By its nature, the therapeutic relationship is unequal. Clients make themselves vulnerable by sharing intimate details of their lives with their therapists. Patients invest trust and authority in therapists, relying on the therapist's judgement for help. Often, clients view their therapists as powerful, parental figures, and patients may interact with the counselor in a child-like way. Many clients idealize, admire, and experience sexual attraction or romantic feelings toward their therapists.

Competent, ethical therapists recognize that these client responses are normal, but they also realize that the power imbalance between therapist and patient negates the possibility of an equal, consenting relationship. Therapists who encourage clients to act on these feelings abuse their position of trust. They misuse the relationship to gratify their own needs, failing to fulfill their responsibility to help the patient. Such manipulation is a violation of the client's trust and a form of sexual abuse, even if the client appears to consent or to initiate the sexual contact.

Many people believe that the power dynamics in the therapeutic relationship so closely resemble those in the parent-child dyad that sex between therapist and patient is psychologically equivalent to incest. For this and for other reasons, several states have criminalized sexual exploitation of patients as a form of statutory rape.

Members of the major mental health professions have conducted research on the prevalence of psychotherapist-patient sexual exploitation. These studies show that approximately 7% to 15% of professionals, in confidential self-reports, admitted to sexual involvement with a client. However, some researchers believe that the actual incidence may be higher.

Although the most common pattern involves a male therapist and a female client, abuse can occur between a therapist and patient of the same gender, or between a female therapist and a male client. According to one researcher, 80% of offenders exploit more than one patient.

Although each person will have a unique response, common reactions include:

	Isolation
	Confusion about the abuse, about the perpetrator, and about one's role in the abusive relationship
	Loss or lessening of ability to trust
	Feelings of guilt and shame
	Anger or rage
	Anxiety and panic
	Mood swings
	Depression
	Suicidal feelings
	Sexual problems
	Cognitive problems, such as difficulty concentrating and intrusive thoughts about the abuse
	Worsening of the problems for which client originally sought treatment
	Reluctance to seek help from another professional

The following behaviors are often indicators that a sexual boundary violation may be occurring:

	Increased or inappropriate therapist self-disclosure
	Longer appointments or appointment at end of day
	Change of location from a professional setting to a social setting (e.g., meeting at a restaurant or bar)
	Introduction of alcohol or misuse of drugs in treatment
	Suggestive or seductive statements, "dirty jokes,'' or other verbally demeaning behavior
	Bartering for services
	Therapist intruding into client's personal life (phone calls at home, social engagements)
	Excessive or intrusive focus on sexuality
	Request for secrecy
	Inappropriate physical contact
	Nudity
	Erotic/sexual contact

Gabbard, G. (ed.), Sexual Exploitation in Professional Relationships. Washington, DC: American Psychiatric Press, Inc., 1989.

Pope, K. and Bouhoutsos, J., Sexual Intimacy Between Therapists and Patients. New York, NY: Praeger, 1986.

Rutter, P., Sex in the Forbidden Zone. Los Angeles, CA: Jeremy P. Tarcher, Inc., 1989.

Schoener, G. et. al., Psychotherapists' Sexual Involvement with Clients: Intervention and Prevention. Minneapolis, MN: Walk-In Counseling Center, 1990. (2421 Chicago Avenue South, Minn., MN 55404)

Walker, E. and Young, P. A Killing Cure. New York, NY: Henry Holt, 1986.