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 Table of Contents    
Year : 2017  |  Volume : 59  |  Issue : 1  |  Page : 14-16
Sexual boundaries in the doctor–patient relationship: Guidelines for doctors

1 Department of Psychiatry; Department of Medical Ethics, St. John's Medical College, Bengaluru, Karnataka, India
2 Department of Psychiatry, St Martha's Hospital, Bengaluru, Karnataka, India

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Date of Web Publication12-Apr-2017

How to cite this article:
Kurpad SS, Bhide A. Sexual boundaries in the doctor–patient relationship: Guidelines for doctors. Indian J Psychiatry 2017;59:14-6

How to cite this URL:
Kurpad SS, Bhide A. Sexual boundaries in the doctor–patient relationship: Guidelines for doctors. Indian J Psychiatry [serial online] 2017 [cited 2021 Jul 24];59:14-6. Available from:

   Background to the Framing of Guidelines Top

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 Top

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 [Boxe 1] and [Boxe 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.

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 Top

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.

   References Top

Kurpad SS, Machado T, Galgali RB. Is there an elephant in the room? Boundary violations in the doctor-patient relationship in India. Indian J Med Ethics 2010;7:76-81.  Back to cited text no. 1
Khan M. Boundary violations and the “curtain of culture”. Indian J Med Ethics 2010;7:172.  Back to cited text no. 2
Bhan A. Boundary violations in patient care: Need for evolving professional practice standards and training. Indian J Med Ethics 2010;7:192.  Back to cited text no. 3
Bangalore Declaration Group. A consensus document requesting the Medical Council of India to take action on the issue of boundary violations in doctor-patient relationships. Natl Med J India 2012;25:96-8.  Back to cited text no. 4
Reforms in Undergraduate and Postgraduate Medical Education. Vision 2015. Medical Council of India; 2011. p. 18. Available from: [Last accessed 2016 Nov 30].  Back to cited text no. 5
Medical Council of India Regulations for Graduate Medical Education; 2012. p. 5. Available from: [Last accessed 2016 Nov 30].  Back to cited text no. 6
Code of Ethics Regulations, 2002, Amended 2009. (Medical Council of India). Available from: [Last retrieved on 2016 Nov 30].  Back to cited text no. 7
Pulla P. Medical Council of India is corrupt, says health minister. BMJ 2014;349:g4762.  Back to cited text no. 8
Mani MK. Boundary violation? Indian J Med Ethics 2011;8:62-3.  Back to cited text no. 9
Pandya SK. Commentaries. National Medical J India 2012;25:98.  Back to cited text no. 10
Nundy S. Commentaries. Natl Med J India 2012;25:98-9.  Back to cited text no. 11
The Bangalore Declaration Group. Boundary violations. Our reply to the commentaries on the Bangalore declaration. Natl Med J India 2012;25:311. Available from: [Last accessed 2016 Nov 30].  Back to cited text no. 12
Brooks E, Gendel MH, Early SR, Gundersen DC, Shore JH. Physician boundary violations in a physician's health program: A 19-year review. J Am Acad Psychiatry Law 2012;40:59-66.  Back to cited text no. 13
Kurpad SS, Machado T, Galgali RB, Daniel S. All about elephants in rooms and dogs that do not bark in the night: Boundary violations and the health professional in India. Indian J Psychiatry 2012;54:81-7.  Back to cited text no. 14
  [Full text]  
Muller M, editor. The Sacred Books of the East. The Laws of Manu. Translated by various authors. Vol. 45. Oxford: Clarendon Press; 1886. p. 83.  Back to cited text no. 15
The Bangalore Declaration Group and The Indian Psychiatric Society (IPS) Task Force on Boundary Guidelines. Guidelines for doctors on sexual boundaries. 2016. Available from: [Last accessed on 2017 Mar 28].  Back to cited text no. 16
The Bangalore Declaration Group and The Indian Psychiatric Society (IPS) Task Force on Boundary Guidelines. Guidelines for doctors on sexual boundaries. Version 3.4. IPS Task Force on Boundary Guidelines. 2016. Available from: [Last accessed on 2017 Apr 4].  Back to cited text no. 17

Correspondence Address:
Sunita Simon Kurpad
Department of Psychiatry, St. John's Medical College, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/psychiatry.IndianJPsychiatry_353_16

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