Despite the prohibition and the harm that can occur to sexually abused clients, a significant number of therapists report on anonymous surveys that they have become sexually involved with at least one client. When the data from the first eight national self-report surveys published in peer-reviewed journals are pooled, there are 5,148 participants providing anonymous self-reports (Akamatsu, 1988;
Bernsen, Tabachnick, & Pope, 1994; Borys & Pope, 1989; Holroyd & Brodsky, 1977; Pope, Keith-Spiegel, & Tabachnick, 1986; Pope, Lev-enson, & Schover, 1979; Pope, Tabachnick, & Keith-Spiegel, 1987). Each of the three professions (psychiatry, psychology, and social work) is represented by at least two studies conducted in different years.
According to these pooled data, about 4.4 percent of the therapists reported becoming sexually involved with a client. The gender differences are significant: 6.8 percent of the male therapists and 1.6 percent of the female therapists reported engaging in sex with a client.
Data from these studies as well as others (for example, reports by therapists working with patients who have been sexually involved with a prior therapist) suggest that therapist-patient sex resembles other forms of abuse such as rape and incest in that the perpetrators are overwhelmingly (though not exclusively) male and the victims are overwhelmingly (thought not exclusively) female (Pope, 1989b). For example, Bouhoutsos et al. (1983) reported a study in which 92 percent of the cases of therapist-patient sex involved a male therapist and female patient. Gartell, Herman, Olarte, Feldstein, and Localio (1986), who reported the first national self-report study of sexual involvement between psychiatrists and their patients, found that 88 percent of the "contacts for which both the psychiatrist's and the patient's gender were specified occurred between male psychiatrists and female patients" (p. 1128).
Data based on therapists' reports of engaging in sex with patients or on therapists' work with patients who have been sexually exploited by a prior therapist have been supplemented with national survey data from patients who have been sexually involved with a therapist. In one study, about 2.19 percent of the men and about 4.58 percent of the women reported having become sexually involved with their own therapists (Pope & Feldman-Summers, 1992).
Yet another source of data (supplementing those provided through reports by subsequent therapists, therapists' anonymous self-reports, and patients' anonymous self-reports) is consistent with the significant gender differences. Data obtained from licensing disciplinary actions suggested that about 86 percent of the therapist-patient cases are those in which the therapist is male and the patient is female (Pope, 1993).
This significant gender difference has long been a focus of scholarship in the area of therapist-patient sex but is still not well understood. Holroyd and Brodsky's report (1977) of the first national study of therapist-patient sex concluded with a statement of major issues that had yet to be resolved: "Three professional issues remain to be addressed: (a) that male therapists are most often involved, (b) that female patients are most often the objects, and (c) that therapists who disregard the sexual boundary once are likely to repeat" (p. 849). Holroyd suggested that the significant gender differences reflected sex role stereotyping and bias: "Sexual contact between therapist and patient is perhaps the quintessence of sex-biased therapeutic practice" (Holroyd, 1983, p. 285).
Holroyd and Brodsky's landmark research (1977) was followed by a second national study focusing on not only therapist-patient but also professor-student sexual relationships (Pope et al., 1979):
When sexual contact occurs in the context of psychology training or psychotherapy, the predominant pattern is quite clear and simple: An older higher status man becomes sexually active with a younger, subordinate woman. In each of the higher status professional roles (teacher, supervisor, administrator, therapist), a much higher percentage of men than women engage in sex with those students or clients for whom they have assumed professional responsibility. In the lower status role of student, a far greater proportion of women than men are sexually active with their teachers, administrators, and clinical supervisors [p. 687; see also Pope, 1989a, 1994].
Although statistical analyses of the first eight national self-report studies published in peer-reviewed journals reveal significant gender effects and also significant effects related to the year of the study (the pooled data suggest that each year, there are about 10 percent fewer self-reports of therapist-patient sex than the year before), there is no significant effect due to profession. According to these data, psychologists, psychiatrists, and social workers report engaging in sex with their patients at about the same rates. Apparent differences are actually due to differing years in which the studies were conducted (there was a confounding correlation between the professions and the years they were studied). The statistical analysis tested the predictive power of each variable (profession and year) once the variance accounted for by the other variable had been subtracted. Year had significantly more predictive power once effects due to profession had been accounted for than the predictive power of profession once effects due to year had been accounted for. Once year of study is taken into account, significant differences between professions disappear.
Bates and Brodsky (1989) examined the various risk factors that have been hypothesized at one time or another to make certain clients more vulnerable to sexual exploitation by a therapist. Their analysis led them not to the personal history or characteristics of the client but rather to prior behavior of the therapist: the most effective predictor of whether a client will become sexually involved with a therapist is whether that therapist has previously engaged in sex with a client.
With access to a considerable set of historical and actuarial data, the APA Insurance Trust (1990, p. 3) revealed that "the recidivism rate for sexual misconduct is substantial." Holroyd and Brodsky's landmark survey (1977) found that 80 percent of the therapists who reported engaging in therapist-patient sexual intimacies indicated that they became involved with more than one patient. The California Department of Consumer Affairs (1997) published its findings in a document that was sent to all licensed therapists and counselors in California and that must, according to California law, be provided by a therapist to any patient who reports having been sexually involved with a prior therapist. This document notes that "80 percent of the sexually exploiting therapists have exploited more than one client. In other words, if a therapist is sexually exploiting a client, chances are he or she has done so before" (p. 14).
Table 13.1 presents additional information, based on a national survey, of 958 patients who had been sexually involved with a therapist. In this study, 80 percent of the patients who had become sexually involved with a therapist only after termination of the therapy were found to have been harmed.
Five percent of the patients described in Table 13.1 were minors at the time that they were sexually involved with a therapist. This finding underscores an important aspect of therapist-patient sex: although much of the literature on this topic seems to assume that the patient is an adult, this is not always the case. In a national study focusing exclusively on minor patients who were sexually involved with a therapist, most (56 percent) were female (Bajt & Pope, 1989). The average age of these girls who were sexually involved with a therapist was thirteen, and the range was from age seventeen down to age three. The average age of the male minor patients was twelve, ranging from sixteen down to seven.
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