WITNESS promotes safe boundaries between professionals and the public. It provides training, and runs a helpline for people concerned with boundary issues in professional practice. Jonathan is also a member of: the Clear Boundaries Project at the Council for Healthcare Regulatory Excellence; the British Psychological Society’s Ethics Committee; the Health Professions Councils Professional Liaison Group on Applied Psychology; the Department of Health Regulation Working Group on Herbal Medicine, Acupuncture and Traditional Chinese Medicine; and the Department of Health Advisory Group on the Professional Regulation white paper
“Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males.”
– Hippocratic Oath, 4th century BC
“Sexual or other abuse of patients by health professionals is, regrettably, more frequent than previously supposed.”
– Safeguarding Patients, Department of Health, 2007(1)
The Council for Healthcare Regulatory Excellence’s (CHRE) “Clear Boundaries” project covers information and guidance for employers, patients and professionals, as well as training and education, research and recommendations for the Fitness to
This new guidance, which is due for release by the end of the year, has been developed through a network of some 500 people, including managers, regulators, patients, royal colleges and charities. It needs to be seen in the context of:
- The government’s white paper Trust, Assurance and Safety.
- The Shipman, Ayling and Kerr-Haslam inquiries.
- The government’s response to the above inquiries.
What are “clear sexual boundaries”?
Following national consultation, violations of sexual boundaries by health employees towards patients are defined as:
“Any words, behaviour or action by a health employee towards a patient* or carer† that could reasonably be interpreted as sexually motivated”(2)
The CHRE report lists four basic rules for health workers:
- It is not permitted for health employees to breach sexual boundaries with a patient or carer because the relationship depends on confidence and trust.
- It is the health employee’s responsibility to establish and actively maintain clear sexual boundaries at all times.
- Health employees must not blame patients or carers for any wrongdoing.
- The patient or carer’s consent is not a defence.
A review of the empirical research literature between 1970 and 2006 found that:(3)
- Sexual boundary violations by health employees commonly result in significant and enduring harm to patients/clients.
- Clear sexual boundaries are crucial to the safety of patient/clients.
- The majority of reported sexual boundary violations involve male employees and female victims.
- Between 38% and 52% of health professionals report knowing of colleagues who have been sexually involved with patients.
- Client vulnerability is associated with higher prevalence rates especially among:
• Women with emotional distress.
• Women with mental health problems.
• People with learning disabilities.
• Disabled people in institutional settings.
• Young males and females.
The study found that a greater awareness of guidelines and sanctions, and targeted educational and training programmes, reduces prevalence rates.
The costs of overstepping boundaries
The study concluded that the costs of sexual boundary violations by health employees towards patients include:(3)
- Serious damage to patients and their families.
- Damage to the reputation of health employees, health services and the individual organisation.
- Significant harm and stress to the staff involved, whether observers or reporters of the alleged violations.
- Significant costs in terms of litigation, management time and reputational damage.
In WITNESS’s view, it is important for practice staff to understand the differences between personal and professional relationships. While in general terms, it may be clear who is a practitioner and who is a patient, there may be situations and circumstances that cause a kind of blurring of the patient–
These may include activities such as sports or social events, or situations where ordinary professional boundaries may be crossed for benign reasons, such as where a practitioner gives a lift to a patient in the rain where this would not normally happen.
Some patients may bring with them experiences of previous violations of their boundaries, whether physical or psychological. For some, this results in a nonassertive manner that means they find it hard to say when they feel uncomfortable with a particular procedure or piece of behaviour. For this group, extra care needs to be taken when carrying our physical examinations, particularly of an invasive kind.
This may also be underscored by a lack of awareness of their own boundaries, or by a need to test and push the boundaries of the professional. What is needed is for clear boundaries to be maintained in order that a safe relationship is maintained.
Boundary violations typically fall into three key types:
- Unnecessary physical examinations.
Cases in the first group are very small in number, but include that of former GP Clifford Ayling, into whom there was a major inquiry after he undertook a large number of clinically inappropriate internal examinations.
The second group, again small statistically, behaves in similar ways to those who exploit children. Typically, they will knowingly blur boundaries, empathising with the patient and bringing them onboard, slowly erasing normal boundaries and altering the dynamic of the relationship. They will often engender a belief that they have special clinical skills, and encourage the patient to become dependent on them.
A “slippery slope” can occur, where boundaries are gradually transgressed over a period of time. This may happen in the following order:(4)
- Practitioner and patient call each other by first names.
- Appointments become less clinical and more social.
- Patient is treated as “special” or as a confidant.
- Practitioner’s self-disclosures occur, often about current personal problems and sexual fantasies about the patient.
- Practitioner begins touching the patient nontherapeutically, progressing to hugs and embraces.
- Contact occurs outside appointment times.
- Appointments are rescheduled for the end of the day.
- Appointment times become extended.
- Practitioner and patient have drinks/dinner together.
- Practitioner–patient sex begins.
It is clear from case reports that the majority of practitioners who are investigated for boundary issues fall into the “naive” or unaware category, and that very few professionals deliberately set out to harm their patients.
It is important to note that while the unintentionally boundary-violating person is in a very different place to the intentional, many of the behaviours may be similar, if not identical. The difference is often that the “unintentional”, or naive, practitioner typically believes, at least in the early stages, that they have genuine feelings about the patient.
Stresses on boundaries can come from the personal circumstances of the practitioner. People who have problems in their personal relationships, and those who are dealing with bereavement, drug and alcohol problems or other major stresses, are more vulnerable to overstepping the boundary than others.
What practices can do
WITNESS suggests that practices develop written policies on boundaries, and ensure that workers and patients are made aware of the CHRE guidance. Overall, it is most important that a culture in which employees and patients are confident about reporting concerns about sexual boundary violations is developed. This might mean a greater openness about boundary issues generally, perhaps some overt discussion or as part of normal surgery business.
Practices may also wish to invest in training in obtaining consent, boundaries, chaperoning and communication skills. It is crucial that staff understand what to do should they feel attracted to a patient, and that staff and patients have appropriate support if something does go wrong.
How do you recognise that boundary violations may be occurring?
WITNESS has developed a simple model to help practitioners and supervisors identify areas of possible concern. The RISC model provides a framework for examining particular behaviours, whether in advance or on reflection:
- Role – the professional’s role.
- Impact – on the client/patient.
- Setting – the context of the work.
- Client’s needs – the patient’s relevant needs.
Using this as a starting point, practitioners and supervisors might usefully ask the following questions when considering an intended action or reflecting on an action that has already taken place:
- Is there a clear reason for the action based on the patient’s need?
- Is behaviour different with this patient than with their other patients?
- Is the particular work outside training?
- Might the patient’s experience of the action be of concern?
- Is the action for the patient’s benefit?
- What is the meaning for the patient?
- What might the effects be?
- Might the patient feel “special” or different from other patients?
- Does the relationship remain clearly professional, or might it become ambiguous and uncertain?
Serious boundary violations cause harm to practitioners, patients and practices. As part of normal risk minimisation processes, practices need to raise awareness and put in place proper processes for ensuring that patients and staff have safe boundaries within healthy and professional relationships.
* “Patient” includes any patient for whom a health employer has a current duty of care.
† “Carers” include any family members of the patient and life partners.
1. Department of Health. Safeguarding patients: the government’s response to the recommendations of the Shipman Inquiry’s fifth report and to the recommendations of the Ayling, Neale and Kerr/Haslam Inquiries. London: The Stationery Office; 2007.
2. Council for Healthcare Regulatory Excellence. Clear Boundaries Project 2006–07. London: CHRE; 2007. Available from: http://www.chre.org.uk/Website/our_work/regulation/projects/boundaries/
3. Halter M, Brown H, Stone J. Sexual boundary violations by health employees: an overview of the published empirical literature. London: CHRE and DH; 2007.
4. Simon RI. The natural history of therapist sexual misconduct: identification and prevention. Psychiatric Annals 1995;