Boundary Violations

Approved by Council: September 2008
Reviewed and Updated: June 2017, May 2018, December 2019

Companion Resource: Advice to the Profession

Other References:

• Information About Funding for Therapy and Counselling
• Brochure: Reporting Sexual Abuse – Do You Think Your Doctor Crossed the Line? (Available in additional languages via Sexual Abuse Complaints page)

Definitions

Boundary:  Defines 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.

Patient: In general, a factual inquiry must be made to determine whether a physician-patient relationship exists, and when it ends.  The longer the physician-patient relationship and the more dependency involved, the longer the relationship will endure.

However, for the purposes of the sexual abuse provisions of the Health Professions Procedural Code (HPPC), a person is a physician’s patient if there is direct interaction and any of the following conditions are met:

• the physician has charged or received payment from the person (or a third party on behalf of the person) for a health care service provided by the physician,
• the physician has contributed to a health record or file for the person,
• the person has consented to the health care service recommended by the physician, or
• the physician prescribed the person a drug for which a prescription is needed.^1,2

In addition, the physician-patient relationship endures for one year from the date on which the person ceased to be the physician’s patient.³

Sexual Abuse: The HPPC 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.⁴

Policy

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

 Sexual Boundary Violations

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.⁵
3. To help ensure sexual boundaries are maintained and that sexual boundary violations do not occur, physicians must:
   1. Not make any sexual comments or advances towards a patient.
   2. Not respond sexually to any form of sexual advance made by a patient.
   3. Explain to patients in advance, the scope and rationale of any examination, treatment or procedure and if asking questions regarding sexual matters why they are being asked.
   4. Obtain consent before proceeding with an examination.⁶
   5. Only touch a patient’s breasts, genitals or anus when it is medically appropriate, and use appropriate examination techniques when doing so.
   6. Use gloves when performing pelvic, genital, perineal, perianal, or rectal examinations. 
   7. 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 physical examination or procedure if clothing needs to be removed, and only exposing the area specifically related to the physical examination 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, only assisting patients with the adjustment or removal of clothing or draping if the patient agrees or requests the physician to do so.
   8. Not ask or make comments about a patient’s sexual history, behaviour or performance except where the information is relevant to the provision of care.
   9. Not make any comments regarding their own sex life, sexual preferences or fantasies.
   10. Not socialize or communicate with a patient for the purpose of pursuing a sexual relationship.
   11. Use their professional judgment when using touch for comforting purposes. Supportive words or discussion may be preferable to avoid misinterpretation.

Third Party Attendance at Intimate Examinations

4. 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 examination⁷, including bringing their own third party if the physician does not have one.
5. If the patient wants a third party present during an intimate examination, and a third party is unavailable or there is no agreement on who the third party should be, physicians must:
   1. Give patients the option to delay or reschedule the examination or be referred to another physician if the examination is not urgently needed, or
   2. Explain the risks of delaying the examination if the examination is urgently needed.
6. Physicians also have the option to request the presence of a third party during an intimate examination. If doing so, physicians must explain to the patient who the third party is. If the patient declines, physicians must consider whether to proceed with the examination based on the best interests of the patient, including whether the examination is urgently required.

Sexual Relations after the Physician-Patient Relationship has Ended

7. Under the HPPC, engaging in any of the following within one year after the date upon which an individual ceased to be the physician’s patient will constitute sexual abuse:
   1. sexual relations with a patient, and/or
   2. sexual behaviour or making remarks of a sexual nature towards their patient.⁸
   Therefore, physicians must not engage in sexual relations with a patient or engage in sexual behaviour or make remarks of a sexual nature towards their patient during this time period. 

8. Where psychotherapy that is more than minor or insubstantial⁹ has been provided,  physicians must not engage in sexual relations or engage in sexual behaviour or make remarks of a sexual nature towards their patient for a minimum of five years after the date upon which the individual ceased to be the physician’s patient.¹⁰
9. Even after the one or five year time period has passed, it may still be inappropriate for a physician to engage in sexual relations with a former patient.¹¹ Prior to engaging in sexual relations with a former patient, a physician mustconsider the following factors:
   • the length and intensity of the former professional relationship,
   • the nature of the patient’s clinical problem,
   • the type of clinical care provided by the physician,
   • the extent to which the patient has confided personal or private information to the physician, and
   • the vulnerability the patient had in the physician-patient relationship.

Sexual Relations between Physicians and Persons Closely Associated with Patients¹²

10. 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.¹³ Prior to engaging in sexual relations with a person closely associated with a patient, a physician mustconsider the following factors:
    • the nature of the patient’s clinical problem,
    • the type of clinical care provided by the physician,
    • the length and intensity of the professional relationship between the physician and the patient,
    • the degree of emotional dependence the individual associated with the patient has on the physician, and
    • the degree to which the patient is reliant on the person closely associated with them.

Mandatory Duty to Report Sexual Abuse¹⁴

11. Physicians mustmake a report in writing to the Registrar of the College to whom an alleged abuser belongs, if:
    1. they have reasonable grounds¹⁵, obtained in the course of practising the profession, to believe that another member of the same or a different regulated health college has sexually abused a patient; and/or
    2. they have reasonable grounds to believe that a member of a regulated health college practising in the facility has sexually abused a patient.

Non-Sexual Boundaries

12. Physicians’ obligations to establish and maintain appropriate boundaries with patients are not limited to sexual interactions. 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.
13. Physicians must consider the impact on the physician-patient relationship and on other patients in their practice when engaging with a patient in a non-clinical context (social or financial/business relationships).

For further information about maintaining appropriate boundaries, please see the Advice to the Profession: Maintaining Appropriate Boundaries document.

Endnotes

^1. O. Reg. 260/18 under the Regulated Health Professions Act, 1991, S.O. 1991, c.18 (RHPA).

^2. A person is not a physician’s patient if all of the following conditions are met:

• There is a sexual relationship between the person and the physician at the time the health care service is provided to the person;
• The health care service provided by the physician to the person was done due to an emergency or was minor in nature; and
• The physician has taken reasonable steps to transfer the person’s care, or there is no reasonable opportunity to transfer care. (O. Reg. 260/18 under the RHPA)

^3. Section 1(6) of the HPPC, Schedule 2, to the RHPA.

^4. Touching, behaviour or remarks of a clinical nature appropriate to the service provided do not constitute sexual abuse (Subsections 1(3) and (4) of the HPPC). It is an act of professional misconduct for a physician to sexually abuse a patient (Section 51(1), paragraph (b.1) of the HPPC).

^5. Such activity constitutes sexual abuse under the HPPC. 

^6. For more information about obtaining consent, please see the Advice to the Profession: Maintaining Appropriate Boundaries document.

^7. Intimate exam includes breast, pelvic, genital, perineal, perianal and rectal examinations of patients.

^8. Subsections 1(3) and (6) of the HPPC, Schedule 2, to the RHPA. The HPPC provides for mandatory revocation for specific acts of sexual abuse including sexual intercourse.  For a complete list, see Advice to the Profession: Maintaining Appropriate Boundaries.

^9. Please see Advice to the Profession: Maintaining Appropriate Boundaries for more information about what is considered minor or insubstantial psychotherapy.

^10. Physicians may be found to have committed disgraceful, dishonourable or unprofessional conduct if they engage in sexual relations with a patient in these circumstances. The Courts have found that certain physician-patient relationships may endure subsequent to the end of the formal relationship, for example, in the case of a long-standing psychotherapeutic relationship.

^11. See footnote 10.

^12. Individuals who possess one or more of the following features:

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

Examples of such individuals include but are not limited to, patients’ spouses or partners, parents, guardians, substitute decision-makers and persons who hold powers of attorney for personal care.

^13. Allegations of professional misconduct could be made under the following grounds: act or omission relevant to the practice of medicine that, having regard to all of the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional and/or conduct unbecoming a physician (Section 1(1), paragraphs 33 and 34 of the Medicine Act, Professional Misconduct Regulation). 

^14. Sections 85.1 to 85.6 of the HPPC.  

^15. Please see Advice to the Profession: Maintaining Appropriate Boundaries for more information about what reasonable grounds means.