Sexual boundaries in the doctor–patient relationship: Guidelines for doctors

BACKGROUND TO THE FRAMING OF GUIDELINES

In 2010, a landmark study called “the elephant in the room” study was published in the Indian Journal of Medical Ethics. This study explored the awareness of sexual and nonsexual boundary violations (SBVs and NSBVs) in the doctor–patient relationship in India, with specific reference to psychiatrists and psychologists in Karnataka and highlighted the need for culturally relevant guidelines in India.[1] Several responses to this paper were subsequently published. One response, by Khan, pointed out that boundary violations are a particular problem in developing countries where there is an absence of a clear ethical and legal framework to deal with the problem.[2] In another response, Bhan underscored the need for professional medical organizations in India, to define what would be construed as acceptable and unacceptable behavior.[3]

In recognition of the fact that SBVs are obviously not limited to psychiatrists, a diverse group of health professionals from across India met in St. John's Medical College, Bengaluru, in February 2011. Their background spanned mental health, medicine, surgery, obstetrics gynecology, pediatrics, pathology, research, medical education, and medical ethics. This meeting generated a consensus document “The Bangalore Declaration,” which was submitted to the Medical Council of India (MCI), with a specific request that that the topic of boundaries in the doctor–patient relationship be introduced in the medical curriculum, so that all medical students could be sensitized to this issue.[4] The MCI, to its credit, did respond by incorporating the topic in the proposed foundation course for medical undergraduate students as part of their Vision 2015 document and Regulations for Graduate Medical Education.[5,6]

The Bangalore Declaration also pointed out the need for clearer guidelines on boundaries for all doctors as the sentence in the MCI code of ethics forbidding adultery and “improper conduct” is plainly inadequate.[7] However, given the various, including existential, issues, the MCI has had to contend with over the last few years,[8] several of the Bangalore Declaration Group felt that the critical issue of elaborating the MCI code of ethics specifically in relation to boundary issues, might be relegated to a back burner. It was felt that better success and acceptance might be at hand if a critical mass of doctors could endorse code/guidelines on sexual boundaries in the doctor–patient relationship. If so, these guidelines could then be presented to the MCI to endorse as a fait accompli. Further, many felt that an initial focus on SBVs would have more impact as there is less debate on the undesirability of SBVs in comparison to NSBVs in India.[9,10,11,12]

THE RATIONALE FOR REQUESTING INDIAN PSYCHIATRIC SOCIETY TO TAKE A PIONEERING STANCE

From data available worldwide (and until we get reliable Indian data, it might be appropriate to assume that the Indian doctor is not behaviorally different from doctors elsewhere), SBVs are obviously not limited to psychiatrists.[13] Indeed, these are not limited to any medical or surgical specialty. However, as with sexual abuse anywhere in the world, it is difficult to get people to talk about it as the consequences of discussion could be aversive to all involved.[14]

However, many psychiatrists have been understanding and supportive of the need to openly discuss the problem of SBVs in academic fora, when they were presented with the results of the “elephant in the room” study. Equally, some expressed anxiety about throwing light onto this problem, fearing that it would unfairly result in “bad press” and get sensationalized. While openly discussing, sexual abuse is difficult, uncomfortable, and even distressing; not talking about it is worse and is not an ethical option. The ancient wisdom of humankind and civilization is manifest in the 3000-year-old Indian Dhramashastra, the Manusmriti, which states “truthfulness is better than silence.”[15]

Given the anxiety and resistance that an endeavor like developing nationally acceptable guidelines for doctors on sexual boundaries was likely to run into, it was felt that it would be easier to first convince a group of ethically minded doctors to frame and discuss guidelines themselves. As several members of the Bangalore Declaration Group were mental health professionals and had been discussing the issues around boundaries in various national fora, it was deemed that one group of doctors who could be more easily convinced of the need to take a pioneering ethical stand on sexual boundaries would be psychiatrists. The Indian Psychiatric Society (IPS) was receptive to the idea of taking up this issue, moved as a resolution in 2015. This led to the formation of a task force on boundary guidelines for the first time, with representation from across the country. These guidelines for doctors on sexual boundaries in the doctor–patient relationship were first drafted by the Bangalore Declaration Group and subsequently worked on by the IPS Task Force on Boundary Guidelines. The members of both these groups are listed in Boxes 1 and 2. The process of framing the final version of the guidelines has been discussed in the preface to the guidelines available at the IPS website.[16] Once one specialty takes the pioneering step to endorse these guidelines as IPS has now done - it is likely that other groups of doctors in India would find it easier to follow suit in their own specialties.

Box 1.

Indian Psychiatric Society task force on boundary guidelines

Box 2.

The Bangalore declaration group

The guidelines (Version 3.4) support documents and affiliations of the members of the IPS Task Force and the Bangalore Declaration Group are available at the IPS website.[16,17]

A RESOLUTE MOVE

We know that sexual abuse occurs in other traditionally respected groups too, such as teachers, religious leaders, and armed forces: All systems where a power hierarchy exists. It is a tragic reflection of our society that we seem to have blackmailed ourselves into inaction and silence. A small, but critical and definitive step to try and stop SBVs effectively is not to brush it under the carpet. Perhaps, most importantly, having a set of guidelines helps the realization that boundary violations are unacceptable and need to be stopped. Realistically, one knows that having guidelines would not necessarily stop abuse, but it could at least be a deterrent. While it is perhaps a small number of doctors who might sexually abuse patients, even one offender is unacceptable, and there is a real risk of serial offences if this is not stopped.

Archimedes said, “Give me a lever and a fulcrum and I will move the earth”. The guidelines for doctors by the IPS are intended to be the fulcrum to provide leverage to move not just the MCI, but the other groups, on the issue of sexual abuse in India.