Although efforts have been made in the past few years to better quantify the incidence of physician misconduct, the extent of the problem remains unknown. A 2022 analysis of data in the National Practitioner Data Bank identified 1,721 reports of physician sexual misconduct between 2000 and 2019, which represents an average of 10.78 reports per 100,000 U.S. physician licensees [1]. A Public Citizen report found that of 1,354 physicians in the United States who had faced reportable sanctions or malpractice payments due to sexual misconduct between 2003 and 2017, 38% continued to hold active licenses and clinical privileges in the states where they faced these consequences [2].

The severity of boundary violations can be conceptualized on a spectrum, with patient exploitation and abuse on one end. One of the most severe cases of boundary violation is sexual misconduct. The Federation of State Medical Boards (FSMB) provides the following definition of sexual misconduct [5]:

…physician sexual misconduct is understood as behavior that exploits the physician-patient relationship in a sexual way. Sexual behavior between a physician and a patient is never diagnostic or therapeutic. This behavior may be verbal or physical, can occur in person or virtually, and may include expressions of thoughts and feelings or gestures that are of a sexual nature or that a patient or surrogate may reasonably construe as sexual.

The American Medical Association (AMA) addresses the issue of sexual harassment and misconduct in its Code of Ethics. Opinion 9.1.1 states, "Romantic or sexual interactions between physicians and patients that occur concurrently with the patient-physician relationship are unethical. Such interactions detract from the goals of the patient-physician relationship and may exploit the vulnerability of the patient, compromise the physician's ability to make objective judgments about the patient's health care, and ultimately be detrimental to the patient's well-being" [6]. According to AMA ethical guidelines, a physician should end the patient-physician relationship before starting a dating, romantic, or sexual relationship with a patient. Further, even nonsexual, nonclinical contact with patients should be avoided if there is a possibility that it may be perceived as or lead to romantic or sexual contact. Additionally, engaging in sexual or romantic relationships with former patients can be problematic if there is any potential for the previous professional relationship to influence the new relationship. Such relationships are considered unethical if the physician uses trust, knowledge, emotions, or influence from the previous relationship, or if the romantic involvement could harm the individual [6].

Patients who experience boundary violations may suffer profound emotional distress, with feelings of betrayal, vulnerability, and exploitation. When a patient's trust in their physician and the medical community is broken, it can lead to feelings of powerlessness, anger, and emotional trauma, negatively impacting their mental health and overall well-being. Some patients will develop acute trauma responses, post-traumatic stress disorder (PTSD), depression, and suicidal ideation [9].

Prior to performing any intimate examination, explicit informed consent should be obtained from the patient and documented. Patients should be given sufficient time to ask questions and provide consent voluntarily. Informing patients of their right to withdraw consent at any time can empower them to make informed decisions about their health care [11].

Ensuring a private and comfortable examination space is crucial for preserving patient dignity. Offering the option of having a chaperone present during the examination can provide additional support and comfort. Providing gowns or drapes to maintain modesty during examinations can significantly enhance the patient's sense of comfort. Take care to position the patient comfortably during the examination, respecting their preferences and physical limitations. Maintaining eye contact and using touch with the patient's consent can further promote a sense of reassurance.

Physicians should be mindful of patient preferences, cultural differences, and sensitivities related to gynecologic examinations. Some patients may prefer healthcare providers of the same gender or have specific cultural norms that impact their perceptions of modesty and healthcare practices. For patients with physical disabilities, healthcare providers should make reasonable accommodations to ensure a dignified and comfortable examination experience.

Providing gynecologic care to survivors of sexual trauma requires an exceptionally sensitive and empathetic approach. Healthcare providers should be educated on the impact of trauma, including its potential long-term effects on survivors' mental and physical health. Understanding the ways trauma can manifest in medical settings, such as triggers, dissociation, or flashbacks, is crucial for creating a safe and supportive environment. Healthcare providers should be prepared to address potential triggers and offer emotional support throughout the process. Encouraging survivors to express their feelings and providing validation can help them cope with emotional distress. Survivors of sexual trauma may experience heightened physical sensitivity and discomfort during the examination. Healthcare providers should prioritize minimizing pain and discomfort by using smaller-sized instruments, providing adequate lubrication, and taking breaks as needed. A patient-centered approach to pain management is crucial to ensure a more positive experience. In some cases, survivors may require additional support from mental health professionals with expertise in trauma [13].

Emergency physicians, who often deal with high-stress and time-sensitive situations, must be vigilant in upholding professional boundaries and adhering to ethical guidelines to ensure patient safety and trust. Those providing emergency care hold a position of authority and power over patients, particularly during moments of vulnerability and distress. This power imbalance can create opportunities for exploitation of patients' trust for personal gain, leading to inappropriate behavior or sexual misconduct. In some emergency department settings, there may be a lack of oversight or inadequate mechanisms to monitor physician behavior. This can create an environment in which inappropriate conduct may go unnoticed or unaddressed. Implementing regular performance evaluations and peer reviews can help monitor physician behavior and identify any concerning patterns or trends [14].

Emergency departments are fast-paced and high-pressure environments, leaving physicians with limited time to establish rapport and engage in thorough communication with patients. Under these conditions, judgement errors, miscommunications, and blurring of professional boundaries are possible.

Emergency physicians frequently encounter traumatic and emotionally taxing situations. Prolonged exposure to distressing events may lead to emotional fatigue and burnout, potentially impacting one's ability to maintain appropriate boundaries. Distressing events that require debriefing with colleagues may make it difficult to strike a balance between discussing experiences and maintaining confidentiality.

In cases of child sexual abuse involving pediatricians or other healthcare providers, the first sign is often grooming behavior employed to gain the trust and compliance of the child and/or caregiver before escalating to abusive acts. The intrusiveness of these activities may escalate over time, starting with seemingly innocent touches and progressing to more overt contact. Examples of grooming behaviors include giving gifts or favors to the child and having unsupervised contact with them. Emotionally vulnerable, intellectually or developmentally delayed, physically disabled, or attention-seeking children may be at increased risk for abuse [15].

One aspect of reflective practice is to review past interactions with patients, colleagues, and other stakeholders. By analyzing these experiences, one can identify instances in which boundaries were appropriately maintained or potentially compromised. In addition, physicians should explore their emotional responses to various situations. This heightened emotional awareness can help identify personal vulnerabilities that may affect one's ability to act appropriately. Healthcare practitioners can learn valuable lessons and implement strategies to prevent similar occurrences in the future [17].

The following approaches are recommended in all physician-patient relationships to help minimize the risk of boundary violations and inappropriate relationships [19,20,21,22]:

Establish boundaries: Maintain clear and professional boundaries with patients at all times. Avoid engaging in discussions or behaviors that may blur the line between a professional and personal relationship.

Transition of care: If a physician realizes they have developed personal feelings for a patient, it is crucial to transfer the patient's care to another qualified healthcare provider. This transfer should be handled with sensitivity and respect for the patient's well-being.

Time and distance: In cases where a patient expresses feelings for the physician, it is essential to maintain professional distance and avoid reciprocating or encouraging such emotions. Over time and with proper communication, these feelings may naturally dissipate. In some cases, avoiding being alone with these patients is best, if possible.

Support systems: Physicians should have access to support systems, such as mentors, peer support groups, or counseling services, to help them navigate emotionally challenging situations and maintain ethical conduct.

Education and training: Medical institutions should provide ongoing education and training to healthcare professionals on maintaining appropriate professional boundaries and recognizing potential ethical dilemmas.

Flexibility in examination techniques is essential when a patient expresses discomfort. Physicians should consider alternative approaches that achieve the same diagnostic goals while minimizing physical contact or exploring less invasive options. Using smaller devises and swabs can minimize discomfort and feelings of invasiveness. Moreover, explaining these alternatives to patients can help them feel more involved in the decision-making process [12].