Sexual Boundary Violations by Health Professionals – an overview of the published empirical literature Mary Halter, Hilary Brown and Julie Stone April 2007 The Council for Healthcare Regulatory Excellence CONTENTS CONTENTS ..................................................................................................2 EXECUTIVE SUMMARY ..............................................................................5 1. .................................................................................................... INTRODUCTION ....................................................................................................................10 1.1 SEXUAL BOUNDARY VIOLATIONS....................................................10 1.2 LITERATURE SCOPING FOR THE CHRE SEXUAL BOUNDARIES PROJECT.............................................................................................12 1.3 KEY FINDINGS ....................................................................................13 2. ................................................................................................................. METHOD ....................................................................................................................14 2.1 SEARCH STRATEGY ..........................................................................14 2.2 SELECTION AND CATEGORISATION OF PAPERS ..........................15 2.3 ISSUES OF DEFINITION .....................................................................16 2.4 LITERATURE REPORT STRUCTURE ................................................18 3. ....................................................................................................... BOUNDARIES ....................................................................................................................19 3.1 INTRODUCTION ..................................................................................19 3.3 DISCOMFORT, ATTITUDES AND LACK OF CLARITY REGARDING BOUNDARY CROSSING .....................................................................21 3.3.1 Introduction....................................................................................21 3.3.2 The studies in detail.......................................................................22 3.3.2.1 Discomfort with sexual issues ................................................22 3.3.2.2 Attitudes to boundary violation ...............................................23 3.4 ATTITUDES TOWARDS PREVENTION AND WAYS TO DECREASE SEXUAL BOUNDARY VIOLATIONS..........................................................29 3.4.1 Introduction....................................................................................29 3.4.2 The studies in detail.......................................................................31 3.4.2.1 Education provision ................................................................31 3.4.2.2 Education impact ....................................................................31 2 3.4.2.3 Empowering the client ............................................................34 4. ............................................... REPORTED PREVALENCE AND INCIDENCE ....................................................................................................................36 4.1 INTRODUCTION ..................................................................................36 4.2 KEY FINDINGS ....................................................................................38 4.3 PREVALENCE REPORTS FROM PROFESSIONALS OF KNOWN SEXUAL CONTACT WITH CLIENTS...................................................39 4.3.1 Overview and limitations................................................................39 4.3.2 The studies in detail.......................................................................39 4.4 PREVALENCE REPORTS FROM PROFESSIONALS CONCERNING THEIR OWN SEXUAL CONTACT WITH CLIENTS .............................42 4.4.1 Overview and limitations................................................................42 4.4.2 The studies in detail.......................................................................44 4.5 PREVALENCE REPORTS FROM CLIENTS OF SEXUAL CONTACT WITH PROFESSIONALS .....................................................................50 4.5.1 Overview and limitations................................................................50 4.5.2 Key findings...................................................................................50 4.5.3 The studies in detail.......................................................................50 4.6 INCIDENCE, AS ASSESSED THROUGH COMPLAINTS OR DISCIPLINARY ACTION ............................................................................53 4.6.1 Overview and study limitations ......................................................53 4.6.2 Key findings..................................... Error! Bookmark not defined. 4.6.3 The studies in detail.......................................................................54 4.7 OTHER AREAS OF SEXUAL BOUNDARY VIOLATION......................58 4.8 CONCLUDING REMARKS...................................................................59 5. ...... THE IMPACT OF SEXUAL BOUNDARY VIOLATIONS ON CLIENTS ....................................................................................................................60 5.1 INTRODUCTION ..................................................................................60 5.2 KEY FINDINGS ....................................................................................60 5.3 THE STUDIES IN DETAIL....................................................................61 3 6. ........ FACTORS ASSOCIATED WITH SEXUAL BOUNDARY VIOLATION ....................................................................................................................64 6.1 INTRODUCTION ..................................................................................64 6.2 KEY FINDINGS ....................................................................................67 6.3 CHARACTERISTICS IN THE PROFESSIONAL ..................................69 6.3.1 Introduction....................................................................................69 6.3.2 The studies in detail.......................................................................70 6.3.2.1 Differences reported in the studies focussing on reported incidence and prevalence .......................................................70 6.3.2.2 Situations in which the professionals find themselves ............71 6.3.2.3 Personality / psychiatric evaluations .......................................72 6.4 CHARACTERISTICS IN THE PATIENT OR CLIENT – CLIENT VULNERABILITY..................................................................................77 6.4.1 Introduction....................................................................................77 6.4.2 The studies in detail.......................................................................77 6.5 THE NATURE OF THE INTERACTION ...............................................80 6.5.1 Introduction....................................................................................80 6.5.2 The studies in detail.......................................................................80 6.6 CLIENT EXPECTATIONS ....................................................................83 6.6.1 Introduction....................................................................................83 6.6.2 The studies in detail.......................................................................83 6.7 COMBINED FACTORS ........................................................................85 6.7.1 Introduction....................................................................................85 6.7.2 The study in detail .........................................................................85 7. .............. MAIN THEMES AND POTENTIAL FOR FURTHER RESEARCH ....................................................................................................................87 7.1 MAIN THEMES.....................................................................................87 7.2 FURTHER RESEARCH NEEDED........................................................89 8. ....................................................................................................... REFERENCES ....................................................................................................................90 4 EXECUTIVE SUMMARY INTRODUCTION Clinical and therapeutic interventions inevitably render individual patients and clients vulnerable, and trust relies on providing a safe and boundaried space in which these can be carried out without compromising the person’s dignity and bodily integrity. Sexual boundary violations occur wherever a clinical or therapeutic relationship is turned into a sexual or sexualised encounter. It is always the responsibility of the practitioner to manage and maintain these boundaries. A scoping of the existing literature was commissioned as one component of the Council for Healthcare Regulatory Excellence’s (CHRE) national project on Clear Sexual Boundaries between health care professionals and patients. The objective was to scan and review current research on sexualised behaviour by health and social care workers towards patients. The review focuses on: • Clarifying the nature of sexual boundary violations • The prevalence of such violations • The impact on patients and clients • Predictors of sexual boundary crossing or violation by