Guidance for the Profession: Maintaining Appropriate Boundaries

Last Updated: March 2026

Physicians are required to obtain express consent prior to all intimate examinations. In most cases, express consent will be given verbally. (For example, a physician may ask “Are you ready to start the exam?” and a patient may respond “Yes, I am ready.”)

Trauma-informed care is an approach that recognizes the high prevalence of trauma (including childhood abuse, sexual assault, and other traumatic experiences) and its lasting impact on health; it is considered best practice in the context of intimate examinations, treatments and procedures.
To integrate trauma-informed care principles into their practices, physicians will need to assume that any patient may have a history of trauma and act accordingly to avoid re-traumatization. Depending on the patient, this may include:
- Letting patients know they have the choice to accept, decline or re-schedule non-urgent care;
- Being alert to verbal and non-verbal signs of patient discomfort; and
- Facilitating opportunities for patients to exercise their agency in clinical encounters (for example, offering self-swabbing options for STI testing).

Physical gestures such as a pat on the shoulder may, for some patients, convey empathy and reassurance. For others, these same gestures may be misinterpreted, experienced as intrusive, or even felt as a violation. When assessing whether non-clinical touch is appropriate, physicians will need to:
- Carefully consider the context, including the nature and length of the therapeutic relationship, the patient’s verbal and non-verbal cues, any known history of trauma or discomfort with physical contact and whether the patient is in a state of undress;
- Be mindful that some patients may be particularly sensitive to touch and that unintended harm may result from even brief, seemingly benign contact; and
- Respect cultural, religious or personal boundaries around physical contact.
When in doubt, physicians can consider whether alternative means of support (such as verbal expressions of empathy) may be more appropriate. Physicians may also consider asking permission before initiating comforting touch.

A person does not have to be a health-care professional to be considered a suitable third party for the purposes of third party attendance, unless otherwise required (for example, by a CPSO order or undertaking).
When a patient books an appointment and the physician is not able to provide a third party, it is best practice to let the patient know at the time of booking that the physician is not able to offer a third party and that they are welcome to bring someone of their choosing (for example, a family member or friend).
Even in the context of examinations, treatments or procedures not typically considered “intimate,” some patients may feel more comfortable with a third party present. Physicians may offer the option of a third party, particularly in any examination, treatment or procedure where clothing needs to be moved or removed.
It is best practice for physicians to document in the patient’s medical record when a third party attended an examination, treatment or procedure and when a third party is declined.

While it is best practice for physicians to leave the room while patients undress and dress, in some circumstances it may be appropriate to draw a curtain between the physician and the patient. Merely turning around and facing away from a patient without a curtain is not acceptable.

Prior to engaging in sexual relations, physicians are advised to verify that they have not provided treatment to the individual within the prior one year.
Where a physician is in doubt as to whether the physician-patient relationship has ended, they should refrain from any relationship with the patient until they seek advice (for example, from legal counsel).

The legislation sets out mandatory penalties for engaging in professional misconduct by sexually abusing a patient. These penalties include suspension and/or revocation of the physician’s certificate of registration.
The law requires these mandatory penalties to be applied, even if there are mitigating factors.
Sexual contact with a patient is considered sexual abuse even if a patient appears to agree to a sexual relationship.

If a patient initiates inappropriate contact, (for example, repeated personal emails or text messages or physical contact, such as hugging) the physician will need to re-establish professional boundaries in a timely manner (for example, by clarifying appropriate communication methods).
It is important to document the inappropriate contact and the steps taken to resolve the issue in the patient’s medical record. Should the behaviour persist or where a patient’s behaviour compromises the physician’s personal safety, it may be necessary to end the physician-patient relationship, in accordance with CPSO’s Professional Obligations: Ending the Physician-Patient Relationship.

Non-sexual boundary violations can occur when a physician has a social relationship and/or a financial/business relationship with a patient.
The following activities have the potential to cause harm particularly when the physician uses the knowledge and trust gained from the physician-patient relationship:
- Asking patients directly, or searching other sources, for private information about patients that has no relevance to the clinical issue;
- Asking patients to join faith communities or personal causes;
- Engaging in leisure activities with a patient;
- Lending to/borrowing money from patients;
- Entering into a business relationship with a patient;
- Hiring a current patient as a member of staff; or
- Soliciting patients to make donations to charities or political parties.

CPSO does not prohibit physicians and patients from interacting within the same social network. However, physicians will need to manage the increased risks associated with having a dual relationship with a patient and re-establish boundaries, as necessary. For example, if a patient asks for medical advice in a social setting, it is best practice to defer the conversation to a scheduled office visit.
CPSO’s Professional Obligations: Treatment of Self, Family Members, and Others Close to You also contains important information with respect to this issue.

Maintaining Appropriate Boundaries

Trauma-Informed Care

Endnotes

Regulated Health Professions Act, 1991, SO 1991, c 18, Schedule 2, Health Professions Procedural Code, s 1(6) (HPPC).
HPPC, s 51(5).