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Good medical practice involves ‘never using your professional relationship to establish or pursue a sexual, exploitative or other inappropriate relationship with anybody under your care. This includes those close to the patient such as their carer, guardian or spouse or the parent of a child patient.1
Sexual misconduct is an abuse of the doctor-patient relationship. It undermines the trust and confidence of patients in their doctors and of the community in the medical profession. It can cause significant and lasting harm to patients.
These guidelines aim to provide guidance to doctors about establishing and maintaining sexual boundaries in the doctor-patient relationship. These guidelines complement ‘Good medical practice: a code of conduct for doctors in Australia’ (Good medical practice). Good medical practice describes what the Medical Board of Australia (the Board) expects of all doctors who are registered to practise medicine in Australia.
Doctors who breach these guidelines are placing their registration at risk and in some cases could be committing a criminal offence.
Trust in the relationship between doctors and patients is a cornerstone of good medical practice. Sexual misconduct is a serious abuse of that trust. Patients have a right to feel safe when they are consulting a doctor.
Patients need to trust that their doctor will act in their best interests, treat them professionally, not breach their privacy and never take advantage of them. Exploitation of the doctor-patient relationship undermines the trust that patients have in their doctors and the community has in the profession. It can cause profound psychological harm to patients and compromise their medical care.
Good, clear communication is the most effective way to avoid misunderstandings in the doctor-patient relationship. Good medical practice includes:
Doctors are expected to act in their patient’s best interests and not use their position of power and trust to exploit patients physically, sexually, emotionally or psychologically. Breaching sexual boundaries is always unethical and usually harmful for many reasons including:
There is a wide range of behaviours that breach sexual boundaries, from making unnecessary comments about a patient’s body or clothing, to criminal behaviour such as sexual assault. Unwarranted physical examinations or inappropriate touching during a consultation and examination may constitute sexual assault. AHPRA will advise and support notifiers2 to report criminal behaviour to the police.
Breaches of sexual boundaries include:
Other behaviours that may breach sexual boundaries include:
2 Notifier/s means a person who has made a notification (complaint) to AHPRA about the alleged conduct of a health practitioner.
3 See ‘Definitions’ in these guidelines.
4 See ‘Definitions’ in these guidelines.
Doctors are responsible for establishing and maintaining sexual boundaries with their patients.
There is no place for sex in the doctor-patient relationship, either in the guise of a ‘consensual’ sexual relationship, or in the form of sexualised comments or behaviour, or indecent or sexual assault.
The start of a sexual relationship between a doctor and a patient may not always be immediately obvious to either the doctor or patient. Doctors need to be alert to warning signs that could indicate that boundaries are being, or are about to be crossed.
Warning signs include but are not limited to:
If a doctor senses any of these warning signs, or if a patient talks about or displays inappropriate feelings towards a doctor or exhibits sexual behaviour, the doctor should consider whether this is interfering with the patient’s care and/or placing the doctor or the patient at risk. In these situations, the doctor should try to constructively re-establish professional boundaries and seek advice from an experienced and trusted colleague or their professional indemnity insurer about how to best manage the situation.
If there is a possibility that sexual boundaries could be breached, or that the doctor may not remain objective, the doctor should transfer the patient’s care to another doctor. This should be done sensitively so that a potentially vulnerable patient is not further harmed.
It may be unethical and unprofessional for a doctor to engage in a sexual relationship with a former patient, if this breaches the trust the patient placed in the doctor. Doctors should recognise the influence they have had on patients and that a power imbalance could continue long after the professional relationship has ended.
A doctor should consider carefully whether they could be exploiting the trust, knowledge and dependence that developed during the doctor-patient relationship before they decide whether to pursue or engage in a relationship with a former patient.
When deciding whether a doctor used the doctor-patient relationship to engage in a sexual relationship with a former patient, the Board will consider a range of factors including:
A patient usually has a personal or emotional relationship with the individual5 involved or interested in their healthcare. This individual may provide them with support and advice. In some cases, such as when they are the parent of a child patient, they may make decisions on behalf of the patient about their healthcare. The individual close to the patient also relies on the doctor and trusts that the doctor is acting in the best interests of the patient.
A sexual relationship between a doctor and the individual close to a patient may affect the judgement of both the doctor and the individual and as a result, may undermine the patient’s healthcare. Such a relationship may be unethical if the doctor has used any power imbalance, knowledge or influence obtained as the patient’s doctor.
When deciding whether a doctor used the doctor-patient relationship to engage in a sexual relationship with an individual close to the patient, the Board will consider a range of factors including:
5 An individual close to a patient includes a parent of a child patient, a spouse, carer, guardian or family member.
A physical examination is an important part of the medical consultation. It can provide valuable information to assist in the diagnosis of patients. However, physical examinations should be clinically warranted. An unwarranted physical examination may constitute sexual assault. This includes conducting or allowing others, such as students, to conduct examinations on anaesthetised patients, when the patient has not given explicit consent for the examination.
Before conducting a physical examination, good medical practice involves:
When conducting a physical examination, good medical practice involves:
Patients may find intimate examinations stressful and embarrassing. The definition of an intimate examination7 depends on the patient’s perspective, which may be affected by cultural values and beliefs. An intimate examination usually means examination of the breasts, genitalia or an internal examination (vaginal or rectal). Doctors should be sensitive and respectful of a patient’s views when discussing the reasons for an intimate examination and should ensure the patient’s comfort, dignity and privacy when conducting an intimate examination.
A doctor may choose to have an observer present during an intimate examination of a patient or in any consultation. The observer is essentially a witness to the consultation and may be a registered nurse employed in the practice. An observer can provide an account of the consultation if later there is an allegation of improper behaviour. Their presence may also provide a level of comfort to the patient.
The observer should:
A patient has the right to decline the presence of an observer. In that case, the doctor can proceed with the consultation without the observer, or choose not to proceed and instead help the patient to find another doctor. The patient also has the right to ask to be accompanied by a support person of their choice.
The principles in Good medical practice apply to the use of social media and other digital communication (e.g. email and text messages) as well as to face-to-face consultations with patients. The Board expects doctors to maintain professional boundaries when using social media and other digital communication to communicate with patients. Doctors must not use social media to pursue a sexual, exploitative or other inappropriate relationship with a patient.
Doctors should also be aware of the potential risks of engaging with patients through social media. Social media can blur professional and personal boundaries and may affect the nature of the doctor-patient relationship.
If a patient tries to engage with a doctor through social media or other digital communication about matters outside the professional relationship, the doctor should politely decline to interact with them and direct them instead to the doctor’s usual professional healthcare communication channels.
For more information, the Board’s Social media policy is accessible from www.medicalboard.gov.au.
The National Law requires registered health practitioners, employers and education providers to report ‘notifiable conduct’ to AHPRA (or the relevant authority in a co-regulatory jurisdiction), to prevent the public being placed at risk of harm.8
‘Notifiable conduct’ includes engaging in sexual misconduct in connection with the practice of the profession. This means engaging in sexual misconduct with individuals under a doctor’s care or linked to a doctor’s practice of their profession.
Mandatory notification requirements aim to prevent the public being placed at risk of harm. The law requires health practitioners to notify AHPRA (or the relevant authority in a co-regulatory jurisdiction) if they believe that another health practitioner has behaved in a way which presents a serious risk to the public. Health practitioners also have a professional and ethical obligation to protect and promote public health and safety and may therefore make a voluntary notification.
For more information about the obligations of health practitioners, employers and education providers to report ’notifiable conduct’, refer to the Board’s Guidelines for mandatory notifications accessible from www.medicalboard.gov.au.
Section 41 of the National Law states that an approved registration standard, or a code or guideline approved by the Board, is admissible as evidence of what constitutes appropriate professional conduct or practice of the profession, in proceedings against a registered health practitioner under this law or a law of a co-regulatory jurisdiction.
The Board or the relevant authority in a co-regulatory jurisdiction will investigate a doctor who is alleged to have breached these guidelines. If the allegations are substantiated, the Board or the relevant authority in a co-regulatory jurisdiction will take action to protect the public.
AHPRA means the Australian Health Practitioner Regulation Agency.
Doctor/s means a registered medical practitioner/s.
Informed consent means a person’s voluntary decision about medical care that is made with knowledge and understanding of the benefits and risks involved. Good medical practice includes:
Intimate examination means an examination that a patient or a member of the public may reasonably regard as intimate, usually the breasts, genitalia or an internal examination (vaginal or rectal). The definition of an intimate examination may also be affected by a patient’s cultural values and beliefs.
National Law means the Health Practitioner Regulation National Law, as in force in each state and territory.
Sexual exploitation or abuse in the doctor-patient relationship means a doctor using the power imbalance, knowledge or influence developed in the doctor-patient relationship to abuse or exploit the patient’s trust or vulnerability for sexual purposes or sexual gratification, including by conducting unwarranted physical examinations.
Sexual harassment means any unwelcome sexual behaviour which is likely to offend, humiliate or intimidate. Sexual harassment is a type of sex discrimination and the Sex Discrimination Act 1984 (Cth) makes sexual harassment unlawful in some circumstances.
Sexual harassment includes:
Sexual relationship means the totality of the relationship between two people, when the relationship has some sexual element, including any sexual activity between a doctor and their patient.
Substitute decision-maker means a person who has the authority to make decisions on behalf of a patient who does not have the capacity to make their own decisions. A substitute decision-maker can be a parent or a legally appointed decision-maker. If in doubt, seek advice from the relevant guardianship authority.
The Board acknowledges the following documents, codes and guidelines, which informed the review of the Board’s guidelines:
Date of issue: 12 December 2018
Date of review: These guidelines will be reviewed from time to time as required. The Board will review these guidelines at least every five years.
These guidelines replace the guidelines that came into effect from 28 October 2011.