Topic: Sexual Relationships with Patients/Former Patients
Notice: A physical therapist sent the Ethics and Judicial Committee an ethics inquiry by e-mail dated May 23, 2001. Below is the text of the Committee's response of August 3, 2001 (not including the identity of the requester):
Dear [name deleted]
In your email of 05/23/2001 to the General Counsel of the American Physical Therapy Association (APTA), you raised certain questions concerning the Guide for Professional Conduct (GPC or Guide), a document of the APTA Ethics and Judicial Committee (EJC or Committee) that interprets the Association's Code of Ethics (HOD 06-00-12-23) (Code). Your ethical questions related to Guide § 2.1.C, which states that a physical therapist "shall not engage in any sexual relationship or activity, whether consensual or nonconsensual, with any patient while a physical therapist/patient relationship exists."
You asked, first, whether a physical therapist may engage in a sexual relationship with a person who was a patient if the therapist first transfers the care of the patient to another therapist. The therapist in your question transferred the care of the patient in order to enable him/herself to initiate a relationship without violating the ethical prohibition against having a sexual relationship with a patient.
Your second question related to a physical therapist who never has been responsible for a person's care. You asked whether such a physical therapist would be acting unethically if he/she had a sexual relationship with the person while that person received therapy (presumably from another physical therapist or rehabilitative professional) at the facility that employs the therapist having the sexual relationship.
Your third question related to physical therapy aides. The Committee understands the question to be (i) whether a physical therapy aide has an ethical obligation to avoid any sexual relationship with a person who is a patient at the facility that employs the aide or (ii) whether a physical therapist with a supervisory role vis-à-vis the aide has an ethical responsibility to make reasonable efforts to ensure that the aide does not have a sexual relationship with any person who is a patient at the facility.
In addition to the foregoing ethical questions, you posed a risk-management question relating to a physical therapist's treating a patient while alone with the patient in a room. You referred specifically to a patient being treated for pelvic floor or structural integration in a private room, particularly by a physical therapist of the opposite sex. You asked whether the APTA has any recommendations with respect to such treatment.
The Committee, in considering the ethical questions you have raised, starts with the recognition that the relationship between a physical therapist and a patient/client is one of the most intense among health care disciplines, given the length of time the physical therapist may be in close physical contact with patients (Scott R, 1998). Patients must be considered vulnerable within this patient/therapist relationship due to their level of trust in the therapist and the power differential inherent in the relationship. Furthermore, during the process of examination and evaluation, the physical therapist may elicit significant personal information from patients, including the sharing of private and perhaps intimate aspects of their life. As a result of this process, some patients may develop a degree of affection for the therapist.
A physical therapist stands in a relationship of trust to each patient and has an ethical obligation to act in the patient's best interest and to avoid any exploitation or abuse of the patient. Thus, if a physical therapist has natural feelings of attraction toward a patient, he/she must sublimate those feelings in order to avoid sexual exploitation of the patient. (R. Scott, 1993).
The APTA's Code emphasizes that a physical therapist has a responsibility to put the patient's interests first and to avoid exploitation of the patient's vulnerability. Principle 1 of the Code states, "A physical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care." Principle 2 states "A physical therapist shall act in a trustworthy manner towards patients/clients, and in all other aspects of physical therapy practice." The Code also exhorts physical therapists to "maintain and promote high standards for physical therapy practice." Code, Principle 6.
The Ethics and Judicial Committee has interpreted as follows the obligation under Principle 1 to respect a patient's rights and dignity and to provide compassionate care:
A physical therapist shall be guided by concern for the physical, psychological and socioeconomic welfare or patients/clients.
Guide § 1.1.B. Given the vulnerability of the patient, the Principle 2 obligation to act in a "trustworthy" manner is particularly relevant to the question of a physical therapist's having a romantic/sexual relationship with a patient. With regard to trustworthiness, the Guide for Professional Conduct says:
A. To act in a trustworthy manner the physical therapist shall act in the patient's/client's best interest. Working in the patient's/client's best interest requires knowledge of the patient's/client's needs from the patient's/client's perspective. Patients/clients often come to the physical therapist in a vulnerable state and normally will rely on the physical therapist's advice, which they perceive to be based on superior knowledge, skill, and experience. The trustworthy physical therapist acts to ameliorate the patient's/client's vulnerability, not to exploit it.
B. A physical therapist shall not exploit any aspect of the physical therapist/patient relationship.
C. A physical therapist shall not engage in any sexual relationship or activity, whether consensual or nonconsensual, with any patient while a physical therapist/patient relationship exists.
Guide § 2.1.A-C. With respect to the Principle 6 obligation to promote high standards of physical therapy practice, the Guide does not contain language that explicitly addresses the issue of romantic/sexual relationships with patients. The Committee would point out, however, that maintenance of the proper therapeutic relationship is important to engendering trust on the part of patients. Physical therapists in any practice setting should conduct themselves in a manner designed to earn the trust of all patients. Any evident failure on the part of a physical therapist to observe the proper boundaries with a patient is likely to have an adverse effect on all other patients aware of the unprofessional behavior. In short, a physical therapist who forms a romantic/sexual relationship with a patient is not promoting the "high standards" of practice that all physical therapists should model.
A. Relationship With Former Patient
The Guide states that a physical therapist may not enter into a sexual relationship "while a physical therapist/patient relationship exists." Guide § 2.1.C. Your first ethics question goes to the permissibility of a physical therapist's initiating a romantic/sexual relationship with a patient after he/she transfers the care of that person to another therapist, acting with the purpose of removing the ethical obstacle to initiating such a personal relationship. The question presupposes that the therapist has stopped treating the patient and has taken steps to transfer his/her care to another therapist - a matter that carries its own ethical responsibilities, discussed below. On the assumption that the physical therapist has taken appropriate steps to transfer the patient to another physical therapist, the question is whether he/she is thereupon relieved of the § 2.1.C obligation to refrain from having a sexual relationship.
The Committee has struggled with the question as to when the restriction in Guide § 2.1.C should be deemed to end. Of course, the restriction obviously applies for as long as the physical therapist continues to treat the patient. Whether the relationship extends beyond the date of the last treatment is a thornier question.
In a certain obvious sense, the patient/physical therapist relationship could be said to end once the therapist stops treating the patient. In addition, the Committee recognizes that interpreting § 2.1.C to mean that the restriction terminates upon the last treatment date would have the virtue of giving relatively clear guidance to physical therapists who strive in good faith to comply with the Guide.
However, the Committee is not willing to say that the § 2.1.C restriction ends once the final treatment session has been concluded. The Committee is troubled by the suggestion that a person deemed to be too vulnerable on Monday would somehow cease to be too vulnerable on Tuesday simply because his/her last treatment occurred on Monday. As explained above, the basic rationale for the §2.1.C restriction is that a patient has (or is likely to have) such a special vulnerability vis-à-vis his/her physical therapist that the risk of exploitation inherent in forming a romantic or sexual relationship is too great to be tolerated. The vulnerability surely is not something that dissipates immediately at the end of the final treatment session, and the Committee is unwilling to adopt a bright-line rule that §2.1.C ceases to apply at that moment. Such an interpretation, frankly, seems certain to be at odds with the reality that justifies the restriction.
The Committee does not believe it feasible to establish any bright-line rule for when, if ever, initiation of a romantic/sexual relationship with a former patient would be ethically permissible. As indicated, the rationale for obstructing such relationships is the risk that the patient "who comes to therapy in a vulnerable state" will be exploited by his/her therapist. The Committee agrees with the reasoning of the Council on Ethical and Judicial Affairs (CEJA) of the American Medical Association (AMA), which has stated with regard to physicians that having a sexual or romantic relationship with a former patient is unethical "if the physician uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship." CEJA Opinion E-8.14, Sexual Misconduct in the Practice of Medicine, referring to a CEJA report of the same name. The Committee notes that the Oregon Physical Therapist Licensing Board condemns as unprofessional conduct any sexual contact with a patient, which it views as including "[e]ntering into a sexual or romantic relationship with a former patient, if facilitated by the former patient's trust or attraction rising out of the therapeutic relationship."
The Committee does not believe that resort to any arbitrary period of time (e.g., three months or two years) can answer the question whether initiation of a romantic or sexual relationship with a former patient would be permissible. The determination whether the physical therapist is/would be using/exploiting trust, knowledge, and/or influence derived from the therapeutic relationship depends on circumstances unique to the particular case. The Committee does not believe that the passage of time, by itself, can provide assurance against the possibility of exploitation of the former patient. The key factors relate to the patient and the character of the relationship during physical therapy, not the mere chronological distance from the last treatment session. The Committee imagines that in some cases a romantic/sexual relationship would not offend § 2.1.C if initiated with a former patient soon after the termination of treatment, while in others such a relationship might never be appropriate.
The determination whether initiating a romantic/sexual relationship with a former patient would be permissible depends not on a quantitative measure of the time since the last treatment session but rather on a host of qualitative circumstances relating to the patient, the physical therapist, and the relationship between them. Disparity between the power, status, and emotional vulnerability of the former patient and that of his/her physical therapist undoubtedly is an indicator of the likelihood that a romantic/sexual relationship would be exploitative. Questions such as the following may be useful in assessing the risk of exploitation:
- Is the age difference between the physical therapist and the former patient substantial?
- Is the patient considerably poorer or less well educated than the physical therapist?
- Does the patient have major psychiatric or psychological problems? Does he/she have problems of substance abuse?
- Has the patient been the victim of abuse, especially sexual abuse?
- Is the patient particularly lonely or extremely shy?
- Is the patient suffering from a separation or divorce, death of a loved one, or economic difficulties?
The physical therapist s own circumstances also are potentially relevant. For example, if the therapist him/herself is in the midst of a personal crisis of some sort the risk of exploitation of the former patient might be greater than otherwise. A physical therapist contemplating a romantic/sexual relationship with a former patient certainly would do well to consider factors such as those sketched above. Such a physical therapist also might do well to consult with a trusted colleague before initiating a romantic/sexual relationship.
As noted, a physical therapist's decision to stop treating a patient always has ethical implications. Some responsibilities apply without regard to the therapist's reason for ceasing to treat the patient. When the decision is precipitated by some romantic/sexual attraction to a patient, the decision to transfer the patient's care raises special considerations that the physical therapist should keep in mind.
As a threshold matter, although continuity of care is generally desirable, the Committee believes that when a physical therapist feels a strong attraction to a patient a determination to transfer the patient may be warranted or even necessary. Of course, the Committee does not believe that a physical therapist should choose lightly to stop treating a patient. However, a physical therapist needs to be honest about his/her own feelings, and if he/she truly feels unable to continue both treating a patient and honoring his/her obligation under §2.1.C, then he/she should take steps to transfer the patient to the care of another therapist (assuming that the patient still needs physical therapy).
In connection with a decision to stop treating a patient the Guide counsels, "In the event the physical therapist or patient terminates the physical therapist/patient relationship while the patient continues to require physical therapy services, the physical therapist should take steps to transfer the care of the patient to another provider." Guide § 2.1.E. When a patient is in need of additional physical therapy, the obligation to take reasonable steps to transfer his/her care applies without regard to the physical therapist's motive for terminating the physical therapist/patient relationship.
The determination as to where a patient should be referred is a practical one that the physical therapist must make with regard to the circumstances and with the patient's interests ever foremost in mind. If the patient's condition required particular skills/expertise not held by other therapists at the site, the referring therapist would be ethically obligated to refer the patient to another clinic, where the necessary skill/expertise would be available, in order to act in the best interests of the patient.
If there were another therapist available at the clinic with the particular skills/expertise required for the patient's care, then the referring therapist could satisfy his/her § 2.1.E obligation by referring the patient to that other therapist. However, because ethics involve practical matters the referring physical therapist should be cautious about referring the patient to another therapist at the same clinic in any case where the physical therapist has a romantic/sexual interest in or attraction to the patient.
For example, in a small clinic, if therapist B (now assuming care for the patient) is absent or unable to treat the patient in question on a particular day, would the patient have to forgo treatment (not in the best interest of the patient) in order to avoid being seen by therapist A, the one who is attracted to the patient? In a large or multi-site clinic, the option for the patient to be seen by other qualified therapists could more likely support the best interests of the patient, and buffer any clinical interaction with the former therapist. Unique elements of the clinical environment or structure however, could potentially result in a scenario where the therapist in question might be drawn into involvement in some aspects of the patient's care - involvement that would be clearly unethical if the therapist had entered into a romantic/sexual relationship with the "former" patient and that might be very imprudent even in the absence of such a relationship.
B. Relationship With Colleague's Patient
Your second question involves a physical therapist and a person for whose care the therapist never has been responsible. We understand your question to be (i) whether such a physical therapist may initiate a sexual relationship at a time when the person is a patient at the clinic that employs the non-treating therapist or, (ii) alternatively, whether such a physical therapist may continue the sexual relationship (or continue the employment) in case the sexual relationship began before the person came to the clinic.
As a theoretical matter, the Committee sees no reason why the § 2.1.C restriction should be deemed applicable with respect to a person who never has been the physical therapist's patient. The mere fact that a person is a patient of a physical therapist's co-worker(s) does not mean that the person is vulnerable vis-a-vis the non-treating physical therapist in the way a patient is.
Nevertheless, the Committee would point out that the existence of a romantic/sexual relationship between a non-treating physical therapist and a person who is a patient at the clinic that employs the therapist is a circumstance that easily can have ethical repercussions.
In particular, the physical therapist(s) responsible for the patient's care has an ethical obligation under Guide § 2.3 to preserve his/her confidences. As a practical matter, if the treating physical therapist(s) were aware of the romantic/sexual relationship, he/she might have to be especially careful not to disclose confidential information to the non-treating therapist. Similarly, the non-treating therapist might face an unusual temptation to utilize his/her position on the professional staff to gain access to confidential information to which he/she should not have access.
Another troublesome possibility is that, in some clinics at least, the physical therapist who has the romantic/sexual relationship might find it difficult, as a practical matter, to avoid having some role in the care of the person with whom he/she has the relationship. See the discussion above concerning the practical difficulty of avoiding such entanglements following the referral of a patient to another therapist employed at the same facility as the referring therapist.
Complications such as these make clear that a clinic's treating a patient who happens to have a romantic/sexual relationship with a non-treating physical therapist is a comparatively risky course. If a clinic decides to countenance such a situation both the treating and non-treating physical therapists should be at pains to avoid the ethical pitfalls.
C. Relationships Between Patients and Aides
Your third ethical question goes to physical therapy aides. In particular, you raise the question whether a physical therapy aide has an ethical obligation to refrain from having a sexual relationship with a person who is a patient at the facility that employs the aide. Your email raises the related question whether a physical therapist has any ethical responsibility to institute (or lobby for) a policy prohibiting an aide from having a sexual relationship with any person who is a patient at the facility.
As a threshold matter the Committee understands its mission to be to interpret the ethical principles and standards applicable to physical therapists and physical therapist assistants. The Committee does not believe that it makes sense for it to speak of the ethical obligations of physical therapy aides, but only to comment on the ethical responsibilities of physical therapists (and physical therapist assistants) that may relate to the presence and activities of aides in a clinic.
The Committee is reluctant to say that a physical therapist has an ethical obligation to institute (or lobby for) a policy prohibiting an aide from having a sexual relationship with a patient. The Committee recognizes that a physical therapy aide may provide support for patient-related duties under the continuous supervision of the physical therapist. Although the Guide makes no reference at all to physical therapy aides, § 4.2.A says that the "supervising physical therapist has primary responsibility for the physical therapy care rendered to a patient/client," and this statement implies that the physical therapist is responsible for taking reasonable measures to ensure that support personnel do not act in a way injurious to patients (e.g., by disclosing patient confidences).
A clinic's adoption of a policy prohibiting physical therapy aides from having romantic/sexual relationships with patients might be an eminently prudent risk-management step, and it certainly would not be ethically objectionable. Indeed, some ethical considerations obviously tend to recommend such a policy. As noted above, physical therapists are obliged to act in the best interests of patients and to promote high standards of physical therapy practice. The Committee believes that fostering patient trust is extremely important. It has no doubt that if physical therapy aides are free to "and do" engage in romantic/sexual relationships with patients, such social behavior may create an atmosphere that is not conducive to generating patient confidence, even if all of the clinic's physical therapists scrupulously honor their ethical obligations under §2.1.C of the Guide. Thus, a policy against socializing between physical therapy aides and patients well might support the goals of Principle 2 (trustworthiness) and Principle 6 (high practice standards) of the Code.
Nevertheless, the Committee is not prepared to say that every clinic (more accurately, every physical therapist with supervisory authority) has an ethical obligation to adopt and enforce a policy prohibiting physical therapy aides from entering into romantic/sexual relationships with patients. The Committee is not sure that a patient's vulnerability vis-à-vis an aide is sufficiently similar to his/her vulnerability vis-à-vis a therapist to justify a requirement that physical therapists endeavor to extend the § 2.1.C restriction to physical therapy aides. The Committee's unwillingness to declare that every physical therapist must impose (or lobby for) such a policy does not mean that the Committee favors freewheeling socialization between aides and patients. On the contrary, as noted above, ethical considerations favor a restrictive approach.
D. Risk Management Issues
Your email asked whether the APTA has any recommendations relating to therapists' treating patients in a private room, specifically when the care involves touching a patient's intimate or private body parts. In this connection the Committee does not understand you to be asking for an ethical interpretation but rather to be seeking primarily risk-management guidance. The Ethics and Judicial Committee is not the APTA's expert on risk management, and it would suggest that you contact the Association's Insurance and Member Benefits Department for guidance.
Your topic does have some ethical implications, and the Committee presents the comments below for your information.
A physical therapist should recognize that touch, in the context of physical therapy examination and intervention, has the potential to be perceived by a patient as erotic or intrusive rather than therapeutic (Schunk C, Parver CP, 1989). The literature strongly supports the benefits of touch as an integral component of physical therapy intervention. However, even perfectly therapeutic touch may offend a patient and lead to charges of misconduct if it crosses a patient's/client's boundaries for intimacy.
Prudent guidelines can lessen the chance of such offense and thus serve the interest of both patient and physical therapist. Over the years, the APTA has included such guidelines in its publications, and other professional resources also present similar guidelines. (See selected references below). Basic risk management guidelines for avoiding allegations of sexual misconduct relating to therapeutic touch include:
- Follow a practice of telling your patients in advance what hands-on examination and intervention procedures you intend to perform and why you intend to use them. Such communication has an ethical dimension. See Guide § 2.4, Patient Autonomy and Consent. It also serves a risk management function, because when a patient understands the rationale for touch associated with the specific procedures, misunderstandings regarding the nature of therapeutic touch are much less likely to arise.
- Provide a same-gender chaperone during patient examination and intervention if requested by the patient or deemed necessary by the therapist
- Implement "knock-and-enter" policies for staff entering a closed-door area used for patient examination and intervention.
Selected resources include:
Purtillo R, A. Haddad. Chapter 13 - The Importance of Recognizing Boundaries, in Health Professional and Patient Interaction, 5th Ed., WB Saunders Co. Philadelphia, 1996.
Schunk, C, Parver CP. Avoiding allegations of sexual misconduct. Clinical Management. 1989; 9(5):22.
Scott R. Habits of Thought: Sexual Misconduct. PT Magazine. October 1993, pp 78-79.
Scott R. Professional Ethics: A Guide for Rehabilitation Professionals. Mosby Co. St. Louis, MO. 1998, pp 132-145.
CEJA Opinion E-8.21, Use of Chaperones During Physical Exams, and the underlying report of the same name, The CEJA Opinions are available in the AMA's online PolicyFinder.
The Committee hopes that this letter is responsive to your concerns. If you have further questions you may communicate them through the APTA's General Counsel, John J. Bennett.
Deborah H. Shefrin, PT, JD
APTA Ethics and Judicial Committee