Guideline for the Prevention of Sexual Abuse - Member Guide

Introduction


Every Naturopathic Doctor is required to treat patients in a manner that respects their personal dignity. The College of Naturopaths of Ontario (CONO) is committed to providing NDs with resources to help them carry out that responsibility.  That includes information on sexual impropriety.

Ontario government legislation requires all health care regulatory colleges to have a Patient Relations Program that includes measures for preventing and dealing with the sexual abuse of patients.  This is an extremely serious matter.  The Regulated Health Professions Act, 1991 (RHPA), mandates severe sanctions against members who are found guilty of professional misconduct in connection with sexually abusing patients. 

The Patient Relations Program includes publishing guidelines for the conduct of members of the College towards their patients.  Please read these guidelines carefully to understand the College’s expectations and you obligations.

Philosophy


The College has zero tolerance for sexual abuse.  The patient-practitioner relationship is based on mutual trust and respect.  Any act of sexual abuse is a betrayal of that trust.

The College will investigate and take appropriate action when it receives complaints or information where it appears that a member may have engaged in this type of behaviour.

Definition of Sexual Abuse
Section 1 of Schedule 2 to the RHPA defines sexual abuse as follows:
   
     “(3)    In this Code, “sexual abuse” of a patient by a member means,
              (a)    sexual intercourse or other forms of physical sexual relations between the member and the patient;
              (b)    touching, of a sexual nature, of the patient by the member; or
              (c)    behaviour or remarks of a sexual nature by the member towards the patient.

      (4)    For the purposes of subsection (3), “sexual nature” does not include touching, behaviour, or remarks of a clinical nature appropriate to the service provided.”

The definition of sexual abuse includes the treatment of spouses, even if there was a pre-existing spousal relationship prior to naturopathic treatment.  A patient’s consent to treatment in these cases is irrelevant; it still amounts to sexual abuse as defined in the legislation.

However, Naturopathic Doctors can treat a spouse in emergency situations where there is no one else qualified to do so. The College considers this acceptable because the benefits of providing the required care in emergency situations outweigh the challenges posed by the personal relationship.

Professional Behaviour


As a member of the College, you are required to ensure that your patients receive naturopathic care in an atmosphere that places no sexual demands upon them, and is free of any sexual connotation or context.

Blatant types of sexual misconduct usually include some sort of overt sexual physical contact with the patient or touching of a sexual nature.  If touching must be involved in the examination or treatment of a patient, explain that beforehand to avoid any misinterpretation or misunderstanding.  Follow the principles of informed consent at all times.

The College understands that in cases of a life-threatening emergency, it may not always be possible to explain the need of such touching beforehand.  In such circumstances, document in the patient chart the exact nature of the touching, the reasons for it, and the circumstances that defined the situation as a ‘life threatening emergency”.

Patients may feel particularly vulnerable in a health care setting.  Therefore, use your professional judgment to determine the patient’s comfort level and whether the presence of an additional person is advisable.

Naturopathic Doctors are responsible for communicating effectively by paying attention to the ways information is conveyed and the words selected.  They must also be compassionate listeners and sensitive to the concerns and needs of patients.  Being aware of cultural and physical barriers that may interfere with clear communications can help Naturopathic Doctors practise in a responsive and responsible manner.

Professional Conduct Guidelines

  1. The Member meets the legislative requirements and conditions of the College as they relate to naturopathic practice.
  2. The Member supports the objectives and purpose of the College and is governed by its rules and regulations.
  3. The Member practices in a professional manner, being guided at all times by respecting human dignity.
  4. The Member keeps confidential all information received in the course of the professional relationship except when reporting is required by law or when the sharing of pertinent information is appropriate for collaboration with other health care providers involved.
  5. The Member continues education/training to improve his/her awareness of sexual abuse issues.
  6. The Member recognizes what the RHPA considers as “sexual abuse of a patient” and “abuse of a sexual nature” and does not engage in such unprofessional conduct.
  7. The Member recognizes that under the RHPA it is mandatory for members to report information or incidents of suspected sexual abuse of a patient by a Member of the same or of a different College to the governing College of the practitioner.
  8. The Member cooperates with College investigations or inquiries into the professional conduct of any member of a regulated health profession.
  9. No member shall falsely impugn the reputation of any colleague.

Appropriate Boundaries


A Naturopathic Doctor must not become sexually involved with his or her patient.  Sexual involvement with a patient is sexual abuse under the RHPA regardless of whether the Naturopathic Doctor believes there is “consent” from the patient.

Sexually inappropriate behaviour can sometime be subtle and inadvertent.  Naturopathic Doctors should consider appropriate professional boundaries in their interactions with both patients and office staff. 

Boundary issues include not only respecting a person’s personal physical space, but also taking into account verbal, emotional and cultural matters.  Because of the power differential inherent in the patient-practitioner relationship, it is always the ND’s responsibility to ensure that appropriate boundaries are maintained, regardless of the patient’s behaviour.

Do’s
  • Be aware of what constitutes appropriate and inappropriate conduct.
  • Be aware that individuals have ethnic, cultural, religious, sexual orientation, gender and socioeconomic differences.  Ensure that you maintain a high level of professionalism with all patients, so that no comments could be considered offensive.
  • Use appropriate draping practices that respect a patient’s privacy.
  • Document on the patient chart anything unusual in the patient-practitioner interaction.
  • Ensure that the patient (and the patient’s authorized representative or substitute decision maker) clearly understands the purpose of any procedures, especially those that require removal of clothing or physical contact.
  • Explain the scope of an examination and reasons for examinations/procedures to patients. Provide ample opportunity for the patient to ask questions.
  • Encourage patients to take an active role in their treatment.
  • Be sensitive to a patient’s discomfort with words or behaviour and change them if necessary.
  • Be aware of a patient’s uneasiness with your physical proximity to him/her and react appropriately.
  • Give patients the option of having a third party present, if that adds to their comfort.
  • Consider the most appropriate ways of providing comfort, e.g. while NDs may intend non-sexual and non-clinical touching of patients to be therapeutic or comforting, supportive words or discussion may be preferable to avoid misinterpretation.
  • Maintain patient confidentiality.
  • Use gloves when appropriate.
  • Obtain consent prior to touching.
Don’ts
  • Make sexual advances towards a patient or respond sexually to any form of sexual advance made by a patient.  Even intimate relations where you have or think you have the patient’s consent are strictly prohibited by the RHPA.
  • Hug or kiss patients.
  • Use gestures, tone of voice, expressions or engage in any other behaviour that may be interpreted as seductive or sexually demeaning or as sexual abuse.
  • Place instruments or supplies upon a patient’s chest, lap or shoulder/neck area.
  • Tell jokes or make comments of a sexual nature.
  • Perform treatment outside your office or work setting (this includes home visits).
  • Make comments about a person’s body or clothing that could be interpreted as sexual in nature.
  • Touch patients excessively or unnecessarily.
  • Comment, inquire or speculate about a patient’s sexual life, practices, or orientation unless clinically relevant.
  • Initiate conversations with patients regarding sexual preferences or fantasies, or participate in such conversations initiated by patients.  Document in the chart if such discussions are initiated by a patient.
  •  Display any material, such as jokes, posters or pictures, that have a sexual connotation or that may be offensive to your patients

Naturopathic Doctor-Patient Relationships


Trust is the cornerstone of the patient-practitioner relationship.  When a patient seeks care from a Naturopathic Doctor, the patient trusts that the practitioner is a professional and as such will treat them in a professional manner.  Sexualizing the relationship is a clear breach of trust.

Power Imbalance
The patient-practitioner relationship is characterized by a power imbalance in favour of the Naturopathic Doctor.
  • A patient depends upon the Naturopathic Doctor’s knowledge and training to provide care.
  • To receive care, patients provide information of a sensitive nature about themselves or family members.
  • Patients allow the Naturopathic Doctor to conduct intimate physical examinations.
  • The transfer of information and the physical examination is one-sided, from patient to practitioner.
  • Patients may feel particularly vulnerable if they:
    • Are feeling unwell, experiencing pain, and/or are worried or afraid;
    • Do not speak the same language as the Naturopathic Doctor;
    • Are undressed or exposed;
    • Have a history of abuse;
    • Have cultural differences.
Principles
  1. A Naturopathic Doctor, being in a position of trust and power, has a duty to act in the patient’s best interest.
  2. Naturopathic Doctors must establish and maintain appropriate professional boundaries with patients.
  3. Sexual activity and “romantic interactions” interfere with the goals of the patient-practitioner relationship and may obscure the Naturopathic Doctor’s objective judgment concerning the patient’s health and well-being.
  4. Sexual misconduct is detrimental to the patient-practitioner relationship, harms individual patients and erodes the public trust in the profession.
  5. Patients must be protected from sexual abuse by Naturopathic Doctors.

Penalties


If a panel of the Discipline Committee finds a member guilty of committing an act of professional misconduct by sexually abusing a patient, under the RHPA it must (as a minimum):
  1. Reprimand the Member.
  2. Revoke the Member’s certificate of registration for a minimum of five years if the sexual abuse consisted of, or included any of the following:
  • Sexual intercourse;
  • Genital to genital, genital to anal, oral to genital, or oral to anal contacts;
  • Masturbation of the Member by, or in the presence or, the patient;
  • Masturbation of the patient by the Member;
  • Encouragement of the patient by the Member to masturbate in the presence of the Member.
In addition to the above penalties, a panel of the Discipline Committee may:
  1. Require the Member to pay a fine of up to $35,000 to the Minister of Finance of Ontario.
  2. Require the Member to pay all or part of the College’s legal costs and expenses, the College’s costs and expenses incurred in investigating the matter, and the College’s costs and expenses incurred in conducting the hearing.
  3. Require the Member to reimburse the College for funding provided for therapy and counseling for patients who were sexually abused by the member.