Inappropriate patient sexual behaviour (IPSB) is defined as ‘a verbal or physical act of an explicit or perceived sexual nature which is unacceptable within the social context in which it is carried out’ (Johnson et al 2006).

Perpetuated by patients, their relatives, caregivers and visitors, this can include but is not limited to activities such as leering, sexual remarks, deliberate touch, indecent exposure, and sexual assault (Cambier et al 2018).

One of the aims of this three-part series on professional boundary issues was to generate discussion among the profession.

On the topic of IPSB, it is recommended that this occur at a local level as every site, public or private, will differ in staff demographics, area of clinical practice and gender mix.

This discussion should happen now.

It will be easier to discuss and develop strategies prior to an adverse incident than be unprepared to deal with IPSB.

Similarly, if not occurring already, students need to be exposed to the potential of IPSB prior to commencing clinical placements, and provided with appropriate strategies on how to handle it.

What is the incidence of IPSB?

There is a relatively high incidence of IPSB towards physiotherapists and physiotherapy students.

A recent study in the US reported that 84 per cent of participants had experienced IPSB at some stage during their career (Boissonnault et al 2017).

This is consistent with earlier studies in the US which reported incidences of IPSB at over 80 per cent (deMayo 1997, McComas et al 1993, Weerakoon & O’Sullivan 1998).

Studies involving Western Australian students found 78 per cent had experienced IPSB after just three or four clinical placements (Ang et al 2010).

This study followed on from an earlier study in WA that found 48 per cent of WA physiotherapists (Cooper & Jenkins 2008) reported experiencing IPSB.

Some of these studies categorised responses into mild, moderate and severe forms of IPSB; however, there may be a risk in defining any form of IPSB in such terms, as labelling any forms of IPSB as mild runs the risk of it potentially being construed as harmless.

Any form of IPSB can be harmful to both the physiotherapist and their organisation.

A physiotherapist on the receiving end of IPSB may experience anger, guilt, fear, anxiety and depression, leading to absenteeism, decreased productivity, loss of motivation and ultimately resignation (Boissonnault 2017).

What are the risk factors for IPSB?

The risk factors linked to IPSB appear to be similar throughout the literature regardless of profession.

It probably comes as no surprise that female physiotherapists experience IPSB at a higher rate than their male colleagues.

Associated with this is that perpetrators are more likely to be male (Boissonnault et al 2017, deMayo 1997, McComas et al 1993, Weerakoon & O’Sullivan 1998, Cooper & Jenkins 2008).

Another risk appears to be relative youth/inexperience. In the WA studies there was a significant difference in the incidence reported by students and graduates compared to more experienced physiotherapists (Ang et al 2010, Cooper & Jenkins 2008).

Similarly in other studies where age demographics were recorded, the incidence was higher among novice practitioners (Boissonnault et al 2017).

A number of reasons have been suggested why this may occur. New graduates may have been exposed to IPSB in their undergraduate training and are more conscious of it.

Experienced physiotherapists may be experiencing IPSB at the same rate as their younger colleagues but may have developed management strategies to minimise the impacts.

Studies also show that clinical setting and diagnosis can influence the risk of staff experiencing IPSB.

For example, staff working with patients who have an acquired or traumatic brain injury, or with patients with dementia or other cognitive impairment, are at higher risk of experiencing IPSB (Boissonnault et al 2017), and students experiencing IPSB were more likely to be on placement in a neurology, rural or musculoskeletal setting (Ang et al 2010).

In contrast, physiotherapists working in the pelvic health area were at lesser risk of IPSB, which may be due to the fact that the majority of pelvic health practitioners were experienced female therapists working with predominantly female patients (Boissonnault et al 2019).

Pelvic health physiotherapists were found to have managed the incidences of IPSB that did arise more effectively than their non- pelvic health colleagues.

How can we manage IPSB?

While we are encouraging discussion and education among the profession as an important step in helping physiotherapists manage IPBS, it goes only part of the way.

In a study of student physiotherapists in Australia, measuring the impact of targeted education on professional boundaries found that education had little impact when students were provided with vignettes describing IPSB.

Of particular concern was the fact that only 30 per cent of respondents found that sexual assault in the form of inappropriate touching by a neurologically impaired patient to be wrong (Cooper et al 2013).

While there may be excuses for this behaviour, it can never be acceptable.

The most recent paper to examine responses and their success or otherwise to halt IPSB was conducted by Cambier et al (2018), and looked at both informal and formal responses.

Informal responses include strategies such as ignoring the behaviour and use of distraction techniques. Formal responses include strategies such as transfer of care and behaviour contracts.

Previous studies have shown that ignoring the behaviour is a common response and Cambier et al (2018) reported that ignoring the behaviour remains an option frequently chosen by physiotherapists; however, not surprisingly, this had little effect on patient behaviour.

Likewise, making light of the behaviour by joking or with humour was not seen as a successful strategy either.

The most popular strategy reported within the informal responses was to distract and redirect the patient into another activity.

This was reported to have had a successful outcome in many cases and in particular with patients who were cognitively impaired.

Other successful strategies included treating in an open space and utilising less physical contact, directly confronting the patient about their behaviour and, where appropriate, expressing anger and disapproval.

The latter, however, were not easily adopted by younger, less experienced physiotherapists.

Of the formal responses, documenting the behaviour, utilisation of chaperones, or handing over care to a colleague were the most popular approaches.

All demonstrated some success in reducing the behaviour.

Implementation of behaviour contracts where appropriate was also associated with positive outcomes.

Surprisingly (or not), formal reporting within the organisation did not routinely improve patient behaviour.

From the other side, a physiotherapist’s behaviour may be a potential enabler of IPSB and should also be considered.

The learnings from the April 2021 InMotion article on boundary crossing (tinyurl.com/azbxndtr) should be viewed as part of a strategy to manage IPSB.

Appropriate professional behaviour will go a long way to maintaining the gap between therapist and patient, which may in turn reduce the risk of IPSB developing.

To reiterate, while you can have friendly interactions with your patients, they are not your ‘friend’, they are your patient. When that distinction is clear, the risk will be reduced.

Along with manners and behaviours, professional appearance (however wrong this may seem) can influence the professional relationship.

Studies have shown that for males, there is an association between perceptions of professionalism and the wearing of business attire (Cooper et al 2016).

Sadly for female physiotherapists, there wasn’t such a definitive finding, with divided views between formal white clinical tops/scrubs and corporate polo shirts.

There was, however, a lower association between perceived professionalism and female physiotherapists in casual wear (Cooper et al 2016). To ensure you present as a professional, it is important to look like a professional.

While some may see the Ahpra and APA codes of conduct as being restrictive, in the case of IPSB these codes can be your friend.

Being asked out on a date by a patient is a common occurrence.

As we have discussed previously, this can never be acted upon with a current patient and is frowned upon with former patients.

You can and should decline a patient’s offer on the basis of compliance with our codes of conduct—this shows professionalism and integrity, and is also a sensitive way of saying no.

A few red flags

Anecdotally, members of the National Professional Standards Panel have heard stories of IPSB, which we share as a warning to the unwary. 

Requests for the last appointment of the day.

In many private practice settings, the majority of staff including colleagues and administrative support staff leave prior to the last scheduled appointment.

If you have concerns about a particular patient’s intentions, then late appointments where there is the potential for you to be working in isolation need to be avoided.

Refusal to wear appropriate drapes provided.

Even if patients state they are happy not to wear drapes, you should insist.

There is a fine line between enough exposure to assess and treat and overexposure, which can then send the wrong signal to the patient if this practice is happily adopted by the treating physiotherapist.

Changes in patient behaviour in relation to clothing and personal appearance.

Patients who are attracted to their physiotherapist may elect to change their dress and appearance at subsequent visits.

While patients can elect to wear whatever they choose, an obvious change in dress and appearance should be a warning sign to the treating physiotherapist.

Too much self-disclosure.

As has been discussed in previous articles, personal communication is rarely just confined to the clinical presentation.

Self-disclosure occurs from both sides. While excessive self-disclosure from the treating physiotherapist is discouraged, the same rule should apply to our patients.

Too much irrelevant personal information needs to be sensitively closed down.

Ongoing bookings when there are no further physiotherapy treatment goals or the patient is very vague on their reasons for seeking further treatment.

The NSW Physiotherapy Council has produced educational videos on a number of professional issues, including two excellent videos on boundary issues and the use of social media, which can be accessed here.

We recommend that all members access these resources.

Click here to read the other articles in this series: ‘Nothing is ever black or white, it’s all just 50 shades of grey’ (February) ‘Am I crossing the boundary?’ (April).

References

Johnson C, Knight C, Alderman N (2006): Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Injury 20 : 687-693

Cambier Z, Boissonnault JS, Hetzel SJ and Plack MM. (2018) Physical Therapist, Physical Therapist Assistant, and Student Response to Inappropriate Patient Sexual Behavior: Results of a National Survey, Physical Therapy, 98; (9): 804–814,

Boissonnault JS, Cambier Z, Hetzel SJ and Plack MM. (2017) Prevalence and Risk of Inappropriate Sexual Behavior of Patients Toward Physical Therapist Clinicians and Students in the United States Physical Therapy. 2017 Nov 1;97(11):1084-1093

deMayo RA (1997a): Patient sexual behaviours and sexual harassment: a national survey of physical therapists. Physical Therapy 77: 739744.

McComas J, Herbert C, Giacomin C, Kaplan D, Dulberg C (1993): Experiences of student and practicing physical therapists with inappropriate patient sexual behavior. Physical Therapy 73: 762-770

Weerakoon P and O'Sullivan V (1998): Inappropriate patient sexual behaviour in physiotherapy practice. Physiotherapy 84: 491-499

Ang, A, Cooper, I, and Jenkins, S (2010). Sexual Professional Boundaries: Physiotherapy Students' Experiences and Opinions. New Zealand Journal of Physiotherapy 38 (3): 106-112

Cooper I, Jenkins S. (2008) Sexual boundaries between physiotherapists and patients are not perceived clearly: an observational study. The Australian Journal of Physiotherapy. 54(4):275-9.

Boissonnault JS, Cambier Z and Hetzel SJ. (2019) Inappropriate Patient Sexual Behavior When Working in Sensitive Areas of the Body: Results From a National Physical Therapy Survey. Journal of Women's Health Physical Therapy: 43; 1; 36-43

Cooper, I., C. Delany, G. Dwyer, R. Godbold, V. Johnston, D. Shirley, and S. C. Jenkins. 2013. Targeted education on the topic of professional boundaries does not change student physiotherapists' opinions or their responses to a series of ethical scenarios. Physical Therapy Reviews 186 (6): 431-438

Cooper, I., C. Delany and Jenkins S. 2016: Comparing patients' and physiotherapists' views of professionalism and professional standing: An Australian perspective. Physical Therapy Reviews. 21 (1): pp. 38-73