This article was downloaded by: [Memorial University of Newfoundland] On: 01 August 2014, At: 16:28 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The Journal of Sex Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjsr20
Some Reflections on Sex Relations between Physician and Patient Conrad Van Emde Boas Psychiatrist and Sexologist M.D. Published online: 30 Oct 2013.
To cite this article: Conrad Van Emde Boas Psychiatrist and Sexologist M.D. (1966) Some Reflections on Sex Relations between Physician and Patient, The Journal of Sex Research, 2:3, 215-218, DOI: 10.1080/00224499.1966.10749566 To link to this article: http://dx.doi.org/10.1080/00224499.1966.10749566
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
The Journal of Sex Research
Val. 2, No.3, pp, 215-218
November, 1966
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
THE DOCTOR-PATIENT RELATIONSHIP Some Reflections on Sex Relations Between Physician and Patient CONRAD VAN EMDE BOAS Sex relations between doctor and patient have at all times and in all places been looked upon as incompatible with medical ethics. Hippocrates specifically rejects them in his oath: " ... Every house I shall only enter for the sake of my patients' wellbeing, refraining from every intentional harm and all seduction, especially from love relationships with women or with men, be they free or bonded." It is obvious therefore that we have no reliable data on these vetoed relationships which would permit statistical and/or other publications. We are dealing here with a matter about which the very persons who could supply these data are wise enough to keep absolutely silent. Consequently, anyone who wishes to penetrate this unexplored field must rely on casual, personal observations. These casual observations are largely based on statements of patients in individual or group-analytical therapy. To a smaller extent the facts have come to me from the colleagues concerned--colleagues under treatment or as partners of those of the first category. If a patient tells us during his or her psycho-therapy that she has maintained sex relations with one or more colleagues, our first reaction-sprung from group narcissism and from good-fellowship-is that we are dealing with a phantasy. These phantasies are common enough indeed. Sometimes, though not always, they will sooner or later betray themselves as such. In that case they are often considered as wish-fulfillment and as proof of a "positive transference." In my opinion, however, it can "hardly be denied that where this wishful thinking is served up as an actual happening, at the expense of the reputation of the physician concerned, strongly aggressive tendencies towards him or her must have existed, and the entire 215
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
LIb
(:ONR.\D V.\N EMDE Bo.\S
relationship must have been of a highly ambivalent character. In such cases we can often find out w/~y it was this particular therapist who became the victim of that false accusation and not some other colleague with whom our patient has been in contact. The physician often emerges as a party to this phantasy by conscious or subconscious provocation of sexual impulses. He pays for this "provocation" with the attack on his reputation, But not all the stories about sex relations with a physician dished up by our patients arc products of the patients' imagination. cannot deny that such relationships are more frequent than we arc inclined to believe. In my own practice-largely psycho-therapeutical and sexuological I have noticed that the frequency of this kind of officially frowned-upon relationship varies within the different branches of the medical profession. Gynecologists offer the most frequent targets. Second on the list are dentists and family doctors. But let me add immediately that psycho-therapists, too, arc not far behind, according to the "statisticsv-s-obviously limited and incomplete which I have compiled from my own observations. Freud's rule of abstinence apparently offers inadequate protection: the young' psycho-therapist, just launched on his career, is an casy and rather willing prey, for which we may either praise the patient's charm or blame our professional training. What I have just said about the "phantasies" apparently applies in many-though not £111- cases of actual sex relations between doctor and patient: both the ambivalent attitude 01 the patient and the provocative element in that of the physician, arc often easy to diagnose. Arc there any general or more specific aspects of these sex relationships and the character structure of the individuals concerned? Certainly there arc. But at this time I would rather restrict myself to some simple reflections on this difficult problem. I. In the first place we must not forget that a certain percentage of physicians -- whatever they may specialize in-and patients belong to the group of "easy victim'>" or "enthusiastic amateurs" who "fall" in every-clay life, too. They will remain true to type in the consulting rooms. 'Ve all know colleagues and patients of this type; they often boast of their promiscuous conquests and mind neither time nor place. 2. or greater importance lor our discussion is a second group, i.c., those cases where a genuine human relationship is involved. Even ill
' 'ie
v-
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SEX RELATIONS BETWEEN PHYSICIAN AND PATIENT
217
an "ordinary" love relationship between two "ordinary" people in "ordinary" life, it is hard to say which part of the "romantic crush," with which the relationship began, is "real" affection, and how much of all this was based on "transference." It is not hard to imagine that this may also apply in a therapeutic relationship which leads to sex relations. Even in a psycho-analytical situation why shouldn't the emotional relationship between doctor and patient develop from the unavoidable transference and counter-transference to something "real"? In other words, why should it preclude real ties of affection, real sentiments that are entirely identical with the belonging, the tenderness and the sensuality of "real love"? The differentiation between these genuine sentiments and transference is far from easy. But I have seen cases where this distinction, both for those concerned and for the expert consultant, was indeed possible. In such cases I consider it a human and ethical problem of the first order whether rigid medical ethics, which veto intimate relationships now and forever, should prevail in the face of any other consideration. We must meet this question openly and unashamedly. We should not pretend, for instance, that in such a situation a legal alliance may be permissible after the therapy has ended (or been broken off) whereas an extra-marital relationship would lead to the most serious professional consequences. This is not pure theory: cases have been known of psycho-therapists who married former patients and were (or remained) accepted as members of their professional organization although the same organization had a short while before expelled another analyst on the grounds that he-many years after successfully completing the analysis-entered into an extra-marital relationship with a former patient. 3. Next, a few words which pertain to my first remark on the "young" therapist: I have the impression that therapists fall more often for a patient's more or less subtle attempts to seduce in the so-called modified techniques, where the patient is not lying on a couch but is sitting facing the analyst, especially when this setting is combined with the more direct, emotionally "warmer" techniques which are now advocated by some therapists. It is clear that complications will more easily arise under such conditions, since it is very hard to draw the lines between a permissible, protective and consoling attitude which can and may be coupled with casual bodily contact: a hand on a forehead, a shoulder to weep on. Where these lines are
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
218
CONRAD VAN EMDE BOAS
not distinct, a critical situation may develop, especially when there is insufficient sensitivity for the mutual provocations which may occur in these forms of therapy: No wonder, therefore, that so many of uswhether we have or have not had those experiences that made Breuer stop his short-lived psychotherapeutic experiments-prefer the safe easy-chair behind the couch. I fully realize that a more thorough and systematic discussion of this engaging subject is both possible and desirable. In view of the delicate nature of the essential data, we ought to consider whether it would not be possible to collect pertinent material by means of international co-operation, guaranteeing absolute anonymity. Included in these studies should be those relationships, that I should like to call "physician-semi-patient" and erotic relationships between therapists and non-patients, which have deteriorated into a "therapeutical" relationship. I have seen many an example of both these forms, which in their structure and progress have much in common with the real physician-patient rels tionships. Typical of the first form is the physician who becomes ensnared in these problems through confidential talks with a friend's wife. I will illustrate the second form with a short case history: A young therapist has a love affair with an artiste a few years his senior. The first night shows her to be vaginistic. They now talk for hours in the dark, revealing the emotional causes of her rather recent disturbance, which she abreacts in a Hood of tears. In the early hours of the morning she is willing and able to receive him. But now he is impotent, which is understandable because all sorts of anti-fetishistic elements have come forward during the night. He remained so, and the relationship soon ended. In conclusion-and as "moral of the tale"-a plain, clinical observation: in my experience the ejaculation ante portam is the "occupational disease" of the physician indulging in sex relations with his patients. He shares this fate with the divorce lawyer who has affairs with his clients. This symptom is in my opinion a self-punishment, revealing the split in the personality of those who think they may with impunity ignore our age-old deontology.
The Journal of Sex Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjsr20
Some Reflections on Sex Relations between Physician and Patient Conrad Van Emde Boas Psychiatrist and Sexologist M.D. Published online: 30 Oct 2013.
To cite this article: Conrad Van Emde Boas Psychiatrist and Sexologist M.D. (1966) Some Reflections on Sex Relations between Physician and Patient, The Journal of Sex Research, 2:3, 215-218, DOI: 10.1080/00224499.1966.10749566 To link to this article: http://dx.doi.org/10.1080/00224499.1966.10749566
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
The Journal of Sex Research
Val. 2, No.3, pp, 215-218
November, 1966
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
THE DOCTOR-PATIENT RELATIONSHIP Some Reflections on Sex Relations Between Physician and Patient CONRAD VAN EMDE BOAS Sex relations between doctor and patient have at all times and in all places been looked upon as incompatible with medical ethics. Hippocrates specifically rejects them in his oath: " ... Every house I shall only enter for the sake of my patients' wellbeing, refraining from every intentional harm and all seduction, especially from love relationships with women or with men, be they free or bonded." It is obvious therefore that we have no reliable data on these vetoed relationships which would permit statistical and/or other publications. We are dealing here with a matter about which the very persons who could supply these data are wise enough to keep absolutely silent. Consequently, anyone who wishes to penetrate this unexplored field must rely on casual, personal observations. These casual observations are largely based on statements of patients in individual or group-analytical therapy. To a smaller extent the facts have come to me from the colleagues concerned--colleagues under treatment or as partners of those of the first category. If a patient tells us during his or her psycho-therapy that she has maintained sex relations with one or more colleagues, our first reaction-sprung from group narcissism and from good-fellowship-is that we are dealing with a phantasy. These phantasies are common enough indeed. Sometimes, though not always, they will sooner or later betray themselves as such. In that case they are often considered as wish-fulfillment and as proof of a "positive transference." In my opinion, however, it can "hardly be denied that where this wishful thinking is served up as an actual happening, at the expense of the reputation of the physician concerned, strongly aggressive tendencies towards him or her must have existed, and the entire 215
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
LIb
(:ONR.\D V.\N EMDE Bo.\S
relationship must have been of a highly ambivalent character. In such cases we can often find out w/~y it was this particular therapist who became the victim of that false accusation and not some other colleague with whom our patient has been in contact. The physician often emerges as a party to this phantasy by conscious or subconscious provocation of sexual impulses. He pays for this "provocation" with the attack on his reputation, But not all the stories about sex relations with a physician dished up by our patients arc products of the patients' imagination. cannot deny that such relationships are more frequent than we arc inclined to believe. In my own practice-largely psycho-therapeutical and sexuological I have noticed that the frequency of this kind of officially frowned-upon relationship varies within the different branches of the medical profession. Gynecologists offer the most frequent targets. Second on the list are dentists and family doctors. But let me add immediately that psycho-therapists, too, arc not far behind, according to the "statisticsv-s-obviously limited and incomplete which I have compiled from my own observations. Freud's rule of abstinence apparently offers inadequate protection: the young' psycho-therapist, just launched on his career, is an casy and rather willing prey, for which we may either praise the patient's charm or blame our professional training. What I have just said about the "phantasies" apparently applies in many-though not £111- cases of actual sex relations between doctor and patient: both the ambivalent attitude 01 the patient and the provocative element in that of the physician, arc often easy to diagnose. Arc there any general or more specific aspects of these sex relationships and the character structure of the individuals concerned? Certainly there arc. But at this time I would rather restrict myself to some simple reflections on this difficult problem. I. In the first place we must not forget that a certain percentage of physicians -- whatever they may specialize in-and patients belong to the group of "easy victim'>" or "enthusiastic amateurs" who "fall" in every-clay life, too. They will remain true to type in the consulting rooms. 'Ve all know colleagues and patients of this type; they often boast of their promiscuous conquests and mind neither time nor place. 2. or greater importance lor our discussion is a second group, i.c., those cases where a genuine human relationship is involved. Even ill
' 'ie
v-
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
SEX RELATIONS BETWEEN PHYSICIAN AND PATIENT
217
an "ordinary" love relationship between two "ordinary" people in "ordinary" life, it is hard to say which part of the "romantic crush," with which the relationship began, is "real" affection, and how much of all this was based on "transference." It is not hard to imagine that this may also apply in a therapeutic relationship which leads to sex relations. Even in a psycho-analytical situation why shouldn't the emotional relationship between doctor and patient develop from the unavoidable transference and counter-transference to something "real"? In other words, why should it preclude real ties of affection, real sentiments that are entirely identical with the belonging, the tenderness and the sensuality of "real love"? The differentiation between these genuine sentiments and transference is far from easy. But I have seen cases where this distinction, both for those concerned and for the expert consultant, was indeed possible. In such cases I consider it a human and ethical problem of the first order whether rigid medical ethics, which veto intimate relationships now and forever, should prevail in the face of any other consideration. We must meet this question openly and unashamedly. We should not pretend, for instance, that in such a situation a legal alliance may be permissible after the therapy has ended (or been broken off) whereas an extra-marital relationship would lead to the most serious professional consequences. This is not pure theory: cases have been known of psycho-therapists who married former patients and were (or remained) accepted as members of their professional organization although the same organization had a short while before expelled another analyst on the grounds that he-many years after successfully completing the analysis-entered into an extra-marital relationship with a former patient. 3. Next, a few words which pertain to my first remark on the "young" therapist: I have the impression that therapists fall more often for a patient's more or less subtle attempts to seduce in the so-called modified techniques, where the patient is not lying on a couch but is sitting facing the analyst, especially when this setting is combined with the more direct, emotionally "warmer" techniques which are now advocated by some therapists. It is clear that complications will more easily arise under such conditions, since it is very hard to draw the lines between a permissible, protective and consoling attitude which can and may be coupled with casual bodily contact: a hand on a forehead, a shoulder to weep on. Where these lines are
Downloaded by [Memorial University of Newfoundland] at 16:28 01 August 2014
218
CONRAD VAN EMDE BOAS
not distinct, a critical situation may develop, especially when there is insufficient sensitivity for the mutual provocations which may occur in these forms of therapy: No wonder, therefore, that so many of uswhether we have or have not had those experiences that made Breuer stop his short-lived psychotherapeutic experiments-prefer the safe easy-chair behind the couch. I fully realize that a more thorough and systematic discussion of this engaging subject is both possible and desirable. In view of the delicate nature of the essential data, we ought to consider whether it would not be possible to collect pertinent material by means of international co-operation, guaranteeing absolute anonymity. Included in these studies should be those relationships, that I should like to call "physician-semi-patient" and erotic relationships between therapists and non-patients, which have deteriorated into a "therapeutical" relationship. I have seen many an example of both these forms, which in their structure and progress have much in common with the real physician-patient rels tionships. Typical of the first form is the physician who becomes ensnared in these problems through confidential talks with a friend's wife. I will illustrate the second form with a short case history: A young therapist has a love affair with an artiste a few years his senior. The first night shows her to be vaginistic. They now talk for hours in the dark, revealing the emotional causes of her rather recent disturbance, which she abreacts in a Hood of tears. In the early hours of the morning she is willing and able to receive him. But now he is impotent, which is understandable because all sorts of anti-fetishistic elements have come forward during the night. He remained so, and the relationship soon ended. In conclusion-and as "moral of the tale"-a plain, clinical observation: in my experience the ejaculation ante portam is the "occupational disease" of the physician indulging in sex relations with his patients. He shares this fate with the divorce lawyer who has affairs with his clients. This symptom is in my opinion a self-punishment, revealing the split in the personality of those who think they may with impunity ignore our age-old deontology.
