Earlier in our series, we noted that most legal and administrative bodies divide sexual misconduct into categories.

Sexual violation is the most serious, since it includes an overt sexual act.

Sexual transgression, which is normally defined as inappropriate touching of a patient. Obviously, there are two ways for such inappropriate touching to occur -- as a deliberate action by the doctor, or as inadvertent or misunderstood contact.

In this report, we are not dealing with deliberate sexual predation by a doctor of chiropractic on patients. Any doctor who finds himself or herself deliberately engaging in any kind of sexual transgression, however "minor" -- or even considering such action -- requires immediate counseling and/or legal proceedings. The chiropractic profession must adopt a zero tolerance attitude toward such behavior if it is to maintain the respect and trust of its patients and the general public.

However, in a "hands on" profession such as chiropractic, there will occasionally be contact with a patient innocent of any unprofessional or unethical intent, but that may be misconstrued as sexual transgression.

This may be part of the routine examination, particularly if an exam procedure requires even partial disrobing, or part of the regular chiropractic adjustive care.

Obviously, chiropractors -- particularly subluxation-based D.C.s who focus solely on vertebral subluxations -- encounter far fewer occasions where such inappropriate touching might occur than a medial doctor does in the course of a full-body exam. Still, there are enough land mines in a chiropractic practice to worry many risk-management experts.

Take, for instance, the following hypothetical cases:

*** You are helping turn a female patient over on the adjusting table and your hand inadvertently brushes or presses against her breasts;

*** A patient tries to show you where her lower-back hurts and exposes part of her upper buttocks;

*** You lean over to give an adjustment at the same moment a patient shifts position, and you press against her.

These types of situations can happen frequently in a chiropractic office and, usually, no one thinks twice about it. You're concentrating on the exam or the adjustment and hardly even notice the point of contact. The patient also is generally aware that some physical contact is part of the procedure and does not react with undue concern.

However, there are times when a patient will misinterpret the contact and perceive it as sexual impropriety. Often, this is due to a heightened sense of awareness on the part of the patient.

After years of victimization, many women now realize they must take responsibility for protecting themselves against improper actions by male doctors. They are encouraged, and rightly so, to be alert to any malfeasance and take actions to stop it. Often it results in a level of suspicion that makes difficult any contact -- even the most innocent. This is most frequently the case with a new patient who hasn't yet learned to trust her chiropractor.

Keep in mind, too, recent research suggests that one in three girls are sexually abused before the age of 18 and approximately 44% of women are victimized by rape or attempted rape at some time in their lives. Women have a right -- and a need -- to be careful.

The best way to avoid having your actions misunderstood or misinterpreted is to be equally sensitive. While a fleeting touch or light pressure might not seem to you as a "big deal," try to put yourself in the patient's position. Better yet, think of the patient as your own sister or daughter. Make sure you apply the chiropractic Golden Rule -- touch your patient only the way you'd expect another D.C. to touch your family members.

The same rule applies to disrobing. Most chiropractors do not require patients to disrobe. Those who do should purchase and use appropriate gowns, give the patients ample time to disrobe in private, and take extra precautions to protect their dignity and privacy.

In addition, it's helpful to explain to your patients exactly what you are doing, to eliminate the element of surprise. By explaining ahead of time, "we're going to turn you onto your right side now," or "I'm going to place my arm over your body to give me better leverage," you prepare the patient and provide a legitimate therapeutic rationale for the action. Also, tell patients specifically how much they need to disrobe (bra only, bra and blouse, belt only, etc.).

If a patient -- particularly a new patient -- appears particularly anxious or protective of her privacy, consider having a female C.A., associate or other staff member remain in the room during the exam or adjustment. On subsequent visits, as you see the patient relax, you may choose to dismiss the chaperon and merely leave the door open to avoid alarming the patient.

Many health care advocates are beginning to agree with Dr. Thomas Gutheil, professor of psychiatry at Harvard Medical School, who stated: "In the present era, chaperoning is clearly indicated and represents valuable protection for both parties. Thus, arguments against its use are archaic and outdated." Although he was speaking specifically about medical doctors, the technique may become essential in chiropractic offices if there is an increase in the number of sexual misconduct suits.

Naturally, if anything occurs that might be considered sexual misconduct, document it in the patient's records immediately, noting exactly what happened and what remedial actions you took (i.e., calling in a chaperon, apologizing, etc.)

This is particularly important if you sense a patient may be deliberately using your innocent touch as a provocation for a lawsuit. Being "set up" is on the increase today, as patients seek to force doctors into settlements. By putting into place proper practice procedures, using chaperons when deemed reasonable, documenting all actions, and being sensitive to the impact of touch, you can minimize the risk of any successful lawsuits.

SOURCES: "When Doctors Cross the Line: Sexual Misconduct in the Doctor's Office," ABCNews, March 31, 2001.

"Handbook on Sexual Abuse of Children: Assessment and Treatment Issues" by Lenore E. Auerbach Walker (ed), 1988.