There has been a growing awareness of the importance of domestic violence as a significant public health issue since the late 1990s, although women have been controlled and assaulted by their partners throughout history. Obstetricians, gynecologists, and midwives have a key role in identifying women who are experiencing domestic violence, documenting the abuse, and ensuring that appropriate advice, support, and interventions can be accessed. Domestic violence is one part of a spectrum of human rights abuses against women and girls that includes rape and sexual abuse, sexual harassment and intimidation at work, “honor killings,” female genital mutilation, trafficking of children and women for prostitution, and systematic rape as a tool of war. Gender-based violence is predominantly inflicted by men upon women and girls; it reflects and reinforces inequalities between men and women and adversely affects the health, dignity, safety, and autonomy of survivors.

The breaking of boundaries in doctor–patient relationships has been discussed in many recent publications, mainly from North America, Australia and New Zealand, where there have also been extensive modifications to codes of medical practice as a result (see Sarkar, 2004). In view of the lessons learned from recent scandals, it is timely to write about the British experience, especially as the delivery of healthcare, the legal and financial contexts, and even the favoured theoretical understandings are so different. In this book, we have concentrated on the paradigm case of the breaching of sexual boundaries, although other areas of transgression are also discussed. The greatest risk appears to exist in the specialties of psychiatry, gynaecology and general practice, and so it is appropriate that this educational book has a multidisciplinary authorship and editorship.

The genesis of the book was in the Royal College of Psychiatrists’ need to respond to both the process and the recommendations of the Kerr/Haslam Inquiry. This formal inquiry, chaired by Nigel Pleming QC, examined how, despite complaints of sexual abuse by patients over many years, two male psychiatrists working from the same hospital in the north of England were able to continue professionally without challenge (Department of Health, 2005; Kennedy, 2006). By reflecting on these events and other cases of boundary transgression, we hope readers may help avoid the repetition of such occurrences.

Are we perhaps too optimistic that people are interested in the topic of abuse within the doctor–patient relationship? After all, the public response to the final report of the Kerr/Haslam Inquiry was very muted. On the other hand, heightened interest in particularly shocking cases seems only to raise denial or distancing from the profession, and demands for extreme punishment and increased regulation from others. Between these two extremes doctors must recognise that it is by being aware of the need for professional boundaries that the vital trust of the public may be maintained. Thus, the Royal College of Physicians’ report (2005) Doctors in Society: Medical Professionalism in a Changing World defines professionalism as: ‘a set of values, behaviours and relationships that underpins the trust the public has in doctors’.

Unequal relationships

Abuses, and taboos to prevent them, do not occur in medicine alone. Any unequal relationship has the potential for sexual abuse and abuse of power built into it.

Royal College of Psychiatrists

Web pages

Psychiatrists’ Support Service

http://www.rcpsych.ac.uk/member/psychiatristssupportservice.aspx

Resource Catalogue

http://www.rcpsych.ac.uk/mentalhealthinfoforall/moreinformation/ordermaterials.aspx

Documents

Good Psychiatric Practice (3rd edition) (Council Report CR154), 2009. http://www.rcpsych.ac.uk/publications/collegereports/cr/cr154.aspx

Vulnerable Patients, Vulnerable Doctors. Good Practice in Our Clinical Relationships (Council Report CR146), 2007. http://www.rcpsych.ac.uk/publications/collegereports/cr/cr146.aspx

Sexual Boundary Issues in Psychiatric Settings (Council Report CR 145). http://www.rcpsych.ac.uk/publications/collegereports/cr/cr145.aspx

Major inquiries

Ayling Inquiry report, 2004

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4088996

Independent Investigation into the Conduct of David Britten, 2008 http://www.verita.net/pages/our_work/107/verita.html

The Kerr/Haslam Inquiry, 2005

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4115349

The Neale Inquiry, 2004

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4088995

The Ritchie report, 2000 (concerning Rodney Ledward)http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4093337

The Shipman Inquiry, 2002

http://www.the-shipman-inquiry.org.uk/reports.asp

Council for Healthcare Regulatory Excellence (CRHE)

http://www.chre.org.uk

Reports from the CHRE

Clear Sexual Boundaries http://www.chre.org.uk/satellite/133

Gives access to:

1. • Guidance for Patients on Clear Sexual Boundaries With Healthcare Professionals

2. • Clear Sexual Boundaries Between Healthcare Professionals and Patients: Responsibilities of Healthcare Professionals

3. • Clear Sexual Boundaries Between Healthcare Professionals and Patients: Guidance for Fitness to Practise Panels

4. • Learning About Sexual Boundaries Between Healthcare Professionals and Patients: A Report on Education and Training

5. • Sexual Boundary Violations by Health Professionals – An Overview of the Published Empirical Literature

Other organisations

Clinic for Boundary Studies (formerly Witness)

http://professionalboundaries.org.uk

General Medical Council (GMC)

http://www.gmc-uk.org

National Patient Safety Agency (NPSA)

http://www.npsa.nhs.uk

Public Concern at Work (PCAW)

http://www.pcaw.co.uk

The following is taken from Vulnerable Patients, Safe Doctors: Good Practice in Our Clinical Relationships (Royal College of Psychiatrists, College Report CR146, 2007). Although the boundaries of the psychiatric encounter are described below, the principles hold for boundaries of all doctor–patient encounters and similarly for the avoidance of boundary violations.

Boundaries of the psychiatric encounter

A number of features help to provide the boundaries of the psychiatric professional encounter, all of which are the responsibility of the psychiatrist. These include:

1. • setting (hospital, clinic, care home or family home)

2. • time (usually within agreed service hours)

3. • duration (agreed and consistently maintained)

4. • use of appropriate professional language

5. • appropriate professional dress and insignia

6. • limited and socially sanctioned physical touch

7. • the patient's mental health needs, not social or sexual needs, being taken as paramount.

There is clear evidence that even minor violations of these boundaries may be damaging to patients. Some are unacceptable in any circumstances, while others are not always clearly harmful to patients. Even those not unequivocally harmful should raise questions for the doctor or patient about their appropriateness, but may not be finally judged except in their detailed context.

The commonest boundary violations are non-sexual, and include inappropriate self-disclosure, involving the patient in a dual role (e.g. employing a patient or a patient's relative), speaking aggressively or rudely to patients and financial exploitation. Sexual violations are less common, but often start with apparently minor boundary violations, such as unjustifiably prolonged sessions, appointments out of working hours, treatment outside the normal place of work, except where clinically justified, and (in private practice) not charging a fee. Sexual boundary violations between psychiatrists and their patients usually take place in the context of a ‘special relationship’, to which the patient ‘assents’ rather than consents; they usually come to light when the relationship ends and the patient then reports the unprofessional relationship. The General Medical Council sees sexual boundary violations by doctors as serious professional misconduct and will normally remove the doctor from the medical register.

Canadian Psychiatric Association: position statement on sexual misconduct

The four points quoted below comprise the position statement submitted by the Professional Standards and Practice Council to the Board of Directors of the Canadian Psychiatric Association and was approved in 1995, when it replaced 1985 statement (online at http://publications.cpa-apc.org/media. php?mid=188&xwm=true).

1. • The Canadian Psychiatric Association deems sexual activity of any kind between a psychiatrist and his or her patient to be sexual misconduct and unacceptable in any circumstances.

2. • The Canadian Psychiatric Association deems any form of sexualisation by the psychiatrist of the psychiatrist–patient relationship to be unethical.

3. • The Canadian Psychiatric Association presumes sexual relationships with former patients to be unethical.

4. • Any member of the Canadian Psychiatric Association losing a medical licence as a result of sexual misconduct will have his or her membership in the Association revoked.

American Psychiatric Association: ‘Principles of medical ethics’

The four points quoted below are taken from ‘Principles of medical ethics, with annotations especially applicable to psychiatry’, published by the American Psychiatric Association in November 2003 as an amended edition of a document first published in 2001:

1. • The requirement that the physician conduct himself/herself with propriety in his or her profession and in all the actions of his or her life is especially important in the case of the psychiatrist because the patient tends to model his or her behavior after that of his or her psychiatrist by identification.

2. • Further, the necessary intensity of the treatment relationship •• may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control.

3. • Additionally, the inherent inequality in the doctor–patient relationship may lead to exploitation of the patient.

4. • Sexual activity with a current or former patient is unethical.

Extract from Clear Sexual Boundaries Between Healthcare Professionals and Patients: Responsibilities of Healthcare Professionals (CHRE, 2008; http://www.chre.org. uk/_img/pics/library/0801_Clear_Sexual_boundaries_professionals.pdf).

Examples of sexualised behaviour by healthcare professionals towards patients or their carers:

1. • asking for or accepting a date

2. • sexual humour during consultations or examinations

3. • inappropriate sexual or demeaning comments, or asking clinically irrelevant questions, for example about their body or underwear, sexual performance or sexual orientation

4. • requesting details of sexual orientation, history or preferences that are not necessary or relevant

5. • internal examination without gloves

6. • asking for, or accepting an offer of, sex

7. • watching a patient undress (unless a justified part of an examination)

8. • unnecessary exposure of the patient's body

9. • accessing a patient's or family member's records to find out personal information not clinically required for their treatment

10. • unplanned home visits with sexual intent

11. • taking or keeping photographs of the patient or their family that are not clinically necessary

12. • telling patients about their own sexual problems, preferences or fantasies, or disclosing other intimate personal details

13. • clinically unjustified physical examinations

14. • intimate examinations carried out without the patient's explicit consent

15. • continuing with examination or treatment when consent has been refused or withdrawn

16. • any sexual act induced by the healthcare professional for their own sexual gratification

17. • the exchange of drugs or services for sexual favours

18. • exposure of parts of the healthcare professional's body to the patient

19. • sexual assault.

The following eight cases, supplied by the GMC, were heard by Fitness to Practise Panels and the final determinations are given in full. They are included here to give real-life examples of doctors who breached boundaries and the GMC principles of Good Medical Practice (GMP). The GMC advises that it does not give clear thresholds between acceptable and unacceptable behaviour: each case which comes before a Fitness to Practise Panel is judged on its own merits and assessed on the particular circumstances of the case.

Cases 1 and 2 led to 12 months’ suspension from the Medical Register; cases 3–8 led to erasure.

Case 1

Summary

The doctor was admonished by a Medical Council outside the UK for pursuing an inappropriate relationship with a vulnerable psychiatric patient.

Relevant paragraphs of Good Medical Practice

The case relates to the Relationships with patients section of GMP, specifically paragraph 32 on maintaining trust in the profession. It also relates to the Probity section, specifically paragraphs 56 and 57 on being honest and trustworthy.

Determination on impaired fitness to practise

The Panel has now considered, on the basis of facts found proved, whether Dr X's fitness to practise is impaired, pursuant to section 35C(2)(e) of the Medical Act 1983 as amended, namely by reason of a determination by the X Medical Council to the effect that his actions amounted to professional misconduct.

The Panel has given detailed consideration to the evidence submitted, based upon the transcripts of the proceedings before the X Medical Council on [date]. It has noted the contents of text messages which passed between Dr X in [date] and a patient, Ms T, who had been under his care for a considerable period of time up to the termination of his contract in [date]. It also took account of the correspondence between Dr X and the X Medical Council and the report by Dr L [date] which was submitted to the X Medical Council Fitness to Practise Committee. The Panel has heard and accepts the evidence of Ms T's extreme vulnerability as a consequence of her social, medical and psychiatric history. That vulnerability would have been known to Dr X, even if he was not fully aware of the entirety of her history.