Secondary Logo

Journal Logo


Preparing New Clinicians to Identify, Understand, and Address Inappropriate Patient Sexual Behavior in the Clinical Environment

Cambier, Ziádee PT, DPT, MSPT

Author Information
Journal of Physical Therapy Education: Spring 2013 - Volume 27 - Issue 2 - p 7-14
  • Free



Difficult interactions with patients take many forms in health care. Patients with sexually inappropriate behavior present particular challenges. Inappropriate patient sexual behavior (IPSB) is defined by Johnson and colleagues as any “verbal or physical act of an explicit, or perceived, sexual nature, which is unacceptable within the social context in which it is carried out.”1(p688) IPSB encompasses a spectrum of behaviors including staring, gestures, romantic gifts, suggestive remarks, propositions, genital exposure, unnecessary touching or physical proximity, sexual assault, threats, and rape.2,3 When the patient’s behavior creates a hostile or intimidating work environment for the clinician, IPSB falls under the legal definition of sexual harassment.4

In 1993, McComas et al published the first study of IPSB in health care, a survey of Canadian physical therapists and physical therapist students.2 In the late 1990s, 2 other studies followed, surveying physical therapists in the US and Australia. Each found that 80%-85% of survey respondents had experienced IPSB.2,5,6Table 1 details the types of IPSB reported by physical therapists and physical therapist students in their practice.

Table 1
Table 1:
Percent of Physical Therapist (PT) and Student Respondents Who Had Experienced Types of IPSB in 3 Surveys

Since McComas et al, research has established sexual harassment by patients as a significant problem for a spectrum of health professionals. The percentage of providers who reported sexual harassment by their patients during their careers ranges from 19%-63% of physical therapists,2,5,6 30%-70% of nurses,7-11 6%-75% of physicians,3,12,13 53% of female psychologists,14 22% of dental hygienists15 and 3% of speech therapists.16 Wide ranges in survey results appear to be related to who is surveyed and the specific questions asked. The highest rates have been reported by researchers who ask clinicians about their experience with specific behaviors.3,5,10,14 Moderate rates have been reported in surveys that limit the timeframe7 or limit reports of sexual harassment to physical contact.11,12

The lowest rates have been reported by speech therapists16 and dental hygienists,15 whose jobs involve the least physical contact, and in studies where the majority of survey respondents are male.12,13 Although the estimated prevalence of sexual harassment by patients varies widely in the literature, its presence and its impact on clinicians supports the importance of including this topic in professional health care training programs.17

The emotional repercussions of sexual harassment include frustration, embarrassment, fear, anxiety, shame, depression, diminished self-esteem, and isolation. Physical manifestations of this stress include headache, insomnia, digestive problems, weight changes, and substance abuse. Harassment can affect work performance, causing impaired decisionmaking, reduced productivity, increased absenteeism, and turnover.6,7,10,18,19 Inappropriate patient sexual behavior can result in the same negative emotional, physical, and professional consequences for health care workers as other forms of sexual harassment. The confusion and self-blame that results from IPSB undermine self-confidence and professional authority.2,8,9,16,17,20-23 Conflict between a clinician’s right to a safe workplace and their fiduciary duty to the patient’s best interests may result in ethical distress. One third of surveyed physical therapists who reported IPSB claimed psychological or workrelated repercussions.2,6 Many respondents also reported ramifications to patient care, such as avoidance of treatments that required touch.24

In a 1994 British study, nurses who believed they could do something about sexual harassment suffered fewer negative health consequences than those who found the situation uncontrollable.8 In training new psychotherapists, Hartl et al found that clinicians who believed they had responded well to IPSB had less of an emotional impact from the incident than those who demonstrated poor self-appraisal.17 These findings indicate that preparing health professionals to respond to IPSB can limit adverse consequences.

In the absence of specific training on IPSB, health care providers often demonstrate unprofessional and ineffective reactions. Ruth Zook, a clinical nurse educator, published 3 articles on training nurses to respond to IPSB.25,61,62 In her work, she discovered that responses generally fell into 2 categories: passive and aggressive. The “passive” nurses ignored or joked about the behavior, or blamed themselves. The “aggressive” nurses belittled, punished, or withheld health care from patients.25 When teaching second-year physical therapist students about IPSB, it has been this author’s experience that students commonly have similar reactions. Some students are reluctant to address IPSB at all, while others react angrily and propose to deny care at the first sign of impropriety. Training provides novice professionals with an opportunity to work through automatic attitudes and replace them with professional and effective responses. Furthermore, interpersonal communication and conflict management have been included in the list of skills and knowledge that represent the minimum required for new graduates, adopted by the American Physical Therapy Association (APTA) in 2005.26 Preparation for IPSB compliments the development of these skills.

Results of a 1997 random sampling of APTA members indicated that nearly 70% of respondents had not received training on how to address IPSB.5 Yet, 88% of physical therapists in the Canadian and Australian surveys felt that training to address IPSB should be part of physical therapist professional education programs.2,6 Responses included the following requests for specific curriculum: a definition of IPSB and the extent of the problem; legal and ethical responsibilities, including refusal to treat; strategies, boundaries and assertiveness, and unacceptable responses; how and when to chart incidents; how to avoid self-blame; and availability of counseling.24,27

Fortunately, preparation for IPSB is becoming more common in entry-level programs. Recent e-mail correspondence with accredited US physical therapist and physical therapist assistant education programs yielded 48 responses from physical therapist programs (response rate 24%) and 89 responses from physical therapist assistant programs (response rate 34%). The majority of program directors reported providing students with formal IPSB training. However, 23% of responding physical therapist programs and 61% of responding physical therapist assistant programs still do not cover this topic, and there is little guidance available in the literature to help educators develop or evaluate their curricula.

Although well-established as a problem over a decade ago, authors disagree about both how to view and how to address IPSB. Some authors have argued that IPSB stems from patients’ unmet emotional needs and advocate exploring patients’ feelings and providing affection.28-31 Other authors have recognized IPSB as sexual harassment and, at times, have seemed to define the patient as an adversary.2,3,6,8-10,32,33 Evidence is scarce regarding the preparation of physical therapists and other professionals for IPSB, however, those who have written on the topic have promoted responses that both protect the professional and educate the patient.17,25,34 The purpose of this article is to propose a strategy for training students entering the physical therapist profession to competently respond to IPSB.


Inappropriate patient sexual behavior is pervasive in clinical practice and has significant negative consequences for both clinicians and patients. Therefore, the position of this article is that entry-level education should prepare students to effectively address such situations. I suggest that the curriculum include the definition and prevalence of IPSB, legal rights and ethical obligations, factors influencing IPSB, assertive techniques, and instruction in effective documentation. I argue that education that highlights both a commitment to the patient and the clinician’s right to protection will assist development of professional behavior. I propose the inclusion of role-play and case studies to encourage students to consider their own values and practice formulating responses. Finally, I contend that training in assertiveness techniques and tools for proper documentation will best prepare students for real-world application.

To address my position, this article will first explore the professional’s duty to the patient and how to foster empathy by considering factors that may contribute to IPSB. Following this discussion I will examine sexual harassment law and its application to patient-professional interactions. Next, I analyze possible responses to IPSB, suggest strategies, and conclude with a discussion of educational methods.

Empathy and Commitment to the Patient

Physical therapists and physical therapist assistants have an obligation to their patients as professionals. Under civil law, clinicians owe both a duty of care and a fiduciary duty to their patients. To uphold the duty of care, clinicians must ensure that the patient does not suffer any unreasonable harm or loss. In the fiduciary relationship, the patient places complete confidence in the clinician due to their superior knowledge and training. Therefore, the clinician must act at all times for the sole interest and benefit of the patient. The clinician is expected to be loyal to the patient and avoid placing personal interest ahead of this duty.

The American Physical Therapy Association also provides guidance for professional behavior, and has developed a set of core values to define professionalism, one of the elements of Vision 2020. APTA’s core values include professional duty, altruism, and compassion/caring. Professional duty demands that the professional demonstrate beneficence, a commitment to improve the health and well-being of the patient. Altruism is defined by APTA as “the primary regard for or devotion to the interest of patients/clients, thus assuming the fiduciary responsibility of placing the needs of the patient/client ahead of the physical therapist’s self interest.”35(p1)Compassion/caring requires empathy, and an attempt to identify with a patient’s motivations for their actions.35 APTA’s Code of Ethics for the Physical Therapist and Guide for Conduct of the Physical Therapist Assistant also provide standards of behavior and are intended for use by practitioners facing ethical challenges.They each include principles of respect and compassion.36,37 Principle 5 of APTA’s Code of Ethics also requires physical therapists to provide notice and alternatives for care to patients who still need physical therapy prior to termination of service.36 State practice acts frequently reinforce APTA standards with legal responsibilities.

Typical passive and aggressive reactions to IPSB as described by Zook usually stem from an inability to empathize with the patient and separate the behavior from the individual. When students characterize a patient by their poor behavior, they are likely to reject the person, which makes it difficult, if not impossible, to act as healers. Zook found that for nurses, understanding the source of the behavior helped to engender empathy for the patient and to support continuation of the therapeutic relationship.25 Exploring factors that influence IPSB may provide students with insight into their patients and enhance students’ ability to care for their patients with empathy.

A wide variety of underlying medical issues are associated with IPSB. Any injury or disease affecting the brain may influence judgment and behavior. Common diagnoses in this category seen in physical therapy include cerebral vascular accident (CVA), traumatic brain injury (TBI), Alzheimer disease, and dementia. Several conventional medications are linked with IPSB, including anticholinergics, benzodiazepines, and antiparkinsonian drugs. Psychological disorders such as delirium, bipolar disorder, schizoaffective disorder, obsessive-compulsive disorder, and substance abuse can also cause hypersexuality or sexual disinhibition. For patients without a preexisting cognitive or psychological diagnosis, development of IPSB can be an important indicator of health changes. Behavioral changes may indicate recent seizure activity, a severe systemic infection or metabolic disturbance, or a urogenital infection or disease.31,38

Many patients with cognitive impairments display lack of insight into their own behavior. These patients may be unable to distinguish between what is or is not socially appropriate. Such individuals may not be able to perceive their impact on others, or lack empathy when others share their feelings. Some patients have difficulty censoring their own behavior and exhibit generalized disinhibition. Others are impulsive and act before thinking through the consequences of their actions. Finally, memory loss may affect the ability to recall prior lessons about social norms and appropriate behavior.39 Patients with impaired problem-solving skills and judgment also may use IPSB as an aggressive response to the stresses of injury and hospitalization.31

Cognitive status is not an excuse to ignore bad behavior. If IPSB continues, it can restrict a patient’s ability to reintegrate into the community and have a negative impact on the achievement of rehabilitation goals.1,39 Therefore, addressing IPSB and helping the patient develop good social skills are an integral part of the rehabilitation program.

Clinicians who work primarily with cognitively impaired patients have frequent experiences of IPSB, although relatively few individual patients exhibit IPSB. In one survey, 70% of rehabilitation professionals working with patients with brain injuries reported that sexual touching by patients was a common problem in their facilities, while 20% reported sexual force by patients was also common.40 However, reported rates of sexually disinhibited behavior by patients with cognitive impairments are low, and many patients with cognitive impairments will not act out sexually. Research indicates that 2%-8% of patients with Alzheimer disease,1,41 2%-15% of patients with dementia,42,43 and 3%-6.5% of patients with acquired brain injury1 exhibit IPSB. A small number of patients may be capable of creating a problem for the majority of staff.

Inappropriate patient sexual behavior is not limited to patients with cognitive disorders or to neurological care settings. In the McComas et al survey, more IPSB incidents were reported in orthopedic settings than in any other setting.2 There are numerous reasons why cognitively intact patients might be sexually inappropriate. Hartl et al have conceptualized 2 dimensions to patient motivations for IPSB: intentional versus unintentional and affiliative versus distancing. Hartl et al distinguish between intentional behaviors in which patients realize their actions are inappropriate and unintentional behaviors in which patients are unaware that what they are doing is wrong. Affiliative behaviors are intended to increase intimacy between patient and clinician, whereas distancing behaviors are intended to damage the relationship.17

It is difficult to discern patient motivations from action alone. For instance, a patient might try to kiss a therapist in order to create physical intimidation, an intentionaldistancing behavior. Another patient may try to kiss a therapist in an attempt to act on romantic feelings while unaware of professional boundaries. This is unintentional-affiliative behavior.

Unintentional behavior often results from a lack of awareness of the professional boundaries between clinician and patient. Examples of unintentional-affiliative behavior include requests for dates and love letters. Patients exhibiting unintentional-affiliative behaviors do not realize that their romantic interests cannot be reciprocated. Physical therapy evaluation and treatment can entail close physical contact, which may confuse the patient.2,5 Patients may misunderstand and sexualize the warmth and caring provided by the clinician.2,17 Patients may have experienced sexual violence themselves and may be confused about sexual boundaries.29 In addition, cultural or generational differences may exist between the clinician and the patient affecting perspective of what is “appropriate.” Unintentionaldistancing behaviors frequently stem from patients’ discomfort with the physical intimacy of the treatment. For instance, some patients may use off-color jokes to dissipate their own anxiety.

Intentional behaviors are those the patients know are not acceptable in a health care setting. Intentional-affiliative behaviors can include flirting and propositions that the patient knows are not appropriate, but hopes may be accepted. Patients may use intentional-affiliative behaviors when they want reassurance that they are still attractive, or to assert their post-injury sexual competence.2,17,28-30 Patients facing mortality may use sexually aggressive behavior to affirm their vitality and distract from anxiety about death.31 Patients may simply be bored, lonely, or want attention.28,31 Patients use intentionaldistancing behaviors to intimidate their health care provider and disrupt the relationship.14,17 Behavior examples include leering, suggestive comments, and masturbation during the physical therapy session. Patients experiencing loss of function or independence associated with injury may be scared or feel powerless. Intentional-distancing behaviors may allow patients to feel an increased sense of control or power in relationship to their therapist.25 Male patients who are uncomfortable in a subordinate position in relation to their female therapist may use IPSB to try to reestablish gender dominance.2,21,29 Patients uncomfortable with a younger clinician making treatment decisions may also use IPSB to shift the power dynamic.17

Students may benefit from a reminder that in each of these cases, there is a fallible human behind the offensive behavior. By setting limits, clinicians can refuse to tolerate the behavior and still show empathy, giving patients the opportunity to reform and receive the care they require. By creating boundaries and consequences, therapists and assistants may help patients develop an increased sense of internal control, as their behavior produces predictable results.44 After publication of Mc-Comas et al, Jules Rothstein, editor of the journal, Physical Therapy, argued, “The dignity of our patients is violated when we allow them to be abusive and sexually inappropriate. To hold patients accountable is to show respect for them as human beings.”45(p738)

Rights of the Physical Therapist and Physical Therapist Assistant

Legally and ethically, physical therapists and physical therapist assistants have a right to a safe working environment. Students can be taught that IPSB is not a reflection on them as individuals or on their job performance. By openly acknowledging that IPSB is common, the physical therapist profession can validate and depersonalize these encounters and empower its members to require respectful treatment from patients.3

The Equal Employment Opportunity Commission (EEOC) defines 2 types of sexual harassment: quid pro quo and hostile environment harassment. In quid pro quo harassment, submission to unwelcome sexual behavior is a condition of employment. In this case, the perpetrator must hold greater institutional power than the target, for instance as a supervisor, manager, or owner. Hostile environment harassment, alternatively, is a situation in which “such [unwelcome sexual] conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile, or offensive working environment.”4(p98) The power relationship between the involved individuals does not affect the designation of harassment in this case.23

The EEOC specifies that perpetrators of harassment may include non-employees and that the employer can be held responsible for such harassment when “the employer (or its agents or supervisory employees) knows or should have known of the conduct and fails to take immediate and appropriate corrective action.”4(p198) Repeated exposure to a patient’s offensive activity, or a single physical assault by a patient, can create an intimidating or hostile working environment if unaddressed. Therefore, IPSB can fall under sex discrimination law, and physical therapy employers have a responsibility to protect their staff from IPSB.20,46,47

Not every instance of IPSB is actionable sexual harassment. Legal designation depends on the experience of the clinician. IPSB is unique to the context and the individuals involved. Two professionals may both recognize a specific interaction as inappropriate, but one may be amused by it, while another may find it frightening. A clinician’s past experiences will affect the type and strength of emotional response to IPSB.17

While male physical therapists are frequently subjected to IPSB,2,5,6 these encounters may not have the same repercussions as for female physical therapists. Multiple studies have demonstrated that men and women experience sexual harassment differently.23,48-50 This distinction was codified into case law by the use of the reasonable woman standard. The judge that defined this standard wrote, “Because women are disproportionally victims of rape and sexual assault, women have stronger incentive to be concerned with sexual behavior …. Men, who are rarely victims of sexual assault, may view sexual conduct in a vacuum without a full appreciation of the social setting or underlying threat of violence that a woman may perceive.”50(p125) In a 2008 study conducted in Ireland, female nurses exposed to IPSB tended to fear for their personal safety, while male nurses were more concerned with mistaken accusations of sexual impropriety.29 This disparity of experience is important in physical therapy because the majority of physical therapists (68%)51 and physical therapist assistants (79%)52 are women, yet male physical therapists are more likely to become the managers and business owners53,54 responsible for taking corrective action in cases of harassment.

The individual physical therapist or physical therapist assistant subjected to IPSB must be the one to judge how it has affected their work environment, what type of support they require, and whether continued contact with the patient is advisable. Often, clinicians will be successful in independently redirecting patient behavior and thus be able to continue the therapeutic relationship. At other times, the clinician may not be comfortable offering the patient a second chance or informing the patient of transfer or discontinued care. In these cases, supervisors and managers have a responsibility to intervene in order to protect the clinician from further harassment.

Students can be encouraged to get support from clinical instructors, mentors, and supervisors. Reporting procedures differ between facilities, but issues with IPSB can be reported to managers, human resources, and/or business owners. Many employers also provide Employee Assistance Programs that offer counseling and legal advice. A clinician has the right to consult a lawyer at any time, before or after reporting to their employer. A charge of sexual harassment must be filed with the EEOC no later than 180 days from the incident and must be completed before a private lawsuit is filed in court.55 In cases of sexual assault, attempted assault, indecent exposure, or stalking, a police report is warranted and the clinician may want to press charges. The National Sexual Assault Hotline makes crisis intervention, referral to local resources, and explanations of the criminal justice system available by phone and online.56

Responding to Inappropriate Patient Sexual Behavior

Very little research has been conducted on the effectiveness of various reactions to sexual harassment. The most common response to sexual harassment is to ignore it,7,57 and the health care literature indicates the same is true of IPSB.2,6,15,29 Many therapists who have used this technique have reported satisfaction with the results.2,6 When caught off guard or in an unsupportive work environment, ignoring the behavior may be justified. However, as a blanket response, it is unlikely to be productive. Evidence indicates that ignoring the behavior is more likely to encourage continuation and possible escalation, rather than putting an end to the unwanted attention.2,15,57,58 In addition, one study indicated that nurses attempting to ignore harassment suffered an average decline in productivity of 10%.7

Physical therapists have also reported taking action to avoid IPSB by limiting private interactions with patients exhibiting offensive behavior.24 Actions may include treating in a more public area, treating with other staff present, selecting treatment methods with less physical contact, limiting time with the patient, and establishing emotional distance. Avoidance is a practical tool and may protect the clinician from further abuse.57 However, it is not always possible in all practice settings, can have a negative impact on patient care, and does not protect colleagues from the same behavior.

Assertiveness emerges in the research as the most successful strategy for answering sexual harassment. In a government-wide survey of federal workers, the largest study of its kind, confronting harassers improved the situation in the majority of cases.57 Another survey of 200 female professors harassed by their students reported similar results.59 One third of respondents to the Canadian physical therapy survey recommended a direct response to IPSB based on their own favorable outcomes.27 Recommendations in health care literature have been mixed, but many authors have advocated an assertive reaction to IPSB as a viable option28,30,33,41,60 or as the primary response.25,32,61,62

An assertive approach requires discussing the incident with the patient and setting boundaries. However, students and experienced clinicians alike are often unsure how to set limits and may ignore bad behavior because they do not know what to say. When emotions flare, an attempt at professionalism can devolve into argument. Shaming the patient by expressing disgust, belittling and scolding, rejecting, judging, and punishing can all damage the therapeutic relationship and escalate the conflict.25 Conversely, laughing or expressing amusement at a patient’s behavior may violate their dignity. Providing students with structure to assist in forming messages and managing interactions can help avoid these pitfalls.

Educational Methods

Having explored the principles and issues involved in IPSB, I will turn my attention to general and specific strategies for training physical therapist students and physical therapist assistant students to address IPSB. Supplemental materials illustrating a sample curriculum module can be found on APTA’s Education Section website.

Interactive curriculum helps engage students in exploring their emotional reactions and practicing responses to IPSB. The literature frequently suggests that students and clinicians practice their skills through roleplay.25,32,41,63 Role-play provides an opportunity to try new ways of communicating in a safe environment, where students can learn from one another’s mistakes.

Zook illustrated the benefits of using roleplay to teach nurses to handle IPSB in her in-services. She described several nurses giggling in role-plays, recognizing their reflexive responses with real patients, and learning to redirect their nervous energy into an assertive response. Nurses also rehearsed reactions to typical patient defenses including insults and distractions such as “Can’t you take a joke?” After role-playing, the nurses reported increased confidence in dealing with difficult patients. Overall, Zook characterized live role-plays as “the heart of the learning experience.”25(p183) A systematic review of training methods for health care workers in acquiring communication skills concluded that practice with peers or simulated patients leads to significant improvement in communication skills and is usually more successful than didactic methods.64

To assist students in formulating responses, curriculum can include the components of a simple assertive statement (Women’s Safety Project, unpublished data, 1995). The best assertive statements are clear, precise, directive, and calm. An effective message consists not only of words but also includes assertive eye contact, posture, tone, volume, and facial expression. When a simple assertive statement does not come easily, or does not eradicate the behavior, the clinician may need other strategies. Physical therapist education programs can teach students several techniques so that they may choose one that best matches their situation and their personality. Three effective techniques are “I think, I feel, I want”25; “active listening/broken record”; and “positive/negative warning”61 (Table 2).

Table 2
Table 2:
Intervention Strategies

In the “I think, I feel, I want” technique, the clinician sets limits while sharing a difficult emotion brought up by IPSB with the patient. The message is structured into 3 statements that can be rehearsed. The first statement is an assessment of the situation. Clinicians can make a positive assessment, such as “I think you are a good person,” or a negative assessment, such as “I don’t think you meant to upset me.” The second statement must include an actual emotion such as anger, hurt, confusion, or discomfort. For instance, “I was embarrassed when you called me attractive.” The final statement sets the conditions for the continued relationship. Again, the clinician can set up the positive conditions they want, “I want our relationship to remain professional,” or the negative conditions they want to avoid, “I want you to stop calling me at home.” A common mistake is to use the second statement to share another thought such as “I feel you were acting inappropriately,” because the power of this technique is in the emotion. Most people do not want to upset others and find it more difficult to be defensive when someone shares how they feel. When patients discover they have caused hurt feelings, they are usually quick to adjust their behavior.

“Active listening/broken record” is an excellent technique to use when a patient argues with a clear assertive statement in an attempt to avoid taking responsibility for their behavior. This strategy allows the clinician to avoid engaging in an argument with the patient, and ensures that an appropriate boundary is set. In this technique, the clinician chooses a short statement of how the patient’s behavior must change to use as the broken record. After each attempt the patient makes to distort, deny, or redirect blame to the clinician, the clinician’s response will end with the broken record. The power of this technique is the repetition of the message. Eventually, patients will realize that they are not getting what they want and will tire of arguing. However, the simple repetition of a boundary alone can be alienating. In order to preserve the relationship, the clinician begins each response with a statement that neither agrees nor disagrees with the patient’s argument, but acknowledges that it has been heard. This is the active listening statement. For instance, a series of broken record/active listening statements could be: “I’m sorry that you feel that I lead you on, and I need you to stop commenting on my body,” “I hear that you think I’m being uptight, and I need you to stop commenting on my body,” “I understand that you did not intend to upset me, and I need you to stop commenting on my body.”

In the “positive/negative warning” technique, the clinician sets limits by offering both positive and negative consequences for compliance. By offering positive outcomes first, the therapist or assistant attempts to motivate and gain patient trust. Negative outcomes can also be primarily motivational, or can provide warning before denying service.61 Clinicians need to choose negative consequences with care, ensuring that they meet their legal and ethical obligations. Any statement made must be enforced; if not, IPSB may worsen. An example of a warning statement is, “If you stop lifting your gown, I will stay with you and help you get stronger. However, if you continue to show me your genitals, I will leave and cancel the rest of this treatment.” When addressing IPSB in patients with cognitive impairment, the clinician can consider the patient’s ability to learn and recall, as well as their capacity for insight and impulse control. For most cognitively impaired patients, a short, simple redirecting command is still appropriate.31,40,41,65,66 Clinicians can ask patients to repeat back boundaries to ensure understanding.66 If necessary, limit setting can be followed with an alternative activity or distraction. When the patient’s hands or mind are engaged in another activity, IPSB may be forgotten.65-67

Individuals with moderate cognitive impairments may require reeducation regarding social norms and help to relearn self-management of their actions. Clinicians can encourage these patients to consider the feelings of those affected by IPSB in order to develop empathy and insight. Explicit explanations of professional relationships will discourage patients from misinterpreting friendly interactions.40,66

For individuals with severe impairments to attention and memory, behavioral modification interventions will be most successful.40,68 With this patient population, consistency is absolutely essential. A written plan that can be followed by all staff interacting with the patient is beneficial.39,66,68 Ideally, plan development will include an assessment by a neuropsychologist. The neuropsychologist can help identify antecedents to IPSB and determine rewards and consequences that will be motivating to the individual. Interventions can consist of clear guidelines, strong environmental cueing, and immediate feedback.40 Clinicians can introduce the plan to the patient, and follow it exactly as explained.39

One example of behavior modification is the use of social contact. Unfortunately, IPSB is often reinforced by the negative attention given to the patient after an incident. Conversely, if approval and attention are routinely made available, removal during immediate time-outs in response to IPSB can be very powerful.68 However, a confused and agitated patient with TBI may be frustrated by the tasks presented in therapies and prefer to be left alone. In that case, time-outs would be more likely to reinforce IPSB and clinicians might employ breaks as a reward for good behavior. An alternate consequence would need to be devised for this patient, such as temporary removal of a beloved item or ceasing a favored activity.

In addition to direct responses, entry-level curriculum can include methods of objective documentation.17,27,32 Documentation creates a record of behavior patterns that may indicate a change in cognitive or medical status. Documentation also establishes legal cause for denying care if the problem persists or for harassment claims if an employer refuses to address the situation. Recording the behavior and sharing information during rounds can alert other staff members to the issue. Valid and reliable tracking instruments for patients with neurological diagnoses are available and can assist in management of behavior issues.42,69 In addition, other documentation including warning letters, behavioral contracts, and formal notices of discontinued care can be utilized to protect against accusations of negligence. Excellent examples of each of these can be found in a pamphlet published by the Royal Australian College of General Practitioners, available online.70


Almost 20 years have passed since the publication of the McComas et al landmark study establishing IPSB as a problem in physical therapy, and there has been no additional evidence published on the topic since 1998. Although recent nursing surveys indicate that levels of IPSB have not diminished in this time period, additional research is needed to assess the current frequency in the physical therapist profession. Future studies may determine what type of IPSB training is currently available to physical therapists and physical therapist assistants and whether that training has been successful in achieving more satisfactory results following incidents of IPSB in clinical settings. Research is also needed to discern how many facilities have explicit policies on IPSB and what aspects of such policies result in the most favorable outcomes for both patients and staff.

In his 1993 editorial, Jules Rothstein called for a cultural shift within the physical therapist profession:

Silence has ill served us all. The time has come for us to consider how we deal with this subject [of IPSB] in our clinical environments. The time has come for us to look at our own behaviors. Do we tolerate, abet, and condone insensitivity and/or cruel interaction? I am not suggesting that the victims are responsible for their own abuse, but I firmly believe that each of us as members of a profession and a society must consider how we have allowed these behaviors to become so common.45(p739)

In order to fully accomplish this shift, and to put an end to the silence to which Rothstein referred, all new physical therapists and physical therapist assistants need to be prepared to address IPSB. New professionals need to know that inappropriate sexual behavior is common and does not reflect on them as individuals, to be aware of their rights and feel confident in standing up for their own needs, and to learn empathy for the patient and accept the individual while rejecting the behavior. Finally, they require practice in effective communication techniques for this purpose. With this educational foundation, new clinicians will bring positive change to the physical therapist profession.


I am indebted to Ann Hallum, PT, PhD, and Linda Wanek, PT, PhD, for providing the opportunity to teach my curriculum at UCSF/SFSU and for their ongoing support and encouragement of my work in this area; and to Mary Ann Wilmarth, PT, DPT, OCS, MTC, Cert MDT, who served as my advisor in the Doctor of Physical Therapy Program at Northeastern University and who provided mentorship in the development of this paper.


1. Johnson C, Knight C, Alderman N. Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Inj. 2006;20(7):687-693.
2. McComas J, Hebert C, Giacomin C, Kaplan D, Dulberg C. Experiences of student and practicing physical therapists with inappropriate patient sexual behavior. Phys Ther. 1993;73(11):762-769; discussion 769-770.
3. Phillips S, Schneider M. Sexual harassment of female doctors by patients. N Engl J Med. 1993;329(26):1936-1939.
4. The U.S. Equal Employment Opportunity Commission. Sexual harassment. Fed Regist. 2010;29(XIV):198-199. To be codified at 129 CFR 1604.1611.
5. de Mayo RA. Patient sexual behaviors and sexual harassment: a national survey of physical therapists. Phys Ther. 1997;77(7):739-744.
6. Weerakoon P, Osullivan V. Inappropriate patient sexual behaviour in physiotherapy practice. Physiother. 1998;84(10):491-499.
7. Cogin J, Fish A. Sexual harassment—a touchy subject for nurses. J Health Organ Manag. 2009;23(4):442-462.
8. Finnis S, Robbins I. Sexual harassment of nurses: an occupational hazard? J Clin Nurs. 1994;3:87-95.
9. Hibino Y, Hitomi Y, Kambayashi Y, Nakamura H. Exploring factors associated with the incidence of sexual harassment of hospital nurses by patients. J Nurs Scholarsh. 2009;41(2):124-131.
10. Libbus MK, Bowman KG. Sexual harassment of female registered nurses in hospitals. J Nurs Adm. 1994;24(6):26-31.
11. McKenna B, Poole S, Smith N, Coverdale J, Gale C. A survey of threats and violent behavior by patients against registered nurses in their first year of practice. Int J Ment Health Nurs. 2003;12:56-63.
12. Coverdale J, Gale C, Weeks S, Turbott S. A survey of threats and violent acts by patients against training physicians. Med Educ. 2001;35:154-159.
13. Gale C, Arroll B, Coverdale J. Aggressive acts by patients against general practitioners in New Zealand: one year prevalence. N Z Med J. 2006;119(1237):U2050.
14. de Mayo R. Patient sexual behavior and sexual harassment: a national survey of female psychologists. Professional Psychol Res Pract. 1997;28(1):58-62.
15. Pennington A, Darby M, Bauman D, Plichta S, Schnuth M. Sexual harassment in dentistry: experiences of Virginia dental hygienists. J Dent Hyg. 2000;74(4):288-295.
16. Williams T, de Seriere J, Boddington L. Inappropriate sexual behavior experienced by speech-language therapists. Int J Lang Commun Disord. 1999;34(1):99-111.
17. Hartl TL, Zeiss RA, Marino CM, Zeiss AM, Regev LG, Leontis C. Clients’ sexually inappropriate behaviors directed toward clinicians: conceptualization and management. Professional Psychol: Res Pract. 2007;38(6):674-681.
18. Paludi M, Barickman R. Academic and Workplace Sexual Harassment. New York, NY: SUNY Press; 1991.
19. Thacker R, Gohmann S. Emotional and psychological consequences of sexual harassment: a descriptive study. J Psychol. 1996;130(4):429-446.
20. Arbeiter J. Sexual harassment: you can do something about it. RN. 1986;49(10):46-51.
21. Schneider M, Phillips S. A qualitative study on sexual harassment of female doctors by patients. Soc Sci Med. 1997;45(5):669-676.
22. Bird S. Harassment of GPs. Aust Fam Physician. 2009;30(7):533-534.
23. Charney D, Russell R. An overview of sexual harassment. Am J Psychiatry. 1994;151(1):10-17.
24. O’Sullivan V, Weerakoon P. Inappropriate sexual behaviours of patients towards practising physiotherapists: a study using qualitative methods. Physiother Res Int. 1999;4(1):28-42.
25. Zook R. Teaching staff to handle a patient’s sexually inappropriate behavior. J Nurs Staff Dev. 2000;16(4):181-183.
26. American Physical Therapy Association website. Minimum Required Skills of Physical Therapist Graduates at Entry-Level. Accessed October 16, 2011.
27. McComas J, Kaplan D, Giacomin C. Inappropriate patient sexual behaviour in physiotherapy practice: a qualitative analysis of questionnaire comments. Physiother Can. 1995;47(2):127-133.
28. Assey J, Herbery J. Who is the seductive patient? Am Nurs. 1983;83(4):530-532.
29. Higgins A, Barker P, Begley CM. Clients with mental health problems who sexualize the nurse-client encounter: the nursing discourse. J Adv Nurs. 2009;65(3):616-624.
30. Murray R. What to do with crying, clinging, demanding, seductive, abusive, and withdrawn patients. Nurs Life. 1981;1(2):32-39.
31. Philo SW, Richie MF, Kaas MJ. Inappropriate sexual behavior. J Gerontol Nurs. 1996;22(11):17-22.
32. Grieco A. Suggestions for management of sexual harassment of nurses. Hosp Community Psychiatry. 1984;35(2):171-172.
33. Heinrich K. Effective responses to sexual harassment. Nurs Outlook. 1987;35(2):70-72.
34. Bruckner J. Commentary. Phys Ther. 1993;73(11):769.
35. American Physical Therapy Association website. Professionalism in Physical Therapy: Core Values. Accessed September 25, 2011.
36. American Physical Therapy Association website. Code of Ethics for the Physical Therapist. Accessed February 6, 2011.
37. American Physical Therapy Association website. APTA Guide for Gonduct of the Physical Therapist Assistant. Accessed January 14, 2012.
38. Lesser J, Hughes S, Jemelka J, Griffith J. Sexually inappropriate behaviors: assessment necessitates careful medical and psychological evaluation and sensitivity. Geritr. 2005;60(1):34-37.
39. Lawrie B, Jillings C. Assessing and addressing inappropriate sexual behavior in brain-injured clients. Rehabil Nurs. 2004;29(1):9-13.
40. Bezeau SC, Bogod NM, Mateer CA. Sexually intrusive behaviour following brain injury: approaches to assessment and rehabilitation. Brain Inj. 2004;18(3):299-313.
41. Higgins A, Barker P, Begley CM. Hypersexuality and dementia: dealing with inappropriate sexual expression. Br J Nurs. 2004;13(22):1330-1334.
42. Knight C, Alderman N, Johnson C, Green S, Birkett-Swan L, Yorstan G. The St Andrew’s Sexual Behaviour Assessment (SASBA): development of a standardised recording instrument for the measurement and assessment of challenging sexual behaviour in people with progressive and acquired neurological impairment. Neuropsychol Rehabil. 2008;18(2):129-159.
43. Tsai SJ, Hwang JP, Yang CH, Liu KM, Lirng JF. Inappropriate sexual behaviors in dementia: a preliminary report. Alzheimer Dis Assoc Disord. 1999;13(1):60-62.
44. Stockard S. Sexually aggressive patient: you don’t have to blush and bear it. Nurs. 1991;21(11):72-73.
45. Rothstein J. Inappropriate patient sexual behaviors. Phys Ther. 1993;73(100):738-739.
46. Raymond B, Raymond M. Confronting the unwelcome: sexual harassment. Phys Ther Mag. 1997;5(3):42-49.
47. Sfikas P. The inappropriate patient. J Am Dent Assoc. 1998;129:1312-1314.
48. Mohipp C, Senn CY. Graduate students’ perceptions of contrapower sexual harassment. J Interpers Violence. 2008;23(9):1258-1276.
49. DeSouza E, Fansler A. Contrapower sexual harassment: a survey of students and faculty members. Sex Roles. 2003;48(11/12):529-542.
50. Fitzgerald L, Swan S, Fischer K. Why didn’t she just report him? the psychological and legal implications of women’s responses to sexual harassment. J Soc Issues. 1995;51(1):117-138.
51. American Physical Therapy Association website. Physical therapist member demographic profile 1999-2008. Accessed February 20, 2011.
52. American Physical therapy Association website. Physical therapist assistant member demographic profile 2009. Accessed October 15, 2011.
53. Johnson M. Sex differences in career expectations of physical therapist students. Phys Ther. 2007;87(9):1199-1211.
54. Rozier C, Hamilton B, Hersh-Cochran M. Gender-based income differences for physical therapy managers. Phys Ther. 1998;78(1):43-51.
55. The U.S. Equal Employment Opportunity Commission website. Federal laws prohibiting job discrimination questions and answers. Accessed February 17, 2011.
56. Rape Abuse and Incest National Network. National Sexual Assault Online Hotline. Accessed March 12, 2011.
57. Erdreich B, Slavet B, Amador A. Sexual Harassment in the Federal Workplace: Trends, Progress, Continuing Challenges. Washington, DC: US Merit Systems Protection Board; 1994.
58. Hotelling K. Sexual harassment: a problem sheilded by silence. J Couns Dev. 1991;69:497-501.
59. Grauerholz E. Sexual harassment of women professors by students: exploring the dynamics of power, authority, and gender in a university setting. Sex Roles. 1989;21(11/12):789-801.
60. Bruckner J. Protect yourself. Phys Ther Mag. 1997;5(3):46.
61. Zook R. Handeling inappropriate sexual behavior with confidence. Nurs. 1997;27(4):65.
62. Zook R. Sexual harassment in the workplace. Am J Nurs. 2000;100(12):24AAAA-24CCCC.
63. de Mayo R. Patient’s sexual behavior and sexual harassment: a survey of clinical supervisors. Professional Psychol Res Pract. 2000;31(6):706-709.
64. Lane C, Rollnick S. The use of simulated patients and role-play in communication skills training: a review of the literature to August 2005. Patient Educ Couns. 2007;67(1-2):13-20.
65. Kamel H, KHajjar R. Sexuality in the nursing home, part 2: managing abnormal behavior— legal and ethical issues. J Am Med Directors Assoc. 2004;5(2):S48-S52.
66. Simpson G, Orchinson R. Sexuality after traumatic brain injury: issues and strategies. TBI Staff Training Website. Accessed January, 29, 2011.
67. Tune L, Rosenberg J. Non pharmalogical treatment of inappropriate sexual behavior in dementia: the case of the pink panther. Am J Geriatr Psychiatry. 2008;16(7):612-613.
68. Alderman N. Managing challenging behavior. In: Wood R, McMillan T, eds. Neurobehavioural Disability and Social Handicap following Traumatic Brain Injury. Hove, East Sussex: Psychology Press LTD; 2001:175-207.
69. Kelly G, Todd J, Simpson G, Kremer P, Martin C. The Overt Behaviour Scale (OBS): a tool for measuring challenging behaviours following ABI in community settings. Brain Inj. 2006;20(3):307-319.
70. Rowe L, Watts I. General Practice—A Safe Place: Tips and Tools. South Melbourne, Australia; The Royal Australian College of General Practioners; 2009.

Entry-level education; Ethical issues; Legal issues; Professional issues; Communication.

Copyright2013 (C) Academy of Physical Therapy Education, APTA