to Articles Index
Sexual Exploitation of Patients By Health
Professionals, A.W. Burgess & C.R. Hartman,
editors, New York: Praeger, 1986, 99-106.
When the Pediatrician Is a Pedophile
Carolyn Moore Newberger and Eli H. Newberger
As recently as the late 70's, child sexual abuse
was considered extremely rare. Recent retrospective
surveys, however, suggest that from 3 to 6 percent
of males and from 12 to 38 percent of females are
sexually victimized during their childhoods (Finkelhor
1979; Russell 1983). Although there is variation
from study to study in estimates of incidence,
the magnitude of the problem is clear. During the
past few years, cases of child sexual abuse have
involved day care centers, prominent families,
and respected institutions (Trainor 1984).
Little is known about adults who commit sexual
acts with children. Available data suggest that
95 percent of the sexual abuse of girls and about
85 percent of the abuse of boys is committed by
men, most of whom are known to the child. The offenders
come from all ethnic and income groups and may
be community leaders who exploit their positions
of prestige to gain access to children. They are
more likely than the general population to be outwardly
religious and rigid about sexual mores (Finkelhor
Most child sexual abusers appear normal to the
rest of the world, and their deviancy is frequently
not recognized by their wives, friends or colleagues.
They may be homosexual, heterosexual, or bisexual;
they may have sexual relations with adults as well
as children or only with children. Some individuals
prefer sustained relations with one child, while
others favor brief sexual encounters with many.
They may rape infants or "initiate" adolescents.
Some sexual abusers operate "sex rings" in
which groups of children become involved with one
or more adults, usually through some neighborhood
or recreational activity (Finkelhor 1984; Burgess
et al. 1984).
Pedophiles, individuals whose sexual preference
is for children, may select professional contexts
in which access to children is assured. Within
the medical profession, pediatrics offers such
access. The pediatrician, usually a beloved and
trusted member of the community, has intimate and
often private contact with children's bodies. When
the pediatrician is a pedophile, the interests
and needs of many parties are compromised: the
children's needs to be free of abuse and exploitation
and to trust adult caregivers, the medical profession's
needs to maintain its standards for care and its
status within the community, and the community's
needs to maintain social order and to trust those
on whom it relies for the care of children.
Such multiple needs and interests are reflected
in our society's confusion over what to do about
the sexual abuse of children. This confusion reflects
a fundamental set of moral conflicts: (1) the conflict
between personal and institutional needs and the
assumption of responsibility for others, and (2)
the conflict between responding with standard rules
of justice and responding with individualized prescriptions
for care. In this chapter, we present a case that
illustrates these central moral conflicts and discuss
how we might resolve them in ways that achieve
an enlightened, moral response.
WHOSE INTERESTS ARE SERVED?
THE CASE OF THE PEDIATRICIAN PEDOPHILE
When we are confronted with sexual abuse, especially
abuse by a powerful professional, all too often
every interest but the child's seems to take priority.
This appears to be true in the case of a pediatrician
we call Dr. Smith.
Dr. Smith was the subject of a disciplinary proceeding
before a state board of registration in medicine.
The pediatrician is a respected, prestigious, and
powerful member of his community. He is married
and an active member of a local church.
During the routine physical examination of a 14-year-old
boy, Dr. Smith removed the child's undershorts
while the boy lay on the examining table and began
stroking his genitals and asking questions about
injury to the penis, sperm color, and problems
with ejaculation. After masturbating the child
to ejaculation, the doctor hugged the boy, saying "I'm
a pretty cute guy," and then kissed him on
the neck. By this time, the child became very nervous
and confused. He was subjected to several more
hugs before leaving the examination room. After
the boy and his mother left the doctor's office,
he told her what had happened.
Shortly after, the boy's family called police.
Although an initial contact was made, the police
inquiry apparently then stopped. No criminal charges
were filed, and there was never any public disclosure
of the incident. Rather, the matter was addressed
six months later in a closed hearing of the state
board of registration in medicine. The board retained
a private attorney to conduct its own investigation
and to serve as the prosecutor in a closed meeting
in which the complainant, other witnesses, and
the doctor would appear.
During the closed inquiry, the doctor claimed
that boys often had ejaculations during physical
examinations and revealed the names of two other
boys. His records showed a private shorthand for
the events and lavish descriptions of the boys'
bodies. He also said that he served often and without
compensation as a lecturer on teen-age sexuality,
that he worked as both a school and a camp physician,
and that his examinations of boys' genitals often
lasted more than five minutes. He steadfastly maintained
that there was no harm in what he did.
The doctor's license was suspended for 30 days
and he was placed on probation for ten years, during
which time he was to seek psychiatric help until
discharged by the psychiatrist. Dr. Smith was instructed
to have a third person present during the examinations
of his patients throughout the probationary period.
Responsibility for arranging for that third person
was left with the doctor.
The parents of Dr. Smith's patients were not notified
of the hearing or its findings, and public communication
was limited to a small notice in the local newspaper.
The self-monitoring and limited public communication,
especially in light of the doctor's failure to
acknowledge any wrong doing, made the effectiveness
of controls over Dr. Smith's practice questionable.
Dr. Smith discontinued psychiatric treatment following
an evaluation period.
In the meantime, two other cases of past abuse
were revealed. The victims were boys who had approached
Dr. Smith with problems after a sex education class
during which he invited children concerned about
sexuality to consult with him. One boy had worries
about homosexuality; the other was worried about
venereal disease and about whether he had impregnated
his girlfriend. These disclosures prompted a reopening
of Dr. Smith's case by the state board of registration.
The deliberations of the second hearing, 18 months
after the initial disclosure, resulted in Dr. Smith's
permanently losing his license to practice medicine.
Dr. Smith again refused to admit wrongdoing. During
at least part of this time, he had continuing opportunity
to molest his young patients.
Dr. Smith demonstrates some of the classic characteristics
of pedophilia (Lanning 1984):
- The perpetrators are male.
- They select a particular age and gender of
- They choose professions (medicine) and specialties
(adolescent pediatrics) that provide legitimate
reasons for sustained (and in the doctor's
case, intimate) contact with the children they
- The perpetrators keep a personal record that
permits prompt retrieval of material about
- They protect themselves.
Several aspects of this case are particularly
interesting. First, after being contacted by the
parents of the child who first reported the abuse,
police contacted the boy's school before even contacting
the doctor. The school secretary was asked to check
the boy's records, and she found four minor disciplinary
infractions. No mention is made in the police records
of whether this was done with the permission of
the child or family. The implicit statement in
the police action is that the child's behavior
in school will have something to do with how the
police will respond to the accusation. This means
that the victim, rather than the act, is the first
line of investigation, at least when the accused
is a powerful member of the professional community.
Second, according to Dr. Smith's testimony, he
was informed by the state and national offices
of the American Academy of Pediatrics and by the
American Medical Association that there are no
guidelines for dealing with this offense. In light
of new estimates of the prevalence of the sexual
abuse of children, of the likelihood that the abuser
is known and trusted, and of the probability that
pedophiles choose positions where they have access
to the victims, these organizations have an obligation
to establish clearly articulated values and procedures.
Third, following a brief period, the discreet
police inquiry stopped. There were no criminal
charges or public disclosures. The doctor continued
in his practice, while the board of registration
in medicine conducted an investigation that resulted
in a closed hearing six months later. These procedures
served to protect the physician and his profession,
but failed to protect the public.
A final highlight of these cases is that Dr. Smith's
conduct was found by the board to be improper,
inappropriate, and unprofessional. This is tantamount
to saying he was a "bad boy" and does
no justice to the seriousness of the charges and
to the effects of the abuse on the victims. Because
there was no public disclosure, Dr. Smith could
take a month-long vacation and thus camouflage
the suspension. He arranged for his own chaperoning.
When the case was reopened after the two previous
patients came forward, he stated on deposition
that he did not believe that he needed treatment,
that what he had done was not wrong, and that his
actions had no effects on the children.
A MORAL ANALYSIS OF THE CASE OF DR. SMITH
The issue of morality is not an issue simply for
the sexual victimizer, but also for the systems
and individuals that respond to the victimization.
How do we articulate a framework for moral choice
to guide public and private behavior, especially
when the interests of powerful adults threaten
to obscure the rights and needs of children?
When we examine professional practice and policy
in relation to child sexual abuse, moral tensions
and conflicts between self-interest and responsibility
and between justice and care are present. Some
of the confusion and conflict around the sexual
victimization of children centers on the extent
to which we feel we should take public responsibility,
and when we do, whether a morality of justice or
a morality of care is the appropriate response.
The Conflict between Self-Interest and Responsibility
The conflict between self-interest and responsibility
is generated in this case in at least three ways.
- Dr. Smith's sexual desires for his patients
versus his responsibility to these children
as a pediatrician.
- The inferred need on the part of the police
to stay in favor with the powerful medical
community versus their responsibility to investigate
openly a case considered a crime by community
- The desire on the part of the medical community
to protect its reputation by secrecy versus
its responsibility to the public to protect
children from sexual exploitation and to allow
parents informed choice about whether they
want their children to be treated by a man
who molested other children in his care.
Clearly each of these were resolved on the side
The first step in applying moral choice is interpersonal
awareness, or being aware of the effects of actions
on others. Dr. Smith appears not able to make that
first step, insisting that what he is doing is
not wrong and does not effect his patients. That
he acted out his own needs, rather than his patients',
is clear. Less clear is how self-interest and responsibility
are defined by his professional peers, who suspended
his license to practice for a brief period but
did not take steps to ensure that additional children
would not be victimized. Is it self-interested
not to inform people that their pediatrician is
a pedophile? Does it protect the image of the profession
that has the task of judging him? Or does it protect
people from the knowledge that caregivers might
be capable of hurting them, knowledge that might
cause harm if people then fail to seek medical
The Conflict between a Morality of Justice
and a Morality of Care
The justice versus care dilemma in child sexual
victimization might be articulated as follows:
How can we maintain social order and justice, while
at the same time respond to individual needs for
healing and care? As a society, we are confused
whether to treat adult sex with children as a crime
to be punished or as a symptom of pathology to
be cured. This confusion has led to a continuing
conflict, with some people arguing for universal
criminalization of child sexual abuse and other
people advocating a more family and treatment-oriented
The conflict between a morality of justice and
a morality of care is evident in several aspects
of this case:
- On the part of the police, the conflict was
between whether to treat this case as any case
of sexual molestation would be treated (i.e.,
to apply a standard of equal justice with the
consequent exposure of a member of the medical
community), or whether to respond to the needs
of the medical community by turning the case
over to its own governing body.
- On the part of the board of registration, the
conflict was whether to treat this case as a
violation of medical conduct, which requires
loss of the privileges of the profession, or
to approach it as a case of a sick physician
who needs to be cured.
The issues of justice or care in relation to the
victims appear not to have been considered.
Resolving the Moral Conflicts of Sex with Children
For everyone who must respond to the sexual victimization
of children (families of victims, clinical providers,
protective workers, members of the criminal justice
and judicial systems, and architects of social
policy), there is' a need to recognize the moral
conflicts the victimization presents. Can we face
the problem when it conflicts with our own needs
and interests? Can we provide justice while not
neglecting individual needs for healing and care?
Three orientations toward persons and problems
can be viewed as characterizing how individuals
and institutions have responded to sex with children.
We suggest that these orientations define a developmental
progression of response to child sexual victimization.
An egocentric orientation. The problems
of child sexual victimization are avoided, denied,
or responded to out of individual need. In the
case of Dr. Smith, the response was in terms of
protecting a powerful profession and a colleague
rather than the children.
A conventional orientation. Criminal
or clinical rules and procedures bind and constrain
action on child sexual victimization. Individual
differences are not understood or acknowledged.
For example, a conventional interpretation of sexual
victimization as a criminal act leads to the universal
prescription of prosecution and punishment. A conventional
interpretation of sexual victimization as psychopathology
leads to a universal prescription of psychotherapy.
Although responsibility for responding to sex with
children is assumed, response tends to be rigid
and ideological. In this case, psychotherapy was
ordered without considering the doctor's motivation
to change. His steadfast belief in the normalcy
of his behavior and his consequent failure to follow
through with treatment means that unless other
options can be considered and applied, children
with whom he has contact will continue to be at
An individualized orientation. Evaluation
of each situation in terms of its own particular
needs and realities guides response, which considers
the needs of the child for emotional support and
protection, the offender's need for corrective
intervention, and our institutions' needs to do
their jobs. A variety of options are available
to be applied in the service of both justice and
TOWARD RESPONSIBILITY IN THE CASE OF DR. SMITH
Can we define a response to Dr. Smith's victimization
of his patients that will protect children from
further abuse and will permit intervention to be
both fair and individualized? As a first step,
we identify goals of intervention for the four
primary constituencies in this case: the community,
the medical profession, the victims, and Dr. Smith.
To maintain laws that deter others and provide
equitable redress for crimes
To apply the law without favoritism
To protect its population from harm
To uphold the ethical imperative to do no
To maintain public trust and confidence
(past and future)
To have an opportunity to recover from
the abuse and to know the abuse was not their
To be protected from sexual exploitation
To be removed from situations where he can
sexually abuse others
To be rehabilitated to assure that he assumes
responsibility for his acts and will not sexually
The task of the responding institutions is to
identify flexible and realistic options that would
satisfy as fully as possible all these goals. Our
preference is for a system of interdisciplinary
practice, with members from the mental health,
law enforcement, legal, and medical communities,
to evaluate $such cases. The protection of children
must be the primary concern, with the protection
of the needs of offenders and institutions secondary.
In our opinion, justice was not served by the
doctor's treatment as a special case, and the care
of children was violated by the failure to inform
parents of the risk of child sexual abuse by Dr.
Smith. In addition, the goal of rehabilitation
was not served by the prescription of mental health
treatment in the face of Dr. Smith's denial of
a need for change. In this case, criminal action
may have been warranted in order to impress upon
Dr. Smith the seriousness of his behavior. Strong
external controls may be necessary, at least initially,
in the face of minimal internal acknowledgement.
Although the ultimate removal of Dr. Smith's license
to practice medicine may be a removal from opportunities
to abuse children sexually, this action may protect
the medical profession more than it protects children
from Dr. Smith. He will no longer have access to
children as a pediatrician, but it does not prevent
access to children in other ways. The power of
sexual desires and preferences in pedophiles is
extremely strong, and pedophiles often form rings
and networks that enable them to have contact with
children. In this context, Dr. Smith is a pedophile
first and a pediatrician second. He should be treated
not as an errant pediatrician, but as a pedophile
who remains a threat to children.
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Powers. 1984. "Impact of Child Pornography
and Sex Rings on Child Victims and Their Families." In Child
Pornography and Sex Rings, edited by A. Burgess.
pp. 111-26. Lexington. Mass.: Lexington Books.
Finkelhor, D. 1984. Child Sexual Abuse.
New York: The Free Press.
_______.1979. Sexually Victimized Children.
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Lanning. K. 1984. "Child Pornography and
Sex Rings." Paper presented at the annual
meeting of the American Orthopsychiatric Association.
Russell, D. 1983. "The Incidence and Prevalence
of Intrafamilial and Extrafamilial Sexual Abuse
of Female Children." Child Abuse and Neglect 7:133-46.
Trainor, C. 1984. "Sexual Maltreatment in
the United States: A Seven-Year Perspective. " Paper
presented at the Fifth International Congress on
Child Abuse and Neglect, Montreal.