Sexual Boundary Violations by Doctors - Context, Regulatory Consequences and Preventive Strategies.

While sexual boundary violations by doctors (SBVs) are viewed with utmost seriousness by disciplinary bodies and tribunals, complaints of SBVs in Australia continue to increase. In 2023, the Australian Health Practitioner Regulation Agency (Ahpra) outlined a "blueprint" to protect patients better from sexual misconduct in healthcare: reform being considered in 2024, by Australian health ministers. Few analyses or studies have offered an overview of the prevalence, effects, and causes of SBVs, nor the duties, liabilities, possible disciplinary action against, and potential treatment of, doctors who commit them. This column offers such an overview, and considers, additionally, whether doctors who may have psychiatric disorders associated with their boundary violations would be suitable candidates for treatment. Ultimately, we contend that a purely "responsive" approach is inadequate, and preventive measures such as screening and more effective education should be considered in medical schools as a way of reducing the incidence of SBVs.

Monstrous Mothering: Understanding the Causes of and Responses to Infanticide.

The deliberate killing of a child by its mother is abhorrent and is associated in the minds of many with mental illness and in particular with postnatal depression. However, at least 50% of perpetrators are neither "mad" nor "bad", and mothers who kill children are not "unhinged" by pregnancy or childbirth. We propose a different explanation: "blind rage" or "overwhelmed syndrome", whereby parents, stressed to breaking point by sleep deprivation or incessant baby crying, respond by lethally harming their child contrary to previous behaviour. The roots of this blind rage may be found in psychosocial disturbances, including the mother's own unsatisfactory experience of parenting which has caused attachment disorders. The legal framework guiding decisions to prosecute and structuring sentencing decision-making following conviction should acknowledge the exceptional stress experienced by such mothers postnatally. Health professionals including midwives and obstetricians should increase their vigilance and arrange referrals for mothers at risk of causing harm or committing infanticide.

Gain of Function and Loss of Control: Genetic Modification of Microbial Agents - Viruses "On Steroids".

Gain of Function refers to genetic modification to enhance certain properties of a biological agent. "Dual use research" refers to experiments which have a primary goal of benefitting humanity, but which could produce harm if misapplied. So, for example, a virus which was being genetically modified (GM) for altruistic reasons might become more transmissible or resistant to vaccines or antimicrobial medications. Such a GM virus has bioterrorism potential. The UN Biological Weapons Convention has not been universally approved and 10 States are not signatories to the Convention. The control of such experiments is variously controlled in certain jurisdictions but in Australia these experiments are well regulated through the Gene Technology Act 2000 (Cth), the National Health Security Act 2007 (Cth) and the Crimes (Biological Weapons) Act 1976 (Cth). The controls on such experiments in Europe and the United States are less precise. There are examples in the United States and Europe where the security provisions to contain microorganisms undergoing research including genetic modification have been breached. This threatens the health and safety of laboratory workers and the wider community.

Batting below Average: Failure to Manage Fatal Zoonotic Diseases.

Zoonotic diseases are those which originate in animals but are transmitted to humans often through an intermediate host such as a wild animal. In Australia Hendra virus (HeV) is a disease of horses with occasional human fatalities and which is spread by the fruit bat. This article explores the lessons learnt from managing the Queensland outbreak of HeV in 1994. The legal framework for the notification and management of prohibited matter including zoonotic diseases in Queensland and New South Wales has been strengthened by provisions in the Biosecurity Act 2015 (NSW) which create strong penalties for failure to notify outbreaks and failure to isolate infected stock and prevent their removal from premises within 24 hours. The response of at least 20% of Queensland equine veterinarians to the new legal obligations has been to cease practising equine medicine. There may be scope for enhanced education of veterinary students in legal obligations under the biosecurity legislation.

Doulas from Cradle to Grave: Integration into Conventional Medical Care.

Doulas are becoming increasingly popular as support persons for the critical processes of birth and death. There is some evidence that their support reduces interventions such as Caesarean sections and instrumental deliveries as well as medicated pain relief. However, there are clear tensions in Australia between doulas and the professional obstetric staff such as midwives and obstetricians. Especially if they challenge proposed obstetric management on behalf of parturient women. Their role in managing the dying may also be open to malfeasance. At present Australian doulas are not regulated by the Australian Health Professionals Regulation Authority (AHPRA) but there is a need for them to be regulated at a local and State or Territory level.

Surgical Experimentation by John Marion Sims in the Pre-Anaesthetic Era.

The reputation of the pioneering gynaecologist J Marion Sims has been brought into question by a scandal over experimental surgery on African American slave women. Sims attempted to find a surgical cure for vesico-vaginal fistulae - an obstetric injury resulting from bladder damage after obstructed labour. His statue was removed from Central Park, New York, in 2018 in deference to the public outcry regarding his racist behaviour. A debate has raged over failures of consent for up to 30 procedures on a single patient which were performed without anaesthesia on vulnerable young slave women. However, this may be an example of "presentism" whereby the "beliefs, attitudes and practices of the 21st century are anachronistically projected retrograde to the early 19th century". This column argues that there are two separate issues: namely, the proposition that slaves could not freely give consent and that the surgery was deliberately tantamount to torture. In the 1850s United States slaves had no civil rights and no adequate anaesthesia was available during the period of surgical experimentation between 1841 and 1845.

Vaginal Dialogues: The Trials and Tribulations of Mesh in the Repair of Prolapse.

Media reports suggest that between 2005 and 2014 an estimated 8,500 patients were injured (including 170 deaths) in Australia by defective medical devices. An Australian representative action against two manufacturers and a supplier of certain medical devices used for the treatment of stress urinary incontinence and pelvic organ prolapse by three women representing over 700 registered class members alleging serious complications of vaginal mesh repair gave rise to a judgment in favour of the plaintiffs in late 2019. The judgment suggests that replacing a set of suspensory components of the levator ani muscle with a rigid matrix of mesh which provided strong support at the expense of flexibility may have been a misguided choice.

In the Footsteps of Teiresias: Treatment for Gender Dysphoria in Children and the Role of the Courts.

The Family Court of Australia has stepped back from a previously perceived need for involvement in the approval of stage 1 and stage 2 treatments, for children requiring gender transformation. At present those children and their families who are in agreement need not seek authorisation of the Family Court to undertake either Stage 1 (pubarche blockade with gonadotrophin-releasing hormone agonists) or Stage 2 treatment (cross-hormone therapy such as oestrogen for transgender males). Stage 1 treatment to suppress pubarche would nowadays be commenced at Tanner stage 2 which commences as early as 9.96 years in girls and 10.14 years in boys. Suppression of puberty continues until the age of 16 years when cross hormonal treatment commences. This article questions the assertion that suppression of puberty by GnRH analogues either in cases of precocious puberty or gender dysphoria is "safe and reversible" and argues that it warrants ongoing caution, despite the Family Court having broadly accepted that assertion.

Eve's Curse: Intolerable Unrelieved Pain in Labour - Necessary Evil or Medical Negligence?

For most prospective mothers, pain in childbirth is their greatest fear. However, intolerable labour pain should no longer be accepted by the health professions. Without adequate pain control in labour fetal damage can be significant. Moreover, if relief from pain is a fundamental human right then surely standards of good obstetric care should include a definition of adequate pain relief in labour and obstetricians should pay due attention to alleviating that pain. At present actions in tort focus on poor medical management of injuries or diseases. Pain and suffering are generally a secondary consequence of that negligence although in the tort of negligence pain can constitute damage. However, it is argued that failure to address pain adequately as a primary issue should be considered medical malpractice or at least unsatisfactory professional performance if there is proof of failure to exercise reasonable care. The possibilities for untreated labour pain to be deemed medical negligence could include maternal post-traumatic stress disorder, fetal brain injury resulting from maternal acidosis and utero-placental hypo-perfusion or even negligent infliction of mental harm on the family members witnessing their family relative in intolerable pain. In this article the nature of labour pain and its fetal effects will be discussed. Effective pain control in labour should be good medicine as well as humane treatment.

Eradicating the legacy of Othello: Western Sydney University's attempt to raise awareness of intimate partner violence.

In Australia scant attention is given to teaching medical students how to identify and manage intimate partner violence (IPV) and sexual assault (SA). In Australia one woman dies weekly from IPV and the prevalence of IPV in Australian women is 29 percent. The Australian Prime Minister labelled it a 'national disgrace' and yet, of the five World Health Organisation (WHO) regions, the Western Pacific Region has the lowest rates in the world.1 Since 2015 reducing IPV has become a national strategy. In undergraduate medicine the obstetric and gynaecological curriculum is a logical and appropriate place for such education given the predominance of female victims. Western Sydney University (WSU) commenced this training as a 1 day practical multidisciplinary workshop on IPV and Management of Sexual Assault in 2017. Prior to that time the University provided less than 2 h of training in IPV or SA in a 5 year undergraduate degree course. The preliminary results suggest that medical students are predominantly positive towards developing skills in dealing with IPV and their enthusiasm and knowledge increases after the workshop.

Medicinal Cannabis in Pregnancy - Panacea or Noxious Weed?

The use of medicinal cannabis has been the subject of enabling legislation in Australia since 2016. At present the medical profession has not supported its use for anything but a few indications which include paediatric treatment-resistant epilepsy (especially Dravet's syndrome), pain syndromes associated with multiple sclerosis, Parkinson's disease and chemotherapy-induced nausea. However, in the United States where medicinal cannabis has been legalised in 29 States and Washington DC, nausea is an approved indication in many jurisdictions and this has been followed by widespread use for pregnancy-induced nausea and vomiting. This may prove to be ill advised as serious concerns have been expressed about its safety in pregnancy particularly its proven potential to restrict fetal and postnatal growth as well as to impair childhood cognitive functions such as memory, verbal skills and emotional development. These reported effects on neuropsychiatric behavioural and executive functions may influence future adult productivity and lifetime outcomes. Twenty-one States of the United States approve the use of legal cannabis for nausea and vomiting including its use in pregnancy. This is likely to encourage complacency regarding its fetal risks in pregnancy. In Australia the federal and State legislation restricts use of legal cannabis by placing the pharmaceutical under Sch 8 of the Poisons Act 1971 Tas which requires specific application for each individual patient use. It is to be hoped that this will prevent the excesses of use in pregnancy witnessed in the United States.

Adaptively Accelerating Reactive Molecular Dynamics Using Boxed Molecular Dynamics in Energy Space.

The problem of observing rare events is pervasive among the molecular dynamics community and an array of different types of methods are commonly used to accelerate these long time scale processes. Typically, rare event acceleration methods require an a priori specification of the event to be accelerated. In recent work, we have demonstrated the application of boxed molecular dynamics to energy space, as a way to accelerate rare events in the stochastic chemical master equation. Here we build upon this work and apply the boxed molecular dynamics algorithm to the energy space of a molecule in classical trajectory simulations. Through this new BXD in energy (BXDE) approach we demonstrate that generic rare events (in this case chemical reactions) may be accelerated by multiple orders of magnitude compared to unbiased simulations. Furthermore, we show that the ratios of products formed from the BXDE simulations are similar to those formed in unbiased simulations at the same temperature.

Alcohol Consumption and Impairment of Surgeons: A Case for Total Abstinence?

In the 2016 appeal Health Care Complaints Commission v Schmidt [2016] NSWCATOD 145, the New South Wales Civil and Administrative Tribunal heard evidence to the effect that the influence of alcohol (alertness, judgment and co-ordination) could occur at blood alcohol concentrations as low as 0.01% and that on-call health professionals should not consume any alcohol. The NSW Health Code of Conduct requires all staff, including contractors, "not to be under the influence of alcohol or drugs when commencing work and while at work", and the Public Health Regulation 2012 (NSW) similarly requires that "health practitioners must not practise while suffering from a physical or mental impairment … that detrimentally affects, or is likely to detrimentally affect, his or her ability to practise or that places clients at risk of harm". If this were to be accepted as a professional standard for on-call medical practitioners, then it would have major implications for much of the medical profession, particularly those on continuous call in private practice whose hours are not delimited. The evidence for alcohol-induced impairment of clinical performance is assessed here through the prism of the cognitive and psychomotor skills requirements for surgeons.

Adaptive free energy sampling in multidimensional collective variable space using boxed molecular dynamics.

The past decade has seen the development of a new class of rare event methods in which molecular configuration space is divided into a set of boundaries/interfaces, and then short trajectories are run between boundaries. For all these methods, an important concern is how to generate boundaries. In this paper, we outline an algorithm for adaptively generating boundaries along a free energy surface in multi-dimensional collective variable (CV) space, building on the boxed molecular dynamics (BXD) rare event algorithm. BXD is a simple technique for accelerating the simulation of rare events and free energy sampling which has proven useful for calculating kinetics and free energy profiles in reactive and non-reactive molecular dynamics (MD) simulations across a range of systems, in both NVT and NVE ensembles. Two key developments outlined in this paper make it possible to automate BXD, and to adaptively map free energy and kinetics in complex systems. First, we have generalized BXD to multidimensional CV space. Using strategies from rigid-body dynamics, we have derived a simple and general velocity-reflection procedure that conserves energy for arbitrary collective variable definitions in multiple dimensions, and show that it is straightforward to apply BXD to sampling in multidimensional CV space so long as the Cartesian gradients ∇CV are available. Second, we have modified BXD to undertake on-the-fly statistical analysis during a trajectory, harnessing the information content latent in the dynamics to automatically determine boundary locations. Such automation not only makes BXD considerably easier to use; it also guarantees optimal boundaries, speeding up convergence. We have tested the multidimensional adaptive BXD procedure by calculating the potential of mean force for a chemical reaction recently investigated using both experimental and computational approaches - i.e., F + CD3CN → DF + D2CN in both the gas phase and a strongly coupled explicit CD3CN solvent. The results obtained using multidimensional adaptive BXD agree well with previously published experimental and computational results, providing good evidence for its reliability.

THE TREATMENT OF INTERSEX AND THE PROBLEM OF DELAY: THE AUSTRALIAN SENATE INQUIRY INTO INTERSEX SURGERY AND CONFLICTING HUMAN RIGHTS FOR CHILDREN.

When a child is born with indeterminate genitalia (so-called intersex or disordered sex development), it becomes very difficult to balance the child's right to determine their own sexual future against the problems of living as a child with an indeterminate gender. Moreover, the initial assignment of gender may prove to be inappropriate and major psychological disturbances in the recipient can arise during adolescence and adult life. The problems of these children were explained to the Australian Senate Committee during its inquiry into intersex surgery in 2013. As a result, the Committee made a number of recommendations, including a proposal that all surgery be deferred until the child is able to consent to treatment. The author argues that the Committee's proposal to delay all modifications of indeterminate genitalia is impractical. The inclusion in the definition of intersex of common conditions (such as hypospadias in genetic male infants) means that necessary and uncontroversial surgery will be delayed until after puberty. This delay may be harmful and adverse to some children's best interests.

Cruise control: prevention and management of sexual violence at sea.

The drug-related death of Dianne Brimble on the P&O cruise liner Pacific Sky in 2002 triggered a wide-ranging review of the safety on board cruise ships operating in the Australian market. This column assesses the frequency of recent sexual assaults on cruise ships and examines the findings and recommendations of the Brimble inquest, focusing on the Commonwealth government's response to those recommendations. The problem of jurisdiction on flag of convenience registered ships is discussed, with emphasis on a possible co-operative arrangement between Australian police and foreign flag states. It seems likely that the United States and Canadian models of cruise ship regulation to enhance passenger safety will in part be introduced in Australia.

Our Father who art in prison: Conviction and rehabilitation for Australian Catholic clergy who are child sexual offenders.

In light of the Royal Commission into Institutional Child Sexual Abuse, this article analyses the custodial sentences of 143 Australian Catholic clergy. The majority of these sentences were for convictions for indecent assault for which the median sentence was two years' imprisonment. It is doubtful whether the Australian community would consider such sentences as adequate, particularly where offences were against children. Current Australian legislation allows for ongoing long-term sanctions, including judicial orders for chemical castration, to be imposed on convicted sex offenders, especially those assessed as being at high risk of re-offending. Clergy on parole are likely to be prohibited from resuming most pastoral responsibilities on the grounds of high actuarial risk of re-offending, but what limited data are available suggests that priests may have low rates of re-offending. If priests do have low rates of recidivism, what then should the Catholic Church do about priests convicted of child sexual abuse offences who want to return to pastoral work and how might they be managed and monitored? Laicisation of offender priests will inevitably produce ostracism and isolation which are conducive to re-offending.

The Australian National Disability Insurance Scheme for cerebral palsy: an end to the "forensic lottery"?

The new Australian National Disability Insurance Scheme is set to revolutionise disability support for an estimated 440,000 disabled persons and in particular for over 35,000 victims of cerebral palsy. The current support for sufferers of cerebral palsy is fragmented and their families and carers expend great time and effort accessing a range of different support agencies. The present "forensic lottery" means that only a small percentage of cerebral palsy victims whose injuries have been caused by medical negligence can secure large settlements under civil tort litigation. The NDIS promises a much more equitable scheme where severely disabled children can receive the necessary early intervention, which is so important to their long-term outcome. Such support will be provided irrespective of "fault", although recouping the costs of lifelong care through civil litigation in medical negligence remains an option. Debate continues about the affordability of such an ambitious Scheme. This is no doubt fuelled by the perceived New Zealand experience of its no-fault Accident Compensation Scheme. The NDIS advantage over almost all "no fault" schemes internationally is that it provides unified comprehensive care and support to cerebral palsy sufferers irrespective of a "treatment injury". Determinations for eligibility will no doubt involve extensive medical documentation. Uncertainty remains about the preparedness of the Chief Executive Officer of the NDIS to pursue health providers in civil negligence where treatment injuries may have been causative.

Sexual violence in armed conflict: the least condemned of war crimes.

Sexual violence in armed conflict has traditionally received poor attention until recent years. It has been the "least condemned of war crimes" although, with the inception of the International Criminal Court and various other international courts and tribunals, convictions of high-profile aggressors are increasing. Only recently Charles Taylor, the President of Liberia, was convicted of war crimes and crimes against humanity which included rape and sexual slavery. He was sentenced to 50 years imprisonment. Is prosecution of these crimes sufficient to minimise sexual violence in war? That seems unlikely given the potential for such violence to be a cheap and effective strategy to terrorise a civilian population and "ethnically cleanse" the newly won territory. However, there is a remarkable variation in the levels of sexual violence in armed conflicts. Some, such as the Israeli-Palestinian conflict, have extremely low levels, whereas in Bosnia and many African states the prevalence of sexual violence is at epidemic levels. The reasons for such differences are many, however, some precipitating factors may be improved by strong military discipline, improved gender balance in armed forces, better political awareness by combatants of the aims of a campaign and pre-deployment ethical training.

Responsiveness to the chlorhexidine epidural tragedy: a mental block?

Paralysis following an epidural anaesthetic is a rare event. The mechanism usually involves accidental injection of skin antiseptic instead of local anaesthetic. Two recent cases, one involving paralysis, the other a "near-miss", are described. The first case resulted in an extensive root cause analysis and an admission of liability by the hospital. The response of the anaesthetic community and the New South Wales Department of Health was swift but failed to produce uniform protocols across the region. Furthermore, the requirement of medical staff to double check medications with a second person before their administration was not addressed. Abandoning a more effective but neurotoxic antiseptic solution in favour of a solution with weaker antiseptic properties, as had previously occurred in one Sydney hospital, could incur higher risks of epidural infection. Defensive medical practice can lead to unwanted negative consequences.