Ryon Horne/AJC

In Kentucky, Dr. Ashok Alur was examining an infection on a patient’s abdomen when he entered forbidden territory. He told the patient she had sexy underwear. Then, he rubbed her and placed his mouth on her genitals. The patient pushed him away and went to police.

“It was so beautiful,” the doctor told her later, when she confronted him. “I couldn’t resist.”

In Missouri, Dr. Milton Eichmann asked a woman badly injured in a sexual assault if she liked being tied up during sex, whether she was easily stimulated and whether she liked to be urinated on. He then told the patient, who was seeing the doctor for treatment of urinary problems, that he was being aroused.

In California, a patient was leaving an appointment with Dr. Mandeep Behniwal, a psychiatrist, when the doctor put his hand down her blouse, grabbed her breast out of her bra and placed his mouth on it. He then exposed himself and ejaculated on her hand.

In New Mexico, Dr. Twana Sparks for years performed genital exams she said were for screening on ear, nose and throat patients who were under anesthesia and hadn’t given consent, the state medical board said. In Texas, Dr. Philip Leonard fondled patients’ breasts or pressed his erections against them during exams, 17 women reported. In Georgia, a patient who saw Dr. Jacob Ward for a back rash and facial redness said the doctor exposed and fondled her breasts and put his hands down her pants.

In each of these cases, described in public records, the doctors either acknowledged what they’d done or authorities, after investigating, believed the accusations. While the scale and scope of the physicians’ misdeeds varied tremendously, all were allowed to keep their white coats and continue seeing patients, as were hundreds of others like them across the nation.

In a national investigation, The Atlanta Journal-Constitution examined documents that described disturbing acts of physician sexual abuse in every state. Rapes by OB/GYNs, seductions by psychiatrists, fondling by anesthesiologists and ophthalmologists, and molestations by pediatricians and radiologists.

Victims were babies. Adolescents. Women in their 80s. Drug addicts and jail inmates. Survivors of childhood sexual abuse.

But it could be anyone. Some patients were sedated when they were sexually assaulted. Others didn’t realize at first what had happened because the doctor improperly touched them or photographed them while pretending to do a legitimate medical exam.

Some doctors were disciplined over a single episode of sexual misconduct. A few physicians — with hundreds of victims — are among the nation’s worst sex offenders. But the toll can’t be measured by numbers alone. For patients, the violations can be life-altering. The betrayal even pushed some to suicide.

How do doctors get away with exploiting patients for years?

Some victims say nothing. Intimidated, confused or embarrassed, they fear that no one will take their word over a doctor’s. Colleagues and nurses stay silent.

Hospitals and health care organizations brush off accusations or quietly push doctors out, the investigation found, without reporting them to police or licensing agencies.

Society condemns sexual misconduct by most citizens and demands punishment. A teenage boyfriend and girlfriend in North Carolina were arrested for “sexting” nude pictures of themselves to each other. A Georgia woman was placed on a sex offender registry for having sex when she was 19 with a 15-year-old who lied about his age. A Pennsylvania teacher who had sex with an 18-year-old student was dubbed a predator and sent to prison.

But when a physician is the perpetrator, the AJC found, the nation often looks the other way.

Physician-dominated medical boards gave offenders second chances. Prosecutors dismissed or reduced charges, so doctors could keep practicing and stay off sex offender registries. Communities rallied around them.

Erin Vance, who was sexually assaulted by an Oregon physician while she was under anesthesia, said the doctor should have been stopped long before she was wheeled into an operating room. He’d been reported by another patient years earlier.

“I keep going back to the ‘Do no harm’ aspect of the Hippocratic oath,” Vance said. “I mean, I couldn’t move. I was completely at the mercy of whoever was there, and it turned out that the person who was there was a serial predator.”

RYON HORNE / AJC Erin Vance was one of at least 12 women sexually assaulted by anesthesiologist Dr. Frederick Field as they lay incapacitated at a hospital in The Dalles, Ore.

Video: Hear in Erin’s own words the impact on being a victim of sexual abuse from a doctor

BRUSHED OFF AS RARE

The Roman Catholic Church, the military, the Boy Scouts, colleges and universities. They have all withered under the spotlight of sexual misconduct scandals and promised that abuse will no longer be swept under the rug.

The medical profession, however, has never taken on sexual misconduct as a significant priority. And layer upon layer of secrecy makes it nearly impossible for the public, or even the medical community itself, to know the extent of physician sexual abuse.

“There just isn’t accurate data,” said Dr. Gene Abel, an Atlanta physician who is a nationally recognized expert in evaluating sexual misconduct by professionals.

The AJC launched its national investigation a year ago after reaching a surprising finding in Georgia: two-thirds of the doctors disciplined in the state for sexual misconduct were permitted to practice again.

Today, after months of unearthing rarely viewed documents and tracking some cases from beginning to end, the AJC is exposing a phenomenon of physician sexual misconduct that is tolerated — to one degree or another — in every state in the nation.

The AJC obtained and analyzed more than 100,000 disciplinary documents and other records from across the country to find cases that may have involved sexual misconduct. Then reporters identified more than 3,100 doctors who were publicly disciplined since Jan. 1, 1999 after being accused of sexual infractions. More than 2,400 were sanctioned for violations that clearly involved patients. The rest were disciplined for sexual harassment of employees or for crimes such as child pornography, public indecency or sexual assault.

Yet many, if not most, cases of physician sexual misconduct remain hidden. The AJC investigation discovered that state boards and hospitals handle some cases secretly. In other cases, medical boards remove once-public orders from their websites or issue documents that cloak sexual misconduct in vague language.

When cases do come to the public’s attention, they are often brushed off by the medical establishment as freakishly rare. While the vast majority of the nation’s 900,000 doctors do not sexually abuse patients, the AJC found the phenomenon is akin to the priest scandal: It doesn’t necessarily happen every day, but it happens far more often than anyone has acknowledged.

‘A DELICATE BALANCE’

Over and over again, records show, predatory physicians took advantage of a doctor’s special privilege — the daily practice of asking trusting people to disrobe in a private room and permit themselves to be touched.

Offenses ranged from lewd comments during intimate exams to molestation, masturbation by the doctor in front of the patient, swapping drugs for sex and even rape. Because many orders are vague or undetailed, it isn’t always clear if a doctor claimed the patient consented. However, the profession says consent is never a defense because of the power imbalance between doctors and patients.

David Clohessy, the executive director of SNAP, a support and advocacy organization for people sexually abused by priests, doctors and others, said many Americans view physicians with too much deference and automatic respect.

“We are so reliant on them, we are so helpless and vulnerable and literally in pain often times when we go in there. We just have to trust them,” Clohessy said.

“So when they cross the boundary and their hands go into the wrong places, we are in shock, we are paralyzed, we’re confused, we’re scared. We just do not want to believe, first of all, that a doctor is capable of this , and secondly that their colleagues and supervisors will not address this immediately and effectively when we report it.”

Authorities say they take allegations of sexual misconduct seriously but sometimes compromise to settle cases without going through protracted battles.

Leanne Diakov, general counsel for the Kentucky Board of Medical Licensure, said medical boards have to consider everything from the state’s need for physicians to the limits imposed by state law. In Kentucky, for example, doctors whose licenses are revoked by the medical board have a legal right to petition for reinstatement two years later.

“It’s always a balance,” Diakov said. “Obviously, the public looks at it and says, ‘Oh my gosh, how are they letting this physician practice.’ It’s a delicate balance between protecting public health resources, protecting patients and acting within the statutory authority that the legislature has given you.”

‘LOST MY JUDGMENT’

Sexual contact between a doctor and a patient, even if ostensibly consensual, is strictly forbidden. In ethical terms, it’s a never event. In a legal sense, it can be a crime. Physicians know it’s a line that can’t be crossed — it’s a prohibition as old as the Hippocratic oath.

Yet, the AJC found, even doctors who molest patients or subject them to bizarre exams for deviant purposes are frequently seen as sympathetic figures in need of therapy instead of predators who must answer to police. They get a diagnosis. They get a treatment. They come back.

Many are cleared to practice again after going to recovery centers where they take lie-detector tests and admit transgressions. They are expected to learn empathy and work through their issues, in some programs through art and yoga and in at least one through equestrian therapy. Others, seen in need only of further education, return to practice after attending weekend “boundary” classes at hotels or college campuses.

Only 11 states have a law requiring medical authorities to report to police or prosecutors when they suspect a sexual crime has been committed against an adult.

Doctors spend years in costly medical schools and training programs. They’re smart. They’re admired. They’re needed. Like the giant banks that were once viewed as “too big to fail,” the nation’s doctors are often considered too precious to discard.

Some of the disciplined doctors interviewed by the AJC expressed remorse. Some felt unfairly targeted by patients hoping to profit from a lawsuit. Others said they were frustrated that professionally damaging reports kept popping up years later, when they viewed their actions as brief lapses in judgment, not a life of misconduct. Most said they had paid dearly for the mistakes.

Behniwal, the California psychiatrist, said the patient who accused him initiated the sexual contact and he didn’t stop himself quickly enough. “For half a minute, I lost my judgment,” he said. Sparks, the New Mexico physician, said she was conducting cancer screening exams when she touched patients, with no sexual intent. But she said she paid a huge professional price because she didn’t have the patients’ consent. Eichmann, now retired and focused on charity work, said he was dedicated to helping his patients and regretted making inappropriate comments.

‘SALVAGE THAT PHYSICIAN’

Some states are apparently more forgiving than others when disciplining doctors in sexual misconduct cases. Georgia and Kansas, for example, allowed two of every three doctors publicly disciplined for sexual misconduct to return to practice, orders on board websites show. In Alabama, it was nearly three out of every four. In Minnesota, it was four of every five.

Nationwide, the AJC found that of the 2,400 doctors publicly disciplined for sexual misconduct, half still have active medical licenses today.

Larry Dixon, the executive director of the Alabama Board of Medical Examiners, has heard the argument that doctors who engage in sexual misconduct should be barred from practice. He doesn’t buy it.

“If you graduate a class of more than 100 people out of the University of Alabama medical school, the resources that have been poured into that education almost demand that you try to salvage that physician — if it’s possible,” said Dixon, who has led the Alabama board for 35 years.

Stop and think, he said, about how badly many communities need their doctors.

“You do not think so? Then leave Atlanta and go down to a little Georgia town and get sick,” Dixon said. “See how far they have to go to find a doctor.”

‘THE UGLY REALITY’

Office of Dr. Philip Leonard in Austin, Texas. He continues to practice despite accusations of sexual misconduct from 17 women.

When examining cases, the AJC found all sorts of surprising twists allowing doctors to keep working.

Dr. Philip Leonard was a well-respected neurologist in Austin, Texas, when the first report of sexual misconduct came in. After one patient told police in 2001 that the doctor had rubbed his erection against her during an exam, 16 other patients came forward making similar complaints.

“It depended on where he was, but the way I like to put it (is) he led with his penis,” one told the Texas medical board, describing how Leonard pressed against her while seeing her for a head injury.

Yet today the 65-year-old doctor practices without restriction.

The medical board initially decided the complaints were credible and suspended Leonard’s license. But it later changed its mind after one patient’s criminal case went to trial and resulted in the doctor’s acquittal. Because there was no forensic evidence, the case hung on the patient’s credibility, which was attacked by the defense when she testified. The jury never heard about the other 16 women.

“It’s sickening,” said Cathryn Blue, the woman whose case went to trial.

RYON HORNE / AJC Cathryn Blue of Lockhart, Texas, near Austin, accused neurologist Philip Leonard of sexual misconduct after leaving his office in August 2001. Sixteen other women eventually came forward, making similar complaints to police and the Texas licensing board. Leonard was acquitted in Blue's case. Prosecutors did not take the other cases to trial.

The medical board reached a deal allowing Leonard to return to practice as long as he saw only male patients for 10 years, a restriction that ended in 2014. He declined to be interviewed for this story.

The physician who served as the board’s president at the time acknowledged that the agreement reflected how the board compromised to reach settlements doctors would accept without costly appeals.

“What (Leonard) did was clearly an abuse of his power over these women,” said Dr. Lee Anderson, a Fort Worth ophthalmologist. “But the ugly reality is, what can we actually achieve?”

‘THE RIGHT THINGS’

When the AJC examined Dr. Jacob Ward’s history, it found the physician is still practicing in suburban Atlanta even though he pleaded guilty after being accused of molesting a female patient.

The patient in 2011 told Woodstock police that Ward squeezed her buttocks, pulled up her shirt and felt her breasts and touched her genitals during an exam.

After Ward’s arrest, the Georgia medical board placed him on probation with restrictions that included a sexual misconduct treatment program and supervision and monitoring of his practice. He also was directed to have a chaperone with female patients.

Ward later pleaded guilty to misdemeanor sexual battery and received two years’ probation.

But documents obtained by the AJC reveal a startling back story: Two other patients had made similar charges against Ward four years earlier and the board did nothing other than write a “personal and confidential” letter to the doctor expressing its “concern regarding exams and patients of the opposite sex.”

Speaking at Ward’s sentencing, the victim in the 2011 case said she had recently learned, on her own, of the previous complaints and that it made her pain even greater.

“How he could still be able to have a practice and see patients right now is beyond me,” the woman said at the hearing.

Cherokee County Judge Dee Morris found the victim’s statement so compelling that he refused to go along with the initial plea agreement, which called for Ward to be sentenced as a first offender.

Ward, who now practices in Canton, declined to discuss his case in detail when contacted by the AJC.

“I’ve done everything I’m supposed to do, per the Georgia board,” he said. “I’m doing the right things.”

‘IT’S FRUSTRATING’

Doctors forced to stop practicing because of sexual misconduct in one state may get a second chance in another.

Alabama revoked Dr. Oscar Almeida Jr.’s license in 2002 after four female patients complained of various improprieties, including fondling and kissing and inappropriate vaginal exams. The Mobile physician steadfastly denied any wrongdoing and fought the decision in the courts, but the board’s ruling was upheld by the Alabama Supreme Court in 2004.

A year later, Almeida applied for a Mississippi license. His request was approved, with the State Board of Medical Licensure saying the doctor “would be an asset to the State of Mississippi.” In 2007, Alabama reinstated Almeida’s license. Its order cites his boundary training and says “it would be a great loss to the medical community, and to the public in general, if a physician of Dr. Almeida’s obvious skill and ability would never again be able to practice medicine.”

Some regulators have a dim view of state hopping. Aaron Haslam, a former executive director of the State Medical Board of Ohio, said he grew weary of seeing doctors that Ohio deemed unfit to practice wind up with licenses in other states.

“It’s frustrating now and it was frustrating then,” he said. “We would try to be tough on an individual that we thought had no business practicing medicine and that individual would lose his license and go set up shop in the state right next to us or in Georgia or in Florida.”

‘THE OBVIOUS QUESTION’

Even when sexual misconduct ends a doctor’s ability to practice, investigators sometimes uncover a trail of misdeeds that goes back for years or even an entire career, highlighting a system that shielded them.

Dr. Paul Emerson, a Michigan osteopath, was sentenced to 12 years in federal prison in 2010 after pleading guilty to a scheme in which he gave out bogus prescriptions in exchange for cash or sex. Three people who received his prescriptions overdosed and died.

When investigators dug into his past to prepare a sentencing memo, they found a long history of sexual misconduct: As an intern at a Detroit area hospital, he drew suspicion for conducting a pelvic exam on a 14-year-old complaining of asthma. In Mississippi, he was discharged from the Air Force after being accused of inappropriately touching female patients, lost his privileges at a hospital for “unprofessional conduct” and was terminated as a prison physician after being sued for sexual harassment by a nurse.

“It is this court’s belief that you simply were finally being caught and being charged with crimes that were perhaps ongoing for a long period of time,” U.S. District Judge Victoria Roberts said at sentencing.

In Maryland, the medical board found that Dr. Ramon L. Gonzalez sexually abused female patients, including adolescents, all the way back to medical school in the 1970s. One patient gave birth to his child. But the doctor’s entire history of sexual malfeasance only came to light years later, baffling even those in charge of disciplining doctors.

“The obvious question,” an administrative law judge wrote in 2002, “is how (Gonzalez) was able to practice medicine for so many years and escape any substantial consequences for his actions.”

‘HALF A LOAF IS BETTER THAN NO LOAF’’

In many states, physicians who engage in sexual misconduct are treated or disciplined in private, keeping patients in the dark.

Georgia sometimes uses private consent orders and private agreements, Robert Jeffery, executive director of the state medical board, told the AJC. “Sometimes half a loaf is better than no loaf,” he said, explaining that such orders are used when the board is concerned a public order may not stick if the doctor fights it.

Public orders, he added, may inhibit doctors from reporting themselves or their peers. “If the response every single time is going to be public suspension, public this, public that, then I think what you would end up with is the unintended consequence of fewer reports,” he said.

In North Carolina, a public order involving Dr. Darlington Hart revealed how he had been subject to years of private actions and warnings.

In 2013, the medical board denied his application to have his license reinstated after he had surrendered it in 2011. To justify the denial, the board revealed a history that had been handled almost entirely in private in both North Carolina and South Carolina.

Allegations against Hart between 2001 and 2010 ranged from inappropriate hugging to sexual assault. All were dealt with through “private letters of concern” and a “private agreement” that required the doctor to use chaperones, take a boundaries course and submit to regular polygraph tests.

The North Carolina board reversed itself a year later and allowed him to start practicing again.

“Dr. Hart has always categorically and emphatically denied that he has ever sexually assaulted a co-worker or a patient,” said Alan Schneider, the doctor’s attorney.

Schneider said private letters do not constitute disciplinary action and that professional evaluations supported Hart’s denials. He said the evidence supported North Carolina’s decision to reinstate the license.

Jean Brinkley, a board spokeswoman, said the mission of the state’s physician-led board is patient protection, not doctor punishment.

“They tend to look at misconduct and look at what went wrong and what can we do to fix it,” she said. Private letters, she said, are used as a tool to help physicians improve.

As far as the public’s right to know, she pointed out that Hart’s history of private letters and confidential board actions was eventually noted in public documents on the board’s website. “At the very least,” she said, “there is a public record that any current, or prospective, patient has the opportunity to see.”

Dixon, the Alabama board’s executive director, said his board holds out confidentiality as a carrot for those physicians willing to admit their wrongdoing.

Alabama requires those doctors to be evaluated and treated by top experts. As long as they stick with the program, the information stays confidential.

“If you are trying to salvage them,” Dixon said, “you do not ruin their reputation.”

‘SAY SOMETHING’

During his years battling the Catholic Church to get it to stop protecting predatory priests, Clohessy said he learned one lesson well: “Secrecy is the enemy.”

He said he sees that enemy at work today when it comes to abusive doctors.

“This tendency on the part of medical boards and medical officials to err on the side of a quiet suspension or a secret, out-of-court deal, that’s a recipe for disaster,” he said. “Crimes are crimes, no matter who commits them. They need to be reported to and investigated by and prosecuted by the independent professionals in law enforcement. Period. Not a panel of your peers, not by some committee of supervisors and not by other people who have earned the same titles you have earned.”

Vance, who was one of 12 women sexually assaulted by anesthesiologist Dr. Frederick Field as they lay incapacitated at a hospital in The Dalles, Ore., said she found the sweeping nature of the AJC’s findings startling.

“It would be one thing if it was only one incident, but to find out how prevalent it is, is frightening and angering,” she said.

Field received a 23-year prison sentence after pleading guilty. Beyond the assaults themselves, another story developed: The hospital, Mid-Columbia Medical Center, knew, or should have known, that Field was dangerous.

Three years before his arrest in 2011, a patient told a hospital administrator that Field fondled her nipples and placed her hands on his penis. Nurses also had notified hospital leaders in a series of memos in 2010 that, because of Field’s misconduct with a nurse, the staff had agreed “to make it a point to not leave anyone alone in Dr. Field’s presence.”

The hospital denied that it failed to act on complaints. Even so, a jury in 2013 ordered the hospital to pay Vance and two other victims $2.4 million in damages.

In a recent interview, Vance said she sensed that Field had kissed her on the lips and pressed her hand against his penis as she was regaining consciousness after surgery in December 2010. However, she didn’t report him to police until she learned of his arrest. At the time of her surgery, she said, she thought she had been dreaming.

“I remember telling myself, ‘It’s a hospital, how could that be true?’” she said.

“I hope people learn from that experience, to know that if they suspect something like that, it’s probably true. Don’t be afraid to say something. It can happen. It does happen.”

— AJC staff writers Johnny Edwards and Alan Judd contributed to this article.