Papers

Gary R. Schoener

“Twelve-year-old killed for having sex; her mother is charged,” reads the small headline in a January 15, 2005 AP story out of Birmingham, Alabama and published in the Minneapolis Star Tribune (page A12).   The brief text tells of “a woman angry with her 12-year-old daughter for having sex” who then killed her in a gruesome fashion.  The story does not reveal with whom she had had sex or give any clues as to why the anger was not directed at the boy or man who had sex with her.

This is a bizarre and troubling but sadly not unique story nor one without precedent.  “Honor killings” of women for extra-marital or pre-marital sex occur in many cultures, and the blaming of even young girls for having sex is commonplace throughout the world.  This is not a question of how human societies got to this point, but rather why we have not moved beyond it.  This broader context is the backdrop for understanding our failure to properly respond to the problem of sexual exploitation of girls and women by people in positions of power.

As a prelude to the examination of our current knowledge and understanding of sexual misconduct by professionals, a brief recapitulation of some history seems in order.  Beyond the normal wish to learn from history so as to avid reliving it, we may now be in a position to understand it in a new light.

T.S. Elliot wrote, in “Little Gidding” (Gardner, 1987, p. 897):

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

Historical Background              

The earliest concerns about physician-patient sex in a written text are found in the Corpus Hippocratum, a body of about 70 medical texts compiled by the Library of Alexandria in Egypt during the 4th and 5th centuries B.C. (Lloyd, 1983). It is not known how many of these works can actually be attributed to Hippocrates, who lived from 460 to 370 B.C., although it is quite likely that he did not write the most famous item in the Corpus, the “Oath,” which is usually attributed to him (Lloyd, 1983).  In both the "Oath" and "The Physician," doctor-patient sexual intimacy is discussed.

The "Oath," usually referred to as the Hippocratic Oath, states, in part: “…with purity and holiness I will practice my art . . . .  Into whatever house I enter I will go into them for the benefit of the sick and will abstain from every voluntary act of Mischief and Corruption and further from the seduction of females or males, of freemen and slaves….” (Braceland, 1969, p. 236)

In “The Physician,” the intimacy of the physician-patient relationship is described thus:

“The intimacy also between physician and patient is close.  Patients in fact put themselves into the hands of their physicians, and at every moment he meets women, maidens and possessions very precious indeed.  So towards all these self-control must be used. Such then should the physician be, both in body and soul.” (Trans. By WHS Jones, cited in Reiser, Dyck & Curran, 1977, p. 5)

During the Middle Ages, the treatise “De Cautelis Medicorum,” thought to have been written by Arnald of Villanova, read, in part: “Let me give you one more warning: Do not look at a maid, a daughter, or a wife with an improper or a covetous eye and do not let yourself be entangled in woman affairs for there are medical operations that excite the helper’s mind; otherwise your judgment is affected, you become harmful to the patient and people will expect less from you. And so be pleasant in your speech, diligent and careful in your medical dealings, eager to help. And adhere to this without fallacy.” (Braceland, 1969, p.236)

The issue of sexual exploitation of women by professionals again emerges in the literature near the end of the 18th Century. Concern about physicians taking sexual advantage of their patients through the misuse of mesmerism (hypnosis) was voiced in 1784 by a Commission of Inquiry headed by Benjamin Franklin. A secret report to the French King, Louis XVI, stated: “…the danger exists. . . since the physician can, if he will, take advantage of his patient. . . .  Even if we ascribe to him superhuman virtue, since he is exposed to emotions which awaken such desires, the imperious law of nature will affect his patient, and he is responsible, not merely for his own wrong-doing, but for that he may have excited in another.”  (Franklin, de Bory, Lavoisier, Bailly, Majault, Sallin, d'Arcet, Guillotin, & Le Roy, 1965, p. 6.)

Perry (1979) notes that at "… the time the report was written…medical doctors enjoyed a bad reputation in the eyes of a significant segment of the lay public." (p. 188) It would be well for all of us in the helping professions, who today enjoy considerable respect, to be aware that such has not always been the case; if we don’t police ourselves more effectively, it could easily cease to be the case.

Erotic feelings between therapist and client are found in the earliest reported cases of psychotherapy—the “talking cure.”  Anna O was treated by hypnosis by Joseph Breuer in 1880.  Subsequently, the case became one of Freud’s most widely discussed models of psychotherapeutic treatment.  Ernest Jones (1953), Freud’s first biographer, reported, on the basis of Freud’s account of the case: “…that Breuer had developed what we should nowadays call a strong counter-transference to his interesting patient…his wife became bored at listening to no other topic…jealous…unhappy and morose.  It was a long time before Breuer…divined the meaning of her state of mind.  It provoked a violent reaction in him, perhaps compounded of love and guilt, and he… [brought] the treatment to an end…that evening he was fetched back to find [Anna O.] in the throes of an hysterical childbirth…the logical termination of a phantom pregnancy…he managed to calm her down…and then fled the house in a cold sweat.  The next day he and his wife left for Venice to spend a second honeymoon….” (pp. 224-225)

In his classic Introductory Lectures in Psychoanalysis, published in 1917, Freud noted the romantic and erotic feelings his female patients exhibited toward him, labeling it transference. In writing on this topic, Freud (1958) clearly indicated that the therapist should not take advantage of the patient's "longing for love" and should abstain from sexual involvement. Freud also noted that the therapist had to struggle with his own countertransference love feelings.

In more recent years, it has come to light that psychoanalyst Carl Jung had a romantic relationship with Sabina Spielrein, whom he treated from 1905 to 1909.  She was 19 years old when she began her analysis.  Subsequently she became a physician and in 1912 joined the Vienna Psychoanalytic Society (Carotenuto, 1984; Kerr, 1993). 

In a letter to Freud dated 4 June 1909, Jung mentions the relationship and indicates that Spielrein was "systematically planning [his] seduction." (McGuire, 1988, p.228) Freud's response, dated 7 June 1909, was supportive and noted that while Freud himself had "never been taken in quite so badly," he had "...come very close to it a number of times and had a narrow escape." (McGuire, 1988, p.230) Freud focused all blame on Spielrein: “The way these women manage to charm us with every conceivable psychic perfection until they have attained their purpose is one of nature's greatest spectacles.”  (McGuire, 1988, p.231)

On 21 June 1909, Jung wrote to Freud that he had met with Spielrein and discovered that she had not been the source of the rumors about their relationship and indicates remorse about "the sins" he had committed: “When the situation had become so tense that the continued preservation of the relationship could be rounded out only by sexual acts, I defended myself in a manner that cannot be justified morally. Caught in my delusion that I was the victim of the sexual wiles of my patient, I wrote to her mother that I was not the gratifier of her daughter's sexual desires but merely her doctor, and that she should free me from her. In view of the fact that the patient had shortly before been my friend and enjoyed my full confidence, my action was a piece of knavery which I very reluctantly confess to you as my father.”  (McGuire, 1988, p.236)

Jung had written to Sabina Spielrein's mother, indicating that he had moved from doctor to friend "the more easily" because he had not charged a fee, and then made a proposition that he would come to regret—that if she wished him "to adhere strictly to [his] role as doctor," she should pay him "a fee as suitable recompense for [his] trouble" (Donn, 1990, p.93).

In his letter of 30 June 1909, Freud reports that he has written to Sabina Spielrein's mother, as Jung asked him to, and that "the matter has ended in a manner satisfactory to all.” He asks Jung to not fault himself for drawing Freud into the situation, asserting "it was not your doing but hers." (McGuire, 1988, p.238)  Again we can see what the problem is--it is seductive women. 

As for the harmful impact of such behavior on the client, Bruno Bettelheim wrote: “Whatever may be one’s judgment of Jung’s behavior toward Spielrein…one must not disregard its most important consequence: he cured her…

“In retrospect we ought to ask ourselves: what convincing evidence do we have that the same result would have been achieved if Jung had behaved toward her in the way we must expect a conscientious therapist to behave toward his patient?  However questionable Jung’s behavior was from a moral point of view—however unorthodox, even disreputable, it may have been—somehow it met the prime obligation of the therapist toward his patient: to cure her.  True, Spielrein paid a very high price in unhappiness, confusion, and disillusion for the particular way in which she got cured, but then this is often true for the mental patients who are as sick as she was.” (Carotenuto, 1984, p. 38)

After Bettelheim’s suicide, a disturbing footnote was added to this seemingly incongruous defense of Jung when former patients, trainees, and staff from Bettelheim’s famed Orthogenic School came forward with stories of emotional and psychological abuse by him. (Angres, Oct. 1990; Schoener, Sept. 1991; Schoener, March 1992)

John Kerr, in A Most Dangerous Method, writes of this history: “Jung was scarcely the only person to become involved with a patient.  Gross's exploits were legendary, Stekel had long enjoyed a reputation as a "seducer," Jones was paying blackmail money to a former patient, and even good Pastor Pfister was lately being entranced by one of his charges. Indeed, the most extraordinary entanglement was Ferenczi's, the amiable Hungarian having taken into analysis the daughter of the woman he was having an affair with and then fallen in love with the girl.”  (Kerr, 1993, p. 379)

In 1913, Ernest Jones, one of Freud’s inner-circle, had become the subject of a complaint by a former patient to the President of the University of Toronto where he was a faculty member.  This patient, who alleged sexual advances by Jones, had come forward with the help and support of her general practitioner.  Jones claimed that the general practitioner, a woman, had a lesbian relationship with the complainant, but the credibility of his defense was undermined by his admission that he had paid the patient in an attempt to buy her silence. (Grosskurth, 1991, p. 56)

F. Scott Fitzgerald’s novel, Tender is the Night, published in 1933, dealt with a psychiatrist, Dr. Diver, who became romantically involved with a woman who was a patient.  In one scene, she asks Dr. Diver if he found her attractive: “He was in it for now, possessed by a vast irrationality.  She was do near that he felt his breathing change, but again his training came to his aid in a boy’s laugh and a trite remark.” (Fitzgerald, 1933, p. 174)

During the next fifty years, a number of novels and movies would include plots involving sexual and/or romantic involvement between professional and client.  Most involved male professionals and female clients.

Despite the fact that the ranks of physicians are overwhelmingly male, such transgressions were not limited to male professionals, even in the early days.  Karen Horney, one of the leading figures in psychoanalysis, said: “As a rule, it is better not to have social relationships with a patient, but I am not terribly rigid about it.  Generally, I have none or a restricted relationship.”  (Wolff, 1956, p. 87)

However, in her biography of Horney, A Mind of Her own, Susan Quinn notes that in her late years, Horney had a romantic relationship with a young man who was in treatment with her, something Quinn (1988, p. 378) attributed to “old impulsive ways [which] survived into middle age.”  Quinn claims that this relationship, begun during the second half of the 1940s, lasted until the end of Horney’s life in 1952.

During the 1960s, the human potential movement blurred some of the distinctions between traditional psychotherapy and new methods such as encounter groups.  The taboo against touch in psychoanalysis was questioned with, for example, one female analyst arguing: “…it seems absurd that any qualified psychoanalyst should be so carried away by contact with a patient, however attractive, that he (or she) could not refrain from complete gratification….” (Mintz, 1969, p. 371)

Despite experimentation with nudity in sensitivity groups (see, for example, Maslow, 1965, p 160, or Bindrum, 1972), only one author argued for sexual contact with clients.  J.L. McCartney, a psychoanalyst, claimed to have experienced “overt transference” with 30 percent of his female patients, including undressing, genital touch, or sexual intercourse with ten percent (McCartney, 1966).  Although no clients complained, McCartney was widely attacked within the profession and was expelled from membership in the American Psychiatric Association.

The next decade opened with the publication of Masters and Johnson’s classic Human Sexual Inadequacy, in 1970, inaugurating the development of the new field of sex therapy.  Ironically, these authors reported that a sizeable number of their clients had reported having had sexual contact with a previous therapist.  The authors labeled such conduct “rape” in a widely reported address to the American Psychiatric Association convention in 1975 (Masters & Johnson, 1975). However, media accounts of “sex therapy” and the use of sexual contact in research and sexual surrogates in therapy left many consumers less clear about what might constitute acceptable therapy.

Martin Shepard’s book (1971), The Love Treatment, based on interviews with eleven clients who reported sexual relationships with their therapists, fueled major controversy.  Popular articles such as “Should you sleep with your therapist?” in Vogue (Weber, Jan 1972) and Shepard’s second book, A Psychiatrist’s Head (1972), resulted in revocation of the author’s medical license, despite the absence of client complaints. (Simon, 1988)

A feminist counter-offensive began with the publication of Phyllis Chesler’s Women and Madness in 1972.  One of the chapters discussed sex between male therapists and female clients based on interviews with ten women who reported such an experience. This was followed by two widely discussed PhD dissertations involving case studies of women who reported sex with their therapists. (Belote, 1974; D’Addario, 1977)

The 1970s also saw the advent of the self-report survey of professional groups with the publication of Kardener, Fuller, & Mensh's 1973 study of a sample of 1,000 physicians in Los Angeles County. Their finding that 10 percent of psychiatrists and other physicians acknowledged erotic contact with clients, and that 5 percent acknowledged sexual intercourse, established the seriousness of the scope of the problem and presaged the ensuing professional debate not to mention a large number of self-report surveys. (Schoener et. al., 1989, pp.25-45)

During this time, the case of Roy v. Hartogs was tried in New York City. It was widely reported in newspapers around the U.S. and Canada.  Julie Roy, the plaintiff, charged Dr. Renatus Hartogs, a psychiatrist with good credentials and the author of a column for Cosmopolitan magazine, had sexually exploited her.  Ms. Roy won the suit and the next year co-authored a book, Betrayal, which was later made into a made-for-TV movie of the same title. (Freeman & Roy, 1976) While not the first such case, its broad publicity led to many other clients coming forward and presaged the local and national coverage of other cases in by news media.

A major discussion of therapist-client sex occurred in May of 1976 at the annual convention of the American Psychiatric Association. The next year, a national survey of psychologists was published whose findings mirrored those of Kardener, Fuller, & Mensh (Holroyd & Brodsky, 1977), and in 1978, a California Psychological Association Task Force undertook a large scale survey of psychologists concerning their knowledge of cases (Bouhoutsos et.al., 1983).

The past thirty years have seen many theoretical articles and discussions at professional conferences, continuing research (largely involving surveys), and repeated efforts to refine the language of professional codes of ethics so as to have more specific prohibitions against sex with clients. Complaints to ethics committees and licensure boards, and malpractice actions related to sexual misconduct by therapists, have steadily increased.  There is no evidence that all of this action, study and discussion, or even the refinements in the ethics codes, have changed professional behavior.

Frustrated consumers who have been sexually exploited and concerned professionals began seeking remedies through media attention and changes in public policy.  In 1984, Wisconsin criminalized therapist-client sex and the Minnesota legislature created a Task Force on Sexual Exploitation by Counselors and Psychotherapists. In 1985, Minnesota criminalized therapist-client sex, making it a felony, and included sexual contact by clergy who were providing counseling for emotional problems. To date more than twenty states have criminalized, the majority of them including clergy among the counselors who are prohibited from having sex with clients. (Bisbing, Jorgenson, & Sutherland, 1996)  Most of those who have testified at hearings in Minnesota and elsewhere have been women victimized as adults or adolescents.

On June 5 and 6, 1986, a national conference entitled “It’s Never OK” was held in Minneapolis and co-sponsored by the Continuing Education & Extension division of the University of Minnesota and the Minnesota Task Force on Sexual Exploitation by Counselors and Therapists.  (The program can be found in Schoener et. al., 1989, pp. 787-792)  The program examined sexual exploitation by psychotherapists and clergy for the most part. The conference drew 250 people from around the United States and it was decided to try to hold these every two years.

Our work and that of these task forces evolved to examine sexual exploitation by all sorts of counseling professions – secular ones and clergy.  This is very different from what was to evolve in the 1990’s around the revelations of sexual abuse by catholic priests.  LINK UP and SNAP originally were focused mostly on one denomination – Roman Catholicism – and heavily focused on abuse of minors.  They were not connecting this with abuse of minors by other types of professionals. Efforts were made in the 1990’s to establish better linkages.  But originally the one movement focused largely on women victims and on all types of professionals as offenders, whereas the other was very focused on clergy and religious perpetrators, especially against male children.

However, after a planned conference in Philadelphia was cancelled, the next conference was not until 1992.  It too was in Minneapolis, and was co-sponsored by the Walk-In Counseling Center and several other groups.  It drew more than 650 people from around the world.  The book Breach of Trust (Gonsiorek, 1995) is largely a compendium of this conference in that its contributors were all presenters.  In 1994 a conference was held in Toronto, Ontario, and drew about 600 people.  In 1998 another was held Boston. Regional conferences and numerous workshops also have been held in Canada, the United States, Australia (1994) and New Zealand (1996).  There have also been two major conferences in Switzerland (2001 & 2002) sponsored by a group called AGAVA. BASTA, run by Estelle Disch in Boston has held retreats for a number of years. (Schoener et. al., 1989, pp203-213)

Jeanette Milgrom of the Walk-In Counseling Center began the first support groups for women victims of sexual exploitation by counselors (secular and clerical) in 1976.  In 1979, Ellen Luepker took over this function and began offering them through Minneapolis Family & Children’s Service.  Ellen went into private practice and continued this work for many years.  (Schoener et. al., 1989, 177-202)

Conclusion

What have we learned from this brief recapitulation of the history and evolution of our concern about sexual misconduct by various professional groups? It is apparent that sexual misconduct by professionals is an old problem and one that has evaded solution. The sexual exploitation of adult women by professionals dates back thousands of years and is mentioned as early as the 3^rd century BC in medical writings. Although publicly discussed cases go back hundreds of years, for the most part women have been blamed for these events rather than seen as victims. 

Although feminism and the growth of broad concern about sexual exploitation of women by persons in a position of power and authority helped bring about a response to sexual abuse, we have a long way to go. It seems that a certain critical level of visibility is necessary before either the profession itself or the community attempts to intervene in a meaningful fashion to prevent or remedy sexual misconduct with clients.

Our history tells us that ethics codes, discussion, and research alone have failed to significantly change the situation.  We have tried “Plan A,” i.e., self-regulation in concert with codes f ethics, and it has not solved the problem. While there has been an evolving understanding of ways in which women victims can be helped and offenders can be evaluated, much still remains to be developed in those areas.  In terms of advocacy and the handling of complaints, while strides have been made, there are still great difficulties in bringing such complaints.

Twenty-four centuries is probably long enough to try any one solution: Now it is time for some new initiatives.

References

Bisbing, Steve; Jorgenson, Linda; & Sutherland, Pamela  (1996). Sexual Abuse by Professionals:  A Legal Guide.  Charlottesville, Virginia:  Michie Company.

Bouhoutsos, J.; Holroyd, J.; Lerman, H.; Forer, B.; & Greenberg, M. (1983). Sexual intimacy between psychotherapists and patients. Professional Psychology: Research and Practice, 14, pp. 185-196.

Braceland, F. (1969). Historical perspectives of the ethical practice of psychiatry. American Journal of Psychiatry, 126, pp. 230-237.

Burgess, Ann & Hartman, Carol.(Eds.) (1986). Sexual Exploitation of Patients by Health Professionals. New York: Praeger.

Carotenuto, Aldo. (1984). A Secret Symmetry: Sabina Spielrein Between Jung and Freud. New York: Pantheon Books.

Chesler, Phyllis. (1972). Women and Madness. New York: Avon Books.

Donn, Linda. (1990). Freud and Jung: Years of Friendship, Years of Loss. New York: Collier Books.

Fitzgerald, F. Scott. (1933). Tender is the Night. New York: Charles Scribner's.

Gabriel, Mary (1998).  Notorious Victoria: The Life of Victoria Woodhull, Uncensored.  Chapel Hill, N.C.:  Algonquin Books of Chapel Hill.

Gardner, Helen. (Ed.).(1987). The New Oxford Book of English Verse 1250-1950. Oxford: Oxford University Press.

Harris, Corra. (1988). The Circuit Rider's Wife. Wilmore, Kentucky: Bristol Books. (Originally published as A Circuit Rider's Wife in 1910).

Hawthorne, Nathaniel. (1991). The Scarlet Letter. Philadelphia, Penna.: Courage Books. (originally published in 1850 by Ticknor, Reed, and Fields).