Professional Obligations: Maintaining Appropriate Boundaries

Professional Obligations

1. Physicians must establish and maintain appropriate boundaries with their patients.

Sexual Boundaries

2. Physicians must not engage in sexual relations with a patient, touch a patient in a sexual manner or engage in behaviour or make remarks of a sexual nature towards a patient.¹

3. To help maintain appropriate boundaries, physicians must not:
   1. Make any sexual comments or advances towards a patient.
   2. Respond sexually to any form of sexual advance made by a patient.
   3. Make any comments regarding their own sex life, sexual preferences, or fantasies.
   4. Ask about or comment on a patient’s sexual history or behaviour except where the information is relevant to the provision of care.
   5. Socialize or communicate with a patient for the purpose of pursuing a sexual relationship.

Physical and Intimate Examinations, Treatments and Procedures

4. Physicians must:
   1. Explain to patients, in advance, the scope and rationale of any examination, treatment or procedure.
   2. Obtain express consent before proceeding with any intimate examination.
   3. Inform patients that they can ask to stop an examination at any time.
   4. Only touch a patient’s breasts, genitals or anus when it is medically appropriate, and use appropriate examination techniques when doing so.
   5. Use gloves when performing pelvic, genital, perineal, perianal, or rectal examinations.
   6. Keep comments professional and relevant to the examination, treatment or procedure.

5. Physicians must show sensitivity and respect for a patient's privacy and comfort by:
   1. Providing privacy when patients dress or undress.
   2. Providing patients with a gown or drape during the examination, treatment or procedure if clothing needs to be removed, and only exposing the area specifically related to the examination, treatment or procedure.
   3. Ensuring that the gown or draping adequately covers the area of the patient’s body that is not actively under examination.
   4. During an examination, treatment or procedure, only assisting patients with the adjustment or removal of clothing or draping if the patient agrees or requests the physician to do so.
   5. Using their professional judgment when using touch for comforting purposes, including considering the possibility of patient misinterpretation and/or the potential impact of unwanted touch.

Third Party Attendance at Intimate Examinations, Treatments and Procedures

6. Regardless of the gender of the physician and/or the patient, physicians must give patients the option of having a third party present during an intimate examination, treatment or procedure, including bringing their own third party if the physician does not have one.

7. If the patient wants a third party present during an intimate examination, treatment or procedure and a third party is unavailable or there is no agreement on who the third party should be, physicians must:
   1. Where the care is not urgently needed, give patients the option to delay or reschedule the examination, treatment or procedure, or be referred to another physician.
   2. Where the care is urgently needed, explain the risks of delaying the examination, treatment or procedure.
8. Physicians also have the option to request the presence of a third party during an intimate examination, treatment or procedure. If doing so, physicians must explain to the patient who the third party is. If the patient declines, physicians may delay or reschedule the intimate examination, treatment or procedure.

Sexual Relations after the Physician-Patient Relationship has Ended

9. Under the legislation, for one year after the date upon which an individual ceased to be the physician’s patient, it is considered sexual abuse if the physician:
   1. Has sexual relations with the individual, and/or
   2. Engages in sexual behaviour or makes remarks of a sexual nature towards the individual.²

Therefore, physicians must not engage in sexual relations with the individual or engage in sexual behaviour or make remarks of a sexual nature towards the individual during this time period.

10. Even after the one-year time period has passed, it may still be inappropriate and/or constitute professional misconduct for a physician to engage in sexual relations with a former patient.³ Therefore, before engaging in sexual relations with a former patient, a physician must consider the following factors:
    1. The length and intensity of the former physician-patient relationship;
    2. The nature of the patient’s clinical issue;
    3. The type of clinical care provided by the physician;
    4. The extent to which the patient has confided personal or private information to the physician; and
    5. The vulnerability the patient had in the physician-patient relationship.

Sexual Relations between Physicians and Persons Closely Associated with Patients

11. It may be inappropriate for a physician to engage in sexual relations with a person closely associated with a patient. A physician may be found to have committed an act of professional misconduct if they do so.⁴ Prior to engaging in sexual relations with a person closely associated with a patient, a physician must consider the following factors:
    1. The nature of the patient’s clinical issue;
    2. The type of clinical care provided by the physician;
    3. The length and intensity of the physician-patient relationship;
    4. The degree to which the person associated with the patient depends on the physician for emotional support; and
    5. The degree to which the patient is reliant on the person closely associated with them.

Non-Sexual Boundaries

12. Physicians must establish and maintain appropriate boundaries with patients at all times, including with respect to social or financial/business matters and must not exploit the power imbalance inherent in the physician-patient relationship.

Glossary

Boundary: The limit of a safe and effective professional relationship between a physician and a patient. There are both sexual boundaries and non-sexual boundaries within a physician-patient relationship.

Boundary Violation: Occurs when a physician does not establish and/or maintain the limits of a professional relationship with their patient.

Intimate Exams: Intimate examination includes breast, pelvic, genital, perineal, perianal and rectal examinations of patients.

Patient: For the purposes of determining whether sexual abuse has occurred, the legislation defines a person as a patient when any one of the following occurs:

• The physician charges or receives a payment for health-care services provided;
• The physician contributes to a health record or file for the person;
• The person has consented to a health-care service recommended by the physician; or
• The physician prescribes a drug for which a prescription is needed to the person.^5, 6, 7

Persons Closely Associated with Patients: Persons may be considered closely associated with a patient if they are:

• responsible for the patient’s welfare and hold decision-making power on behalf of the patient;
• emotionally close to the patient and their participation in the clinical encounter, more often than not, matters a great deal to the patient;
• persons with whom the physician interacts and communicates about the patient’s condition on a regular basis, and to whom the physician is in a position to offer information, advice and emotional support.

Sexual Abuse: The legislation defines sexual abuse as follows:

• Sexual intercourse or other forms of physical sexual relations between a physician and their patient;
• Touching, of a sexual nature, of a patient by their physician; or
• Behaviour or remarks of a sexual nature by a physician towards their patient.^8, 9