Vol. 23 Issue 20
Inappropriate Patient Sexual Behavior
Part II: Choosing appropriate responses
This is the second article in a two-part series on understanding and handling inappropriate patient sexual behavior in the health care setting. Part one appeared in the Sept. 17 edition and addressed understanding patient behaviors based on a review of the literature.
Most health care workers will experience inappropriate patient sexual behavior (IPSB), also called inappropriate client sexual behavior (ICSB), at some point in their careers. Such behaviors can be classified as mild (flirting, suggestive statements), moderate (crude sexual remarks, deliberate touching) or severe (exposure of sex organs, attempts at sexual fondling or activity).
Studies find that a majority of medical students, physical therapists, occupational therapists, OT students and nursing students report having experienced IPSB. In my practice, I have observed and experienced IPSB many times, and believe it is very common. Patients may exhibit IPSB due to neurological dysfunction, longstanding sexual dysfunction, fear of loss of sexual function, attempts at control or diversion from treatment, hostility, or confusion about the health care worker's intent.
Responses to IPSB vary. Health care workers commonly choose to ignore the behavior. Some discuss it with clients. Less often, they report the behavior to supervisors or discuss it with friends. Some threaten to withdraw their services. Some respond with aggression, disgust or anger.
When clinicians withdraw services due to IPSB, the patient may not receive appropriate care. Negative effects of IPSB on health care providers include decreased work performance and psychological stress. Knowing what to do when you experience IPSB can help the health care provider, the client and the facility to minimize negative effects and benefit all concerned.
How to Cope with IPSB
There is no one best response to IPSB. Each situation will depend on who is behaving inappropriately, the severity and type of behavior, the subject (e.g. new student or experienced therapist) and the setting. However, there are some useful guidelines and suggestions that can help determine the best response.
Be assertive. Zook (2000) has several excellent strategies she suggests to the nurses she educates. First, she counsels self-awareness; don't deny your feeling about the IPSB. If necessary, talk about your feelings with peers, supervisors or counselors.
Next, provide feedback to the person acting inappropriately in an assertive, nonthreatening manner. If he or she is touching you, remove the hand or step away. State clearly what behavior is unacceptable. An assertive response can also include a statement of how the behavior makes you feel.
Set limits by telling the client the consequences of the behavior, such as, "If you stop, I'll finish your treatment and we can talk about what's bothering you; if not, I'll have to stop and leave." Zook emphasizes that you must enforce the consequences, and ensure that others follow the same plan.
Don't ignore. Ignoring a behavior was frequently cited as a response in IPSB studies. I would recommend this only when a behavior has never occurred before and is mild. Sometimes the behavior will not be repeated if it does not elicit a response. I emphasize that no therapist should permit any behavior from a client that they would not accept from anyone else. If anyone touches you inappropriately, feedback should be firm and immediate. In fact, permitting inappropriate behavior because the person is a patient or client is effectively telling them that they don't count as sexual beings and is counter-productive in every way.
Be honest. In dealing with a flirtatious patient, honesty is the best policy. If a patient wants to have a personal relationship with you, it's best to explain clearly that such a relationship is unethical, unprofessional or even illegal, and that you would never consider it. This helps to depersonalize the issue.
Be clear. If you suspect a patient has sexual preoccupations or if your treatment might be misconstrued for any reason, it is very important to protect yourself. Make sure the patient understands the procedures and the reasons for them, such as, "I need to put my arms around you to help you transfer from this chair to the bed," or "It's important for you to learn how to wash yourself, and I am going to help you."
If the patient is unable to understand or responds inappropriately anyway, you should immediately report the behavior. Often other caregivers may be having the same experience, and an interdisciplinary behavioral plan should be developed. This is often the case with long-term care clients with dementia. In these cases, a different caregiver may not elicit the behavior. Sometimes one health care worker is better able to tolerate the behavior than another.
For students. Often it is inexperienced therapists and students who are challenged by IPSB. Patients may choose them because they are easiest to embarrass and intimidate. As with any challenging patient behavior, the beginning therapist or student should always report IPSB and seek assistance from a supervisor. Writing in her ADVANCE column "Issues in Fieldwork," Crist (1998) agrees that students being sexually harassed by patients should report immediately to their fieldwork educators for assistance and support. If the harassment continues or the student is having an inappropriate relationship with the patient, he or she should be removed from the fieldwork site.
I have found fieldwork to be a good time for OT students to learn how to deal with IPSB, especially since they are so likely to encounter it repeatedly during their OT careers (see Case Study).
For supervisors. If you are an administrator or supervisor, it is important to let your staff know that assistance is available with difficult patient issues like IPSB. It would also help for everyone to know the facility's policies on sexual harassment. Unfortunately, not every supervisor is comfortable or skilled at dealing with sexuality issues. I have been told about OT students who reported IPSB to their supervisors and were directed to continue providing therapy services but given no assistance in handling the behavior.
If a supervisor is unable or unwilling to help, the student or therapist should immediately seek assistance elsewhere, whether from another therapist, an administrator or other professional, or from the student's educational institution. If you are a supervisor and don't know how to advise your supervisee, you are responsible for seeking further help with the problem.
It's important to remember that the patient's behavior is always about the patient, and not about you. A telling example of this happened to me. I had just invited some co-workers in a busy clinic to my home when my patient said, "When are you going to invite me to your house?" I replied, "I'm your therapist, and you know we don't have that kind of relationship." He accepted this right away.
But I thought about his statement and what it might indicate, so I continued, "It sounds like you're becoming interested in a social life again, after your long illness and rehabilitation. Is that what's happening?" And immediately he started telling me about a new woman he met, and how he was starting to think of dating, and the conversation moved away from me to what was really happening in the patient's life. We decided this was a great sign of recovery for him, and he felt very happy.
In fact, I question if it's really always "inappropriate" when patients make sexual overtures toward health care workers, -particularly if they have undergone significant changes in their health and function. Patients in rehab want to know how others will respond to them with their disabilities; who better to test their new "selves" on than the nurses and therapists who have been caring and accepting of them.
Of course, it would be inappropriate for the health care workers to agree to the relationship, but it's not so inappropriate for the patients to try. It shouldn't surprise or shock us, and we should be ready to respond. We are all sexual beings throughout our life cycles, and everyone is entitled to sexual expression.
After explaining why you will not have a personal relationship with the patient, I recommend asking if they have any questions or concerns about sexuality and sexual function with their condition or disability.
Inappropriate patient sexual behavior is here to stay. But with assertive, nonjudgmental responses, appropriate assistance and a team approach, most therapists can learn to deal with these behaviors more comfortably and effectively.
References available at www.advanceweb.com/OT or upon request.
Judith Dicker Friedman, MA, OT/L, has been an occupational therapist for 18 years. She can be reached at firstname.lastname@example.org.
Case Study: "George"
A male OT colleague at a large urban inpatient rehabilitation center was supervising a young OT student who we'll call Jane. The supervisor came to me with a problem.
Jane was working with George, a young man with traumatic brain injury. Whenever she did any "hands on" treatment, he would say things like, "I love it when you touch me," and, "It feels so good." She was uncomfortable with the behavior, of course; the supervisor asked if we should transfer George to a male therapist.
While changing therapists was an option, I thought we could start with a less drastic approach. I guessed that George really liked having Jane for his therapist, and he would be motivated to keep her. I suggested that Jane tell George his behavior was making her uncomfortable, and that if it didn't stop she would not be able to continue to work with him.
Not surprisingly, George agreed to stop. It took some ongoing cueing and reminders, since he did have significant cognitive deficits, but he soon stopped the IPSB.
I also suggested she ask George if he had any friends at the facility, and how he was feeling. It turned out that he was terribly lonely. He had been homeless when he was hit by a car and injured; no one came to visit him. His grooming was poor, as were his social skills.
Jane used his desire to have companionship as a springboard for improving his grooming and his social skills. She referred him to all the social programs at the facility. George's "inappropriate behavior" became the basis of very important therapeutic interventions.
–Judith Dicker Friedman