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Sex Between Therapists and Clients

Kenneth S. Pope

Abstract: Sex between therapists and clients has emerged as a significant phenomenon, one that the profession has not adequately acknowledged or addressed. Extensive research has led to recognition of the extensive harm that therapist-client sex can produce. Nevertheless, research suggests that perpetrators account for about 4.4% of therapists (7% of male therapists; 1.5% of female therapists) when data from national studies are pooled. This chapter looks at the history of this problem, the harm it can cause, gender patterns, the possibility that the rate of therapists sexually abusing their clients is declining, and the mental health professions' urgent, unfinished business in this area.

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When people are hurting, unhappy, frightened, or confused, they may seek help from a therapist. They may be depressed, perhaps thinking of killing themselves. They may be unhappy in their work or relationships, and not know how to bring about change. They may be suffering trauma from rape, incest, or domestic violence. They may be bingeing and purging, abusing drugs and alcohol, or engaging in other behaviors that can destroy health and sometimes be fatal.

The therapeutic relationship is a special one, characterized by exceptional vulnerability and trust. People may talk to their therapists about thoughts, feelings, events, and behaviors that they would never disclose to anyone else. Every state in the United States has recognized the special nature of the therapeutic relationship and the special responsibilities that therapists have in relation to their clients by requiring special training and licensure for therapists, and by recognizing a therapist-patient privilege which safeguards the privacy of what patients talk about to their therapist.

A relatively small minority of therapists take advantage of the client's trust and vulnerability and of the power inherent in the therapist's role by sexually exploiting the client. Each state has prohibited this abuse of trust, vulnerability, and power through licensing regulations. Therapist-patient sex is also subject to civil law as a tort (i.e., offenders may be sued for malpractice), and some states have criminalized the offense. The ethics codes of all major mental health professionals prohibit the offense.

The health care professions at their earliest beginnings recognized the harm that could result from sexual involvement with patients. The Hippocratic Oath, named after the physician who practiced around the fifth century B.C., prohibits sex with patients as does the code of the Nigerian Healing Arts, which was created prior to the life of Hippocrates. Freud, a pioneer of the "talking cure," emphasized the prohibition in his writings. The historical consensus among health care professionals that sex with patients is prohibited as destructive continued into the modern age. In the landmark (i.e., one of the first women to successfully bring suit against her therapist on these grounds) 1976 case of Roy v. Hartogs, the court held: "Thus from [Freud] to the modern practitioner we have common agreement of the harmful effects of sensual intimacies between patient and therapist."


What are the "harmful effects" the court referred to? While the scientific and professional literature had contained carefully documented individual case studies and theoretical papers describing the harm that therapist-patient sex could cause, larger scale studies began to emerge in the 1960s and 70s.

William Masters and Virginia Johnson, for example, gathered data from many research participants for their 1966 report Human Sexual Response and the 1970 report Human Sexual Inadequacy. They were surprised at the number of participants in their samples who had engaged in sex with therapists.

The extensive data that Masters and Johnson collected on each participant allowed them to compare the consequences of sex with a therapist to the consequences of other events such as consensual sexual relationships with a spouse or life-partner, consensual sex occurring outside long-term relationships, and various forms of rape, incest, and abuse.

So striking were the harmful consequences associated with therapist-patient sex that Masters and Johnson wrote: "We feel that when sexual seduction of patients can be firmly established by due legal process, regardless of whether the seduction was initiated by the patient or the therapist, the therapist should be sued for rape rather than malpractice, i.e., the legal process should be criminal rather than civil."

Psychologist Phyllis Chesler, in her landmark 1972 study Women and Madness, included a section on therapist-patient sex. She reported consequences among the sample of women whom she studied including severe depression and suicide.

Pope and Vetter published a national study of 958 patients who had been sexually involved with a therapist. The findings suggest that about 90% of patients are harmed by sex with a therapist; 80% are harmed when the sexual involvement begins only after termination of therapy. About 11% required hospitalization; 14% attempted suicide; and 1% committed suicide. About 10% had experienced rape prior to sexual involvement with the therapist, and about a third had experienced incest or other child sex abuse. About 5% of these patients were minors at the time of the sexual involvement with the therapist. Of those harmed, only 17% recovered fully.

The three studies mentioned above represent only a few of the diverse sampling procedures used to study the harm that can result from therapist-patient sex. Diverse studies have gathered samples of patients who never again sought mental health services as well as those who later entered into therapy again with a new therapist. Patients who have experienced therapist-patient sex have been compared to carefully matched control groups of patients who have experienced sex with their treating physicians who were not therapists and of patients who have been in psychotherapy but not experienced therapist-patient sex. The effects of therapist-patient sex have been assessed by independent clinicians, by subsequent therapists of the patients, and by the patients themselves. Data have been collected using structured behavioral observation, standardized tests and other psychometric instruments, clinical interview, and other methods.

What follows is a brief description of 10 of the most common reactions that are frequently associated with therapist-patient sex. These reactions are: (a) ambivalence, (b) cognitive dysfunction, (c) emotional lability, (d) emptiness and isolation, (e) impaired ability to trust, (f) guilt, (g) increased suicidal risk, (h) role reversal and boundary confusion, (i) sexual confusion, and (j) suppressed anger. While common, these reactions do not characterize all patients who have been sexually involved with a therapist.

A. Ambivalence

Extreme ambivalence can be one of the most debilitating consequences of sexual involvement with a therapist. Caught between two sets of conflicting impulses, those suffering this consequence may find themselves psychologically paralyzed, unable to make much progress in either direction. On one hand, they may want to escape from the abusive therapist, from the destructive relationship, and from the continuing effects of the abuse. They may wish to break the taboo of silence that the therapist has imposed, to speak out truthfully about what has happened to them. They may seek justice and restitution in the courts. They may try to prevent the therapist from abusing other patients by filing formal complaints with professional ethics committees, the hospital or clinic (if any) employing the therapist, and licensing agencies, in part to see if to what degree these organizations are serious about protecting patients from abuse. They may try to make sense of and work through their experience of abuse so that they can move on with their lives.

But on the other hand, they may believe that they need to protect the abusive therapist at all costs. Abusive therapists are often exceptionally adept at creating and nurturing these dynamics. Exploited patients may learn from the therapist that the most important thing is to keep the sexual relationship secret so as not to harm the therapist's career. They may have been led to believe that the sexual relationship was an act of great self-sacrifice on the part of the therapist, a moral and ethical act that was the only way that the therapist could "cure" whatever was wrong with the patient.

Ambivalence of this kind is often found among those who have experienced other forms of abuse. Incest survivors, for example, may experience contradictory impulses to flee the abusive parent, and yet also to cling to and protect that same parent. Similarly, some battered women will desperately want to escape to safety but also feel an overwhelming impulse to submit to the batterer, to take all blame upon themselves, and to keep the battering secret from all others.

B. Cognitive Dysfunction

Many people who have been sexually involved with a therapist, whether the sex started before or after termination, will experience intense forms of cognitive dysfunction. There may be interference with attention, memory, and concentration. The flow of experience will often been interrupted by unbidden thoughts, intrusive images, flashbacks, memory fragments, or nightmares. These cognitive impairments may interfere significantly with the person's ability to work, to participate in social activities, and sometimes even to carry out the most routine aspects of self-care. Sometimes the pattern of consequences may fit the model of post-traumatic stress disorder.

C. Emotional Lability

Emotional lability reflects the severe disruption of the person's characteristic ways of feeling in a way that is similar to cognitive dysfunction reflecting the severe disruption of the person's characteristic ways of thinking. Intense emotions may erupt suddenly and without seeming cause, as if they were completely unrelated to the current situation. The emotional disconnect can be profound: a person can describe a wrenchingly sad event and burst out laughing, or talk about something funny or wonderful and begin sobbing.

Emotions begin to feel alien and threatening, as if they were unwanted intruders into the inner life. Cognitive dysfunction can involve interrupting the flow of experience with unbidden thoughts, intrusive images, etc.; emotional lability can involve interrupting the flow of experience with extreme, unpredictable, rapidly shifting feelings. The person begins to feel helpless, as if the emotions were completely out of control, as if he or she were at the mercy of a powerful, intrusive enemy, an occupying force.

D. Emptiness and Isolation

People who have been sexually involved with a therapist may experience a subsequent sense of emptiness, as if their sense of self had been hollowed out, permanently taken away from them. The sense of emptiness is often accompanied by a sense of isolation, as if they were no longer members of society, cut off forever from feeling a social bond with other people.

The sense of emptiness and aloneness can feel overwhelming and horrifying that Elma Pálos described clearly. Pálos had been the therapy patient and sexual partner of Sándor Ferenczi. Pálos's mother had also been the therapy patient and sexual partner of Ferenczi. She wrote in 1912: "This being alone that now awaits me will be stronger than I; I feel almost as if everything will freeze inside me . . . . If I am alone, I will cease to exist."

E. Guilt

People who become sexually involved with a therapist may become flooded with persistent, irrational guilt. The guilt is irrational because it is in all instances the therapist's responsibility to avoid sexually abusing a patient. It is the therapist who has been taught, from the earliest days of training, that engaging in sex with patients is prohibited, no matter what the rationale. It is the therapist whose ethics code clearly classifies sexual involvement with patients as a violation of ethical behavior. It is the therapist who is licensed by the state in recognition of the need to protect patients from unethical, unscrupulous, and harmful practices, and it is the licensing boards and regulations that clearly charge therapists with refraining from this form of behavior that can place patients at risk for pervasive harm.

As the research summarized in subsequent sections will show, gender effects in this area are significant. It is possible that gender may be associated with the ways in which this irrational guilt develops and is sustained. Psychiatrists Melanie Carr and Gail Robinson wrote: "[W]omen are often programmed to take responsibility for and feel guilty about relationships and their problems. The almost universal expression of guilt and shame expressed by women who have been sexually involved with their therapists is a testament to the power of this conditioning" (p. 126). Psychiatrist Virginia Davidson, analyzing the similarities between therapist-patient sex and rape, wrote:

Women victims in both instances experience considerable guilt, risk loss of love and self-esteem, and often feel that they may have done something to "cause" the seduction. As with rape victims, women patients can expect to be blamed for the event and will have difficulty finding a sympathetic audience for their complaint. Added to these difficulties is the reality that each woman has consulted a therapist, thereby giving some evidence of psychological disequilibrium prior to the seduction. How the therapist may use this information after the woman decides to discuss the situation with someone else can surely dissuade many women from revealing these experiences.

F. Impaired Ability to Trust

When therapists intentionally and knowingly violate their patients' trust, as they do when they decide to become sexually involved with them, the effects on the patients' ability to trust can be profound and lasting. Therapy may rest on a foundation of exceptional trust. People may walk into the offices of complete strangers and, if the stranger is a therapist, begin talking about thoughts, feelings, and impulses that they would reveal literally to no one else. Every state, appreciating the exceptionally sensitive nature of the "secrets" that patients may entrust to their therapists, have established in their laws a formal therapist-patient privilege. The ethics codes of all major mental health professions recognize the therapist's responsibility to maintain confidentiality when patients trust the therapist to the extent that they disclose personal information in therapy.

Beyond investing therapists with trust regarding their own privacy, confidentiality, and "secrets," patients trust therapists to act in a way consistent with patient well-fare and to avoid intentionally engaging in any behavior that not only is unethical and prohibited by law but also places the patient at so needless a risk for harm. In some ways, therapy is similar to surgery. Patients agreeing to surgery allow themselves to be opened up physically because they have been led to believe that the process has some reasonable prospects of leading to improvement. They allow a professional to do to them--i.e., cut into them--what they would not let anyone else do. They trust that the professional will not take advantage of them or abuse them, sexually or otherwise, during this process. Therapy patients submit themselves to a process in which they open up psychologically because they also have been led to believe that this process is likely to yield improvement. They trust therapists to avoid any exploitation or abuse during the process.

It was Freud who first noted this similarity. He wrote that "talking therapy" was "comparable to a surgical operation.'' Like the surgeon, the therapist worked with "a dangerous instrument . . . . [I]f a knife will not cut, neither will it serve a surgeon." According to Freud, The responsible therapist always honestly acknowledged the potential for enormous destruction: "[I]t is grossly to undervalue both the origins and the practical significance of the psychoneuroses to suppose that these disorders are to be removed by pottering about with a few harmless remedies. . . . [P]sychoanalysis ... is not afraid to handle the most dangerous forces in the mind and set them to work for the benefit of the patient."

G. Increased Suicidal Risk

As a group, patients who have been sexually involved with a therapist have significantly increased risk of both suicide attempts and completed suicides when compared with the general population and other groups of patients. The research published in peer-reviewed journals suggests that about 14% will make at least one attempt at suicide and that about one in every hundred patients who have been sexually involved with a therapist commit suicide.

H. Role Reversal and Boundary Confusion

Therapists who sexually exploit their patients tend to violate both roles and boundaries in therapy. The focus of sessions shifts from the clinical needs of the patient to the personal desires of the therapist. The therapist brings about a reversal of roles: the sessions and the relationship are no longer about the therapist being of use to the patient in service of the patient's welfare but rather the patient being of use to the therapist in service of the therapist's sexual gratification. The fundamental clinical, ethical, and legal boundary that would prevent a therapist from turning patients into sources for the therapist of sexual pleasure, experimentation, relief, variety, or control is violated.

In a legitimate therapy, the therapeutic process, effectiveness, and improvements that therapist and patient work on during each sessions is expected to continue between sessions and, ultimately, after termination. Entering psychotherapy to become less depressed, to overcome stage fright, or to resolve conflicts with a partner would make little long-term sense if the depression stage fright, and conflict resumed immediately after termination. Unfortunately, the harm as well as the benefits that therapy brings about can be long-term. The negative effects of the therapist's violation of boundaries and reversal of roles can generalize beyond the therapy and persist long after the termination of the therapy and the sexual relationship. The roles and boundaries that people use to define, mediate, and protect the self may become not only useless for the patient but also self-defeating and self-destructive.

I. Sexual Confusion

It is perhaps not surprising that many patients who have been sexually exploited by a therapist wind up deeply confused about their own sexuality. Psychologist Janet Sonne served as one of the group therapists in 1982 and 1983 for some of the patients who participated in the UCLA Post Therapy Support Program, the first university-based program offering services to patients who had been sexually involved with their therapists, conducting research in this area, and providing training to graduate students. She wrote that female patients who had been sexually involved with a prior therapist "expressed a cautiousness or even disgust with their sexual impulses and behavior as a result of sexual involvement with their previous therapists. For some female clients who identified themselves as heterosexual before they were involved sexually with female therapists, there tended to be significant confusion over their 'true' sexual orientation."

The experience of sex with a therapist leaves some patients believing that their only worth as human beings is to provide sexual gratification to others. Some engage in sex with others on an almost obsessional basis as re-enactment of the sexual relationship with the therapist.

Especially when the patient is experiencing feelings of emptiness and isolation, the specific sexual activities previously experienced with the exploitive therapist--often re-enacted in the midst of flashbacks--may represent an attempt to fill up the self and break through the isolation. For still other patients, sex becomes associated with feelings of irrational guilt. They may engage in demeaning, degrading, joyless, painful, harmful, or dangerous sexual activities that seem to express the conviction: "I am guilty, worthless, and deserve this." Some may become so confused about sexuality that they begin labeling a variety of feelings and impulses as "sexual." They may, for example, say that they are sexually aroused whenever they are feeling intensely angry, depressed, anxious, or afraid.

J. Suppressed Anger

Many patients who have been sexually abused by a therapist are justifiably angry, but it may be difficult for them to experience the anger directly. Some may feel only numbness in situations that, according to them, would have previously evoked anger. Some may turn the anger inward, becoming enraged at themselves. The anger directed inward may lead to self-loathing, self-punishment, and self-destructive behaviors including suicide.

Offending therapists are often skilled at manipulating patients into suppressing their anger. Some may use intimidation, coercion, or even force and violence to ensure that a patient will suppress anger rather than feel and express it directly. One therapist would yell at a patient, who had a history of having been sexually abused, whenever she started to become angry at him for touching her sexually during the sessions. She became terrified of her own anger, and of the possibility that anyone else might become angry at her. During her subsequent therapy she would sit in silence for long periods of time, terrified to say anything, finally whispering something along the lines of, "You're angry at me, aren't you." Psychologist Janet Sonne, describing the findings of the UCLA Post Therapy Support Group, wrote: "Although the patient may occasionally acknowledge her intense rage, she will more often suppress her anger for fear of being overwhelmed by it, or of harming its object (the therapist) or others."


Exceptional gender differences have emerged from the diverse research models investigating therapist-client sexual involvement. Data from each research approach suggest that offending therapists are overwhelmingly (though not exclusively) male while exploited clients are overwhelmingly (though not exclusively) female. Each method of study has strengths and weaknesses, but in each, the number of male offenders exceeds the number of female offenders and the number of female victims exceeds the number of male victims, even after the over-all proportions of male and female therapists and of male and female clients have been taken into account. The extreme gender differences led UCLA professor Jean Holroyd, principal investigator of the first national study of therapist-patient sex, to write that "sexual contact between therapist and patient is perhaps the quintessence of sex-biased therapeutic practice": female clients do not have equal access to non-abusive therapy. The following section reviews peer-reviewed findings representing 4 of the major methods of study.

One approach to gathering data in this area is to obtain anonymous reports from current and former therapy clients about whether they were or were not sexually involved with their therapist. (Please follow this link for an example of anonymous reports from therapy clients.) The data from this approach shows that clients who report having been sexually involved with a therapist are overwhelmingly more likely to be female than male.

A second approach is to obtain anonymous reports from therapists about whether they have or have not been sexually involved with clients. Table 1 summarizes national self-report studies of therapists that have been published in peer-reviewed journals. The base rate of the behavior (i.e., engaging in sex with a client) is relatively low and thus the statistical differences are not always significant. However, it is worth nothing that even though some of the differences are not statistically significant, in no study does the percentage of female therapists reporting sexual involvement with a therapist equal or exceed the percentage of male therapists. In one of the studies the percentage of male offenders is nine times as large as the percentage of female offenders.

When the data from all 8 national studies in Table 1 are pooled, overall about 4.4% of the therapists report having engaged in sex with at least one client. Offenders are about 4 times more likely to be male than female: overall about 7% of the male therapists reported engaging in sex with one or more clients; about 1.5% of the female therapists reported engaging in therapist-client sex.

Table 1 - Results of 8 Studies of Sex with Clients Using National Samples of Therapists1
Study Publication date Discipline Sample size Return rate % Male Therapists Reporting Sex With Clients % Female Therapists Reporting Sex with Clients
Holroyd & Brodsky 2 1977 psychologists 1,000 70% 12.1% 2.6%
Pope, Levenson & Schover 1979 psychologists 1,000 48% 12.0% 3.0%
Pope, Keith-Spiegel & Tabachnick 1986 psychologists 1,000 58.5% 9.4% 2.5%
Gartrell, Herman, Olarte, Feldstein & Localio 3 1986 psychiatrists 5,574 26% 7.1% 3.1%
Pope, Tabachnick & Keith-Spiegel.4 1987 psychologists 1,000 46% 3.6% 0.4%
Akamatsu 5 1988 psychologists 1,000 39.5% 3.5% 2.3%
Borys & Pope.6 1989 psychiatrists, psychologists & social workers 4,800 56.5% 0.9% 0.2%
Bernsen, Tabachnick & Pope 1994 social workers 1,000 45.3% 3.6% 0.5%

Above table adapted from the book Sexual Involvement with Therapists: Patient Assessment, Subsequent Therapy, Forensics

Table notes:

1 This table presents only national surveys that have been published in peer-reviewed scientific and professional journals. Exceptional caution is warranted in comparing the data from these various surveys. For example, the frequently cited percentages of 12.1 and 2.6, reported by Holroyd and Brodsky (1977), exclude same-sex involvements. Moreover, when surveys included separate items to assess post-termination sexual involvement, these data are reported in footnotes to this table. Finally, some published articles did not provide sufficiently detailed data for this table (e.g., aggregate percentages); the investigators supplied the data needed for the table.

2 Although the gender percentages presented in the table for the other studies represent responses to one basic survey item in each survey, the percentages presented for Holroyd & Brodsky's study span several items. The study's senior author confirmed through personal communication that the study's findings were that 12.1% of the male and 2.6% of the female participants reported having engaged in erotic contact (whether or not it included intercourse) with at least one opposite-sex patient; that about 4% of the male and 1% of the female participants reported engaging in erotic contact with at least one same-sex patient; and that, in response to a separate survey item, 7.2% of the male and 0.6% of the female psychologists reported that they had "had intercourse with a patient within three months after terminating therapy" (p. 846; see also Pope, Sonne, & Holroyd, 1993).

3 "Respondents were asked to specify the number of male and female patients with whom they had been sexually involved" (p. 1127); they were also asked "to restrict their answers to adult patients" (p. 1127).

4 The survey also included a question about "becoming sexually involved with a former client" (p. 996). Gender percentages about sex with current or former clients did not appear in the article but were provided by an author. Fourteen percent of the male and 8% of the female respondents reported sex with a former client.

5 The original article also noted that 14.2% of male and 4.7% of female psychologists reported that they had "been involved in an intimate relationship with a former client" (p. 454).

6 This survey was sent to 1,600 psychiatrists, 1,600 psychologists, and 1,600 social workers. In addition to the data reported in the table, the original article also asked if respondents had "engaged in sexual activity with a client after termination" (p. 288). Six percent of the male and 2% of the female therapists reported engaging in this activity.

(For a discussion of these national studies and their implications, see Sexual Involvement with Therapists: Patient Assessment, Subsequent Therapy, Forensics.)

A third approach examines actuarial data from licensing boards, ethics committees, and other agencies that adjudicate complaints against therapists. A study of licensing board disciplinary actions in regard to therapist-client sexual involvement, for example, found that in 86% of the cases, the disciplined therapist was male and the client was female.

A fourth approach gathers data from subsequent treating therapists. Anonymous surveys have asked large samples of therapists whether they have encountered in their clinical work any clients who had been sexually involved with a prior therapist. The largest such studies that gathered data on both the gender of the client and the gender of the offending therapist found that in about 88-92% of the cases, the sexually exploited clients were female and the offending therapists were male.

It is worth noting that although the clients who have been sexually exploited by a therapist are often spoken of as if they were adult men and women, in a significant number of cases, the clients are minors. In the national study reported by Pope and Vetter, for example, one out of every 20 clients who was sexually involved with a therapist was a minor.

One national study of therapist-client sex involving minors found that the majority were female. The average age of a minor female client who had been sexually involved with a therapist was 7. They ranged in age from 3 years old to 17. The average age of a minor male client who had been sexually involved with a therapist was 12. The boys in this study ranged in age from 7 to 16.

Gender differences also occur in a related area of research: sexual attraction to clients. Table 2 summarizes some of the findings from 2 studies of sexual attraction. In these studies, over 80% of the psychologists (in the 1986 study) and social workers (in the 1994 study) reported feeling sexually attracted to at least one client. About 92-95% of the male participants compared with about 70-76% of the female participants in these two studies reported feeling sexually attracted to at least one client.

Table 2 presents the results when participants were asked to try to identify the most attractive characteristic of the client to whom they were attracted. The hundreds of characteristics were sorted into about 20 major categories. With the following two fascinating exceptions, there were no significant gender differences between the male and female therapists in mentioning the various characteristics. However, female therapists were overwhelmingly more likely than male therapists to mention "successful" as a sexually attractive quality. On the other hand, male therapists were overwhelmingly more likely than female therapists to mention "physical attractiveness."

Characteristics of Clients to Whom Psychotherapists Are Attracted Social Workers Psychologists
Physical attractiveness 175 296
Positive mental/cognitive traits or abilities 84 124
Sexual 40 88
Vulnerabilities 52 85
Positive overall character/personality 58 84
Kind 6 66
Fills therapist's needs 8 46
Successful 6 33
"Good patient" 21 31
Client's attraction 3 30
Independence 5 23
Other specific personality characteristics 27 14
Resemblance to someone in therapist's life 14 12
Availability (client unattached) 0 9
Pathological characteristics 13 8
Long-term client 7 7
Sociability (sociable, extroverted, etc.) 0 6
Miscellaneous 23 15
Same interests/philosophy/background to therapist 10 0

The data about psychologists in the above table come from a national study published as "Sexual attraction to patients: The human therapist and the (sometimes) inhuman training system" by Kenneth S. Pope, Patricia Keith-Spiegel, and Barbara G. Tabachnick, American Psychologist, vol. 41, pages 147-158 The data about social workers in the following table come from a national study published as "National survey of social workers' sexual attraction to their clients: Results, implications, and comparison to psychologist" by Ann Bernsen, Barbara G. Tabachnick, and Kenneth S. Pope, Ethics & Behavior, vol. 4, pages 369-388.

The findings of these and subsequent studies suggest that a significant proportion of therapists carry in their imagination sexualized thoughts, images, or fantasies of their clients, and focus on them when the client is not physically present. For example, in the 2 studies summarized in Table 2, 27-30% of male therapists, compared with 13-14% of female therapists, reported that while they themselves were engaging in sexual activity with someone else (i.e., not the client), they engaged in sexual fantasies about the client.


Although the prohibition against sex with patients reaches back beyond Freud, beyond the Hippocratic Oath, and at least as far as the code of the Nigerian Healing Arts, it was only with systematic research that began in the 1950s that the profession began to understand the depth, pervasiveness, and persistence of the harm that can result when therapists abuse their license, role, power, and trust.

Partly as a result of this increasing understanding of the consequent harm, it came to be recognized as more than a violation of professional or clinical ethics, of licensing laws, and of the civil laws (i.e., patients can sue offending therapists for malpractice in the civil courts). An increasing number of states have criminalized therapist-client sex, some classifying it as a felony. As one court held in reviewing the constitutionality of criminalizing therapist-client sex concluded:

the state has a legitimate interest not only in protecting persons undergoing psychotherapy from being sexually exploited by the treating therapist but also in regulating and maintaining the integrity of the mental health profession. It is equally obvious to us that the legislative decision to criminally proscribe a psychotherapist's knowing infliction of sexual penetration on a psychotherapy client is reasonably related to these legitimate governmental interests. . . . [It] therefore comports with due process of law.

Whether because of increasing recognition of ways in which sex with a therapist can harm a client, increasing legal penalties, or other factors, studies suggest that fewer and fewer therapists are sexually abusing their patients. The 8 national studies published in peer-reviewed journals that are summarized in Table 1 draw on anonymous self-reports from 5,148 therapists. Psychiatry, psychology, and social work each provide data in at least two independent studies conducted in separate years, allowing statistical analysis of possible trends. When all factors are taken into account in statistical analysis, there is a significant gender effect, which was discussed in a previous section. Interestingly, there are no significant differences among psychiatrists, psychologists, and social workers in self-reports of engaging in sex with clients. [Footnote: The apparent professional differences in Table 1 are, the statistical analysis suggests, the result of a confounding correlation between two variables: "profession" and "year of study." A statistical analysis incorporating the data and variables of all studies allowed comparative evaluation of how much predictive power each variable (i.e., profession and year of study) had after the variance accounted for by the other variable was subtracted. Year of study possessed significantly more predictive power after effects due to profession had been accounted for than the predictive power of profession after effects due to year had been taken into account. When the predictive power of year of study is accounted for, there are no significant differences among the professions.]

The effect due to year of study is statistically significant: There is about a 10% drop in the self-reports of therapist-client sex each year. (This does not, of course, mean that there will be no self-reports of therapist-client sex after 10 years; each year the drop is only 10% of the prior year's level.)

Research suggesting that the rate of therapists sexually abusing their clients may be declining is encouraging but it is far from enough. The mental health professions have made a modest beginning in overcoming the self-protective guild orientation, the vulnerability to self-idealization, the difficulty acknowledging and taking responsibility for reprehensible behavior, the conspiracy of silence, the impulse to the tendency to disbelieve or blame clients who appear to have suffered harm because of a therapist's unethical behavior, the habit of seeing causes and sources of problems as external to the profession, and other less-than-perfect traits of therapists that have made it hard to address issues of therapist-client sex effectively.

The time is overdue for the mental health professions to put an end to the "quintessence of sex-biased practice," in the words of Jean Holroyd, that puts female clients, both minor and adult, at far greater risk than male clients for damaging sexual exploitation by a therapist. Adults and children who are hurting, confused, vulnerable, sometimes desperate, who come for help and place their trust in therapists deserve more than to be used to gratify therapists' sexual impulses.

To help others who come to them with their problems, the mental health professions must first take care of their own problem of sexually exploitive therapists.

Related works:

NOTE: This chapter, "Sex Between Therapists and Clients,” by Ken Pope, appeared in Encyclopedia of Women and Gender: Sex Similarities and Differences and the Impact of Society on Gender (pages 955-962; vol. 2) edited by Judith Worell and published by Academic Press, October, 2001, 1264 pages, ISBN 0122272455. It is presented here only for personal, individual use. Academic Press owns the copyright to this chapter. Questions about any uses involving copyright should be addressed to Academic Press


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