HACKENSACK, N.J. » One doctor won his medical license back after he served time in prison for sexual crimes against female patients. He is a registered sex offender on lifetime parole supervision.

Another physician accused of sexual impropriety is restricted from having patients remove their underwear during exams — or be alone when treating girls age 10 or older — under a confidential agreement that hides his name from the public.

And a third, who pleaded guilty to sexual contact with three female patients, was barred from treating women but allowed to see male patients in the presence of a chaperone — until he violated that requirement and lost his license again.

New Jersey’s system of handling accusations of sexual misconduct by doctors was called into question by revelations early this year about the case of Gangaram Ragi, a Teaneck dermatologist who continues to practice despite a dozen allegations of groping patients.

Now a review by The Record shows it to be a system that is at times porous, inconsistent and opaque, one that allows physicians to resume their practice despite evidence of serious improprieties.

Even convicted abusers, who have violated their positions of trust in disturbing ways, have been returned to work by the state Board of Medical Examiners.

Who these doctors are — and the limits placed on them — may not always be apparent to patients.

Requirements for chaperones and other restrictions — such as bans on breast and pelvic exams — have sometimes been concealed in private agreements between the state and physicians that are not available to the public. Those who are publicly disciplined have generally not been required to tell patients about any of the limits they practice under. The onus is on the consumer — who might never choose to be treated by these doctors — to ferret out information.

There also are documented instances of physicians violating orders to use chaperones; discovered in some cases when another claim arises.

Problems with the system are evident in the fact that the state official in charge is making changes in the wake of The Record’s coverage of the Ragi case.

“We want to make sure the actions that are taken are not to protect licensees, they’re to protect the public,” said Steve C. Lee, the acting director of the state Division of Consumer Affairs. “That’s our obligation.”

The state doesn’t keep track of how many complaints or board actions are related to sexual misconduct, but it is clear that only the smallest minority of the state’s 33,000 licensed doctors have been accused of sexual crimes or improprieties.

There are at least 18 cases where doctors are practicing under license limitations, either imposed publicly by the board or incorporated in confidential agreements due to allegations or findings of sexual misconduct. Experts note these doctors, conservatively, can each treat hundreds of patients a year.

And that’s just one piece of the picture. Buried in state files are cases where doctors have persuaded state officials to lift sanctions. Experts also note many cases likely go unreported by embarrassed victims.

New Jersey and other states face particular difficulties making cases against doctors, who have inherent credibility in society. In instances where doctors face criminal charges those problems can be abetted by a justice process that has allowed some defendants to avoid convictions or admissions of guilt by entering a pretrial intervention program.

Because theirs are administrative proceedings, medical boards use a lower level of proof, requiring “a preponderance of evidence” rather than the criminal justice system’s standard of “beyond a reasonable doubt.” But allegations often center on what took place behind closed doors, leaving the cases subject to differing uncorroborated accounts. That raises legitimate concerns about whom to believe.

Yet, New Jersey is considered to have among the weakest systems of physician discipline. There are states that take a harder line — especially in the most glaring cases — by taking away licenses permanently from physicians convicted of sex crimes.

“I think the penalty this type of conduct often warrants is really permanent removal of licensure by the state medical board,” said Dr. Michael Carome, director of the health research group at Public Citizen, a Washington, D.C.-based watchdog group. “When it involves sexual intercourse, sexual relationships with a patient, taking advantage of that relationship or inappropriate touching, I think those situations warrant the harshest and permanent action.”

In 2012, his organization ranked New Jersey 43rd nationally in serious sanctions that officials impose against doctors.

Lee acknowledged the New Jersey system can sometimes fall short. In May, he began a review of sexual misconduct cases in response to public scrutiny of the Ragi matter, where a ban on treating women was imposed.

“Some of the discipline we’ve seen at this stage doesn’t seem sufficient based on what we know,” said Lee.

Lee has been working with the board to improve transparency, bolstering the agency’s website and making it easier for consumers to know that a physician can’t treat women without a chaperone present. He’s also called for an aggressive approach to discipline, seeking the toughest penalty appropriate, and says he wants discipline to be imposed “with more consistency.”

“I don’t know why certain decisions were made, but sitting where I sit it does appear from my review of past discipline that some doctors received too many chances,” he said.

A wide range of purported behavior has come before the board, including kissing and sexual relationships with patients, possession of child pornography, sexual harassment of colleagues, fondling and outright sexual assaults. Some cases are settled quickly with consent orders, others drag on, working their way slowly through administrative and appellate courts.

The medical board has discretion when it comes to discipline and state officials say there are no mandated penalties for a specific act or crime. Likewise, when a license suspension or revocation occurs, if or when a doctor can seek reinstatement is up to the board, not prescribed by law.

Depending on the case, the board may require a psychosexual evaluation, therapy, ethics and boundaries courses, and enrollment in a program that assesses and monitors health care professionals with impairments. Oversight, monitoring and treatment may continue after practice is resumed — with restrictions — and physicians may be able to work only as an employee of a medical practice.

The Record’s review revealed a number of unsettling cases, where officials have returned licenses to doctors guilty of sexual crimes and others where practice limitations such as chaperone requirements haven’t been followed.

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Raymond Reiter first asked for his medical license to be reinstated nearly five years after his release from prison, where he served one year of a three-year sentence.

Reiter pleaded guilty in 2001 to sexual assault and four counts of criminal sexual contact involving five women — four of them his patients — age 18 to 50.

The youngest was suffering from severe pain in her neck and back after a car accident, records show. He watched her get dressed and undressed, becoming aroused. When she asked for a gown during one visit, he told her she didn’t need one. When she tried to bring her grandmother into the exam room during another, he refused. He said she had a nice body and made other inappropriate comments. During one encounter, he removed her bra, pushed her panties to her thigh area, placed a hand on her breast and put a finger in her vagina while pushing his penis against her body, she told authorities, according to the records.

Reiter, 60, is now a registered sex offender.

At first, the board denied Reiter’s request for reinstatement, and various evaluations were ordered. An education plan was required after a skills assessment showed areas of “need in both medical knowledge and judgment.”

In 2008, the board granted Reiter a limited license to complete the plan, during which he interviewed and examined patients with a chaperone. In 2011, it restored his license with various conditions — including that he treat women only with a chaperone present, continue therapy, and only work as an employee of a medical practice or facility.

Reached by phone, Reiter initially said he was inclined to answer questions posed by a reporter, calling it “part of his penance.” But he later declined, noting the embarrassment he had already caused himself and others.

“I’m extremely grateful that I’ve gotten a second chance. I’ve done the most I can with it, and I’ve grown from my transgression,” he said. “I’m a good person. I acted horribly. As I say, I’m grateful for my chance, for my reinstatement.”

In some states he wouldn’t have the opportunity. In Illinois, doctors and other health care workers who are registered sex offenders or have been convicted of an offense based on sexual conduct during patient care can’t continue to practice. By law, their licenses are permanently revoked without a hearing.

Minnesota won’t allow anyone convicted of a felony sex crime to hold a medical license; revocation is permanent. California also permanently revokes the license of registered sex offenders.

Reiter was permitted to reapply in five years, but time frames vary. Union County doctor James J. Mauti was found guilty of one count each of third- and fourth-degree criminal sexual contact in 2013 in a case involving a medicated patient who was also an employee. The board revoked his license but said he could reapply after “successful completion” of any criminal sentence.

Mauti received 364 days in jail. His lawyer said he’s been released on bail pending appeal of the conviction; he has maintained his innocence throughout the case. His sentence requires he register as a sex offender and, like Reiter, be on parole supervision for life.

Former Wayne internist Leonard Joachim was arrested three times and entered two guilty pleas before his license was revoked this year.

Following complaints by two female patients, he pleaded guilty in 1995 to touching one of them “about her breasts and buttocks” for his own sexual gratification, board records show. The board put him on probation and required he see female patients only with a chaperone, a restriction that was lifted in 1997.

He was arrested again in 2003 for sexual contact with a patient but charges were dismissed after a grand jury didn’t indict. The administrative case continued for years before the board, which found grounds for disciplinary action but again permitted him to continue practicing with a chaperone when seeing female patients.

In 2011, Joachim was charged with sexual assault involving a 25-year-old patient during an unchaperoned, after-hours office visit. He ultimately pleaded guilty to a lesser charge.

The board, meanwhile, temporarily suspended his license and then this year revoked it — among its findings was that he failed to use a chaperone on numerous occasions. A man answering a phone for Joachim said he would not be interested in commenting.

“Astoundingly, this is the third time respondent is before us on allegations and findings of a sexual nature,” the board said in its final order.

Michael LaFon lost his medical license after pleading guilty in state court to criminal sexual contact involving three female patients in 2003 and was put on four years probation.

He asked for his license back in 2008. In a letter to the board, the Gloucester County prosecutor said his office had entered into a plea agreement with LaFon only to ensure he “was never placed in a situation, at least in New Jersey, where he would be able to engage in this type of behavior again.”

The prosecutor said LaFon’s agreement to surrender his license, among others, satisfied the state.

After LaFon’s arrest, additional claims of misconduct surfaced, including improper sexual comments, inappropriate hugging and kissing of patients and having intercourse with patients and their spouses, board documents show. One allegation came from a male patient. But there were no additional criminal charges.

The board returned LaFon’s license in 2011. He was barred from treating women but could practice on men with a chaperone present. The reinstatement order said it was clear he “misused his license to facilitate his own sexual desires and aims” but had also “gone to great lengths to secure treatment and make changes to his life.”

His license was revoked again in March, this time for breaking the chaperone rule and falsifying patient records — discovered by law enforcement during an unrelated investigation.

LaFon said he “never assaulted anybody” and has been wrongly portrayed as an “evil, predatory, horrible person.”

He said his accusers were financially motivated and in “these three instances, these people all came on to me.” But he said he takes “full blame for allowing things to go on in my office, for encouraging or wanting things to go on that shouldn’t have gone on.”

He said he “jumped through hoops” to get his license back — therapy, assessments, and more — and maintains he didn’t falsify records or violate the chaperone requirement. He tried to provide privacy to his patients; he said his chaperone was less than 14 feet away at a reception desk and the exam-room door was open.

LaFon can reapply for his license in 2020.

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The board has a lot of discretion in how it handles cases and that has produced some widely inconsistent resolutions.

Ragi, the Teaneck doctor, who has long denied the charges, had a case that took a decade to resolve on two fronts with numerous accusers. On the criminal side, he did two stints in the Pretrial Intervention Program for sexual assault involving digital penetration and other charges that were later dismissed. The medical board found the statements of many of his accusers “compelling” and “credible.” He was reprimanded, paid hefty fines and agreed to stop practicing for six months. He’s also prohibited from ever treating women again.

The only physician in the state other than Ragi presently barred from treating women is Dr. Chowdhury Azam, a Middlesex County psychiatrist, who faced a single criminal accusation of groping a female patient, stood trial and was acquitted. An administrative law judge, however, found he had inappropriately touched the patient’s breast, calling the victim “competent and credible.” Unlike Ragi, he was suspended by the board.

Azam said the patient, who he was treating for opiate addiction, also sued him for “financial gain.” He said the claim and subsequent board actions “ruined my livelihood” and “destroyed” his life. No other patient claims arose, he said.

Cases that churn through the system are as varied as their outcomes. Each involves unique circumstances, they are frequently complex and the stakes are high, both for the victims and the physicians.

Board records show neurologist Jonathan Fellus had a sexual relationship with a patient suffering from a mild traumatic brain injury, seizures and other complications from a car accident. The two had sexual contact at his home, a hotel and in exam rooms at a rehabilitation center. She became pregnant, he told her he wouldn’t leave his wife and she grew despondent.

“Dr. Fellus had a sexual encounter with a patient, and at the same time, he is an extraordinary physician and it’s a real loss to patients that he cannot continue to practice,” said Joseph Gorrell, his attorney. “And the question is how you balance those two things.”

Gorrell said Fellus is one of only six doctors in the country who do the type of work he does. In his filings with the board, the lawyer said he noted the cases of five other physicians who had relationships with patients but whose discipline ranged from reprimands to suspensions of varying length. The state, meanwhile, cited several cases where the license was revoked.

The neurologist admitted the conduct and lost his license last year. He was told he can reapply for it in three years.

Trenton doctor Zahid Hussain was criminally charged after allegedly masturbating while examining a 31-year old female patient. The woman claimed in a 2010 complaint that he had her lay on her stomach, caressed her lower back. When she realized only one of his hands were on her back, she sat up and saw what he was doing.

Another patient claimed that a year earlier he masturbated in her presence, improperly touched her and made sexually graphic comments, board records show.

The criminal matter ended with the doctor’s entry into the pretrial program. A call to his board lawyer was not returned.

His license was temporarily suspended in 2011 and revoked the next year; it was returned in August. For at least five years, he is required to have a chaperone present whenever he examines any patient.

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Some, like the Trenton doctor, are under public orders to have chaperones. For others, restrictions have been hidden in confidential agreements.

At least 16 doctors are required to have a chaperone present during exams, either when they treat women or, for some, any patient. Nine are under public board orders requiring chaperones, including Hackensack doctor Adam Goldfarb who was indicted in 2012 on charges that he sexually assaulted a patient, and Ridgewood pediatrician Mohammed Iqbal, who was charged with having sexual contact involving two adults under his care.

Goldfarb did not return a call for comment; a board order shows he denied the allegations and, in addition to the chaperone requirement, agreed to take a boundary and cultural competency course. Iqbal, too, did not respond to a telephone call. His license was returned in 2013 following a period of indefinite suspension; his first attempts at reinstatement were denied, initially because he had not submitted to a necessary evaluation and later because he had not followed treatment recommendations.

Another doctor who is on suspension will need a chaperone — and will not be permitted to treat any patients or employ staff under age 21 — when he resumes practice. Dr. Ravinder Sharma, board records show, was arrested in Middlesex County and charged with having sexual contact with a 16-year-old intern on two occasions. He did not return calls.

In these three cases the criminal courts diverted the doctors to the state’s Pretrial Intervention Program.

Seven other physicians must have chaperones under so-called Private Letter Agreements; seven agreements were obtained by The Record through a records request, but names, dates and other details were redacted.

At least two of them were put in place when the board lifted public restrictions on the doctor, making it appear to any consumer who checked the state website that no limits were in place.

In one case, the board removed restrictions on a doctor’s license, yet privately prohibited him from performing gynecological and breast exams and required a female staffer to be present when he treats women. In another, the board issued a physician an unrestricted license, but privately required he have a chaperone present any time “you encounter a female patient.”

In the case of the doctor banned from examining patients without their underwear on, the confidential agreement says that, while “formal disciplinary action” is not warranted, “you should consider this letter to be a letter of admonishment.”

In August, the board took steps to shore up part of the system, adopting uniform chaperone requirements that mandate they always be licensed health care professionals and file regular reports with the board. The new rules require doctors post a sign “in a prominent place” informing patients that visits will be chaperoned — although not the reason why.

But some health care advocates say this may not be enough, that patients need direct notification. Others note that chaperones are paid by the physicians and may be a nurse or other member of the office, which poses the potential for a conflict. And they are not necessarily a permanent safeguard, since doctors can have the chaperone requirement removed.

The Record could find only one doctor ordered to have a sign in his office advising patients that a female health care professional must be present during exams.

Lee said the board hasn’t struck a private agreement with a physician since 2013 and it will continue not to do so. He’s also directed the division’s enforcement bureau to make certain all physicians with license restrictions are abiding by them. And physician profiles on the board’s website, he said, are being updated to more clearly inform the public about doctors practicing with chaperones and other constraints.

None of the new actions taken by Lee and the board will change orders or private agreements already in place.

As it takes a harder line, the board has more recently gotten a number of doctors to agree to temporarily stop practicing while their cases are pending before the board. They include Fair Lawn cardiologist John Strobeck, who has been criminally charged with fondling female patients and Clifton psychiatrist Theodore Jasper, who state officials allege had sex with his bipolar patient. Both doctors have denied the allegations.

Asked if doctors should be permitted to practice after a sex-crime conviction, Lee replied: “It’s hard to say.” He noted cases are not “one size fits all” and said “discretion is a useful thing as long as the decision makers are keeping the public interest in mind.”

“Doctors, just like anyone, they can be rehabilitated,” Lee said.

“But the board should take every step that they need to take to make sure that that happens. And if they’re not convinced that a doctor is rehabilitated, they should not be permitted to continue practicing,” he added.

Still, time and again, physicians have gotten second chances.

Consider Surendra M. Sharma, a heart specialist who has practiced in Hudson, Passaic and Bergen counties and has a disciplinary history with state officials that spans two decades.

New York revoked his license in 1991 for allegations of sexual misconduct involving two patients — one a 13-year-old girl — and harassing a nurse to induce her to lie; New Jersey followed in 1992.

But New Jersey reinstated him in 1995, records show, after New York’s findings pertaining to the nurse were overturned and “credible” evidence was offered of his innocence.

He was required to have a chaperone when treating female patients.

The next year a 15-year-old patient claimed he inserted his fingers in her vagina during an exam for an upper respiratory ailment — similar to the New York allegations — and he had to cease practicing again. She said there was no chaperone present.

Three years later, his license was returned. He was again ordered to use a chaperone when treating women and prohibited from “examinations of genitalia.”

Restrictions on his license were publicly lifted in 2006. On the very same day, a private agreement was filed with the board in which Sharma, who could not be reached for comment, agreed to use a chaperone when treating women and be under the supervision of another physician.

In 2008, the state found evidence he had violated both conditions, and he privately agreed to stop practicing while an investigation was pending. That same year he was permitted to see patients again after entering into another confidential agreement with chaperone and supervision requirements.

The supervision condition was lifted in 2010, but the chaperone requirement continued.

Another patient complaint of sexual misconduct followed. In 2013, he told the Hudson County Prosecutor’s Office he visited a patient at her home for treatment and to deliver medicine without a chaperone. He admitted having feelings for her and kissing her, a board order shows.

His license was revoked in March 2014 and the state agreed to release his private agreements to The Record.

He can apply for reinstatement in five years.