POLICY: Sexual Boundaries
The Fiduciary Relationship
The fiduciary relationship is an ethical relationship of trust between the patient and physician. The relationship is such that a power imbalance exists. The patient depends on the physician’s knowledge and training to provide care. There is a one-way transfer of information from the patient to the physician and patients often allow physicians to conduct intimate physical exams. Patients may also feel vulnerable when unwell, fearful or undressed. These factors create an imbalance of power.
The physician assumes responsibility for this relationship and must act only in the patient’s best interests. Even when a patient has made sexual advances it is the physician’s responsibility to reassert the appropriate boundaries.
Consider the CMA code of ethics:
1. Consider first the well being of the patient.
13. Do not exploit patients for personal advantage.
The College recognizes that there are no circumstances in which sexualized conduct in the current patient/physician relationship is acceptable. Such activity is abusive regardless of whether the physician believes he or she has consent. It is the responsibility of the physician to never cross the line into sexual impropriety/violation. The College bylaws state:
8.1 Bylaws Defining Unbecoming, Improper, Unprofessional or Discreditable Conduct
(a) In this section:
(ii) “Sexual impropriety” and “sexual violation” include, but are not limited to:
1. Acts or behaviours which are seductive or sexually-demeaning to a patient or which reflect a lack of respect for the patient’s privacy, such as examining a patient in the presence of third parties without the patient’s consent or sexual comments about a patient’s body or underclothing;
2. Making sexualized or sexually-demeaning comments to a patient;
3. Requesting details of sexual history or sexual likes or dislikes when not clinically indicated;
4. Making a request to date a patient or dating a patient;
5. Initiation by the physician of conversation regarding the sexual problems, preferences or fantasies of the physician;
6. Kissing of a sexual nature with a patient;
7. Physician-patient sex whether initiated by the patient or not;
8. Conduct with a patient which is sexual or may reasonably be interpreted as sexual such as touching any sexualized body part of a patient except for the purpose of an appropriate examination or treatment;
9. Touching any sexualized body part of the patient where the patient has refused or withdrawn consent;
10. Sexual acts by the physician in the presence of the patient.
(b) The following acts or failures are defined to be unbecoming, improper, unprofessional or discreditable conduct for the purpose of Section 46(p) of the Act. The enumeration of this conduct does not limit the ability of Discipline Hearing Committees to determine that conduct of a physician is unbecoming, improper, unprofessional or discreditable pursuant to Section 46(o):
(xvi) Committing an act of sexual impropriety with a patient or an act of sexual violation of a patient.
(xvii) Committing an act of sexual harassment in the physician’s professional capacity.
The dynamics of a patient/physician relationship do not necessarily end with the completion of treatment or transfer of patient care. There is always a risk of abuse of power on the part of the physician since, consciously or not, he or she may use or exploit the trust, information, emotions or power created by the former relationship.
Given the special nature of the psychotherapeutic relationship, it is rare for personal relationships to be established between physicians and their former psychotherapy patients in which the previous patient/physician relationship is not exploited in some way.
Factors to consider when deciding whether contact with a former patient is appropriate may include:
- Type and duration of the therapeutic relationship.
- Circumstances surrounding the termination of the patient/physician relationship.
- The patient’s degree of vulnerability.
- The patient’s and physician’s understanding of the dynamics and boundaries of the patient/physician relationship.
Physicians are expected to report a boundary breach by another physician to the College. Paragraph 48 of the Code of Ethics for Saskatchewan physicians, part of College regulatory bylaw 7.1 states:
48. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by a colleague or concerns, based upon reasonable grounds, that a colleague is practicing medicine at a level below an acceptable medical standard, or that a colleague’s ability to practice medicine competently is affected by a chemical dependency or medical disability.