Professional Boundaries:

..Prevention of Sexual Abuse & Sexual Misconduct

The Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) is the regulatory body for the professions of speech-language pathology and audiology in Alberta. ACSLPA carries out its activities in accordance with provincial legislation to protect and serve the public by regulating and ensuring competent, safe, ethical practice of speech-language pathologists and audiologists.

The intent of this guideline is to support regulated members in practicing in compliance with the standards of practice with respect to therapeutic relationships and professional boundaries. The guideline is founded upon the following guiding principles:

• ACSLPA believes that the sexual abuse of and/or sexual misconduct towards patients by regulated members is unethical and an abuse of the therapeutic relationship. ACSLPA holds a zero-tolerance stance towards any abuse or misconduct of this nature by regulated members. Regardless of the patient’s conduct and/or consent, it is always the responsibility of the regulated member to maintain professional boundaries and abstain from engaging in sexual abuse and/or sexual misconduct.
• ACSLPA regulated members are expected to be fully informed of the terms and implications of the Health Professions Act (HPA) and the issues related to the avoidance and prevention of sexual abuse and/or sexual misconduct.
• ACSLPA regulated members are accountable for practicing in accordance with the ACSLPA Standards of Practice and Code of Ethics regardless of their role, practice area or practice setting. Breach of the Standards of Practice or Code of Ethics may constitute unprofessional conduct.

In accordance with the ACSLPA standards of practice on Professional Boundaries and Standard Area 5 – Sexual Abuse and Sexual Misconduct, regulated members must maintain appropriate professional boundaries with clients, professional colleagues, students, and others at all times; and protect patients from sexual abuse and sexual misconduct.  The Health Professions Act (HPA) requires that colleges take measures to for preventing and addressing sexual abuse and sexual misconduct by providing educational requirements and guidelines for the conduct of regulated members. This guideline is meant to provide this educational component to regulated members, along with ACSLPA’s Jurisprudence E-Course. Both educational components include concepts related to trauma informed practice.

Clarification of Terms Used

It should be noted that throughout this guideline, the more narrowly defined terms of health services and patient are used in reference to sexual abuse and sexual misconduct.

• Health services, as defined in the HPA, refer to the specific services provided by regulated members in their professional roles as speech-language pathologists and audiologists.
• Patient, as defined by ACSLPA, is the direct recipient of the health services provided
  by the regulated member and does not include others such as their parent, guardian
  or substitute decision-maker. If service is provided in accordance with the Standards
  of Practice, ‘patient’ does not include the regulated member’s spouse, adult
  interdependent partner or other person with whom the regulated member is in an existing sexual relationship.

ACSLPA foundational documents, including the Standards of Practice, use broader definitions for the following terms, which are used in reference to professional boundaries and trauma informed services in this guideline:

• Client refers to “a recipient of speech-language pathology or audiology services, and may be an individual, family, group, community, or population. An individual client may also be referred to as a patient.”
• Professional services refer to “any service that comes within the practice of a regulated profession; for the professions of speech-language pathology and audiology, these are as outlined in section 3 of Schedule 28 of the HPA.”

The relationship of the four terms can be illustrated as follows:

Under the Health Professions Act (HPA) and the changes introduced with Bill 21, regulatory colleges such as ACSLPA are required to implement a series of measures to prevent sexual abuse of and/or sexual misconduct towards patients by regulated members.

This Bill required that ACSLPA:

• develop Standards of Practice related to sexual abuse and sexual misconduct;
• define who is a patient and set rules regarding sexual relationships between patients and regulated members;
• provide a program of education and training for regulated members to prevent and address sexual abuse of and/or sexual misconduct towards patients by regulated members;
• develop a Patient Relations Program that provides funding for treatment and counselling of victims of sexual abuse of and/or sexual misconduct towards patients by a regulated member;
• must institute severe penalties including:
  • mandatory cancellation of registration and practice permit for any regulated member whose conduct is deemed to be sexual abuse; and/or
  • mandatory suspension of registration and practice permit for any regulated member whose actions are deemed to be sexual misconduct;
• post discipline histories of regulated members for sexual abuse of and/or sexual misconduct towards patients on a public-facing website; and
• provide training for staff, hearing tribunals and council members to prevent and address sexual abuse of and sexual misconduct towards patients by regulated members.

Sexual abuse of and/or sexual misconduct towards patients by regulated members is considered unprofessional conduct. It can have significant negative impact on patient confidence and well-being and can erode the public’s trust of speech-language pathologists and audiologists. It involves an abuse of power on the part of the regulated member resulting in blurring of professional judgment and objectivity, essential to the delivery of patient-centred services.  In most cases, sexual abuse and/or sexual misconduct are the result of failing to maintain professional boundaries and not heeding the warning signs of potential boundary crossings.

ACSLPA holds a zero-tolerance stance towards any regulated member who engages in sexual abuse of and/or sexual misconduct towards patients. ACSLPA regulated members must:

• Abstain from conduct, behaviour or remarks directed towards patients that constitute sexual abuse and/or sexual misconduct.
• Not enter into sexual relationships with patients.
• Be cognizant of the circumstances and/or issues that can lead to, or be misinterpreted, as sexual abuse and/or sexual misconduct.

The consequences to the regulated member resulting from a complaint of sexual abuse and/or sexual misconduct are mandatory and severe and include cancellation or suspension of the registration and practice permit.

Clarification of Terms Used

For the purposes of this guideline, in reference to sexual abuse and sexual misconduct, the term ‘patient’ is used. Other ACSLPA guidelines use the more broadly defined term ‘client’ in reference to other practice issues. Regulated members are encouraged to review the section ‘Clarification of Terms Used’ in the Introduction section of this guideline for a more comprehensive explanation of the differentiation between these terms. Definitions of both terms are also included in the Glossary of this guideline.

Defining Sexual Abuse and Sexual Misconduct

Sexual Abuse

Sexual abuse, as defined by the HPA, “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;

• masturbation of a regulated member by, or in the presence of, a patient of that
  regulated member;

1. masturbation of a regulated member’s patient by that regulated member;
2. encouraging a regulated member’s patient to masturbate in the presence of that regulated member; and
3. touching of a sexual nature of a patient’s genitals, anus, breasts or buttocks by a
   regulated member.”

Sexual abuse applies to a variety of actions that include, not only actual physical touching or intimate behaviour, but also any threats or attempts of a sexual nature.

Sexual Misconduct

Sexual misconduct, as defined in the HPA, “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.”

Sexual misconduct covers a broad spectrum of activities. It is characterized by behaviour or remarks of a sexual nature towards a patient that are unwelcome, unwanted and inappropriate, and that the regulated member ought reasonably to know will offend, humiliate or have an impact on the patient’s well-being. Sexual misconduct does not include sexual abuse. Some examples of sexual misconduct
can include:

• Sexually suggestive comments or gestures;
• Inappropriately touching or hugging a patient;
• Commenting inappropriately on a patient’s appearance;
• Requesting details of a patient’s sexual history that are not relevant for the health service provided by the speech-language pathologist or audiologist; and/or
• Exploiting any real or perceived imbalance of power in a manner that is sexual in nature.

It is the regulated member’s responsibility to closely monitor their interactions with patients to ensure that behaviour and comments are always professional and appropriate to the therapeutic relationship. Regardless of a patient’s sexual advances and/or consent, it remains inappropriate for a regulated member to engage in a sexual relationship with a patient. Sexual abuse of and/or sexual misconduct towards persons other than patients is also deemed inappropriate and may result in the member being investigated for unprofessional conduct.

Please see Appendix 1 for examples of potential sexual abuse and sexual misconduct situations.

Patients

Within the context of the HPA, ACSLPA’s definition of a patient refers specifically to the individual receiving health services from a regulated member. It does not include the patient’s parent, legal guardian, substitute decision-maker, or any other person associated with that individual. A regulated member of ACSLPA abstains from conduct, behaviour, or remarks directed towards a patient that constitutes sexual abuse as defined by the HPA.

To demonstrate this standard, the regulated member:

1. must not enter into or have a sexual relationship with a patient, and
2. must not threaten or attempt to have a sexual relationship with a patient.

Parents, Guardians, and Substitute Decision-Makers of Patients

In addition to refraining from sexual abuse/sexual misconduct with patients, regulated members should avoid any actions of a sexual nature, physical or verbal, with a patient’s parent, guardian or substitute decision-maker. Unwelcome sexual comments or gestures to individuals associated with a patient are inappropriate and can erode the trust of the therapeutic relationship. Intimate relationships with these individuals create a conflict-of-interest situation, which can obscure the regulated member’s objectivity and judgement in relation to their patient. These types of situations may result in a finding of unprofessional conduct.

The Regulated Member’s Partner or Spouse

Regulated members must be mindful of the fact that providing services to someone with whom they are in an existing sexual relationship may disrupt the trust inherent to the therapeutic relationship and have an impact on the regulated member acting in the patient’s best interests.

To avoid the risk of unprofessional conduct, regulated members should, except in particular circumstances, abstain from providing a health service to a spouse, an adult interdependent partner or other person with whom they are in an existing sexual relationship. Particular circumstances include:

• The regulated member provided the health service to the individual in emergency circumstances or in circumstances where the service is minor in nature.
• There is no abuse of power imbalances arising from the health service being provided.
• If further care is required, the regulated member takes reasonable steps, as soon as possible, to transfer care of the individual to another regulated member or regulated health professional.

In the exceptional circumstance that a regulated member is providing health services to their spouse, adult partner, or other person with whom they are in an existing sexual relationship, it is understood that their relationship would fall outside of ACSLPA’s standards of practice.

Former Patients

Former patient means a person to whom one of the following apply:

• For episodic care[1], no health service has been provided for at least 7 days and there is no expectation of an ongoing professional relationship between the regulated member and the patient.

• The patient and/or regulated member has terminated the professional relationship, the termination has been acknowledged by both parties, and at least 30 days has passed since the termination.
• If neither of the above apply, there has been no health service provided by the regulated member to the patient for one year (365 days).

A regulated member of ACSLPA must abstain from conduct, behaviour, or remarks directed towards former patients that constitute sexual abuse or sexual misconduct, as defined by the HPA. The regulated member must not enter into a sexual relationship with a former patient unless:

• There is no ongoing power imbalance between the patient and the speech-language pathologist or audiologist arising from the former professional relationship;
• Sufficient time has passed since the last time health services were provided by the SLP or audiologist, having regard for the nature and extent of the professional relationship between the speech-language pathologist or audiologist and the patient;
• The patient knows and understands that the professional relationship has ended; and
• The patient has consented and is capable of providing consent.

There are significant penalties for sexual abuse and sexual misconduct imposed by the HPA.
Regulated members must carefully consider whether the person is a former patient before entering into a personal relationship.

[1] Episodic care means an isolated, short-duration, and minor health service provided to a patient where there is no expectation of continuing care by the regulated member.

Professional boundaries are the parameters that define safe therapeutic relationships (between a regulated members providing a health service to patients) and safe professional relationships (between a regulated members providing a professional service to clients). Note that throughout this section on professional boundaries, this guideline uses the broader term ‘client’ (i.e., any recipient of speech-language pathology or audiology services).

These parameters set limits for these relationships and are based on the recognition of the inherent power imbalance, the vulnerability of the client and the responsibilities of the regulated member in the therapeutic or professional relationship. Professional boundaries help the regulated member and the client recognize the difference between therapeutic and personal relationships and avoid potential misunderstanding of words and actions.

Professional boundaries can be influenced by factors such as the physical environment, the length of time of the therapeutic relationship, and the achievement of certain therapeutic goals. A professional boundary can therefore be a dynamic line which, if crossed, will constitute unprofessional conduct and misuse of power.

Inherent to establishing therapeutic relationships is knowing where to draw the line between a professional relationship and a personal one, and how to avoid crossing that line. To do so,
regulated members must acknowledge:

• The power imbalance inherent to the client-provider relationship;
• The expectations for appropriate care; and
• The regulated member’s duty of care.

As professionals, there are systemic and legal expectations that regulated members hold each other accountable. Reporting potential breaches in conduct is an essential step in enforcing conduct standards and following the HPA.

Self-Reporting

Under the HPA section 127.1(1), regulated members are responsible for self-reporting to the Registrar:

• Findings of unprofessional conduct against them with another regulatory body or in another jurisdiction (e.g. another province, territory, country) and must provide the College with the decision;
• Findings of professional negligence against them in a lawsuit; and
• Criminal charges or criminal convictions against them.

Reporting Other Regulated Members

Under section 127.2(1) of the HPA, regulated members must report the conduct of another regulated member to the complaints director if they have reasonable grounds to believe that the conduct of the regulated member constitutes sexual abuse or sexual misconduct, or the procurement or performance of female genital mutilation.

Exception: This reporting requirement does not apply if the information was received while providing professional services to another regulated member. For example, if regulated member A received the information while providing professional services to regulated member B, then the reporting requirement does not apply to regulated member A.

Reporting by Employers

Under section 57(1.1) of the HPA, employers must give notice as soon as possible to the complaints director if they have reasonable grounds to believe that the conduct of a regulated member constitutes sexual abuse or sexual misconduct.

The process for sexual abuse and sexual misconduct follows the complaints process described in the HPA with additional protections for the public, including:

• That certain types of resolution and alternative resolution are not available;
• Mandatory minimum penalties after a finding of sexual abuse or sexual misconduct;
• Requirements for at least one member of the Hearing Tribunal to have the same gender identity as the patient;
• Requirements for trauma informed training and sexual violence training for the Hearing Tribunal;
• An opportunity for a complainant of sexual abuse or sexual misconduct to provide an impact statement at the hearing; and
• Mandatory publishing of decisions.

Under the terms of the HPA, ACSLPA is required to have a number of measures in place to address sexual abuse and sexual misconduct by its regulated members.

Complaints Process

Patients who feel they have been the subject of sexual abuse or sexual misconduct are encouraged to make a complaint with the ACSLPA Complaints Director. More information related to the processes for dealing with concerns and complaints can be found at acslpa.ca.

Funding for Treatment and Counselling

As required by the HPA, ACSLPA funds patient treatment and/or counselling when there is a complaint involving sexual abuse and sexual misconduct towards a patient by a regulated member.

• The treatment and/or counselling is organized and provided through an independent third-party program.
• Sessions are held in confidence, including from the College.
• Accepting funding for treatment and/or counselling is voluntary. It is the patient or caregiver’s responsibility to contact the independent third-party program if they are approved for funding.

A patient’s eligibility and approval for funding will end:

• After a period of time, if the maximum amount of funding is reached; or
• When complaint proceedings are finished.

A decision by ACSLPA to provide funding to a patient does not constitute a finding of unprofessional conduct against the investigated person. The two processes are independent.

Public Facing Register

Because ACSLPA’s role is to protect and serve the public interest and not to serve the needs of the regulated members, the College must report certain information about imposed practice permit conditions and hearings on its website, in the Annual Report submitted to the Government of Alberta and kept available on ACSLPA’s website, to other Canadian regulatory bodies, and on the General Register.

The College may also share with other SLP/Audiology governing bodies if a regulated member or former member is under investigation or has had complaints.  All hearing decisions, notices of hearings or appeals, and some resolutions agreements, as agreed to by the investigated member, are published on ACSLPA’s website.

This appendix provides examples of potential situations that could lead to sexual abuse and/or sexual misconduct. Considerations for regulated members are outlined in order to prevent allegations of sexual abuse and/or sexual misconduct.

1. A Patient Makes Unwanted Sexual Advances

A speech-language pathologist is running a fluency group for adult stutterers. A male patient in the group is always trying to get her attention, complimenting her looks and consistently staying after the group making sexual advances. He repeatedly asks the speech-language pathologist to go out on a date.

The regulated member should consider the following steps that can be taken when a patient crosses professional boundaries:

• Outlining to the patient the nature of the therapeutic relationship and how professional boundaries must be maintained at all times throughout the delivery of health services.
• Refusing to be engaged; explaining the ethical and regulatory responsibilities of the therapeutic relationship and maintaining professional boundaries.
• Documenting in the patient’s chart the dates, the nature of their conduct and remarks, and the communication with the patient about their behaviour.
• Discharging the patient and transferring them to another provider if required for patient and clinician safety, following appropriate discharge procedures (e.g., documentation).
• Reporting the patient’s behaviour to a supervisor or colleague and following any other workplace policy on responding to situations of this nature.

2. Physical Proximity and Touch During a Clinical Interaction

A male audiologist is working alone in an office at night. A young female patient is being seen for a vestibular assessment in a darkened room; there usually are no other individuals in the waiting or treatment rooms. Portions of the vestibular assessment require physical touching of the patient’s head and neck area.

The regulated member should consider the following to promote patient safety and a safe environment for the patient:

• When booking the appointment, openly explain to the patient the nature of the assessment setting and invite them to rebook or bring someone along if there are concerns, particularly around the time of day that the appointment will take place.
• Prior to starting the assessment, explain the various steps that are involved, the positioning of the patient, where and how they will be touched.
• Obtain the patient’s informed consent and remind them that they can stop the procedure at any time if they are uncomfortable.
• Reassure and check regularly with the patient throughout the procedure to ensure that they understand and continue to consent.
• In the patient’s chart, document consent, refusal (if appropriate), concerns and reactions.

3. Romantic Relationship with a Patient

The audiologist and the patient were attracted to each other and had a friendly professional relationship. During the delivery of health services, they met accidentally, at a cross-country ski club that they had both independently joined. After a month of meeting weekly for cross country skiing and social interaction, they contemplated starting a romantic relationship.

The regulated member should consider the following to prevent and avoid any allegations of sexual abuse:

• Abstain from entering into a romantic or sexual relationship with a patient regardless of the patient’s consent and behavior.
• At the earliest signs of any romantic feelings:
  • Explain to the patient that professional behavior must be guided by regulatory and ethical responsibilities,
  • Discuss the nature of the therapeutic relationship and how professional boundaries must be maintained at all times throughout the delivery of health services, and
  • Discharge the patient and transfer to another provider.
• Consult with colleagues and ACSLPA representatives as required.
• Document the management of the situation.

4. Sexual Relationship with a Former Patient

A female speech-language pathologist treated a male patient with moderate post brain injury, one on one, for a year. A year passed and they happened to meet in the community, began dating and contemplated starting a sexual relationship.

The regulated member should consider the following to prevent and avoid any allegations of sexual abuse:

• Determine whether the time interval that has passed since the last health services were provided is sufficient to ensure that there is no lasting power imbalance and dependency from the therapeutic relationship.
• Determine if the former patient has the capacity to understand that the therapeutic relationship is over, and the power imbalance no longer exists.
• Reflect on the nature of the patient’s injury, their degree of vulnerability and the extent to which issues of a personal nature were discussed during the delivery of health services.
• Consult with colleagues and ACSLPA representatives as required.
• When the above are taken into account, the regulated member may decide that it would never be appropriate to enter into a sexual relationship with this former patient.
• If the regulated member does decide to enter into a sexual relationship with the former patient, should speech-language pathology/audiology services be required in the future, the individual should be transferred to another appropriate provider.

Alberta College of Speech-Language Pathologists and Audiologists. (2022). Code of ethics. https://www.acslpa.ca/code-of-ethics/

Alberta College of Speech-Language Pathologists and Audiologists. (2023). Standard area 5.0 sexual abuse and sexual misconduct. https://www.acslpa.ca/members-applicants/standards-of-practice/

College of Audiologists and Speech-Language Pathologists of Ontario. (2023). Professional relationships and boundaries position statement. http://www.caslpo.com/sites/default/uploads/files/PS_EN_Professional_Relationships_
and_Boundaries.pdf

College of Physiotherapists of Alberta. (2024). Therapeutic relationships guide for Alberta physiotherapists. https://www.cpta.ab.ca/docs/87/Therapeutic_Relationships_Guide_2024.pdf

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College of Registered Nurses of Alberta. (2019). Protection of patients from sexual abuse and sexual misconduct standards. https://nurses.ab.ca/media/prrjzrog/protection-of-patients-from-sexual-abuse-and-sexual-misconduct-standards-2022.pdf

College of Speech and Hearing Health Professionals of British Columbia. (2019). Clinical practice guideline: Where’s the line? Professional boundaries in the therapeutic relationship. https://cshbc.ca/wp-content/uploads/2019/02/CSHBC-CPG-05-Professional-Boundaries-Where-is-the-Line.pdf

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