Sexually inappropriate behavior in professional practice: Complaints to the Medical Ethics Tribunal (Uruguay, 2012–2024)

Abstract

Introduction

Sexual violence is a globally prevalent phenomenon that impacts all sectors, including the medical profession. Several publications have raised concerns about inappropriate sexual behavior in professional practice. This is the first Uruguayan report, aimed at systematically organizing the complaints submitted regarding these sexual transgressions to the official tribunal responsible for the ethical oversight of the profession.

Method

This is a retrospective, observational study examining the judgments issued since 2012.

Results

Complaints related to this issue constituted 11.77 % of the total. All physicians reported were male. Psychiatrists and gynecologists were the most frequently cited specialists and received the most severe sanctions. Nearly all complainants were women. Many complaints involved physical contact and verbal abuse and almost all complaints resulted in sanctions against the physicians, including professional suspensions.

Conclusions

The limited number of cases requires caution in conclusions. From the data we report, based on all reported cases, the following emerges: 1) Inappropriate sexual behaviors in professional settings are not exceptional. 2) They are underrepresented within the realm of complaints related to breaches of medical ethics. 3) These behaviors reflect gender inequality and are exacerbated by other asymmetries inherent in the clinical relationship and hierarchical structures. 4) Users of mental health and gynecological services are particularly vulnerable. 5) Despite evidentiary challenges, legal proceedings succeed in overcoming the presumption of innocence and sanctioning offenders. 6) A lack of national regulations with greater specificity for such transgressions was observed.

Resumen

Introducción

La violencia sexual es un fenómeno prevalente a nivel mundial del que no escapan los médicos. Varias publicaciones alertan sobre comportamientos inadecuados de connotación sexual en el ejercicio profesional. Este es el primer reporte uruguayo, y su objetivo es sistematizar las denuncias interpuestas por estas transgresiones sexuales ante el tribunal oficial responsable de la tuición ética de la profesión.

Materiales y métodos

Es un estudio retrospectivo y observacional sobre los fallos dictados desde 2012.

Resultados

Las denuncias por esta causa fueron el 11,77 % del total. Todos los médicos denunciados fueron hombres. Los psiquiatras y ginecólogos fueron los especialistas más expuestos, y los que recibieron sanciones más graves. Las denunciantes fueron casi todas mujeres. Las denuncias incluyeron mayoritariamente contacto físico y abuso verbal. La mayoría de las denuncias culminó con sanciones para los médicos y con suspensiones para el ejercicio profesional.

Conclusiones

El limitado número de casos obliga a la prudencia en las conclusiones. De los datos que reportamos, con base en todos los casos denunciados, surge: 1) Los comportamientos profesionales inadecuados de connotación sexual no son excepcionales. 2) Están subrepresentados en el universo de las denuncias por faltas a la ética médica. 3) Reflejan la desigualdad de género y su potenciamiento con otras asimetrías propias de la relación clínica o la jerarquía laboral. 4) Las usuarias de servicios de salud mental y ginecológicos tienen especial vulnerabilidad. 5) Pese a las dificultades probatorias, la instrucción logra derribar la presunción de inocencia y sancionar a los transgresores. 6) Se constató la falta de normas nacionales de mayor especificidad para este tipo de transgresiones.

Introduction

Sexual violence, defined by the WHO as “any sexual act, any attempt to consummate a sexual act, unwanted sexual comments or advances, or actions to traffic or otherwise directed against a person's sexuality through coercion by another person, regardless of the person's relationship with the victim, in any setting, including the home and the workplace,” is a prevalent phenomenon worldwide.¹

One particular form of this type of violence is inappropriate sexual behaviour practised by physicians in their professional practice. Although there is scarce literature on the subject, publications from different countries warn of its existence.^2–10 This is the first report to study the situation in Uruguay based on complaints received by the Medical Ethics Tribunal of the Medical Association of Uruguay. Law N° 18.591¹¹ created the Medical Association of Uruguay (CMU for its initials in Spanish) as a non-state public entity with the mission of “guaranteeing the practice of the profession within the established ethical framework for physicians and the community.”^12–14

Ethical authority is exercised through the Medical Ethics Tribunal (MET), based on the Code of Medical Ethics (Law No. 19,286)¹⁵ and other applicable national or international standards.^12,13 Indeed, Article 81 of the Code of Medical Ethics provides: “The enunciation of principles, norms, and duties made by this Code does not imply disregard for others inherent to fundamental rights and freedoms and the ethical foundations of medicine.”

The MET can impose a limited range of sanctions: warning, reprimand, educational sanction, and temporary suspension from the registry for up to 10 years. MET rulings may be appealed for revocation before a High Court of Appeals. Rulings that determine suspension from the registry must be referred to the Ministry of Public Health (MSP) for legality review and enforcement of the sanction. The rulings are published on the CMU website.¹⁶ Some of the rulings refer to complaints alleging inappropriate professional behaviour with sexual connotations against physicians in their professional practice, whether in relationships with patients, colleagues, or other workers.

This article reviews the rulings issued by the MET following these complaints of inappropriate professional behaviour with sexual connotations since its creation on November 8, 2012. Its objective is to systematise the complaints filed with the MET for inappropriate professional behaviour with sexual connotations and to provide relevant information about the complaints, the complainants, the accused, and the rulings they gave rise to.

Materials and methods

This is a retrospective, observational study of the decisions issued by the Medical Ethics Tribunal (MET) following complaints of inappropriate behaviour with sexual connotations in professional practice. The study period corresponds to decisions issued between November 8, 2012, and July 31, 2024.

We reviewed all decisions of the Medical Ethics Tribunal and the High Court of Appeals, which are publicly accessible and available on the CMU¹⁶ website.

Inclusion criteria: all rulings in which the complaint alleges inappropriate professional behaviour with sexual connotations.

The variables studied, operational definitions, and units used were as follows:

• •

  Inappropriate behaviour with sexual connotations in professional practice: all sexual behaviour and relationships that are ethically prohibited for physicians in their relationships with patients, colleagues, and other healthcare workers are displayed in the professional work context.

• •

  Regarding the complainants: a) natural person. Patient, patient's family member, or person with an employment relationship with the reported physician. b) Legal entity. Public or private healthcare institution.

• •

  Regarding the reported individuals: a) Sex. Female or male. b) Specialty. The specialty practised in relation to the reported incident.

• •

  Regarding the complaints: a) Sex of the alleged victim of the reported incident. b) Time elapsed between the reported incident and the filing of the complaint with the MET, measured in completed months: less than one month, between one month and 12 months, and more than 12 months. c) Complaints in other areas for the same incident: police and criminal, civil, administrative. These categories are not mutually exclusive. d) Type of inappropriate behaviour with sexual connotations reported: verbal (oral or written), physical contact, inappropriate emotional/sexual relationship. These categories are not mutually exclusive. e) Location of the reported incident: healthcare setting (clinic, inpatient ward), non-healthcare setting (other areas of the healthcare institution), home, online means (telephone, social media, email). These categories are not mutually exclusive.

• •

  Relationship between the alleged victim and the offender: a) Clinical relationship. b) Employment relationship.

• •

  Regarding the rulings: a) Sanction: yes or no. b) Type of sanction imposed: warning, reprimand, educational sanction, suspension from the registry. The suspensions from the registry were grouped according to their duration in months and years. c) MET ruling: unanimous; by majority. d) Appeal for reversal before the High Court: yes or no. e) Confirmation of the appealed rulings: yes or no. f) High Court ruling: unanimous or by majority. g) Approval of the suspension rulings by the health authority: yes or no. h) Rules on which the sanctioning decisions were based: are specified.

Results

At the time of closing this survey (July 31, 2024), the CMU website had published 102 final rulings corresponding to complaints filed during the study period. Of these, 12 (11.77%) referred to allegations of inappropriate behaviour with sexual connotations in the practice of medicine.

Of these 12 complaints, the majority were filed by individuals (n = 9): 8 by the individuals claiming to be the victims and one by a family member. The remaining 3 were filed by legal entities: a public health institution (n = 2) and a private health institution (n = 1).

All of the reported physicians (n = 12) were male.

The specialties of the professionals reported were: psychiatry (n = 3), general medicine (n = 3), gynaecology (n = 2), traumatology (n = 1), digestive endoscopy (n = 1), family and community medicine (n = 1), and internal medicine (n = 1).

The people who claimed to be victims of the reported conduct were almost all women (n = 11).

The time elapsed between the alleged events and the complaint filed with the MET was: less than one month (n = 2), between one month and 12 months (n = 4), and more than 12 months (n = 6).

Of the 12 complaints, 10 were associated with administrative investigations, 5 with police or criminal complaints, and one with a civil action.

The types of sexual conduct reported included: physical contact (n = 10), verbal abuse (n = 8), and inappropriate romantic or sexual relationships (n = 2).

The majority of the reported incidents occurred in healthcare settings (n = 10); 5 via telematic means (phone calls, WhatsApp messages, or email); 4 in non-healthcare institutional settings; 2 at the patient's home.

Most of the MET's first-instance rulings (n = 9) were disciplinary, after concluding that the complaint was fully or partially proven. The remaining (n = 3) were initially dismissed on the grounds that they did not meet the minimum evidentiary standard. The MET's rulings (n = 12) were mostly unanimous (n = 11). The remaining rulings were acquittals adopted by a majority, with one dissenting vote in favour of sanctioning the accused.

In 8 of the 12 cases, the MET's rulings were subject to appeals for reversal before the High Court: 6 were appealed by accused physicians who had received suspension sanctions, and 2 by the complainant, whose complaint had been dismissed.

The High Court upheld seven of the eight appealed rulings. In the remaining case, it overturned the majority acquittal of the MET and sanctioned the accused physician. All of the High Court's rulings were adopted unanimously.

An analysis of the final rulings shows that, of the 12 complaints, the alleged behaviour was considered proven in nine (in two cases, the allegation was partially proven: verbal abuse but not physical contact). In one case, ethical misconduct was deemed to have occurred, although not with sexual intent. The remaining two cases were closed without sanction.

Regarding the final sanctions imposed (n = 10), suspensions from the practice of medicine (n = 7) predominated. The remainder were warnings (n = 2) and reprimands (n = 1).

The periods of suspensions ranged from 3 months to 8 years: 3 months (n = 1), 6 months (n = 2), one year (n = 1), 3 years (n = 1), 6 years (n = 1), and 8 years (n = 1). These rulings (n = 7) were mostly handed down to psychiatrists (n = 3) and gynaecologists (n = 2).

Of the 7 suspension rulings, 5 were approved by the Ministry of Public Health. In one of the final rulings that was not approved, the health authority reduced the suspension from 3 years to 8 months. This ruling was challenged before the Administrative Litigation Court, and as of the date of this report, no resolution has been issued.¹ In the remaining case, the Ministry of Public Health rejected the suspension for reasons of legality, rendering the sanction null and void. The legal provisions on which the sanctioning rulings were based were Law No. 18.591¹¹ (Creation of the Medical Association of Uruguay), Law No. 19.286¹⁵ (Code of Medical Ethics), Law No. 19.580¹⁷ (Gender-Based Violence Against Women), and Decree 258/992¹⁸ (Rules of Medical Conduct and Patient Rights).

In addition to the laws and decrees mentioned in Table 1, the rulings relied on various other international standards, such as the Hippocratic Oath in the current version provided by the World Medical Association's Declaration of Geneva (5 cases), the Madrid Declaration of the World Psychiatric Association (3 cases), the Canadian Medical Association's Code of Medical Ethics (3 cases), the American Psychiatric Association's Principles of Medical Ethics with Notes Specially Applicable to Psychiatry (2 cases), and the World Medical Association's Code of Medical Ethics (1 case).^{14,16,19–23}

Table 1.

Standards mentioned in the rulings and number of times cited.

Standard cited in rulings	Number of citations	Text of the cited standard
Law No. 19.286 (Code of Medical Ethics)
art. 2	1	a) Medical professionals must care for the health of individuals and the community without discrimination of any kind, fully respecting human rights.
art. 2	1	e) Physicians must always strive for the highest level of excellence in professional conduct.
art. 3	5	It is the duty of physicians, as health professionals, to follow the following fundamental principles and values:a) Respect the life, dignity, autonomy, and freedom of every human being and strive for the benefit of their physical, mental, and social health.
art. 3	3	b) Do not use their professional practice to manipulate people from a value perspective.
art. 26	3	Every physician has the duty to:a) Protect and respect the privacy of the patient's body and emotions when questioning, examining, or treating them.
art. 29	2	Physicians must always respect the human being who has placed their trust in them. The medical procedures undertaken will never be simple technical gestures, but will be integrated with all the essential values of the doctor-patient relationship.
art.71	1	Good human relations between colleagues are fundamental for their own sake, for their impact on patient care, and for the coexistence within the collective work environment. Defamation, insults, and comments that could harm a colleague in the exercise of their profession are unethical, beyond the considerations that justice may impose.
art. 75	1	As a member of the healthcare team, the physician will respect the work and independence of other professionals and demand reciprocity. The hierarchy within the team must be permanent but cannot be an instrument of domination or personal aggrandisement. The physician is only responsible for those acts of the team that are his or her responsibility to personally supervise.
art. 78	1	The Medical Association of Uruguay will be the formal body to resolve any ethical conflict that arises in the physician's relationship with the institutions in which he or she works, with patients and their environment, as well as with colleagues and other members of the healthcare team.
art. 81	1	The statement of principles, standards, and duties made by this Code does not imply disregard for others inherent to fundamental rights and freedoms and the ethical foundations of medicine.
Decree 258/992 (Medical conduct and patient rights)
art. 1, inc.1	1	The physician must ensure the highest quality of care for the patient, providing the most appropriate care for the case, according to the means at his or her disposal, that is most effective, causes the least suffering, and produces the fewest adverse side effects and inconveniences, at the lowest possible cost to the patient and the society he or she belongs to.
Law N° 18.591 (Creation of the Medical College of Uruguay)
art. 24	1	The Medical Ethics Tribunal is competent to hear all cases of medical ethics, deontology, and deceology that are requested by the State, individuals or legal entities, or members of the Medical Association of Uruguay.All submissions to the Medical Ethics Tribunal must be submitted in writing.The Medical Ethics Tribunal shall have a period of fifteen days from receipt of the matter to rule on the appropriateness of its consideration and treatment according to the subject matter of its jurisdiction.
Law N° 19.580 (Law on Gender-Based Violence Against Women)
art. 2	1	Article 2.1 The provisions of this law are of public order and general interest. The eradication of violence against women, children, and adolescents is hereby declared a priority, and the State must act with due diligence to this end.

Discussion

Sexual misconduct “is perpetrated and experienced throughout society, including across the full spectrum of health care professions, and there is no evidence that professionals commit it disproportionately compared to any other social group.”⁴

Our study showed that 12% of the rulings published between November 8, 2012, and July 31, 2024, arose from reports of inappropriate professional behaviour with sexual connotations. It is reasonable to assume that the number of reports is underestimated, as is the case with all forms of sexual abuse, because they tend to occur in the private sphere, in this case, the medical office.⁹ In fact, Uruguayan jurisprudence includes convictions of physicians for inappropriate professional behaviour with sexual connotations that occurred during the study period and that did not result in a complaint to the MET.²⁴

The time elapsed between the reported events and the filing of the complaint varied greatly: from a few days to more than a year (in one case, up to 15 years). This is suggestive of the resistance that a victim may feel when exposing themselves to this type of process, for the same reasons that underreporting of cases is predictable. The literature warns that this could be due to victims experiencing feelings of disbelief, guilt, or shame, as well as a fear of reporting or simply an unwillingness to take on the responsibility of revealing the facts.²

The complainants were not always the victims themselves; in some cases, they were healthcare institutions or family members. This finding could confirm the barriers victims may encounter when filing a complaint. It also suggests that some abusive situations are not perceived as such, at least not immediately. When the complaint was filed by a healthcare institution for abuse suffered by a client, it cannot be ruled out a priori that it was part of a procedural strategy within the framework of employment or reparation lawsuits. The doctors accused were all men. On the one hand, this reflects the well-known male predominance in all forms of sexual violence.¹ The same is indicated by studies on sexual abuse in the healthcare field in Colombia, Australia, the United Kingdom, and the United States.^2–4,7 This clear male predominance, combined with the high feminisation of the medical profession in Uruguay, indicates that this type of professional behaviour, far from being explained solely by the power asymmetry that characterises the clinical relationship, is determined by cultural factors linked to gender inequalities.^14,25

Almost all of the complaints deemed proven correspond to transgressions that occurred in the context of the clinical relationship, except for one that affected a non-physician healthcare worker and another that involved a physician who was hierarchically dependent on the accused. In all of them, the gender factor was added to the power relationship within the clinical or employment relationship, exacerbating inequality.

It is highly significant that psychiatry was the most compromised specialty, both in terms of the number of complaints admitted and the number of sanctions applied and their severity. This particularly asymmetrical clinical relationship and the particular vulnerability of these patients seem to facilitate this type of behaviour. Therefore, there are international documents that very clearly delineate the boundaries that psychiatrists should not cross and the reasons for this. The Madrid Declaration of the World Psychiatric Association (August 25, 1996) states that “with regard to the violation of boundaries in the clinical relationship, it maintains that: the psychiatrist-patient relationship is often the only relationship that allows, in agreement with the patient, the exploration of the deep personal and emotional world. The basis of the trust necessary to carry out a comprehensive treatment is the psychiatrist's respect for the patient as a human being and for their dignity.”... “By understanding these facets of the patient, the psychiatrist is in an advantageous position, which is permitted by the patient themselves based on their expectations of trust and respect. Taking advantage of this knowledge for sexual advances, manipulating the patient's fears and sexual desires, is a violation of trust, even when the patient gives consent.”^14,21

It cannot be overlooked that 10 of the 12 complaints admitted resulted in sanctions by the MET and the CMU High Court of Appeals, despite the obvious difficulties in proving these violations. This could indicate that the universe of complaints mainly includes the most flagrant cases. In this sense, it seems significant to recognise the seriousness of inappropriate professional behaviour with sexual connotations, which in many cases resulted in the sanction of temporary suspension from the registry, in several cases for prolonged periods.

It is significant that, unlike that which occurs with some cases processed in the judicial system, the complaints considered by the MET were not preceded by a public or media campaign. Furthermore, the only case in which mass media coverage on television preceded the complaint filed with the MET was dismissed for lack of merit.

Even with the evidentiary difficulties for complaints of this nature, the very broad agreement between the MET and the High Court, and between the members of both collegiate bodies, indicates that the investigation overturned the presumption of innocence of the accused doctors with a sufficient degree of conviction to enable the imposition of sanctions.

Another noteworthy result is that, except in one case, the sanctioned doctors did not receive civil compensation. This would seem to indicate that the true motivation for the complaints was not an ulterior purpose of financial compensation, beyond what might be appropriate. The ethical standards on which the sanctions were based were mostly generic, such as Article 3 of the Code of Medical Ethics: “It is the duty of the physician, as a health professional, to follow the following fundamental principles and values: a) to respect the life, dignity, autonomy, and freedom of every human being and to seek as a goal the benefit of their physical, mental, and social health; b) not to use professional practice to manipulate people from a value perspective.”

This exposes the lack of more specific provisions defining and prohibiting inappropriate professional behaviour with sexual connotations, as do some international documents cited in the rulings.

Conclusions

The number of cases (n = 12) requires caution in the conclusions, which may be ratified or rectified when a larger number of cases are identified.

From the data we report, based on all cases reported in Uruguay to the MET between November 8, 2012, and July 31, 2024, the following emerge:

1. In line with reports from other countries, inappropriate professional behaviour with sexual connotations by physicians in Uruguay is not exceptional.

2. The analysis of the rulings suggests that inappropriate professional behaviour with sexual connotations is underrepresented in the universe of complaints, as is the case with other forms of sexual violence.

3. These behaviours, which reflect gender inequality, are exacerbated by other power asymmetries, such as those derived from the clinical relationship or the work hierarchy.

4. Users of mental health and gynaecological services are particularly vulnerable to this form of sexual violence, although not exclusively so.

5. Despite the obvious difficulties involved in proving events that occur in private contexts, the complaint and subsequent investigation achieved evidentiary standards that enabled the offenders to be punished.

6. The legal references in the rulings revealed the absence of more specific national standards applicable to this type of violation.