Here are few excerpts from the guidelines on Sexual
boundaries from the Indian Psychiatry Society Task Force and The Bangalore
Declaration Group, which have been put on the Medical Council of India website.
1. “It is the ethical duty of all doctors to ensure
effective care for their patients. This would mean that their own conduct
should in no way harm their patient. Sexual relationships between doctors and
patients invariably harm both the patient and the doctor. Trust, which is
central to an effective doctor patient relationship, is inevitably damaged. In
view of the power gradient that invariably exists in the doctor patient
relationship, the onus is on the doctor to ensure he or she does not enter
into a romantic or sexual relationship with a patient.
2. While the laws relating to sexual abuse in India
generally pertain to women, these Guidelines aim to be gender neutral and
serve as a guide to a code of conduct on doctors of any gender, and to
protect patients of all genders too.
3. Doctors should ensure that they do not exploit
the doctor patient relationship for personal, social, business or sexual
gain
4. In view of the power gradient in the doctor patient
relationship and possible transference issues, doctors are reminded that even
‘consensual’ sexual activity between patients and doctors irretrievably changes
the therapeutic nature of the doctor patient dynamic. This would be
detrimental to the patient (even from the viewpoint of interfering with good
medical care). This would mean that even if it is the patient who attempts to
initiate the sexual relationship, it would be against good medical practice for
a doctor to enter into such a relationship. Besides, it can be said that
consent in a power imbalanced relationship is not true consent. While in some
situations it may not be considered as ‘illegal’, these Guidelines would still
consider it as a Sexual Boundary Violation (SBV).
5. Any nonconsensual sexual activity would amount to
sexual abuse/ molestation/ rape and doctors would be answerable to the law of
the land. (Indian Penal Code
laws relate to rape, child sexual abuse, sexual molestation, adultery and
sexual harassment in the workplace). Sexual activity with a person less than 18
years of age in India amounts to statutory rape (consent immaterial). The Indian
Penal Code states that consent for a sexual relationship with a woman of
‘unsound mind’, is deemed invalid and amounts to rape. The Indian Criminal
Law Amendment Act (2013) lists out details of what behaviour is tantamount
to sexual harassment and stalking. Section 376C (d) states the punishment for
anyone in a position of authority in a hospital, if they misuse their authority
by having sexual contact with someone under their care.
6. It is obviously important for doctors to take a
relevant sexual history and perform appropriate physical examination. This
should be done sensitively and documented properly in the notes. If intimate
examination is done, gloves should be used, a chaperone present and indication
and findings documented in the notes. All this should be communicated properly
to patients, to prevent any subsequent misunderstandings. The doctor should
not touch a patient inappropriately in the guise of physical examination or
sexual therapy, for own sexual gratification. Doctors need to be aware that
sexual boundary violations (SBVs) can occur in all gender dyads.
7. If treatment that requires the patient to be
sedated is used (like electroconvulsive therapy, or any procedure that requires
anaesthesia), a nurse should be present during the induction and recovery of
anaesthesia. This is good medical practice, not just a deterrent to sexual
abuse.
8. Doctors are reminded that even a relationship
with a former patient is discouraged and could be construed as unethical,
as the previous professional relationship can influence the current
relationship. There are serious difficulties in defining the time frame that
should elapse after the doctor patient relationship is terminated, after
which a doctor may consider having a sexual relationship with a patient (if
existing laws of the Indian Penal Code are not broken). One difficulty is that
the ending of ‘treatment’ does not signify the end of the ‘doctor patient
relationship’ in view of multiple issues involved, including relapse rates of
illnesses and individual vulnerabilities of patients. If, for whatever reason a
doctor feels it imperative to have a romantic/ sexual relationship with a
patient (and again, if this does not involve the breaking of any laws), then
the doctor should ensure the patient’s care is ‘handed over’ properly to
another doctor. It is extremely important that the doctor discuss the issue
with at least one senior colleague to ensure that the doctor himself/herself is
not entering a relationship due to his/her own vulnerabilities which need to be
addressed and the former patient is clearly not being exploited. Till evidence
suggesting otherwise be obtained, IPS puts the time frame as ‘one year at
the very least, after termination of the doctor patient relationship’, with the
emphasis on ‘at the very least’.
9. It is impractical to have a detailed list of do’s
and don’ts regarding Non Sexual Boundary Violations ( NSBVs) as often it is the
context which differentiates an acceptable boundary crossing from an
unacceptable boundary violation. However, it would be useful to note that sometimes
NSBVs can ‘slip into’ SBVs. It would be important for all doctors to be
alert to warning signals in their own (or in their colleague’s), as well as
patients’ behaviour in these situations.
10. Doctors are reminded to ensure that they use
social media responsibly, as it can inadvertently lead to a blurring of
professional boundaries.
11. As doctors are to ensure they do not exploit the
doctor patient relationship for sexual gain, it would also imply that these
Guidelines extend to protect the family members of patients too. (This
would extend to family members who are also part of the therapeutic doctor
patient/ family dynamic).
12. Any failure to follow these Guidelines, if reported
to the Indian Psychiatric Society (IPS) will be referred to the Ethics
Committee. It is suggested that all allegations of SBV be taken up for
initial enquiry by the Ethics Committee of the IPS. If considered
appropriate, they will refer the case to the local “Internal Complaints
Committee” (as required by the Supreme Court mandated law on Prevention of
Sexual Harassment of Women in the Workplace (Prevention, Prohibition and
Redressal Act 2013.) Though this law pertains to women at the workplace, many
hospitals/ nursing homes have gender neutral policies, which extend to patients
too. If any criminal act is reported, then the appropriate process of enquiry
by the police should be initiated. Doctors are reminded of their own ethical
obligation to report unethical conduct by colleagues. (As listed in Section
1.7 of The Indian Medical Council (Professional conduct, Etiquette and Ethics)
Regulations, 2002). Where children are involved, reporting is mandatory or
risks imprisonment (Protection of Children from Sexual Offences Act, POCSO
2012).
13. Though these Guidelines pertains primarily to
patients, doctors are reminded that similar care should be extended to
interactions with students, colleagues and other professionals in the
multidisciplinary team- indeed anyone who is in a ‘power imbalanced
relationship’ with the doctor.
14. False allegations can occur. It is important for doctors to be alert to warning
signals and risk situations. If the doctor finds him/ herself in the midst of
an allegation (whether true or false), it would be important to reach out to
colleagues for support. Members of the IPS should be available to support a
colleague during any enquiry into an allegation. In the event of an allegation,
support should not mean ‘covering up’ the issue. If the allegation proves true
on enquiry, the colleague should be supported to the face the consequences of
his or her behaviour. Steps should be taken to access help to try and ensure
that the behaviour does not recur and patients are protected.
15. The Indian Psychiatric Society recognizes that SBVs
are not restricted to any particular group of doctors, indeed not restricted to
doctors alone, but occurs in all professional groups. In endorsing these
Guidelines for Doctors on Sexual Boundaries, the Indian Psychiatric Society
takes one step towards effective action against sexual abuse in our society.”
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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