General Medical Council

Maintaining boundaries - guidance for doctors

November 2006

1. 1. In our core guidance for doctors, Good Medical Practice we advise that:
• You must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them¹.
• You must treat patients with dignity².
• You must protect patients from risk of harm posed by another colleague's conduct...The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary³.

This supplementary guidance is intended to provide more detail about how to comply with these principles.

1. 2. Trust is a critical component in the doctor-patient partnership: patients must be able to trust doctors with their lives and health. In most successful doctor-patient relationships a professional boundary exists between doctor and patient. If this boundary is breached, this can undermine the patient's trust in their doctor, as well as the public's trust in the medical profession.
2. 3. The doctor-patient relationship may involve an imbalance of power between the doctor and the patient. This could arise, for example, from the doctor having access to expertise and healthcare resources which the patient needs, or the possible vulnerability – emotional or physical – of a patient seeking healthcare. This may be particularly acute in some specialties such as psychiatry but can arise in any relationship between doctor and patient.

Sexual and Improper Emotional Relationships with Current and Former Patients

1. 4. In order to maintain professional boundaries, and the trust of patients and the public, you must not establish or pursue a sexual or improper emotional relationship with a patient. You must not use your professional relationship with a patient to establish or pursue a relationship with someone close to them. For example, you must not use home visits to pursue a relationship with a member of a patient's family.
2. 5. You must not pursue a sexual relationship with a former patient, where at the time of the professional relationship the patient was vulnerable, for example because of mental health problems, or because of their lack of maturity.
3. 6. Pursuing a sexual relationship with a former patient may be inappropriate, regardless of the length of time elapsed since the therapeutic relationship ended. This is because it may be difficult to be certain that the professional relationship is not being abused.
4. 7. If circumstances arise in which social contact with a former patient leads to the possibility of a sexual relationship beginning, you must use your professional judgement and give careful consideration to the nature and circumstances of the relationship, taking account of the following:
• when the professional relationship ended and how long it lasted
• the nature of the previous professional relationship
• whether the patient was particularly vulnerable at the time of the professional relationship, and whether they are still vulnerable
• whether you will be caring for other members of the patient's family.
5. 8. If you are not sure whether you are – or could be seen to be – abusing your professional position, it may help to discuss your situation with an impartial colleague, a defence body, medical association or (confidentially) with a member of the GMC Standards and Ethics team.

Intimate Examinations

1. 9. It is particularly important to maintain a professional boundary when examining patients: intimate examinations can be embarrassing or distressing for patients. Whenever you examine a patient you should be sensitive to what they may perceive as intimate. This is likely to include examinations of breasts, genitalia and rectum, but could also include any examination where it is necessary to touch or even be close to the patient.

Chaperones

1. 10. Wherever possible, you should offer the patient the security of having an impartial observer (a ‘chaperone') present during an intimate examination. This applies whether or not you are the same gender as the patient.

1. 11. A chaperone does not have to be medically qualified but will ideally:
• be sensitive, and respectful of the patient's dignity and confidentiality
• be prepared to reassure the patient if they show signs of distress or discomfort
• be familiar with the procedures involved in a routine intimate examination
• be prepared to raise concerns about a doctor if misconduct occurs.

In some circumstances, a member of practice staff, or a relative or friend of the patient may be an acceptable chaperone.

1. 12. If either you or the patient does not wish the examination to proceed without a chaperone present , or if either of you is uncomfortable with the choice of chaperone, you may offer to delay the examination to a later date when a chaperone (or an alternative chaperone) will be available, if this is compatible with the patients best interests.
2. 13. You should record any discussion about chaperones and its outcome. If a chaperone is present, you should record that fact and make a note of their identity. If the patient does not want a chaperone, you should record that the offer was made and declined.

Intimate examinations

1. 14. Before conducting an intimate examination you should:
1. a. explain to the patient why an examination is necessary and give the patient an opportunity to ask questions ;
2. b. explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any potential pain or discomfort;
3. c. obtain the patient's permission before the examination and record that permission has been obtained;
4. d. give the patient privacy to undress and dress and keep the patient covered as much as possible to maintain their dignity. Do not assist the patient in removing clothing unless you have clarified with them that your assistance is required.
2. 15. During the examination you should:
1. a. explain what you are going to do before you do it and, if this differs from what you have already outlined to the patient, explain why and seek the patient's permission;
2. b. be prepared to discontinue the examination if the patient asks you to;
3. c. keep discussion relevant and do not make unnecessary personal comments.
3. 16. You must follow the guidance in Consent: patients and doctors making decisions together.
4. 17. By highlighting some of the issues associated with intimate examinations, this guidance does not intend to deter you from carrying them out when necessary. Following this guidance and making detailed and accurate records at the time of examination, or shortly afterwards, will help you to justify your decisions and actions.

Intimate examinations of anaesthetised patients

1. 18. You must obtain consent prior to anaesthetisation, usually in writing, for the intimate examination of anaesthetised patients.
2. 19. If you are supervising a student you should ensure that valid consent has been obtained before they carry out any intimate examination under anaesthesia.

Sexualised Behaviour and Your Duty to Report

1. 20. In order to maintain professional boundaries and the trust of patients and the public you must never make a sexual advance towards a patient nor display ‘sexualised behaviour'. Sexualised behaviour has been defined as ‘acts, words or behaviour designed or intended to arouse or gratify sexual impulses and desires'⁴.
2. 21. If you have grounds to believe that a colleague has, or may have demonstrated sexualised behaviour when with a patient, you must take appropriate steps without delay so that your concerns are investigated and patients protected where necessary. Where there is a suspicion that a sexual assault or other criminal activity has taken place, it should be reported to the police.
3. 22. Guidance on steps you should take is included in Good Medical Practice, in Management for doctors and in the supplementary guidance, Raising concerns about patient safety.
4. 23. If you are not sure what to do, discuss your concerns with an impartial colleague or contact your defence body, a professional organisation or the GMC for advice.
5. 24. You should respect patient confidentiality wherever possible when reporting your concerns. Nevertheless, the safety of patients must come first at all times and therefore takes precedence over maintaining confidentiality. If you are satisfied that it is necessary to identify the patient, wherever practical you should seek the patient's consent to disclosure of any information and, if this is refused, inform the patient of your intention to disclose the information.
6. 25. In all cases where a patient reports a breach of sexual boundaries, appropriate support and assistance must be offered to the patient. All such reports must be properly investigated, whatever the apparent credibility of the patient.
7. 26. If a patient displays sexualised behaviour, wherever possible treat them politely and considerately and try to re-establish a professional boundary. If you should find it necessary to end the professional relationship you must follow the guidance in paragraphs 38-40 of Good Medical Practice.

1. 1 Good Medical Practice paragraph 32

   2 Good Medical Practice paragraph 21b

   3 Good Medical Practice paragraph 43

   4 Kerr/Haslam Inquiry Report