Sexual Boundaries in the Doctor–Patient Relationship
https://www.medicalboard.gov.au/codes-guidelines-policies/sexual-boundaries-guidelines.aspx
🔷 GENERAL OVERVIEW
- Sexual misconduct:
- Is a breach of the doctor–patient relationship
- Undermines community trust and professional standards
- Can result in long-term harm to patients
- Is sometimes a criminal offence
- Applies to:
- Current patients
- Individuals close to patients (e.g., parent of a child patient)
- Former patients (in some circumstances)
🔹 1. THE FOUNDATION OF THE DOCTOR–PATIENT RELATIONSHIP
1.1 TRUST
- Central to good medical practice
- Patients must:
- Trust doctors to act in their best interests
- Feel safe, respected, and free from exploitation
- Sexual misconduct represents a serious violation of that trust
- Results in:
- Psychological harm
- Compromised medical care
- Loss of community confidence in the profession
1.2 GOOD COMMUNICATION
- Prevents misunderstandings
- Components of effective communication:
- Active listening to patients
- Respecting patient values and preferences
- Explaining nature and need for all examinations/treatments
- Confirming patient understanding
- Regularly updating patient on progress
🔹 2. WHY BREACHING SEXUAL BOUNDARIES IS UNETHICAL AND HARMFUL
- Power imbalance: Doctor holds authority; patient may be vulnerable or dependent
- Trust violation: Medical care must be solely for patient benefit
- Patient safety: Sexual behaviour from a doctor can be emotionally/physically harmful
- Objectivity: Romantic involvement erodes clinical judgement
- Public confidence: Misconduct deters people from seeking care or sharing personal information
🔹 3. BREACHES OF SEXUAL BOUNDARIES
3.1 EXAMPLES (Spectrum of behaviours)
- Seeking or engaging in sexual relationships with patients
- Conducting non-indicated physical exams
- Behaviours of a sexual nature:
- Sexual remarks/jokes/innuendo
- Flirtation or seductive conduct
- Sexual touching
- Sexual acts in front of patients
- Comments designed to arouse sexual desire
- Inquiring about sexual history when not relevant to clinical care
- Sexual exploitation, harassment, or assault
3.2 OTHER INAPPROPRIATE BEHAVIOURS
- Requesting unnecessary undressing
- Providing inadequate draping/privacy
- Engaging in sexual relationships with:
- Patient’s parent, spouse, carer, or family
- Former patients, particularly where prior vulnerability exists
🔹 4. MAINTAINING SEXUAL BOUNDARIES WITH CURRENT PATIENTS
Warning signs (for doctors):
- Sharing personal/sexual details with a patient
- Fantasising or daydreaming about a patient
- Accepting or initiating social invitations
- Scheduling non-urgent after-hours visits
- Patient behaviours:
- Sexual comments/language
- Excessive personal questioning
- Over-affection or giving gifts
Recommended action:
- Re-establish professional boundaries constructively
- Consult indemnity insurer or senior colleague
- Consider transferring care if objectivity is compromised
- Do so sensitively, to avoid further distress to the patient
🔹 5. SEXUAL RELATIONSHIPS WITH FORMER PATIENTS
May still be unethical if:
- Exploits prior trust, vulnerability, or emotional dependence
Board will assess:
- Length and intensity of previous care
- Nature of treatment (psychological/emotional care especially relevant)
- Time since last clinical contact
- Circumstances of relationship formation
- Vulnerability and dependence of former patient
🔹 6. SEXUAL RELATIONSHIPS WITH INDIVIDUALS CLOSE TO PATIENTS
- Includes parent, spouse, carer, guardian, family member
- May affect:
- Clinical objectivity
- Patient trust and quality of care
- Board considerations:
- Duration/type of care
- Emotional dependence of the individual
- Doctor’s use of knowledge or influence from patient’s care
- Importance of patient’s treatment to the family member
🔹 7. PHYSICAL EXAMINATIONS
Before examination:
- Must be clinically justified
- Obtain informed consent
- Explain:
- Reason for exam
- What it involves
- Rights to refuse
- Allow undressing/dressing in private
- Do not assist unless patient requests help
- Offer presence of a support person
During examination:
- Respect signs of withdrawn or uncertain consent
- Use draping to preserve dignity
- Use gloves for genital/internal exams
- Exception: some paediatric external exams
- Minimise time patient is undressed
7.1 USE OF OBSERVERS (CHAPERONES)
- Especially in intimate examinations (breasts, genitals, rectal, vaginal)
- Observer should be:
- Qualified (e.g., nurse)
- Acceptable to patient
- Aware of role and respect confidentiality
- Patient may decline an observer
- Doctor can proceed, or help find another practitioner
🔹 8. SOCIAL MEDIA AND DIGITAL COMMUNICATION
- Maintain same professional standards as in-person
- Do not use social media to:
- Flirt, initiate sexual/inappropriate relationships
- Social media can blur personal–professional boundaries
- Redirect patients who initiate informal contact to clinical channels
🔹 9. OBLIGATION TO REPORT SEXUAL MISCONDUCT
- Mandatory notification (under National Law) to AHPRA if:
- A health practitioner poses serious risk due to sexual misconduct
- Applies to:
- Registered practitioners
- Employers
- Education providers
- Some exceptions exist in WA and QLD
- Voluntary notifications also encouraged as part of professional duty
🧾 DEFINITIONS (Key terms)
- Sexual relationship: any relationship with a sexual element
- Sexual exploitation: abuse of professional power for sexual gratification
- Sexual harassment: unwanted behaviour of a sexual nature (e.g., comments, touching, exposure)
- Intimate examination: typically involves breasts/genitalia/rectal exams (patient perspective matters)
- Informed consent: voluntary and fully informed agreement
- Substitute decision-maker: legal authority to consent on behalf of patient lacking capacity
⚖️ LEGAL FRAMEWORK & ENFORCEMENT
- Issued under Section 39 of the National Law
- Used in regulatory proceedings to define appropriate conduct
- Reviewed every 5 years (current as of December 2018)
- Breaches may lead to:
- Investigation by AHPRA or Medical Board
- Suspension, deregistration, or referral to police