“When a yes should mean no”: doctors and boundaries.

We thank Dr Bhan for his letter in response to our paper ‘Elephant in the room’. He has correctly noted that even what might be described as consensual acts of sexual boundary violations (SBVs) between doctors and their patients are not truly so due to the power differential in their relationship. This is why our paper points out that “consensual” acts of SBVs with adults are considered unethical but not illegal — barring issues around the law on adultery in India at present. We refer to “consensual” within inverted commas, as the validity of consent for such acts is questionable because the patient might have said “yes” — or at the minimum did not say “no” — because of transference issues. Transference reactions are the attitudes and feelings patients bring into the relationship based on their relationship with significant others in their life.

Is there an elephant in the room? Boundary violations in the doctor-patient relationship in India.

An anonymous postal survey on the awareness of the occurrence of nonsexual and sexual boundary violations (NSBV and SBV) in the doctor-patient relationship in India was conducted with psychiatrists and psychologists working in the state of Karnataka in India (n=51). Though this was not designed to be a prevalence study on violations, the results suggest that both NSBV and SBV do occur and, more importantly, respondents felt that this is an area which needs urgent attention in India. There was disagreement on whether some behaviours in certain situations could be construed as NSBV in the Indian culture. Though several respondents agreed that there was a need to develop guidelines on this issue in India, there was a perception that the problem was not in the availability of guidelines but in their implementation. The ethical implications of the study are discussed.