Consultation 013

Sexual Boundary Violations

It’s not just about sex

Reason for amending the standard: It’s important for physicians to uphold the highest professional standards in all their interactions with patients, inside and outside the office. Setting appropriate boundaries helps maintain the trust of patients and the public, and protects physicians as well as patients.

The amendment proposes to:

  • rename the standard Boundary Violations,
  • broaden the standard to include personal, social, financial or business relationships with patients that could present a risk of conflict of interest or coercion, and
  • clarify minimum expectations for appropriate boundaries.

The standard also establishes boundaries in physician-learner relationships.

Deadline to provide feedback is December 1, 2017.



Increasingly we’re recognizing that boundary violations can occur in other areas as well, and still cause the same concern around conflict of interest.Dr. Jeremy Beach, Assistant Registrar
Do you agree with the proposed changes or have concerns? How would they affect your practice?

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Recent Comments

I agreed with the amendment but there are some areas of the amendment that are controversial and contravene basic fundamental rights;The amendment makes some assumption that are not open to members; 1, That clinical situations and non clinical situations should be treated the same way i.e " all things being equal" . We all know that clinical situations are like controlled experiments and all participants are not blinded i.e the participants have specific and defined role (physician/patient)whereas non clinically situations may be blinded .
Many physicians will have been used to meeting people in the aeroplane, buses, train and malls etc who will greet them and the physician
will not recollect where he or she ever seen the face before and it will be after further introduction and clarification the patient or patient's relative will
divulge the information of having met the physician in clinical situations .This scenario is common with Emergency , walk in clinic and Locum physicians.This means physicians who unknowingly get into social, financial or personal relationship in this kind of situation can find himself/herself in trouble down the road.
Another controversial terminology is use of the word "close" . Does this means there are other personal relationship that are not close and acceptable ?
Another controversial area is anonymous online relationships that can be very extensive e.g sexual , financial, social and both parties may not have seen each other for months before engaging in this relationships.
I can decided to buy shares in a company that i don't know belong to my patient and somehow we meet at AGM which can be taken for socializing and financially involved with a patient.
Other controversial statements include "minimal risk of continuing power imbalance and after a suitable period " . How will this be determine during investigation. This suggest that same
scenerio can lead to different outcome and findings depending on the panelists . This give rooms for bias and emotions which can influence decisions.

Another area of interest is the role of the College and extent of the involvement of the College in peoples personal , social and financial matters since there are Federal and Provincial laws governing this type of relationships . Will the College say the physician took advantage of the patient in a business agreement when two people agreed to start a business and both parties lawyers were involved in this agreement.
The other issue is the burden of proof . In clinical situations it is very easy to look at the charts and interpret if there is issue with patients management but outside Clinical setting to say that this is what actually happen is always difficult if there are no records or credible eye witness.
Another important area is a physician in a small town who is actively involved in the different social/community groups can easily get into issues with this amendment.

I agreed that standard need to be maintained and expectation of the society is high and for the profession to remain noble there is a need to continue modify and amend the
standard to meet this expectation, however it should not be at the detriment of people's privacy and civil rights which Canada is a leader and champion for years .

Member , Canadian Civil Liberty.

Reuben Hamed jason
Other healthcare professional

Informed consent should be verbal. I understand that some have suggested the informed consent be written... I think this would be a deterrent to doing diligent and complete medical care. There are already enough deterrents to doing a genital exam and asking written consent would be very cumbersome and time consuming. It could also have the effect of making the patient less comfortable or question the importance of an exam that really is important. I have heard so many stories of a diagnosis becoming obvious when the patient is finally examined, for example; the huge bartholins gland cyst not detected by the first few Drs who didn’t look, or the bacterial vaginitis that turned out to be a retained tampon. We should definitely not be doing any exam or test without informed consent, however a requirement for written consent is excessive and likely would cause harm.

Cynthia Soneff
Family physician
Alberta Physician

I think there are many portions of this that make sense. There are a few that seem outside of the colleges impractical at best or unjustifiable. For example providing privacy while patient is dressing or undressing. For example if I have performed a complete skin examination for skin cancer screening for a patient and he is in his underpants and the patient needs a biopsy on his arm. It seems impractical to leave the room to allow him to put his trousers only to have me return to put in local anesthesia in the site on his arm to biopsy. That seems to create a much more odd visit as opposed to the true purpose of the exam which is to screen for disease. It seems much more logical to ask them to dress but leave the arm exposed so a biopsy can be performed while the procedure tray is being set up in the room. The next area is the recommendation to not enter into any personal, social, financial or business relationship with a patient that could present a risk of conflict of interest or coercion. That works if you will never see your patients outside your office. However many of us practice in smaller communities making this virtually impossible to follow. How can a physician possibly know what could possibly present a risk of conflict of interest? Does this mean we cannot have business, social or financial dealings with a patient? I cannot have employ an accountant who is my patient? Really? I also find the proposed standard of avoiding promoting our personal beliefs or causes to a patient indefensible. Imagine the governments cuts healthcare in a draconian way. Is the college truly suggesting that it would be wrong of a physician to state to patients that you believe this is harmful to patients and they should contact their MLA if they have concerns? That actually seems like the ethical thing to do. Namely advocating for patient care and promoting improved service. Last of all I don't know if the college can actually justify between consenting adult physicians a mandate to remove themselves from any role teaching the physician learner. Imagine you have a small program like neurosurgery. The staff physician and the R5 resident are engaged. It would then be a boundary violation for the staff to teach the learner at rounds or administer mock examinations in preperation for their Royal College Exam? How is this logical, helpful or justifiable? These are just some cursory thoughts as I read through the document.

Isaiah Day
Alberta Physician

The part about "personal beliefs" is too vague and restricting. Does this mean if my patient asks me my opinion regarding an issue, I can only say that the College won't allow me to share that. It is not uncommon to get asked "Well, what would you do doc?", or "what would you do if it was your child".

Chris Kendall
Alberta Physician

The Learner Advocacy & Wellness Office serves all undergraduate and postgraduate learners at the University of Alberta. Each year we have several distressing disclosures of boundary crossing by preceptors in the clinical environment. We are very much in support of providing more specific language around ‘under powered’ individuals in the clinical environment with special note of learners. Not surprisingly, most learners are reluctant to formally bring concerns forward for fear of career repercussions to their academic evaluations or career aspirations. Hence, the scope of boundary crossing involving preceptors and learners is grossly underestimated.

First, we believe the changes demonstrate much improvement overall and are more inclusive. We have provided a few suggestions to perhaps be even more explicit with issues that fall outside of the evaluation realm that are specific to learners.

In order to address the concerns of sexual boundary violations between learners and staff, there may be a few options that we have discussed amongst our group in the LAW Office (Dr E. Dance, Dr M. Lewis, Dr C. Goldstein).

One would be to change the wording in the second point to include learners -
A regulated member must not:
(a) sexualize a clinical or educational relationship by:
(i) using sexualized or over-familiar comments, gestures or tone of voice with a patient, learner, or subordinate;
(ii) requesting details of a patient’s sexual or personal history when not medically indicated;
(iii) engaging in any form of sexualized body contact with a patient, learner, or subordinate, including inappropriate touching or hugging, frotteurism, kissing, fondling or a sexual act;
(iv) initiating or accepting any sexual advance toward/from a patient, learner, or subordinate;
(v) initiating or accepting any sexual advance toward/from any person with whom the patient has a significant interdependent relationship (e.g., parent, child or significant other);
(vi) socializing and/or communicating with a patient, learner, or subordinate in the context of developing a sexual relationship;
(vii) terminating a clinical relationship for the purpose of pursuing a close personal or sexual relationship;
(b) enter into any personal, social, financial or business relationship with a patient, learner, or subordinate that could present a risk of conflict of interest or coercion; or
(c) promote his/her personal beliefs or causes to a patient,learner, or subordinate .

Or... extra comments specifically about sexual advances could be added to parts 5, 6 (and my added 7), such as:

(5) A regulated member must not enter into any new relationship with a learner1 that could subsequently present a risk of conflict of interest or coercion while responsible directly or indirectly for teaching, supervising, and/or evaluating that learner.
(6) A regulated member who has a pre-existing (current or past) close personal or intimate relationship with a subordinate physician or learner1 must:
(a) notify the applicable clinical and academic leaders of the relationship;
(b) remove him/herself from any role teaching or evaluating the physician or learner; and
(c) remove him/herself from any discussion of the performance of the physician or learner.

(7) A regulated member must not sexualize an encounter with a learner, use sexualized or over-familiar comments gestures, or tone of voice with a learner, engage in any form of sexualized body contact with a learner including initiating or accepting any sexual advances toward a learner while responsible directly or indirectly for teaching, supervising or evaluating that learner.

Melanie Lewis MD FRCPC
Associate Dean, Learner Advocacy & Wellness, University of Alberta
Alberta Physician

I have a concern that the drafting of section 2(b) with respect to not entering into "any personal, (or) social ...relationship...that could present a risk of conflict of interest." is too broad. Due to the broad sweep of relationships and interactions covered by this drafting as well as the very broad "could present a conflict of interest", absent further clarification, there could end up being a multitude of unintended consequences that flow from this section, particularly in small communities where everyone knows everybody else. It may then become extremely difficult for doctors to see patients in the small communities in which they live without then walling themselves off from the rest of the community, resulting in isolation. This could have the unintended consequence of making it even more difficult to retain doctors in rural areas.

In addition, there may also be a problem with respect to the family members of doctors who know each other socially. Again there may be issues with this section, for instance, where one of the family members needs to see a doctor who they know socially because that doctor happens to practice in a very specialised area where he/or she is the only doctor, or only one of a very few doctors, who perform a particular procedure.

Debra Meakins

These boundary violations make sense, especially those involving learners, as I heard of potential exploitation during my medical school clinical rotations: "(7) A physician regulated member must not enter into a sexual any new relationship with a learner1 such as a medical student, other health professional learner, graduate student,resident or fellow while they are that could subsequently present a risk of conflict of interest orcoercion while responsible for teaching and/or evaluating that learner. "
" (5) A physician who has had a received psychotherapeutic relationship with a patient must not engage in a sexual or intimate relationship with that patient at any time during or
after the conclusion of the psychotherapeutic relationship. treatment from the regulated member." I agree this is an absolute boundary under all circumstances.
Most of these boundary violations make sense for urban centres, but I wonder if in smaller centres dual relationships are impossible to avoid? The standard "...) initiating or accepting any sexual advance toward/from any person with whom the patient has a significant interdependent relationship such as (e.g., parent, child or significant other)" may be impossible to meet (eg. a rural family physician is treating an elderly patient who is at least in part dependent on an adult child. The adult child is befriended in a social setting, and only later is the parent-child relationship discovered by the physician).

Sandi Frank
Alberta Physician

I think that the proposed standard is very reasonable; however, I worry about the inclusion of "tone of voice" in the standard (in 2, a, i), as it is something that seems both very subjective, and difficult to gauge/prove after the fact. E.g. If a patient complains about inappropriate touching, they can describe fairly objectively how and where they were touched. If they complain about inappropriate tone of voice however, there is no way to go back and "rehear" the tone, unless the patient was recording the physician, in which case it still might be a very subjective judgement on the part of the person evaluating the tone.

Emily M.
Medical Student
Alberta Physician

Re the regulated member must not promote his/her personal beliefs or causes to the patient: this could be unfortunately be seen as preventing a member from sharing ideas or beliefs that the member believes, and maybe correctly so, may heip the patient with their particular medical problem. The member must not pressure the patient to accept such. Could it be modified to say the regulated member must not urge the patient to accept his/her personal beliefs or causes?

Ray Hetland
Alberta Physician

While I appreciate the need to protect patients and Doctors from sexual exploitation and to guide against conflict of interests.
Lots of proposed regulations violate sections of Canadian bills of rights.
Banning a Doctor from having financial and business relationship with their patient..particularly amount to OVERREACH and particularly disturbing. It means my Chinese Doctor cannot come to my Chinese grocery store for shopping, or I cannot ask him to guarantee a Bank loan for me to expand my business. This is 2017, and not 1840. As a regulatory body, you cannot violate the constitution while trying to regulate your practice.

Dee Kollins
Free Citizen

no issue

Susan Le Doux
President of AACM (Alberta Association of Clinic Managers)
Stakeholder organization

I am in general agreement with these standards. However, in my opinion, the section on patient draping should be amended by noting that in emergency resuscitation situations it is often necessary for patients to be unclothed.

Noel Gibney
Alberta Physician

I support the amendments

Kevin Hildebrand
Dr K A Hildebrand Professional Corporation
Alberta Physician

The new rules seem to be very clear and appropriate.
However, there is no mention of penalties. Recent cases reported in the Messenger seem to provide very lenient penalties for these activities. Unless it is very clear that right to practice medicine will be lost, it appears that some physicians do not have sufficient internal controls to avoid these relationships.

James Dickinson
Professor of Family Medicine
Alberta Physician

Not realy a substantial change, but I am of opinion that your organisation should not be too prescriptive about relationships outside the clinical and professional boundaries

Ernst Snyman
Alberta Physician

I have subspecialty training in male and female sexual health. I think the proactive/positive tone of the instructions in Section (1) is an improvement.
Regarding informed consent, as stated in the Standard of Practice, consent can be implied by the patient showing up for the assessment (such as an ultrasound) and affirmed by oral consent when the ultrasound technician introduces themselves, and once more if the Radiologist needs to repeat the exam of a body part. Verbal consent prior to any form of physical examination - BP, listening to the chest, examination of genitalia - can be quickly discussed and a decision reached.
I know that (2)(a)(ii) is meant to protect the patient from inappropriate questions and I certainly agree with it. I think the current wording is too vague but I don't know how to make it better. The 1994 WHO statement on sexual rights includes access to sexual health care. Patients can be hesitant to bring up sexual concerns because of previous negative stigma to the subject, and historically doctors have been uncomfortable in initiating basic questioning as part of general information gathering. We've been working so hard to train physicians to become more comfortable initiating sexual health discussion. It's getting better. I wouldn't want this article of the Standard to discourage physicians from making general enquiries of sexual health for fear they are inappropriate.

Theresa McCallum
Alberta Physician

I agree with your recommendations

Hasan Hafiz
Alberta Physician

Informed consent for intimate or sensitive examinations is vague and could be difficult to obtain in practice. We do numerous ultrasounds of the breast and pelvis (often transvaginal) per day, and it would be difficult in a busy practice to get informed consent. Also, would mammography be considered an intimate examination?

Michelle Noga
Radiologist at Medical Imaging Consultants, and in Edmonton Region hospitals
Alberta Physician