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Privacy and Confidentiality in the Therapeutic Relationship

Section 7
Disclosure of Sexual Abuse

Question 7 | Test | Table of Contents

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The correct answer, of course, is C, assist the woman to become aware of services available to her in regard to the abuse. Reporting applies only to minor children.

Let's look at Section 7, Disclosure of Sexual Abuse. Since many therapists interface with physicians, I felt it would be a good idea to include in the course a section which helps us examine the ethical issues that physicians face regarding confidentiality. The basis of this is Robert Veatch's Patient Physician Relations.

Here is what Veatch calls "The Case of the Homosexual Husband." Now this is a really good example, and I referenced this at the beginning of the Home Study Course where the physician is faced with a real dilemma regarding breaches in confidentiality when he is treating two patients.

♦ "The Case of the Homosexual Husband"
David, the oldest of three children, was a son of a well-to-do manufacturer. David's father valued physical prowess and athletic accomplishments, areas in which the boy showed little interest. When David was twelve or thirteen years old, conflicts with his father resulted in almost nightly arguments. It was evident that David's father had become concerned about his son's mannerisms and considered them to be effeminate.

David's school work deteriorated considerably, and he became withdrawn. His father decided to send him to military school, but he remained there only six months. By this time, David had told his parents that he was a homosexual and that he had engaged in and was engaging in homosexual practices. He came home and completed his high school studies, but he did not go to college and continued to live at home.

He was treated for gonorrhea, asthma, and infectious hepatitis. At the age of twenty-one, to gain exemption from the draft, his physician attested to the fact that he was a homosexual.

Five years later, Joan visited her family physician for a premarital serological exam. The physician was the same practitioner who had treated David. Joan was twenty-four years old and had been under his care since the age of fourteen. A close and warm relationship had developed between the physician and Joan's family, so it was normal for him to ask about her fiancé. When he did, he learned that she was about to marry David. She had known him only briefly, but well enough, she felt, to be certain about her choice. Nothing more was said at the time.

David and Joan were married shortly thereafter and lived together for six months. The marriage was annulled on the basis of nonconsummation. David told Joan that he was homosexually oriented, and she learned as well that not only did they share the physician, but also the physician was aware of David's homosexuality. She subsequently suffered a depression as a result of this experience and was angry that her physician had remained silent about David. She felt that she could have been spared this horrible episode in her life -- that it was his duty to inform her. His failure to do so was an act of negligence resulting in deep emotional scars.

To whom did the physician owe primary allegiance? Do the interests of one patient prevail over the requirements of confidentiality surrounding another's case?

Veatch states, at least in uncomplicated cases, the practitioner should convey to the patient any medically relevant information that would be potentially meaningful or useful in medical decision making. The physician's Hippocratic ethic instructs him to do what he thinks will benefit his patient.

However, according to Veatch the tradition of physician ethics on confidentiality is not at all clear. The Hippocratic Oath, is ambiguous, it states that the physician should keep secret things he learns in his practice that ought not to be "spread abroad." Which things those are is not specified. The World Medical Association's (WMA) version of the Hippocratic Oath states simplistically that the physician will keep confidences entrusted in him.

On the other hand, Veatch feels the version by the American Medical Association takes a quite different approach. Its principle of ethics says that the physician ought not to disclose things learned in confidence except in three cases: when disclosure is required by law, when it is in the patient's interest, or when it is in the interests of other people.

Sounds similar to the Therapist's Code doesn't it?

The AMA indicated the physician's duty to disclose to persons other than the patient from whom the relevant information has been learned, thus taking a much more social course. But it opens the door for a wide range of disclosures.

No where does the traditional physician's ethics say anything about resolving conflicts between duties to two patients whose interests may conflict and may differ from the practitioner's.

Duty to Report Abuse vs. Duty of Confidentiality
Next let's examine just such a case, "When a Doctor's Duty to Report Abuse Conflicts with a Duty of Confidentiality to the Victim," by T.J. David.

Fifteen years after she has been admitted to hospital with unexplained bruising, a woman asks to see her pediatric medical records. Professor T. J. David describes the dilemma surrounding the women's allegations of sexual abuse.

Here's a case where a Doctor's Duty to Report Abuse conflicts with the Duty of Confidentiality to the Victim.

A 21 year old woman asked to see her medical records from a children's hospital. The pediatrician in charge of her case was approached by the hospital administration.

The case was one of possible non-accidental injury. Because of the risk of misunderstanding what had been written in the notes, not to mention their poor legibility, the pediatrician met the woman and went through the medical records with her. He also gave her a full photocopied set to keep. The woman had been a patient 15 years before. At 6 years of age she had been admitted to the hospital for a few days' observation, because she had a large number of bruises for which there was no adequate explanation. Screening tests gave no evidence of a coagulation disorder and a skeletal survey showed no fractures.

Careful inquiries were made of social services, the Child Abuse Agency, the health visitor, the child's general practitioner, and her school. All reports were favorable. The girl came from a good family, there were no concerns, and there was nothing in her background to suggest that this was a case of non-accidental injury.

As a result, social services decided not to hold a case conference and the child was discharged. The pediatrician notified all the above agencies about the bruising, and it was suggested that any further episodes of bruising should be reported immediately to social services. The child was never seen again with injuries.

When the pediatrician saw the 21 year old woman, he had no idea why she wanted to look at her records. He was concerned that the family might have been disrupted because of the earlier inquiries into possible child abuse or that we had failed to detect abuse and she had been injured further.

After the pediatrician had gone through her hospital notes, the woman explained that the bruises had been inflicted deliberately, and that she had wanted to see from her medical notes if we had known about the sexual abuse that she had experienced. She had been sexually abused by a male baby-sitter over a period of weeks, and had been beaten up by this man whenever she had shown an unwillingness to cooperate. He had threatened to harm her if she ever reported him; She did not report him.

The woman said that this man still lived in the same neighborhood and now had a young daughter of his own. The pediatrician and woman discussed at length what action she might take. She was unwilling to report the matter to the police or social services, and she repeatedly said that he should not under any circumstances share this information with anyone else. She told the pediatrician that she had had bulimia for some years. This she attributed to her childhood experiences, and she feared that bringing the subject out into the open now would make her distressed and depressed.

The woman's request to maintain confidentiality placed the pediatrician in a difficult position. Her story, if true, suggested that other children might have been harmed or might still be at risk, and he saw little reason to doubt her. The question was whether the pediatrician had a duty to report the matter that outweighed respect for the woman's rights for confidentiality.

- David, T. J. (1998). Child sexual abuse: when a doctor's duty to report abuse conflicts with a duty of confidentiality to the victim. BMJ, 316, 55-57.
- Reamer, F. G. (2009). Social Work Ethics Casebook: Cases and Commentary. Washington, DC: NASW Press.
- Reamer, F. G. (2001). Tangled Relationships: Managing Boundaries in the Human Services. New York: Columbia University Press.
- Veatch, R., PhD. (1999). The Patient-Physician Relation, The Patient as Partner. Indiana University Press.

Strengthening Sexual Assault Victim's Right to Privacy
- Zannoni, J., MSW, LICSW. (n.d.). Strengthening Sexual Assault Victim's Right to Privacy. Connecticut Sexual Assault Crisis Services, Inc. Retrieved October 19, 2018.

Peer-Reviewed Journal Article References:
DeCou, C. R., Cole, T. T., Lynch, S. M., Wong, M. M., & Matthews, K. C. (2017). Assault-related shame mediates the association between negative social reactions to disclosure of sexual assault and psychological distress. Psychological Trauma: Theory, Research, Practice, and Policy, 9(2), 166–172.

Gueta, K., Eytan, S., & Yakimov, P. (2020). Between healing and revictimization: The experience of public self-disclosure of sexual assault and its perceived effect on recovery. Psychology of Violence. Advance online publication. 

Gupta, S., Bonanno, G. A., Noll, J. G., Putnam, F. W., Keltner, D., & Trickett, P. K. (2011). Anger expression and adaptation to childhood sexual abuse: The role of disclosure. Psychological Trauma: Theory, Research, Practice, and Policy, 3(2), 171–180.

Karnani, S. R., & Zelman, D. C. (2019). Measurement of emotional blackmail in couple relationships in Hong Kong. Couple and Family Psychology: Research and Practice, 8(3), 165–180.

Mimran, M. (2020). Review of flirting with death: Psychoanalysts consider mortality [Review of the book Flirting with death: Psychoanalysts consider mortality, by C. Masur, Eds.]. Psychoanalytic Psychology, 37(3), 259–261.

Linda B., a battered woman, informs you that her husband has threatened to kill her. He owns a gun. She has been unable to sleep soundly and has developed generalized anxiety. She is afraid that if her husband finds out that she has told you about his abuse, that he will follow through on his threat. You should...
a. urge your client to leave her husband and move to a shelter for battered women
b. work with the client to document the frequency, magnitude and duration of her reactions to the husband's threats
c. inform your client of her options
d. interview the husband in order to help him avert behaving in a way that will cause problems for both his wife and himself
To select and enter your answer go to Test.

Section 8
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