A Guide for Patients: Protecting Patients from Sexual Abuse or Misconduct

What Can Patients Expect from Their Physiotherapist?

Click here to read the guide as a PDF.

Physiotherapy is a self-regulating profession. All physiotherapists must be registered with Physiotherapy Alberta if they want to deliver physiotherapy services in the province. As regulated health professionals, physiotherapists are required to comply with the Standards of Practice, Code of Ethical Conduct, and legislation relevant to their practice. This includes the rules established by Bill 21: An Act to Protect Patients and the Health Professions Act.

Physiotherapy Alberta’s role is to register qualified and competent physiotherapists, administer a continuing competence program, and promote and advocate for excellence in physiotherapy practice. We also set and enforce practice and professional standards and investigate complaints from patients and members of the public.

On November 19, 2018, the Government of Alberta passed Bill 21: An Act to Protect Patients. The Bill set out several changes to the Health Professions Act (HPA), the legislation that physiotherapists and other regulated health professionals must comply with. These changes were made due to concerns about sexual abuse and sexual misconduct of patients by health professionals. These issues are important to Physiotherapy Alberta - College + Association (Physiotherapy Alberta). They are also issues of broad concern to the public. To be clear, sexual misconduct and sexual abuse of patients by physiotherapists were always against the Standards of Practice and Code of Ethical Conduct of Physiotherapy Alberta.

What the legislation does is:

  • Require health-care regulatory colleges to define the term patient and when a patient/provider relationship (also known as a therapeutic relationship) exists.
  • Define in detail the behaviours that constitute sexual misconduct and sexual abuse (for the complete definitions of sexual abuse and sexual misconduct as found in Bill 21, see Appendix 1).
  • Set minimum mandatory penalties for regulated health professionals found to have engaged in sexual misconduct or sexual abuse of patients.
  • Direct how health-care regulatory colleges are to conduct investigations and hearings when complaints include a component of sexual misconduct or sexual abuse.  

In short, physiotherapists are not allowed to engage in any form of sexual relationship with a patient. They are also not allowed to engage in behaviours or comments that are sexual in nature that they know or ought to know will cause offence or humiliation to the patient or negatively affect the patient’s health and well-being.

Physiotherapy is a diverse profession. Physiotherapists work with patients from across the lifespan, from the very young to the very old. Physiotherapists work in a range of healthcare and community settings, and work with people who have a wide range of health concerns. This makes it challenging to describe what patients can expect from their physiotherapist, as there will be some variation in the patient experience depending on why you are seeking physiotherapy services.

One thing is consistent - physiotherapy is a touching profession. Much of what physiotherapists do in their day-to-day practice involves the use of touch to assess and treat movement and movement problems. This includes feeling for changes to body tissues or limitations in movement, feeling swelling or muscle tightness, and the use of hands to move muscles and joints to improve flexibility or to assist with activities such as exercise. Physiotherapists frequently work in close proximity to people, commonly within what would be considered personal space in a social setting.

With that in mind, it’s reasonable to ask what constitutes appropriate or inappropriate touch in physiotherapy practice.

Appropriate touch:

  • The purpose has been explained and is consistent with the reason you came to see the physiotherapist. If the purpose is not obviously consistent with the reason you came, the physiotherapist explained why what they want to do is necessary.
  • You granted permission.
  • Lasted for the duration necessary for the stated purpose and no longer.
  • Ended if or when you said stop.

Inappropriate touch:

  • The purpose has not been explained or is not consistent with the reason you came to see the physiotherapist.
  • You did not grant permission.
  • Continued longer than the duration necessary to complete the assessment or treatment.
  • Did not stop when you said stop.

 

Physiotherapists should be aware of non-verbal cues that may signal discomfort and should follow up to find out the source of discomfort (physical discomfort related to treatment versus discomfort with being touched). Examples of these non-verbal cues include:

  • A startle reaction
  • Withdrawing from touch
  • Tensing when touched

However, despite their best efforts, physiotherapists may not always note and respond to such non-verbal cues. If you are uncomfortable at any time with what your physiotherapist is doing, it is important that you speak up and tell them to stop.

You do not need to provide a reason, but it may help your physiotherapist to plan for future treatments or offer other options if you can explain why you asked them to stop.

If you are a survivor of sexual abuse or other interpersonal violence it will help your physiotherapist to plan their treatment approach if you disclose this to them. You do not have to provide details of your history, but by identifying that you are a survivor and any triggering actions, situations or words your physiotherapist should be able to plan accordingly to avoid causing you distress. They will also be aware of the need to monitor your response to treatment more closely and work with you to develop a signal that you can use to indicate when you need the physiotherapist to stop what they are doing.

Physiotherapists are expected to create an environment where you feel safe, are encouraged to speak up when uncomfortable, and in which your discomfort is taken seriously and responded to appropriately.

Physiotherapists build effective working or therapeutic relationships with their patients through the course of treatment. Research has demonstrated that effective therapeutic relationships have an important positive influence on treatment outcomes.

Physiotherapists are also required to establish and maintain appropriate professional boundaries with their patients. When appropriate boundaries are in place, they help the physiotherapist to establish an effective therapeutic relationship and enable quality physiotherapy care. When boundaries are not maintained, the line between professional and personal relationships can be blurred leading to problems including:

  • Inappropriate behaviour
  • Taking short cuts or making assumptions in assessments, treatments or communications
  • Allowing professional judgment to be affected by the personal relationship

These problems can lead to poor outcomes and a loss of trust in the physiotherapist and the health-care system in general.

Effective therapeutic relationships differ from personal relationships in several ways.

Professional relationship:

  • Limited to the duration of treatment
  • Limited to the treatment location
  • To provide physiotherapy services to the patient
  • Organized around the provision of physiotherapy services
  • Unequal. The physiotherapist is in a position of power, having more knowledge, influence, and access to private information
  • The physiotherapist is primarily responsible to establish and maintain the professional relationship
  • The physiotherapist offers their training and experience and the patient places their trust in this
  • The physiotherapist receives payment for patient care

Personal relationship

  • No limit - may be lifelong
  • No restriction, anywhere
  • Pleasure, companionship
  • Unstructured
  • Shared power
  • Shared
  • Equal
  • Shared

There is also an inherent power imbalance between you and your physiotherapist. This power imbalance is due to the physiotherapist’s unique knowledge and skills, their access to your private information, and your reliance on them for care. While physiotherapists must be mindful of and seek to equalize the balance of power in the therapeutic relationship, it is acknowledged that this is never fully achieved.

This power imbalance means that physiotherapists must avoid circumstances in which they may use that power inappropriately, realizing that you are in a vulnerable position when seeking care.

Due to the risks of combining personal and professional relationships, physiotherapists need to avoid personal relationships with their patients outside of work, personal contact through social media, and treating people with whom they have a close personal relationship. Sometimes the physiotherapist may not be able to avoid treating people with whom they have a personal relationship. If this happens, the physiotherapist needs to be very careful to develop and maintain an appropriate therapeutic relationship and professional boundaries.

Under the rules established by Bill 21 and Physiotherapy Alberta’s Standards of Practice, the physiotherapist must avoid sexual relationships with current patients or patients they have treated within the last year. It does not matter if you are the one making the advances, are an adult, and provide consent to the relationship. The legislation is very clear - if the physiotherapist engages in the sexual relationship, they are breaching their professional obligations and may permanently lose their license to practice.

You can expect your physiotherapist to conduct themselves professionally and work to help you address your health concerns. When seeing a physiotherapist, you can expect them to:

  • Treat you with respect and empathy.
  • Maintain professional boundaries appropriate to the therapeutic relationship.
  • Clearly explain the assessment tools or techniques they wish to use and their purpose.
  • Solicit and answer any questions you may have about the assessment.
  • Obtain your consent before beginning the assessment and confirm your ongoing consent during the assessment.
  • Clearly explain what the assessment findings indicate and the proposed treatment plan to address the issues identified, including:
    • The nature and purpose of the treatment
    • The risks and benefits of the treatment proposed
    • Any treatment options
    • The consequences of agreeing to or declining the proposed treatment
  • Solicit and answer any questions you may have about the proposed treatment.
  • Work with you to develop a treatment plan that addresses your needs and respects your boundaries.
  • Obtain your consent before beginning the treatment and confirm your ongoing consent during the treatment (both during the first appointment and during subsequent appointments).
  • Stop what they are doing any time you tell them to.
  • Respect your right to question, refuse or withdraw from physiotherapy services at any time.

What does this sound like in the real world? Examples of things your physiotherapist may say include:

  • I’d like to start by asking you some questions about your general health and the problem that has brought you here today.
  • It is important for me to see how your knee moves to understand what’s causing you pain. I see you brought some shorts with you. I will step out of the room for a few minutes. Can you change into your shorts, so we can continue with the assessment?
  • What questions do you have about what I have told you?
  • Your wrist looks red. May I touch it to see if it is also swollen or warm?

If you think a physiotherapist has engaged in inappropriate conduct, call Physiotherapy Alberta. This is the case regardless of whether the inappropriate conduct is sexual in nature or not. If you are unsure whether what your physiotherapist did or said was appropriate, we also want to hear from you.

Physiotherapy Alberta’s job is to make sure physiotherapists know and follow the rules and to address your concerns if they do not. Please contact Physiotherapy Alberta at 780-438-0338 or info@physiotherapyalberta.ca if you think that you or someone you know has been sexually abused by a physiotherapist or you have concerns about the physiotherapy care you received.

Every complaint is investigated.

We understand that it can be difficult to file a complaint, and that this may be an upsetting time for you. Physiotherapy Alberta is committed to helping you navigate the situation as smoothly as possible. For more information about the complaint process visit the complaints section or call our Complaints Director at 780.702.5351.

Sexual Abuse is defined in the Health Professions Act, and “means the threatened, attempted or actual conduct of a regulated member towards a patient that is of a sexual nature and includes any of the following conduct:

  1. Sexual intercourse between a regulated member and a patient of that regulated member;
  2. Genital to genital, genital to anal, oral to genital or oral to anal contact between a regulated member and a patient of that regulated member;
  3. Masturbation of a regulated member by, or in the presence of, a patient of that regulated member;
  4. Masturbation of a regulated member’s patient by that regulated member;
  5. Encouraging a regulated member’s patient to masturbate in the presence of that regulated member;
  6. Touching of a sexual nature of a client’s genitals, anus, breasts or buttocks by a regulated member.”

Sexual Misconduct as defined in the Health Professions Act, “means any incident or repeated incidents of objectionable or unwelcome conduct, behaviour or remarks of a sexual nature by a regulated member towards a patient that the regulated member knows or ought reasonably to know will or would cause offence or humiliation to the patient or adversely affect the patient’s health and well-being but does not include sexual abuse.”