WASHINGTON — The first time that Dr. Anthony Bianchi came onto a patient, California's medical board alleged, the gynecologist placed a chair against the exam room door, put his fingers into the woman's vagina and exposed his erect penis.
The second time, the board claimed, he told a patient that he couldn't stop staring at her breasts and recounted a dream in which he performed oral sex on her in the office.
The third time, the board charged, he told a pregnant patient suffering from vaginal bleeding that she shouldn't shave her pubic hair before her next visit, as he was getting too excited.
These episodes led to disciplinary actions by the state's medical board in 2012 and in 2016. Bianchi agreed not contest the charges, and he held onto his medical license. Under a settlement with California's medical board, he agreed to seek therapy and refrain from treating women during five years of probation.
Bianchi did not respond to telephone messages from The Associated Press left for him at the workers' compensation clinic in Fresno, California, where he now evaluates occupational health claims.
In recent months, Hollywood moguls, elite journalists and top politicians have been pushed out of their jobs or resigned their posts in the wake allegations of sexual misconduct. In contrast, the world of medicine is often more forgiving, according to an AP investigation.
When the doctors are disciplined, the punishment often consists of a short suspension paired with mandatory therapy that treats sexually abusive behavior as a symptom of an illness or addiction, the AP found.
Decades of complaints that the physician disciplinary system is too lenient on sex-abusing doctors have produced little change in the practices of state medical boards. And the #MeToo campaign and the rapid push in recent months to increase accountability for sexual misconduct in American workplaces do not appear to have sparked a movement toward changing how medical boards deal with physicians who act out sexually against patients or staffers.
The sentencing of Larry Nassar, a former doctor for the U.S. Olympic gymnastics program convicted of abusing more than 150 women and girls, has put a high-profile case of physician misconduct in the spotlight. But across the country, most doctors accused of sexual misconduct avoid a medical license review entirely. A study last year found that two-thirds of doctors who were sanctioned by their employers or paid a settlement as the result of sex misconduct claims never faced medical board discipline.
"There's been a failure of the medical community to take a stand against the issue," said Azza Abbudagga, a health services researcher with nonprofit advocacy organization Public Citizen.
She published a report recently detailing sexual misconduct among physicians. Its findings showed that of the 253 doctors reported to the National Practitioner Data Bank for having been sanctioned by their respective hospitals or health care organizations for sexual misconduct, or paid a settlement that stemmed from such an allegation, 170 of them were not disciplined by state medical boards, even though all boards have access to the reports filed with the data bank.
"They could tell the public that they will investigate every single case. There are many things that can be done, even just having a policy of zero tolerance," she said. "If every single hospital would just take a stand and issue a statement saying clearly that any sexual misconduct with patients won't be tolerated and that there will be consequences including permanently revoking the medical license of every doctor found guilty."
Current guidelines from the Federation of State Physician Health Programs, which represents doctor rehab programs in 47 states, are largely silent on handling sexual misconduct treatment and describe sexual harassment as a "cause of impairment" in a doctor. Programs to treat doctor impairment are inherently supposed to be "nondisciplinary," per the federation's guidelines.
Linda Bresnahan, who heads the federation, said its guidelines are being rewritten and, despite their language, should not be applied to sexual misbehavior. A statement provided by the federation says only about half of doctor rehab programs nationwide accept doctors accused of sexual misconduct, a choice the group considers to be "a local issue beyond the purview of national guidance."
The harm committed by sexually abusive doctors is aggravated by the personal nature of the doctor-patient relationship, according to experts and doctors' victims.
When Marissa White came to Dr. Gunwant Dhaliwal in 2007 for neck pain after a car accident, he reached under her shirt and into her bra, grabbing her breasts.
A jury convicted him of misdemeanor battery in the case, and Florida's medical board concluded that his crime demonstrated his "lack of good moral character" and "lack of worthiness" to practice medicine. But despite that finding — and at least six other similar allegations made by women patients and employees, both before and after the incident with White, according to court cases and police complaints — Dhaliwal can still be found practicing at his Tampa-area urgent care clinics.
"I had to sit there in front of him, look him in the eye, they made their guilty verdict and that's it, nothing came of it," White told the AP of her experience at trial. She still lives in Florida, but won't even go to the neighborhood where Dhaliwal practices medicine.
"He should have lost his license a long time ago. He should have lost it the first time it happened."
But his office manager told the AP that, while the Florida board referred him to the state's impaired physician network for evaluation, nothing came of it.
"They did an evaluation and did not find anything wrong," the woman told the AP. "They don't do any treatment."
The office manager, who refused to provide the AP with her full name, noted that Dhaliwal had not had any new complaints brought against him since his settlement with the medical board. When the AP asked to speak with Dhaliwal, she said that he was declining on the advice of his lawyers.
Dhaliwal did not respond to requests for comment left with his clinic's staff or a voicemail left with his lawyer.
Examples of problematic behavior are easy to find in states across the country.
In Arkansas, Dr. Robert Rook was allowed to keep his family practice open, so long as he's chaperoned, despite facing multiple criminal charges for rape. Prosecutors subsequently downgraded the charges to more than 20 counts of sexual assault in the second- and third-degree, charges for which Rook says he is innocent.
Rook did not return phone messages left with a secretary at his Conway office. He is set to face trial later this year.
The Idaho State Board of Medicine in May reinstated the license of Richard Pines, a child and adolescent psychiatrist who lost his license in 2013 after the board accused him of having sexual relationships with four former patients, including taking nude photos of a 14-year-old and convincing the boys that he needed to practice giving naked massages to keep his medical license.
The state's highest court in 2015 ruled that Pines had engaged in sexual misconduct, but determined that two of the four alleged victims were not former patients. The court remanded Pines' case to a lower court and vacated his punishment, instead ordering the board to re-evaluate the scope of disciplinary action based on the charges the court upheld. The court's order also blasted the board for being impartial, accusing its members of "passionately railing" against Pines in its decision.
The AP reached out to Pines' former employers and contacted his most recent attorneys, but was unable to reach him. The AP also left a message for a biller at Sage Health Care, where Pines still processes invoices. The receptionist said Pines bills through the office but was unable to provide more details about his current practice.
State-authorized programs that attempt to oversee the rehabilitation of doctors who have committed sexual misconduct aren't always forthcoming about their methods. In Florida, the Professional's Resource Network, which the state medical board assigned to evaluate Gunwant Dhaliwal after his battery conviction, asked the AP to provide detailed questions and a list of sources before it would answer questions.
After the AP provided the head of the program, Alexis Polles, with basic questions about the program's approach to clearing doctors for return to work after instances of sexual abuse, she declined to answer any of them.
The lenience of penalties for sexually abusive doctors sometimes a source of frustration even for members of the medical board who administer the discipline, according to Jason Rosenberg, a former chairman of the Florida medical board.
"This is incredibly inappropriate," Rosenberg said during one 2013 meeting when Florida's medical board allowed James Yelton-Rossello, a psychiatrist alleged to have molested jailed psychiatric patients, to keep his license. The settlement with the Florida board of medicine did not require Yelton-Rossello to admit guilt.
"You can't do this and serve french fries," Rosenberg said at that meeting, citing fast food restaurants' policies against hiring sex offenders. "I'm ashamed of what's going on here."
Yelton-Rossello's lawyer did not respond to telephone messages or an email request for comment.
Some medical boards blame administrative law judges for tying their hands from seeking harsher punishments.
In an interview last year, Rosenberg said he responded to an administrative law judge's refusal to uphold a different license revocation by attempting to compel that doctor to display a sign stating "I molest patients" in his office.
Rosenberg's effort failed, though some doctors have been required to post signs in their office stating that they must be chaperoned in the presence of female patients.
Bob Cohen, the chief judge in Florida's division of administrative hearings, rejected the idea that administrative law judges are responsible for watering down the punishments of sexually abusive doctors. He said the board of medicine could seek to override administrative law decisions they disagree with, something the Florida board acknowledged in a statement to the AP.
"One of the reasons they don't always appeal is they have a lot of cases," Cohen said of state health officials. He acknowledged, however, that "consistency" was a goal in punishments, and that past leniency shown to doctors sets a precedent for weaker punishments in the present day.
The question of doctor punishments is part of a larger problem in the medical field. Numerous factors, including hospitals' disinclination to report abusive doctors, to shortfalls in a private, interstate system meant to flag them to future employers, and patients' simple reluctance to challenge a medical professional, skew the field in doctors' favor, according to a 2016 investigation by the Atlanta Journal-Constitution.
Some doctors who are reported to medical boards for sexual misconduct receive reprimands instead of suspensions. G. Eric Nielson, a medical malpractice attorney in Utah, says that's because doctors tend to try to protect other doctors as much as possible.
"There's an institutional bias on the part of the medical review board," he said. "They're generally doctors, they work very hard to get their medical degrees and they're very, very disinclined to yank the license of another doctor. The primary focus is: Let's take care of the doctor and help him get through this problem."
A medical board in California in 2009 revoked the license of Dr. Kamron Hakhamimi after it ruled that his conduct constituted abuse, neglect and exploitation when he prescribed powerful drugs to a woman he met online and then had sex with her; he had previously pleaded no contest to a pair of misdemeanor charges stemming from the incident. But the board stayed the revocation in favor of seven years' probation and a requirement that he complete an ethics class and a course on professional boundaries, though the California Department of Health Care Services barred Hakhamimi from participating in any federally funded programs for 12 years.
When contacted for comment, Hakhamimi said, "Nothing happened in the clinic. No medical malpractice, no suspension." When asked whether the courses were effective, he said, "they're mandatory for a reason: It's a business," and then hung up.
Sexually abusive physicians are not generally required to apologize or even acknowledge having acted inappropriately in order to keep their license. Three years after his misdemeanor battery conviction, for example, Florida doctor Dhaliwal was acquitted of molesting another patient. He took the opportunity to issue a news release calling the women who have accused him of misconduct liars motivated by greed.
In email statement, Florida Medical Board spokesman Brad Dalton said the doctor disciplinary boards "do not have the legal authority to force a physician to speak or place a gag order on them to prevent them from doing so."
In practice, even some lawyers who represent doctors find the physician health programs to be problematic.
David Spicer, who has represented doctors facing medical board discipline in Florida, says the state's doctor rehabilitation program isn't well designed to evaluate or treat sexual misbehavior. The program's key component, he said, is a "one-size-fits-all" requirement that doctors engage in therapy sessions and not get into trouble for a specified period, generally five years.
Spicer said Florida's program, run by an independent organization called the Physician Research Network, does a better job dealing with doctors' who abuse alcohol or drug, but it hasn't been effective at evaluating or treating doctors with sexual problems.
Experts in the treatment of sexual misbehavior question whether the treatments mandated for doctors who molest patients are even appropriate for such misconduct.
"It's insufficient," said Rory Reid, a UCLA psychology professor who studies addiction and hypersexual behavior. While some types of sexual behavior, such as the compulsive viewing of pornography, might best be addressed through addiction treatment therapy, rehabilitation programs for sex offenders typically focus on restitution and empathy for a person's victims.
"We have clinical trials for everything underneath the sun," Reid said. "But there's not one clinical trial that I'm aware of on the efficacy of treatment for doctors who have engaged in sexual misconduct."