Sexual and romantic relationships between professionals and clients are often considered to be unethical because of the power differential between them and the resulting dependence and vulnerability of the client. Such relationships are inappropriate whether they are initiated by professional or client. Similar standards often exist in institutions in which health professionals undergo education and training. Such relationships may compromise the academic objectivity of the teacher, and the involved student may be seen as a “favorite child” within the training environment. Such standards are likely to carry over into the professional lives of students as licensed health professionals. Teaching institutions, whether universities or clinical facilities, should include, as part of their basic curriculum, discussions about what a healthy teacher-student relationship can be, including topics such as mentoring, balancing personal and professional priorities, faculty-student boundaries, and possible conflicts of interest. Institutions should also define appropriate standards regarding consensual sexual and romantic relationships that are consistent, enforceable, and agreed upon by faculty, human resources personnel, and institutional counsel. Terminology should be consistent with the professional literature. These standards, their rationale, and consequences of violations should be clearly explained to both faculty and students and should appear in relevant documents issued to them (e.g., handbooks). Complainants need to be supported and protected from retaliation. Graduate students, fellows and residents should be included in such standards and discussions since they often serve a dual role as both teacher and student.

• Faculty-student boundaries; Sexual misconduct; Sexual exploitation; Consent for sexual relations; Professional development

Plaut SM (2020) Consensual Sexual and Romantic Faculty-Student Relationships in the Health Professions: Institutional Roles. JSM Sexual Med 4(4): 1041.

The idea of consensual sex as victimization might seem to many like an oxymoron. Yet, there are many instances where one might question the validity of sexual consent, such as intoxication, developmental disability, or extreme social pressure [1].

The validity of consent is also questionable in trust-based relationships, in which there is a power differential between two parties. Such relationships include doctor-patient, teacherstudent, clergy-parishioner, coach-athlete, and other professional pairings. In such relationships, one party must trust the skill, knowledge, expertise, and assessment of the other. Consensual sex can be initiated mutually, coerced by the more powerful party, or even initiated by the less powerful, vulnerable, dependent party [2,3]. Regardless of how the romantic relationship is initiated, professional objectivity may be compromised at the very least. At times, the emotional effect on the dependent party can be devastating [3-5].

One might ask whether at least some consensual relationships between faculty and students work well and even become successful marriages. Of course, this may happen [6], but like many areas of law and ethics, restrictions are often agreed upon because of the level of risk, just as speed limits may vary depending on whether one is driving in a populated area or out on a superhighway.

The policy on consensual relationships enacted by Stanford University provides one example of how prohibitions might be tailored to specific types of relationships in the academic community [7]. Others may or may not agree with these distinctions. The policy states clearly that “sexual or romantic relationships between teachers and undergraduate students are prohibited – regardless of current or future academic or supervisory responsibilities for that student.” A second type of student is defined as “graduate and professional school students, postdoctoral scholars, and clinical residents or fellows.” In such cases, sexual or romantic relationships are prohibited “whenever a teacher has had, or in the future might reasonably be expected to have, academic responsibility over any student.” Similar prohibitions exist for staff (e.g., residence deans, administrators, coaches) and students. Although there is no prohibition of sexual or romantic relationships among students, a student in such a relationship with another student “shall not exercise any evaluative or teaching function for that student.”

In the health professions, the negative effects of consensual sexual relationships between parties of unequal status is considered serious enough that such relationships have been prohibited in ethical codes and licensing laws for many years [2,3]. As will be discussed below, many kinds of nonsexual boundary crossings may also be considered inappropriate in a professional relationship. However, sexual and romantic relationships are considered serious enough that they are often singled out in ethical codes and institutional policies.

When such relationships occur between teachers and students in academic institutions, not only may the same consequences occur as in other professional situations, but this is also a time when teachers are expected to model the kinds of professional behavior that will be expected of the student after completion of their training program. Papadakis and her colleagues [8] showed that medical students who were resistant to professional standards during the educational process were more likely to be disciplined by licensing boards after their training period. Therefore, it may be said that teaching institutions in the health professions have important roles in both emphasizing the importance of such professional standards and enforcing them when necessary.

Unfortunately, however, professional institutions are often seen as unresponsive to concerns about boundary violations, not only in the health professions, but in other professional settings as well [9]. These patterns of unresponsiveness have become even more apparent since the emergence of the socalled “MeToo” movement. It may be surprising to learn that the movement actually started in 2006 as a local campaign against sexual assault. It was popularized in 2017 at the time of the Harvey Weinstein disclosures [10]. The many public disclosures about alleged sexual victimization since that time have led to a greater consciousness about sexual victimization and calls for more effective institutional response. Even though the MeToo movement focused initially on sexual assault, there has also been greater attention on the appropriateness of consensual relationships in the academic setting [11-14].

This paper will recommend two things that training institutions can do to address the potentially negative impact of consensual sexual and romantic relationships. First, they can enhance understanding of professional boundaries and how to prevent boundary violations through their educational and orientation programs for both faculty and students. Second, they can establish and effectively enforce standards regarding intimate relationships between faculty and students. To begin, however, it will be useful to provide a bit of background information about the teaching of ethics and professionalism in the health professions and to explain why it is important to consider the importance of professional-client boundaries as part of that teaching.

Ethics and professionalism in professional education

Most if not all programs in the health professions include educational components that may be referred to as professionalism or ethics or both. Such teaching may include not only laws and ethics of professional behavior, but other important aspects of professional life as well. Areas covered may include mentoring, professional dress and demeanor, confidentiality, gender issues, professional-client relationships, sexual harassment, student mistreatment, the importance of self-care, and how one can most effectively balance priorities of professional and personal life [15-17]. If these areas are not formally covered, they may be addressed more informally and variably as part of what some call the “hidden curriculum” [18]. If inappropriate boundary crossings are to be most effectively prevented, however, the case may be made that such teaching and discussion should be given a high priority [19,20].

Faculty-student boundaries in the health professions

There is a need for balance in all relationships, and it is here that the institution’s first important role begins. For example, Viorst [21] advises married couples, to “figure out how intimate you can be without suffocation and how separate you can be without alienation.” Trust-based relationships can be too distant or too close and the balance often depends on the personalities of the participants and the roles they are playing. Rogers [22] emphasized the importance of a good balance in his classic paper, Characteristics of a Helping Relationship. He asks, “Can I be in some way which will be perceived by the other person as trustworthy, as dependable or consistent in some deep sense? Can I let myself experience positive attitudes toward this other person – attitudes of warmth, caring, interest, liking, respect?” But then he goes on to ask, “Can I be strong enough as a person to be separate from the other? Am I securing enough within myself to permit him his separateness?”

Deresciewicz [23] has written that there is a valid place for a kind of passionate relationship between teacher and student. “The good teacher,” he writes, “raises in students a burning desire for his or her approval and attention, his or her voice and presence, which is erotic in its urgency and intensity. Students will sometimes mistake this earthquake for sexual attraction and the foolish or inexperienced or cynical instructor will exploit that confusion for his or her own gratification. But the great majority of professors understand that the art of teaching consists not only of arousing desire, but of redirecting it toward its proper object, from the teacher to the thing taught. Teaching, (William Butler) Yeats said, is lighting a fire, not filling a bucket.” So clearly, he would draw the line at sexual expression of the passion and even eroticism that a good teacher may arouse in a student.

It is also important, when discussing the continuum of teacherstudent boundaries, to talk about nonsexual boundaries that may also contribute to an effective teacher-student relationship [16,24,25]. There may not necessarily be any institutional rules about nonsexual boundaries, but perhaps there may be departmental or school policies or recommendations. One example is the extent of faculty access to students, especially in these times, when communications may occur by text messaging or e-mail [26]. The larger institution may draw the line at sex, but there may be other boundary crossings that are considered either constructive or inappropriate to a sound teacherstudent relationship. Schools or departments may at least have discussions about the pros and cons of nonsexual boundaries, and a faculty group may thus establish a “standard of practice.” Consideration of theoretical case vignettes may help immensely in such discussions. Here are a few examples [27]:

• A third-year medical student on an inpatient rotation is asked out by the chief resident.

• A clerkship faculty member asks a student to baby sit her dogs for the weekend while she is away at a conference.

• A student invites a faculty member to be a friend on her Facebook page.

• A student has just finished her psychiatry rotation. On the rotation, the student has diagnosed herself as having ADHD, and social anxiety. She highly respects her attending psychiatrist and wants him to be her therapist.

A number of questions may be asked about each of these vignettes. Does it matter which party initiates such a relationship? To what extent, if at all, might things like relative gender, sexual orientation or relative age be taken into account? Might this activity create a conflict of interest for either party? Might such an activity place these parties on a “slippery slope” that could lead to a romantic or sexual relationship? To what extent might such an activity lead to perceptions in the academic environment that a given student is a “favorite child”?

The author recently gave a talk about these issues at a university from which a faculty member had resigned after an investigation of a sexual boundary crossing. Since the details of the alleged offense were not public, some faculty members were now confused about where boundaries should be drawn. As one person asked in our discussion, “If I have coffee with a student, am I going to be fired?” Another asked about the advisability of having parties at the home of a faculty member. A third issue was the advisability of a faculty member providing direct financial support for a needy student. Such questions and anxieties might be more easily addressed if faculty members and perhaps students as well, had a chance to discuss the positive and negative implications of various boundary crossings.

Preventing boundary violations

In having such discussions, it would be helpful to point out that certain risk factors have been identified that may make it more likely for either faculty or students to cross appropriate boundaries. These may include problems in personal relationships, a lack of support from other sources, clinical depression, or a conviction that a closer relationship may buy favor or approval from the other party [3,24].

Certainly, if a faculty member sees such a risk factor in a student they are mentoring, it may be helpful to suggest other support resources, such as a student affairs officer, counseling, or appropriate student resources. For example, an emotionally dependent student may be encouraged to depend less on external authority and more on internal authority in making life decisions [4]. Students who feel they have been taken advantage of may be reluctant to express concern because of their own feelings of helplessness, self-blame, or fear that they will not be supported by the institution.

There are also questions we can ask ourselves when confronted by a difficult boundary decision. The author has proposed a practice called progressive boundary analysis [5]: “If I cross this boundary, what might be the possible consequences, for me for the student, for the academic environment?” “Whose needs are really being met by this behavior?” Faculty members feeling an urge to transcend an appropriate boundary might consult with a colleague about their honest perspectives.

Unfortunately, there are occasionally faculty members who will engage in serial consensual sexual relationships with students. In the great majority of cases, however, such relationships are more related to circumstances in the lives of specific faculty and students. In either situation, we each have the ability to make an informed decision about whether or not to cross a sexual boundary.

In the Broadway musical The Book of Mormon [28], a group of young Mormon missionaries are wondering how they might deal with threats to their values and convictions in a new environment to which they had been assigned, including attractions to other people. Their advice to each other, expressed in song, was simply to “turn it off.” If we are really committed to the principle that erotic relationships between faculty and students are inappropriate, we can, if we wish, simply decide for ourselves that certain kinds of people are going to be off limits [6].

Defining and addressing boundary violations

The second important role of a teaching institution regarding possible boundary violations is to develop sound policies and to enforce them in a way that is fair to both faculty and students [29,30]. The Liaison Committee on Medical Education [31], for example, makes it clear that instances of possible student mistreatment should be addressed on a systemic basis. Specifically, “A medical school develops effective written policies that define mistreatment, has effective mechanisms in place for a prompt response to any complaints, and supports educational activities aimed at preventing mistreatment. Mechanisms for reporting mistreatment are understood by medical students, including visiting medical students, and ensure that any violations can be registered and investigated without fear of retaliation.”

If a teaching institution, whether a university or clinical facility, is genuinely committed to the idea that consensual sexual or romantic relationships between faculty and students are inappropriate, this needs to be clearly and unequivocally stated as a matter of policy. For maximum effectiveness, the rationale for such a policy should hopefully be understood and supported not only by faculty, but also by student affairs administrators, deans, department chairs, university counsel, and human resources personnel. Language should be consistent with the professional literature in the field. These policies should include possible sanctions that may be imposed if an accused person is found to be in violation

It should be clear to students and to faculty advisors and student affairs administrators how to report alleged violations, and confidential counseling should be offered to complainants throughout the process of investigating the allegation. As with other forms of sexual misconduct, assurances need to be provided that student allegations will be taken seriously and that students will be protected from possible retaliation [24,25,32].

These standards and expectations should be openly communicated to both faculty and students, for example in faculty and student handbooks, and should specifically include fellows, residents, and graduate students as either possible offenders or victims, since they play both teaching and student roles [7]. The critical issue is the power differential between the two parties.

Bazerman and Tenbrunsel [33] have noted how often, in institutional life, “we neglect to notice and act on the unethical behavior of others.” Sexual victimization of students through consensual relationships can be devastating to students, disruptive to the teaching environment, and can damage the offending faculty member’s career, to say the least. Such incidents can be minimized if teaching institutions openly discuss this issue with both students and faculty, if all parties are aware of both risk factors and possible consequences, and if complaints of policy violations are taken seriously. Given the likely variability in how various teaching institutions might address this issue [12,30] constructive open discussion and prevention is always the best approach in a healthy academic environment.

The author is indebted to Mira Brancu, Ann McCullough, and Judith Plaut for their insightful comments on the manuscript.

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