June #92 : Hitt and Run - by Walter Armstrong

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Table of Contents

Hitt and Run

Wish You Were Here?

A Kennedy Goes Global

¡Neggie Niños!

Clubbing

Iraq, War & HIV

Follow the Diva

POX and All

ADAP to Feds: $ ASAP

The TAC Offensive

Neg & Pos

Trendspotting

Dig That Pipeline!

Dem Dere Eyes

Life Inside With C

That Bouncing Bug!

Well, G Whiz!

Smears For Straights?

Kentucky Fried Friendship

Soak 'N' Snooze

Markdown for the Count

Mailbox

Thirtysomething...else



Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


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June 2003

Hitt and Run

by Walter Armstrong

When a towering figure in AIDS medicine and activism admits he had sex with a patient, it raises questions about the special bond between HIVers and their doctors. The answers may be even more challenging


Until charges of sexual misconduct and a cancer diagnosis clouded his future, Scott Hitt, MD, was the golden boy of AIDS medicine and advocacy. In a 1994 profile, the Los Angeles Times reported that Hitt had been dubbed the “Ever-Ready Doctor” for the relentless drive he displayed in AIDS activism and in personally attending to his 600-plus HIV patients. During the Clinton administration, Hitt shuttled between LA and Washington, where he chaired the President’s Advisory Council on HIV/AIDS. Appointed in part as a reward for helping deliver the gay vote to Clinton, Hitt, then only 35, was the first openly gay person to head a presidential advisory body. But he proved to be anything but a rubber-stamp for the administration. Hitt showed rare courage—and courted displeasure from many Democratic Party regulars—by spearheading a vote of “no confidence” in Clinton for his refusal to lift the ban on federal funding for needle exchange. In fact, Hitt has spent much of his career doing well by doing right. He was a partner in what was once the nation’s largest, most innovative—and perhaps most lucrative—private HIV practice, LA’s Pacific Oaks Medical Group. He has also served on the boards of many of the nation’s top AIDS service organizations (ASOs). John Stansell, MD, who has clocked two decades at UCSF’s Positive Health Program after founding the Washington, DC, gay Whitman-Walker Clinic in the late ’70s, says, “He was certainly one of the first to place himself on the front lines of AIDS advocacy. He brought a visibility to the cause that it urgently needed, in terms on both policy and funding.” Actor and activist Judith Light offers this tribute: “Scott Hitt’s contribution to fighting AIDS and serving people with AIDS is inestimable. He is one of the pivotal people in the struggle.”

Hitt, who had escaped a mobile-home childhood in Tucson to graduate from medical school at 23, also found time for an enviable personal life. The charismatic, GQ-handsome doctor drove a silver Mercedes. He and his longtime partner, artist Alexander Koleszar, owned an expensive home in the Hollywood Hills, where they hosted lavish parties—from Gay Pride celebrations to AIDS and political fundraisers—around their pool.

Today, the party is over. The doctor himself is seriously ill, suffering from metastatic colon cancer. Diagnosed four years ago, the disease emerged from remission in the spring, and Hitt, now 44, has begun a new round of chemotherapy. “His prognosis is grim,” a colleague says flatly. Hitt’s professional rep is ailing, too. The Los Angeles Times revealed last September that the California Medical Board, after a private two-year investigation, had just filed a formal complaint against Hitt. In a case that recalls his former boss, Bill Clinton, the board charged Hitt with two separate, unrelated incidents of “grossly negligent” sexual misconduct. His crime? Hitt allegedly participated in mutual masturbation with two male patients in his Pacific Oaks office in the summer of 2000. The founder and president of the American Academy of HIV Medicine (AAHIVM), a groundbreaking guild to promote HIV as a medical specialty and improve patient care, Hitt may have  harmed his own mission.

In the Hitt case, according to the board’s report, one patient came in for a routine check-up in August 2000: “After Respondent [Hitt] asked the patient to remove his pants, Respondent commented that the patient had a small lump or mole or wart on his penis that needed to be examined. Respondent encouraged the patient to become erect in order to facilitate the examination. Patient X was nervous and unable to obtain an erection by masturbating himself. Respondent assisted by massaging the patient’s penis. At some point, Respondent and the patient mutually masturbated each other.”

Hitt, who declined to talk to POZ for this story, acknowledged his actions when confronted by his Pacific Oaks partners in 2000. The fact that the official complaint doesn’t identify the patients makes it impossible to reach them or to fully understand their side of the story. But the acts it describes seem—to some degree—consensual, and fit the very definition of casual gay sex. They also clearly violate professional codes of conduct. In the document, Hitt allows that he “crossed some boundaries.” He has voluntarily completed an unspecified rehabilitation and will forgo treating patients.

But should he? For POZ, the Hitt case raises questions not only about Hitt himself and whether he has been—or, under the current consensus, could be—treated fairly. It also raises a deeper question about whether the bond between gay doctors and their gay patients, particularly those with HIV, is—or should be—exempt from the traditional rules that govern medical conduct. Many doctors avoid treating personal friends and family members, but from the early days of the AIDS epidemic, people with AIDS, especially white gay men, have often found the best treatment from gay doctors who were part of their social (and sexual) peer group. If casual sex is more common in gay culture generally, is it also more common in gay doctor-patient relationships? And if so, is that always wrong?

California law is clear: “[I]n no instance shall consent of the patient or client be a defense,” and every code of professional medical ethics concurs. In this view, the patient is dependent on, and vulnerable to, the doctor—a power imbalance that renders even subtle suggestions coercive (“Respondent encouraged the patient to become erect in order to facilitate the examination”) and consent moot. Openly gay psychiatrist Marshall Forstein, MD, of Harvard Medical School, insists that the situation, even for gay men, is “really quite simple. Look, ‘consensual sex’ between doctors and patients, whether heterosexual or homosexual, is an oxymoron. Because the patient gives power over to the doctor, the patient cannot make an informed decision. So it’s up to the doctor to take responsibility. Some might say that the hypersexualization of gay culture—that we can’t keep it in our pants—might be some larger societal cause. But it doesn’t make the act any more consensual.”

Leonard Morse, MD, chair of the American Medical Association’s Council on Ethical and Judicial Affairs, emphasizes the trust in the relationship more than the power: “A doctor and a patient have a relationship that is about effective treatment,” he says. “It’s bonded in trust. If the doctor took advantage by making it sexual, that trust would just melt away, and the effectiveness of the recommendations would be terribly weakened.”

Such is the gospel. But in talking to gay men with HIV, POZ heard opinions that were considerably more nuanced; some, accepting, even nonchalant. Most of these men knew of sex between gay doctors and HIV patients. Mike Barr, editor of the Treatment Action Group’s TAGline, ticked off examples of well-known HIV specialists performing oral sex on the exam table, swapping medical care for erotic favors and asking patients out on dates. “It’s my guess that virtually every gay doctor has had sex with—or at least made overtures to—a patient at one time or another,” Barr says, “so it may be a little disingenuous to take too absolute a stand against it.” Most HIVers said they cared deeply about their doctor—and that the feeling was mutual. A few admitted to having “crushes.” (More than a few, when shown a photo of Hitt, happily said they would “do” him. What’s more, the internet chat group on the subject of gay sex between doctors and patients has some 7,193 members.)

There’s no hard data to support Barr’s contention that casual sex between gay docs and HIVers is not only common but, in fact, the norm. But such a finding would not necessarily be surprising to some experts. “Gay men, because of homophobia and how we were raised, start from a place of real loss and need,” says Ken Haller, MD, the president of the Gay and Lesbian Medical Association. “When you factor in two decades of AIDS, and maybe both the doctor and patient having HIV, it’s easy to understand how in this intense relationship, the needs and losses get acted out, as is often the case with gay men, in a sexual way.” Clearly, if most (or even a large number of) gay docs are having sex with patients, it suggests one of two things: either that the traditional standards are correct, and gay doctors, as a group, are out of line; or that the standards do not apply, and the doctor-patient bond is undergoing profound and controversial changes. When POZ spoke to gay doctors, however, nuance, let alone acceptance, was scarce. There was much sympathy for Hitt, but the consensus was “love the sinner, hate the sin”—with a note of “there but for the grace of God go I.” Doctors seemed to find it difficult to even say the phrase sex with patients. “In a personal sense, it’s very difficult to be a physician,” John Stansell says. “Often you are placed in delicate positions, and it’s difficult to determine what is correct and incorrect.”

But Howard Grossman, MD, a leading New York City HIV doc, had no such difficulty. “[What Scott did] was unethical. But clearly, gay men have a looser idea of what we are willing to do sexually. We want to break down barriers wherever we find them,” says the openly gay Grossman, who serves on the AAHIVM board. “We have more room for this thing to happen as far as not being so quick to judge. But [by all the attacks on Scott], you would think he had murdered somebody.”

If “transgression” is central to the sexuality of many gay men, HIV may make such feelings more immediate. “You have a beautiful boy on the exam table coming on to you—it can be tough to say no,” says one doctor who requested anonymity. “I have gay patients who, if I fell down in the street, would step right over me. But when I’m in the white coat, they find it a real turn-on—especially HIV patients, who feel their doctor is keeping them alive.” Even absent an erotic charge, HIV introduces sex into the doctor-patient relationship in ways unlike any other disease. One responsibility of AIDS docs, for example, is to educate their patients on how to protect themselves and their partners through safer sex.

In fact, the roots of the PWA patient-empowerment movement reach back to the relationships gay men had with their STD doctors in the late ’70s. As one long-term survivor and activist recalls, “STDs were stigmatized by straight doctors, but gay men were coming down with them on a weekly basis. So volunteer clinics developed that were often staffed by their own clients—and the doctors were clients, too. Of course, they were cruisey as hell,” he adds with a laugh.

These community-minded physicians and grassroots clinics became, out of necessity, the first AIDS docs and ASOs. Throughout much of the ’80s, the disease was so shunned by mainstream medicine and research that the docs who treated PWAs knew little more than their patients about the mysterious disease. Docs practiced what was, in essence, battlefield medicine, working, with limited resources, under enormous stress and immeasurable loss. Treatments were untested, toxic and difficult to access. Patients often had to make their own life-and-death decisions; to survive meant rejecting the traditional role of the dependent, vulnerable patient. In a situation where the patient is empowered and informed and the doctor doesn’t have the answers, the power imbalance dissolves, even reverses. So patients pushed their doctors to become advocates, challenging the established medical order to respond to the exploding epidemic. Such were the confusing times in the first days of AIDS when Scott Hitt began practicing medicine.

The argument that this unique history has carved different boundaries, including sexual ones, does not wash with many AIDS leaders. “It’s like we have no code of conduct as gay men,” says an executive at a top ASO. “What’s more serious than taking advantage sexually of a patient under your care? They are depending on you for saving their life.”

To be sure, the taboo—and, in some states, laws—against doctor-patient sex are intended to protect the patient. “There are many reasons for the ban on sex,” says Catherine Hanssens, the former head of the AIDS Project at Lambda Legal Defense and Education Fund. “A patient who has received top-quality care may feel pressured to change doctors, especially if the relationship sours,” she says. “Or a patient may feel emotionally inclined to overlook substandard care.” A longtime survivor of HIV told POZ that having sex with his doctor would so distract and complicate his treatment as to put his life at risk. “I’ve been a patient of my primary-care doctor for 15 years,” he says. “Yet I refuse to call him by his first name. The thought of a sexual relationship with the physician who plays the major role in keeping me alive and maintaining my quality of life makes me want to run for the Pepto-Bismol.” But Bill Melamed, also a longtime survivor, amfAR board member and a patient of Scott Hitt, calls this illogical. “You don’t have to have sex with your doctor to feel reluctant to complain about substandard care—anyone who just likes his doctor can feel that way. And any kind of interpersonal relationship—not just sexual ones—can ‘sour’ and make you feel like you should seek a new doctor.”

Indeed, the very blurring of black-and-white rules—sexually and otherwise—has helped save their lives. “There were times when I felt so shitty about myself that I found consolation in doctors who would remind me that I was still a flesh-and-blood, living man,” another longtime survivor says. “And that included flirting with me, whether they were serious or not. Someone who made me feel sexy also made me feel like surviving.” Today it is taken for granted that an HIV diagnosis does not end your sex life, or render you categorically undesirable. But this was certainly not the case in the early years—the right (and responsibility) of a sex life had to be won by PWAs.

Last September, less than a week after the LA Times story appeared, the American Academy of HIV Medicine board met in San Diego. According to Grossman, one board member, whom he declines to name, called for Hitt’s ouster. There were other vocal dissenters. “The vast majority was clearly for keeping Scott on,” Grossman says. Yet soon after announcing that Hitt would remain president, the board abruptly shuffled his title to CEO. “Because of all this unfortunate publicity, he wants to be in a less visible position, and we think that’s a good idea,” says Judith Feinberg, MD, the AAHIVM board’s chair. “Scott’s focus has been shifted into the areas—[such as] government issues—in which he has unique skills and capabilities.” Still, the group has presented a united front.

“There’s not clearly a victim,” Grossman says, summing up their position. Indeed, neither of Hitt’s accusers appealed directly to the California Medical Board. When one phoned Pacific Oaks soon after an alleged incident, the practice’s then-CEO, Tucker Goho, took the call. “I believe that [the complainant] realized he participated in the act just as much as the physician did,” Goho says. “And that maybe he should have stopped as well.” Goho adds that he thinks the patient was afraid to publicize the matter. “Since Dr. Hitt is a very public figure, [the complainant] realized it would have become very newsworthy,” says Goho. “He did not want the limelight.” Regardless, Pacific Oaks felt bound to conduct its own investigation and report the findings to the state board. “There was some feeling [from Hitt] that we could have done things differently,” says Pacific Oaks managing director Gary Cohan, MD. “We’re surprised by the amount of animosity. We just went by the book. A lot of places might have tried to just sweep it under the carpet.” No written statement exists from the second patient, either—according to a source, Hitt himself acknowledged that incident during questioning at the Pacific Oaks offices.

Now Hitt must defend himself against anonymous charges. Under such conditions, a simple no-contest defense is often preferable. In fact, there are several peculiarities of the Hitt case suggesting Hitt may be the victim of a smear campaign (which is not to say that the charges he acknowledged are untrue). One is how the LA Times learned of these accusations. According to Jane E. Allen, who broke the story, someone anonymously mailed the medical board’s complaint to the paper. “A lot of people think that [Pacific Oaks, where Hitt was a partner from 1989 until the events of 2000] leaked this,” says AAHIVM’s Judith Feinberg. The charges exacerbated what had already become a dicey relationship, and the parting was less than amicable. “They had knowledge of this, and there was acrimony. It would have to be your logical assumption, but I have no proof.”

“That’s just untrue,” says Pacific Oaks’ Cohan. “It all goes back to taking responsibility for your own actions.” Hitt has indeed admitted, in the LA Times, to doing “things I regret.” He told the paper: “In July of 1999, my life fell apart. I was diagnosed with colon cancer. My odds of recovery were very slim. While undergoing three surgeries in 45 days as well as chemotherapy, my judgment was impaired.”

The imbroglio has so far done no apparent damage to the academy’s work. The group still boasts some 1,600 docs, who treat some 275,000 patients—more than half of all HIVers in care nationwide. (Just last year, with Hitt at the fore, AAHIVM scored a major victory when California passed the first legislation requiring HMOs to refer all HIV positive patients to AIDS specialists.) But Michael Weinstein, president of the AIDS Healthcare Foundation, cautions: “The work of the academy is an uphill battle under the best circumstances. It would be a great shame if the academy, and HIV as a subspecialty, were sacrificed to the fate of any one individual.”

In yet another peculiar twist, POZ has learned that a male ex–AAHIVM employee filed a sexual harassment suit against Hitt and the academy last November. Michael Shelton, whose lawyer did not return POZ’s requests for comment, accuses Hitt of making Shelton watch computer porn, exposing himself and making sexual advances to Shelton, among other charges. In March, Hitt filed a cross-complaint charging that Shelton, who performed clerical and related tasks, “engaged in a continuing course of misconduct designed to bilk and defraud [Hitt]”: including submitting inaccurate and excessive billing statements and seeking reimbursement for expenses not incurred in the course of his service. The matter has yet to be adjudicated. Feinberg dismisses Shelton’s charges as “an old claim that has resurfaced. Our lawyer found no basis.”

Hitt has said that he intends to fight the charges, which carry no civil or criminal penalties, at his June 17 California Medical Board hearing. Although he could have his license suspended or revoked, the odds are on his side. According to the Public Citizen’s Health Research Group, 60 percent of doctors accused of sexual misconduct in California from 1990 to 1999 ended up on probation. Just 18 percent had their licenses suspended; 19 percent lost them. Feinberg believes it’s better to err on the side of compassion. “If he’s not practicing medicine but lobbying the government, how puritanical should we be?” she says. “As physicians we’re supposed to think that if you have a problem, you can overcome it. We give people room to change. We’re healers.”

Meanwhile, Hitt soldiers on. “I…have learned a lot more about myself,” he said last fall in an interview in In Los Angeles, a biweekly gay magazine. “I sorted out a lot of my issues, including my childhood molestation and rape by [a family member] and the death of my mother from cancer at the same age that I was diagnosed.”

Of course, between his early sexual abuse and his cancer diagnosis three decades later, Hitt spent 20 years at ground zero of the AIDS holocaust. “A lot of people see Scott as an enigma, as some sort of machine that goes nonstop, that doesn’t know how to turn itself off,” Hitt’s lover, Alexander Koleszar, told the LA Times in 1994. “It’s like he’s almost afraid to stop. Because if he did, and acknowledged the emotionally volatile issues around him, seeing his friends die on a daily basis, it would be too much for him.” Given all this, compassion may be the right response.

Regardless of how the Hitt case plays out, the AIDS epidemic has clearly raised new questions about the profoundly human partnership borne of the unique intimacy between doctor and patient. “I cannot say, ‘Because of A, B, and C, I did D.’ I can only say that I have done a lot of searching,” Hitt told In Los Angeles. In trying to understand the larger issues the case raises, medical ethicists, health care professionals and patients will likely also be doing a lot of searching for years to come.




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