Forty years ago this month the feminist writer Phyllis Chesler published an article in New York magazine entitled “The Sensuous Psychiatrists.” In her article, which was excerpted from her landmark work Women and Madness, Chesler described her interviews with eleven women who had been sexually exploited by their therapists. In some cases the therapists were psychiatrists who also prescribed medication. Some were in group therapy, some in individual. Chesler’s report included the following pithy summary of the sex:

“Nine of the 10 therapists assumed a "missionary" position during sexual intercourse for the first time and in general throughout the sexual treatment. Seven of the women did not experience orgasm the first time; four women never did throughout the treatment; seven of the women eventually experienced orgasm after from one to nine months. Four of the therapists had difficulty maintaining an erection.”

The least one can say of the behavior of these therapists is that it was a disgusting violation of medical ethics, and at worst that it inflicted life-threatening pain and sorrow on the patients. That such behavior is deeply immoral is not a new idea. The Hippocratic Oath prohibits not only sex with patients but sex with anyone in the household, “free or slave.” Of course, the fact that the Oath’s authors saw fit to include this prohibition suggests that the practice was far from unknown, even then. In 20th century psychiatry, among the important figures who are said to have violated this part of the Oath include Carl Jung, Bruno Bettelheim, and Karen Horney.

Such was the tenor of the times forty years ago that the behavior Chesler described was not only not uncommon — a 1973 study found that 5 percent of psychiatrists and other physicians acknowledged sexual intercourse with patients — by the early 1970s it was even being unashamedly recommended as “therapeutic “ by some “experts”, virtually all of whom happened to be male . The psychiatrist Martin Shephard became famous for his 1971 book The Love Treatment: Sexual Intimacy Between Patients and Psychotherapists, writing that “A sexual involvement can indeed be a useful part of the psychotherapeutic process."

Because physical evidence of these violations is hard to obtain, there was and is (like all rape) limited legal recourse for the victims. The therapists, of course, claimed the sex was not only consensual but medically indicated. There were some well-publicized lawsuits, including one involving Dr. Renatus Hartogs, who happened to have been the ex-husband of one of my relatives. Hartogs’ photo appeared on the front page of New York City tabloids, and when his ex-wife met him for lunch he was in disguise. Remarkably, the patient ultimately won the suit.

About 15 years later Dr. Jules Masserman, a former president of the American Psychiatric Association, was sued by four former patients who claimed that he had drugged and sexually abused them. Once again, the cases were settled out of court, according to his New York Times obituary. Just before his death in 1994 Masserman wrote a book with his wife in which he denied the charges against him that were depicted in a made-for-TV movie.

From my own experience as a child and young adult growing up in the midst of the group therapy and encounter movements, my impression is that the problem worsened in the 1960s. Before that it was not uncommon for physicians to marry their patients or former patients. But the freewheeling encounter groups of the 60s came along in the midst of social and sexual revolutions that contributed to the power of psychological and spiritual authority figures – ironically, just as the clout of other authorities was being challenged. Although well-intentioned and often therapeutic, the physical touching that was part of the encounter movement also caused some barriers to fall.

At the extremes, some encounter groups included nudity and even more overt forms of abuse that were supposed to be “therapeutic." These were not representative, but in general one can say that the movement that emerged from the science-oriented humanistic psychology of the early 1960s too often had devolved into bizarre and sometimes dangerous practices by the time Chesler’s article appeared.

Even for those of us who lived through this period it can be hard to recapture the mood of the times. In 1973, I attended a session at an international group therapy congress. The session was called “Going Out with the Group.” As I recall the principal speaker was a Scandinavian psychiatrist who described the alleged therapeutic advantages of, for example, taking a therapy group out for pizza after the session. During the discussion an agitated, slightly older male American psychiatrist asked, “How far do you go with your patients? Do you sleep with them?” Pausing, the presenter answered somewhat sheepishly, “only very rarely.”

I would welcome reports from readers of this blog, but my impression is that sexual exploitation by psychotherapists is less of a problem now than it was then. A review of various surveys from 1977 to 1994 suggests that the problem has somewhat lessened. The 1977 survey found 12 percent of male therapists and 2.6 percent of female therapists reported sex with clients; in the 1994 survey the numbers were 3.6 percent and 0.5 percent.

Of course, surveys like these have their limitations. Nonetheless I do perceive a gradual change, partly due to the fact that feminists like Chesler called attention to the issue. But perhaps even more important have been the changed demographics of the helping professions, which are now dominated by women, especially in the fields in which talk therapy is practiced. Psychiatry, to the extent that it is still largely a male profession, is mainly a pharmaceutical practice. The locus of emotional intimacy has changed. These shifting patterns of demographics and reimbursement also have to do with different insurance arrangements than was the case decades ago, when much therapy was out-of-pocket, and there is far more scrutiny by third-party payers. So also there is less long-term therapy (for better or for worse), in which vulnerabilities could gradually be exploited.

As a teacher of medical ethics for more than 30 years, I wish I could say that improved awareness and enforcement of ethical standards have been the main sources of improvement. But in fact, to the extent that even the implicit advocacy of such exploitation is no longer acceptable, we have to attribute the change in large part to other factors.

Perhaps there is at least a useful lesson here: rather than attacking an ethical problem head on, progress in professional ethics sometimes requires change in the conditions that enable a vice to flourish.

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