| Sexual Abuse of a Patient
Naturopathic Doctors, along with all health care practitioners, are expected to ensure Ontarians receive health care in a safe and professional environment. Reflecting this expectation, all regulatory health colleges under the Regulated Health Professions Act, 1991 (RHPA) have zero tolerance for client/patient abuse.
This College, like the others, has zero tolerance for sexual abuse and 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.
Incidents of sexual abuse of patients by health care practitioners do occur and the RHPA mandates severe sanctions against members who are found guilty of professional misconduct in connection with sexually abusing patients. The law recognizes the significant harm that results from the sexual abuse of a patient by a health care professional.
It is important for NDs to remember that while the patient-practitioner relationship is based on mutual trust and respect, there is also an inherent power imbalance in favour of the Naturopathic Doctor. As such it is the ND's responsibility to establish and maintain appropriate professional boundaries with patients. This includes refraining from any conduct that is or could be perceived as sexual abuse.
The College has developed a number of standards and guidelines that set out its expectations of members. The standards and guidelines are also intended to assist NDs in providing their services in a way that not only fosters in their patients feelings of trust and safety, but to assist NDs in providing services that are completely professional and place the best interests of their patients as primary.
Legislation and Definition of Sexual Abuse
Sexual abuse of patients is defined in the Health Professions Procedural Code (Schedule 2 of the RHPA), or the Code, as it is generally known. Sexual abuse is described as the following:
- Sexual intercourse or other forms of physical relations between the member and the patient
- Touching of a sexual nature of the patient by the member
- Behaviour or remarks of a sexual nature by the member towards the patient
"Sexual nature" does not include touching, behaviour, or remarks of a clinical nature appropriate to the service provided.
As required by the Code, if a panel of the College's Discipline Committee finds a member has committed an act of professional misconduct by sexually abusing a patient, it may,
- Reprimand the member, or
- 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 of, 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, the panel may,
- Require the member to pay a fine of up to $35,000 to the Minister of Finance of Ontario,
- 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,
- Require the member to reimburse the College for funding provided for therapy and counselling for patients who were sexually abused by the member.
Treating a Spouse
The definition of sexual abuse in the RHPA includes the treatment of spouses, even if there was a pre-existing spousal relationship prior to naturopathic treatment.
The Code defines spouse as a:
- person who is the member's spouse as defined in section 1 of the Family Law Act, or
- person who has lived with the member in a conjugal relationship outside of marriage continuously for a period of not less than three years.
Even though the spouse may have consented to be a patient and receive treatment it is always the responsibility of the Naturopathic Doctor to be aware of the applicable laws. In this case, according to the definition in the legislation, providing naturopathic care to a spouse is considered sexual abuse.
However, in emergency situations where there is no one else available who is qualified to provide the necessary care, Naturopathic Doctors may treat a spouse. The College considers this acceptable because the benefits of providing the required care in emergency situations outweighs the challenges posed by the personal relationship.
Prevention of Sexual Abuse
Along with holding members who commit acts of sexual abuse accountable, as we mentioned above, the College also provides NDs with resources intended to prevent the sexual abuse of patients. One such resource, the Guideline for the Prevention of Sexual Abuse, can be found on the College's website here. Preventing sexual abuse includes establishing the appropriate professional boundaries with patients. Proper boundaries include not only respecting a person's personal physical space, but also taking into account verbal, emotional and cultural matters.
Naturopathic Doctors should be very aware of how they communicate to patients by paying attention to the ways information is conveyed and the words selected. They must be compassionate listeners and sensitive to the concerns and needs of patients. Being aware of language or cultural, and physical barriers that may interfere with clear communications can help Naturopathic Doctors practice in a responsive and responsible manner.
If touching is required during examination or treatment of a patient, explain what is involved and what the patient can expect beforehand in order to avoid any misinterpretation or misunderstanding. Follow the principles of informed consent at all times.
Patients may feel particularly vulnerable in a health care setting and may not always express their concerns. Therefore, use your professional judgment to determine the patient's comfort level and whether the presence of an additional person is advisable in certain circumstances.
Mandatory Reporting of Sexual Abuse of a Patient
As stated in the College's Mandatory Reporting Guideline, all health care practitioners have a responsibility to report sexual abuse.
If you have reasonable grounds, obtained in the course of practicing the profession, to believe that a ND or a member of another college has sexually abused a patient, you are required to report it to the appropriate college. Information regarding the College's complaints and reports process can be found on the website here.
The legislation also states that the patient's name is to be included in the report only if the patient gives consent.
Should you become aware that a patient might have been sexually abuse by a health care professional you need to explain to the patient that you are legally obligated to report this to the provider's regulatory college. Explain that you can only provide the patient's name in the complaint if they consent, however, not providing it may make it more difficult for the college to fully process the complaint.
If the patient does not consent to including their name then the ND must still make the complaint but leave the patient's name out. If the patient consents to including their name this consent should be obtained in writing and kept on file.
The ND should also explain to the patient how they can make a complaint and why they should consider doing so.
A report does not need to be made if the member does not know the name of the alleged abuser, however best efforts should be made to obtain the abuser's identity.
Members need to take this reporting obligation seriously as the College relies on this information to fulfill its mandate. It is important to understand what sexual abuse is and to be able to identify when it may be happening, keeping in mind that sexual abuse often does not start with overt actions on the part of the abuser.
The seriousness of the mandatory reporting requirement is reflected in the timeframes for reporting as stated in the Code as follows:
"The report must be filed within 30 days after the obligation to report arises unless the person who is required to file the report has reasonable grounds to believe that the member will continue to sexually abuse other patients, or that the incompetence or the incapacity of the member is likely to expose a patient to harm or injury and there is urgent need for intervention, in which case the report must be filed forthwith."
The RHPA specifically addresses sexual abuse of patients by members. There may be other types of sexual behaviour that, while not triggering a mandatory report to the College, would still be considered professional misconduct. For example, sexual harassment in the workplace is never appropriate and would be considered unprofessional; however, it does not require a mandatory report. A person who is the subject of or witness to sexual harassment by a member may voluntarily report that behaviour to the College.
Patient Relations Program
Under the RHPA, the College of Naturopaths of Ontario, like every other health regulatory college in Ontario, is required to have a Patient Relations Program. The program provides education and resources to help patients and Naturopathic Doctors to understand proper professional behaviour, and to prevent the sexual abuse of patients.
One component of the program is for the College to maintain a fund intended to cover the costs of any therapy or counselling that patients need as a result of sexual abuse by a Naturopathic Doctor. Patients can request funding from the College which may be provided following a review of eligibility by the Patient Relations Committee.
As regulated health professionals, Naturopathic Doctors have a responsibility to do all that they can to prevent the sexual abuse of patients and to assist health regulatory colleges fulfill their mandate to protect the public and to hold members accountable for their actions.
Member Guide: Guideline for the Prevention of Sexual Abuse
Patient Guide: Understanding Sexual Abuse
Mandatory Reporting Guideline
Standard of Practice for Therapeutic Relationships and Professional Boundaries
Professional Misconduct Regulation
Regulated Health Professions Act and the Health Professions Procedural Code