Boundary Violations and Sexual Abuse Policy

Purpose:

This policy articulates the College’s expectations for abiding by the legislative provisions forbidding sexual abuse of a patient articulated within the Health Professions Procedural Code (Code), which is Schedule 2 of the Regulated Health Professions Act (RHPA).

The trust inherent in the professional-patient relationship is reflected in registrants’ ethical obligations and legal requirements to maintain appropriate boundaries and report any instances of sexual abuse by a regulated health professional.

Definitions:

Boundary: Boundaries define the limit of a safe and effective professional relationship between a registrant and a patient. Boundaries are based on trust, respect, and the appropriate use of power.

Boundary Violations: Boundary violations occur when a registrant does not establish and/or maintain the boundaries of a professional relationship with their patient and/or abuses their power. A boundary violation is the point at which a relationship changes from professional and clinical to unprofessional and inappropriate. Boundary violations exploit the power imbalance inherent in the registrant-patient relationship and may be sexual or non-sexual in nature.

Patient: According to the RHPA, a person is a patient of an individual health care professional,[1] not of the health care practice. Although the RHPA’s definition of “patient” is not exhaustive, it makes it clear that, at a minimum, a person is considered a registrant’s patient for the purpose of the sexual abuse provisions if there is direct interaction and any of the following has happened:

  • The registrant has, in respect of a health care service provided by the registrant to the person, charged or received payment from the person or a third party on behalf of the individual;
  • The registrant has contributed to a health record or file for the person;
  • The person has consented to a health care service recommended by the registrant; [2] or
  • The registrant has prescribed a drug to the person for which a prescription is needed. [3]

The only situation in which a person who falls within the definition above may not be classified as a patient is if all the following conditions are met:

  • There is an existing sexual relationship between the person and the registrant at the time the health care service is provided;
  • The health care service provided to the person by the registrant was minor in nature or was provided in an emergency; and
  • The registrant has taken reasonable steps to transfer the person’s care, or there is no reasonable opportunity to transfer care. [4]

The Code also establishes a minimum period of one year after a person ceases to be a health care professional’s patient, during which time a sexual relationship between registrants and former patients is prohibited. The one-year period runs from the date the registrant-patient relationship is formally terminated, which does not necessarily coincide with the date the patient last received health care services from the registrant. Termination often requires the registrant to take active steps to end the professional-patient relationship, as outlined in the College’s guideline, Ending the Pharmacist-Patient Relationship. It also requires the registrant to cease providing any health care and pharmacy services (including pharmaceutical advice) to the patient.

Engaging in a sexual relationship with a patient before waiting the full year after terminating the professional-patient relationship can lead to a finding by the Discipline Committee of the College of professional misconduct for sexual abuse of a patient. As discussed below, such a finding may attach to a mandatory penalty of revocation of the registrants professional’s certificate of registration.

Sexual Abuse: The sexual abuse of a patient by a registrant is defined as: [5]

  • Sexual intercourse or other forms of sexual relations between the registrant and the patient;
  • Touching of a sexual nature, of the patient by the registrant; or
  • Behaviour or remarks of a sexual nature, by the registrant towards the patient.

Sexual abuse does not include touching, behaviour, or remarks that are clinically appropriate to the service being provided.

Policy:

In the registrant-patient relationship, registrants hold a position of power by virtue of having:

  • Professional knowledge and skills patients rely on for their well-being;
  • Access to pharmaceuticals and devices patients rely on to manage their health;
  • Access to patient’s personal health information; and
  • A position of authority in relation to patients’ pharmaceutical needs.

Because of the power imbalance that exists between registrants and their patients, any sexual or romantic relationship a registrant has with a patient is considered an act of professional misconduct and possibly sexual abuse.

Registrant – Patient Relationship

Registrants have an obligation for maintaining the professional integrity of the clinical relationship.

A co-existing sexual and patient relationship is considered to be professional misconduct and an act of sexual abuse, regardless of whether the relationship is consensual.

  • Registrants are not permitted to provide routine care to individuals with whom they have an existing sexual relationship. This includes spouses. [6] The only exception is for the provision of care in an emergency or where the service is minor in nature – and only if the registrant takes reasonable steps to transfer care to another registrant or there is no opportunity to do so. For more information read the Treating Self and Family Members policy.

A pharmacy staff member who has received assessment, treatment or any other pharmacy services from a registrant is also considered to be a patient for the purpose of applying the sexual abuse provisions of the Code.

Boundary Violations

Registrants must establish and maintain appropriate boundaries with their patients at all times.

  • An appropriate relationship between a registrant and a patient is one that is professional and clinical in nature, rather than personal. An appropriate boundary in a registrant-patient relationship is one that complies with the Code of Ethics and the Standards of Practice.
  • Sexual boundary violations occur when a registrant’s relationship with a patient becomes personal in nature, including a relationship that is romantic or sexual in nature.

Appropriate Professional Boundaries 

To help ensure appropriate professional boundaries are maintained, registrants must:

  • Not engage in romantic relationships of any kind with patients
  • Not respond sexually to any form of sexual advance made by a patient
  • Not make sexualized comments about or to a patient. This includes, but is not limited to:
    • Not criticizing or commenting unnecessarily on a patient’s appearance, sexual preference or identity
    • Not asking details of sexual history, behaviour or performance except where related to the purpose of the consultation
    • Not talking with patients about their own sexual preferences, fantasies, problems, activities or performance
    • Avoiding any behaviour or remarks that may be interpreted as sexual by a patient
  • Make consensual physical contact with a patient only when clinically necessary, and avoid any physical contact with a patient that could be perceived as inappropriate
  • Show sensitivity and respect for the patient’s privacy and comfort at all times, including by:
    • Providing consultations in a conducive, safe environment utilizing non-judgmental and respectful practice approaches
    • Being mindful of diverse religious and cultural backgrounds
  • Avoid social interactions with patients that may lead to romantic involvement. Personal interests must not supersede professional, financial, or business obligations, and must act in the best interest of patients.[7]

Registrants are ultimately responsible for supporting the practice setting to detect and stop potential boundary violations.

Sexual Abuse

Registrants must not touch a patient in a sexual manner, become sexually involved with a patient, or engage in behaviour or make remarks of a sexual nature towards a patient.

  • As outlined in the definition of “sexual abuse” above, any form of physical sexual relations between a registrant and a patient (including a spouse) is considered to be sexual abuse.
    • In the event that a registrant is required to provide care to an individual with whom they have an existing sexual relationship in an emergency or where the service is minor in nature, the registrant must take reasonable steps to transfer care as soon as practically possible.

(See the definition of a patient above, and the Treating Self and Family Members policy)

  • When in doubt as to whether a clinical relationship exists or has terminated, registrants should refrain from any sexual or romantic relationship.
  • Sexual relationships between registrants and caregivers of patients also raise concerns about breach of trust and power imbalance. Registrants are advised to refrain from sexual or romantic relationships with caregivers of patients.

Relationships with Former Patients

The registrant must terminate the clinical relationship with a patient, as outlined in the Ending the Pharmacist-Patient Relationship guideline (including by ceasing to provide any health care or pharmacy services to the patient). The registrant must ensure that at least one year has elapsed after termination prior to engaging in a sexual or romantic relationship.

Even after one year has passed, the registrant must consider whether the clinical relationship has created a vulnerability or dependency on the part of the patient that may make it inappropriate to engage in a sexual or romantic relationship, regardless of the amount of time that has elapsed after terminating the clinical relationship.

  • Sexual contact with a former patient may be considered professional misconduct even if it is not considered sexual abuse as defined under the Code. A sexual or romantic relationship is inappropriate in cases where the clinical relationship has created a vulnerability or dependency on the part of the patient such that the power imbalance in the registrant-patient relationship continues to affect the patient’s objectivity.

If at least one year has passed since the termination of the clinical relationship, there is no vulnerability or dependency on the part of the patient, and there are no other circumstances that would make a sexual or romantic relationship inappropriate, registrants who subsequently begin a sexual or romantic relationship with a former patient must be cautious not to provide any health care or pharmacy services (including pharmaceutical advice) to the former patient. If such advice or services are provided, it may re-establish a registrant-patient relationship, thereby engaging the sexual abuse provisions of the RHPA.

Mandatory Revocation

The Code states that a panel of the Discipline Committee must revoke a health professional’s certificate of registration if it is found that sexual abuse of a patient occurred and that the sexual abuse consisted of, or included, any of the following: [8]

i. Sexual intercourse;
ii. Genital to genital, genital to anal, oral to genital or oral to anal contact;
iii. Masturbation of the member by, or in the presence of, the patient;
iv. Masturbation of the patient by the member;
v. Encouraging the patient to masturbate in the presence of the member; and
vi. Touching of a sexual nature of the patient’s genitals, anus, breasts or buttocks.

It is important to point out that mandatory revocation is attached to other findings of professional misconduct, in addition to sexual abuse of a patient as set out above. Regulations under the RHPA specify that professional misconduct associated with findings of guilt related to certain sexual offences within the Criminal Code also trigger mandatory revocation of a regulated health professional’s certificate of registration. [9] Convictions for these Criminal Code offences (and the related mandatory revocation provisions) do not require the victim to be a patient.

Mandatory Reports

All health care professionals governed by the RHPA are required to file a written report with the Registrar if, in the course of practising their profession, they form reasonable grounds to believe that a registrant of any regulated health profession has sexually abused a patient. [10]

The report must be made within 30 days after the obligation to report arises; however, if you have reason to believe that there is continuing sexual abuse of a patient, or that a registrant will sexually abuse other patients, then the report must be made without delay. The report must include:

  • The name of the patient who has been sexually abused (only if written consent has been given by the patient OR, if the patient is incapable, by the patient’s representative);
  • The name of the registrant filing the report;
  • The name of the registrant who is the subject of the report; and
  • An explanation of the alleged sexual abuse.[11]

Once the report is received by the College, the information will be reviewed to determine next steps, which may include conducting a formal investigation.

Failure to submit a mandatory report when it is required could result in a fine of up to $50,000 for an individual or up to $200,000 for a corporation. Registrants are protected from reprisal for making reports in good faith. [12]

Reporting of Possible Sexual Abuse through the Complaints Process

The College also receives information about possible sexual abuse of a patient through its complaints process. Under this process, the patient, or a third party, may file a complaint with the College alleging that a registrant has sexually abused a patient. Again, such information is reviewed by the College to determine next steps, which may include the appointment of an investigator to conduct a formal investigation.

Funding For Therapy and Counselling

The Code requires each health professional college to establish a program to provide funding for therapy and counselling for a person who, while a patient, was sexually abused by a registrant. This program is administered by the Patient Relations Committee. [13]

Funding is available for five years from the day on which the person first received therapy or counselling after the alleged sexual abuse occurred, or five years from the day the College receives a complaint or report of sexual abuse by a registrant. The maximum amount of funding that may be provided is the amount that the Ontario Health Insurance Plan (OHIP) would pay for 200 half-hour sessions of individual out-patient psychotherapy with a psychiatrist on the day the person becomes eligible for funding.[14]

Legislative References:

Protecting Patients Act, 2017

Regulated Health Professions Act, 1991, SO 1991, c18

Pharmacy Act, 1991, SO 1991, c36

Family Law Act, RSO 1990, c F.3

Criminal Code, RSC., 1985, c. C-46

Additional References:

Funding for Therapy and Counselling

Specified Offences Triggering Mandatory Revocation

Zero Tolerance of Sexual Abuse and Harassment (Pharmacy Connection, Winter 2018)

The Protecting Patients Act 2017: New Regulations Now in Effect (Pharmacy Connection, Spring 2018)

Guideline — Ending the Pharmacist-Patient Relationship

Implementation

Published: May 31 2022
Version #: 4.00
College Contact: Pharmacy Practice

Revision History
Version # Date Action
1.00 February 1995 Sexual Abuse Prevention Plan and Dating Guideline were adopted.
2.00 September 2011 Revised guideline and renamed to Maintaining Appropriate Boundaries and Preventing Sexual Abuse and Harassment.
2.01 June 2014 Revised guideline and renamed to Preventing Sexual Abuse and Harassment and to reflect the College’s opinion that pharmacists and technicians should not be permitted to routinely treat spouses or other family members, which is outlined in the Treating Self and Family Members policy.
3.00 November 2021 Revising Preventing Sexual Abuse and Harassment guideline to reflect the creation of the Protecting Patients Act 2017. The policy was renamed Boundary Violations and Sexual Abuse policy, and revised to reflect the new policy template.

 

  1. Subsection 1(6) of the HPPC, Schedule 2 to the RHPA; and section 1 of O. Reg. 260/18 under the RHPA
  2. Health Care Consent Act, 1996
  3. Subsection 1.1 of O. Reg. 260/18 under the RHPA
  4. Subsection 1.2 of O. Reg. 260/18 under the RHPA
  5. Subsection 1(3) of the HPPC, Schedule 2 to the RHPA
  6. For the purposes of the RHPA’s sexual abuse provisions, “spouse” refers to either: (a) a spouse as defined under section 1 of the Family Law Act, RSO 1990, c F.3, or (b) a person who has lived with the member in a conjugal relationship outside of marriage continuously for a period of at least three years.
  7. Ontario College of Pharmacists. Code of Ethics. (2015). https://www.ocpinfo.com/library/council/download/CodeofEthics2015.pdf
  8. Subsection 51(5)(3) of the HPPC, Schedule 2 to the RHPA
  9. O. Reg. 262/18 under the RHPA
  10. Section 85.1 of the HPPC, Schedule 2 to the RHPA
  11. Section 85.3 of the HPPC, Schedule 2 to the RHPA
  12. Subsections 93(1)-(3) of the HPPC, Schedule 2 to the RHPA
  13. Section 85.7 of the HPPC, Schedule 2, to the RHPA
  14. O. Reg. 59/94 under the RHPA