At Opening Up, our analysis of doctor misconduct has repeatedly identified sexual boundary violations as a significant source of patient harm. We argue that the General Medical Council’s (GMC) guidance on relationships with patients lacks clarity and relies too heavily on doctors to interpret ethical boundaries for themselves.
In 2024, when psychiatrist Benjamin Sessa appeared at his fitness-to-practise Tribunal, he told the panel that he had consulted the GMC’s guidance and his indemnity provider about the rules on relationships with patients. Then, in his own words, “my heart overtook my head” and he went on to pursue a relationship with one of his former patients.¹ The patient was highly vulnerable and had a history of self-harm, of which Dr Sessa was aware. The patient subsequently died by suicide.
Sessa is not alone. In a separate case, medical student Cian Hughes not only checked the GMC guidance himself, he sent it to 17-year-old Patient A and asked her whether she thought it applied to their situation.² He concluded that the guidance did not clearly prohibit the relationship and chose the interpretation he preferred.
Both cases raise the same question: does ambiguity in the guidance make it easier for professionals to rationalise harmful conduct?
What the Guidance Says
The GMC’s guidance states: “You must not pursue a sexual or improper emotional relationship with a current patient”.³ It does not give a definition of ‘improper’ or ‘emotional relationship’.
The guidance is even vaguer when it comes to former patients. It states that such relationships “may” be inappropriate depending on factors such as the patient’s vulnerability, the length of the clinical relationship, and the time elapsed since treatment ended. However, it provides no minimum timeframes, no definition of vulnerability in this context, and no objective criteria for determining when a relationship becomes acceptable. As a result, substantial room for interpretation remains.
The guidance also does not give clear answers to a number of scenarios that might arise in practice. For example, what obligations apply to medical students who hold no formal clinical responsibility, as was Hughes’ situation when he first encountered Patient A?
Guidance That Offers Loopholes
Doctors are expected to assess their own conduct against the guidance and determine whether a relationship is ‘inappropriate’. Given that they have a personal interest in the outcome, objective self-assessment is an unrealistic expectation. Where guidance is open to very different interpretations, some doctors will choose the one that suits them, as demonstrated by the cases of Sessa and Hughes.
Who Should Draw the Line?
In 2011, a survey of 282 GPs by Pulse found that half (48%) believed doctors should be allowed to have a sexual relationship with a patient on their practice’s list if the patient moves to another practice.⁴ The GP Dr Tony Grewal was quoted at the time as saying:
“An absolute ban on sexual relationships with patients or former patients is an unfair limitation on the right to pursue happiness for doctors and patients alike.”
At Opening Up we are reject that argument.
Cases of sexual misconduct by health professionals are fundamentally abuses of power and erosions of professional boundaries. They can cause significant long-term harm to patients, even in cases where there appears to be consent. This is reflected in complaints from patients who sometimes did not recognise the harm, or did not feel able to report it, until many years later.
Healthcare relationships are not ordinary relationships: every clinical encounter carries a built-in power imbalance. Health professionals hold authority, expertise, status in society, and access to patients’ personal information. Patients have medical visits to receive treatment and support: healthcare settings are not accessed as dating platforms.
Once we argue that doctor-patient personal relationships are sometimes acceptable, we create a movable line. Movable lines create grey areas, and those are the areas that bad actors often exploit. This poses risks to patient safety.
Of course, if healthcare professionals are asked where that line should be drawn, many will favour discretion and flexibility. The boundary of what constitutes ‘improper’ is currently defined largely by regulators, tribunals and healthcare professionals themselves. But those who experience the harmful consequences of boundary violations are patients and their voices are notably absent from the conversation.
Survivors of doctor-patient abuse have first-hand experience and understanding of how boundaries are tested, how harm occurs and the impact. Their experiences should be central in shaping guidance and interventions intended to prevent sexual misconduct and abuse. The lines that survivors draw between acceptable and unacceptable are likely to be very different from the lines that many healthcare professionals themselves might draw.
A Better Way
Ultimately, issues involving doctor-patient relationships are questions about whether there has been an abuse of power (which may or may not involve grooming) and whether that relationship constitutes sexual misconduct or abuse. Doctor-patient abuse can present in complex ways and it is not always immediately obvious. There are some measures that could help reduce the likelihood of this:
1) Tighten the existing guidance by defining terms more specifically and reducing areas of ambiguity. One step further would be a blanket prohibition on personal relationships and contact with patients and former patients for a defined minimum period (closer to years, not months). This would create a consistent threshold that is less open to subjective interpretation.
2) Decisions about professional boundaries should not rely solely on self-assessment. Introducing a mandatory requirement to declare a personal interest in a patient or former patient to a supervisor or independent body would introduce at least some external scrutiny.
3) Publish clear sanctions for boundary violations and apply them consistently. Healthcare professionals should understand the consequences of misconduct, and patients should have confidence that concerns will be taken seriously and addressed appropriately.
4) Ensure guidance is evidence-based. Research is needed to identify gaps in current guidance, understand how professional boundaries are breached in practice, and co-produce reforms with survivors and experts in the prevention of abuse and grooming.
5) Implement evidence-based interventions that support the identification and prevention of sexual misconduct and abuse. This should include transparent and accessible reporting systems that allow patients, families and staff to raise questions and concerns about health professionals.
6) Ensure all medical students and qualified health professionals receive training on professional boundaries before they begin working with patients. Regular mandatory refresher training should reinforce these standards throughout their careers, helping to ensure that expectations are clear and consistently understood.
Ultimately, guidance on doctor-patient relationships is not only about where professional boundaries should be drawn, but who gets to draw them. Guidance is one of several interventions that needs survivor-centred reform in order to reduce the risk of significant harm to patients.
We would like to signpost you to the stellar speech by Hannah Gadsby, “The Good Men” & Misogyny, which has had a significant influence on our thinking on power dynamics and how boundaries get drawn: https://www.youtube.com/watch?v=OEPsqFLhHBc
References
GMC, Medical Practitioners Tribunal Service, Determination: https://www.gmc-uk.org/registrants/4438407
GMC, Medical Practitioners Tribunal Service, Determination: Dr Cian Hughes, https://www.gmc-uk.org/registrants/7280579
GMC, Maintaining personal and professional boundaries, paragraph 9. https://www.gmc-uk.org/professional-standards/the-professional-standards/maintaining-personal-and-professional-boundaries/maintaining-personal-and-professional-boundaries
Pulse, ‘Half of GPs back change in rules on sex with patients’, July 2011. https://www.pulsetoday.co.uk/news/regulation/half-of-gps-back-change-in-rules-on-sex-with-patients/