She was the only person I trusted and eventually she
succeeded in convincing me to get help. I was very scared and reluctant,
but I couldn't stand the pain anymore. With Sarah's help I finally sought
out another therapista woman this time. In the beginning I avoided
any mention of my relationship with Carl, but she kept gently inquiring
and eventually it spilled out.
My new therapist never pushed me but her encouragement helped me
to talk about my experience with Carl. She was patient, accepting, and
didn't try to talk me out of my feelings. She also explained the way
therapy works, especially how it is normal to develop a strong emotional
attachment to someone (particularly a therapist) who is kind, caring, and
attentive. She also explained how an unethical therapist can exploit these
vulnerabilities to satisfy his own needs. My new therapist helped me
sort out what I did with Carl, and I came to realize that I was not to
blame for what happened. Sometimes I still question whether I can trust
anyone but I am feeling more confident and hopeful that I can also work
through my failed marriages and problems with men and even start
again in a new relationship.
WHAT ARE BOUNDARIES?

In every relationship, personal or professional, there necessarily exist
certain physical and psychological "boundaries." The boundaries help
define the relationship: in personal relationships people tend to get closer
to one another, perhaps to touch each other in physical ways; they also
tend to reveal more of their thoughts and feelings to each other. In
professional relationships the boundaries are different: people generally
keep a greater distance, both physical and psychological. Boundaries are
important in relationships, not only because they establish the type of
relationship, but because they also establish such points as where one's
own reality ends and where another's begins. In fact, they distinguish
one person from another, giving each a separate identity: this is me and
this is you.
Unlike a physical boundary, which is tangible and often measurable,
a psychological boundary is more abstract; it is made up of thoughts,
feelings, sensations, and intuitions. But psychological boundaries, while
intangible, are nevertheless very real. People with healthy boundaries
are keenly aware of where their own "space" ends and where another's
begins and can readily discern when a boundary has been crossed.
People without a healthy sense of boundaries, on the other hand, find
it difficult to make those kinds of assessments. Sometimes it's even
difficult to tell such things as what they themselves think, how they feel,
and what they want: in short, how to define one's "self." Individuals
without clearly defined boundaries may have a hard time distinguishing
between their own needs and wishes and those of others. They may not
be able to make decisions, know how they feel or what to think, and
depend upon other people to tell them how to conduct themselves. The
other's thoughts and wishes become the referent from which they make
their own choices. So, instead of asking, "How do I feel?" "What do I
think?" or "What do I want?" a person without strong boundaries will
ask, "How does he/she feel?" or "What would he/she want me to do?"
The absence of a clear experience of boundaries makes it difficult to
establish healthy or mature relationships with others. Without bound-
aries it is difficult to maintain a sense of limits: what is appropriate
within the relationship and what is not. The absence of defined bound-
aries makes it dangerous even to have relationships because such people
may not realize when a line is being crossed and their boundaries are
being violated: a clear indication that the relationship may be dangerous
or abusive. Indeed, for just this reason people without healthy, defining
boundaries tend to enter and stay in harmful or exploitative relation-
ships.
Psychological boundaries are largely put into place during childhood.
The child's experience (how it is treated by family and other important
people) determines how its boundaries become defined and how well
they will subsequently function. When a young child's needs are met
(e.g., it receives appropriate responses, is properly fed and clothed, and
is made to feel safe and secure), the child develops a sense of personal
boundary. This is because when it is hungry, tired, otherwise uncomfort-
able, and cries to be cared for, it gets attention. The child learns what
its own experience is; what it senses and feels, and eventually what it
thinks. These experiences belong to the child, and together they form a
sense of a "self delineated by boundaries. The child may test the limits
of its boundaries by crying louder, longer, or more frequently, and it
learns how far its personal boundary extends.
When a child's needs are not met (because they conflict with those of
its caretakers), the child's boundaries become defined by the needs of
others, limiting the development of the sense of "self." The child does
not learn to experience its own needs; it experiences only the needs of
others. This blurs the boundaries between the child and others, ulti-
mately preventing the child from differentiating its own needs from
those of others.
As a young child, Katie was praised and rewarded by her mother

for physical closeness (hugs, etc.) and proximity (keeping Mom
company rather than playing with peers). She was also rewarded
for adopting her mother's interests and attitudes, which her mother
considered a sign of respect. In fact, Katie's mother felt threatened
by signs of her independence, fearing that it would result in Katie's
growing up and leaving her. As an adult, Katie had a confused
sense of who she was (her emotional boundary). In her relation-
ships she sought consensus and withdrew from conflict. She sought
to please others and felt valued and comfortable when she was able
to do so.
Peter grew up as an only boy in a family with four siblings. When

Peter was a young child, his father wanted him to achieve every-
thing he had wanted for himself: to be an athlete, a professional
man, financially successful, etc. When Peter was frightened to try
something new, his father would push him to succeed. At times
Peter would rebel and withdraw, particularly when his lack of abil-
ity disappointed his father. As an adult, Peter also had a distorted
sense of emotional boundary. He was afraid to get too close to
people, fearing that his inadequacy would ultimately lead to rejec-
tion.
Early experiences are important in determining the strength of an indi-

vidual's boundaries: when they are secure, where they are weak, and
how they can be breached. Young children, still undeveloped, are partic-
ularly vulnerable, and all children as they are in the process of devel-
oping are at risk for having their emotional "space" invaded at times.
Greater violations, such as violent acts of assault or trauma, and an
extended duration of violation, such as sexual or emotional abuse over
a period of months or years, have significant enduring effects on the
child's development of boundaries.
Tammy's parents believed that physical illness and out-of-sorts be-

havior were the result of contaminants in the body being stored up
in the colon and bowels. Whenever Tammy wasn't feeling well or
misbehaved, they would give her an enema in order to "detoxify"
her, getting rid of the poisons in her body. She would cry, scream,
and beg them not to hurt her, but she was made helpless as a result
of being restrained while her body was violently entered. Tammy
had no control of either her physical or psychological boundaries.
Psychological boundaries can also be violated through deceit and ma-

nipulation.
When Jill was 4 years old she attended nursery school. She devel-
oped a strong attachment to the class pet, which was a long-haired
guinea pig named Sally. She really loved this animal and fed and
attended to it as though it were her own. During school vacation
she was asked to take Sally home and care for her. Jill was de-
lighted. Although she knew that she would be away for part of the
vacation, she was sure that her father would care for Sally in her
absence. While she was away, her father neglected Sally and she
died. Before Jill returned, her father decided to replace Sally, only
to find that hers was a rare breed. Instead he replaced it with a
short-haired breed which also had different facial markings. When
Jill returned, her father told her that he had given Sally a haircut.
Jill burst into tears, insisting that it wasn't Sally, but was admon-
ished to control herself. Her father didn't want to hear any more
about Sally. It wasn't until many years later when her grandmother
died while Jill was away at college and she was never informed
until the end of the semester (so she wouldn't ask to travel home)
that she realized that this was a lifelong pattern of deception, of
which Sally's disappearance was the first remembered incident.
EXAMPLES OF DAMAGED BOUNDARIES

The following are some examples of how damaged boundaries are
often experienced by the individual. This is not an exhaustive list, but it
indicates many of the telltale signs of weakened or vulnerable bound-
aries that put a person at risk for being manipulated. These are:
It is difficult for you to ask for what you want and need and hard
to say "no" to other people when you would like to.
It is easier to take care of other peoples' needs and desires than
your own. It is also easier to go along with them than express
your own opinions.
Other people seem to know you better than you know yourself.
They also seem to know what is best for you.
It is hard to make decisions because you frequently don't know
how you feel or what you think about important things.
When feelings are present they are so strong that they are over-
whelming. It is difficult to control the "volume," to turn feelings
up or down and still be in touch with them.
Relationships seem to be one-way and you always put more into
them than you get out of them. But even though you're not get-
ting what you want, you stay with them just the same.
Other people's moods have a big effect on you because you feel
responsible for them. When they are happy, you are happy.
When they are sad or angry, you blame yourself.
Disturbing thoughts or memories keep popping into awareness

and sensations occur in parts of your body for no apparent
reason.
Concentrating and paying attention are often difficult. You are
too easily distracted or influenced by things going on around you.
Learning from your mistakes is not easy. You seem to keep mak-
ing the same errors in judgment repeatedly, and you have little
confidence in your own experience.
Other people seem to have a better grasp of reality than you do,
so you depend upon them to tell you what is true and real.
People can take and borrow things from you without returning
them or repaying you. What's theirs is theirs and what's yours is
theirs.
THE CONSEQUENCES OF DAMAGED BOUNDARIES

In psychotherapy, a patient usually seeks out the services of a thera-
pist at a time that her psychological condition is compromised. She has
suffered some sort of loss, an interruption in relationships or another
upsetting event. The therapist recognizes her compromised position and
is expected to work with it. At the same time, however, he also knows
that as a result of her situation, she is likely to be particularly susceptible
to being influenced. She presents herself because she may be confused
or frightened, but she wants help and is usually willing to do whatever
it takes to get it.
What does she discover when she submits herself to the therapeutic
process? In order to heal, she finds, she is urged to open herself up to
the therapist and to confide in him about the most private or intimate
events in her life. If she really wants to be helped, she has to risk low-
ering her psychological "guard" and exposing her weaknesses and vul-
nerabilities. By virtue of her upset and his position, the therapist be-
comes cast in a role that wields substantial power. The patient is
exposed, vulnerable, and willing. He is trained to evaluate her emotional
status and to alter or influence it in a beneficial way. So what if he
chooses to manipulate it in a way that benefits him rather than her?
What if he does so in a way that, in the beginning, makes her feel loved
and special? And what if she is an individual whom he has determined
(within his professional capacity) comes to therapy with a weakened
sense of boundaries?
In most professional relationships it is apparent that the client, patient,

or student is, in many respects, subject to the power, control, and influ-
ence of the professional. Indeed, this is the essence of a fiduciary rela-
tionship. The fiduciary needs something, and the professional is pre-
sumed to be able to provide it. But at the same time this substantial
difference in power sets the stage for misuse or corruption. In psycho-
therapy, because of the nature of the process, the therapist's particular
training, and the upset of the client, the opportunity for abuse is greatest.
Nevertheless, many of these same factors come into play in other profes-
sional relationships, and the potential for abuse follows close on its
heels.
Therapists, of course, recognize the power that their position holds
and the particular vulnerabilities of the individuals they treat. They are
expected to be especially sensitive to the need to respect patients'
boundaries. The ethical therapist, recognizing that he must exert a pow-
erful influence to persuade a patient to respond to his treatment, is par-
ticularly cautious when it comes to maintaining a clear boundary be-
tween himself and his patient. Some professionals, poorly trained or
untrained in human behavior, may be less aware of the significance of
boundaries. Others may disregard what is learned. Most, however, are
well aware of their clients' susceptibility and their ability to influence
their clients' decision making. Unfortunately, all too many professionals
come to recognize their ability to manipulate their clients into providing
sexual favors as well.
TRANSFERENCE
What would account for the fact that a woman, who is often bright,
attractive, accomplished in many areas of her life, and perhaps even
married, becomes sexually involved with her therapist or other profes-
sional whose services she engages? Why would she allow herself to be
used, exploited, and betrayed by someone purporting to care for her
well-being? The answer to these vexing questions relies on the concept
of "transference," which was originally described by Sigmund Freud in
his early work in psychoanalysis. Transference occurs when an individ-
ual in a current context (such as psychotherapy) attributes to someone
present in that context (the therapist) the thoughts, feelings, desires, or
emotions that were experienced in a prior context (usually her child-
hood). So if, for example, a patient has earlier experienced her father
as cold or dictatorial, she may interpret something that is said or done
by the therapist as though he, too, were cold and dictatorial without re-
alizing that she has "transferred" her long-standing impressions of her
father onto the therapist as though she were still interacting with her
father.
In this process the patient is said to "project" these feelings, thoughts,
and wishes (experienced in early childhood and then "repressed" or for-
gotten) onto the therapist. Characteristics from the patient's unconscious
are attributed to the therapist, and they cause the patient to relate to him
consciously as the therapist, but unconsciously as that other person from
her childhood. An ethical therapist knows to analyze the transference
with the patient and to use the valuable information about what is oc-
curring in the patient's unconscious to help the patient.
Through the transference process, a patient is likely to experience
both positive and negative emotions toward her therapist. When the
transference is positive, the patient may develop strong feelings of close-
ness and trust, often leading to emotions of intimacy, affection, and ad-
miration of the therapist. In some cases patients develop intense sexual
feelings and erotic fantasies for the therapist because of the intimacy,
intensity, and safety of the therapeutic situation. Positive transference
can be a powerful emotional experience, and it is not unusual for pa-
tients to feel that they are in love with the therapist. When the transfer-
ence is negative, the emotional experience for the patient can be equally
intense, and if not properly handled can lead to the premature termina-
tion of treatment.
Jenny was referred to Dr. L., a private psychologist, to help her

sort out numerous issues surrounding a very troubled marriage.
Although she initially rejected the idea of a male therapist, who
she felt would side with her husband, she found Dr. L. to be sur-
prisingly understanding, accepting, and supportive of her needs and
values. He listened patiently as she reported episodes of repeated
abuse and feelings of profound disappointment. After several ses-
sions with Dr. L., who was kind, caring, and attentive to her needs,
Jenny felt herself being able to let go of some of her negative
attitudes toward men. The contrast between her husband and Dr.
L. was remarkable and she felt herself wanting to trust and to love
again. Dr. L. became everything she wanted in a man: he was soft,
nurturing, accepting, and yet powerful and in control. As time went
on she became more and more attracted to him, eventually fanta-
sizing about romantic involvement with him.
According to Freud, these feelings (which he called "transference

love") are generated by the therapeutic process itself; they are not the
same as love experienced outside the therapy and they have little to do
with the particular attributes of the therapist per se. Instead it is a pro-
cess in which the therapist purposefully induces trust and intimacy in
order to (1) analyze the patient's response and (2) use the relationship
to influence the patient's response to treatment. Transference, used prop-
erly, is a constructive tool in psychotherapy, allowing the therapist to
understand where and how particular conflicts developed and how they
continue to affect the patient in her adult life. When the transference is
understood by the patient as well, it can contribute significantly to the
healing process.
Development of the transference is not related to the patient's intelli-
gence or any particular personality traits. Indeed, most patients are un-
aware of its occurrence and therefore do not resist it. It does, however,
result in patients' becoming highly susceptible to the influence of the
therapist. It is particularly dangerous if the therapist tries to use that
influence to take advantage of, or "exploit," the patient. An ethical thera-
pist will communicate to his patient, expressly or implicitly, that the
therapy situation is a safe environment where boundaries will be re-
spected and transference feelings will not be used to violate the patient's
boundary.
If transference is so fundamental to the therapy process that virtually
all patients experience it in some way, why would some, but not others,
fall victim to sexual exploitation? The answer lies in the relationship
between the concepts of transference and boundaries. There are two
"typical" victims. One type of victim is vulnerable because she, as a
child, was sexually abused by a significant male figure in her life, such
as her father or other male close to her (boundary is violated). As a
result her emotional development is fixated around needing to deal with
the consequences of that trauma. This unresolved conflict, originating in
her past and usually repressed, comes to the fore in therapy. The patient
unconsciously fuses the therapist with the father (transference) and in
her mind sets the stage for a reenactment of those early events. Indeed,
in the usual case she does so without even understanding what is taking
place (it is unconscious). And at the same time, a powerful dependence
on, and longing for, the therapist is created (transference love).
Dale was sexually abused by her father some time before the age
of 10. She remembers little about the abuse, although, with the
help of therapy, many of the painful details are emerging. Little by

little she has exposed so much of herself to her therapist that she
has begun to establish, for the first time, the type of connection
that a parent would have with a child. For the first time Dale has
been willing to reach out and trust someone, seemingly without
fear of how vulnerable her deepening sense of affection and trust
makes her feel.
The other type of woman who is at risk for exploitation is one who
has been emotionally neglected and deprived of adequate affection. She
may feel unattractive and despair that she will ever know the feeling of
being special and finding fulfilling love.
Ellen was the youngest child of two-career parents who were

highly devoted to their work. Her birth was unplanned and her
parents were ambivalent about having another child. All three chil-
dren were raised largely by hired household help. Ellen was less
physically attractive and intellectually gifted than the other chil-
dren. She spent much of her life emotionally withdrawn, seeking
but never really expecting small signs of acceptance and involve-
ment from her parents, who rarely paid attention to her. Her will-
ingness to please them was evident, but they were usually too busy
with their own lives to respond.
When this type of woman enters psychotherapy as an adult, she may

be yearning to establish an intimate bond. Indeed, her difficulty in doing
so in other relationships may be exactly what brings her to therapy.
When, in due course, the transference relationship evolves, she may
come to think that she has at last found that special person who will
fulfill her frustrated needs, including whatever unfulfilled childhood
wishes have been repressed. The transference relationship becomes an
essential part of her life. It seems to become the reference point from
which all choices and decisions are made. For example, when a decision
arises is her life, her first thoughts are "How would he feel about it?"
"Would he be pleased?" "What would he think of me?" or "Is this what
he would choose?" She will go to great lengths to maintain her illusion
that a special relationship is being realized and that her needs are finally
being fulfilled.
Patients who experience this type of transference often feel no sense
of volitional choice or control, but are driven by their need to maintain
this very important relationship. They are so compelled by their intense

emotion that even a high intelligence and strong moral character are
insufficient to enable them to exercise sound judgment about this partic-
ular relationship. Of course the therapist, understanding the transference,
knows what his patient is experiencing and can choose to use the trans-
ference either constructively (to benefit the patient) or destructively (for
his own self-interest), violating the sexual boundary and leading the pa-
tient into a sexually exploitative relationship.
COUNTERTRANSFERENCE
Why would a professional breach his fiduciary and ethical responsi-
bilities and violate a patient's sexual boundary? The process that proba-
bly accounts for much of this was identified by Freud as "countertrans-
ference." Countertransference is described as the therapist's reaction to
the patient's transference. Like transference, countertransference is a re-
flection of earlier events and unresolved conflicts in the therapist's own
life that are now "projected" onto the therapy situation. Triggered by
the patient's transference and his reaction to being "loved" by a submis-
sive and admiring woman, an unethical therapist will seize the opportu-
nity to use the patient to satisfy his own unfulfilled needs.
Being a therapist is often frustrating and unrewarding: Dr. Q.'s

practice was usually busy but involved a lot of patients who regu-
larly complained about their situations, the slow pace of therapy,
and the great expense involved. When a patient like Marlene
comes along, it can make all the difference in the world. She came
through her crisis within three sessions and was very grateful for
the help that Dr. Q. had given her. He began to look forward to
his sessions with this attractive woman, who showered him with
compliments and admiration. He felt he deserved, but rarely re-
ceived, the kind of acknowledgment that Marlene gave him. At
times he felt almost intoxicated by her adoration.
Just as "transference love" results from feelings generated by the pa-

tient's past experiences and not any particular attributes of the therapist,
so countertransference has little to do with the individual attributes of
the patient. It is the result of the therapist's own issues that he responds
to certain patients in particular ways. Indeed, this is the reason that many
therapists seek personal therapy before practicing their profession. It
helps them to understand how their own experiences have shaped them
and how those experiences are likely to affect their judgment or practice.
While countertransference reactions are also an expected part of the
therapy process, they should not be allowed to intrude in the patient's
therapy. It is up to the therapist to work them out on his own. To allow
countertransference reactions to intrude is a first step toward using a
patient for the therapist's benefit, to work out his own problems in the
patient's therapy. Patients who are vulnerable to being used in that way
do, in fact, attempt to reverse roles and provide "therapy" for the thera-
pist. This is a common precursor to the breach of the sexual boundary
and ultimately to the demise of the healing relationship.
When Dr. F. was brought before the Board of Registration on

charges of sexual exploitation, he was actually relieved that he
would now be forced to confront what he knew to be his own
significant unresolved personal issues concerning women and sex-
ual performance. As a child he never felt able to win his mother's
love. No matter how well he succeeded in school or at sports,
she never would acknowledge him. He suffered from feelings of
insecurity, and during adolescence he developed a preoccupation
with sexual accomplishment. He delayed getting involved in sexual
relationships because he felt insecure about his sexual perfor-
mance. He wanted women to worship him because of his ability to
please them. Becoming a therapist gave him the power and the
opportunity to act out his fantasies.
MANAGING THE TRANSFERENCE

What should clients, patients, or students expect when it becomes
apparent that transference or transferencelike phenomena pervade the
professional situation? And how should the professional respond when
it is evident to him that transference reactions are affecting the course
of the relationship? In large part, it depends upon the nature of the
services. In psychotherapy, it is appropriate for the patient and therapist
to discuss the feelings that are created so that the transference can serve
its therapeutic function: it can be analyzed; its roots can be explored;
and its implications for the patient's present life can be addressed. An
important part of the therapeutic process is to work through and resolve
transference reactions, leading the way to healthy relationships with ap-
propriate peers.
Should a client be prepared to discuss transference reactions with her

divorce lawyer? Should a student discuss her "crush" on a teacher with
that teacher? The answers to these questions are less clear. Lawyers,
teachers, and other professionals untrained in the analytical sciences
cannot be expected to handle a client or student's transference reac-
tions as though they were psychotherapists trained in that discipline.
And if they try, there is no guarantee that their efforts will result in
more good than harm. So if a client or student reveals a personal or
sexual attraction to an untrained professional she may expect him to
respond as any other man being approached by an admiring or amorous
woman would.
Does this mean that he is free to respond as though she were not his
client, student, or other fiduciary? No. Even if the professional cannot
be expected to be trained in transference principles, he does need to
fulfill his fiduciary obligations and refrain from all conduct which might
harm the fiduciary, even if she initiates the (inappropriate) contact. The
definition of "inappropriate" varies from one profession to another, and
so does the proper response (see chapter 3). For example, not all profes-
sions impose the blanket prohibitions of sexual contact that the mental
health professions do. Each profession maintains its own code of ethical
principles and some variation exists. What is always required, however,
is a primary obligation not to jeopardize the well-being of the fiduciary
by engaging in a course of conduct that takes advantage of the influence
that comes out of the professional relationship.
Chapter 3
Sex and Power in Other

Professional Relationships
CASE STUDY: DEBBIE
I was referred to Dr. F., a highly regarded obstetrician/gynecologist, by

a girlfriend who had just delivered twins through natural childbirth. It
was at a time that natural deliveries were just beginning to come into
vogue in this country and few physicians were willing to do them yet. I
was not pregnant at the time but my husband and I wanted children and
I thought that when the time came, I, too, would love to try this new
approach to childbirth.
When I first met Dr. F. I remember being taken aback by him. He
was a strikingly handsome man with a manner that was so gentle and
sophisticated that any woman would have to be attracted to him. But as
I came to know him better, it was clearly more than his looks and his
manner that swept me off my feet; it was his patience with me and his
willingness to talk as much as I needed to about my concerns about
birth control, getting pregnant, and even starting a family. When he
fitted me with a diaphragm, for example, I had a hard time manipulating
it. Dr. F. was a very patient teacher and he would help me practice until
I felt more capable of doing it correctly and quickly.
One time when I went to see Dr. F. I was still having trouble with
the diaphragm and he asked me if something was going on with Joe that
was affecting my use of contraception. I just couldn't get the hang of it
and he figured, rightly, that maybe something was wrong in my mar-
riage. Well, I never would have even mentioned it to anyone else, but I
was really starting to resent the fact that I had to use contraception
because Joe was still not "ready" to start a family. We had been married
for 6 years and I wasn't getting any younger, but Joe kept putting me
off and there never seemed to be a "good" time to talk about having a
child. Dr. F.'s interest and patience were very supportive to me and I
felt grateful to him.
After about 6 months that subject became obsolete when, inadver-
tently, I ended up getting pregnant anyway. Joe actually surprised me
by being uncharacteristically loving, and before the baby was born, I
think he actually got excited about the prospect of fatherhood. Even
Joe's renewed sense of commitment to me, though, didn't seem to affect
my growing attachment to Dr. F.
My first pelvic examination after I got pregnant was something I will
never forget. Instead of doing the usual Pap smear and internal exam,
Dr. F. had me lie on his table and went about touching and examining
my entire body. His hands glided so easily that it was as though he were
giving me a massage, and for the first time in my life it felt as though I
were being touched by a man who really cared about me. And then, as
though it were planned that way, he hooked up the machine that let me
hear my baby's heartbeat for the first time, and he was there to share
one of the most wonderful moments of my life.
As delivery grew near, my apprehensions about motherhood started
to set in. What if I don't know how to care for a baby? And what if.
. . . Dr. F. was always there to answer my questions and quell all of
my fears. What a perfect human being, I thought, and, of course, Joe
paled by comparison. What I didn't realize was that Dr. F. was setting
me up for a ride, and that it would end with me flat on my face. Some-
how by telling my story, I hope that it won't happen to someone else.
Near the end of my pregnancy I was feeling awkward and unattrac-
tive, weighing more than I had ever weighed at any other time in my
life. Joe wouldn't even approach me sexually, supposedly because he
didn't want to hurt the baby. But I felt fat and clumsy and got suspicious
every time Joe even looked at another woman (who, of course, always
seemed graceful by comparison). I even started to wonder whether
something was going on between Joe and our housekeeper. Dr. F., on
the other hand, always commented on my appearance, saying things like
Sex and Power 29
"Pregnancy makes you glow." Joe just never knew what to say, so
mostly he would say nothing. During the last few months my doctor
visits became more frequent and I really started looking forward to
seeing Dr. F. He made me feel good about myself and was always reas-
suring about the pregnancy. Every time I thought something might be
wrong, or even when I just felt like talking to him, he was always there,
always patient, and he always knew what to say. I wondered whether I
could have made it without him.
When the time came for delivery, there was no one that I wanted
around more than Dr. F. I was excited but also scared that something
might happen to the baby. But I knew that I could trust Dr. F. to deal
with whatever came up. When "hard labor" began I really started to feel
out of control and I was so grateful that he was there to get me through
it. And when the baby was born, alive and healthy, I just wanted to hug
him and share with him what had to be the most incredible experience
of my life.
Two weeks after leaving the hospital I saw Dr. F. again. I was con-
vinced that he had to be the most wonderful human being in the world,
and I showed up for my appointment dressed and made up as though I
were going to the opera. I was still fat and unshapely, but when Dr. F.
approached me as though he was anticipating my arrival, it didn't seem
to matter. In fact, he greeted me with a kiss and it didn't seem the least
bit awkward. What happened after that seems, in retrospect, like part of
a well-staged plot. All he needed to say was that he reciprocated my
attraction to him and I was immediately ready to make plans for an
affair. In fact, not only did we have sex, but we did so repeatedly, and
I never allowed myself to realize that it was the only thing we seemed
to share now. I had convinced myself that he was so perfect and so
virtuous that whatever he wanted, I was privileged to be able to give
him.
My life changed significantly after the baby was born. I wasn't work-
ing anymore and it seemed tedious to be at home all day long with just
an infant to talk to. I also experienced some postpartum "adjustment"
that was really hard for a while. My "affair" with Dr. F. was the only
excitement in my life, especially since my relationship with Joe was
back to where it was before I got pregnant. But Dr. F. didn't want to
talk about that anymore; now he just seemed interested in having sex.
And surprisingly, Joe didn't ever catch on that something was going on.
He didn't notice me much when I needed him, and he didn't notice
when things had changed.
I suppose it shouldn't have surprised me that this relationship

wouldn't last forever. Dr. F. was such a sweet and attractive man that I
bet he could have had any of his patients. And if he wanted to have sex
with me, out of shape and insecure, I should have known that there had
to be others. Well, there were. Many others. One afternoon after about
4 months of twice-a-week "appointments" Dr. F. told me that he just
didn't have the time anymore, and that I didn't really need him anymore.
Can you imagine, I didn't need him!
I was really devastated after our relationship ended. It was as though
a part of me died, and I didn't know how to live without it. I couldn't
talk to Joe about how I felt and I was afraid to tell anyone else. I
found out later when someone else filed a complaint with the Board of
Registration that a number of women had come forward, claiming that
Dr. F. had taken advantage of them as patients. But what is really the
most frightening is that I know that no matter how angry I am at Dr. F.,
if he'd take me back, even knowing what I know now, I probably still
couldn't resist. We shared something so special and I felt things that I
never felt before or since. Without him my life feels bleak and empty.
The previous chapters explored how boundary violations in the context

of psychotherapy put the patient and the healing process at risk, as sex-
ual relations between therapist and patient are virtually always harmful
to the patient. This chapter addresses the question of whether sexual
intimacy in other professional relationships is also harmful to the "fidu-
ciary"the person who engages the professional to perform services for
her. Its purpose is to explore the unique aspects of several such relation-
ships and determine whether, in each circumstance, a transferencelike
phenomenon arises, creating a significant risk of professional exploita-
tion.
CLERGY AND PARISHIONERS

Chapter 2 discussed the occurrence of the "transference" phenome-
non, which occurs routinely in psychotherapy and perhaps other contexts
in which a dominant figure such as a psychotherapist attempts to gain
the trust and confidence of his patient. Transference is largely a function
of the imbalance of power between a person in need and a caring and
attentive professional, one who encourages her to reenact unfulfilled
childhood needs and wishes, including those of which she may not even
Sex and Power 31
be conscious. That chapter concluded that sexual intimacy under those

circumstances is inappropriate and exploitative because the patient is not
acting on a genuine love attraction to the therapist, but rather is involved
in a "process"one that is inherent in the therapeutic relationship.
When used appropriately it can be a powerful resource for the therapist
to use in the treatment; when used inappropriately (and thus exploited)
to satisfy the therapist's own needs it can be a powerful destructive
force.
Does a clergyman command the same type of status, trust, and respect
that are accorded a psychotherapist? Do transferencelike phenomena oc-
cur in a similar way? Certainly to the extent that a clergyman is engag-
ing in pastoral counseling, transference reactions can be expected to
develop as part of the process. But even when the clergyman is acting in
the capacity of a religious leader of parish activities other than personal
counseling, his position in the community is clearly very powerful. In a
very real sense clergy are the symbolic representation of God: the stan-
dard bearers of their faith. The religious community ordains only its
"best" to the position of leader, and the clergyman takes on significant
responsibilities when he accepts that role. He becomes the symbolic
figure of transcendence, and few followers would doubt that such a per-
son would be worthy of their trust.
The reality that clergymen are not gods but are human beings with
needs of their own, including sexual needs, perhaps comes as a surprise
to some parishioners. To them he is a representative of a higher author-
ity whose vested power he would never abuse. Most parishioners expect
that they can approach a clergyman with any problem, particularly (but
not necessarily) one that would arise in a traditional "pastoral counsel-
ing" setting, and receive understanding and advice that would only be
in their best interest. Indeed it is just this expectation that makes the
sexual boundary violations of clergy so insidious. People are so inclined
to believe their preaching and follow their dictates that much sexual
exploitation by the clergy is justified solely on the basis that if a clergy-
man said it was all right, it must be so.
Among the realities of religious following is that almost all of the
clergy are males, while a majority of parishioners are women. As
women continue their efforts to enter the clergy, this may change in the
future. As yet, however, a great imbalance of the sexes in the clergy
remains. Additionally those parishioners who seek counseling are pri-
marily women, and it is these women who are more likely to be attracted
to the power and authority that are attributed to clergy.
To a woman who is somewhat dependent, as are some (but certainly

not all) women who are active in religious affairs, the clergy is seen as
a source of strength, truth, and hope that there is a solution to whatever
difficult life situation might arise. Often the solution that is sought is
not just a practical answer but a spiritual solution that will serve as a
guide for conducting one's life. What these women seek in most cases
is a safe place to express feelings and concerns, and to work through
them. If, in the intensity of an intimate exchange, an individual finds
herself experiencing sexual feelings toward a clergyman, these feelings
are not unusual and need to be understood as such. This requires a clear
respect for the individual's boundaries. A woman should never have to
be concerned that those feelings might be exploited.
Even if the clergyman mistakenly (or not) thinks that he reciprocates
a parishioner's intimate feelings toward him, he also knows that a needy
person who reaches out for understanding and help is likely to be
strongly affected by the vast difference in their respective positions and
power. He is not just a colleague; he is the clergy, who are expected,
above all, to do no wrong. Certainly one could rely on such an individ-
ual not to take sexual advantage of a person who looks up to him be-
cause of his position.
How do clergymen rationalize their own behavior? As with most
other abusive men, their behavior is more a reflection of who they are
than their position. Their position gives them the opportunity, and it
may lead them to the temptation to use their power to act in a way that
satisfies their own needs. Exactly what those needs are is also difficult
to generalize. Many clergy come from very religious homes or back-
grounds in which the expression of sexuality is taught to be wrong,
dangerous, and even immoral. But because this does not fully suppress
their instinctual sexual desire, certain conflicts and ambivalent feelings
develop anyway, only to be expressed in an obsessive sexual fantasy
life. The highly visible position of the clergy in the community prevents
them not only from acting on their sexual desire, but often from even
acknowledging the conflict. Too often their human sexual desire sur-
faces anyway, and when they are tempted by opportunity, some do not
resist.
Often clergy are lonely people. They are in a unique position in the
community, but one that makes it difficult for them to develop relation-
ships which would allow them to express their sexual needs. When a
parishioner approaches such a man with a personal, marital, or sexual
problem, it may be, for him, a rare opportunity to indulge his sexual
Sex and Power 33
fantasies with a real person and to express and gratify some of his own
needs. But sexual exploitation under these circumstances is too obvious
and too forbidden for the average clergyman. It still needs to be rational-
ized in terms of the "helping" function that is part of the position: "She
needs to feel good about herself," or "Only I can help her feel alive
again," or even "She needs to realize her potential."
Once the clergyman is able to convince himself that his actions are
for the good of the parishioner, he may still need to believe that it is
acceptable for him to act: "If it feels good to both of us, it must be
right." If his reasoning is successful in convincing him that his inten-
tions are honorable and that his actions are useful, it creates the neces-
sary self-justification. Furthermore, often this rationalized logic appears
real: in fact, the parishioner seems happy, valued, or loved in just what
she wished for and perhaps had never before experienced. He may be-
lieve what appears to be a renewed sense of joy and liveliness resulting
from the "lightness" of his efforts, and the result, therefore, justifies the
means.
So why is it so wrong? It is wrong because it is based on an illusion
of benefit that can rarely be sustained. As with any relationship com-
posed of transference reactions, the more powerful person is idealized
and even worshiped. When that person is a clergyman, the potential for
idealization is even greater. The parishioner does not view him as an
equal, and so cannot relate on that basis. The relationship is based upon
an imbalance of power. It does not allow for the development of a union
that is mutual, and therefore it cannot be healthy. Instead, what evolves
are clear roles of dominance and subservience, determined only by the
more powerful partner.
Even if some sort of true partnership could be established, there is
still the problem that the subservient partner wants the relationship to
continue, but the clergyman is usually not prepared to leave either his
position or his wife, if he has one. For him to carry on this type of
relationship with a parishioner, particularly one he is counseling, would
require more than that he be able to rationalize it to himself; he must
eventually come to terms with the fact that the religious community
would view it as exploitative. When the newness and excitement of the
relationship pass and the reality of its costs to him remains, the over-
whelming likelihood is that he will terminate the relationship, often
leaving an unsuspecting parishioner emotionally devastated. If it was a
counseling relationship, the harm that results is similar to that caused by
an abusive psychotherapist. And it has the potential for even greater
impact because the parishioner has placed her faith and trust in this
symbol, as though he were a god himself, only to be betrayed. And so
she thinks, "If you can't trust your clergyman, who can you trust?"
ATTORNEYS AND CLIENTS

One of the central themes of this book is that exploitation occurs
primarily in the presence of "transferencelike" reactions, in which a rela-
tionship built on an inherent imbalance of power is coupled with pro-
found trust or faith in the more powerful party. Is the attorney-client
relationship one that is likely to generate a transferencelike reaction in
the client? The answers become less defined and more difficult when we
move away from the clear obligations of those engaged in the helping
professions. Clients, of course, can be just as dependent upon their attor-
ney for his services as the patient or parishioner is upon the therapist
or clergyman. One important difference, however, seems to be that the
dependency is often related to specific assistance with a practical matter
and is not necessarily the type of emotional reaction that leads the client
to endow the professional with broad ranging and undue power and
control over her. To the extent that the attorney-client relationship ap-
pears, in fact, to be one of "equals" in a relationship in which both
parties command a substantially equal amount of respect for who they
are, the opportunity for undue influence based upon transferencelike
phenomena is less likely. This, however, is not always the case and
transference reactions have been observed in attorney-client relation-
ships.
Transference phenomena in the attorney-client relationship are most
likely to occur when the client is involved in an emotionally charged
situation such as a divorce proceeding. In these cases a client can be as
emotionally distraught as any patient seeking psychotherapy. In fact,
many lawyers find themselves needing to assist divorce clients through
the legal proceeding in a way that would be better accomplished by a
mental health professional. In those cases, emotional turmoil is prevalent
and anxiety and fear abound. A kind and empathic attorney who re-
sponds in a caring and attentive manner certainly creates the opportunity
for the development of transferencelike reactions. A client can become
emotionally dependent upon him, both to resolve legal matters and to
help in coping with the stress and anxiety of the circumstances. In these
cases a client may be as vulnerable to sexual exploitation as any patient
Sex and Power 35
in psychotherapy and all of the constraints that apply to a therapist

should be equally applicable to her lawyer.
The question of whether a client is psychologically dependent or vul-
nerable can depend upon both the individual client and the circum-
stances. In some cases the client's emotional state is transient (i.e., the
result of a particularly stressful situation); in other cases her condition
is a feature of an enduring psychological problem and not a function of
a passing circumstance. People with strong and long-standing feelings
of low self-esteem or self-worth are particularly vulnerable to manipula-
tion by someone who treats them in a positive, accepting way and makes
them feel worthy, wanted, and attractive. Attorneys are not trained to
determine whether or not a client's situation is transient or enduring.
Even in those cases in which a client's vulnerability is temporary and
a result of circumstances, she may still be vulnerable and susceptible to
manipulation if she is feeling unloved, undesirable, and rejected. Her
vulnerability is further exacerbated when she reveals it to her attorney,
as she inevitably must since usually it affects her case. For example, if
a client tells her lawyer that she so fears going to court and telling her
story in public that she is willing to give up her fair share of marital
property to prevent it, the lawyer now knows of that weakness, and that
knowledge makes her vulnerable to him.
An attorney who would attempt to coerce a client into complying with
his sexual demands or otherwise seduce her into a sexual relationship
usually does so in a number of characteristic ways. In the most obvi-
ously exploitative situation, the client is told that the attorney will ex-
change sexual favors for services or will not represent her unless sexual
favors are part of the deal. If she is desperate enough, she may believe
that she has no choice but to comply; if she is intimidated, she may
rationalize that sex as part of the deal is not such a big price to pay.
In other cases the client might receive a sexual advance after the
representation has begun, making her may feel fearful or threatened
about objecting. She may believe that because her case has begun (per-
haps some fees have been paid) she cannot go elsewhere. Perhaps she
is afraid that if she does not comply, her case will not receive enough
attention or be handled competently. Sometimes she may be right.
In still other cases, the sexual contact is initiated by either party as a
consequence of the transferencelike reaction that has emerged in the
course of the relationship. In such a case, for example, a needy depen-
dent client is approached by a more powerful, trusted, and respected
professional who treats her in a kind, caring, and attentive manner. She
feels valued and attractive and is attracted to the man who makes her
feel good about herself. The relationship progresses like any other court-
ship, and she may be as interested as he is in having it move to a sexual
level. Because of the nature of the attorney-client relationship, it may
be less obvious to her that an exploitative situation is occurring. She, as
an adult female, has of her own volition engaged the attorney's services.
She has negotiated a "contract," fully competent to enter into such an
agreement. This is not much different from hiring someone to fix her
car or paint her house. Or is it?
While the client is certainly legally competent to enter a contract, she
is in a highly emotional state. She does not know anything about the
law and looks to the attorney to solve her problem through his wise
counsel and competent representation. The services he offers are not
psychological treatment, but many of the components are similar, and
the likelihood that a transference reaction will develop is great. An ill-
informed or unethical and opportunistic attorney can easily take advan-
tage of a client in this emotionally vulnerable condition. This can result
in great harm to the client.
The negative consequences to those who are exploited by an attorney
engaged to represent them have been documented. First, since an ex-
ploitative relationship is generally not one in which the more powerful
person has any commitment, the lawyer is likely soon to lose interest in
the relationship, probably as soon as the case is over. Any continued
interaction would have to be on mutually acceptable terms, which was
not the case in the prior relationship. Most abusive men are unwilling
to give very much and are unwilling to maintain mutual relationships.
Abusive men are not looking for democracy. They are looking for domi-
nance and control. When the professional situation ends and greater mu-
tuality is expected, typically the abusive professional is no longer inter-
ested. He would rather move on to exploit the next unsuspecting victim
than continue with one whom he is no longer in a position to dominate.
Through powerful transference reactions victims become emotionally
attached to this powerful person and letting go causes them great pain.
The emotional consequences can be severe. It is not uncommon for vic-
tims to become depressed, even suicidal, with symptoms similar to those
experienced by victims of sexual abuse by psychotherapists. As their
self-esteem and self-worth plummet, they come to view themselves as
permanently victimized.
Another consequence of attorney-client abuse is that the victim may
Sex and Power 37
have difficulty in the future trusting other professionals when similar

services are again needed. When a client has been taken advantage of
by her lawyer, for example, she is more likely to feel fearful and dis-
trustful toward the next person acting in a fiduciary capacity. It may
even prevent her from seeking help that she really needs. The result of
this type of abuse often is that the victim feels embarrassed, shamed, or
humiliated, and she may even blame herself for the abuse. As a result,
she becomes unwilling to seek the help she needs. Indeed, she expects
the worst, both of herself and of the new professional.
The final concern, and one that is of major significance, is that the
quality of the legal representation may suffer significantly when an attor-
ney is having a sexual relationship with his client. The motives and
behavior of such an attorney are affected by more than his professional
judgment, and this "dual capacity" does not necessarily cause him to act
in his client's best interest. For example, suppose the lawyer believes
that a lasting commitment is evolving between him and his client. Does
he really want her to have custody of her children? Furthermore, what
happens if this adulterous sexual relationship is revealed during the trial?
It may have a significant effect on what the client is awarded, in terms
of both child custody and property. Finally, if the lawyer believes that
his best advice will disappoint his client/lover, perhaps causing her to
end the relationship, he may withhold or alter it, leaving her without the
quality of representation that she needs.
PROFESSORS AND STUDENTS

Sexual intimacy between teachers or professors and students has re-
ceived far less attention than similar relationships involving other pro-
fessionals. Although it occurs with alarming frequency, discussion about
it is noticeably absent even in the professional literature. It is, however,
a phenomenon that is receiving growing awareness and concern. Perhaps
Woody Allen's film Husbands and Wives will allow the subject to be
acknowledged as the serious problem that it is.
There are three major categories of teacher-student intimacy, two of
which are beyond the scope of this book. The first, which is discussed
briefly in Chapter 6, is what amounts to sexual harassment. In these
cases a student is approached by a teacher or professor who offers a
better grade, a recommendation, or some other clear benefit to the stu-
dent in exchange for sexual favors. Such offers, which can be communi-
cated either directly or indirectly, are clearly illegal and unethical, and
a number of cases have been brought through the courts or reported to

appropriate state and federal agencies.
The second type of situation involves child molestation, such as when
a teacher sexually abuses a minor student. Again, the abuse can be overt
(a sexual touching or "battery") or be more subtle (sexual references,
gestures, or less offensive touching). A number of cases have been
brought against teachers accused of sexual offenses, and disciplinary
action, including dismissal, has resulted in some cases. These, too, are
beyond the scope of this book.
The third category of cases are those that begin (and often end) as
cases of consensual sex between two adults, one of whom happens to
be a student and another who happens to be her teacher or professor.
The relevant question is whether such sexual relationships are somehow
inherently harmful to the student, giving the teacher an ethical, if not a
legal, obligation not to let it happen. In other words, the question is
whether the teacher somehow exploits his position by allowing sexual
intimacy to develop with someone whom he is engaged to serve as
teacher.
Even within this third category of cases, there are different and dis-
tinct clusters or scenarios that result in sexual intimacy. In some cases,
for example, a professor makes sexual advances to several students,
preying on a new "crop" each year and simply carrying on a relationship
with any or all who are interested. There may or may not be more than
one sexual relationship at any given time, and typically the professor has
no sense of commitment. Some of the students, of course, may believe
otherwise, but rarely will the professor take responsibility for any emo-
tional entanglement. When the student graduates or leaves the institu-
tion, the professor moves on to someone else.
Another common pattern occurs when a professor, usually in midlife
or later life, is attracted by a particular student's enthusiasm or energy
and her admiration of his position and accomplishments. This middle-
aged professor may have had no prior intention of becoming sexually
involved with a student but finds himself unwittingly attracted to a stu-
dent who offers a spark of life that he has not experienced for a long
time. Perhaps she generates an interest in him that he finds difficult to
resist. These relationships also are likely to run a short course, either
because he ultimately finds that he has too much to lose to continue in
such a relationship (a wife, a career, respect in the community, etc.) or
because he loses interest in the student when he realizes that her level
of maturity cannot sustain his interest.
Sex and Power 39
Yet a third typical pattern involves professors and students who are
drawn to each other specifically by their mutual attraction to the imbal-
ance of power, per se. It is the power differential itself that spawns the
attraction. Often, but not always, it involves older men and younger
women, with the younger woman being attracted to his more powerful
position, greater wisdom, and higher authority, or perhaps just his pro-
fessional status. He, on the other hand, enjoys the relationship just be-
cause the woman occupies a subordinate, dependent role and is not seek-
ing to be an "equal." Both are content with the imbalance of power, and
the relationship lasts as long as the power differential is preserved (e.g.,
for as long as the student will continue to look up to him). These rela-
tionships sometimes sustain a long-term commitment if both partners
remain comfortable with the power and status difference. This situation
is more likely than any other to result in a lasting relationship.
The final category involves individuals attracted to one another who
could meet anywhere under any circumstances but happen to meet on
campus. This interpersonal attraction may be a function of their being
in a setting where new and exciting things are happening around them;
it may be a function of who they are and how they relate to each other;
or it may be a function of the totality of the situation that a transfer-
encelike or countertransferencelike reaction results in one or both of
them. In these cases there are a certain intimacy and excitement about
what they are engaged in (the education and/or the university commu-
nity) as well as a certain vulnerability of the student, who is less sophis-
ticated and likely to be admiring of the older, wiser, and more powerful
professor.
In those cases in which the student is being "exploited," that is, being
used for the sexual gratification of the teacher, it is clearly an inappro-
priate relationship. It denigrates the educational process, which is sup-
posed to teach (and therefore model) ethical and enviable behavior. The
unsuspecting student is harmed when she puts her faith and trust in a
professional who she has every right to believe would act in her best
interest. Instead she learns that he has used his position to gratify his
own desires and he leaves in his wake disappointment and emotional
pain. Some student-victims report that the relationship felt incestuous
because teachers are supposed to act in the place of parents (in loco
parentis) while they are in school and, like parents, are not supposed to
have sexual relations with the children in their care. Even though the
student may no longer be a minor, a relationship with an older paternal
figure whom she has good reason to trust can leave the same type of
scars that result from an incestuous relationship with a parent or trusted

family member.
Those cases in which there appears to be "consent" between student
and teacher present the most complex situations. They are complicated
because they are unpredictable, and the outcome can be disastrous for a
student in one case, yet in another case it can seemingly lead to a long-
term, and apparently meaningful, relationship. Those whose task it is to
create fair but explicit policies are confronted with a variety of difficult
issues that include both the individuals' freedom to choose whom they
associate with and the institution's need to protect vulnerable students.
Policymakers cannot escape this dilemma but instead must face the is-
sues responsibly in light of the serious consequences that can result.
A singularly important initial question is whether the teaching profes-
sion can be "sexualized" and yet retain its integrity and its purpose.
Teaching, of course, particularly at the university level, is largely geared
toward communicating sophisticated information to students who are
willing to work at learning it. Additionally, however, teachers are inevi-
tably role models for still-impressionable students who look up to them
as both mentors and idols who have achieved a high level of accom-
plishment. To the student, teachers are idealized adults much as parents
are idealized by children. Just as a child has certain expectations of her
parents, students have expectations of teachers, and one of them is that
they put the interests of the student first. But that is not always the case.
When a teacher satisfies his own sexual needs through a student, he not
only risks harming that student but risks jeopardizing educational pro-
cesses by communicating to students that they cannot rely on those who
are hired to educate them to provide appropriate care.
Another potential problem that teacher-student sexual intimacy creates
is that students who ultimately enter those service professions that spe-
cifically prohibit sexual contact with fiduciaries (such as physicians,
therapists, lawyers, clergy) may develop a distorted sense of the sexual
boundary in their own professional lives. While, on the one hand, they
may be taught that violating sexual boundaries is wrong, on the other
they have been shown that, in reality, those who teach about boundaries
nevertheless do it anyway. The professional literature suggests that pro-
fessionals who, as students, participated in sexual intimacies with their
instructors are at significantly higher risk for violating sexual boundaries
in their own practice. What they seem to learn is that there is the ideal
(that which is preached to them) and there is the reality (that which is
practiced). To the extent that the teacher is, in fact, a role model, it is
Sex and Power 41
easy to understand why these students would be more willing to engage

in, and then rationalize, their own sexual exploitations.
Students training to be professionals need to be taught within their
educational and training programs what sexual exploitation is, how and
why it happens, what the consequences are, and what they can do if
they find themselves tempted by an exploitative situation. Combatting
this problem requires that students be able to address this issue candidly
and safely with the teachers who are training them. If sexual intimacy
is occurring within the very program in which students learn about it, it
is unlikely that the subject can be addressed in an open and effective
manner. On the other hand, if sexual boundaries are modeled to be clear
and unbreachable, then students can discuss it freely and without fear.
They can also be helped to understand the phenomenon of sexual at-
traction and how to manage it effectively.
Finally, there is the problem that although the teacher-student inti-
macy may be "consensual," the nature of the "consent" is always sus-
pect. For example, if a student "consents" to have sex because she per-
ceives that granting sexual favors to a professor will produce some
benefit, is that true consent? If a student grants sexual favors to a teacher
because she is attracted to him, but part of the attraction is his ability to
use his power and status on her behalf, is this true consent? Most stu-
dents probably never even ask themselves what, exactly, they are at-
tracted to. And so the line blurs between truly consensual relationships,
relationships based upon mutual "use" of each other, and relationships
that are blatantly based on the providing of sexual favors.
As more educators recognize the magnitude of the problem and the
severity of the potential harm to students who become victims of sexual
exploitation, a number of colleges and universities are developing spe-
cific regulations for faculty which prohibit sexual contact with students.
These generally pertain to all faculty members who teach or supervise
students in any capacity within the institution. The prohibition is often
limited to sexual contact with students who are currently enrolled in a
class or program being taught, directed, or supervised by such a faculty
member.
PHYSICIANS AND PATIENTS

Although physicians are bound by the Hippocratic Oath to refrain
from sexual contact with their patients, the question of whether there is
sound justification for prohibiting consensual sexual relations between
physician and patient is not an easy one. Once again, two important
questions need to be answered. First, can the purpose of the original
professional relationship still be accomplished if a sexual relationship
arises? Second, are there inherent transferencelike effects that preclude
a mutual and nonexploitative relationship?
As discussed earlier, it is often difficult to obtain the competent, ob-
jective, and unbiased professional advice of someone with whom an
intimate relationship is shared. There is too great a likelihood that per-
sonal issues will affect professional judgment. At the very least, if a
patient decides to become involved sexually with her physician, she
should be willing to have medical services rendered elsewhere. The
more problematic question is whether transferencelike effects inevitably
permeate the doctor/patient relationship, so that the very situation is in-
herently based upon power and illusion.
Transference reactions develop when there is an imbalance of power
that leads one to be attracted to, or perhaps intimidated by, a person of
greater status or position. A physician is frequently the type of profes-
sional who is idealized: one who without question can be entrusted with
patients' care and well-being. He is someone who is expected to look
out for the patient's interests. Indeed, he has taken an oath to do no
harm. There is every reason to view the physician as a provider of care
rather than an individual who has needs and desires of his own. Some-
times transference makes it difficult to alter this image, and it persists
despite evidence to the contrary. When it's the image that cannot be
altered, the risk of exploitation is present.
Let's assume that a physician (or other health professional) and a
patient meet in a professional context, are attracted to one another, and
agree that because of the attraction, the patient will consult a different
professional for professional services. Let's assume that it is a consen-
sual relationship between a non-mental health provider and a patient. It
does not violate the clear mandate that proscribes psychotherapists and
related professionals (e.g., clergy) from abusing the special nature of
those relationships. It also is not a relationship that involves an impres-
sionable youth, still in school and still needing the protection of institu-
tional policy. Can it still be exploitative?
The cases that have been brought before disciplinary bodies and legal
authorities fall into three general categories. At least the first two en-
compass conduct which is clearly illegal and unethical. The first in-
cludes sexual contact under the pretext of examination or treatment.
There have been a number of cases involving gynecologists or chiro-
Sex and Power 43
praetors who have engaged in sexual acts under the guise of examining
or treating a patient. These will be discussed in greater detail in Chapter
7. The second includes sexual contact which is initiated while the patient
is drugged, anesthetized, or, worse, incompetent. Also included in this
category are physicians who demand sex in exchange for prescribing
excessive quantities of controlled substances. These, too, will be dis-
cussed in some detail in Chapter 7 and are beyond the scope of this
discussion.
The third category, which is relevant here, includes sexual contact
(often kissing and fondling) that occurs without consent during the
course of medical treatment. The cases that have been pursued in court
or before disciplinary boards are those that have been egregious, and
disciplinary action would be expected if the charges were proved.
But what about those cases of consensual sexual relations? Is there
anything wrong when a patient and physician who find each other attrac-
tive carry on a mutual relationship? In some cases patients have later
claimed that, in retrospect, they only participated because of intimida-
tion, coercion, or some other transferencelike phenomenon. Some claim
that in the absence of such influence, they would not have consented.
Does such a grievance or blaming of the physician amount to self-serv-
ing hindsight because the relationship went sour? Or was the patient
genuinely manipulated, used, and then discarded: in short, exploited?
On that question, the jury is still out.
Certainly it is not difficult to understand that an impressionable or
vulnerable woman, when approached by a compassionate and attentive
physician who made a sexual advance toward her, would respond in an
accepting manner. It is also not difficult to understand that she might be
influenced by his attending to her physical well-being. In fact, in some
cases, she might even be afraid to say "no" because she believed that
he might modify or withhold treatment if she did. At this point, how-
ever, our understanding of the process of exploitation is not well enough
defined for the law and disciplinary bodies to impose punishment, the
Hippocratic Oath notwithstanding. There still needs to be more than an
intangible factor of intimidation present; the physician usually has to
offer or threaten to withhold his professional services directly, or, at a
minimum, create a reasonable impression that he will, before his sexual
advances are likely to subject him to discipline.
Chapter 4
Early Warning Signs: The Prelude

to Exploitation
CASE STUDY: CAITLIN
I was a sophomore at a small college in Minnesota. All of my life I

wanted to be an engineer. My parents tried to convince me to be a nurse
or a schoolteacher, but I was determined not to get stuck in women's
jobs. I grew up as the only girl in the shadow of two successful brothers,
and I wanted to accomplish something myself. I was tired of not being
taken seriously because, after all, I was just a girl.
I made it through my freshman year without too much trouble, even
though I felt very isolated because there were only two other women in
my program. The next year, though, was different: I had to take the
physics courses. I hated physics. There was just something about it; I
never seemed to be able to make sense of that subject. Right from the
beginning I dreaded the course, but I knew I had to get through it.
Jack T. was a part-time professor who just came in to teach beginning
physics. You could tell from the start that he was different from a lot of
other professors. He really was an engineer, and he worked in the field
at a high-level job. He didn't just sit around the school and teach theory;
he was out there doing important things and making a name for himself.
Even though I hated physics, I had a sense that I could relate to Jack
(which, by the way, he wanted us to call him). He was down-to-earth,

and he knew his stuff. You could see that he lived in the real world,
and he always made a point of showing us how a theory would be
applied in a real situation. It's hard to explain, but after a few weeks I
wasn't so scared about physics anymore. The subject matter still daunted
me, but I felt okay in the courselike somehow I would make it
through.
Three weeks after the course started, Jack posted his office hours.
Since most of the time he was not around, it wasn't as though you could
casually drop in. You had to make an appointment and when he said he
was available, I was first to sign up. I actually wasn't having a particular
problem at the time, but I was still so afraid of physics that I thought
I'd better get some help anyway.
Our meeting was scheduled right before class, and when I got there
Jack was so nice that I couldn't believe it. We talked about engineering;
we talked about me; we talked about the college; we even talked about
my parents. Everything seemed so easy. We never even mentioned the
course; we spent all of the time just getting to know each other. When
the hour was over we ended up walking back to class together, and just
before I sat down he invited me to come back next week to talk about
whatever I had come for, since we never even got around to that. I
agreed impulsively and the next week couldn't come fast enough.
There were so many things that passed through my mind over the
next few days that I don't think that I even fully appreciated what was
going on. It was hard being in a program with so few other women. It
was hard being away from home. Even though I was never very popular
in high school, I always had a small group of close friends, and when
something came up, there was always someone to talk to. Boy, did I
wish they were around now to talk about Jack.
When I returned for my next meeting the following week, Jack was
again as nice as could be. He really seemed to care about me. It's funny,
but in class he was always so focused on the material that you'd never
know how nice he really was. Alone he was very different, and I felt
that I could talk to him about anything. This time we did get around to
the purpose of my visit. I told him that although I wasn't completely
lost yet, I knew it would only be a matter of time since physics was so
hard for me. He seemed to immediately understand, and offered to set
aside a regular hour for mea "tutoring" session, of sorts. That was
just fine with me, and the thought of saying "no" never even crossed
my mind. I felt like I had been saved.
Early Warning Signs 47
In what became our first regular session, Jack made it obvious that he
was attracted to me, and not just as a student. Surprisingly, that never
crossed my mind. Actually, what happened was that he asked me out to
dinner, and when I didn't respond immediately, he just asked where he
should pick me up. It felt a little weird, but when I tried to find a reason
that I shouldn't go, I couldn't think of any. It's true that he was probably
a lot older than meprobably in his forties or so. I didn't know if he
was married. And, of course, he was my teacherbut I never thought
twice about that since he was so nice, and that felt good.
We "dated" for only a short time when things began to move fast.
One night we had been out late. We both probably had a little too much
to drink. When we got back to my apartment he followed me up, which
was fine because I really didn't want him to leave. We went inside and
I still didn't quite know what to do, so I offered him another drink.
About half an hour later when he started undressing me, I sat paralyzed,
thinking that if I asked him to stop, he might never come back. I was
thinking that this was too weird; I also wondered what my father might
say if he knew. I'm sure that all the alcohol we consumed had something
to do with it, but probably things would not have been all that different
if we were sober.
Needless to say, physics was not a problem that semester. When it
came time to do our projects, Jack not only helped me pick a topic, but
he virtually designed and constructed the whole thing. It went great, and
I was relieved to have gotten through it, but I also felt a little guilty that
I barely participtated. He insisted that I had helped with it, but we both
knew that I could never have done it myself. And so how should I have
felt when I got the second highest grade in the class? Remember, this
was the course that I hated. And this was the course that stood between
me and my dreambeing an engineer.
The final exam was no different. By then Jack and I were having sex
regularly, and I was really enjoying it. Jack had been preparing me for
the exam, virtually telling me exactly what would be on it. But one
night in the middle of exams I got a call from my father. He asked me
how I was doing and I let slip out a few words about Jacknot that I
was sleeping with him or anything, but just that we had become friends.
My father was immediately horrified, and made me promise him that I
would tell him if Jack tried to "pull" anything. I denied that anything
was going on, but afterward I started feeling weird again about Jack.
Was it just that he was older than me? Or was it because he was my
teacher?
That night I was a little cool toward Jack, and told him that I didn't
feel like seeing him right then. He was a little stunned and made it clear
that he needed to see me if I were to do well on the exam. I wasn't
used to having a man threatening me, but it certainly felt like he was
pressuring me, and it scared me, so I said "okay." Maybe it was just
because my father's words were still ringing in my ears, but from that
moment on my relationship with Jack was never the same. I let him
come that night, even though I knew that I didn't want him there. We
had sex but I couldn't respond, and I think he knew it. Less than a week
later school was over and I flew home. Jack and I haven't had any
contact with each other since then.
All too often victims of sexual exploitation report that they noticed early
on in the professional relationship that something about the relationship
did not seem right. Either the professional seemed distracted from the
purpose of the relationship or he seemed to take an unusual interest in
them without any real basis for doing so. Many victims ignore these
early indications, either attributing their suspicions to their own hyper-
sensitivity or perhaps even being flattered by the extra attention. But in
many cases it is just these early indications, when recognized, that can
prevent an abusive situation from developing.
The first important step in recognizing activity that may lead to sexual
abuse is being aware of those intuitive feelings that indicate an im-
pending boundary violation. These are the early warning signs or "red
flags" that signal that a bad situation may be brewing. In fact, intuition
or instinct is one of the most effective tools for sensing what is going
on in the early stages of sexual exploitation. For people who are in
turmoil, confused, or frightened, or those who are inexperienced, trust-
ing one's own instincts is a difficult task. In some cases it is this very
inability to rely on oneself that has brought about the need for profes-
sional assistance. Maybe there's a crisis: the individual is emotionally
distraught, lacks knowledge, or perhaps is just not confident about her
own capacity to understand what is going on. Perhaps the possibility of
being exploited by a professional is just so foreign a notion that it never
even enters her mind. Indeed, it is those very people who are least able
to call upon or trust their own instincts who become vulnerable to the
judgments, opinions, influence, and coercion of people who try or pre-
tend to help. Finally, sometimes it is a student who is frightened, inexpe-
rienced, immature, or perhaps overly ambitious who comes under the
influence of an exploitative teacher. On the surface, he appears to be

concerned, caring, knowledgeable, and a reputable authority who can be
trusted. In short, sexual exploitation can occur under the most unassum-
ing circumstances and anyone can become a victim.
In the great majority of situations professional relationships feel "pro-
fessional": the client, patient, or student feels respected and understood
and, above all, feels the professional is committed to serving her. In an
abusive situation, however, the professional relationship often feels
wrong: it creates uneasy, anxious, fearful, or confused feelings. Fre-
quently this is due to the presence of one or more of the "warning signs"
that will be detailed in this chapter. At the very outset of a professional
relationship it is important to pay attention to intuition, instinct, or the
"feel" of the situation, and not to be reluctant to act, quickly if neces-
sary, if any of these warning signs appears.
People often find that one of the most telling signs of trouble is a
feeling of ambivalence toward the professional. Ambivalent (or con-
flicting) feelings about the same situation lead people to be confused
and uncertain about how to act. Sometimes, for example, the client,
patient, or student may at the same time feel both attractive and special
to the professional, but also inferior, insecure, and perhaps even fright-
ened of him and what he might do. A particular omen is feelings of
uncertainty about possible sexual attraction and attractiveness. More-
over, if a client, patient, or student has sexual boundaries that are inse-
cure, she may be especially at risk for a sexual boundary violation.
What should her response be? First, she must not be willing to go
along and act out those feelings, at least until she has had an opportunity
to evaluate them. The best approach is to talk about them, preferably
with the professional, or, if appropriate, his supervisor. Often it is un-
comfortable to do so and creates an awkward situation, particularly
when she's not even sure that anything is, in fact, wrong. Maybe it was
a hunch; perhaps the potential victim is being oversensitive. It is particu-
larly difficult to discuss intangible and unproven feelings or impressions
with a stranger. People are often concerned about looking foolish or
hurting other people's feelings. If that is the case, she may want to
discuss it first with an allya friend, a relative, a mentor, or even a
counseloranyone who is available, whom she can trust. Of course,
such a person must be sensitive to the reality that professionals can do
destructive things such as breach their ethical and fiduciary obligations.
Ultimately, however, if the situation does not change and a would-be
victim's concerns persist, her only options are (1) to confront the issue,
(2) to leave the professional relationship, or (3) to risk becoming a vic-

tim of exploitation.
Many people find that getting an independent consultation or a second
opinion is a useful way to determine whether there is, in fact, a problem.
Lingering doubts, if not resolved, can lead to significant impasses that
inhibit one's ability to act and impede progress because there is such
uncertainty about the person who has been retained to provide services.
If those concerns are ultimately resolved, the patient, client, or student
probably comes away with a renewed sense of purpose and renewed
confidence in the professional relationship. If, on the other hand, after
discussing the situation, there is still doubt about whether a potentially
exploitative situation is brewing, this is a "red flag" and the potential
victim must be alert.
There has been substantial research in the area of sexual boundary
violations. These have yielded a number of specific early warning signs
that a problem might exist, and the individual should beware. These
warning signs are grouped into two categories: (1) those which are often
specifically associated with sexual activity and appear to lead directly
to subsequent sexual boundary violations, and (2) those which are not
specifically sexual in nature but have been observed to be harbingers of
or actual precursors to subsequent sexual boundary violations.
BOUNDARY VIOLATIONS
Specifically Sexual Warning S i g n s A s s o c i a t e d

with S u b s e q u e n t Boundary Violations:
1. The professional seems to take an unusual interest in discussing
sexual matters. He often moves the conversation in that direction:
Joan had gone to see her son's pediatrician because she was con-
cerned that his bed-wetting was not stopping. Dr. K. was a very
busy man and she was pleased that he was listening to her and not
trying to rush her along. Dr. K. inquired about things in a con-
cerned manner and patiently listened to her answers. He then began
to ask her about her own relationship with her husband and more
specifically about their sex life. She felt very uncomfortable and
thought something was not right, but she continued to answer be-
cause she was concerned about her son.
2. The professional seems to take pleasure in hearing about the de-

tails of his clients' sex lives and may give specific suggestions for sexual
activity even though his advice on that subject was never sought:
Father Bob had a reputation for "helping," and when Judy's mar-
riage seemed to be heading for the rocks, she naturally turned to
him. She and Jim had a strong physical attraction for each other,
but they didn't seem to agree on anything else. Father Bob wanted
to know all about that attraction, including what went on in bed.
In fact, he didn't want to hear about anything else. Even though
Judy told him that she and Jim had no problem in that area, he
still kept inquiring and even wanted to demonstrate for Judy other
sexual activities that she might do for Jim. Judy became very un-
comfortable because that was not what needed to be worked out
between her and Jim, but Father Bob was such a kind and saintly
man that she trusted that he knew what was best for them.
3. The professional tries to interfere in sexual matters, even going so

far as to suggest when and with whom to have sex:
Mr. B. was Debbie's guidance counselor in high school. She went

to him when the situation at home got really bad with her dad
drinking a lot and fighting all the time with her mom. Debbie
couldn't concentrate on any school work and was starting to have
some serious academic problems. She wanted to talk to him about
her parents, but he wanted to talk about her social life and what
she did with the guys. He did not like some of the boys she dated
and he frightened her by saying bad things about them and telling
her that they would give her a deadly disease. Debbie really needed
someone to talk to about what was going on at home but she just
couldn't get Mr. B. to pay attention to her real problems.
4. The professional encourages seductive dress or behavior:
Sally couldn't understand why she was having trouble meeting

men and holding onto a relationship. She thought she was attrac-
tive and always tried to be upbeat. Her social worker told her that
she wasn't able to see herself from a man's point of view. He said
that she acted too "sweet" and that her dress looked matronly. He
offered to take her shopping to get some things that men liked. He
also suggested that he could teach her to be sexy. Sally didn't think
that she could handle this kind of help, but she didn't have anyone
else to turn to and really felt that she could benefit from a man's
advice.
5. The professional acts seductive and makes sexual jokes or refer-

ences that are clearly inappropriate to the situation:
Karen's doctor sent her for a chest x-ray because her cough was
not clearing up. The radiologist kept her sitting in the hospital
gown long after the x-ray was completed. While we waited for the
films to be developed, he started telling her about the different
types of breasts of patients he had seen and making sexist jokes
about breasts. Karen was sitting there undressed but she was afraid
to get up because the films hadn't dried yet and she wasn't sup-
posed to return to her regular doctor without them.
6. The professional recommends that having a sexual relationship

with him is an appropriate and professionally accepted way of coping
with a particular problem:
Jill was depressed for most of her life and never knew why. She
used to make up explanations based on whatever was going on in
her life, but she knew deep down that it wasn't those things that
were bothering her. One day after watching a television talk show
about rape, Jill had a memory flash about being sexually molested
as a young child. When she told her therapist about it, he said that
he understood it immediately, that other things that were going on
now made sense, and that the treatment she needed was apparent.
He said Jill was "emotionally stuck" in her childhood experience
and needed a "therapeutic" sexual relationship in order to over-
come her depression and move on in her life. As a caring and
experienced therapist he volunteered to provide the treatment that
he thought she needed.
7. The professional suggests some sort of social relationship with

him, outside the professional environment (school, office, etc.), pre-
senting an invitation for dinner, drinks, or another type of inappropriate
and nonprofessional appointment ("date"):
Anyone who has been involved in a child custody battle with a

bitter and angry ex-spouse who is looking for revenge knows the
magnitude of the upset and stress that accompany that type of cir-
cumstance. After dealing with years of an unhappy marriage and
the conflict of the divorce process, Sarah did not have much left
for this custody fight. Her attorney, seeing how stressed and over-
burdened she was, embraced her one day and said that he would
not only win her case but would also provide her with the comfort
she needed during this trying time. He suggested that she return
that evening and join him for "drinks and comfort." Sarah was so
much in need of what the attorney offered that it almost seemed to
be a miracle that he took such special interest in her. Not only did
Sarah need a good lawyer to represent her in her case (and he was
supposed to be the best), but she felt that he could help pull her
back together emotionally so that she would have something posi-
tive to offer her children if, as he promised, his representation won
their custody.
8. The professional appears to be sexually aroused during profes-

sional office visits:
Going to confession was never one of Cara's favorite things to do,
but she did it because her parents insisted and because she was
afraid not to. When she was 14 years old her parish got a new
priest. During her first confession with him, Cara confessed to kiss-
ing and petting with a boy from the neighborhood and also to not
wanting to come to confession. Father P. was very understanding
and said that it might be easier and more "modern" to continue
their discussion in his study. He then escorted her to his study
room. She sat on a sofa and he pulled up a chair next to her. He
held her hand while they talked. Then, she reports, "It got very
weird." She could feel his hand become sweaty and could hear his
breathing speed up. While he talked to her he started rubbing him-
self. Cara remembers distinctly being more frightened of him than
she was of God. Nevertheless her family were all extremely devout
and she could never think of reporting this behavior even though
she knew that it was improper and it bothered her a lot.
9. The professional schedules appointments at times that he claims
will provide more time or privacy than is usual, such as in the evening
or at the end of his workday:
Sue had recently moved into town and found a dentist through the
Yellow Pages. He was able to see her quickly and fixed her bad
tooth. He also commented that her teeth looked as if they had been
somewhat neglected and said that they could use a good cleaning.
He suggested to her that she come back that night after he had
finished with his last patient so that he would have plenty of time
to spend to do the job right. Sue had the feeling that he was not
really interested in her teeth but didn't know anyone else in town
and figured that he was, after all, a professional man and that she
could handle whatever came up.
10. The professional inappropriately recommends alcohol or drugs as

a means of "relaxing" or as an aid to coping with the problems being
addressed:
Sheila's chemistry professor told her that her poor school perfor-
mance was due to her being very "uptight" and tense all the time.
He told her that her body was trying to "communicate with her
consciousness" through her poor academic achievement. He sug-
gested that Sheila needed to relax and "let go," and he offered her
this new drug called "Ecstacy." He said that a lot of his students
used it and it really helped them to let go of what was bothering
them and concentrate on their schoolwork. Sheila was eager to do
well and accepted his offer.
11. The professional's manner is excessively familiar or he initiates

physical contact such as standing too close, touching, or making other
intimate contact which may appear accidental or inadvertent:
Janet had gotten to know her English professor, with whom she
had taken two classes over the past year. When she approached
him in his office to discuss an assignment, Prof. D. was his typical
friendly self. He took her coat and greeted her with a warm hug.
Janet wasn't at all concerned until he started using sexually explicit
language that she had never heard him use before when in class.
Janet recalls that she felt as though he was molesting her with his
words, and she became really frightened. When she got up to
leave, he stood at the door and she had to brush against him in
order to get out.
Other Warning Signs Not Specifically Sexual but

That Often Lead to Sexual Boundary Violations:
1. A feeling that the relationship is moving from a professional level
to an inappropriately personal level:
Nancy had an uneasy feeling when her attorney began scheduling

her appointments at the end of the day. She was particularly con-
cerned the last time, when she found that everyone else in the
office had left, her attorney was in his shirt sleeves and had his tie
off, and he greeted her with the offer of a cocktail. She suspected
that their business relationship was changing, but she was reluctant
to speak to him about it, in part because she felt herself attracted
to him and was actually hoping that he might feel the same about
her, but mostly because she really needed his particular expertise.
2. A sense that the professional is preoccupied with himself and his

own problems and is using office time to talk about himself:
Dr. B. was Julie's first and only gynecologist. Having a man as

her "female doctor" took some getting used to, but her mother said
he was "the best" and she knew that she could always trust her
mom's judgment. During one of their recent visits Julie could
sense that Dr. B. was distant and distracted. She asked him whether
he was okay and he began to tell her about a problem that he
was having at home. His wife had become an alcoholic and had
emotionally abandoned him. He talked a lot about his feelings of
loneliness, and Julie could feel herself wanting to help him and
make him feel better.
3. A professional who discourages getting a second opinion or who

encourages secrecy about the professional relationship:
Jenny had continued to see her minister for pastoral counseling

even though she couldn't see that it was doing much good. Initially
Jenny had experienced some relief, but she couldn't maintain it,
and she repeatedly lapsed into bouts of depression. The minister's
"treatment" consisted of hypnotizing her twice a week and then
supposedly talking to her subconscious while she was in the trance.
Often Jenny did not remember what happened during a session but
the minister said that it wasn't important for her to remember any-
thing consciously. Since Jenny was feeling worse rather than bet-
ter, she asked for a referral so she could consult a mental health
professional and get another opinion. He told her that she should
not do so because it would interfere with their work. He also said
that few traditionally oriented therapists understood hypnosis, that
they would try to sabotage their relationship, and that it was im-
portant that they keep the sessions strictly between themselves.
4. A professional who offers to have his services paid for by having

the client "work off the fee through working for him:
Patricia didn't have enough money to pay for very many consulta-
tions with Mr. J., a professional violin instructor. She was told that
he was the best at dealing with novices but was almost certain that
she could not afford to see him regularly. At their first meeting
Patricia hoped that Mr. J. would at least direct her to someone she
could afford. Instead, and much to her surprise, he said that he
would instruct her himself and that she could work part time in his
office as his assistant as a way of paying him back. She felt as if
she had just been given a gift and was very grateful.
5. The professional dogmatically imposes his values on you and re-

fuses to provide his services unless you accept those values:
Rabbi D. was a charismatic and powerful community leader. He

was overwhelmingly dynamic, perhaps a force sent from God him-
self. He seemed to know about everything and expressed himself
with such confidence, articulateness, and power that it was virtu-
ally impossible to disagree with him. If people ever dared to ques-
tion him, he would verbally intimidate and humiliate them, even
in public. If they didn't eventually give in, they would be asked to
leave the congregation. Many of the women who attended his ser-
vices were both attracted to and terrified of him at the same time.
6. The professional offers to provide services that are outside the area
of his expertise and beyond the scope for which he had originally been
hired:
Dr. K. was Amy's family doctor. When her children were born, he
naturally did the deliveries. When later Amy needed a cyst re-
moved, Dr. K. insisted that he would handle it himself. Whenever
the family had a medical matter, regardless of what it was, Dr. K.
handled it. He was always wonderful to everyone, but he never
encouraged anyone to use a specialist even after he made a couple
of mistakes that could have caused real harm. When eventually
Amy needed a hysterectomy, she turned to Dr. K. for a referral,
but again he insisted that he would do the procedure himself. When
Amy questioned his expertise in this area and expressed her con-
cern about the seriousness of the operation, Dr. K. said that she
was always very special to him and that he did not trust anyone
else to look after her needs. He said that he would make sure that
everything went smoothly for her. Amy had known him for so long
and was so anxious about the operation that she was afraid to go
to a stranger, especially without a referral from Dr. K.
7. The professional suggests participation in activities which are

clearly dishonest, unethical, or illegal:
During the course of her treatment with Dr. F., a prominent derma-
tologist, Kim knew that she would be leaving her job and didn't
know when she would be reemployed. When she told Dr. F. that
she would be unemployed for a while, he suggested that he could
bill her health insurance now for her next course of treatments so
that if she were unemployed and therefore had no health insurance,
he would have already been paid and treatment could continue.
When Kim told him that it sounded unethical, he became very cold
and distant and said that he and his colleagues did this all the time
as a way of helping patients. He said that if she didn't trust his
ethics, she should go elsewhere. Kim was in the middle of her
treatments, was about to lose her insurance, and felt that she had
no other choice.
8. The professional shows signs of being bored, forgetful, irritable,

detached, or overly critical; when this is brought to his attention, he
becomes defensive or remains unconcerned:
It was hard for Lisa to adjust to John's condition. Her husband,

who for years had been such a strong and courageous man, was
now a weak and dependent victim of heart disease. Their physician

recommended that Lisa see Mr. W., a social worker who special-
ized in helping family members cope with chronic illness. Mr. W.
evaluated her situation and said that he could help. She needed to
talk and often found herself talking about the same things over and
over again. During her third visit Lisa thought that she heard Mr.
W. refer to her husband by the wrong name. She dismissed it as a
trick that her mind was playing because she was so upset. During
the next few visits, as Lisa continued to go over and over the same
concerns, she developed a sense that Mr. W. was not paying atten-
tion and even thought she noticed him struggling to keep his eyes
open. She was so hurt and angry that she just started crying and
screaming at him for abandoning her after promising to help. His
response was to become very huffy and aloof and to accuse her of
putting her anger toward her ailing husband onto him. Lisa was
very confused and unsure, thinking that he might be right.
9. The professional asks for personal favors like running his errands
or getting his coffee, or perhaps even solicits gifts:
When Reverend G. asked Betsy to do some things around the par-

ish house, she felt privileged to be singled out by him. This soon
developed into a regular routine of her doing errands and chores.
She did not realize at the time that he was testing her ability to be
influenced by demonstrating her willingness to honor his requests
no matter how silly, inconvenient, or nonsensical they might be.
Once she became accustomed and willing to do whatever he asked
without question, she found that his requests became far more per-
sonal and intimate in nature.
10. The professional inquires about business matters that have noth-
ing to do with the reason for consulting him:
Regardless of what Paul needed or wanted to talk about, Dr. P.

would always steer the discussion to what was going on with his
company. After he once innocently shared his excitement about
getting a big government contract, Dr. P. always spent part of the
visit asking about the business even though it had nothing to do
with why Paul was there to see him. Paul later found out that Dr.
P. was buying and selling stock on the basis of the information
that Paul gave him. Paul found out about this when Dr. P. ap-
proached him to have a more intimate relationship, suggesting that

if Paul's company knew that he was sharing insider information
outside the company, his job might be at risk.
The first group of warning signs are clearly sexual in nature and never
have a place in a professional relationship. This is so even if a sexual
relationship is not specifically prohibited by a code of ethics or a law.
The reasons for this have been discussed in the early chapters of this
book: at the very least, it undermines efforts to accomplish the work
that the professional was engaged to do; at the worst it leads to direct
harm to the victim, often with long-term psychological, emotional, and
economic consequences.
The second group of warning signs which are not specifically sexual
in nature may not be as clear, and they may not lead to abuse. On the
other hand, they are often equally telling, indicating that a sexual ad-
vance is coming. These signs often warn that the person who was en-
gaged for his professional services or turned to for help has his own
agenda. At the very least, they may indicate that his own needs might
impair or preclude his ability to provide his services appropriately and
competently. If his agenda involves satisfying his personal needs, he
may do so without regard to the consequences. And, in order to meet
those needs, he can exploit, manipulate, coerce, control, intimidate, hu-
miliate, compromise, and disenfranchise, often over and over again,
moving from one victim to another.
Initially, sexually exploitative behavior may take the form of nonsex-
ual and seemingly benign conduct. What happens in this early stage is
the start of an evaluative process in which a possible victim's vulnerabil-
ities and potential for exploitation are identified and tested. Once this
occurs and her vulnerabilities are exposed and accessible, the exploit-
ative professional will follow his usual course. The typical perpetrator
does this over and over again, exploiting a number of victims with little
concern or remorse for the damage that is done.
The warning signs that are blatantly sexual in nature should be
viewed, unequivocally, as an indication of imminent exploitation. Those
that are not obviously sexual in nature are not necessarily indicative of
abuse; they have only been observed as precursors to abuse under some
circumstances. So what should a potential victim do after she confronts
the professional and discusses the unwanted behavior? At least with re-
spect to those who observe warning signs that are blatantly sexual, even
if the professional apologizes and is reassuring that the behavior will
stop, one must still be reluctant to continue with him. Trust is a feeling
that must be earned; once betrayed, it is unlikely ever to be fully rees-

tablished. And without trust, there is no certainty that the interests of
the client, patient, or student will be protected.
Exploitative behavior has consequences beyond the immediate mo-
ment and it is important to understand its long-term effects. Sometimes
potential victims have the opportunity and wherewithall to think through
the circumstances and perhaps consult others about questionable behav-
ior. Just as often, however, a victim is drawn into the excitement of the
moment: the feeling of being special, and perhaps the feeling of being
loved. In short, the victim is seduced. Many victims do willingly partici-
pate in sexually exploitative behavior, being unable to identify it as such
at the beginning. It is often not until the relationship ends, or perhaps
until others find out about it, that the victim comes to recognize what
has occurred.
At the beginning of such a relationship, a potential victim is presented
with a seemingly seductive situation in which she has to make a choice
about how to respond. Sometimes family, a friend, or a suitable profes-
sional is available to consult. Other times the future victim is on her
own. In either case, the most dangerous course is for her to remain
silent; silence plays into the hands of the abuser, who depends upon his
victim's being intimidated by the circumstances and having no power to
act on her own behalf.
On the other hand, sometimes to a "victim's" surprise, a profession-
al's intentions are not exploitative, but rather have been misinterpreted.
In that case when a client, patient, or student approaches him and con-
fronts him with her concerns, usually he will be only too willing and
even eager to address the matter. This is his opportunity to "clear the
air" so that the professional relationship can continue without any suspi-
cion or uncertainty. Thereafter, the professional services can go forward
without a cloud of suspicion.
Finally, there are situations in which a victim listens to her own in-
stincts, talks to others, and makes every effort to determine whether a
certain professional she has engaged has exploitative intentions. She
may or may not have confronted him directly, but still, she's simply not
sure. At this point, to err on the side of caution is to terminate the
relationship. The potential consequences for a victim are great: not only
does she risk being harmed, but the original purpose of the professional
relationship may be lost. Trust is an essential element of most fiduciary
relationships, and without it the quality of the services is too often com-
promised.
Chapter 5
Filing a Complaint Against Your

Therapist: The Mental Health
Paradigm Revisited
CASE STUDY: ABBY
It's been 4 years since my relationship with Jerry ended. He was a

therapist whom I went to see because I was having a hard time after my
divorce and trouble with my 7-year-old son, Joey. I was still very angry
at my ex-husband, Steve, who left me to marry his 22-year-old secre-
tary. Every time Joey would spend a weekend with Steve, he would
come back and talk all about his dad's fiancee and how he would be
lucky to have two "moms" after the wedding. It was driving me crazy
and my best friend, Donna, recommended that I talk to her therapist. I
was skeptical at first, because I never thought that he would be able to
do anything. But Donna raved about him so much that I thought I would
give it a try.
Within a couple of sessions he had told me everything I wanted to
hear: that I wasn't crazy; that I had the right to be mad at Steve; and
that I was a special person and had a lot going for me. Sometimes he
would just stare at me and tell me how pretty I looked and how a man
would be "nuts" to let go of me. After a few weeks I knew I was really
getting attached to this man. I'm not really sure why, but he was so
caring and attentive and I really got to love just being with him. I guess
he knew what I needed and he knew just what to say.
And then it just happened. I showed up one day for a session and we
ended up making love. It seemed so easy, so natural, and so right. We
were both lonely, both searching for someone elseand both perfect for
each other. Or so I thought. Our relationship lasted for about five-and-
one-half months. We would see each other every week at my regular
appointment and sometimes in between. We would talk about ourselves
and each other and what we wanted out of life. And mostly we had sex.
A couple of times he was so eager to get my clothes off that it seemed
like that's all he really wanted. But I kept telling myself that Jerry really
cared about me and that's just how he showed it.
The relationship ended much the same way that my marriage ended:
one day Jerry just dumped me. He said that he had to "scale down" his
practice and he no longer had time to see patients who didn't really
need him. He said that I was fine and he even hinted that the sex I had
with him was just what I needed to help me and that I was "cured" now.
This man who had been so kind and so caring just all of a sudden didn't
need me anymore.
What was different about being dumped this time was that I had be-
come attached to Dr. Jerry in a way that I had never felt with Steve. It
seemed like I could talk to him about anything, and he was never critical
or demeaning. At times it seemed like he understood me even better
than I understood myself. It seemed so perfect. When it ended I was
devastated. I was so upset and I didn't have anyone to turn to. I couldn't
even tell Donna because I had never told her what had gone on between
me and Dr. Jerry and I just couldn't tell her now. This time I was
really depressed, and not because of Steve and Joey, but because of
what happened with this man who, only 6 months earlier, didn't even
exist in my life. I had forgotten all about my ex-husband of almost 10
years and the father of my child, and I was devastated by a man I barely
knew. It made no sense. It seemed that he knew exactly what he was
doing. I was in love, or so I thought, and I didn't pay much attention to
anything else. He was billing my insurance company for the time that
we were having sex.
Almost 2 years after this happened, Donna confided in me something
that I could never have told her: Jerry had been having sex with her.
And at about the same time he dumped me, he dumped her also. She
was as torn up inside as I was and for weeks we would talk about
nothing else. We found strength in each other and sometimes we would
Filing a Complaint 63
fantasize about getting revenge. Then one day just as our rage was start-
ing to subside, Donna read something in a magazine about sex between
therapists and patients being unethical and possibly illegal. She followed
up this article and we both began to see how we were really abused and
why this experience had been so especially painful for both of us. We
became like two women looking for a cause and we were willing to do
anything to get back at this man. Probably neither of us might have
pursued him alone, but together we managed to get through a lot of
embarrassment and a lot of legal red tape.
First we went to the State Board of Registration, where this man was
licensed to practice. They took our complaint but told us they would
have to begin an investigation and that because of funding cutbacks, the
backlog for investigating complaints was quite long. After many weeks
of waiting, we went back to follow it up and found that they had not
yet even begun to process our papers. This went on for about five-and-
one-half months and finally someone from the Board of Registration
contacted us. It was a man who took our story again; he remarked that
there were no other complaints on file about this therapist and he did
not know exactly how far this investigation would go. Several months
after that we were told that Dr. Gerald P. had been called before the
Board and denied any wrongdoing. Because there were no other com-
plaints on file, no formal disciplinary action was taken and the file was
closed.
At about the same time that we were waiting for some action by the
licensing board, Donna had also heard that some of these cases were
being brought to court. She didn't know whether they were going
through criminal channels or whether lawsuits could be brought, but
after we heard the decision of the Board of Registration, we decided to
see a lawyer.
Neither Donna nor I had any great familiarity with lawyers so I went
to the woman who did my divorce. She was nice enough and seemed
competent but she had never heard of patients' suing psychotherapists
for improper sexual contact. When she looked into it, however, it was
another story. She found that several states actually had criminal laws
against therapist-patient sex and, if we had been in such a state, the
therapist could actually go to jail. Our state did not, so we had to pursue
him ourselves.
Our lawyer suggested the possibility of a civil lawsuit. She said that
the therapist could be sued because his conduct was unethical and usu-
ally considered to be malpractice. In fact, she said that if he had mal-
practice insurance, it might even pay our claim. In any event our case
was likely to get a lot of media attention and Jerry was certain to be
embarrassed and humiliated, even if we ultimately lost our lawsuit.
That was the good part. What we also found out is that lawsuits are
tough on both parties. We had to expect to be asked about the details of
our sexual relationship with the therapist, as well as with anyone else.
We had to expect the details of our therapy to be discussed (even though
they were supposed to be confidential) since we were suing the therapist.
And we had to expect that he would lie, probably deny ever having
touched us, and probably suggest that we were hysterical or nuts or were
even hallucinating the whole thing. Of course, we were lucky that there
were two of us; otherwise there might be no one to back up our story.
In the unlikely event that Jerry admitted that he had sex with us, there
would be another set of legal obstacles. He would undoubtedly claim
that we consentedand, indeed, we did. He would probably say that we
asked for itand maybe we did. And then there was the time problem.
The law doesn't let you wait forever before you have to bring your
lawsuit, and we might have already waited too long.
After the lawyer explained all of the procedural pitfalls, then she got
to the hardest part of all. She asked us whether we were prepared to see
Jerry, face-to-face, and accuse him of luring us into a sexual relationship
with him. She needed to know whether we could handle the cross-exam-
ination about the most intimate parts of our liveswhatever they asked
us. We would undoubtedly be asked about why we ever consented, and
whether we led him on. We had to expect that Jerry would use whatever
he had learned about us to try to force us to drop our lawsuit. In many
ways this seemed to be the ultimate violation, but, ironically, one of the
few things that Jerry managed to teach us was to have the strength to
go forward with what we believed. And so we did.
A victim who has been sexually exploited by a professional may have

available several courses of action from which to choose, depending
upon the state where the services were rendered and the nature of the
recourse sought. In the mental health field (where there are established
procedures) the various options include filing a complaint with the
Board of Registration that licenses the therapist (if he is licensed), filing
a complaint with a professional association or society (if any) of which
the therapist is a member, filing a criminal complaint (in those eleven
states that have a criminal law against sexual exploitation by therapists),
and/or filing a civil lawsuit to collect monetary compensation from the

offender. This chapter will set forth the criminal, disciplinary, and licen-
sure penalties that a victim of sexual exploitation by a therapist may
pursue; Chapter 6 addresses the possible civil options.
ADMINISTRATIVE REMEDIES
Professional Organizations
There are numerous professional associations of which a psychothera-
pist may be a member. On the national level such professional organiza-
tions include the American Psychiatric Association, the American Psy-
chological Association, the National Association of Social Workers, the
American Psychoanalytic Association, and the American Association for
Marriage and Family Therapy. On the local level virtually every state
has a similar association (e.g., the Massachusetts Psychological Associa-
tion). Participation in these organizations is voluntary. A practitioner
may be a member of all, some, or none of these organizations. Thus the
first task for a victim who chooses the administrative route is to deter-
mine which, if any, have him as a member.
Once it is determined that the therapist does belong to one or more
such organization(s), the next step is to file an "ethics" complaint. Vic-
tims can call the organization identified and inquire about the appro-
priate procedure, but typically there is a specific form (often provided
by a subcommittee which initially investigates complaints of ethical vio-
lations) which can be sent out. The form will seek a detailed description
about what happened and why the victim believes that it constitutes a
violation of the association's ethical policies. In cases of sexual exploita-
tion, the violation is usually clear. For example, the ethical code of the
American Psychiatric Society specifically states the following:
The necessary intensity of the therapeutic relationship may tend to

activate sexual and other needs and fantasies on the part of both
the patient and therapist, while weakening the objectivity necessary
for control. Sexual activity with a patient is unethical.
It is important to keep in mind that in virtually all cases the complain-

ant will be required to sign the complaint. Many victims would prefer
to issue a complaint anonymously, even if they think that the therapist
would know who complained. However, in the vast majority of cases
the process will not go forward unless the victim is willing to sign (and
likely swear to) the charges and ultimately to defend them if necessary.
Some victims back out when they find that it's necessary to sign the
complaint. Why? First, they find out that when they file a complaint,
they have to sign a "waiver," which means that the therapist can go into
their file and dig out whatever confidential information he has about
them to use to defend himself. It doesn't mean that he can use personal
information that doesn't have any bearing on the complaint, but a lot of
victims are ashamed of or embarrassed about what might come out, and
they're not willing to risk what might be said.
Another reason that victims back out is that they become frightened
of retaliation from the therapist or publicity that makes it known that
they were patients. In fact, actual retaliation is rare, and the maximum
possible confidentiality is maintained. The reality is, however, that when
a victim files a complaint, some of the privacy (the so-called privilege
from disclosure) is lost and it is not always predictable what might be
disclosed about the complainant.
The next step, if it is at all possible, is to identify or locate other
victims. This is extremely important because a complaint with more than
one victim is likely to be taken very seriously, which is not to say that
a single complaint would not. But if two or more victims corroborate
each other's story, a favorable outcome is likely. So how might a victim
find other victims? One route is for the victim to talk to whoever made
the referral to this therapist. If it is an individual, the victim might in-
quire about his or her experience, and that of others who were referred.
If the victim referred other people, she might inquire about what their
experience was. Particularly in smaller communities, often this type of
news gets around, and often somebody knows somebody who had a
similar experience. Also, since psychotherapy is a field in which word-
of-mouth referrals are the norm, often a "network" of patients who are
served by the same therapist is formed. And since an abusive therapist
is likely to have more than one victim, there is some chance that others
can be identified.
Another possibility for finding other victims is to inquire with the
local licensing board or professional association that is handling the
complaint. It may not reveal the identity of other victims, but usually it
will tell a complainant whether or not other complaints have been filed.
This information may be valuable for future use.
The next step is that the association will disclose the complaint to the
accused therapist and require him to respond in writing. He has a certain
period to do so, but often it will be extended and committees are gener-
ally quite liberal about allowing as much time as is needed. One possi-
bility that the victim needs to be aware of at this point is that the thera-
pist may file a "countercomplaint," which means that he attempts to
accuse his accuser of some misbehavior. Since presumably the victim is
not a member of that organization, a complaint against a nonmember
doesn't have any "teeth"; actually its intent is to harass and intimidate
the complainant. It also gives the victim some idea about whether the
therapist is going to admit his wrongdoing or instead attempt to malign
and discredit the victim. Even for a victim who knows that she is right,
sometimes it takes a lot of strength to go forward. Many victims think
it just isn't worth the effort.
After the accused therapist submits his written response, an investiga-
tion is usually started, unless it appears clear from the complaint that no
ethical violation occurred or unless the conduct is admitted. Since there
is no real "defense" to sexual misconduct, the circumstances of the mat-
ter do not really matter and a formal investigation will not be required.
In most cases, however, the misconduct is at least initially denied and
the committee handling it will investigate the matter. The victim is not
usually involved in this phase unless the committee has to come to her
for more information.
The next step in this proceeding is that a meeting is usually convened
so that a hearing can be held. Sometimes, but not always, the accuser
will be asked to be present. The most important factor that determines
whether or not the victim is needed is whether there is a dispute with
the therapist about what happened. If he admits to his conduct, the vic-
tim does not need to be there to hear it. Even if he attempts to accuse
the victim of willingly participating and even encouraging it, it still
should not matter. Sexual misconduct is always the responsibility of
the therapist, and the fact that the victim agreed does not affect that
obligation.
After the hearing, the subcommittee generally makes a recommenda-
tion to the entire ethics committee. Eventually it will be heard by the
full Board of Directors. Their functions are to determine the final dispo-
sition of the case and to vote on a penalty. Penalties range from requir-
ing a verbal or written apology to expelling the practitioner from the
organization. Unfortunately, even expulsion cannot prevent a therapist
from practicing, and usually the professional associations recommend
less harsh penalties (except for repeat offenders) since once a therapist
is expelled, no professional organization may be left to monitor his con-
duct. Many victims are discouraged from pursuing this course simply
because the penalties aren't harsh enough. What they may not realize,
however, is that the consequences to a therapist of disciplinary proceed-
ings are much greater than can be measured by the penalty: sometimes
it ruins his future ability to get clients or even to practice.
The complaint process from beginning to end can take anywhere from
a few months to a couple of years. Many victims get frustrated by the
delays, particularly if they think that the cause is that their complaint is
not being taken seriously. Yet another frustration is that victims are not
always advised of the disposition of their cases. Sometimes they hear
nothing. If they inquire, however, they should at least find out whether
the therapist was found to be guilty or not, even if the association will
not tell what, if any, penalty was imposed.
And what, exactly, are the possible penalties? The most common ones
include requiring the therapist to apologize, monitoring (through super-
vision) the therapist's work, putting the therapist on probation (as a
member of the organization), and expelling him from the organization.
In general, sexual misconduct is considered to be a severe offense and
the more severe penalties would apply. In those cases where it is a first
offense, however, particularly if only one victim comes forward, a lesser
penalty might be expected.
The benefit of choosing this route is that there need not be any ex-
pense to the victim; it is not necessary to hire an attorney. In fact, the
complainant may not even need to testify or confront the abusive thera-
pist. On the other hand, there are also some drawbacks to this procedure.
First, not all practitioners are members of professional organizations
(and therefore bound by their ethical codes). If the therapist is not a
member, the organization will not take the complaint. Second, many
victims find the procedure for filing complaints with these organizations
complicated. Others feel that the ethics procedure seems inherently un-
fair because the committee is itself made up of other psychotherapists
who could be prejudiced on behalf of their colleagues. In the past, this
was, in fact, often the case. It seemed futile to file a complaint because
it would be processed by the "old boy network." The professionals
seemed to protect their own, and complaints seemed to be "quashed,"
"misfiled," or otherwise trivialized.
Today this is usually not the case. With the increase in courageous
victims coming forward and the extensive media coverage that some
cases have received, the therapists themselves now understand the seri-
ousness of the problem of patient-therapist sex and the damage it causes
both to patients and to the profession. So today they are more likely to
be both interested in and motivated toward putting a stop to the problem.
Victims still complain that resolutions are inadequate because the pro-
fessional association's most potent remedy is mere expulsion from that
organization. Of course, it is true that an abusive therapist is not pre-
vented from practicing and, indeed, continuing to abuse other patients.
Ethics complaints do make a difference, however. A therapist who is
accused once must always look over his shoulder and wonder whether
it might happen again. It tarnishes his professional reputation and stand-
ing in the community. More importantly, it may cause him to examine
his own behavior seriously, and in the long run that may be the greatest
benefit.
Licensing Authorities
If a victim thinks that a complaint to a professional organization is an
inadequate remedy because of the narrow range of penalties, a complaint
with a licensing board may provide a better solution. Licensing boards
get their authority from state governments to oversee the practices of
professionals who are licensed by them. They are also obligated to pro-
tect consumers by, among other things, revoking the licenses of profes-
sionals who are unfit to practice. Generally psychiatrists are under the
licensing authority of the state medical board, while psychologists, so-
cial workers, and other counseling professionals are licensed, if at all,
by separate professional licensing boards.
Just as the professional association may not be able to provide any
recourse because the therapist is not a member, so licensing boards may
also be unable to reach an abusive therapist. In many states, therapists
need not be licensed to practice and can even practice if their license is
revoked. For example, in most states a psychologist must hold a license
in order to call himself a "psychologist" publicly, but no particular li-
cense, training, or experience is necessary to call or advertise himself as
a "psychotherapist" or "counselor." As a result, when a patient is re-
ferred to such a person, she may not know unless she is willing to ask
exactly what his credentials are or whether a complaint has ever been
filed against him.
The complaint procedure with a licensing board is similar to that of a
professional organization. The complainant fills out a written complaint
identifying the name, dates, and specific acts of the accused. The licens-
ing board can either forward the complaint to the state attorney general's
office, if the conduct reported is criminal in that state, or can process it

and begin its own internal investigation. After a preliminary investiga-
tion, the board may decide to file a formal complaint, or, if it decides
that the charge is without merit, to close the case.
Assuming that the case is found to have merit, the board has the
option of trying to settle the matter. This means that if the therapist
admits that the sexual contact occurred, he can voluntarily submit to the
recommendation of the board (e.g., censure, probation). If he does not
admit it, or if he and the board cannot agree on a sanction, it is then
usually submitted to an administrative law judge, who decides the mat-
ter. An administrative proceeding occurs without a jury and without the
same procedural rules that would apply in a court of law. However, the
accused therapist will usually have an attorney and evidence will be
presented as in any other case. A decision is rendered by the judge on
the basis of the evidence that is presented.
Usually in a licensure proceeding the accused will be called upon to
testify. Since the accused is a "witness," it is not necessary for her to
have a lawyer, but if she's thinking about a civil suit later on, she may
want to consult one before the hearing to advise her about what she
might say that would affect the subsequent civil suit. The accused can
also be "cross-examined," which means that both sides will ask ques-
tions, and once again the accused loses the privacy and confidentiality
that otherwise govern those sessions spent with the therapist. Fortunately
there are enough safeguards that truly confidential information should
not be revealed unless it is directly related to the sexual contact.
The decision of the administrative judge is sent back to the licensing
board, which is then entitled to accept or reject the decision. The action
of the licensing board is final, however, and if the therapist later at-
tempts to go to court to challenge it, the decision will likely be upheld.
The boards have a number of sanctions available to them, including
suspension or revocation of a license, reprimand (e.g., public criticism),
censure (e.g., public or private disapproval), a fine, or even the require-
ment that the therapist perform a certain amount of public service.
Among the many cases that have been brought over the years, the full
range of various sanctions has been imposed.
Disciplinary proceedings conducted by licensing authorities also have
a number of advantages and disadvantages. The major advantage is that
the accused avoids going to court and testifying in an open forum, per-
haps before a jury. Further, if the board finds against the therapist, the
cost to him can be great, including public embarrassment and loss of his
license to practice his profession. However, the cost to the accused is

usually less than it would be if a court action were involved.
The disadvantages of an administrative proceeding are also signifi-
cant. Although the accuser is spared going to court, she must usually
appear at the administrative hearing. This can be very stressful, particu-
larly for someone who has already been abused once. The complaint
and proceedings can also be time-consuming. More importantly, how-
ever, the victim has to be prepared to discuss and repeat her story a
number of times throughout the proceeding. And in the end, even if the
most potent remedy, license revocation, is imposed, in many cases the
offender can still practice, unlicensed, under a different title.
Gerri was devastated when her psychotherapist, who engaged her

in a sexual relationship 2 months after she began therapy, decided
that he no longer had time to continue that relationship. Gerri had
not told anyone about it, but it came out when she became suicidal,
and the therapist was reported to his licensing board. She had just
started with a new psychotherapist and had not yet been able to
confront this experience when the licensing board called her to
testify. During the hearing she was asked, repeatedly and in pains-
taking detail, exactly what happened and how she participated.
Throughout the hearing she felt as though she were on trial. When
her new therapist tried to guide her in working through the experi-
ence to heal the wounds, Gerri simply could not go over it again,
and this reluctance inhibited her recovery.
Criminal Complaints
Currently eleven states have criminal laws that make it illegal for a
mental health professional to engage in a sexual relationship with a pa-
tient: California, Colorado, Florida, Georgia, New Hampshire, Iowa,
Maine, Michigan, Minnesota, North Dakota, and Wisconsin. There are
also some states that are considering similar legislation (Maryland, Mas-
sachusetts, New Mexico, and Pennsylvania). The purpose, of course, is
to discourage sexual misconduct further by making it a criminal offense
(indeed, often a felony) and increasing the penalties for those who are
found guilty.
For the most part the criminal statutes, as drafted, are far-reaching.
For example, the Wisconsin statute applies to all persons who practice
or present themselves to the public as practicing as therapists, whether
or not they are licensed. This includes psychiatrists, psychologists, social

workers, nurses, counselors, and the clergy. It also covers a wide range
of sexual "contact," including intercourse, oral sex, sodomy, and inti-
mate kissing and touching. Laws in other states, Minnesota, for example,
also prohibit sexual contact with former patients under certain circum-
stances, particularly when the professional relationship was terminated
primarily for the purpose of beginning a sexual relationship (see Chapter
9). Additionally, some of the criminal statutes prohibit sexual intimacy
if the patient remains emotionally "dependent" on the therapist, even
after termination. This, of course, is difficult to prove but it benefits the
patient because it puts the burden on the therapist to show that the pa-
tient was not still dependent. The important factor is that the criminal
laws are intended to cover virtually all practicing therapists, are intended
to prohibit a wide range of sexual behavior, and cover a variety of cir-
cumstances.
Sandy had been seeing a social worker, Mr. R., for approximately
6 months when he began to initiate inappropriate sexual conduct.
Several times when her session was over he would stand so that
she had to squeeze by him in order to leave. On another occasion,
during a session when she was very upset about something that
had happened during the week, he approached her and kissed her
in an erotic way, later claiming that it was an aspect of his method
of therapy.
In those states that have not made sexual exploitation a criminal of-
fense, cases of sexual misconduct are still occasionally prosecuted as
criminal acts if the conduct was extreme. For example, if a patient was
approached by the therapist in a sexual way and refused or otherwise
objected to the advances, and he persisted by forcing himself on her,
she might be able to charge him with the criminal offense of rape. Simi-
larly, if sexual contact was made without her knowledge (e.g., during
hypnosis) or because under the circumstances she was unable to consent
(e.g., as a minor or incompetent person), a rape charge would be appro-
priate. For example, in a California case in the early 1960s a psychiatrist
was convicted under a statutory rape law for having sexual contact with
an underaged (16-year-old) girl. This is the exception, however, as few
cases are prosecuted criminally except in those eleven states in which a
specific law is in effect. In fact, there is a great reluctance among both
patients and law enforcement agencies to pursue criminal charges

against therapists who engage in sexual misconduct.
Most of the specific statutes that make therapist-patient sexual contact
a criminal offense classify the conduct as a felony, which is the most
serious type of criminal act. Despite this, the penalties for sexual mis-
conduct vary. In Colorado, for example, the criminal statute looks at the
type of sexual act performed and imposes a lesser penalty for "sexual
contact" than for "sexual penetration." Other statutes provide lesser pen-
alties for a first violation and stiffer penalties for subsequent violations.
In California, for example, a first offense is a "misdemeanor," which is
a lesser criminal offense than a felony. In Florida, all offenses are felon-
ies but the "degree" (and thus the penalty) increases when there is a
subsequent conviction.
The penalties imposed under the various laws depend upon the statute
and the seriousness of the offense, but they range from "up to 5 years"
in prison to "up to 15 years" in prison and fines from "up to $5,000" to
"up to $30,000." In all cases the sentencing judge has the discretion to
determine the penalty within the guidelines provided by the statute. He
or she often exercises substantial discretion to impose a just penalty.
IS CONSENT A DEFENSE?
The question of whether it should even be considered that a patient
might have somehow "consented" to sexual contact with the mental
health professional has been hotly debated. Because of the nature of the
relationship, most victims do, in fact, "consent" and may even encour-
age sexual intimacy. Nevertheless, as discussed in Chapter 2, this is not
"true" consent because patients are generally unfamiliar with transfer-
ence phenomena and generally do not recognize that what they experi-
ence as "love" is actually a transference reaction. Therefore, whatever
"consent" there is results from unrealistic feelings of intimacy and af-
fection which are part of the process of psychotherapy and are know-
ingly and intentionally elicited by the therapist. Consequently, most
courts, civil and criminal, recognize that whether or not a patient may
have voluntarily participated in her own exploitation does not affect the
ethical obligation of the therapist not to take advantage of her.
When Dr. S. was charged with improper sexual contact with a

patient, he defended himself on the basis that she had initiated the
relationship and that he resisted her sexual advances. He sought to

testify that it was only when she had threatened to attempt suicide
if he rejected her that he ultimately consented to a sexual relation-
ship because he thought it was necessary to keep his patient alive.
Most criminal statutes do not, in fact, even allow the defendant (thera-
pist) to assert "consent" as a defense to the criminal prosecution. On the
civil side, many courts will consider whether the patient "consented" to
whatever conduct occurred but will also consider the circumstances of
the consent, particularly the transference issues.
Although eliminating "consent" as a defense to sexual exploitation
would seem to be a great benefit to victims, its effect has been mixed.
As more states consider criminal legislation, a number are troubled by
the inference that any person who consults a mental health professional
must, for legal purposes, be treated as a child, mentally and legally
incapable of saying "no." The answer seems to be that even a competent
and capable adult is vulnerable to undue influence under certain circum-
stances, and this is presumed to be one of them.
Those states which have criminal laws that make sexual exploitation
illegal have them because they consider it to be a serious and complex
problem which they believe can best be addressed in this way. Many
women are particularly vulnerable because of past histories of sexual
abuse and other difficult clinical problems that leave them easily ex-
ploited. Some actually appear seductive. An ethical therapist will recog-
nize and treat this behavior for what it is and see it as a resource to be
used to perform the services for which he was engaged. Those who use
this opportunity to exploit patients cause further damage in the very area
in which they are most needy and vulnerable. They do so knowingly and
intentionally. Many states believe that criminal laws are an appropriate
sanction for such misconduct.
There are several benefits to the victim in having a criminal law that
punishes sexual misconduct. First, it is anticipated that at least some of
the therapists who are prone to exploiting their patients will be deterred
by criminal penalties. Second, criminal prosecution does not depend
upon an unsuspecting patient to file a lawsuit. Once such a patient dis-
cusses the sexual misconduct with anyone, including a new therapist, it
may be reported to the criminal authorities. She may not even know
about it. Thus the threat of heavy fines, imprisonment, and a criminal
"record" is greater than the threat of a "mere" civil suit.
For the victim, criminal penalties do not yield any direct benefit in
that she gets no financial award. But for some victims, it is more im-
portant to their well-being to see the abuser punished, even imprisoned.
Victims of exploitation often are left with unresolved feelings of shame
and guilt about their participation in the sexual relationship. Making
such conduct by a therapist criminal places the "blame" where it belongs
and helps resolve some of those feelings of shame and guilt. At the
same time, if a therapist is found guilty in the criminal case, it will make
it almost certain that the patient will win the later civil suit because guilt
has already been established.
It is important to realize that it is almost certain that an accuser will
be called upon to testify against the therapist in a criminal case. Because
the stakes are so high, most therapists do not admit to sexual miscon-
duct, and the accuser, as the "star" witness, will be expected to prove
that it happened. She can expect that the therapist's lawyer will attempt
to discredit her, using anything that the therapist can tell him to cast
doubt on her credibility. Patients of psychotherapy are sitting ducks for
having their credibility attacked, and they have to expect that whatever
the therapist knows might be used as ammunition. In the end the per-
sonal toll that a criminal trial takes can be enormous. Sometimes this
actually aids a victim's recovery process, but too often it is an unpleas-
ant experience she never forgets.
Society may also benefit from criminal laws against sexual exploita-
tion, at least to the extent that it prevents abusive therapists from harm-
ing other patients. Once a criminal prosecution occurs, it is likely that a
proceeding before the state licensing board, attempting to revoke the
therapist's license, will follow. Local publicity is likely. The intent is
that the general public, particularly those who engage mental health pro-
fessionals, better understand the problem and avoid becoming the next
victim.
Not surprisingly, there are also drawbacks in making sexual exploita-
tion a criminal offense. Among the most significant is the possibility
that reporting will actually be deterred because the stakes are so high
for the offender. Many therapists are more willing to report offending
colleagues when they know that the purpose is to "rehabilitate" rather
than severely punish them. If the penalty is imprisonment, some will be
more reluctant to report an offense. Some victims may also be deterred
from reporting by the requirements of the criminal law. Even though the
victim does not make the decision to prosecute, she has to participate in
a criminal prosecution and her willingness to do so greatly affects the
success of the case.
The victim's willingness to participate in a criminal prosecution is

something that she must consider seriously. Is she prepared to have her
privacy invaded? Is she strong enough to publicize her victimization? In
too many cases, victims are too fragile to undergo a criminal prosecution
and it actually causes more harm than good, including impeding recov-
ery. Instead of getting relief from those feelings of guilt and shame, if
she is not ready to deal with the powerful emotions that arise, she may
feel worse.
Yet another pitfall of the criminal process is that if the victim is con-
templating bringing a civil lawsuit (which, unlike the criminal case, does
benefit her) she may be deterred after going through the truly grueling
process of a criminal prosecution. In the criminal case, she doubtless
will have to testify and be cross-examined about her sexual conduct with
the therapist. If this process is really traumatic, as it can be, she may
not be willing to subject herself to the legal system yet again, even to
obtain compensation for the harm done to her.
The therapist who sexually abused Jennifer was reported to the

authorities by a friend of hers and was prosecuted in a criminal
court. Jennifer was subpoenaed to testify. When the therapist's
lawyer was entitled to cross-examine Jennifer, he grilled her over
and over again about how she dressed and what she said and forced
her to describe, in painful detail, exactly what kind of advances
and sexual conduct occurred. The therapist was ultimately con-
victed, and Jennifer was advised that winning the civil lawsuit to
"pay" her for what was done would be easy. After having been
traumatized by the criminal trial, Jennifer refused to submit to the
legal process again, even though it would be an easier case, and
even though it might help her pay for subsequent therapy.
Probably the most troubling aspect of the criminal law is its inability
to distinguish between those therapists who habitually and intentionally
exploit and abuse their patients as long as they can get away with it,
and those who unwittingly allow it to happen once and are better reha-
bilitated than punished.
Dr. K. had been a therapist for 33 years. Within that period, he

had engaged in sexual relationships with more than twenty women.
According to him, he was never involved with more than one at a
time and he only became involved when he believed that it would
benefit the patient. In fact, the vast majority were devastated by

the experience and several became suicidal. He continued to prac-
tice this type of "therapy," however, until he was finally reported
and prosecuted by his state, which made sexual misconduct of psy-
chotherapists a criminal offense.
Dr. B. had practiced psychotherapy for 26 years and always be-
lieved that sexual contact with a patient was strictly forbidden.
However, at the age of 52 and in the midst of a divorce, he found
himself increasingly attracted to a patient who initiated a social
relationship with him. She suggested that her "therapy" could be
finished and that such a relationship would be of great benefit to
both of them. Dr. B. rationalized that since he would be seeing
her, he could determine whether she needed more therapy and refer
her to a colleague if needed. Soon after they began a sexual rela-
tionship, Dr. B. recognized that the patient did, indeed, need fur-
ther treatment. He also realized that her attraction to him had to be
sorted out and that his sexual relationship with her prevented her
from getting the necessary treatment.
To a large extent, the criminal statutes are not able to make meaning-
ful distinctions between those who need to be rehabilitated, those who
need to be deterred, and those who need to be punished. But for an
individual victim it probably does not make a lot of difference, and
the criminal law may go a long way toward improving awareness and
understanding about sexual exploitation. Those therapists who are capa-
ble of rehabilitation should be required to have it; those who are not
should be prevented from practicing. The administrative and criminal
alternatives outlined in this chapter indicate that this problem is increas-
ingly being taken seriously and that its consequences are recognized as
real. No one remedy has proved to be a perfect solution, but along with
the civil options discussed in the following chapter, the recourse avail-
able to victims reflects an awareness of the seriousness of the problem.
Chapter 6
Bringing Your Therapist to Court:

The Costs and Benefits of
Private Lawsuits
In many cases exploited women who seek to pursue their abusers are
content to have the licensure board or criminal courts, discussed in the
previous chapter, process and act upon their complaints. The conse-
quences to the professional range from private censure and formal disci-
plinary procedures to loss of license or membership in professional orga-
nizations to ultimate imprisonment in some states. Although the vast
majority of abusive therapists are never subjected to any formal sanc-
tion, the costs to those who are can be enormous. It is not unusual for
such a practitioner to be ostracized from the professional community
and even to lose his ability to practice and earn a living. Yet there is
another, potentially more devastating consequence: the risk of a civil
lawsuit. Not only can this result in substantial awards of money damages
to a successful victim, but the emotional costs of defending a civil law-
suit can be even greater than those connected with an administrative
proceeding. This is now a public forum, unprotected by privileged pro-
cedures or confidentiality. This chapter will highlight the civil remedies
that may be available to a victim as well as the defenses and obstacles
that she may be required to endure.
WHY A LAWSUIT?
Victims of sexual exploitation bring civil lawsuits for monetary recov-
ery for a number of reasons. Sometimes they feel that the administrative
sanction, if any, was inadequate punishment for the suffering they expe-
rienced. Sometimes they believe that criminal action should have been
taken. Sometimes they simply feel that justice is not done if the abuser
has suffered no monetary loss. Perhaps they will seek money damages
in order to have the resources to secure professional help to deal with
the consequences of the exploitation, or to continue whatever services
the therapist had been engaged to perform. Some people find that a civil
action can be therapeutic, challenging the victim's ability to face her
abuser and fight back. In that case, initiating a court action and meeting
the abuser face-to-face, often for the first time since the betrayal, are
symbolic of the victim's progress toward recovery. Like no other avail-
able remedy, the civil lawsuit puts the victim back in control and assures
her of the opportunity to be heard.
After Terri was abused and then abandoned by her psychotherapist,

she became very depressed and thought she could never bear to
see him again. Several weeks after she started new therapy, how-
ever, her depression turned to anger as she started to come to grips
with the abuse. As the therapy progressed, Terri felt more and
more that she was ready to take control of what happened to her
and force the psychotherapist to confront her and everyone else
and admit what he did.
LEGAL THEORIES AND PROCEDURES

Bringing a civil lawsuit against a therapist who exploits a patient's
trust is similar to filing suit against any professional who has caused a
personal injury. It begins with a "complaint." This amounts to a state-
ment of what happened between the patient and the offender, along with
a brief description of why the law makes him legally accountable for
those actions in court. The "legal theory" or basis on which these cases
are typically brought depends upon the jurisdiction. Currently four states
have passed statutes that provide a legal basis for bringing a civil lawsuit
for sexual exploitation: California, Illinois, Minnesota, and Wisconsin.
In those states where there is no specific statute, the legal theory gener-
ally used today is "malpractice." This means that there was a profes-
Bringing Your Therapist to Court 81
sional relationship between the patient and the therapist, that the thera-
pist had a professional duty of care, and that he failed to carry it out in
a nonnegligent manner.
In earlier days cases were typically brought under a different legal
theory, usually "criminal seduction" or "alienation of affections." These
suits were usually unsuccessful, however, primarily because by the time
the first cases were brought, laws against alienation of affections and
similar actions were, one by one, being abolished in most jurisdictions.
A case brought in Michigan in 1968 illustrates the problem. In that
matter a husband and wife sought the services of a therapist for marriage
counseling. During the course of the counseling the therapist allegedly
persuaded the wife to obtain a divorce and engage in a sexual relation-
ship with him. The husband brought suit under the legal theories of
breach of contract, professional malpractice, assault and battery, negli-
gence, and fraud. The court said that although these various theories had
been stated as the legal basis for the suit, the underlying complaint really
amounted to criminal seduction and Michigan recently had abolished
that action by statute.
Not long after the Michigan case, others arose in other jurisdictions,
some of which apparently were more sensitive to the seriousness of this
problem. A number of different "theories" of law were tried, and eventu-
ally "professional malpractice" was successful. Sexual exploitation is
now considered malpractice for two reasons: First, courts have been
increasingly willing to accept that violating an obligation of trust which
is an important part of the therapeutic relationship constitutes an act of
malpractice. Second, more and more courts have been willing to ac-
knowledge the transference phenomenon (see Chapter 2) and to hold
that sexual misconduct constitutes a mishandling of the transference.
Courts have not been uniform in holding that sexual exploitation al-
ways amounts to malpractice. In a Massachusetts case in the 1980's, for
example, the Supreme Judicial Court of Massachusetts suggested that
sexual exploitation by psychologists, psychiatrists, social workers, and
gynecologists would likely constitute malpractice because it "arises out
of" the professional relationship; however, in cases of sexual exploita-
tion by other professionals, such as dentists, it would not. Because of
the unique relationship of these professionals, primarily therapists, with
their patients (specifically including issues of transference and depen-
dence) sexual misconduct is thought to "arise out of" the very nature of
the professional relationship.
The first major exploitation case to succeed on a theory of profes-
sional malpractice occurred in New York in 1976. In that case a woman

alleged that she was coerced by her psychiatrist into engaging in a sex-
ual relationship with him for over 13 months as part of prescribed ther-
apy. The New York court allowed her to sue for professional malprac-
tice and a jury awarded her $100,000. The court ultimately reduced the
award to $25,000 on the basis that it was excessive. In 1976 this type
of case was still a novelty.
Professional malpractice has now emerged as the universal basis for
bringing suits for sexual exploitation. It is based upon a "contract" the
patient makes with the therapist to provide professional services and to
exercise all due "skill, care and diligence." This, of course, expressly
requires that the treatment not cause harm. But while this explains why
it is wrong to provide a treatment that is harmful, it does not explain
how exploitative sex is considered a treatment of any sort. Why isn't it
an intentional harm, not substantially different from intentionally injur-
ing a patient in another way unrelated to the prescribed therapy?
The answer seems to lie in two different arenas, one practical and the
other conceptual. The practical answer is that the incidence of sexual
exploitation is disturbingly high, and, if it is not caused by the profes-
sional relationship, certainly it develops within that relationship. If there
is to be a practical remedy, it must be the professional who implements
it. Indeed, professional liability is the most direct route to eliminating a
problem that arises out of professional practice. The conceptual answer
lies within the understanding of the transference and countertransference
phenomena described in detail in Chapter 2.
TRANSFERENCE
Transference reactions can result in strong feelings of attraction to
an empathic and attentive therapist. The mental health professions are
unequivocal in recognizing that such phenomena are an integral part of
the therapeutic relationship. They also recognize that as a consequence
of transference, patients are vulnerable to undue influence primarily be-
cause they do not understand the nature of their attraction to the thera-
pist (or the therapist's "countertransference" reaction). Understanding
these issues has enabled the courts to formulate legal standards concern-
ing the mishandling of these therapeutic phenomena. Specifically, if a
patient does not understand her attraction to her therapist, she cannot act
in a truly consensual way (see Informed Consent). The "negligence"
or "malpractice," therefore, refers to the therapist's manipulation of the
transference. When the therapist elicits strong feelings of trust, depen-

dence, and intimacy, his responsibility is to use them in a productive,
therapeutic way. His failure to do so or, worse, his exploitation of those
feelings is a violation of his due care that is recognized in all of the
ethical codes of these professions. Because of the powerful nature of
transference, the potential for abuse is great.
Countertransference can cause a therapist to develop what he believes
to be an attraction to the patient. Sometimes therapists do, in fact, de-
velop strong feelings toward their patients. If not recognized and han-
dled appropriately, it dramatically increases the possibility that he may
try to seduce a patient, who never benefits from these actions. At the
very least the patient loses the opportunity to obtain the treatment that
she initially sought from the therapist. In most cases the emotional con-
sequences are much more severe, often even tragic. Misuse of counter-
transference also constitutes malpractice.
The transference phenomenon was introduced into the legal literature
in 1968 in a Missouri lawsuit. In that case a female patient of a male
psychiatrist sought damages for the effects of her sexual relationship
with him. Having originally sought treatment for headaches and diar-
rhea, the patient was cured of these symptoms but became involved in
an ongoing sexual relationship with the doctor. They both expressed
love for each other, and he encouraged her to leave her husband. The
Missouri court which heard the case recognized the transference and the
resulting undue influence which makes a patient vulnerable to manipula-
tion and exploitation. Finding that the defendant psychiatrist was liable
for malpractice, the court stated: "The defendant did not treat [the pa-
tient] properly and as a result she was injured. He mishandled the trans-
ference phenomenon, which is a reaction that psychiatrists anticipate and
must be handled properly."
More recently, a federal court of appeals in 1986 demonstrated sub-
stantial understanding of the transference phenomenon and patients' re-
sulting inability to understand their physical or sexual attraction to a
therapist. In that case a divorced woman obtained counseling from a
social worker for nearly 7 years. During the fifth year the counselor
initiated romantic contact, encouraging the patient to act upon her pro-
fessed feelings of attraction to him. This continued throughout the re-
mainder of her treatment. The court held that sexual exploitation under
such circumstances constitutes a mishandling of the transference phe-
nomenon and gross negligence on the part of the therapist.
Other courts under similar circumstances have also considered sexual
contact with patients to constitute a violation of a fiduciary duty and an

ethical obligation. Civil lawsuits generally contain these grounds as well,
but suing on the basis of professional malpractice has proved to be a
better legal approach. Although the courts still linger behind in their
willingness to recognize the severe and potentially devastating effects of
exploitation by therapists, they are now generally willing to accept the
validity of the transference phenomenon.
LEGAL DEFENSES
After a lawsuit is filed, the accused is entitled to state his "answer,"
which generally consists of either a denial that the acts occurred or an
admission that they did occur but with an explanation or "defense" for
his conduct. At trial, he will be required to try to prove what he puts
forth in his answer. A number of common defenses have been attempted
with varying degrees of success.
Defense 1: Statutes of Limitations

Statutes of limitations address the amount of time that a victim of any
wrong can wait until it becomes "too late" to pursue her claim. They
are based upon the notion that victims should have a certain period after
an injury occurs within which to decide to bring suit and take the initial
steps to process it. On the other hand, after too long a period, it becomes
too difficult to prove or disprove the claim because memories fade and
evidence gets stale or lost. The period varies from state to state and
depends upon the type of case. What these statutes attempt to do is
balance the patient's need to pursue her claim and the need of the ac-
cused not to have to defend old claims. Statutes of limitations for this
type of action range from 1 to 4 years.
Debbie sought treatment from Dr. R., a psychologist who main-

tains a practice in Massachusetts, in April 1989. Their sexual rela-
tionship began in June 1989 and their last sexual contact was on
November 22, 1989. Thereafter she saw him once more, on De-
cember 3, 1989. The statute of limitations for this type of case in
Massachusetts is 3 years. The court is likely to find that the statute
"runs" on November 21, 1992.
There are very few exceptions to the statutes of limitations. One is a

legal doctrine known as the "discovery rule." This allows the time the
victim has to pursue her claim to be extended if she can prove that she
did not, and could not, "discover" the injury within the period prescribed
to bring the lawsuit. In those cases most courts are willing to extend the
period, giving the victim a reasonable amount of time after she has (or
"should have") discovered her injury, to bring suit.
David was treated in June 1984 for a broken ankle. During the
evaluation he was accidentally subjected to a very large dose of
radiation. The statute of limitations for personal injury was 2 years
in his state. However, it was not until February 1992 that any evi-
dence of cancer appeared which could be attributed to the overdose
of radiation. The statute of limitations will probably begin in Feb-
ruary 1994 and will "run" in February 1996.
Because of the nature of sexual exploitation by therapists and the

consequences of transference phenomena, it is entirely possible that a
victim may not realize that she has been victimized or recognize the
extent of the harm within the prescribed period. It is often not until
many years later, perhaps after reentering therapy with another therapist,
that she comes to understand that she was a victim of exploitation.
Maybe she believed that because she consented or, at very least, did not
object to the therapist's sexual advances, she has no claim against the
abusive therapist. This, of course, is not the case, but she may not recog-
nize it until after the period has elapsed. A number of courts have been
forced to deal with the question of whether the discovery rule should
apply under these circumstances.
In the federal lawsuit discussed previously, the victim filed suit nearly
3 years after the abuse began in a state that had a 2-year statute of
limitations. The court applied the discovery rule (which is used primar-
ily in medical malpractice actions) and allowed the claim on the basis
that the victim did not "discover" the wrong done to her until she con-
sulted a psychiatrist some years later and learned that the exploitation
caused her further emotional difficulties.
More recently, in a 1991 case also in Massachusetts, the Supreme
Judicial Court held that the statute of limitations would not start to run
until a victim knew that she might have been injured by her psychother-
apist's misconduct. Recognizing that the causes of psychological injury
can be subtle and the behavior is often justified to the patient as proper
or acceptable, the court held that the time begins to run when the "rea-
sonable person who ha[d] been subjected to the conduct" would have
recognized that she may have been injured by improper conduct.
Defense 2: Informed Consent

The most obvious potential defense to claims of sexual exploitation
is that the patient, a legally competent adult, consented to the sexual
activity. The theory of informed consent is that both doctor and patient
communicate, understand, and respect each other's duties and obliga-
tions, particularly those concerning the potential benefits and risks of
treatment. Most importantly, it is the patient and not the doctor who
ultimately decides what is in her own best interest. In some cases, how-
ever, particularly those in which there is a substantial imbalance of
power, the doctor has a special obligation if he believes that she may
be highly susceptible to influence and not really capable of giving fully
informed consent. Part of the obligation is to exercise particular care. In
psychotherapy, the patient consents to an initial, provisional treatment
plan, but she is not likely to understand her evolving experience of the
treatment, particularly the transference phenomenon. As a result, thera-
pists must recognize that, as to treatment issues involving transference,
even an intelligent, capable person can be unduly influenced. Conse-
quently, there is no true informed consent. Special care is necessary so
as not to manipulate, abuse, or exploit the transference relationship.
Kerry was referred to Dr. A. by her family doctor for treatment of

depression. After several weeks of therapy, she began to feel better
about herself and started to develop strong feelings of attraction
toward Dr. A. In fact, it was she who pursued him and suggested
that she wanted to have a sexual relationship with him. Her expres-
sion of affection seemed sincere and Dr. A. had developed feelings
of his own for Kerry.
At this point it is up to the doctor to recognize the transference, be

willing to work through it with the patient, but at the same time be clear
and unequivocal that he will not now, nor at any future time, have any
sort of sexual contact with the patient.
At the onset of the professional relationship, prior to any transference
involvement, patients "bargain for" therapeutic treatment, not a sexual
relationship. If, as therapists acknowledge, the transference renders true

voluntary consent impossible because of the issues that develop, then
informed consent about acting on transference feelings (such as agreeing
to, or even initiating sexual contact with the therapist) is virtually mean-
ingless.
Defense 3: Contributory Negligence

A similar but not identical legal concept that the courts have ad-
dressed is a principle known as "contributory negligence." A victim is
contributorily negligent if she somehow voluntarily contributes to her
own injury, whether or not her participation is intentional.
Michael was walking against a traffic light when he was hit by a

car which was speeding. Because of excessive speed, the driver
was unable to stop. The driver is likely to be found "negligent" for
driving too fast, but Michael may be found "contributorily negli-
gent" for walking against the traffic light. Depending on the state
and how much Michael "contributed" to his injury, his award may
be either reduced or denied.
Is a patient contributorily negligent in being sexually exploited if she

"consents" to or even initiates sexual contact with her therapist? The
mental health professions are unequivocal in saying "no." They insist
that the power structure and transference dynamics are so important that
there can be no voluntary consent, under virtually any circumstances.
With respect to the law, most civil courts will admit and consider evi-
dence of the surrounding circumstances for possible contributory negli-
gence. This could include, for example, her knowledge that the therapist
was married and therefore the sexual contact was illicit. Furthermore, in
those states where criminal statutes exist, consent is irrelevant and not a
defense.
In practice, courts today usually recognize the tranference phenome-
non as a valid principle and ultimately do not accept either informed
consent or contributory negligence as a defense. Nevertheless, it seems
illogical that if a patient agrees to a sexual relationship (and appears in
court to be legally competent) that nonetheless she was, in fact, psycho-
logically incapable of giving informed consent. The practical conse-
quence in the civil actions is that her psychological and sexual history
is put on display in an attempt to discredit her claim. Courts are notori-
ously slow in demonstrating the understanding and sensitivity that would

be required to overcome this conceptual hurdle: that is, recognizing that
a woman who is in all other respects capable and competent to make
informed decisions can nevertheless be so unduly influenced that she
loses her ability to make this voluntary, informed decision in a rational
manner. This would shield her from having to put her psychological and
sexual history on display, instead allowing the transference phenomenon
to be set forth to explain her participation.
DAMAGES (COMPENSATION FOR THE VICTIM)

The final legal obstacle that a victim must overcome is proving that
she was injured or damaged as a result of the sexual relationship with
her therapist. The purpose of civil lawsuits is only to compensate vic-
tims for harm actually suffered. Consequently, an important part of her
"case" is her ability to prove that she was injured or "damaged" by the
acts of the accused therapist. In cases of sexual exploitation, the re-
sulting harm is often difficult to demonstrate or explain to a jury. The
best way of doing so is to bring in another therapist who has since
evaluated the victim and can explain the harm that was done.
In addition to the legal theories discussed earlier, courts often recog-
nize a legal claim known as "negligent (or intentional) infliction of emo-
tional distress." This means that in committing the wrong, the accused
negligently or intentionally caused emotional suffering. This "emotional
distress" aspect of the claim is largely what results in monetary awards,
since there is often no physical injury. The dollar value of emotional
distress is highly subjective and may depend upon the victim's ability
to communicate the real impact of the harm suffered effectively.
What are the elements of emotional distress that a jury can consider?
These may include overwhelming feelings of guilt, abandonment, anger,
sexual dysfunction, inability to trust, and, not infrequently, risk of sui-
cide.
A final item of the monetary award that is allowed by some courts is
known as "punitive" damages. Particularly in those cases in which the
other damages are inadequate to punish a defendant, a court might im-
pose punitive damages for egregious, willful, wanton, reckless, or outra-
geous behavior.
Elizabeth was sexually exploited by her psychotherapist and suc-

cessfully sued him for her injuries. The jury found that she suffered
from emotional distress as a result of his conduct. Her "injury"
included sexual dysfunction and undue feelings of anger and aban-

donment. The jury awarded $10,000 for treatment with a subse-
quent therapist, $30,000 for "compensation" for her emotional dis-
tress, and $50,000 in "punitive" damages to punish the abusive
conduct.
Juries will award damages to a sympathetic victim who can prove

that she suffered as a result of being exploited. The dollar value of these
cases is highly unpredictable, depending on the makeup of the jury and
the presentation of the case. Low damage awards can be increased with
punitive damages; on the other hand, the court may also be able to
reduce an award which it believes to be excessive. In the case that oc-
curred in New York discussed previously, the court reduced a $100,000
award to $25,000 on the basis that the victim's psychological condition
as it existed prior to the sexual violation was severe, and its award
should reflect only the aggravation of that condition. Nevertheless, many
courts' attitudes toward sexual exploitation have changed considerably
since that decision and even multimillion-dollar awards have been seen
today.
LIABILITY OF EMPLOYERS
A final issue that has confronted a number of courts is the question
of whether the employer of an abusive therapist should be legally re-
sponsible to a victim of sexual exploitation. If, for example, a patient
goes to a mental health agency and is exploited by the therapist assigned
to her, is the agency liable? Not surprisingly, the courts are not consis-
tent in the way that they treat this issue. On the one hand, employers
are generally liable for acts of their employees which occur within the
scope of the employment. On the other hand, employers are generally
not liable for intentional or illicit acts which do not necessarily occur as
a consequence of the employment. Of course, the employer would argue
that it neither authorized nor even knew about the exploitation.
In the federal matter discussed previously, the federal appeals court
upheld an award of $150,000 on the basis that the sexual relationship
between therapist and patient could not be understood apart from the
therapeutic relationship: Although the sexual aspect was clearly not
within the "scope" of the therapist's duties, it nevertheless "arose out
o f the practice of an employee. The employer was therefore considered
liable for the acts of its employee.
An alternative theory has been used in arguments against employers
in those cases in which the court has found that the sexual relationship
was outside the scope of employment and therefore not the responsibil-
ity of the employer. In a case in Colorado, a court held that although an
employer should not be held liable for an illegal or forbidden act of its
employee, it could be liable for negligent hiring or supervision of that
employee. That case involved a parish priest who had previously been
known by the diocese to have sexually exploited other parishioners and
had done nothing about it.
Dr. K. was employed by Tri-State Mental Health Services. A jury

found that he had sexually exploited a patient and awarded her
$25,000 in damages. Tri-State was also named as a defendant on
the basis that it employed Dr. K. and that it should have better
supervised his activities. Tri-State defended itself on the basis that
(1) sexual contact with patients was illegal in its state and (2) that
it occurred away from the employer's premises. Depending on the
state and on whether or not Tri-State had any reason to know that
Dr. K. was abusing his patients, the employer may or may not be
liable.
Like the administrative and regulatory mechanisms discussed in the

previous chapter, so far the civil law seems to have done relatively little
to curb the problem of sexual exploitation among therapists. Clearly a
large part of the problem, which also serves to discourage victims from
coming forward, is the erratic enforcement. Most abusive therapists
know that the probability of getting caught and being held accountable
is reliably low. Many also expect to be shielded by the unspoken "con-
spiracy of silence" between professionals whereby each is very reluctant
to speak out against another. Nevertheless, the consequences to the few
can be severe and, even if a therapist is ultimately absolved of the
charges, the judicial and administrative proceedings are demanding and
certain to take an enormous toll.
Chapter 7
Legal Recourse for Sexual

Exploitation by Other
Professionals: The Emerging Law
CASE STUDY: LORI
I was referred to attorney Jeff K. by a girlfriend who was divorced

three-and-one-half years earlier. Jeff had gotten her a fabulous settle-
ment and I was scared to death about facing my husband, Dave, in court.
When I didn't jump at his first offer of half the house and nothing else,
Dave hinted that he might try to take my children away. When I heard
about how Jeff always got what he wanted for his clients, I knew that I
desperately needed him to take my case.
When I first met Jeff I was immediately struck by his smooth and
gentle manner. He gave me the impression that he absolutely knew what
he was doing and that he cared about getting good results for his clients.
I was delighted when he agreed to take my case. He asked for $2,500
up front, which my girlfriend told me was the usual "retainer." I didn't
know exactly what that meant but I assumed it at least meant that he
was stuck with me. I certainly felt a lot better knowing that Jeff was
handling the divorce.
Thinking back, one thing that surprised me was that a couple of times
Dave's lawyer inquired about a reconciliation and both times Jeff imme-
diately dismissed the possibility, without asking me what I thought or
even giving it serious consideration. I rationalized it at the time as trial

strategy, but I kept wondering whether he would ever ask me about it.
In fact, Jeff often made decisions about the case for me, and I figured
that it was how he managed to get such great results. I also sort of
admired a man who would take charge and felt that I was in good hands.
Right from the beginning there were so many things that I liked about
Jeff. He was good-looking, but not in a flashy way. His personality was
almost a Jekyll and Hyde in that he was kind and patient with me and
such a tough fighter when he dealt with Dave's lawyer. I think that
that's probably what I liked the most about him: I knew he could get
what he wanted. Also, right from the beginning Jeff gave me the sense
that somehow my case was special, that he really cared about my getting
those kids, and that he really cared about me.
The third time I met with Jeff he asked me to go out for a drink
afterward. He didn't try to pressure me. He just said that it would be
good for both of us to unwind and that he enjoyed my company and
would like to spend a little more time to get to know me. He was a
perfect gentleman that evening and whatever reluctance I felt when he
first asked soon disappeared. I had a great time and I got a little better
glimpse of that Jekyll and Hyde personality, but in a way that made me
more comfortable. He seemed to say that there was him and there was
his work, and that as a litigator, he needed to maintain a tough facade.
But he assured me that the real Jeff was the kind and gentle man I knew
and I ate it all up.
It was only a matter of weeks before Jeff and I were seeing each
other regularly and we quickly became involved sexually. Having Jeff
in my corner made me feel secure and having him pay attention to me
and love me made it much easier to get through the divorce. But to tell
the truth, a part of me was afraid to think too much about what was
going on. Sometimes he would make references to our future together,
but I really couldn't see beyond getting divorced from Dave. In any
event I didn't want to rock the boat because I was desperately afraid of
losing the kids.
After about 8 torturous months Jeff and my husband's lawyer started
serious negotiations. Now I needed Jeff more than ever because all kinds
of confusing proposals were being kicked around and I had no idea what
some of them meant or even what was best for me. Did I want alimony
or a larger share of the house? If I agreed to joint custody, what would
happen if Dave decided to move out of town? I was in no condition to
think through the consequences of these things and I needed to rely on
Jeff to do what was right.
Legal Recourse 93
Right before the holidays of that year we were close to settlement and
Dave even seemed a little more generous about my share of the house.
But he was dead set against alimony and I didn't think I could make it
with just the income from my part-time job. The house was going to be
sold, but who knew when or how much it would bring. I looked to Jeff
for those answers and in his typical self-confident way, he just kept
telling me not to worry. He said I should be grateful that Dave wasn't
fighting for the children and besides, alimony would probably end if I
remarried or lived with another man. Well, I had no thought of remar-
rying but I did know that the bills had to be paid every month. When
we got to the final negotiation, Dave's lawyer was adamant about the
great settlement he was offering and Jeff was really pressuring me to
take it. I was confused and I was scared, and when Dave mumbled
something (I don't even know what) about the kids, I just grabbed the
offer, frightened as I was.
Right from the start I regretted taking that deal. I was relieved that
there was no fight over the children, but scared that I didn't have ade-
quate income to support them. I also found out later that once alimony
was waived in the original settlement, it was virtually impossible to get
it later. Things ended up in a mess. The house didn't sell for over a year
and I had to get a full-time job just to make ends meet. Dave paid some
child support, but it wasn't reliable and it barely covered the extra day
care since I had to work so many more hours. Of course, I don't know
what else might have been possible, but I've always wondered what
might have happened if I had held out for alimony.
What happened to Jeff? Our relationship lasted for about 3 months
after the divorce when he told me that he really wanted to marry me.
For me, it was much too soon to think about a commitment to another
man, particularly since my children needed me more than ever and the
demands of my new job were already affecting my ability to care for
them. When I told Jeff that I wasn't ready and couldn't think about
marriage now, he said something that floored me: "How do you think
you're going to make it with no husband and no alimony?" he demanded
to know. It wasn't until that moment that I realized what I think I may
have understood all along: Jeff had his own agenda, and if I married
him, I would have been better off forgoing alimony and taking a larger
share of the property since alimony would end when I remarried
anyway.
The fact was that marrying Jeff at that time wasn't in the cards for
me. As I think back on it, I dated him mostly because I was afraid to
say "no." Of course, there was a part of me that liked Jeff and was
turned on by his kind manner, his powerful position, and his obvious
interest in me. At the time, I needed his strength, but after the divorce,
I was more interested in taking care of my children and developing my
own supports. Jeff helped me a lot but he never told me that the settle-
ment that he recommended only worked if I went along with his plans
for me to marry him. I didn't, and my children and I paid the price for
many years to come.
For years the mental health professions have been plagued with the
knowledge that many practitioners within their ranks have taken advan-
tage of unsuspecting patients by engaging them in sexual relationships.
For a long time, little was said and less was done. However, in recent
years the professions themselves, recognizing the magnitude of the prob-
lem and the severity of the consequences to victims, have taken a visible
role in denouncing and punishing such conduct. As sexual exploitation
became better understood in that field, many of the other professions
were also forced to examine the conduct of their own members. Not
surprisingly, remarkably similar occurrences were found, as was a new
trail of victims. Some other professions have been slower to respond,
however, but in recent years they, too, have been forced to come to
terms with this widespread problem.
ATTORNEYS
The legal profession has recently received substantial publicity con-
cerning sexual exploitation among lawyers, particularly divorce lawyers.
In 1992 the state of California declared a "ban" on lawyer/client sexual
relations while the lawyer is representing the client, if the relationship
affects the quality of the legal services. The prohibition provided little
guidance about how the representation might be affected, although eth-
ics boards had addressed that issue on numerous occasions. Shortly after
California adopted its position, Oregon followed suit, also prohibiting
lawyer/client sexual relations. At the same time Illinois was carefully
reviewing a similar regulation, although it has yet to take action as this
book goes to press. No actual cases have yet tested the application of
the new California or Oregon rules, although numerous cases covering
the same matter have been the subject of disciplinary proceedings
throughout the country. California has a civil remedy for sexual exploi-
tation in addition to its already existing administrative (disciplinary) ac-
Legal Recourse 95
tion, including the removal or suspension of a member's license to prac-

tice law.
Unlike psychotherapists, who identify a specific therapeutic process
(transference) as responsible for their ability to exert undue influence on
their patients, lawyers are less exact about what it is about the lawyer-
client relationship that can result in similar undue influence. What has
been said is that there is a power imbalance (i.e., the lawyer knows more
about how to handle the legal matter than the client) which requires
the client to place his trust and confidence in his lawyer. As the more
knowledgeable person, the lawyer therefore becomes more influential.
This is traditionally known as a "fiduciary" relationship in which one
individual seeks the services of another simply because an "expert" in
the field is needed to assist the layperson in making independent, in-
formed judgments about what is in her best interest. As a result, she
hires an expert, the lawyer, whom she, as the client, must then trust.
She may reveal to him highly confidential information, even sometimes
including a confession of criminal conduct, with confidence and faith
that the lawyer will use this information only to assist her and always
act in her best interest.
Is this a transference or transferencelike relationship? The answer ap-
pears to be that it has many of the same features of the special relation-
ship which is technically reserved for mental health professionals. Al-
though it is less obvious, the transferencelike relationship may occur in
a very compelling way. Transference feelings can result when one per-
son (the client or patient) views another person as being in a more pow-
erful role, akin to that of a parent, and experiences (even acts out) feel-
ings of unquestioning trust, dependency, and need. In theory, what seem
to make the lawyer/client relationship less compelling are that the de-
pendency and need are not necessarily of an emotional nature and that
emotional involvement with the client is not necessary in order for the
attorney to perform his services. Often, but not always, the issues are of
a practical nature (real estate transactions, preparing a will). As a result,
the attorney's client is more likely to be able to make a judgment about
whether she welcomes emotional involvement with her lawyer. But not
necessarily.
Lawyers often deal with emotionally troubling circumstances such as
divorces and personal injury, as well as with emotionally distraught cli-
ents. They also deal with clients who are ignorant about their option to
find another (nonabusive) lawyer. Lawyers deal with clients who are
scared or intimidated about their circumstances (whatever their entangle-
ment with the law might be). Lawyers also deal with clients who have
dependent personalities and/or who are afraid to say "no" if approached
with an inappropriate or unwelcome request (for example, for sexual
intimacy) by their attorney. While it is unclear how much transference
may be involved in a particular case, what is certain is that at least the
fiduciary obligation owed to these clients includes the duty not to re-
quire, coerce, or cajole them into a sexual relationship.
The question of whether lawyers, like psychotherapists, should have
a legal as well as a moral obligation to recognize undue dependency and
not take advantage of it is a more difficult one. Unlike psychotherapists,
lawyers are not trained to recognize and deal with transference and
countertransference phenomena. Of course, lawyers could be trained to
understand enough to recognize transferencelike reactions: how they oc-
cur and how to deal with them. Lawyers could certainly be trained to
understand that when a dependent or needy client confronts a kind and
attentive professional who undertakes to pursue her cause zealously cer-
tain transferencelike feelings can arise. They could also be trained to
understand that clients who are in an emotionally vulnerable state (as
when going through a divorce) are more prone to transference reactions.
They can also come to understand that certain rules of professional con-
duct result from this occurrence. The real problem is that, in practice,
transference is more complicated to understand and address by one un-
trained in mental health. The prelude to sexual involvement is often
complicated. It is not always possible for an untrained professional to
recognize the inappropriate precursors to exploitative conduct. And so
the result is that lawyers find themselves on the brink of prohibited
conduct, searching for excuses or rationalizing their behavior because
they never understood why they were at risk for becoming the perpetra-
tors of sexual exploitation.
The alternative to requiring lawyers to understand and deal with trans-
ference phenomena is simply to require them to understand what it
means to abuse a fiduciary relationship. All professionals can be ex-
pected to recognize that when their clients have to place their blind faith
and trust in them, they must not abuse that trust. Then it is only a small
leap to prohibit the professional from engaging in any kind of relation-
ship with a client that might influence or impair the client's free will. In
fact, all professions have adopted a code of ethics that operates to do
just that. Psychotherapists have specifically identified sexual relations
as, per se, such an activity. Other professions are beginning to reach the
same conclusion. Numerous cases have been brought under legal stan-
Legal Recourse 97
dards of ethics when lawyers have influenced or coerced a client, engag-

ing them in sexual relations.
Atty. G. was a divorce lawyer. Sharon was his client. Atty. G.

was kind and attentive to Sharon's case and she was emotionally
vulnerable. At one point Atty. G. told Sharon that he was sexually
attracted to her. She submitted to his advances, uncertain whether
she, too, was attracted to him (e.g., was she attracted to him, or to
his position and his interest and attentiveness to her?) She was
certain that she didn't want to lose him as her lawyer and wasn't
sure what would happen if she declined his sexual advances.
In a Wisconsin case an attorney was accused of suddenly asking a

client to remove her clothes while they were meeting in his office. When
she refused, he turned off the lights and began to fondle her. Without
citing a specific rule, the Wisconsin Supreme Court upheld a 90-day
license suspension on the basis that there was an ethical obligation bind-
ing attorneys that prohibited unsolicited sexual contact.
Another common situation occurred in an Iowa case. An attorney was
accused of kissing and fondling an inmate whom he was assigned to
represent. An Iowa court said that the lawyer had an ethical obligation
to behave in a professional manner. The court determined that his con-
duct was not "temperate and dignified" as required by the code of ethics,
and he received a reprimand.
More recently, two highly publicized cases occurred in New England,
one in New Hampshire and one in Rhode Island. In the New Hampshire
case a 34-year-old married woman sued her divorce lawyer for engaging
her in a "consensual" sexual relationship with him while he was repre-
senting her in the divorce action. The woman had been under the care
of a psychiatrist for treatment of a mental condition. On three occasions
beginning within a week of meeting this client the lawyer initiated sex-
ual contact with her, professing great attraction and claiming that he,
too, was experiencing a deteriorating marriage. When in due course the
lawyer terminated the sexual relationship, the client was left with only
a hope that somehow their relationship might be salvaged.
With a significantly deteriorated emotional state and the urging of a
compassionate psychiatrist, the woman was eventually able to find a
new lawyer and she initiated both a complaint before the New Hamp-
shire Bar Association and a private lawsuit. The disciplinary proceeding
before the bar association was heard first; there it was determined that
a sexual relationship did, in fact, occur (contrary to the denial of the

lawyer). As for whether or not she consented: that did not matter, said
the court. The lawyer knew that she was in an "emotionally fragile"
state and was under treatment for a mental disability, and it violated his
"fiduciary" (professional) obligation to her when he preyed on her
known vulnerability and engaged her in a sexual relationship. In the
lawsuit that followed, a jury awarded her $125,000 for the emotional
pain and suffering that resulted from the lawyer's unethical conduct.
A short time later the case in Rhode Island was heard. In that case
another woman also sued her divorce lawyer for engaging her in a sex-
ual relationship with him. She, too, claimed to be in an emotionally
compromised situation as she dealt with a difficult divorce. Furthermore,
in that case the lawyer's law partners were also sued on the grounds
that they knew of the improper sexual relationship and reportedly looked
the other way.
Numerous other cases have been brought around the country for sex-
ual misconduct and exploitation at the hands of lawyers. In the past
penalties generally included private or public censure, reprimand, sus-
pension of license, and outright disbarment (loss of license to practice
law). Recently, however, they have also included the possibility of a
private lawsuit brought by a client who claims to have been injured as
a result of the improper conduct.
While disciplinary proceedings against lawyers for unethical sexual
misconduct have been numerous, civil suits are still relatively rare. The
legal basis for such suits against psychotherapists is usually "malprac-
tice," since the therapist is thought to mishandle the transference phe-
nomenon, which is a specific part of the psychological treatment. That
legal theory is more difficult to apply to lawyers since managing trans-
ference is not a recognized part of legal practice. Instead the basis for a
malpractice action is that lawyers are usually said to breach their fidu-
ciary obligations to clients when they engage in sexual misconduct.
The idea that a lawyer who sexually exploits a client might be sued
civilly on that basis is quite new. In fact, the first case brought against
a lawyer for sexual exploitation as a basis for legal malpractice was
tried in California in 1983. In that case the plaintiff brought suit alleging
legal malpractice, fraud, battery, and intentional misrepresentation on
the basis that she had agreed to engage in sexual relations with the
defendant (her attorney) only when he said that he "[couldn't] possibly
get anyone pregnant." The plaintiff did, in fact, become pregnant, with
substantial resulting physical complications. The court said that the at-
Legal Recourse 99
torney owes a fiduciary duty to his client and that duty may be breached
by engaging her in sexual relations while also representing her. The
court intimated that a client could bring a civil suit for breach of fidu-
ciary obligations pertaining to financial claims, and that an action should
be allowed for physical injury as well.
As to the suggestion that it was unethical for the attorney to have
engaged his client in sexual relations, the court noted that a civil lawsuit
arising out of an alleged ethical violation had never been brought in
California at that time (1983). It suggested that such a claim might be
brought before the California Bar Association. Less than 10 years later,
California became the first state specifically to prohibit lawyers from
sexually exploiting their clients.
While a civil lawsuit against an attorney who engages a client in a
sexual relationship now has precedent, not all cases, even recently, have
been successful. For example, in a 1989 Illinois case a woman engaged
a divorce attorney who succeeded in coercing her into having sexual
relations with him. After a second incident, however, she fired him and
engaged another lawyer, who handled her case competently. When she
sued for legal malpractice and breach of fiduciary duty, her lawsuit was
dismissed for two reasons. First, the court held that the lawyer had no
duty to refrain from sexual relations with his client. Second, she suffered
no actual harm because her case was eventually resolved to her satisfac-
tion.
Since that case, however, Illinois has come to the forefront in the
legal profession's quest to eliminate sexual exploitation from the prac-
tice of law. Currently it is considering a rule that would prohibit such
conduct, as California and Oregon have. In fact, in a subsequent Illinois
case, an appeals court specifically referred to sexual relations between
lawyers and clients as "the legal profession's 'dirty little secret.' " In
commenting that a sexual relationship between a divorce lawyer and his
client is inherently exploitative, one of the justices, in a well-reasoned
opinion, specifically identified two factors that contribute to a lawyer's
not being able to serve his client adequately under those circumstances:
first, sexual relations with a married woman constitute adultery, and evi-
dence of adultery could adversely affect the woman in her divorce action
in terms of child custody, alimony, or division of property. Second, the
lawyer/client relationship is privileged (i.e., confidential and private) but
only in respect to the conversations held in the context of their profes-
sional relationship. If she talks to him about her case during personal
time, it may destroy the privilege of confidentiality.
Finally, in a 1991 California case, a woman claimed that she engaged

a lawyer to represent her, but he delayed and withheld his legal services
after she refused to grant him sexual favors. The court allowed her to
go forward with a lawsuit for legal malpractice on the grounds that such
conduct fell below the standard of skill and care that is required of the
legal profession. This case occurred prior to the recent prohibition, and
the court stopped short of declaring that sexual relations between a law-
yer and client, even during the period of representation, are per se viola-
tions of a lawyer's fiduciary duty or obligation to his client.
California and Oregon have recently taken a giant step forward in
the direction of putting an end to sexual exploitation in lawyer/client
relationships. Other states may be on the brink of following suit. As a
result of a new provision, it should become easier for victims to bring
not only complaints, but lawsuits, against lawyers who exploit them in
this way. It is not entirely clear, however, how such provisions might
operate. After considerable debate over the proposed prohibition, the
compromise that California reached was to adopt a regulation that pro-
hibits attorneys from "demanding or requiring" sexual favors from cli-
ents in return for legal services or as a condition of providing legal
representation. Recognizing that sexual involvement can impair a law-
yer's ability to represent his client's interests fully and fairly, the new
provision makes disciplinary action possible if an attorney has sexual
relations with a client and this relationship adversely affects the quality
of the legal representation. Only when actual cases are brought will it
become clear whether the provision has real "teeth."
CLERGY
As discussed in Chapter 1, sexual relationships between clergy and
parishioners are inherently suspect because of the tremendous power
imbalance that makes it difficult for a parishioner to say "no" to a re-
quest for a sexual favor, indeed any favor, made by such an authoritative
leader as a clergyman. To many parishioners, the clergy are godlike
figures with a power and authority that make it difficult to question their
motives. They are individuals whom people are taught to trust and to
respect. Above all, they are certainly not people who parishioners might
suspect would take sexual advantage of them.
When a clergyman plays a role not only of religious leader but also
of spiritual counselor under circumstances in which a particular parishio-
ner needs counseling for a personal problem, the opportunity for abuse
Legal Recourse 101
is even greater. The parishioner now reveals a vulnerability as she shares

some of the most intimate parts of her life with him. Not surprisingly,
therapeutic transference occurs, and so she may develop an exaggerated
emotional dependence on the person who is now acting as both pastor
(religious leader) and counselor (personal healer). It is virtually impossi-
ble to conceive of a sexual relationship under those circumstances that
would not be exploitative or not lead to harm.
The legal cases involving sexual misconduct of clergy generally fall
into two categories. In the first, which will not be discussed here in
great detail, is the pedophilic clergyman. These people generally prey
on children, often boys, and any type of sexual contact under any cir-
cumstances is considered improper, illegal, and exploitative. No author-
ity professes any credible explanation for involving children in sexual
activities of any sort, and such acts are consistently held to constitute
illegal child molestation and a breach of the fiduciary duty of the clergy.
Numerous cases have been brought against clergy who abuse young
children, including the highly publicized Massachusetts case of Father
James Porter in which a Catholic priest was charged with, and subse-
quently admitted, sexual abuse of dozens of young boys who served in
his parishes beginning in the 1960s. The Porter case was brought in both
civil and criminal court with claims against the priest himself and the
dioceses in which he served. The latter was sued for having known
about, but doing too little to stop, his egregious behavior.
Another case involving a child and a clergyman occurred in Oregon.
In that case a claim was brought against a Lutheran church charging
that a pastor had established a "confidential relationship" with a young
woman when she was 13 years old. He had acted as her pastor, coun-
selor, teacher, and "surrogate father" and thereafter abused that position
by manipulating her into having a sexual relationship with him, which
lasted into her adulthood. Interestingly, the court seemed less concerned
with the fact that the woman was a minor when the abuse started than
with the fact that there can be no real consent when there is such a great
power imbalance between the parties.
The second type of claim that is commonly brought against the clergy
for sexual misconduct with their parishioners occurs in the context of
pastoral counseling. In these cases the legal theory differs little from
that which applies to psychotherapists except that there may be another
level of abuse because the power imbalance is even greater: not only
does the parishioner experience transference issues in the psychothera-
peutic sense, but the abuser is also a religious leader seemingly acting
at the hand of God. It is difficult for a woman to come to understand

that a relationship which feels so right because of the transference and,
further, is sanctioned by the church is nevertheless immoral and abusive.
This is a blatant betrayal of trust and professional responsibility.
In a Colorado case, a couple with marital difficulties sought counsel-
ing services from their parish priest. He later took advantage of the
wife's emotional vulnerability by engaging her in a sexual relationship
that ultimately contributed to the collapse of their marriage. The court
held that, on the basis of the counseling relationship, the sexual relation-
ship constituted a clear breach of the duty owed to the parishioners. The
decision fell short of a blanket condemnation of clergy who engage in
sexual contact with parishioners. Interestingly, this court also noted that
its decision would have been significantly more difficult if the priest had
attempted to justify his conduct on the basis that it was consistent with
his religious beliefs. No other court has adopted the suggestion that
the professional duty to parishioners would be any less as a result
of sincerely held beliefs of a clergyman. What this case does demon-
strate is how reluctant courts are to challenge the ethics of the church.
In fact, in Colorado clergy are expressly exempted from legislation
which prohibits psychotherapists from engaging in sexual relations with
patients.
The more difficult situation with respect to clergy is one that no court
has yet addressed directly. That is the question of whether a mutual,
consensual sexual relationship between a clergyman and parishioner
would constitute an inherently exploitative relationship even if there
were no indication of power being abused to coerce an unsuspecting
individual. The presence of a significant power imbalance has been dis-
cussed in detail in Chapter 3. Yet the boundaries that exist in the pasto-
ral counseling relationship do not exist for a parishioner who simply
comes to know and to be attracted to a clergyman in the ordinary course
of church business. In one case a Lutheran minister admitted to having
sex with more than thirty women in his congregation. At one point he
described the women he attracted as "emotionally needy." He also com-
mented that he never targeted a woman unless he was sure that she
would consent. The eventual harm to these victims was enormous: sev-
eral were divorced as a result of the sexual exploitation and one at-
tempted suicide. After receiving treatment for his abusive behavior, he
eventually admitted the dynamics of what was occurring: his victims
were vulnerable and he was in a position to exploit that vulnerability.
He referred to his own behavior as "authority abuse."
Legal Recourse 103
DOCTORS
Yet another clear opportunity for sexual exploitation arises in the con-
text of nonpsychiatric doctor/patient relationships. In these cases sexual
contact is initiated by the physician during or after medical treatment.
Such relationships often occur in one of several ways. In some cases,
sexual conduct is recommended as part of treatment. For example, this
might occur among practitioners known as "sex therapists" or other
practitioners who purport to treat sexual dysfunction or other sexual dis-
orders. Without commenting on the ethics or effectiveness of sex ther-
apy, it becomes exploitation when a patient presents herself to a prac-
titioner for a specific problem or treatment and is somehow coerced into
submitting to sexual conduct which is not therapeutic and is not intended
to benefit her.
In other cases the sexual contact is perpetrated as part of medical
treatment, sometimes during an obstetric or gynecological evaluation.
For example, a relatively common complaint is that a gynecologist
might touch a patient during an examination, manipulating her genitals
in a sexual way. In a number of cases, gynecologists have been accused
of other types of sexual contact, both oral and genital, including sexual
intercourse.
It is important to note that in cases of gynecological malpractice, as
in psychiatric malpractice, most courts have held that the sexual miscon-
duct "arises out of" the medical practice, such that it is usually consid-
ered "malpractice" and not a separate act of some sort of sexual abuse.
Yet in most other (nonpsychiatric) medical contexts sexual misconduct
is more likely to be considered abuse or exploitation than malpractice.
This is important because a physician's medical liability insurance may
cover the claim if the sexual misconduct is labeled "malpractice," but
generally will not cover situations that are labeled "exploitation" or
"abuse."
The remaining cases, not involving psychotherapy or gynecological
services, are more difficult to prove as being inherently exploitative. As
discussed in Chapter 3, the imbalance of power and the necessary trust
that a patient places in her physician creates a particular professional or
"fiduciary" responsibility of the physician. This duty requires that he not
use the faith and trust placed in him to extract favors, sexual or other-
wise, from a patient who is entitled to believe that he is acting in her
best interest or who may be intimidated by his power and thus afraid to
say "no."
In a 1992 Massachusetts case, the court addressed the question of

whether a dentist's sexual abuse of a woman during dental treatment
somehow "arose out of" his professional practice. The court specifically
noted that in contrast to the transference phenomenon that occurs in
the psychotherapeutic context, "there is nothing inherent in the typical
relationship between patient and dentist that makes the patient unusually
susceptible to accept the sexual advances of the dentist." The woman
argued that his "extremely gentle and caring" manner (particularly for
someone who was afraid of dental treatment) made the sexual abuse
"intertwined" with the special care that the patient sought from the den-
tist. The court did not agree and denied her claim that the sexual mis-
conduct "arose out of" the dental treatment.
What is clear from the Massachusetts case is that the patient was
arguing that some sort of transferencelike phenomenon had occurred
between her and the dentist, brought about by the interaction of his
professional stature, his kind and gentle manner, and her vulnerability
her fear of dental treatment. While the court declined to acknowledge
any validity to her argument, what was important to the patient was not
whether the dentist was guilty of sexual misconduct; the existence of
the sexual relationship was established. What the patient wanted to
prove was that the conduct "arose out of" the dentist's treatment of her
so that his malpractice insurance might ultimately pay the bill.
It is not clear yet whether courts will be inclined to recognize and
apply transference theory to cases other than those involving psycho-
therapy. It is difficult to deny that power imbalance involving an author-
ity figure and a vulnerable patient, along with the need for that patient
to trust the authority figure (here, the doctor), contributes greatly to a
patient's feeling dependent and submissive. Whether this is labeled spe-
cifically as a "transference" occurrence as it is in the mental health field
is not the important issue. What is important is the notion that a special
relationship is created in which one person (the more powerful party) is
in a unique position to exploit his power by extracting sexual favors
from the other person (the less powerful party), who trusts his motives
and depends upon his acting in her best interest.
Sexual relationships between doctors and patients (other than those in
the mental health field) which appear to be both voluntary and consen-
sual have thus far not been considered. Is a consentual sexual relation-
ship with a physician, even during the course of medical treatment,
something which the law should regulate? There is no clear answer to
this. The medical profession specifically prohibits sexual relationships
Legal Recourse 105
between physicians and their current patients, but there appear to be no

legal cases in which nonpsychiatric physicians have been sued or disci-
plined for a voluntary, consensual sexual relationship with an adult pa-
tient, even during the course of treatment. Although power and status
may play a role, when there is no overt deception or coercion, there
appears not to be an impetus for prohibiting such activity or disciplining
those who engage in it.
There have been a number of special situations which have resulted
in disciplinary action. For example, in a 1986 Minnesota case a physi-
cian had his license revoked on grounds that, among other things, he
wrote drug prescriptions with excessive frequency for a female patient
who agreed, in turn, to have sexual intercourse with him while under
his care. There it was relatively easy to establish that the conduct
amounted to overt coercion and was therefore clearly unethical. Not-
withstanding the Hippocratic Oath, there is a paucity of lawsuits that
squarely address physicians' having consensual relationships with their
patients.
While lawsuits are rare, however, this does not mean that a patient
who has been sexually exploited is without recourse. There are still ad-
ministrative remedies against such physicians including disciplinary ac-
tions which can result in suspension or revocation of license. There are
also civil or even criminal actions if a rape or sexual assault has oc-
curred. For example, in a number of cases patients have claimed that
sexual activity occurred either while the physician was examining them
or while they were under anesthesia. In those cases there is a clear
absence of consent and even criminal action is appropriate.
TEACHERS AND PROFESSORS

The dynamics between professors or teachers and their students that
make the latter vulnerable to exploitation and abuse are easy to under-
stand. Usually there is a significant age difference between teachers and
students. Except in rare or exceptional instances, there is a significant
difference of professional status. Moreover, students are taught to re-
spect and obey teachers, who act in the role of parent (in loco parentis)
while the student is in school. Teachers are held out to students as role
models whose conduct is to be admired and emulated. For these reasons
it is not difficult to see that a student might be unduly influenced when
approached by a teacher who suggests that she is "special" or "attrac-
tive" to him. The relationship dynamic is similar to that created by trans-
ference. The student may experience attraction; she may also experience
confusion and even coercion. She may be overly eager to please. In
most cases it is difficult for a student to "consent" freely to sexualizing
the relationship. Indeed, the exercise of truly responsible decision mak-
ing may be virtually impossible.
The cases relating to teacher/student sexual involvement that have
been brought through the courts and other administrative bodies fall into
two distinct categories: consensual sexual relationships between teachers
and students and sexual harassment. Sexual harassment, in which a stu-
dent is overtly coerced into the sexual relationship, is not only improper
but illegal. So-called consensual relationships present the more difficult
problem here. It is these relationships that exploit the student involved
in a manner that is similar to that of other professionals who exploit
their clients or patients.
A number of colleges and universities now specifically address con-
sensual sexual relationships with students in their codes of professional
conduct for faculty members. In general, most impose an outright prohi-
bition by declaring that it is unethical for a faculty member to engage
in sexual contact with a student. Some impose disciplinary measures
against those who do, regardless of whether the student ever objects. In
fact, a number of universities now have specific provisions that impose
strict penalties (including dismissal) on teachers who become sexually
involved with their students. Tufts University in Medford, Massachu-
setts, recently adopted a Policy Statement on Consensual Relationships
which includes the following:
Amorous, dating or sexual relationships between faculty members,

academic administrators and students are impermissible when the
faculty members and academic administrators have professional re-
sponsibility for the student. Voluntary consent by the student in
such a relationship is suspect, given the fundamental nature of the
relationship. . . . A violation of this policy may result in disciplin-
ary action.
Even schools with no written policy have determined, in specific

cases, that improper conduct by its faculty members is adequate grounds
for discipline. For example, in California, a male teacher was dismissed
on grounds that, while supervising students in a laboratory, he held a
female student's hand, grabbed her, held her tightly, kissed her, and,
after a short period of time, tried to embrace her again. The student
Legal Recourse 107
objected and eventually reported the incident. The teacher sued when
the college dismissed him, but the court upheld the dismissal on the
basis that the teacher's conduct was immoral and warranted the harsh
penalty of dismissal.
In another case an Iowa teacher was terminated for engaging in a
sexual relationship with a high school student even though the teacher
denied sexual contact and there was no direct evidence that it had oc-
curred. The school board considered the credibility of the teacher and
student and also the results of a polygraph (lie detector) test taken by
the student. The court upheld the school's dismissal of the teacher even
without direct evidence of the student's charges.
In yet another case, an Arizona school dismissed a teacher when a
teenage student's parent reported that the teacher had engaged in an
improper relationship with the student. The school district dismissed the
teacher, not only on the basis that the relationship occurred, but that the
teacher had thereafter lied when the charges were being investigated.
The teacher defended himself on the basis that the charges pertained to
his personal life. The court upheld the dismissal on grounds that the
conduct also related to the teacher's role as teacher. The school had
a legitimate interest in determining whether he had acted improperly,
particularly since, if the conduct was illegal, the school might have been
held responsible. Ultimately, however, the dismissal was based upon the
teacher's refusal to cooperate with the investigation of the school board.
When sexual exploitation occurs under circumstances that are coer-
cive to the student, the conduct of the teacher might amount to sexual
harassment. The cases involving instances of sexual harassment within
schools and particular colleges and universities are numerous. "Sexual
harassment" usually takes one of two forms. The first is known as "quid
pro quo" (literally "something for something"). Here students are ap-
proached by teachers or other authority figures (administrators, tutors,
etc.) and offered "something" in exchange for sexual favors. The "some-
thing" might be a better grade, a better recommendation for graduate
school or employment, or some other favor that the authority figure is
in a position to grant.
The second form of sexual harassment is known as " 'hostile' or 'poi-
soned' environment." In these cases the student is subjected to repeated
instances of sexual invitations, references, innuendos, or perhaps offen-
sive jokes, pictures, gestures, conduct, or remarks. Unless the conduct
is severe, it may not amount to harassment until the student makes it
clear that the conduct is offensive and unwelcome and tries, unsuccess-
fully, to stop it. Sexual harassment is considered to be a form of illegal

sex discrimination and victims may be able to sue the offender as well
as the institution that employs him.
Unlike consensual relationships between faculty and students, sexual
harassment is overtly coercive and offensive and does not require vic-
tims to prove that some sort of inherent vulnerability was exploited in
order to secure consent. While sexual harassment is now recognized to
be a major problem within schools and universities, sexual exploitation
is also becoming an increasingly serious concern. Schools are just begin-
ning to address it in a serious way, and recourse available to victims
depends upon the particular code of conduct, the state laws, and the
circumstances of the case. There are, however, a growing number of
schools that are developing stricter standards and more stringent en-
forcement of existing regulations to protect their students.
Chapter 8
Overcoming the Psychological

Effects of Exploitation
What happens to an individual who has been sexually exploited by a

professional whom she relied on and trusted? As discussed in previous
chapters, there is a substantial likelihood that once a victim has been
betrayed by one professional, she will have difficulty trusting another
professional, whether or not from the same discipline. A victim's reac-
tion is often similar to that of a child who has been exploited by a
family member or friend, or a woman who has been raped by an ac-
quaintance: her willingness, or perhaps her ability to trust, is shattered.
Although she now really needs to be able to reach out for services, her
capability to do so is severely damaged. She does not know whom, if
anyone, she can trust. Too often the consequence is that she trusts no
one. Without treatment, this lack of trust can last forever. The first task
for a victim of exploitation is to find someone to talk to, ideally a pro-
fessional experienced in dealing with the effects of traumatic experience.
People who are untrained in working with trauma sometimes do more
harm than good.
THE TRAUMA OF EXPLOITATION

Like a victim of violent crime, a victim of exploitation finds herself
becoming obsessively preoccupied with what has happened to her. She
may cut herself off from other relationships, not only because she does
not trust people, but also because she feels shamed and embarrassed by
what happened. She wonders how she could have let this occur. She
genuinely begins to doubt herself. In fact, she also risks substantial dam-
age to her work, and her productivity may be affected as a result of her
excessive preoccupation with her victimization.
Donna was sexually exploited by a lawyer whom she engaged to

handle a lawsuit in which she sustained personal injuries. She had
submitted to her attorney's sexual advances largely because she
didn't know that she could "fire" him and she was afraid that her
case would be given short shrift if she declined. She never felt
good about it and often tried to back out. After the case was over
and she had some time to reflect on what had happened, she
learned that she could have simply taken her case elsewhere. She
felt stupid about not knowing better, she was ashamed that she had
allowed herself to be used, and she wondered about her ability in
the future to handle difficult situations.
Victims often find it difficult to talk about their experience, even with
their closest friends and relatives. They feel alienated and unable to
reach out for help. A consequence of this psychological withdrawal is
that they risk offputting and creating tensions in their marriage, their
family, and other relationships.
Not surprisingly, the specific emotional and psychological conse-
quences that victims usually experience are well documented in the pro-
fessional literature. When the exploitation occurs in the context of a
healing relationship (particularly mental health), victims are likely to
have already been feeling injured, fragile, and confused. They placed
their hope and trust in "the doctor" to make them well. They had every
reason to feel safe and to anticipate no further injury. Indeed, they are
usually naive, reaching out for help, only to have their need and faith
betrayed. It should be no surprise that the consequences can be severe.
Like victims of other egregious abuses, incest, or rape, victims of sexual
exploitation suffer many of the symptoms of major trauma. The range
of symptoms is great, but one of the most common is severe and debili-
tating guilt feelings, often irrational in content. These can be persistent
and even become chronic if untreated. They directly result from a vic-
tim's feeling responsible for the sexual involvement, particularly if she
had agreed to participate. And if she experienced sexual feelings or fan-
Overcoming Psychological Effects 111
tasies during the exploitation, as many victims do, she may view this as
evidence that she brought about her own abuse. So she feels guilty,
shamed, and deeply humiliated.
Debbie was drawn into an exploitative relationship with her gyne-

cologist. She remembers being attracted to him from the beginning,
and she jumped at the opportunity to become involved with him
sexually, even though she knew that he was married. The relation-
ship lasted for only a couple of months, when Dr. S. told her that
his wife was becoming suspicious. Debbie assumed that he had
simply found someone new. In fact, it had become the talk of the
town that Dr. S. slept with all of his patients, but Debbie had some-
how felt that she was different. When she was dumped, she was
sure that she had gotten just what she deserved and was so humili-
ated by the experience that she refused to reveal it to anyone.
A second major symptom that victims experience is ambivalence.

They have difficulty making decisions and seemingly ordinary choices.
Sometimes it is extreme and irrational. What may seem particularly un-
reasonable is their ambivalence about their perpetrators, on the one hand
wanting them back and on the other wanting to see them punished. They
know that they have harmed them, causing them both to hate and to fear
them. And yet at the same time, they still feel close and special to them,
wanting them back and even trying to protect them.
Lori was sexually exploited by her minister, to whom she had gone
for pastoral counseling. They began a sexual relationship and after
about 6 months he ended it, saying that he had come to realize that
it was inconsistent with his responsibilities to the parish. Lori had
become very attached to him and was devastated by this rejection,
particularly since she had left her husband in the interim. When
she was approached by a church authority who wanted her to file
a formal complaint, she was overcome by feelings of not only
anger and betrayal but also affection for him and even regret about
ruining his career.
Victims may feel that escaping from the relationship is necessary for
their survival, but it also feels dangerous and disloyal. They wonder
about how this situation might someday come back to haunt them. As a
consequence of this ambivalence some become emotionally paralyzed.
It can take a long time, and require great effort, merely to get to a point
where the victim is able to decide to act on her own behalf.
Another common consequence of exploitation is that victims feel pro-
found and pervasive emptiness and aloneness. They may experience
feelings that what happened was somehow not real, or that it was real
but did not happen to them. They feel disconnected from the event and
they cannot understand the relationship between its cause and effect.
This feeling of "disconnectedness" can persist even long after the sexual
involvement ends. This depth of loneliness enhances the emotional
alienation and sense of isolation, causing further distress and feelings of
helplessness.
Elizabeth had never even heard of sexual exploitation when she

fell victim to an unethical psychologist. She knew of no one who
would even understand her situation and was sure that anyone she
might talk to would blame her for her participation. She was also
not ready to talk to other mental health professionals, particularly
because she thought that they would try to protect their own. She
eventually retreated into herself, unwilling or unable to reach out
for help. She finally got treatment after an attempted suicide,
which, to her, seemed the only way of stopping the pain.
An additional symptom of sexual exploitation is a feeling of intense

anger which the victim is unable to express or even acknowledge. This
suppressed rage, if turned inward, may lead to an increased risk of sui-
cide or other self-destructive behavior.
Many victims also experience intense, chaotic, and conflicting emo-
tions. These emotions appear unpredictably and leave the victim over-
whelmed by their intensity. Unexpected and unmodulated mood states
leave a victim feeling out of control. Whatever personal relationships
she has left suffer as a result of this emotional lability and volatility.
Sometimes sexual exploitation affects a victim's cognitive (thinking)
abilities as well. She experiences flashbacks, nightmares, and other dis-
turbing intrusive thoughts and images. Her ability to concentrate or pay
attention, even to compelling events, may be impaired. Routine tasks
are difficult, and complex work is virtually impossible. And then there's
the spiral effect: her emotional state deteriorates, causing greater upset
and disruption; the greater upset further damages her emotional state
and simultaneously affects her ability to think clearly and focus her at-
tention and concentration.
Finally, sexual exploitation often makes it difficult for victims to es-

tablish a trusting relationship with others, either personal or professional.
It even makes it difficult for them to trust themselves: their actions and
their judgment. So they are unsure of themselves, assuming that their
judgment must be faulty. They lose confidence in their ability to per-
ceive and experience what is real, and this particularly affects their abil-
ity to make wise choices and decisions. Often it is this inability to trust
themselves and to trust others that prevents them from seeking the help
they need.
Sandy knew that she needed help after she was sexually exploited
by her chiropractor. She had been sexually abused as a child and
she never really got over it. Now all of the same feelings were
returning and she knew they wouldn't go away on their own. She
had no idea, though, even where to start looking for someone who
would understand and could treat her type of problem. How could
she decide who was qualified? And how could she be sure that it
wouldn't happen again? For months she did nothing, paralyzed by
her skepticism that anyone would really try to help her.
In too many cases, after being exploited once, victims become unwill-
ing to trust not only that profession with which they have a bad experi-
ence but other professions as well. Not only do they not want to consult
another therapist, they are suspicious of their gynecologist, chiropractor,
and accountant as well. In essence, the mistrust manifests itself in an
overgeneralized fashion. And since they also no longer trust themselves
to distinguish between what is good and what is bad for them, they are
ruled by fear and confusion.
Victims who finally seek help often face a long and difficult process.
Not only have they resisted reaching out to another professional, but
they have also prevented others from reaching out to them. So deep and
pervasive is the damage that they become their own worst enemy. In
many cases it takes a concerned friend or relative who watches their
pain and inability to function to persuade them to seek professional help.
RECOVERY BEGINS
Because the victim of sexual exploitation by a professional bears
many of the same symptoms as victims of other forms of sexual betrayal
(including the presence of posttraumatic stress reactions), the goals of
recovery are similar to those of trauma resolution. Recovery begins

when victims can sort out what was their fault and what was not. In a
successful trauma case, the victim would be able to develop conscious
control over her memory of the traumatic events, no longer suffering
from flashbacks, nightmares, intrusive thoughts, or other involuntary dis-
ruptive memories. She would be able to talk about her feelings about
being exploited without becoming overwhelmed by the memory. Survi-
vors move from needing to disconnect themselves from those feelings
and numbing themselves from feeling to being able to talk about the
event as though it were genuinely a part of their past, and not of the
present.
The initially debilitating symptoms of anxiety and depression also be-
come tolerable and predictable, even though the memory of their previ-
ous severity remains. A victim who meets these goals regains a sense
of stability, allowing her to address the critical issues necessary for re-
covery: relating to others (which includes reducing her isolation) and
regaining her capacity to make connections with others. In understand-
ing the true nature of her exploitation and trauma, the survivor can heal
her damaged sense of self and begin once again to trust her own judg-
ment. Whatever obsessive thinking, emotional lability, or behavioral pa-
ralysis existed is replaced by a renewed ability to evaluate realistically
and to make choices. Self-blame is replaced by self-esteem.
Nancy was sexually exploited by a professor when she was in col-

lege. She was too embarrassed to discuss this experience with any
of her friends. She also didn't trust any of them not to scandalize
her participation. Having isolated herself from all of her friends,
she had little desire to interact with anyone. For months she did
not report the matter and refused to allow anyone she knew to try
to help. It wasn't until her mother, concerned over her plummeting
grades, insisted that she seek help that she was forced to come to
terms with this trauma. Once she did, however, she made steady
progress and was able to resume forming relationships.
While the goals of a successful recovery from sexual exploitation are

clear and well understood, the means of achieving them are less appar-
ent. Self-help, advocacy, and psychotherapy groups are some of the
means for beginning the healing process. They help reduce isolation and
alienation and offer a survivor the opportunity to make psychological
and social connections by forming mutually supportive relationships

with others who have been through similar traumatic experiences. Nev-
ertheless, individual psychotherapy is still the primary mode of treat-
ment. And while there is no formula which guides a successful therapy,
it has become possible to highlight the issues that are particularly im-
portant to the recovery process.
One of the most critical needs of a victim of sexual exploitation is a
new therapeutic situation which emphasizes honesty and clear communi-
cation. Boundary violations cause such pervasive damage that only an
atmosphere of absolute openness and candor will enable emotional reha-
bilitation to succeed. A victim needs to be in a new situation in which
the boundaries are absolutely clear and where she experiences freedom
of expression, which especially includes her reservations about the treat-
ment itself, without fear of rejection, reprisal, or defensiveness from the
therapist. The environment must be both stable and consistent to give
trust a chance to develop.
It is not unusual for victims, particularly initially, to experience vola-
tile and unmodulated emotional states and to challenge, confront, react
to, and reject therapeutic efforts. Only if a victim manages to get her
therapist's serious attention, patience, and reliability in spite of her poor
attitude will treatment succeed. Treatment is slow, particularly in the
beginning, and it is important that the victim be able to set the pace in
accordance with her ability to move forward. In short, a strong working
alliance between an experienced, nondefensive professional and the
fragile victim is essential. Because these victims so readily feel shamed,
threatened, and mistrustful, the therapeutic environment must be abso-
lutely safe and nurturing. There a victim can test and retest the bound-
aries before any real progress will be made in the healing process.
Once this type of environment is established, transference and coun-
tertransference phenomena will occur. The transference may be a reen-
actment of unconscious themes reflecting what occurred in the original
exploitative situation. Indeed, recovering victims may have sexual feel-
ings in this relationship as well. When they do, sometimes they react to
those transference feelings with great anxiety, shame, guilt, and fear.
Although the experience of erotic transference is not unusual and can
even be part of the healing process, the recovering victim sometimes
feels that she is once again out of control and vulnerable to exploitation.
The difference is that this time the transference will not be used to
manipulate and control the patient.
Sally became sexually involved with her lawyer when she was
going through her divorce. They had sex several times while he
was handling her case. Shortly after it was over, however, he
seemed to lose interest and was never able to find time for her.
When Sally realized that this "affair" was, in fact, over, she began
treatment with a therapist. Within a short period, however, she
found herself having the same feelings toward the therapist that
she had earlier felt toward her lawyer. Because she was frightened
that she might be victimized again, much of the work of therapy
had to focus on Sally's ability to understand her feelings and man-
age her emotional states even before she could begin to trust the
therapy situation.
As discussed in Chapter 2, strong transference feelings in a patient

often lead to countertransference in the therapist. Understanding and
managing transference/countertransference entail the same considera-
tions that they do in any ethical therapy, but for the recovering victim,
who is usually fragile and skittish, even an inkling of mismanagement
can be fatal to the treatment.
For some victims of sexual exploitation, treatment with psychotropic
medication is useful in helping to dampen acute emotional and physio-
logical states. Since physical dysfunction will impede progress, proper
nutrition, exercise, and rest are necessary parts of the treatment program.
A victim whose acute symptoms are stabilized can begin to accept new
information about her victimization and, using imagery and other cogni-
tive-behavioral techniques, can begin to understand her present re-
sponses to her traumatic experience. As understanding of the situation
develops, the victim slowly stops blaming herself and instead restruc-
tures the way she thinks about it. A renewed sense of self, free of guilt,
shame, and blame, eventually follows.
Throughout the recovery process survivors must be encouraged to ex-
press the full range of feelings about their experience, including feelings
about the perpetrator. Those feelings may not always seem rational, es-
pecially when those who experience them still want to defend the vic-
timizer or even have him back. But that's part of the process of working
through the experience. Additionally, unexpressed feelings can prevent
victims from becoming survivors by keeping them stuck in the cycle of
shame, blame, and guilt. Survivors also often need to talk about a trauma
over and over again until new insights and emotions are integrated.
When Diane first entered therapy she couldn't even think about the
details of her experience of being exploited. It would immediately
bring an overwhelming flood of images and emotions which pre-
vented her from coming to terms with her victimization. After sev-
eral sessions of working through the fear of confronting those im-
ages, Diane was encouraged to write down her memories of the
experience whenever they occurred. Instead of pushing them away,
Diane would acknowledge them, think about them, and record her
experience in words. The process of writing down her thoughts
and then sharing them in therapy was a good way for her to break
the ice and ultimately a bridge to her being able to relive the whole
experience, including the feelings.
As victims of exploitation make progress toward recovery, usually the

guilt, shame, and longing for the perpetrator give way to anger. Anger
is healthy. It gives the victim the energy she needs to complete her quest
for resolution. For many victims-turned-survivors who reach the final
stages of recovery with a renewed sense of dignity and trust in them-
selves the feelings of anger are unambivalent and are experienced appro-
priately. This anger may fuel the desire to confront an abuser through
institutional, regulatory, or legal channels. The desire to do so indicates
that victims have attained a clear understanding of what happened, espe-
cially their own role and responsibility. For some, this is an important
part of trauma resolution and the healing process.
For some, healing and recovery are not complete without confronting
a perpetrator, often publicly. And here, she may again face danger. A
victim who pursues her abuser may encounter retaliation. In order to
defend himself, the abuser may psychologically revictimize her by, for
example, denying that sexual involvement ever occurred. Some claim
the victim made up the story to avenge a real or imagined slight, that
the event was imagined or hallucinated. And of course, a victim needs
to expect that the professional will use whatever special knowledge he
gained through the professional relationship to absolve himself, even at
the cost of revictimizing the injured party. A professional who acted in
an unethical manner once may do so again in order to protect himself.
Sometimes perpetrators go so far as to blame the victim for their own
conduct, claiming that they initiated the sexual contact or enjoyed it and
wanted it to continue. In one case in the 1960s a psychologist success-
fully used his knowledge of his victim's emotional condition to claim
that she really suffered no additional harm because she was already so
disturbed. Such tactics, used to intimidate a victim and attack her credi-
bility, can be psychologically devastating, particularly to a victim in
recovery. Confrontation may not be the solution for every victim. Such
a person must be clear about not only her motivation for confronting
her abuser, but also her own strength to withstand his attacks on her
credibility, morality, mental health, and so forth. But if she is able to do
it, she creates for herself the opportunity to transcend the lasting effects
of the trauma. She can feel vindicated and also feel that her actions may
prevent the perpetrator from harming other victims.
Chapter 9
Sex After Termination: The Nature

of Consensual Relations, the
Residue of Power, and the
Unresolved Issues
Earlier chapters discussed various reasons that sexual relationships be-

tween professionals and the individuals they serve can be exploitative
and result in harmful and enduring consequences. This chapter considers
whether, and to what extent, the same issues that create the potential for
exploitation during the ongoing professional service phase of a relation-
ship continue after that phase ends.
In some cases the professional relationship has an established course,
and both parties clearly understand the beginning and the end. College
professors and students, for example, both recognize from the beginning
that a course, semester, or other period of academic training will, in a
predictable and due course, end. A particular professor and particular
student may not know whether another program will follow, but eventu-
ally the point comes when the teacher/student relationship ends. Once
that phase is over, whether a subsequent intimate relationship between
them is still inherently exploitative is a more problematic question.
The relationship between attorney and client, on the other hand, may
or may not have an identifiable ending. For the most part, an attorney
is engaged to handle a specific legal matter, and when that matter ends,
the relationship terminates. There are, however, at least two exceptions
to this general rule. One is when a particular legal matter may be ongo-
ing: (1) a divorce that requires continuing supervision of the court (and
hence the lawyers), or (2) a "family lawyer" relationship in which an
attorney handles all of the family's legal matters as they arise from time
to time. Even in those cases, however, specific legal matters are usually
individual cases, and most people know that they can go elsewhere, if
necessary, when the next matter arises.
The relationship between physicians and their patients is more com-
plicated. A woman may engage her obstetrician for a limited period of
time (during her childbearing years) but may retain him as her gynecolo-
gist indefinitely. Another individual may go to the same general prac-
titioner frequently throughout her lifetime. She may consult a specialist
once, or she may find that the problem recurs or another one requiring
his services develops. Hence, unless there is an ongoing relationship
with a regular practitioner, the physician/patient relationship is one that
comes and goes without necessary or predictable regularity.
The relationship between clergy and parishioners is even more com-
plicated. An ongoing relationship between a particular clergyman and
his parishioners may be indefinite, limited only by his service to the
parish. On the other hand, to the extent that a clergyman is a representa-
tive of a higher spiritual being, the relationship may continue indefi-
nitely, even in the absence of his physical presence. Many parishioners,
however, view the clergy in the same light regardless of whether they
serve their parish or another. Furthermore, if the clergyman is, at some
point, asked to perform pastoral counseling, his role as counselor may
go through a course, with or without a defined ending, while he contin-
ues to serve the parish.
By far the most complicated relationship between professionals and
their clients occurs in the mental health field. The reasons for this are
many and have been discussed elsewhere in this book. They are no less
complicated even after the "official" professional relationship has been
terminated. In fact, the difficulty that some clients experience in termi-
nating a therapeutic relationship reflects the effects of these complica-
tions. Because all of the concerns about sexual contact after professional
services end are present in the mental health field, that discipline will
be used as a benchmark, and the posttermination issues that may exist
in other fields will be discussed in terms of the similarities and differ-
ences that have been noted.
Sex After Termination 121
MENTAL HEALTH PROFESSIONS

The question of whether sexual contact is acceptable after termination
of a mental health relationship raises two issues: (1) whether it is proper
to terminate the professional relationship in order to establish a personal
(i.e., sexual) one and (2) whether it is proper to begin a sexual relation-
ship after the professional relationship is terminated in due course. In all
fields, the issue of sexual contact after termination calls into question
the tension between wanting to protect former clients from the residual
effects of the professional relationship and wanting not to interfere un-
duly with the freedom of individuals to enter into desired and consensual
liaisons. (In the mental health field, it also raises the issue of whether
the previous treatment might be "undone" if the patient is later harmed
by a subsequent sexual relationship with the therapist which ends badly
for the patient.)
Peggy was treated by Dr. M. for depression during a time when

her daughter was suffering from leukemia. The therapy addressed
many issues around the theme of separation and loss and Peggy
had made significant progress in coping with the likely loss of her
daughter. After the therapy ended, Peggy and Dr. M. began a sex-
ual relationship. When inevitably it ended two-and-one-half
months later, Peggy suffered even greater symptoms of depression
and it appeared that she had not benefited from the therapy.
Termination often brings to the fore the personal dynamics between pro-
fessional and client, some that change and others that persist even after
the service is terminated.
Termination can mean different things for individuals in different con-
texts. Clearly it is more eventful to end a relationship with someone
with whom there has been an intimate connection than with someone
who has performed an isolated service which is simply no longer
needed. Mental health counseling, whether in the context of psychother-
apy or pastoral counseling, is certainly among the most intimate of pro-
fessional relationships. That individual shares her thoughts, desires, mo-
tivations, and fantasies, exposing to another's scrutiny the most personal
parts of herself. Inevitably she develops feelings about the therapist who
performs that function (i.e., develops a transference). Terminating a
transference relationship is an important part of the therapeutic process.
It is usually accomplished through open discussion in which both parties
acknowledge that a particular type of relationship has been shared. It

becomes clear that this relationship arose out of and then became an
important part of the treatment process. What it means to the patient to
end this relationship in light of both present and past issues that are
revealed through the transference is thoroughly examined. When the
therapy has accomplished as much as it can, whether or not ultimate
goals have been achieved, bringing it to closure (with the patient moving
on to independent functioning) is a necessary part of the process.
For many patients the termination of therapy creates anxiety and ap-
prehension. At the point of termination patients must often let go of
their illusions that therapy is a cure-all, and that it will somehow trans-
form them into different people. They usually come to understand, and
even appreciate, that the therapist who seemed so powerful is human
and has his limitations. The very decision to end therapy raises issues
surrounding separation. Sometimes for the first time patients are forced
to recognize how dependent they have become upon the therapist. Not
only have they come to feel close to him, but the loss of that relationship
means that they can no longer rely on the therapist's concern, under-
standing, and, at times, wise counsel.
Lisa had been in therapy for almost 3 years. Her insurance, which
paid for 20 weeks a year, had run out for that particular year and
Lisa had come to believe that she had made as much progress as
was possible. In fact, she and her therapist agreed that there had
been significant gains and that she was ready to terminate. When
the reality of not being able to rely on him anymore actually set
in, however, Lisa experienced a deep sense of loss. They discussed
this issue at their last scheduled meeting, when, to her surprise, her
therapist expressed his own sorrow about losing their relationship.
When he hinted that he might be interested in developing a "per-
sonal" relationship with her, Lisa felt it was an offer that was too
good to pass up.
In some cases a patient may agree to (or even suggest) some other
type of relationship (including a sexual one) as a way of preventing the
separation. Clearly the patient's ability to evaluate the merits of a sexual
relationship is clouded by her feelings of loss. Indeed, one of the im-
portant functions of the termination phase of therapy is to deal with
these feelings in a constructive manner, one that helps the patient to
grow out of her childhood needs and into more mature and realistic
modes of relating to others.
There is considerable debate within the mental health field about
whether the very nature of the therapeutic relationship and process
makes sexual contact improper even after the professional phase of the
relationship ends. Researchers who have studied the dynamics of this
phase in order to formulate guidelines do not always agree what they
should be. In fact, considerable debate continues between two points of
view: some believe that a sexual relationship between therapist and for-
mer patient always "exploits" the special nature of the therapeutic rela-
tionship; others believe that after a reasonable period of time, the effects
of the therapeutic relationship dissipate and individuals no longer need
to be protected from their own discretionary choices.
Notwithstanding the ongoing debate, most therapists agree that even
after a therapeutic relationship ends, there are residual effects of the
treatment process. But do these effects subside over time, or do they
ever truly end so that the therapist and patient can thereafter become
involved with one another on an intimate level without "exploiting" the
personal and private information revealed in the therapy? This is the
subject of the ongoing debate. There is only general agreement that
the factors that contribute to the unique nature of the ongoing therapeu-
tic relationship are also those that extend the potential for exploitation
beyond the termination of the therapeutic relationship.
What, exactly, are these factors? Again the most significant one is the
ongoing presence of "transference," which was discussed at length in
Chapter 2. Most patients develop significant transference feelings which
make them vulnerable to undue influence by the therapist, upon whom
the transference reactions are focused. The consequence of transference
is often that the patient tends to idealize the therapist, attributing to him
qualities and intentions which may, in fact, not exist. This distortion by
the patient cannot be fully addressed unless a proper professional termi-
nation takes place. It is in the analysis of the transference and subse-
quent termination that the patient learns about her unique way of altering
reality to satisfy her unfulfilled childhood needs. In so doing, she identi-
fies more mature and realistic ways of meeting her needs. She can also
see how her judgment is influenced by the transference.
At the same time, the patient's decision-making capacity may still be
impaired by the very condition that brought her into the therapist's care.
Individuals enter therapy for a variety of reasons, but usually there is an
identifiable cause or precipitating circumstance that leads a person to

seek out a psychotherapist. In addition, there are often underlying and
more pervasive psychological problems which are triggered by the pre-
cipitating event. The underlying issues vary widely, of course, from pa-
tient to patient, and it is even possible that in some cases her issues do
not impair her decision-making capacity at all. In a great many cases,
however, the underlying psychological condition contributes signifi-
cantly to the way in which the patient views her world, processes her
experiences, formulates her thoughts, and directs her actions. All this
can occur outside conscious thought and beyond the exercise of free
will. Additionally, of course, whatever upset is associated with the pre-
cipitating circumstances contributes to her state of mind and affects her
judgment.
A third element arises out of the "fiduciary" nature of the therapeutic
relationship. A patient who seeks out the services of a therapist does so
because she is in need of services and is willing (usually) to vest in him
her trust that he will act on her behalf. Of course, the services she seeks
are those which lead to a solution to the problem that brought her into
therapy, not a sexual relationship. If, in response to her call for help,
what she is offered is a sexual relationship, she is likely to feel that, in
some way, it is the cost of receiving that help. In many cases this coer-
cion is not understood by the patient, but instead results from the thera-
pist's willingness to "sexualize" the relationship, that is, to allow the
sexual dynamic between therapist and patient to become the focus of
their relationship. The coercion usually will not take the form of an
overt threat"If you don't agree to sex, you will be abandoned." In-
stead, the patient is more likely to be led to believe that sex is part of
her being "special" and is necessary to retain that distinction and get the
benefits of his special treatment for her problem.
The theme of "abandonment" is exacerbated by another reality of the
therapy: the therapist, because of the very nature of his role, has unique
insight into the patient's conflicts and vulnerabilities. If his intention is
to exploit that knowledge, he is likely to know when and how to do so.
That knowledge of where a patient is vulnerable gives the therapist an
unfair advantage in influencing or coercing a patient to consent to his
wishes. This is the so-called imbalance of power that was also discussed
at length in Chapter 2. The imbalance of power is no less significant
where it is the patient who seeks the sexual relationship; the therapist
always has the option (and, indeed, the responsibility) of working
through the patient's sexual feelings without acting on them.
A final element that contributes to the possibility of exploitation is a

variation on the theme that sex is somehow part of the treatment. The
patient is told, or it is somehow implied, that sex with the therapist is a
way of addressing and solving her problems. In fact, the role of therapist
as healer is entirely inconsistent with the role of lover, and there is
virtual agreement that mental health treatment cannot be provided by a
sexual partner. A therapist who attempts to do both deprives the patient
of the very services that he agreed to provide.
The more difficult question, of course, is how the patient is affected
by these concerns after the treatment ends. One answer is that some, but
not all of them dissipate when the treatment ends. For example, after
termination there is no longer a concern about the therapist's performing
the functions of therapist and lover at the same time, since he is no
longer her therapist. Even then, however, there is the haunting question
of whether the goals of therapy were met and the therapeutic relation-
ship properly terminated if the idea of sexual involvement was being
contemplated at the time.
What most authorities agree do not end, but may lessen over time,
are the effects of the transference and the differences of power between
the therapist and the patient. The passage of time provides the opportu-
nity for the patient to reflect on reasons that she feels attracted to the
therapist and to continue to analyze her transference reaction. It allows
her to view him in a more realistic light, less distorted by the compelling
feelings that are present during the therapy. Much of the debate over
whether sexual contact can ever be appropriate after termination centers
on the existence of residual transference. Some therapists believe that
transference always remains as an overriding phenomenon; others be-
lieve that its dissipation over time eventually leaves it at a manageable
level.
With respect to the inherent difference in power between the therapist
and the patient, this becomes less of a factor upon the termination of
therapy, particularly when patients come to realize that therapy and
therefore therapists have limitations. At the same time the therapist no
longer "has something," that is, his "cure" potential, which the patient
needs and to which she can be held hostage. Nevertheless, some power
differential continues in light of the fact that the patient's emotional
vulnerabilities were the focus of the relationship. In the usual case the
therapist reveals few of his own conflicts and foibles. Hence, there con-
tinues to be unequal access to one another's vulnerabilities which can
still affect issues of power between them. Most practitioners agree that
this subsides over time, but whether, and how soon, is a subject of
ongoing debate.
Dale formally terminated therapy about 7 months before the possi-

bility of a sexual relationship with her prior therapist arose. He had
called her a few times to see how she was doing and to "stay in
touch," but for all intents and purposes the therapy had ended.
During their phone conversations he always wanted to talk about
her old problems, almost as though he were trying to reactivate
them. In their most recent contact, Dale became very upset when
she began to question her ability to attract and sustain a relation-
ship. It was then that the therapist told her that he had always been
attracted to her and asked to see her socially. Dale was overcome
by this dream-come-true. She wanted to prove that she was attrac-
tive and could hold on to a man.
LAWS CONCERNING TERMINATION OF THERAPY

Because of the magnitude of this problem in the mental health profes-
sions many states have regulated therapist sexual contact with patients.
Not surprisingly, in the other professions, for the most part, they have
not. Even among mental health workers, however, there is disagreement
about the role of the law, criminal or civil, in regulating posttermination
sexual relations and many states continue to wrestle with this issue. In
those states with laws making sexual behavior illegal during treatment,
sexual contact after termination of the professional relationship is gener-
ally also covered. For example, California and Florida make it a criminal
offense for a therapist to terminate a therapeutic relationship solely or
primarily for the purpose of engaging in a sexual relationship. Thus in
most cases termination of therapy in order to engage in sexual relations
is viewed as if there had been an ongoing therapeutic relationship. Inter-
estingly, however, that is not the case in California. There a therapist can
avoid liability, even in those cases in which he specifically terminates a
professional relationship in order to begin a sexual one, if he has re-
ferred the patient for treatment to an independent therapist. (The statute
is unclear about whether the patient even has to consult the independent
therapist, as long as an appropriate referral is actually made.)
Minnesota, which also regulates posttermination sex by law, is even
more restrictive. Minnesota subjects a therapist to its criminal penalties
if he has sexual contact with a former patient, even after treatment has
been properly terminated, if, in the eyes of the court, the patient is found
to have remained "emotionally dependent" on the therapist. This appar-
ently means that at any time after the termination of a therapeutic rela-
tionship, a therapist can be found guilty of sexual misconduct if it can
be proved that the patient was still emotionally dependent on him. On
that basis, it would seem that he could never know, ahead of time,
whether a sexual relationship with a former patient might someday sub-
ject him to criminal responsibility. In practice, however, this offense has
not yet been successfully presented. If put to a serious challenge, it may
also be found to be unconstitutional.
Minnesota's criminal law, like the "common law" of most states, also
provides for criminal penalties if "therapeutic deception" was associated
with the sexual relationship. This means that if, for example, the thera-
pist told the patient that sexual contact was somehow part of the treat-
ment, he would be guilty under that provision of the criminal law. In a
civil court a therapist who deceives a patient in this way may be sued
for fraud or a similar offense, in addition to his responsibility for sexual
misconduct.
The states that impose criminal laws to regulate sexual relationships
after termination of therapy usually require that there be a "waiting pe-
riod" between the time that the therapeutic treatment ends and a sexual
relationship begins. In most cases the waiting period is either 1 or 2
years. Not coincidentally the civil laws that exist in four states (impos-
ing civil liability on therapists who have sex with their patients) also
impose a waiting period after termination of treatment during which
sexual contact is forbidden. A final provision, which some states believe
is too far-reaching, is that during the "waiting period" before a sexual
relationship will be permitted, the parties may not even have social con-
tact. This mandate is difficult to regulate, and some believe it to be
unnecessarily restrictive.
The professional societies which, to a greater or lesser extent, also
regulate the conduct of their members have all imposed specific guide-
lines concerning sexual relationships with patients. To date, however,
only a few have issued guidelines concerning sexual contact with former
patients. They also have limited effect since no practitioner has to be a
member of any professional society in order to practice his profession.
Further, the most that such a society can do is to expel the individual
from its membership. Neverless, these professional societies are highly
influential, not only within the professions, but also with respect to the
subsequent actions of regulatory (licensing) boards. Therefore, if a mem-
ber is disciplined by his own professional society for conduct which

violates its code of ethics, that action may influence a licensing board
that gives the next ruling on the case.
OTHER PROFESSIONS
To what extent are patients, clients, or students of other professionals
affected by the residual effects of the original relationship once that
previous relationship has concluded? Just as in the mental health profes-
sions, the answers seem to lie with the issue of whether, and to what
extent, a transference or transferencelike occurrence was a part of the
relationship and whether it is likely to continue after the professional
services end. In some instances a continued imbalance of power may
also play a role after termination.
In Chapter 3 we discussed the transferencelike issues that can occur
in the attorney/client relationship (particularly in the divorce context)
and described how they can affect an ongoing relationship. Does a client
continue to be affected by these issues after the professional relationship
ends? Currently no state attempts to regulate sexual contact after termi-
nation although commentators have argued that a waiting period is in
order. The argument is that even when the client's legal business is fully
concluded, the transferencelike reactions, if they occurred, would take
time to diminish. The power differential can also continue to be an issue,
particularly with clients who may not have access to other lawyers or
may not realize that they can terminate their relationship with one and
engage another. In some instances (e.g., divorce and child custody cases)
a client may be concerned that future disputes would best be handled
by the lawyer who has been involved in her case, and thus feel depen-
dent and not realize that she can always go to another lawyer. This
puts the former client at risk for being manipulated, intimidated, and
exploited.
The Code of Ethics of the American Medical Association makes it
improper for a physician to enter into a relationship with a former pa-
tient in which he "uses or exploits trust, knowledge, emotions or influ-
ence derived from the previous relationship." In general medicine, un-
like the position taken by the American Psychiatric Association, there is
no presumption that the original relationship inherently gives rise to the
potential for such exploitation. Once again, at issue is whether a power
differential or transferencelike phenomenon continues after the termina-
tion of treatment. For physicians and for attorneys, and for many of the
same reasons, the dynamics of transference and power do exist but prob-
ably also diminish over time. As discussed previously, some specialties
such as obstetrics and gynecology are more conducive to transference
reactions and more time may be required before their effect on the deci-
sion-making process diminishes.
There are no laws that attempt to regulate nonpsychiatric physicians'
sexual relationships with patients after the termination of treatment. This
poses an interesting irony within the mental health field in states such as
Florida: psychologists, who are regulated by the Board of Psychological
Examiners, are subject indefinitely to civil and even criminal penalties
for sexual contact after termination, whereas psychiatrists are regulated
by the medical board, which allows sexual contact immediately after
termination.
Sexual contact between teachers and students after termination of an
academic program is not regulated even by those colleges and universi-
ties that make it unethical while the teacher/student relationship exists.
Finally, sexual contact between clergy and former parishioners is gen-
erally not regulated, except to the extent that the clergyman performs
the services of pastoral counselor. In the latter case, the clergy is subject
to the same legal and ethical constraints as other mental health profes-
sionals. Notwithstanding the absence of regulations, however, sexual
contact between a former clergyman and a former parishioner is likely
to raise virtually the same issues that were present during his service.
Even more so than for mental health workers, the unequal "power" is-
sues remain intact.
In summary, while virtually all mental health (and counseling) profes-
sionals agree that transference and unequal power issues extend beyond
the actual treatment relationship, they are not all in agreement as to the
duration and severity of the effects. There continues to be a tension
between a great concern for individuals who might be unwittingly ex-
ploited and a desire to allow individuals to relate to one another volun-
tarily, free of governmental and other institutional interference. In the
absence of valid and reliable scientific data that document the harmful
effects of posttermination sexual relationships, it has been difficult to
impose a "per se" rule. Instead, the trend seems to be toward a "cooling
off period in which each partner takes time, after termination, to reflect
on, assess, and decide whether a sexual relationship is desirable.
In all other professions where issues of transference and power are
not conceptualized as being intrinsic to the professional/client relation-
ship, and where there is even less scientific basis for regulating behavior,
there are few prohibitions against individuals who choose to have an

intimate relationship that develops out of the previous professional rela-
tionship. Freedom to choose one's associates is a fundamental personal
right, and, at this point, there is insufficient reliable indication that for-
mer patients, clients, students, and others cannot make their own in-
formed choices. On the other hand, the problem of sexual abuse by
professionals is one that has burgeoned as an increasing number are
found to be abusing their positions of trust. As research continues, the
balance may shift from promoting rights of association to protecting
individuals who are at risk for harmful consequences associated with
sexual exploitation.
Afterword
In this volume the authors have examined the problem of sexual exploi-
tation in professional relationships. It is clearly a complex and troubling
issue, often swept under the rug out of sight. In the absence of sound
scientific data, we are left to speculate about how widespread the prob-
lem really is and how profound are its effects. The authors have at-
tempted, within the limits of present knowledge, to portray the various
conditions that lead to this type of misconduct and its psychological and
legal implications. What continues to be impressive is the seeming lack
of professional interest in this area, at least until very recently. While
mental health professionals have been pioneers in this field, others have
been slow to respond. The legal profession seems to be proceeding cau-
tiously, more likely in an effort to protect itself than out of any concern
for the public welfare. The medical professions have proscribed sexual
misconduct with patients since the days of the Hippocratic Oath, but
only recently is it thinking earnestly about enforcing its own code.
Clergy, teachers, and allied health professionals are also just beginning
to acknowledge the seriousness of the problem within their ranks.
Acknowledging the problem is one thing; doing something about it is
quite another. The mental health professions have acknowledged the
problem for years, but they, too, have proceeded cautiously in policing
132 Afterword
their own. But slowly and surely, there is a growing effort to study the
problem, document its prevalence, and develop strategies for assisting
its victims. Currently professional associations are mounting widespread
efforts to establish strict ethical policy and encourage legislative con-
trols. Yet even today it is unclear exactly what direction social policy
will ultimately take. While the professions struggle to confront the issue,
they cannot help but be influenced by their defensive self-interest and
"old boy" protectionism.
It is disheartening to those of us who see the devastating effects of
sexual exploitation to witness how it can be trivialized by arguably our
most influential force: Hollywood. Film makers produce and distribute
powerful images and messages that confuse the issues and, more sig-
nificantly, may actually desensitize the public to the seriousness of the
problem by appearing to condone some clearly unethical and exploit-
ative behavior. For example, in the 1991 Hollywood blockbuster The
Prince of Tides, Barbra Streisand played a glamorous psychiatrist and
Nick Nolte the troubled brother of her psychotic patient. Less than a
year later another highly promoted film, Final Analysis, was released.
In this popular film Richard Gere played a handsome psychiatrist and
Kim Basinger the beautiful sister of his severely neurotic patient. What
these widely viewed films have in common is the theme of the well-
intentioned psychiatrist who becomes sexually involved with a patient's
sibling. The relationship is initiated innocently, of course, to gain infor-
mation that might be helpful in the treatment of the "patient." In The
Prince of Tides the psychiatrist is involved in her own bad marriage; in
Final Analysis the psychiatrist is simply overcome by the woman's
beauty and her own abusive marriage. Granted, in neither case does the
psychiatrist become involved with the identified "patient." Nevertheless
it is clear in both films that the psychiatrist has extended the treatment
relationship to include the sibling and, in so doing, has developed an
intense relationship that can only be understood within the context of
transference/countertransference phenomena. While the objects of the
psychiatrists' attraction are not the patients, per se, it is undisputed that
the sibling is an extension of the patient and just as deeply involved in
the treatment.
In The Prince of Tides, the relationship is highly romanticized and
there is virtually no attempt even to question the ethics of the sexual
relationship. In Final Analysis there is a perfunctory questioning of the
psychiatrist's behavior by a concerned colleague and longtime friend,
but once the colleague sees how beautiful the woman is, he seems to
Afterword 133
understand the attraction and no longer questions the relationship. What

is the message to the viewing public (and recipients of such services)?
Could it be that such relationships are understandable and, indeed, ac-
ceptable, as long as there is adequate justification, for example, the
glamour of a Hollywood sex object? What is the effect of repeated expo-
sure to such images and messages? Could it desensitize the viewer to
the unacceptable nature of such behavior and the great damage that it
ultimately causes?
We are left with a classic case of a culture at odds with itself. Is
this type of behavior sexually exploitative and unacceptable, or does it
somehow become acceptable under the right circumstances? Does a
powerful sexual attraction, a so-called affair of the heart, somehow ex-
cuse irresponsible behavior? On the one hand, a growing number of
states are going so far as to declare that such relationships are criminal;
on the other, Hollywood is condoning, if not glamorizing, such behavior.
These mixed messages are certain at least to perpetuate the confusion,
if not to dilute the efforts of those who are genuinely concerned about
the problem of sexual exploitation and the betrayal of trust.
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Index
Abandonment, 55, 58; in legal sense, 88; ition and, 48; nonsexual warning signs
theme of, in therapist-patient relation- of, 55-59; sexual warning signs of,
ship, 124 50-54
Alienation: symptom of sexual exploita-
tion, 110, 112; overcoming (in healing Child molestation, 38
process), 114 Chiropractors, 7; cases of patient exploita-
Ambivalence: toward professionals, 49; tion, 8,42-43, 113
symptom of sexual exploitation, 111 Clergy, 7, 40, 131; legal cases involving
Anger, 9; in legal sense, 88; sign to sexual misconduct of, 101, 102, 120;
healthy recovery, 117; symptom of sex- nature of parishioner relationships, 30-
ual exploitation, 112 34, 100, 120; pastoral counseling and,
Anxiety: initial feelings of, 49; overcom- 101-2, 120; pedophilic clergyman, 101
ing (in healing process), 114, 115; ter- Coercion, 3, 43, 48, 59; in attorney-client
mination of therapy and, 122 relationships, 35; overt, 105, 106, 108;
Association, rights of, 130 sexual harassment and, 107, 108
Cognitive-behavioral techniques, 116
Board of Registration, State, 25; filing a Complaints: criminal, 71-77; ethics, 65-
complaint with, 30, 63, 64 69; filing with licensing authorities,
Boundaries, and the "self," 15-16; conse- 69-70
quences of damaged, 18-19; distortion Confidentiality, 99; loss of, 64, 66, 70,
of, 17; examples of damaged, 18-19; 79; waiver of, 66
maintaining, 20, 41 Consensual relationships: between doctor
Boundary violations, 17-18, 25, 40; intu- and patient, 41, 42, 43, 82, 104-5; im-
140 Index
Consensual relationships (Continued) Fiduciary, 30; professions prohibiting con-

balance of power in, 3; between lawyer tact with, 40; relationship with profes-
and client, 97; between teacher and stu- sional and, 20, 60, 95, 96, 124
dent, 38-41, 106, 108; after termina- Fiduciary obligations, 26, 96, 103; breach
tion of professional relationships, 121 of, 49; violations of, 84, 98, 99, 100
Consent, of victim: based on fear, 3; in- Flashbacks, suffered by victim, 112; over-
formed, 86-87; as a legal defense, 7 3 - coming (in healing process), 114
75, 86-87, 88; "true," 9, 73. See also Freud, Sigmund, 20, 22, 24
Consensual relationships
"Conspiracies of silence," 10, 90 Guilt, feelings of: in legal sense, 88; re-
Contracts: attorney-client, 36; therapist- solving, 75, 76, 116; resulting from
patient, 82 "voluntary" sexual participation, 8, 75,
Contributory negligence, 87-88 110-11; transference and, 115-16
Countertransference, 24-25; depicted in Gynecologists: case examples of sexual
Hollywood films, 132; doctor/thera- exploitation, 2, 55, 111; case study of
pist's misuse of, 82-83; victim's recov- sexual exploitation, 27-30; examination
ery from, 116-17 procedures and, 5, 42-43, 103; nature
Criminal complaints, 71-77 of patient relationships, 4-5, 120, 129
"Criminal seduction," in legal theory, 81
Hippocratic Oath, 41, 43, 105, 131
Hollywood, depiction of patient exploita-
Dentists, 7, 54, 81, 104 tion in films, 132-33; desensitization of
Depression, 9; clinical cases of, 9-10, 55; public and, 132; effect on viewer, 133;
overcoming (in healing process), 114; in Final Analysis, 132; in The Prince
transference and, 36; undermining pre- of Tides, 132
vious treatment of, 121 "Hostile environment" (a form of sexual
Disconnectedness, feelings of: in exploit- harassment), 107
ative situations, 112; persistence of, Hypnosis: in legal sense, 72; used in treat-
112; reduction of, 114
ment, 55-56
"Discovery rule," 85. See also Statutes of
limitations Incest, 8, 40, 110; "professional," 1, 8, 39
Doctors, 7; disciplinary actions against, Informed consent, 86-87
105; Hippocratic Oath and, 41, 43, In loco parentis (in the role of parent),
105; nature of patient relationships, 39; teachers, 105
103-5; patient's trust in, 8, 110; profes- Intimacy, sexual: between attorney and
sional responsibility of, 103; sexual client, 96; between clergyman and pa-
contact and, 103; sexual misconduct of, rishioner, 32; between doctor and pa-
103 tient, 42-43; in legal sense, 72; be-
tween teacher and student, 37, 40-41;
Emotional dependence: in legal sense, 72, between therapist and patient, 4, 25;
127; patient's recognition of, 122; trans- after termination of relationship, 121
ference feelings and, 95-96, 104 Intrusive thoughts, 112; overcoming (in
Emotional distress, in legal sense, 88 healing process), 114
Employers: liability of, 89-90; negligent
supervision, charges of, 90, 101 Laws and statutes, dictating appropriate
Erotic fantasies, in transference process, professional conduct, 71-77, 127; con-
21, 115 cerning termination of therapy, 126-28;
Index 141
criminal offenses and, 71-77, 126; Penalties, for sexual misconduct, 67; im-
problems with prosecution, 76. See posed by professional organizations,
also Statutes of limitations 67-68; imposed by schools, 106-7; im-
Lawsuits: case studies of, 61-64, 77; posed under laws, 73, 74-75
civil, 79-80, 98-99; compensation for Physicians: the Code of Ethics of the
victim and, 88-89; criminal prosecu- American Medical Association and,
tion and, 74-77; earlier court cases, 81, 128; consensual sexual relations be-
83; legal defenses and, 84-88; private, tween patients and, 41, 42, 43; nature
97, 98; professional malpractice and, of patient relationships, 42; transfer-
81, 82, 100; resulting in disciplinary ac- ence reactions and, 42
tion, 105; steps in filing, 64-68 "Poisoned environment" (a form of sex-
Lawyers: case examples of client exploita- ual harassment), 107
tion, 9, 110; case study, 91-94; client Post-traumatic stress reaction, 113
involvement, and effect on legal judg- Power: abuse of, 7, 8, 102; of clergy,
ment, 37, 100; client's transference re- 100; imbalance of, 3, 20, 95, 101, 104,
actions and, 26, 35, 36; disciplinary 124; transference and, 21, 30, 42, 128-
proceedings against, 97-100; nature of 29; victim's attraction to, 39, 94
client relationships, 95-96, 119-20, Professional associations: filing a com-
128; prohibition of sexual contact, 5-6, plaint with, 64-69; guidelines concern-
99; suspension of license, 95 ing sexual contact, 127-28
Licensing, of professionals, 69; suspen- Projection, 21, 24
sion and, 95, 98 Psychoanalysis, 20
Licensing boards: disciplinary proceed- Punitive damages, 88-89
ings of, 70-71, 75; filing a complaint
with, 69-70; influence of professional
"Quid pro quo" (something for some-
societies on, 127-28; sanctions im-
thing), sexual harassment and, 107
posed by, 70
Malpractice: "discovery rule" and, 85; in- Rape, 1; criminal offense of, 72; trauma
surance coverage, 63-64, 103, 104; of exploitation and, 109-10
lawsuits, 81-82, 99-100; in legal the- Recovery: aided by criminal trial, 75; in-
ory, 80-81, 98; "negligence," 82-83; hibited by board hearing, 71; process
sexual exploitation and, 81-82; sexual of, 113-18
misconduct and, 103 Rehabilitation, of offenders, 75, 77
Repression, 21
Nightmares, suffered by victim, 112; over-
coming (in healing process), 114 Second opinion, 50; professional's dis-
couragement of, 55
"Old boy network," 10, 68, 132 Self, boundaries and, 15-16; recovery of,
114-18
Parishioners: contact with clergy after ter- Self-doubt, 9
mination, 129; involvement in court Self-esteem, 4, 11, 35; lowered by depres-
cases, 101-2; nature of relationship sion, 9, 36; recovery of, 114; transfer-
with clergy, 30-34, 100, 120. See also ence reactions and, 36
Pastoral counseling Sex discrimination, sexual harassment
Pastoral counseling, 31, 120, 129; abuse and, 108
of authority in, 55-56, 111 Sex therapists, 103
142 Index
Sexual abuse, 1; child molestation and, Therapeutic deception, 127

38; effects on early development of "Therapist-patient sex syndrome," 4, 63,
boundaries, 17; steps in prevention of, 68; as a criminal offense, 73
48-50; transference process and, 22; Transference/transferencelike phenomena,
victim's vulnerability, 74 20-25; in attorney-client relationships,
Sexual harassment, 1; compared with con- 34-36, 95-96, 104; in clergy-parishio-
sensual relationships, 108; forms of, ner relationships, 30-31; depicted in
107-8; school policies of, 106; teacher/ Hollywood films, 132; in healthy envi-
student involvement and, 106-8 ronment, 115; in legal sense, 81, 83,
Sexual violence, 1, 109 87-88, 104; management of, 25-26,
Shame, feelings of: resolving, 75, 76, 116; in physician-patient relationships,
116; resulting from "voluntary" sexual 42, 43; power differential in, 34, 42,
participation, 8, 37, 75, 111; transfer- 95, 128; termination of, 121-23, 125,
ence and, 115-16 128-29; in therapist-patient relation-
Social isolation, 9, 112, 114 ships, 20-24, 82-83, 86-87; victim's
Statutes of limitations, 84-86; "discovery unawareness of, 73
rule," 85 "Transference love," 22, 24
Suicide, 9; in legal sense, 88; transference Trauma: effects on early development of
reactions and, 36; victim's propensity boundaries, 17, 22; recovering from,
to, 74, 77, 102, 112 114-18; symptoms of, 110
Trust: the Code of Ethics and, 128; ele-
Teachers/professors: case study of exploi- ment of fiduciary relationships, 59-60;
tation, 45-47; consensual relationships inability to trust, 88, 109; in physi-
with students, 38^11, 106, 108; power cians, 103; renewed, 117; in therapists,
differential in student relationships, 39; 4,83
as role-models, 6-7, 38; sexual contact
after termination, 119; sexual harass-
Unconscious, and transference, 21, 22
ment and, 37, 105-8; sexual intimacy
between students and, 37-41
Termination, of professional relationships, "Waiting period," in legal sense, 127
21, 60, 72, 120-29; attorney-client, Warning signs, of sexual abuse, 48-50;
128-29; clergy-parishioner, 120; doc- boundary violations and non-sexual,
tor-patient, 120, 128; therapist-patient, 55-59; boundary violations and sexual,
120-26 50-54, 59
About the Authors
JOEL FRIEDMAN is a psychologist who has served for the past 20

years on the faculty of the Harvard Medical School and the Massachu-
setts General Hospital. He is the co-author of Women and the Law, Law
and Gender Bias, Sexual Harassment, and Date Rape.
MARCIA MOBILIA BOUMIL is a faculty member of Tufts University
School of Medicine. She is the author of numerous articles and the co-
author of Medical Liability, Women and the Law, Law and Gender Bias,
Sexual Harassment, Date Rape, and Law, Ethics and Reproductive
Choice.

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The paper used in this book complies with the

Chapter 1 Sexual Intimacy in Professional Relationships 1

For decades people have put themselves in the hands of professionals,

It is currently estimated that one-third of all money awarded for medical

I was 27 years old and had gotten an M.B.A. from an Ivy

Steve tells us that he distinctly remembers Ginny's first visit. He said:

I recall that Ginny came into my practice at a difficult time in my

tuition. It was one of our typical brief but annoying interactions

For me our first few meetings were uneventful. Dr. L. was a

There was something so comforting about just being there with a

I began to look forward to my sessions with Ginny. They were

After about a month we got into the subject of when my first

I think it was during this discussion that the powerful reality of

Steve also remembered this incident vividly:

As time went on and Ginny began to tell me some of the things

When asked to describe her sexual attraction to Steve, Ginny recalls:

Ginny described a particular meeting when her feelings for Steve

For weeks we had been talking about really important events in

Steve recalled that session only too well:

Ginny continued in a very deliberate tone:

When I finally looked up at him, it almost seemed like he, too,

In an instant Steve faced a defining moment in his life which he de-

Sexual Intimacy in Professional

fore, generally refer to men and women, respectively, as perpetrators

Because of the nature of the relationship, the professional is often able

Kerry was referred by a friend to Attorney Jacobs when her mar-

In most cases the sexual relationship that results is short-lived; it lasts

dents seemingly voluntarily to consent to such relationships without

When Kerry's chiropractor began to touch her in a sexual way

Another reason that sexual exploitation by professionals resembles

Michelle was sexually exploited by her divorce lawyer when she

What about the responsibility of the client, patient, or student who

Judy sought the help of a psychologist after many years of suffer-

The statistics indicating the incidence of sexual exploitation by pro-

Sexual Exploitation in the Mental

CASE STUDY: KKISTEN

WHAT ARE BOUNDARIES?

As a young child, Katie was praised and rewarded by her mother

Peter grew up as an only boy in a family with four siblings. When

Early experiences are important in determining the strength of an indi-

Tammy's parents believed that physical illness and out-of-sorts be-

Psychological boundaries can also be violated through deceit and ma-

EXAMPLES OF DAMAGED BOUNDARIES

Disturbing thoughts or memories keep popping into awareness

THE CONSEQUENCES OF DAMAGED BOUNDARIES

In most professional relationships it is apparent that the client, patient,

Jenny was referred to Dr. L., a private psychologist, to help her

According to Freud, these feelings (which he called "transference

help of therapy, many of the painful details are emerging. Little by

Ellen was the youngest child of two-career parents who were

When this type of woman enters psychotherapy as an adult, she may

this very important relationship. They are so compelled by their intense

Being a therapist is often frustrating and unrewarding: Dr. Q.'s

Just as "transference love" results from feelings generated by the pa-

When Dr. F. was brought before the Board of Registration on

MANAGING THE TRANSFERENCE

Should a client be prepared to discuss transference reactions with her

Sex and Power in Other

CASE STUDY: DEBBIE

I was referred to Dr. F., a highly regarded obstetrician/gynecologist, by

I suppose it shouldn't have surprised me that this relationship