Editor’s note: This story contains descriptions of sexual assault and abuse, and could be triggering for survivors.

Every year, thousands of new doctors recite some form of the Hippocratic Oath—a code of ethics from the American Medical Association that has roots dating back to ancient Greece—during their medical school graduation ceremonies. The specifics vary depending on the institution, but typically, each new class of physicians pledges to respect the confidentiality of patients, uphold the integrity of the medical profession, and to avoid harm. It’s not just an empty rite of passage: The oath serves as a kind of public, spoken contract between new doctors and their future patients.

Yet there are times when certain physicians violate that oath to prey on the more vulnerable. Besides the widely covered trial of disgraced former Olympics gymnastics team doctor Larry Nassar, there have been other reported cases of patient abuse in recent years. An Atlanta Journal-Constitution investigation in 2016 identified more than 2,400 cases of doctors across the United States who had sexually assaulted their patients. And a 2017 review published in the journal Sex Abuse analyzed 101 different cases of patients who were sexually violated by a physician. Also disturbing is the fact that for decades, medical students practiced pelvic exams on unconscious patients under anesthesia—a practice that came to widespread public attention in 2019. This was done without their consent or knowledge.

When is enough, enough? We talked to patients and advocates about their experiences—and what needs to change in order to prevent this kind of sexual abuse from persisting.

‘I didn’t even realize what was happening’

Emma* was 22 when she went to the hospital for an echocardiogram, a test that uses ultrasound to show how the heart muscle and valves are working. Diagnosed with scleroderma, an autoimmune disorder that can tighten blood vessels, her doctor wanted to see if the disease was progressing. “It was my first echo and I didn’t really know what to expect,” Emma says. “I was put in a room and the [male] technician told me to take everything on the top half of my body off. He gave me a hospital gown, but he didn’t leave the room while I was changing. It made me super uncomfortable.”

Then, Emma says, he asked her to lie down, roll over to face him, and expose her top half to him. “The technician moved the [transducer] across my chest to read my heart, but he was touching my breasts to move them to adjust the monitor, which made me very uncomfortable,” Emma says. “At some point, I made a face and he said, ‘I know it’s uncomfortable, but this is a daily thing for me and doesn’t even faze me.'” His response did little to ease Emma’s discomfort. “I went home and took a shower because I just felt so awkward,” she says.

Still, because an echocardiogram involves using a machine to read the heart, Emma wasn’t sure if what the technician did was technically wrong. It wasn’t until she got another echocardiogram a couple of years later at a different hospital that she realized a boundary had been crossed. “This time, the [female] technician left the room while I changed into the hospital gown and during the actual echo, I was completely covered,” Emma says. “Afterward, I told the technician what had happened to me the first time. She got visibly upset and said, ‘I’m so sorry that happened to you. It should not have gone like that at all.” The technician told her that there is no reason to be fully exposed during an echocardiogram and patients always have the right to change in private.

“It’s hard for [patients] to believe something like [abuse] could happen when they’re putting their health and body into the hands of someone who is to be trusted.” —Dorianne Mason, director of health equity, National Women’s Law Center

Emma says what shook her the most about this experience is that she has always felt confident about speaking up when feeling uncomfortable. “My dad works in law enforcement and I’ve grown up having these types of conversations,” she says. “But I didn’t even realize what was happening, which is very upsetting.”

Dorianne Mason, the director of health equity at the National Women’s Law Center, says abuse by health professionals is often able to persist because not all patients know what proper medical protocol is for procedures—and what behavior crosses the line. “Often, patients don’t really know what to expect [from a procedure], so they don’t have a standard to measure it by,” Mason says. “It’s hard for them to believe something like [abuse] could happen when they’re putting their health and body into the hands of someone who is to be trusted.”

Mason says the first steps for preventing sexual abuse in hospital settings are better education for patients on what the laws are and knowing where to turn if a line has been crossed. There are laws at both federal and state levels outlining patients’ rights, but they are often hard to find or understand on your own without a lawyer. (Mason says the NWLC is working on providing easy-to-understand resources to rectify this.)

For the record, Mason says deliberately watching a patient undress, subjecting a patient to an intimate examination without the patient’s consent, touching the genital area without gloves, making sexual comments about a patient’s body or orientation, and requesting details about sexual likes and dislikes are all illegal—regardless of what state you live in.

While knowing what the law has to say certainly helps, Mason says not to underestimate the importance of trusting your gut. “If you feel that something going on is wrong, chances are it is,” she says.

‘He was someone who knew how to abuse his powers’

A few years ago, Jessica* went to her family physician and expressed concern about being unable to achieve orgasm. “I was concerned about whether it was a physiological issue and about the length of my labia,” she says. Her doctor referred Jessica to a gynecologist, who in addition to doing the traditional type of reproductive health services you would expect at a gyno, also performed certain cosmetic procedures. (This is fairly common among gynecologists—it’s a specific medical field known as cosmetic gynecology.)

Jessica told the gynecologist, who was male, about her concern about achieving orgasm, and he performed an exam. “He told me there was nothing physically wrong with me that would contribute to that, but he could still perform a labiaplasty [a surgery that reduces the size of the labia minora or majora], if that was something I was interested in,” Jessica says. After being told that labiaplasty can help with clitoral orgasms, she decided to move forward with the procedure.

“During the procedure, it was me, the doctor, and a nurse,” Jessica said. She explains that she had local anesthesia and was awake during the whole thing. (During a labiaplasty, patients typically have a choice between local or general anesthesia.) “While he’s doing the labiaplasty, he starts asking me questions about my dating life. Like, how many dates with a guy I had been on and if I had slept with him yet,” Jessica recalls. Though she felt uncomfortable, she answered his questions in an effort to keep the conversation casual. “Then, he started asking me what sorts of things I liked sexually,” she says. “I just kept going along with it, because I didn’t know what to do. I was just lying there with my legs spread, feeling very exposed.” At the end of the procedure, Jessica says the doctor kissed her forehead and left the room.

“I feel like he was someone who knew how to abuse his powers.” —Jessica*

Jessica knew that her OB/GYN had crossed a line, and shared her experience with her family physician. As far as she knows, her complaint was not recorded anywhere officially. She chose not to take further action because she didn’t want to go through the emotional trauma of retelling her experience, especially when she assumed the outcome wouldn’t be in her favor. “I just thought that this was something that wasn’t as cut and dry as something like rape, you know?” she says. “He had a nurse in the room, and I feel like he was someone who knew how to abuse his powers in a gray area and not in a way that would get him in trouble.”

Mason runs into the idea of “gray areas” all the time in her work; many people think that something has to be physical or sexual assault for it to be illegal. But that’s not true, she says. “What many people think of as a gray area is not, in fact, a gray area,” she says. And she sympathizes with Jessica and others like her who feel the time and emotion it takes to win a court case will be too trying to endure. “For survivors of any type of abuse, it’s a personal choice of how they want to engage and hold that person accountable,” she says. “But at least from the perspective of the Law Center, we want to ensure that the process is just, fair, and robust, so that if a person decided to go down that path it will be worth it. For me, it comes down to people knowing their rights and then, if they decide to take action, knowing that the process is not meant to further traumatize them or increase harm.”

Mason says there are a few different courses of action for patients who want to take action against a doctor. One is calling the local police station directly. Or, she says, someone can tell officials at the hospital where the abuse occurred. “Someone can also log a complaint with the state medical review board or with the Office of Civil Rights,” she says. All of these methods serve as the first step to getting what happened on the record.

Complaints are prioritized by how much of a perceived threat a health-care worker is to the patient (or future patients). Reports of sexual misconduct are usually given high priority and once a complaint is lodged, the state medical board is meant to start a formal investigation. Typically, the accused provider’s medical license is suspended for the duration of the investigation. Sometimes the medical board will schedule a court hearing; other times, consequences will be settled out of court.

While this process may sound straightforward, it isn’t, as navigating state medical review board sites can be complicated for the average patient. “This is the difficulty when talking about practical applications of people’s rights,” Mason says. “It’s too complicated of a system to navigate. They are not built for people to get justice easily.”

Lauren Powell, MD, a consultant and the former executive director of Time’s Up Healthcare, adds that patient sexual abuse is an issue she says her organization is well aware of and will be a future focus. (Currently, the group is focused on the abuse of health-care professionals, not patients themselves.) Dr. Powell says the difficulty of navigating the legal system, and the financial burden it can cause to victims is one reason why the Time’s Up legal defense fund was established in 2018. (It was initially started to combat workplace discrimination and sexual harassment in health-care and other industries, but is a resource that patients can use, too.)

Additionally, Dr. Powell says the Legal Network for Gender Equity offers free consultations and some of the nearly 700 attorneys that are part of this network will take cases for a reduced fee. Besides these resources, some other groups that provide legal help for patients who experienced sexual abuse include Equal Rights Advocates, the National Organization for Women, and The National Center for Victims of Crime.

“We need bigger systematic changes that make [reporting misconduct] easier and this needs to happen at a [government] policy level,” Mason says. Whether or not these policy changes will be made is currently hanging in the balance. Mason says before the pandemic, there were conversations happening at a legislative level addressing sexual abuse in health care, but it was put to a halt once COVID-19 hit. “Section 1557 [of the Affordable Care Act] provides a vehicle for addressing this type of abuse,” she adds. This law is meant to protect patients’ rights, both in terms of safety and to prohibit discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. The important provisions are under threat because of the current case against the Affordable Care Act before the Supreme Court. “If the ACA falls, so do all the protections under it,” she says.

‘I was worried people would say what happened to me wasn’t that bad’

While being unclear of the laws and feeling pessimistic about justice being served are two reasons patient abuse in health-care settings often goes underreported, another reason is that many victims feel shame about their experience.

Ilene* works as a patient advocate in a hospital, a role she became passionate about after her son died due to a medical error. Some of the core roles of a patient advocate are to inform the patient of what procedures should look like, protect their autonomy, and represent the patient’s concerns to doctors, nurses, and other medical providers if they are unable or uncomfortable doing so themselves. Despite her profession, Ilene has kept a sexual misconduct incident she experienced herself a secret for over 25 years, telling no one until being interviewed for this article. “I didn’t want to be judged,” she says. “I was worried people would say what happened to me wasn’t that bad.”

Ilene says she has experienced sexual misconduct twice, once at a hospital and once at a chiropractor’s office. The first time was 25 years ago. “I wanted to start volunteering in the hospital where my son died and in order to do so, needed a physical,” she says. During her exam at the hospital, Ilene says the physician put his hands on her breasts and started rubbing them around, which she says she recognized right away as out of line. “I said, ‘Oh my God,’ and jumped off the table.” Ilene never said anything to anyone about the experience.

“I just thought, ‘Do they think they’re flirting? Do they think women want this?'” —Ilene

Ilene says she was abused again during an appointment with a chiropractor 10 years later. “I was lying facedown on the table [for a chiropractic adjustment] and he stuck his hand down the back of my pants.” Ilene says she was completely startled because the chiropractor didn’t offer an explanation—and in her view, there was no clear reason for him to touch her in this way. Despite her shock, she says she ignored it, never told anyone, and never went back to that chiropractor again.

Ilene says she was also sexually abused in high school by a group of boys, but she says what she experienced at the hand of health-care workers has been more difficult for her emotionally. “Physically, what happened to me [in high school] was so much worse but because I had a lot of support and people really rallied around me, it was easier than what I experienced at the hospital and chiropractor’s,” she says. “Both times, I just thought, ‘Do they think they’re flirting? Do they think women want this?’ Dealing with it in silence made it so much worse, but I didn’t see the point of speaking about it.”

Mason says, unfortunately, it isn’t unusual for patients to feel the mixture of shame and confusion that Ilene felt. “There is so much [perceived] trust and intimacy between a health-care provider and a patient, which can not only make someone more vulnerable but often can make it more difficult to describe because the [abuser] is someone in a position of power who knows more than them about the procedure,” she says.

The power of speaking up shouldn’t be overlooked; it’s vital for creating awareness and better policies that protect patients (such as Section 1557), all of which help make reporting abuse easier and ensure allegations are taken seriously. “The #MeToo movement as a whole has shone light on harassment and assault in various settings in a way that has helped expand protection, elevate rights, and calls for change,” Mason says. “But we have not yet had that experience when it comes to interactions with medical providers.”

Ilene says that she is finally sharing her experiences after 25 years in the hope that being a voice can lead to systematic change and safer hospitals. “If women don’t share their experiences, they might not know that what happened to them is wrong or happens to others,” she says. “There needs to be more awareness about what is and isn’t okay to happen in a hospital setting. Because if you don’t know what’s not okay, it can just keep happening.”

*Name has been changed or last name withheld.