Boundaries and the meaning of touch

Originally published in the August/September 2015 issue of Dispatch

Touch is a profound and essential part of the human interaction. It is the way we maintain connections, soothe and comfort each other. However, for dentists, the use of touch beyond the prescribed confines of their work can be a risky business.

For dentists, the oral cavity is their work zone and touch in that area is assumed as professionally necessary and appropriate. But what happens if the dentist goes beyond the oral cavity? Dentists know that any form of sexual touch is forbidden and viewed as sexual abuse, an abuse of power and a serious boundary violation. Boundary violations are always harmful and usually reflect an abuse of power and exploitation of the patient where the patient’s interest is replaced by the dentist’s interest. The Regulated Health Professions Act lays out clearly the prohibitions on touch or behaviours which may be interpreted as sexual.

But what about the pat on the arm or the hand on the shoulder? Can these behaviours be problematic? First of all, dentists need to recognize that these casual behaviours are boundary crossings. Boundaries represent the limits of the professional role and determine what a dentist does and what a dentist does not do. Boundary crossings are actions by the dentist which are not part of the normal professional role, but would not exploit the patient’s interest in any way, e.g. answering a question from the mother of a young patient, such as “Do you have any children?”

When the dentist must touch the patient beyond the oral cavity for clinical reasons: positioning etc., then permission or explanation should precede the activity. The dentist is moving into the patient’s personal space: that zone of comfort around a person. The size and comfort of that zone can vary. Variation in personal space size can be a factor of culture, history and personality. We all know people who speak inches from your face and others who stiffen when hugged hello.

The dentist may think a pat on the arm or shoulder to be friendly, or reassuring and completely innocent; however a patient may experience it quite differently. Let’s look at several examples.

Example A

Indra lives in a small community that has only one dentist, a male. She belongs to a culture where the touching of females by non-related males is unwelcome and severely restricted. The touch on her arm by the dentist is shaming and increases her anxiety. She decides not to return for a follow-up but finds a female dentist even though it involves long travel.

Example B

John, a respected academic, was patted by the dentist upon leaving his appointment. He found the pat demeaning even if it was well-intentioned.

Example C

Sara has a history of childhood sexual abuse. She has not discussed this with her dentist. Given the rates of sexual abuse of young females in Canada, the chance that dentists will have clients with a history of childhood sexual abuse is high. For these women, any unexplained touch can feel invasive, frightening and raise anxiety regardless of the gender of the dentist. Going to the dentist can be a source of extreme anxiety and reason to avoid the dentist’s office. Childhood sexual abuse often involves invasion of the mouth of the child and always involves invasion of personal space. When the dentist puts a comforting hand on Sara’s shoulder following a long and difficult procedure, her body goes rigid. Of course, similar anxieties may occur in male survivors of childhood sexual abuse.

Example D

Other vulnerable populations such as the intellectually, visually or hearing challenged may find touch confusing or frightening so an additional explanation may be needed for touch of any kind beyond the oral cavity, including positioning. Most dentists are well-intentioned in their use of touch, however, attention to the meaning of touch will increase comfort for all patients. As a guiding principle, dentists should be prepared to explain any touch behaviours beyond the oral cavity. As a practical guide, dentists should behave only in ways they would in front of a colleague and with behaviours they would be prepared to document. Any touching of a non-clinical nature that a dentist would not do in front of a colleague is probably wrong.