early everyone in academic medicine knows of intimate relationships between faculty and medical trainees. In two studies, about one out of 20 medical students acknowledged having had at least one consensual relationship with a faculty member during training,^1,2 17 percent of female psychology students reported intimate sexual contact with an educator during training,³ and a startling 46 percent of female medical trainees report nonconsensual sexual interactions involving faculty, such as sexual harassment, discrimination or coerced sexual intimacy.⁴

The same issues emerged in the world of private medical practice. Is it ethical for a physician to initiate an intimate relationship with a coworker? Under what circumstances would this be permissible or problematic? Sexual misconduct by physicians involving patients has long concerned licensing bodies, communities and governments. Professional education about appropriate personal boundaries with patients, co-workers and between medical faculty and their trainees has remained largely unaddressed.⁵ Such relationships raise important ethical questions involving personal autonomy versus benefits and harms to coworkers, students, patients and the physicians themselves.

Should a private relationship be of institutional or societal concern?
Our culture values individual freedoms, strongly supporting the rights of mature individuals to develop relationships without undue regulatory interference. Sexual relationships are intensely private, and it is abhorrent to consider them being scrutinized by governments and institutional regulators. Nevertheless, in limited circumstances, regulatory oversight of private relationships is accepted, including relationships in which behavior is perceived to have overwhelmingly negative impact on a community or when especially vulnerable persons might be exploited. Inappropriate touching of patients by physicians, domestic abuse, marital rape and incest are examples of behavior that our society proscribes. The American Medical Association (AMA) Council on Ethical and Judicial Affairs has consistently ruled that some intimate relationships, such as those between trainees and teachers, patients and doctors, and physicians and co-workers, should be discouraged.⁶

The following discussion centers on teacher-student relationships, which could occur in the academic setting. Similar concerns apply, however, if the physician has the power to influence evaluation of a coworker of unequal status or power within a health care institution. A physician who has or will in the future provide medical care for a patient should avoid a personal relationship because the power differential between physician and patient is too vast for such a personal relationship to be truly consensual. Physicians must monitor themselves to avoid inappropriate speech to or touching of patients or coworkers that could be interpreted as flirting, coercing or suggesting a personal relationship. Differences in power and influence in the medical workplace create the potential for coercive and disruptive interactions between physicians and staff and even between physicians themselves. Intimate relationships in the work setting can thus set the stage for claims of harassment, a hostile work environment and coercion.

Are faculty-student relationships truly consensual?
Many professionals question whether such relationships can ever be truly consensual when the teacher is in a position to affect a student’s evaluations and future career prospects. Even when a teacher may not actually intend to coerce a student, the student may harbor the belief or fear that his/her evaluations will suffer if he/she does not engage in the relationship or that he/she will be elevated if they do.

Several studies show that trainees who develop sexual relationships with their teachers commonly feel, at least to some degree, coerced to enter or remain in the relationship and that these feelings increase over time.^1,2 For example a student who is dependent on financial aid for his/her education, but whose aid is contingent on good grades, may not feel he/she can reasonably refuse to enter into an intimate relationship if approached by a key evaluator. A large number of students also reported that the relationship had a significantly negative impact on career plans and relationships with other teachers.^1,2 Even when such relationships begin consensually, studies indicate that they frequently result in fear, regret and disproportionate guilt on the part of the student as time goes on.⁵

Do such relationships cause harm to anyone else?
There is disturbing and strong evidence that students who engage in a sexual relationship with a faculty member are at increased risk of future sexual misconduct or abuse involving their own students or patients.^4,7,8,9 An inappropriate faculty-student relationship can impair the faculty member’s ability to recognize and deliver appropriate feedback when the student commits errors in clinical decision-making or has other performance issues. When faculty members consciously or subconsciously “gloss over” training issues because of their relationship with the student, it results in negative effects not just on the patient under their immediate care but on that student’s future patients as well.¹⁰

Policies to address faculty-student relationships
One way to mitigate conflicts of interest generated by an intimate relationship between a student and faculty member is for the teacher to withdraw from any role that might involve either supervising or evaluating the student, both now or in the future. This may be more difficult than it appears. In the case of medical students and residents, it can affect daytime clinical schedules, call obligations and cross-coverage issues and may therefore be nearly impossible to implement. Moreover “supervision and evaluation” extend beyond clinical situations: Faculty meetings, reports and comments that directly or indirectly affect performance evaluations submitted by others should be avoided as well.

How should interactions between the student and faculty member be handled when the relationship has ended? The emotional aftermath of the relationship may inappropriately influence future evaluations of the student by the faculty member or of the faculty member by the student. For just such reasons, the University of California implemented a policy at all nine campuses in 2003 that prohibits teachers from dating either students who are in their classes or students for whom they might reasonably expect in the future to have academic responsibility.¹¹

AMA’s position is that “consensual relationships” between a teacher and student are particularly wrong if a current supervisory relationship exists between the two, but they also should be avoided if it is possible that the trainee might unexpectedly come under the supervision of the teacher in question at some future time.⁶ The fact that such future circumstances may be impossible to anticipate argues for avoiding intimate faculty-student relationships altogether.

Special cases
The rights of adults to make autonomous decisions are a dominant ethical principle, and policies entirely prohibiting intimate faculty-student relationships are therefore problematic and undesirable. It is clearly unethical, however, for a faculty member to engage in repeated relationships with students such that, in the words of Pope, the teacher “seems to regard the trainee pool as a ‘private game reserve’ or well stocked lake, replenished every year.” Such behavior amounts to a form of sexual predation and is specifically exploitative of students. It also harms the teacher and his/her work by discrediting him/her within the trainee pool.¹²

In summary
Intimate relationships between medical trainees and their teachers present unique and troubling ethical questions and are at best imprudent. Blanket policies prohibiting all such relationships are overly broad, though, and interfere too much with the rights of adults to have private relationships. Institutional policies regarding such relationships should require at a minimum that the teacher end any current or future supervisory role over the student when such a relationship develops. Teachers need to be aware that such relationships carry the risk of harming their credibility as teachers and the credibility of the faculty group to which they belong.

Finally, sexually predatory behavior in the academic or private practice setting is entirely unethical and should be subject to disciplinary action when it occurs. Anesthesiologists should realize that speech and behavior within the workplace that once was tolerated may no longer be permitted. The creation of an uncomfortable workplace by the use of “flirting,” suggesting that an intimate relationship exists and telling of sexually explicit “jokes” are no linger permissible because they are unethical and may be illegal under federal regulations intended to protect workers.

References:
1. Carr M, Robinson GE, Stewart D, et al. Resident-educator sexual involvement. Am J Psychiatry. 1991; 148:216-220.
2. Gartrell N, Herman J. Olarte S, et al. Psychiatry residents and sexual contact with educators and patients: Results of a national survey. Am J Psychiatry. 1988; 145:690-694.
3. Glaser RD, Thorpe JS. Unethical intimacy: A survey of sexual contact and advances between psychology educators and female graduate students. American Psychologist. 1986; 41(1):43-51.
4. Moscarello R, Margittai KJ, Rossi M. Differences in abuse reported by female and male Canadian medical students. CMAJ. 1994; 150:357-363.
5. Robinson GE, Stewart DE. A curriculum on physician-patient sexual misconduct and teacher-learner mistreatment Part 1: Content. CMAJ. 1996; 154:643-649.
6. For a complete list and files of AMA CEJA rulings, refer to www.ama-assn.org/ama/pub/category/3840.html.
7. Baldwin DWC, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment and harassment during medical school. A survey of 10 United States schools. West J Med. 1991; 155:140-145.
8. Pope KS, Levenson, H, Schover LR. Sexual intimacy in psychology training. Am Psychol. 1979; 34:682-689.
9. Strasburger LH, Jorgenson L, Sutherland P. The prevention of psychotherapist sexual misconduct; Avoiding the slippery slope. Am J Psychother. 1992; 46:544-555.
10. Ryan CJ. Sex, lies and training programs: The ethics of consensual sexual relationships between psychiatrists and trainee psychiatrists. Austral N Z J Psych. 1998; 32:387-391.
11. Paulson A. Student/teacher romances off limits. Christian Science Monitor. Feb 17, 2004.
12. Pope KS. Therapist-patients syndrome: A guide for attorneys and subsequent therapists to assessing damage. In: Gabbard Go, ed. Sexual Exploitation in Professional Relationships. Washington DC: American Psychiatric Press; 1989:39-55.

Gail A. Van Norman, M.D., is Clinical Associate Professor, Department of Anesthesiology, Faculty Associate, Department of Biomedical Ethics, University of Washington, Seattle, Washington, and staff anesthesiologist, Pacific Anesthesia, Tacoma, Washington.