Article
Sexual boundary violations in the doctor-patient relationship have wide-ranging negative consequences and can impact patients' health, work capacity and relationships with family and friends.
Sexual boundary violations (SBVs) in relationships between patients and healthcare personnel are associated with a range of different reactions and emotions in the patients concerned. Such experiences can be difficult to report and have serious consequences for the patients' life and health, both in the short and long term.
In recent years, the Varhaug and Frosta cases in Norway have shed light on the potential consequences of healthcare personnel breaching professional boundaries and sexually violating patients. These cases have garnered considerable media attention, and prompted a critical examination of the legislation and the practices of supervisory authorities. The Norwegian Board of Health Supervision has conducted an internal review of cases investigated by the supervisory authority in which healthcare personnel have had a sexual relationship with a patient/service user or committed an SBV (1) . The Committee for the Abuse of Patients by Healthcare Personnel (Pasientovergrepsutvalget ) examined SBVs in the health and care sector in the period 2010–2020, including the Varhaug case and other cases, with a view to changing such practices (2) . The Norwegian Healthcare Investigation Board (NHIB) recently presented the report Abuse disguised as treatment , which is about healthcare workers subjecting patients to sexualised actions (3) .
The purpose of these reports was to assess whether there is uniform management of cases investigated by the supervisory authority (1) , assess the case management of the abuse of patients by healthcare personnel (2) , and help prevent healthcare personnel from subjecting patients to sexualised behaviour (3) . Although the patient perspective is addressed to some extent (for instance, NHIB's report describes the burden on patients to report such behaviour), it is beyond the scope of the reports to examine the current knowledge status on the consequences of SBVs for patients. SBVs by healthcare personnel can have similar consequences as other forms of sexual abuse (4) and can resemble abuse in other asymmetric power relations (5) . However, some consequences are specific to this context.
Reactions to boundary violations
Reactions to boundary violations
SBVs in relationships between healthcare personnel and patients can take various forms. The Norwegian Board of Health Supervision deals with cases ranging from romantic relationships to SBVs and sexual violence (1) . Patients' reactions can depend on the severity of the behaviour, but even minor boundary violations are associated with considerable negative effects for patients (6) . In cases involving romantic relationships, patients' reactions may be more ambivalent and less emotionally distressing – at least in the short term (7) .
Patients' fear of illness, combined with trust in the care provided by the healthcare personnel, makes them more susceptible to being persuaded to undergo examinations and treatment
Patients can be unsure about whether what is happening constitutes abuse. They may question their own interpretations and assessments of the situation. The fundamental trust that is necessary for a successful therapeutic relationship can lead patients to doubt their own experience, even when something happens that they suspect is unprofessional. Patients' fear of illness, combined with trust in the care provided by the healthcare personnel, makes them more susceptible to being persuaded to undergo examinations and treatment. Examples of this are found in the testimonies from the Frosta case, where a description is given of how the doctor talked about cancer to patients and reassured them that he was simply being thorough while repeatedly subjecting them to invasive and painful examinations (8) . A similar example is seen in a British case, where a patient stated that the doctor exploited her fear of cervical cancer to gain control over her and subject her to frequent and unnecessary examinations (9) .
Difficult to report
Difficult to report
Healthcare personnel who commit SBVs can instil fear in patients through manipulative or threatening behaviour, and patients may rightfully be concerned about not being believed if they report what is happening to them (10) . Patients with mental illnesses are particularly at risk of not being believed. Unfortunately, there are numerous instances where psychiatrists have continued to abuse multiple patients over extended periods because those who reported the incidents were not taken seriously (11) .
Patients may also have limited awareness of reporting procedures, including where and to whom they can report such incidents. They may be unsure of the potential consequences for themselves and the person involved, as well as how it could affect both their own family and friends and those of the person being reported. They may also fear media attention if the case becomes public knowledge.
Intense emotional reactions
Intense emotional reactions
Being subjected to an SBV can lead to intense emotional reactions. A US study from 2001 reported that participants who had been in sexually exploitative situations experienced a wide range of distressing and sometimes life-threatening emotions and symptoms during and after the incidents (12) . Even patients who were under anaesthesia when subjected to an SBV experienced severe reactions, such as panic attacks, nightmares and increased risk of suicide. A quarter of the participants had to be hospitalised, mostly due to depression, suicidal ideation or attempted suicide (12) .
A quarter of the participants had to be hospitalised, mostly due to depression, suicidal ideation or attempted suicide
SBVs frequently lead to depression and increased risk of suicide (13) . Therapist-patient sex syndrome was first discussed in the 1980s (14) and consists of ten aspects: ambivalence, a sense of guilt, feelings of emptiness and isolation, sexual confusion, impaired ability to trust, identity, boundary and role confusion, emotional lability (including depression), suppressed rage, increased suicide risk and cognitive dysfunction. Some sources also highlight other potential reactions to SBVs, such as patients doubting their own sense of reality (15) or experiencing deep mistrust, grief and shame (16) .
Inadequate health care
Inadequate health care
Patients who are subjected to SBVs do not receive adequate health care. SBVs are contrary to professional ethical guidelines and the requirement to provide adequate health services under the Health Personnel Act (1) . In some cases, patients do not receive proper treatment for the health condition that led them to seek help. In certain instances, the underlying health condition worsens, for example in the form of mental health problems such as anxiety and depression (17) . Patients will also suffer harm and emotional distress as a result of the SBVs.
Recent research on the repercussions of SBVs in relationships between healthcare personnel and patients is limited. Even relatively recent articles do not reference sources later than 2010 (18, 19) . However, the academic literature has consistently shown over several decades that the consequences are extremely serious for the patients involved. Both healthcare personnel and patients need to understand that patients can have a wide range of experiences, reactions and emotions when subjected to such behaviour.
Generalised mistrust and reduced work capacity
Generalised mistrust and reduced work capacity
Reduced trust in healthcare personnel in particular, and in others in general, is a common reaction to an SBV (14, 16) . When patients lose trust in health services, they may stop seeking help when needed. As a result, their health could deteriorate significantly due to the lack of appropriate treatment for the primary issue, while the SBV itself may lead to very negative consequences.
When patients lose trust in health services, they may stop seeking help when needed
For some patients who have been subjected to SBVs by healthcare personnel, the resulting lack of trust will extend to other relationships. This generalised mistrust creates problems in relationships with healthcare personnel, but also in other areas. Some patients develop a lasting inability to form close relationships (12) , and others may no longer be able to trust even themselves (13) .
Two-thirds of participants in a study (12) reported a reduced work capacity following an SBV. Reduced work capacity and labour force participation can entail slower career progression than anticipated and adverse effects on earnings. Depression and concentration problems are major contributors to diminished work capacity (12) .
Challenges for subsequent practitioners
Challenges for subsequent practitioners
Patients who seek treatment after experiencing an SBV by a healthcare provider can display significant symptoms of mental illness and functional impairment (20) . They are also susceptible to revictimisation by subsequent practitioners (20) . Meeting other patients with similar experiences can be beneficial (5) , and group counselling or support groups can help reduce the sense of isolation (5) . When multiple patients have experienced an SBV by the same practitioner, it can be beneficial for them to meet and share their experiences (5) . Healthcare personnel can encourage and facilitate these interactions.
For healthcare personnel working with this patient group, it is important to recognise and accept the patients' mistrust (16) . Professional consultation can help healthcare personnel provide the most professional care possible to patients who have previously experienced an SBV (5) . Maintaining a clearly defined professional role is essential, and discussions with patients to clarify expectations and establish professional boundaries in the caregiving relationship can be beneficial (16) . By addressing patients' loss of trust and respecting professional boundaries, healthcare personnel can help provide an appropriate and supportive healthcare provision.