Susan was lying on the examination bed naked, covered only by a towel, when her osteopath started massaging the inside of her vagina and licking her breast.
He had told her to take off her underwear so he could treat her for a tailbone injury.
When she told him to stop, osteopath Richard Davis looked up at her and said: "I thought you might like it."
"He called it therapy but it wasn't," said Susan, 64.
As she walked home that day, the shocked woman thought to herself, "I just paid to be violated."
Susan was one of 10 female patients who gave evidence against Davis, who was handed an eight-year prison sentence in 2014.
However, many predatory health professionals don't end up behind bars - with some even returning to practise after violating their oaths, a Herald on Sunday investigation has found.
More than 90 health-care professionals have been found guilty of sexual misconduct by medical authorities over the past 10 years.
Some have broken their patient's trust in shockingly brazen ways, such as offering to pay for sex, sending photos of their genitals, plying alcoholic patients with wine, or sexually touching patients under the guise of a routine medical check.
An analysis of all sex-related cases before the Health Practitioner's Disciplinary Tribunal (HPDT) since 2006 has highlighted a convoluted four-pronged disciplinary system that critics say protects the health professional's reputation over public safety.
In more than a third of the 91 cases that have come before the HPDT and the Human Rights Review Tribunal, the physicians have been granted permanent name suppression either by the tribunals or courts, meaning the public will never know their identity and patients will never know their past.
The investigation also found authorities had imposed loose safeguards on offending health workers - including nurses, doctors, dentists, psychologists and other professions - to allow them to continue practising. Dozens of perpetrators have returned to work after attending a sexual boundary class or under the supervision of colleagues.
Some examples include:
• A doctor convicted of possession and distribution of 290,000 child pornography images, and with a psychiatric diagnosis of paraphilia involving compulsive masturbation, was allowed back to work with medication, counselling and monthly mentoring meetings.
• A Marlborough GP who told a patient to undress on his medical bed, unnecessarily touched her vagina without wearing gloves and later falsified his consultation notes to justify the examination was suspended for 18 months and told he would need a chaperone when treating female patients.
• A Dunedin nurse who had sex with a vulnerable patient, who had expressed suicidal threats, was suspended and told to undergo an ethics and sexual boundary course before returning to practise.
• A doctor treating a patient with depression lowered his office blinds, told her to bend over the examination bed, grinded her from behind and later unzipped his pants and asked for oral sex. He was ordered to have a supervisor present when treating female patients for three years.
Any disciplinary action enforced by the HPDT is listed on the Medical Council's public register while it is in effect, but that sanction is automatically and totally wiped once time has been served, the Herald on Sunday found.
Tribunal decisions such as suspension or conditions are imposed for no more than three years and do not appear after that time has elapsed, a council spokesman said.
Women's rights activists say these safeguards are "woefully inadequate" and claim authorities are treating sexual misconduct as a lapse in judgment rather than a red flag for future offending.
"It's totally alarming that we have doctors still practising after being found guilty of sexual misconduct," said Lynda Williams, coordinator of the Auckland Women's Health Council.
"This is being treated as though it's a minor transgression of the boundaries and it isn't. It's the most serious one of all."
International patients' rights expert Professor Ron Paterson, of Auckland University, said authorities must be skeptical about "claims of one-off innocent behaviour" when it comes to sexual misconduct.
Research showed this type of behaviour "can be a warning sign" for deep-seated problems, said Paterson, a former long-serving Health and Disability Commissioner. "Do I think going to a course in medical ethics is sufficient to address these problems? No," he said.
Last week, the Medical Board of Australia selected Paterson to lead a review on health professionals being chaperoned while under investigation for serious misconduct. The number of offending health practitioners in New Zealand given the green light to work again was concerning, he said.
"The primary purpose of our system for regulating health professionals in New Zealand is to protect patients. It may be time to have a relook at what is happening here."
Williams agreed, stating that the "outrageously lax" disciplinary system needed an overhaul to ensure every predatory health professional was struck off the register immediately.
Doctors who have sex with their patients or sexually abuse patients "should never, ever, ever be allowed near another patient," she said. "That should be the end of their career and I find it so alarming that it's not, especially given that sometimes we are not allowed to know who they are."
Philip Pigou, chief executive of the Medical Council, conceded there were cases where the behaviour of doctors had been "entirely unacceptable" and caused harm to the public.
He said he could understand why some people may feel it's unacceptable that doctors guilty of sexual transgressions were allowed to return to work, but added that the council would not let any doctor practise "without appropriate safeguards."
"In the case of sexual offending, a full psychological and psychiatric assessment is conducted before they go back to work," he said.
If the assessment finds the doctor's risk of reoffending is low or manageable by conditions, such as a chaperone, "that effectively opens the door for that doctor to practise," Pigou said.
Twelve Kiwi doctors are currently practising under conditions and they are regularly, and sometimes secretly, monitored by the council. To put this figure into perspective, 15,500 doctors are practising nationwide.
"We believe our system does work and that the public is safe," Pigou said.
Of the 23 doctors found guilty of sexual misconduct in the past 10 years, the Herald on Sunday found at least eight are still practising or involved in health centres. Five have either retired or moved overseas.
It is not possible to find out whether the remaining 10 are still treating patients because they have been granted name suppression.
Since 4000BC, the Hippocratic Oath has banned physicians from having sex with patients.
Sexual relationships between patients and physicians constitute an "unethical abuse of power", wrote Professor John Coverdale, a New Zealander now with the Baylor College of Medicine center for medical ethics in Houston, Texas.
Any sexual transgression of the physician-patient relationship "would destroy patient's trust in the profession and would destroy the profession of medicine itself," Coverdale wrote in an email to the Herald on Sunday.
The 91 health professionals disciplined for sexual misconduct over the past decade represent only a tiny fraction of those practising today. But this figure is also likely understated given the significantly low sexual assault reporting rates in New Zealand and the fear victims have when speaking out against those in positions of power.
Kathryn McPhillips, executive director of the sexual abuse support service HELP, said the psychological trauma was overwhelming enough for victims, let alone facing authorities or lodging complaints. Predatory health professionals often targeted patients who were vulnerable, former victims of sexual abuse or those who suffered mental health problems, she said.
"They choose people who won't tell, or if they do tell won't be believed."
In the most extreme cases of sexual misconduct, criminal charges are laid.
Three doctors are currently facing charges of a sexual nature before the courts in New Zealand.
• GP Dr David Lim of Hastings is accused of stupefying and indecently assaulting male patients in surgical rooms and treatment cubicles.
• The second doctor, who has name suppression, faces charges involving the sexual assault of four male patients during consultations.
• The Medical Council said it could not provide any details about the third doctor.
On the other end of the spectrum are sexual transgressions that usually stem from broken boundaries such as grooming, inappropriate romantic connections or consensual sex with patients.
Last year Dr Vijay Harypursat, 49, was found guilty of sexual misconduct by the HPDT for forming an inappropriate relationship with a 22-year-old patient who had mental-health issues and a history of sexual abuse.
He showered the patient with gifts, told her it wasn't possible for him to stop thinking about her and falsely claimed her medical tests were "wonky" in order to meet her privately, outside his Whangarei clinic.
Uncomfortable with the doctor's advances, the patient asked Harypursat via text: "Im not sure if u have thought about that oath u took."
To which he replied: "I don't take the Hippocratic Oath lightly."
Harypursat was suspended for nine months, but allowed to return to practise under supervision when treating female patients.
Four weeks later, in September last year, he was caught seeing female patients alone.
The current disciplinary system is protecting health professionals, not the public, advocates say.
Launching a complaint against a health professional is a convoluted process and can take up to three years to complete, with complainants often having to take part in four separate investigations.
Last year, the Health and Disability Commissioner received its highest ever number of complaints - 1880. Of those, 100 were upheld and resulted in formal investigations, with 14 health professionals referred on for discipline.
Critics say the process is "grindingly and painfully slow".
The Medical Council admitted that for patients and families "there can be frustration and anger about the time taken to investigate their complaint".
During this lengthy process, the health professional is usually granted name suppression and allowed to continue practising.
A detective who investigated a sex-offending doctor told the Herald on Sunday what struck him the most about the case was how the doctor's "position of power" allowed him to manipulate victims and get away with it for so long.
"He's a doctor so he thinks he's bulletproof," said the detective, who spoke on the condition of anonymity.
For Susan, being violated by osteopath Richard Davis didn't really come as a shock to her. "I'd been touched inappropriately by doctors before. I guess that's just sort of my opinion of male practitioners now," Susan said.
She only went to police after her local newspaper put a call out for victims to come forward and she became afraid teenage patients may have been similarly assaulted.
Susan does not think any health practitioner with a chequered sexual background should practise again, regardless of conditions or safeguards.
"It shouldn't be allowed because they will do it to other people when they're alone again; they'll do it just because they can," she said.
"What affected me about it the most is he was the first person to touch me sexually after my husband died and that is never going to change, that will never go away."
Roll of Dishonour
• Ambulance driver Christopher King was jailed for 14.5 years for sexually assaulting patients in the back of an ambulance in 2014. One patient was only 15 and had been beaten by her boyfriend, one suffered temporary paralysis and another was terminally ill and died before King was brought to justice. Evidence in the trial indicated that King had filmed the assaults on his cellphone and later deleted the videos.
• In 2010, 58-year-old nurse David Dawson was struck off after he was found guilty of sexual misconduct. He formed an intimate relationship with a 14-year-old intellectually disabled girl he met on the children's ward at Rotorua Hospital. Dawson confessed he loved the teenager and sent her sexually explicit text messages and flowers on Valentine's Day. It took more than three years for Dawson's registration to be cancelled through the disciplinary tribunal.
• Psychiatrist Manilall Maharajh had an inappropriate sexual relationship with a vulnerable patient and paid her more than $35,000 to mislead the Health and Disability Commissioner and avoid sanction. Maharajh had filmed a sex tape featuring himself and the patient which was used against him in a disciplinary hearing. The patient lost her virginity to Maharajh, after being referred to him with symptoms of depression and anxiety. His registration was cancelled in 2013.
• Dr Christopher Heron, of Auckland, was fined $5000 after being charged with inappropriate behaviour with a 15-year-old girl. The doctor bought the girl a scooter and a phone, drove her in his Porsche, massaged her feet and asked her to wear sexually provocative clothing. He also bought her contraceptive pills and condoms without asking and questioned her about her menstrual cycles. Heron had ceased practising at the time of the hearing, but the tribunal said it would have suspended him for 12 months.
1) Patients lodge complaints with regulatory bodies, such as the Medical Council, or the Health and Disability Commissioner. Complaints take, on average, 12 months to be investigated.
2) If a health professional breaches the code of conduct, the Medical Council will refer them to the Professional Conduct Committee for prosecution, while the HDC can prosecute via the Director of Proceedings.
3) Prosecutions take place either before the Human Rights Review Tribunal or the Health Practitioners Disciplinary Tribunal, which oversees 24 health professions in New Zealand. The HPDT is made up of a chairperson from the tribunal, three health professionals and a member of the public. It has the power to cancel the registrations of health professionals, suspend them or impose conditions on their practising certificates for up to three years.