After medical regulators said he fondled patients, exposed himself and traded drugs for sex, Dr. David Pavlakovic easily could have lost his license. Law enforcement thought his acts were criminal.

Instead of losing his job, Pavlakovic was placed in therapy. He was allowed to return to practice. And he didn’t even have to tell his patients.

The way Alabama handled Pavlakovic’s case reflects a growing trend across the nation: Medical regulators are viewing sexual misconduct by doctors as the symptom of an impairment rather than cause for punishment. Doctors who abuse, regulators and therapists say, can be evaluated and managed ” sometimes with as little as a three-day course on appropriate doctor-patient “boundaries,” other times with inpatient mental health treatment that may include yoga and massage.

Society has become intolerant of most sex offenders, placing some on lifelong public registries and banishing others from their professions or volunteer activities. But medical regulators have embraced the idea of rehabilitation for physicians accused of sexual misconduct, a national investigation by The Atlanta Journal-Constitution found.

Increasingly, it is left to private therapists, rather than police investigators, to unearth the extent of a doctor’s transgressions. There is little pretense of the check and balance of public scrutiny. Instead, some in the medical profession have discouraged public input, concerned it could trigger outrage that disrupts important work.

Even doctors with egregious violations are allowed to redeem themselves through education and treatment centers, which have quietly proliferated over the past two decades.

After boundary training and treatment, California reinstated a doctor who’d had a string of young women take off their underwear as he watched and then had them move their legs or butt cheeks so he could see or touch their anus and genitals. His victims included a high-school-aged girl in for a head cold.

Montana restored the license of a physician who served time in federal prison on a child pornography charge. The doctor exemplified the transformation that can result from treatment, the president of Montana’s medical board said this spring at a convention of medical regulators in San Diego.

“This was a very negative thing for the public,” Nathan Thomas said, acknowledging public criticism of the board’s decision.

Still, “I feel that this is a great example of the advocacy of our program,” Thomas said.

The doctor, discussed in news accounts and public documents, has moved from child to adult psychiatry and will have permanent monitoring.

Public detractors must not halt the work of rehabilitating physicians, echoed the incoming president of the Federation of State Physician Health Programs, Bradley Hall.

“I don’t think there’s a wrong time to do the right thing,” Hall told the convention. “If I’m the licensure board and my duty is to protect the public, and I want something like this to work to help build professionals, then I’m going to do that process irrespective of what other people say.”

In Pavlakovic’s case, regulators sent him for evaluation by Atlanta-based Behavioral Medicine Institute. The Alabama Medical Licensure Commission found he had engaged in a pattern and practice of inappropriate sexual behavior with patients. It suspended him for just under a year ” most of that time while its investigation was pending ” and fined him $10,000.

The board then adopted the treatment center’s recommendations. Among them, Pavlakovic would attend therapy, go to ethics classes, take a lie-detector test twice a year and consent to having his practice monitored.

He also would have to post “principles of medical practice” on his office wall. But he wouldn’t have to tell patients why the document was there.

Prosecutors dropped the criminal charges. The commission lifted its requirements in less than two years.

Pavlakovic and his attorney declined to comment.

These education and treatment programs are being used by regulators in virtually every state. In its review of public disciplinary orders for 2,400 physicians accused of sexual misconduct with patients since 1999, the AJC found that, with rare exceptions, all of the 1,200 who are still licensed were ordered to undergo treatment, training or both.

Therapists who run the treatment programs say physicians must meet high standards to return to practice.

“And justifiably, rightfully so,” said Philip Hemphill, who for more than a decade oversaw a program for troubled professionals at Pine Grove Behavioral Health and Addiction Services in Mississippi. “I mean, they’re entrusted with the public safety, which is different than other people.

“But they still should have an opportunity for intervention and monitoring,” he said. “They still have the ability to practice. It’s not all of who they are. That aberrant behavior is not the entire person. “

All the treatment and training programs have been called transformative. But no good data exist on how many doctors who complete boundary classes or treatment programs repeat as sexual abusers. Most sex assault victims never report their abuse. What’s more, much of the research into recidivism has been done by centers or practitioners with a financial stake in demonstrating their effectiveness, the AJC found.

Patients who have experienced sex abuse by doctors are skeptical.

“The damage they do to a family, or a woman, going on to the rest of her life, is just irreparable,” said Marilyn Nowak, who said she was abused by her psychiatrist decades ago and that the damage has lasted a lifetime. She now volunteers in a network that helps other victims.

“If you send these doctors for rehabilitation ” I’m sorry but that’s not enough for what they do to you,” she said. “They should pay for that.”

Treatment Not Intended To Punish

The Catholic Church once secretly sent sex offender priests for psychiatric treatment, then returned them to service. The abuse, the church reasoned, was a spiritual failing requiring repentance and forgiveness.

Most medical authorities have embraced a similar approach, but through the lens of sexual abuse as the sign of a mental disorder. The Federation of State Medical Boards, which represents regulators across the nation, lists its policy on sexual boundaries under “Impaired Physicians,” not under “Conduct and Ethics.”

The philosophy: These physicians are struggling, like those suffering from alcohol or drug addictions.

Faced with complaints that a doctor has sexually violated patients, boards investigate and often order a psychiatric evaluation before deciding what, if any, action to take.

If a physician isn’t found to be afflicted with a serious mental disorder, he might be directed to take classes on maintaining proper boundaries with patients. These courses often play to a sense that a physician may have been drawn into a sexual boundary violation by risky patients. The training aims to teach doctors how to avoid that and protect themselves.

“It has seemed to us that physicians are not well trained in this whole area,” said William Swiggart, co-director of Vanderbilt University’s Center for Professional Health, which offers a three-day boundaries course. “That the rules are there, but they’re not aware of them; they’re tricky to find, and they change from time to time.”

Physicians who commit more serious infractions and have complex and ingrained psychiatric disorders may have to enroll in a more intensive treatment program.

Disciplinary documents present a catalog of disorders blamed for doctors’ violations. Frotteurism, where doctors were said to find excitement through the sense of non-consensual touching. Paraphilia, a catch-all for conditions where unusual acts cause sexual excitement. Impulse-control disorder, bipolar disease, post-traumatic stress disorder, depression and burnout are among other diagnoses.

The treatment is not intended to be punitive.

Victims’ Suffering Rarely Mentioned

The Sante Center for Healing in Argyle, Texas ” its slogan: “miracles happen on the hill” ” offers group work and individual sessions to restore professionals suffering from what it calls any addicted disorder.

Along with those sessions, it also advertises therapy through yoga (many offenders loathe the paced, reflective activity, one advocate said) and equine therapy (the horses see through bullies and charmers).

For many medical authorities, the gold standard of evaluation and treatment was Behavioral Medicine Institute, until founder Dr. Gene Abel retired that business this year. Where other therapists concentrate on analyzing an offender’s mind, Abel’s method concentrated more on analyzing the offender’s behavior and teaching him to interrupt bad patterns that can lead to sex abuse, through both understanding the conduct and developing negative associations with it ” for example, through odor aversion therapy.

The treatment programs have common goals: to break down the physician’s denial. To get him to be honest about how much he did and how much of it was his responsibility. To develop insight into why he did it. And to teach him to have empathy for his victims and his future patients.

Some programs measure growth in empathy by looking closely at how the doctors treat their support staff, such as cafeteria workers and receptionists. “We look for clear evidence of being able to empathize in multiple situations, to see through other people’s eyes,” said Jes Montgomery, who has directed sexual programs at both Sante and Mississippi’s Pine Grove.

After treatment, therapists give medical regulators their opinion on whether a doctor is safe to return to practice. Boards often rely on that assessment or an independent multi-day evaluation.

In California, Dr. Esmail Nadjmabadi, the doctor who watched patients undress and touched the genitals of the high-school-aged girl, took two boundary violation courses and a professionalism course. He was “evaluated and found fit to practice by three experts,” an administrative law judge wrote. “He has undergone a brief course of psychotherapy and gained insight from it. But most importantly, Petitioner has changed and matured.”

Dr. Nadjmabadi acknowledes truth of allegations (p. 9)

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The board last year adopted the judge’s proposal to restore Nadjmabadi to practice.

Nadjmabadi and his lawyer did not respond to messages from the AJC.

Left out of these deliberations is the victim.

In the thousands of board orders the AJC reviewed, it was rare to see any mention of the harm suffered by abused patients, or whether they received treatment or had an opinion on reinstating the doctor.

Reid Finlayson, who runs the assessment program at Vanderbilt, said the question of bringing the doctor’s actual victim or victims into the program, so he might understand the impact of his violations, is “a little awkward.”

The way sexual abuse happens, he said, often “it just gets to a point where forgiveness is very, very difficult.”

Coaxed By Confidentiality Promise

Historically, it was up to regulators to take complaints and decide whether a doctor was fit to practice. While the doctor’s patients are unlikely to be notified of public orders for treatment or monitoring, the information may be available on medical board websites to those who seek it out. Employers also could find out when boards report sanctions to a national data center.

But under confidential physician health programs offered in many states, doctors with compulsive behaviors may be diverted from the legal environment of regulators to the clinical environment, where medical privacy prevails.

That encourages colleagues to report offending doctors and doctors to report themselves, regulators say.

“Physicians who are ill deserve the same privacy in their health care treatment as the general public, and if they’re not afforded privacy, they will not seek appropriate care and will then work in an impaired state,” Doris Gundersen, immediate past president of the Federation of State Physician Health Programs and head of Colorado’s program, said in a written statement.

These programs were originally set up to deal with alcohol and drug addiction, but some now also deal with sexual boundary issues. Doctors are expected to be fully forthcoming with their therapists. With some, the doctors may admit to a host of past violations without being reported to medical authorities or law enforcement.

“One of the key components of a psychotherapeutic contract is that the patient can say whatever he or she wants to without severe consequences,” wrote Glen Gabbard, a leading researcher in psychoanalysis and physician sexual misconduct.

Medical boards are notified if a physician is deemed not safe to practice or has failed to complete the program. Other doctors may return to practice with no notice to the public.

No one tracks how many abusive doctors have been shielded in this way.

Some states, however, limit use of diversion programs by doctors accused of sexual misconduct. In an effort to better protect patients from sexual exploitation, Pennsylvania’s board said its program cannot be used in lieu of disciplinary or corrective actions.

Pennsylvania officials declined to comment.

Others say the entire focus on rehabilitation sometimes goes too far.

Some doctors’ conduct is so outrageous, said Idaho Board of Medicine Chairman Robert Ward, that it doesn’t matter how much they are rehabilitated. They should not be returned to practice, he said.

“They’re using their position of power to do something they could never do in any other position,” he said. “It’s irrevocably harming those people.”

Success A Certainty? Knock Wood

As treatment programs for sexual misconduct have sprung up across the country over the past two decades, they have marketed themselves with ads, brochures and sales booths at medical regulators’ conferences.

“It’s a huge industry,” said Sam Slaton, chief operating officer of Sante.

All programs say there are certain doctors who just can’t be rehabilitated safely and will not be cleared to return to practice. But they claim remarkable success at turning around a broad range of offenders.

Medical boards also have a stake in touting the programs’ success. Their official mission is to protect the public health. But they are also under public pressure to meet demand for doctors and under pressure from doctor groups to lighten up on public disciplinary orders. And each doctor whose license is challenged fights tooth and nail to remain in practice. Boards can’t afford to take all those fights all the way.

Strapped for cash and resources, they are only too happy to offer accused doctors an alternative path.

And they should, said Dr. Steven Altchuler, a former member of Minnesota’s medical board who helped write the Federation of State Medical Boards’ guidelines on sexual misconduct. While there is no excuse for sexual misconduct, there is a range of violations and the harm they can cause, he said. So regulators should evaluate various factors, starting with patient harm, in considering what sanctions are appropriate.

“If you’ve got somebody with an illness, and you can monitor them and keep the illness under control, and if you do they’re not going to harm somebody else, do we serve the citizens of our state well by taking this person who could otherwise be an effective physician ” and not harm anybody again after they’ve been appropriately punished ” out of the field?” Altchuler said.

Among the practitioners regarded as most successful is Abel, the Atlanta specialist in sexual disorders, who has claimed that only 1 percent of those he treated re-offended. He has advised the U.S. Sentencing Commission, still gives talks on his methods and invented a widely used assessment test.

His methods are rigorous. Key to his success, he said: long-term monitoring of the physician after he returns to practice, with chaperones attending his patient work; co-workers and patients filling out forms; and periodic polygraphs to assess the doctor’s compliance.

“We follow the physician forever,” said Abel. “Or at least five years.”

Abel once testified that it was inevitable that one of his cleared patients someday would re-offend.

Dr. Abel: ‘Inevitably, there will be some recidivism’ (p. 8)

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However, he testified, he had never heard of any Georgia doctor who went through his program abusing any other patient. “So what that means is that if you take a physician and treat them, the recidivism possibilities for that individual drops to zero,” he said.

His testimony came in 1999 in the case of anesthesiologist Donald Taylor, who was fighting to get his job back at Kennestone Hospital after being accused of sexually abusing patients, including a 16-year-old girl. Abel testified that Taylor had been treated and was safe to practice.

But the lawyer challenging Abel noticed something, and pointed it out:

In the midst of declaring his certainty about his success, Abel lifted his hand and knocked wood.

Taylor didn’t win his job back, but he did keep his license. The Georgia medical board allowed him to continue practicing with treatment and monitoring.

Monitoring ended in 2008. In 2013, the board ordered an evaluation after a patient alleged that Taylor hugged, kissed and touched her at appointments starting in 2010 and later engaged in oral sex with her in his office. She later filed suit. The evaluation found he had engaged in sexual relationships with a patient and an employee.

The board suspended Taylor and ordered more treatment. Three months later, the board reinstated him. Today he practices at his pain clinic in Marietta. He did not respond to telephone or email messages left at his clinic.

Safety Measures Can Be Evaded

No one really knows how well various programs work.

Public board orders on regulators’ websites reveal dozens of physicians who were found to have re-offended after taking part in education or treatment programs.

In Wyoming, for example, Dr. Jason Lovell was ordered in April 2012 to take a boundaries course after a complaint that he was involved in a personal relationship with a patient. He attended the three-day course that August. Little more than two weeks afterward, he had sexual contact with another patient during an appointment. He voluntarily surrendered his license, then was reinstated last year after long-term intensive treatment, he said.

Another violation after boundaries course (p. 14)

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“I really wish that I had done that before,” Lovell told the AJC. “In my opinion I don’t think that just taking a course is enough.”

Montgomery, who worked at Sante and Pine Grove, said he and his colleagues are researching recidivism after sexual misconduct treatment and have found almost none.

But he and other researchers acknowledge that no effort to determine recidivism is comprehensive. With many sexual misconduct cases dealt with in secret from beginning to end, no effort can be complete.

To guard against new offenses, medical authorities typically impose a variety of restrictions, at least for a time, when an offender is allowed to return to practice.

Lie-detector tests are now common. Often, doctors must employ chaperones to accompany them with female patients. Doctors who had sex offenses with minors may only be allowed to treat patients 18 and older. Some abusive doctors are restricted to treating only men.

In fact, all those measures can be evaded ” and have been, the AJC found in reviewing public disciplinary records on thousands of doctors.

Leonard Saxe, a former Congressional staffer whose work helped keep polygraph requirements out of federal law in the 1980s, told the AJC it was absurd to use them in significant decisions about doctors, since doctors have the scientific training to learn how to beat the test.

Chaperones may be sent out of the room to get an instrument. Adult patients may bring along their children.

All board-ordered restrictions are usually lifted after a time.

Lack of long-term close tracking of offenders is another gap, said Keith Durkin, a criminologist at Ohio Northern University who studies occupational crime and deviance. “The recidivism rate increases with the follow-up period,” he said. “Come 10 to 25 years down the road, they know the sanctioning board’s not watching them.”

No matter what measures are in place, the evaluation and treatment systems can’t be sure every doctor is safe.

Sometimes doctors con their therapists.

“Some predatory physicians readily catch on to what the evaluating psychiatrist is looking for and may present a convincing performance that persuades the examiner that the accused physician is suitable for psychotherapy,” Gabbard wrote in a 1999 paper. “When such physicians enter into a psychotherapeutic relationship, they may be able to ˜go through the motions’ without making any fundamental change.”

Gabbard didn’t respond to an AJC interview request.

Boundary course teachers and therapists interviewed by the AJC generally acknowledged that was true.

“There’s always the chance that we get a real psychopath who plays the system really well and knows what to say,” said Swiggart, with the Vanderbilt program. “We’re not equipped to catch that.”

Durkin said decisions about returning doctors to practice should be informed by tough scrutiny and reflect the will of the public, not the medical profession.

“At the end of the day, society has to make this judgment,” the criminologist said. “Victims are living with this the rest of their lives.”

” AJC staff writers Becca Godwin and Jeff Ernsthausen contributed to this article.