Spousal Treatment Submissions from Organizations - Health ...

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:College of Chiropractors of Ontario2

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Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:College of Dental Hygienists of Ontario37






Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:College of Physicians and Surgeons of Ontario43






Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Association of Optometrists49






Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Chiropractic Association55




















Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Opticians Association75

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)January 13, 2012Health Professions Regulatory Advisory Council56 Wellesley St W., 12 th FloorToronto, ON M5S 2S3Mr. Jones enters an opticianry practice with a prescription from his optometrist. The optician examines theprescription, consults with Mr. Jones as to type of lenses and frames he requires. Mr. Jones makes a selection,the optician records all the necessary measurements. The optician advises Mr. Jones that his prescriptionglasses will be ready for pick-up in 10 days. The optician processes payment so that Mr. Jones may obtainreimbursement under his employer's Extended Health Plan and Mr. Jones leaves.The foregoing scenario unfolds dozens of times each day in opticianry practices across Ontario and is,therefore, completely unremarkable. This particular encounter is different, however, because Mr. Jones and theoptician who attended to him happen to be married. The optician was completely professional and had nophysical contact with Mr. Jones during the session (other than that authorized by subsection 1 (4) of the HealthProfessions Procedural Code). Nor did the optician say or do anything that was even remotely "sexual". Theoptician is nonetheless subject to a finding of professional misconduct by the College of Opticians because ofthe sexual relationship that is inherent in their marital relationship. Any other optician or regulated healthprofessional who witnessed the encounter would be required to report it to the College. Under subsection 51 (5)of the Procedural Code to the Regulated Health Professions Act, as currently drafted, the College of Opticianshas no alternative other than to revoke the optician's license to practice the profession for five years and thatdisciplinary action must be posted on the College's website. For the otherwise unremarkable act of dispensing apair of glasses to her husband, the optician will be unable to practice her profession for five years and willevermore carry the label "sex offender".The Ontario Opticians Association (OOA) asserts that the situation described is completely ludicrous and isn'tnecessary to protect Mr. Jones from harm, nor does it serve the public interest. The OOA unequivocallyendorses the government's position of zero tolerance for sex abuse of patients by health care practitioners andstrongly believes that patients should be secure from the risk of sexual abuse by health care practitioners.Nevertheless, the OOA also strongly believes that the universal prohibition against the treatment of spouses --which results in 23 (soon to be 28) professions being governed for this purpose in exactly the same way -- andthe automatic revocation of registration, need to be reconsidered. The OOA understands that the prohibitionand automatic revocation of registration may be called for with respect to some health care professions, but notwith respect to opticianry. The OOA knows of no other jurisdiction in which opticians are 1) prohibited fromproviding opticianry goods and services to their spouses; or 2) subject to automatic revocation of their right topractice the profession if they do so.The OOA recommends the following:The universal and absolute prohibition against treating spouses and the mandatory registrationrevocation requirement for doing so remain in the Procedural Code.The onus be placed on individual Colleges who wish to be exempted from the provision to demonstratewhy this prohibition need not apply to their members and why it is in the public interest.The statutory prohibition against treating spouses be applied on a profession-by-profession basis76

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)with "spousal exemptions" included in the profession-specific acts.Where the profession specific Act contains a spousal exemption, that College's regulations shouldspecify the conditions or circumstances under which a Member of that College may treat his or herspouse, with a clear bias towards avoiding spousal treatment when other alternatives are reasonablyavailable. The requirement for comment and Ministry review and approval of the regulation should besufficient to ensure that appropriate interprofessional consistency and standards of public protection aremaintained.No changes should be made to those provisions that define or otherwise relate to sexual abuse by aregulated health care practitioner prompted by a complaint by any patient (including a spouse).We thank HPRAC for the opportunity to comment on this vitally important area of health professional regulationand trust that HPRAC finds our comments constructive.Yours sincerely,Lorne Kashin, ROPresidentOntario Opticians Association77

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Society of Occupational Therapists78

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Response to HPRAC Consultation onMinisterial Referral on Mandatory RevocationProvisions and Treatment of Spouses byRegulated Health ProfessionalsJanuary 18, 2012Ontario Society of Occupational therapists55 Eglinton Ave. E., Suite 210Toronto, Ontario M4P 1G8416-322-3011/osot@osot.on.ca79

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)The Ontario Society of Occupational Therapists (OSOT) appreciates the opportunity to provide commentto the Health Professions Regulatory Advisory Council’s consultation on the Ministerial referral onmandatory revocation provisions and treatment of spouses by regulated health professionals in Ontario.OSOT, the voluntary professional association of Ontario occupational therapists, represents amembership of over 3500.The issues related to the application of the mandatory revocation requirements relating to sexual abusewhen a regulated health professional treats a spouse are complex. The Society appreciates the delicatenature of finding a balance that assures strict attention to a zero tolerance position on sexual abuse andyet does not inadvertently apply penalties to competent, well-intentioned registered healthprofessionals who meet their regulatory standards in their professional practice.OSOT forwards input to this consultation that is built upon the following assertions;OSOT supports a position of zero tolerance to sexual abuseOSOT supports the goals of the Regulated Health Professions Amendment Act, 1992 whichadded requirements to encourage the reporting of sexual abuse and ultimately, to eradicate thesexual abuse of patients by members of regulated health professions.OSOT supports the regulatory positions of the College of Occupational Therapists of Ontarioarticulated in the Professional Misconduct Regulation (Ontario Regulation O.REG. 95/07), theStandards for Professional Boundaries, April 2009, the Standards for Prevention of Sexual Abuse,2007 and the Standards for Psychotherapy, August 2010 which relate to sexual abuse, theestablishment of relationships with a client, and to the treatment of a spouse or family member.In short, the profession has supported positions that direct occupational therapists to;Avoid providing occupational therapy services to his or her own family members orpartner…where professional boundaries may not be sustainable (Standard 8 – ProfessionalBoundaries)Avoid non-professional relationships with current clients (Standard 9 – Professional Boundaries)Avoid personal relationships with former clients, unless it can be reasonably established thatsufficient time has elapsed since the professional relationship ended and the OT candemonstrate that the client is no longer dependent on the occupational therapist.Never enter into a sexual relationship with a current client, or someone with whom the clienthas a significant personal relationship (e.g., child’s parent) ( Standard 1 - Prevention of SexualAbuse)280

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)With reference to the practice of psychotherapy, an OT should not have a close personalrelationship with the client at any time, including following the termination of psychotherapy.(Standard 10 – Standards for Psychotherapy)Further, occupational therapists are required to use their professional judgement to be aware of andapply knowledge to the prevention, setting and management of boundaries in a wide variety ofcircumstances. In light of trust and power relationship issues, the occupational therapist must keep inmind that it is his or her responsibility to prevent boundary violations from developing through an abuseof this power. The onus is on the occupational therapist to recognize issues of power and control and toanticipate, be alert to, respect and manage boundaries, and practice in a manner which establishes andpreserves the client’s trust. (Professional Misconduct Regulation)First QuestionIn your view, should alternatives currently mandated in the RHPA with respect to the treatment of aspouse by a regulated health professional be considered? If yes, please propose appropriatealternatives.The Ontario Society of Occupational Therapists supports consideration of alternatives to the mandatoryrevocation provisions of the RHPA.Why should alternatives be considered?While occupational therapists support the regulatory positions mentioned above which would restrictincidence of the treatment of a spouse by an occupational therapist, the Society recognizes that theremay be situations where avoidance (the term “avoid” is utilized in the standard) may be impractical.Occupational therapists who live and practice in rural or remote parts of the province may be a singularresource to the public in their region. “Avoidance” of treating one’s spouse may result in lack of accessto OT services for the client or expense of travel for the client or their health professional. In somecases, occupational therapists who develop expertise in a particular practice area may be the recognizedservice provider for a particular OT service in their region. Examples might include hand therapy,seating and mobility assessments, driver rehabilitation assessments, etc. “Avoidance” of treating one’sspouse may preclude client access to service and expertise. In such cases, the public interest would bebest served by enabling an OT to provide treatment to their spouse providing they practice competentlyand consciously within the regulatory provisions relating to boundaries and prevention of sexual abuse.Alternative ProvisionIt is OSOT’s opinion that the provisions of the RHPA were to prevent sexual abuse of clients by healthprofessionals, not to prevent access to care for spouses of health professionals. OSOT surmises that themandatory revocation provisions did not anticipate the court’s interpretation of a regulated healthprofessional treating their spouse as sexual abuse. Though the fine line between enabling access andpreventing abuse exists, OSOT believes that regulatory colleges have the capacity to set clear regulatoryguidance about setting professional boundaries, preventing sexual abuse, and treating family, through381

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)standards of practice. To this end, we would further assert that Colleges would have the means andcapacity to address any complaint of sexual abuse with the appropriate discretion that is afforded anycomplaint. All complaints should be investigated in a timely manner to determine whether theprofessional’s practice complied with the profession’s regulations and standards of practice.Investigation would enable exploration of whether the spousal relationship pre-dated treatment,whether vindictive forces ( such as the divorce exemplars of the legal suits referenced) are factors, therationale for the health professional’s choice to not avoid treatment of a spouse, etc. Such a processwould not preclude the potential for revocation of registration if sexual abuse (in an exploitive, criminalnature) was found to have occurred, but it would allow for alternate appropriate actions of theComplaints and Reports or Discipline Committees should the complaint investigation process determinethat sexual abuse as we believe was intended by the Act was not a factor.OSOT supports an alternative that would allow regulatory colleges discretion when addressing anddisciplining complaints involving a registrant’s treatment of their spouse.Second QuestionIf you find that there are appropriate alternatives to the mandatory revocation provisions in the RHPAwith respect to the treatment of a spouse by a regulated health professional, in you view:a) Do the alternatives pose a risk of harm to the public?b) Do the alternatives service the public interest?Addressing Risk of HarmOSOT asserts that the mandates of the regulatory colleges to protect the public interest are served byclear, effective and enforced regulations and standards of practice. These regulatory directives shouldprovide guidance to registrants about boundary issues, prevention of sexual abuse, etc. Enabling aregulator to review a complaint on the basis of good standards of practice, in our opinion, offersprotection to the public.OSOT has not recommended removal of the provision of mandatory revocation when exploitive sexualabuse is at fault. This is critical, we believe, to enable the colleges to demonstrate their commitment tozero tolerance. However, allowing colleges discretionary power in investigating and discipliningcomplaints of sexual abuse does not remove this strong message. In our opinion, it simply allows thecollege to assure that the exploitive sexual abuse has occurred, and that they are not simply revoking aregistration because of a marital relationship.The Society suggests that this recommendation to allow regulatory discretion enables the regulatorycolleges to exercise controls appropriate to their profession and its practice. We recognize that this mayintroduce some variability amongst professions. This variability may be confusing to the public. It willbe important that health professionals assume responsibility for managing professional boundarystandards and communicating these to their clients.482

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)The public may perceive that the removal of mandatory revocation provisions exposes some clients togreater risk. Clients who seek psychotherapy services from regulated health professionals (includingoccupational therapists) may be one group for which this concern would be apparent. Therecommendation to remove the mandatory revocation provision does not, however, preclude anycollege from establishing standards of practice and codes of conduct that may be unique to the practiceof psychotherapy. These can provide more stringent protections, as may be deemed appropriate, towhich professional misconduct is measured. For example, the College of Occupational Therapists ofOntario published Standards for Psychotherapy in 2010.Addressing the Public InterestWhile protection of the public is paramount and the tolerance of sexual abuse unsupportable, as long asthese principles are addressed in alternate provisions for dealing with health professional treatment ofspouses, OSOT believes that there may be a public interest benefit in allowing for treatment of spousesin some cases. From an occupational therapy perspective, this would be most apparent in rural andremote communities where access to service and professional expertise may be more appropriatelyenabled by allowing health professionals to treat spouses without the repercussion of mandatoryrevocation of registration.The legal examples provided in HPRAC’s background documents give evidence to the complicated,elongated and expensive legal investigations and appeals that can rightly follow revocation ofregistration when exploitive sexual abuse has not been at issue. Procedural cost savings are a realisticbenefit of changes to more discretionary management. Ultimately the public pays for regulatoryinefficiencies and would be served if effective and cost-savings mechanisms were engaged.The Ontario Society of Occupational Therapists is pleased to have contributed to the discussion of thisimportant issue. Should further clarification of our positions and recommendation be desired, pleasecontact Christie Brenchley, Executive Director at cbrenchley@osot.on.ca or 416-322-3011 ext 224.583

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Association of PsychologicalAssociates84

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)January 18, 2012TO: Health Professions Regulatory Advisory Council (HPRAC)RE: Consultation on Mandatory Revocation Provisions and Treatment of Spouses byHealth Care ProfessionalsThe Ontario Association of Psychological Associates (OAPA) thanks you for theopportunity to respond in regards to the recent HPRAC consultation on the Treatment ofSpouses by Regulated Health Professionals in Ontario. While OAPA believes that theoriginal legislation regarding sexual misconduct and health clients was developed withthe spirit of maintaining public safety and the protection of vulnerable populations, weshare the concerns of many of our allied health peers that the original legislation hasbeen worded in too broad a manner and that this has led to the inappropriateapplication of sexual misconduct principles to those who are in a treatment relationship(intentional or otherwise) with a spouse, common-law partner, or another preexistingsexual relationship.In general, psychology regulatory colleges and associations have typically perceived thepsychological treatment of spouses (and similar relations) as an ethically questionableact due to the inherent power imbalance that occurs in therapeutic treatment andpsychological assessment. That being said, these groups have also recognized thatthere may be situations where such treatments are unavoidable (e.g., crisis response)or have a less inherent imbalance due to the application of acts that, whilepsychological in nature, are not necessarily considered a traditional health act where apower imbalance would occur (e.g., industrial/organizational psychology).Fortunately, public protection from spousal treatment that would be deemedinappropriate has been well regulated within the profession of psychology for sometime. This has been managed through regulations regarding dual relationships, that, inessence, prevent a clinician from participating in a professional relationship where apreexisting relationship could influence the actions or behaviours of either the clinicianor the client. If such a “dual relationship” exists, a member of our college would be seenas acting in an unethical manner. This would result in an investigation, a possible findingof professional misconduct, and a penalty or regulatory action that is fitting andappropriate to the nature of the act of misconduct.16 – 1375, ch. Southdown Rd. ® Suite 303 ® Mississauga, ON ® L5J 2Z1www.oapa.on.ca85

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Unfortunately, the wording of the current legislation means that the College ofPsychologists of Ontario may be forced to respond to a less serious dual relationshipinvestigation as if it were a case of sexual misconduct. This would include mandatoryregistration revocations that are in keeping with the current legislation. While OAPAagrees that there are few situations where the treatment of spouses is appropriatewithin the profession of psychology, we adamantly oppose the viewing of these acts asone of sexual misconduct. Our concerns also go beyond the simple unintendedapplication of these acts at the college level, as we recognize that there could be caseswhere this legislation is applied in an abusive manner (e.g, the legislation could be usedby a punitive spouse in a divorce proceeding).Further to this, OAPA recognizes that there are also several other health professionswhere the treatment of spouses would not have an inherent power imbalance (e.g., thehome care management of a spouse by an appropriately trained nurse; denturist work).In these matters, we are supportive of our allied health peers, in that we believe that theappropriateness of the treatment of spouses by regulated health professionals shouldbe considered at the regulatory college level under stipulations regarding dualrelationships and power imbalances. As these principles are already in place in nearlyall ethical practice guidelines, it is OAPA’s position that spousal treatment should beexcluded from more global legislation regarding regulated health professions as awhole.We appreciate that OAPA has been provided with an opportunity to respond toward thematter currently being considered. We look forward to having an opportunity to speak toyour committee on this matter further if our concerns have not been made sufficientlyclear in this response.With kind regards,Michael Decaire, M.A., C.Psych.Assoc.Ontario Association of Psychological Associates, President86

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:College of Denturists of Ontario87

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Contact InformationFields marked with a * are requiredI am responding* (select the appropriate answer from the drop-down list and click to make the selection):First Name: *Last Name: *Title:Occupational Type (select the appropriate answer from the drop-down list and click to make the selection):Organization Name:Organization Type (select the appropriate answer from the drop-down list and click to make the selection):Geographical Location (select the appropriate answer from the drop-down list and click to make the selection):Telephone (including area code):E-Mail Address: *Health Professions Regulatory Advisory Council 488

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Questionnaire1. In your view, should alternatives to the mandatory revocation provisions currently mandated in the RHPAwith respect to the treatment of a spouse by a regulated health professional be considered? If yes, pleasepropose appropriate alternatives.Please explain the rationale for your position.You may include evidence and/or citations where applicable.If you require more room than the space provided, please attach a separate page.Health Professions Regulatory Advisory Council 689

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)2. If you find that there are appropriate alternatives to the mandatory revocation provisions currentlymandated in the RHPA with respect to the treatment of a spouse by a regulated health professional, in yourview:A. Do the alternatives pose a risk of harm to the public?B. Do the alternatives best serve the public interest?Please explain the rationale for your position.You may include evidence and/or citations where applicable.If you require more room than the space provided, please attach a separate page.Health Professions Regulatory Advisory Council 890

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)3. Do you have any other comments about the issue of mandatory revocation provisions and treatment ofspouses by regulated health professionals?If you require more room than the space provided, please attach a separate page.Health Professions Regulatory Advisory Council 1091

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Dental Association92


Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)SUBMISSION TO:HEALTH PROFESSIONS REGULATORY ADVISORYCOUNCILMANDATORY REVOCATION PROVISIONS ANDTREATMENT OF SPOUSES BY REGULATED HEALTHPROFESSIONALSSUBMISSION BY:Dr. Harry Höediono, President of the Ontario Dental AssociationandDr. Ronald Yim, Chair of the Zero Tolerance Task Force of the Ontario Dental AssociationOn Behalf of the Ontario Dental AssociationJanuary 18, 201294

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Inquiries regarding this submission should be directed to:Frank BevilacquaDirector, Professional, Government and Component Society AffairsOntario Dental Association4 New StreetToronto, OntarioM5R 1P6Tel: 416-355-2255Email: frankb@oda.on.caPage 2 of 1695

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Ministerial Referral on Mandatory Revocation Provisions andTreatment of Spouses by Regulated Health ProfessionalsQuestionnaireQuestion 1: In your view, should alternatives to the mandatory revocation provisionscurrently mandated in the RHPA with respect to treatment of a spouse by a regulated healthprofessional be considered? If yes, please propose appropriate alternatives.PreambleThe Ontario Dental Association (ODA) is a voluntary professional organization that represents thedentists of Ontario. The ODA appreciates the opportunity to comment on this important issue, and wouldlike to thank the Health Professions Regulatory Advisory Council (HPRAC) for considering thecomments and proposal included in this response.Ensuring the public interest is a central tenet of the Minister’s Referral. The ODA, through its advocacyefforts on behalf of dental patients, has a longstanding history of placing great value on advancing thepublic interest. The ODA represents dental patients because there is no provincial organization dedicatedto representing the oral health needs of Ontarians; this is a strong signal of the ODA’s commitment to thepublic interest. It is through this frame of reference that the ODA presents its submission in response tothe Minister’s Referral.The ODA fully supports the principle that predatory and exploitative sexual behaviour of regulated healthprofessionals, directed at patients, cannot be tolerated. Preventing and ultimately eradicating sexual abusein the health care setting through appropriate and targeted measures is an important policy goal.Similarly, the ODA fully supports the need for introducing a legislative change to enable dentists to treattheir spouses and partners. Under no circumstances should a dentist be deemed by law to be guilty ofsexual abuse, where there has been no sexual abuse, simply for treating a spouse or partner.The Regulated Health Professions Act, 1991 (RHPA) includes mandatory revocation provisions withrespect to treatment of a spouse by a regulated health professional. It is the ODA’s position that acomprehensive alternative to the mandatory revocation provisions within this context is necessary. Thisresponse will outline the rationale for amending the legislation in its current form, will propose a viablealternative that does not incur risk of harm to the public, and will further describe how this alternativebest serves the public interest.Deviation from Legislative IntentThe intent of the sexual abuse provisions within the RHPA is to encourage the reporting ofsexual abuse and to eradicate the sexual abuse of patients by members of regulated healthprofessions. However, there is a key failing within the legislative scheme. The provisions, asinterpreted by the Court of Appeal for Ontario, equate spousal treatment by a regulated healthprofessional with sexual abuse. The context of spousal treatment is not considered.There is an unacceptable disconnect between the intent of the sexual abuse provisions and theactual effects of their enforcement in cases of spousal treatment by regulated healthPage 3 of 1696

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)professionals. A significant unintended effect is the punishment of health professionals such asdentists who have not engaged in the exploitative conduct that the provisions were drafted toaddress. It was never the intent of the RHPA provisions to prohibit regulated healthprofessionals from treating their spouses. This point was recognized by the Hon. Ruth Grier,former Minister of Health, in a 1993 letter addressed to Jim Henderson, M.P.P. where it wassuggested that regulations would be developed to clarify matters related to spousal treatment. Ittruly is regrettable that was never done. In the letter the Minister further stated the following:“I am sure you appreciate that an important principle of statutoryinterpretation is that the words of a statute are to be read in their entirecontext, in their grammatical and ordinary sense, and harmoniously withthe scheme of the legislation, its object and the intention of thelegislature. There is no intention within Bill 100 to prohibit maritalrelations between dentists and their spouses.”The letter in its entirety appears in Appendix A. In 1995 former Assistant Deputy Minister ofHealth, Jodey Porter, responded via letter to an inquiry about whether the RHPA prohibited aregulated health professional from treating his or her spouse. An excerpt of the letter received bya number of health professions appears below and the letter appears in its entirety in AppendixB:“The objective of the sexual abuse provisions in the RHPA is to detersexual abuse of patients by regulated health care professionals. As youknow, sexual abuse is defined under RHPA as:• sexual intercourse or other forms of physical sexual relationsbetween the member and the patient;• touching, of a sexual nature, of the patient by the member; or• behaviour or remarks of a sexual nature by the membertowards the patient.However, under RHPA “sexual nature” does not include touching,behaviour or remarks of a clinical nature appropriate to the serviceprovided. Thus, assessment and treatment of spouses by [omitted] inthe course of practicing [omitted] is not prohibited under RHPA. Itis not the intention of the legislation to regulate the relationship betweenspouses.” (emphasis added)Another letter dated January 20, 1995 from Jodey Porter, addressed to Dr. George Citrome,President of the Royal College of Dental Surgeons of Ontario indicated that the legislation wasnot intended to regulate the relationship between spouses and that the College could advise itsmembership that they can continue to provide dental treatment to their partners. This letter hasalready been shared with the Ministry of Health and Long-Term Care.Page 4 of 1697

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Unwarranted PunishmentThe Court of Appeal for Ontario has also recognized the discord between spousal treatment andthe legislative intent of the sexual abuse provisions. When rendering its decision in Leering v.College of Chiropractors of Ontario, 2010 ONCA 87 the Court of Appeal stated at paragraph 2:“Because of the mandatory penalty of five years out of practice for thehealth care professional, courts have struggled with the application of thesection in circumstances that may not appear to fit the ordinaryunderstanding of sexual abuse, such as where the patient is a spouse or inan intimate partnership with the health care professional.”In Mussani v. College of Physicians and Surgeons of Ontario (2004), 74 O.R. (3d) the Court ofAppeal for Ontario observed that the application of the sexual abuse provisions of the RHPA canbe unjust. The Court stated at paragraph 72:“There are admitted problems with zero tolerance/ mandatory penaltyregimes. They are rigid. They can lead to results in individual casesthat are harsh, extreme, and even arguably unjust. They deprive thebody imposing the penalty of any discretion to tailor the result to meetthe requirements of the circumstances. In particular, they deprive thereviewing body of any flexibility in responding to situations where theremay be genuine consent to a relationship between mature adults, and nopower imbalance or exploitation on the part of the health professional.”Impact of Sexual Abuse/ Mandatory Revocation Provisions on Regulated HealthProfessionalsIf the Discipline Committee of a College finds that a member has committed an act ofprofessional misconduct by sexually abusing a patient, that member’s certificate of registrationwill be revoked for a minimum of five years. A finding of sexual abuse can have a profound anddevastating effect on a health professional’s career. Where this comes only as a consequence ofspousal treatment this outcome simply cannot be justified.The inability to earn a living in one’s area of professional expertise is a severe penalty. Thepunishment, however, extends far beyond the immediate effects. Section 23 of the HealthProfessions Procedural Code of the RHPA requires that revocations of certificates of registrationare noted on the Register established by each College. The Register is accessible to the public.To illustrate, a health professional loses her certificate of registration as a consequence ofproviding treatment to her spouse. This is noted on the Register for her profession, and she willbear the label of a sexual offender as long as she is listed on the Register. When she closes herpractice in compliance with the penalty, there is nothing to prevent public announcements fromlinking this health professional’s practice closure to her sexual abuse of a patient. Even if hercertificate of registration is re-instated after five years, the consequences of the penalty willcontinue. When prospective patients consult the Register in an effort to find a provider, there isPage 5 of 1698

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)reasonable certainty they will not choose a person who is considered a “sexual offender” todeliver their health care.The importance of addressing this issue comprehensively cannot be overstated. The provisionsof the RHPA that address mandatory revocation of a health professional’s certificate ofregistration in the context of spousal treatment cannot be addressed in isolation. It is notacceptable to move from an outcome where a health professional loses his or her certificate ofregistration for sexually abusing a patient, where no such abuse occurred, to an outcome where ahealth professional is noted on the Register as sexually abusing a patient, but is no longer subjectto the mandatory penalty. This does little to alleviate the injustice of the provisions in theircurrent form. The ODA strongly believes that the advice HPRAC provides to the Ministershould include reasoned consideration of the sexual abuse provisions in their totality, as relatedto spousal treatment, rather than just addressing the issue of mandatory revocation.Proposed AlternativeThe ODA supports an alternative to the mandatory revocation provisions that upholds theexisting protections to the public while minimizing the unintended legislative effect of brandinghealth professionals as sexual offenders where they have not committed sexual abuse in the truespirit of its meaning.The ODA proposes that the RHPA is amended to allow the Discipline Committee of a Collegediscretion when addressing complaints involving a member and his or her spouse. Specifically,the Discipline Committee should have the authority to exercise discretion when examining on acase by case basis the totality of the circumstances involving a member and his or her spouse, todetermine whether a member’s conduct constitutes sexual abuse of an exploitative or predatorynature. Where it is determined that a member has committed an act of professional misconductthat does not constitute sexual abuse the Discipline Committee should have the discretion to:make an order under subsection 51 (2) of the Health Professions Procedural Code of theRHPA without any requirement to make an additional order under subsection 51 (5) of theHealth Professions Procedural Code of the RHPA.The ODA has a strong interest in collaborating with HPRAC to develop proposed legislativelanguage for amending the RHPA in accordance with the ODA’s proposal. The Association willbring the appropriate resources to the table to ensure the outcome is to the benefit of allstakeholders.The ODA’s proposed alternative also includes a component that can be undertaken by theindividual Colleges. As a regulator, each College is uniquely positioned to determine whether itis appropriate for its members to provide treatment to spouses. Some Colleges haveimplemented Standards of Practice that restrict and deter treatment of family members, includingspouses. Any College would have the option to develop a Standard of Practice to restrict orprohibit spousal treatment if it believed this would be in the best interest of the public.Page 6 of 1699

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Question 2: If you find that there are appropriate alternatives to the mandatory revocationprovisions currently mandated in the RHPA with respect to the treatment of a spouse by aregulated health professional, in your view:A. Do the alternatives pose a risk of harm to the public?B. Do the alternatives best serve the public interest?Part AWhen proposing an alternative that affects the current regime, it is important to do so withrecognition that the purpose of the sexual abuse provisions under the RHPA must be fullyupheld. The purpose is stated in section 1.1 of the Health Professions Procedural Code of theRHPA:1.1 Statement of purpose, sexual abuse provisionsThe purpose of the provisions of this Code with respect to sexualabuse of patients by members is to encourage the reporting of suchabuse, to provide funding for therapy and counselling for patientswho have been sexually abused by members and, ultimately, toeradicate the sexual abuse of patients by members. 1993, c.37, s.5.Nothing in the ODA’s proposed alternative, as outlined in the response to Question 1, points toan increased risk of harm to the public. Amendments to the RHPA as described would in no waynegatively impact on the purpose of the sexual abuse provisions as stated in section 1.1.The Colleges, when examining member conduct and determining disciplinary decisions, shouldbe entrusted to exercise discretion with integrity and an unrelenting commitment to public safety.The Colleges have gained an extensive experience base over the past 18 years in terms ofimplementing RHPA requirements. The Royal College of Dental Surgeons of Ontario’s recordis exemplary; the College has been serving the public interest since 1868, and has a record ofexcellence in managing complaints and rendering disciplinary decisions. The commitment ofthe Colleges to their mandate was acknowledged by the Hon. Deb Matthews in ‘The Minister’sQuestion’ section of the present Ministerial referral. She expressed her confidence in theColleges as follows:Patient Safeguards“It is my view that the health regulatory Colleges have done in thepast and will continue to do, now and in the future, an exemplaryjob in monitoring their members, following up on reports and fullyinvestigating and enforcing the law respecting the sexual abuse ofpatients by members.”Despite the confidence of the Minister, some stakeholders may express concerns with the ODA’sproposed alternative to the sexual abuse/ mandatory revocation provisions that would allowPage 7 of 16100

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)dentists to treat their spouses/ partners. One potential concern relates to patient populations thathave been recognized as being vulnerable. Certain health professions acknowledge the potentialfor patient vulnerability particular to that discipline and have implemented measures under theRHPA to safeguard patient safety. Accordingly, as aforementioned, even if Colleges areafforded additional discretion, they can develop and enforce measures such as Standards ofPractice to prevent members from providing treatment to spouses, should spouses be considereda vulnerable patient population.Related to the above point is the recognition that a power imbalance can occur within certainpatient-practitioner relationships. This was one of the findings of the 1991Task Force on SexualAbuse. It is unreasonable to translate this finding broadly to spouse-practitioner relationships. Itis not unusual for a health professional to be in a spousal relationship with another healthprofessional, or a professional of another discipline where there is no power imbalance.Part BThe ODA is of the view that its proposed alternative will best serve the public interest. Thisdiscussion should, however, be prefaced by noting how the sexual abuse/ mandatory revocationprovisions in their current form operate to the detriment of the public.The response under Question 1 addresses the hardship that a health professional can suffer in theevent of loss of his or her certificate of registration. This loss can additionally have tremendousadverse effects on members of public. If the health professional provided financial support todependents, these dependents would be impacted. If the health professional operated a practiceand was forced to close that practice, employees could suffer the consequences.It is further possible that an entire community could experience compromised access to care.Consider the following example: the dental care needs of a small community in Ontario areprovided by two dentists who happen to be spouses of one another. If as members of thecommunity they each received dental care from one another, and if this came before theDiscipline Committee, it is possible that both dentists could have their certificates of registrationrevoked. The entire community could be without reasonable access to dental care andindividuals may be forced to seek dental care at locations considerably distant from their homes.The above example also underscores how access to health care services would in fact beimproved if health professionals were able to treat their spouses. In parts of Ontario there maybe a single practitioner of a given health profession who is responsible for the care of patients ina large geographic area. Under the current legislation the spouse of that practitioner cannotreadily access the health care services of that profession and may have to travel a significantdistance to receive care.The freedom to choose one’s health care provider is a point that resonates with many members ofthe public. Some patients would like to benefit from the professional expertise of a spouse, aperson whom they trust implicitly, but are denied this choice. The public would benefit from aPage 8 of 16101

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)legislative scheme that no longer punishes health professionals who provide treatment to theirspouses.Question 3: Do you have any other comments about the issue of mandatory revocationprovisions and treatment of spouses by regulated health professionals?Ontario Stands AloneIn July 2011 HPRAC conducted a review titled: Mandatory Revocation Provisions andTreatment of Spouses by Regulated Health Professionals: A Jurisdictional Review. The reviewexamined the legislation, regulation, codes and standards relating to seven regulated healthprofessions in 10 Canadian provinces, 6 U.S. states, as well as the U.K., Australia, New Zealandand South Africa. The research determined that Ontario is the only jurisdiction that penalizesspousal treatment through mandatory revocation of a health professional’s certificate ofregistration for a minimum of five years. The issue of sexual abuse of patients is one that isexperienced across jurisdictions. And yet other jurisdictions have found ways to address theissue that do not have the dual effect of severely punishing health professionals whom have notengaged in predatory sexual abuse in the true spirit of its meaning.A Sensible ApproachThe province recently applied a sensible approach toward the sexual abuse provisions includedwithin Ontario Regulation 166/11 under the Retirement Homes Act, 2010. Subsection 1(3)(b) ofthe Regulation provides that the definition of “sexual abuse” does not include:(b) consensual touching, behaviour or remarks of a sexual nature betweena resident and a licensee or staff member that is in the course of a sexualrelationship that began before the resident commenced residency in theretirement home or before the licensee or staff member became a licenseeor staff member.The drafters of the Regulation recognized that in the context of retirement homes there may bedefined circumstances where a sexual relationship with a patient is non-exploitative andappropriate. A similar, logical approach could be taken with regard to considering the ODA’sproposed alternative to the sexual abuse and mandatory revocation provisions within the RHPA.Historically, dentists have been able to treat their spouses. The ODA respectfully requestsHPRAC to recommend strongly that the Minister introduce appropriate changes to the RHPAthat will again allow dentists to treat their spouses/partners without such treatment being definedby law as sexual abuse.Concluding RemarksThe ODA is grateful for the opportunity to present this submission to HPRAC for itsconsideration. The Association is a strong proponent of the public interest and believes that thePage 9 of 16102

Ontario Dental Association Submission, January 18, 2012Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)proposed alternative to the sexual abuse/ mandatory revocation provisions, as outlined in thisresponse, best serves the public. The ODA welcomes further dialogue with HPRAC on thismatter and is available to collaborate on developing legislative language in support of thisproposed alternative.All of which is respectfully submitted.Page 10 of 16103

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Appendix A104




Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Appendix B108


Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Association of Speech-LanguagePathologists and Audiologists110

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Fields marked with a are required(select the appropriate answer from the drop-down list and click to make the selection):On behalf of an OrganizationMaryCook:Executive Director(select the appropriate answer from the drop-down list and click to make the selection):Representative/Employee of Regulated Health Professional AssociationOntario Association of Speech-Language Pathologists and Audiologists (OSLA)(select the appropriate answer from the drop-down list and click to make the selection):Regulated Health Professions Association(select the appropriate answer from the drop-down list and click to make the selection):Ontario(including area code):416-920-3676:mcook@osla.on.caHealth Professions Regulatory Advisory Council 4111

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Please explain the rationale for your position.You may include evidence and/or citations where applicable.If you require more room than the space provided, please attach a separate page.Yes.Let each regulatory College have the authority to set own disciplinary measures for its registrants based on risk - on acase-by-case basis. Should not be a regulation but instead a Best Practices Guideline.The mandatory revocation for treatment of spouse should be eliminated. The mandatory revocation for 5 years is harsh and inour opinion an inappropriate disciplinary action.Treatment of a spouse by for example , by a psychologist or physician, is not the same risk of harm as an audiologist conductinga hearing test or a speech-language pathologists assessing a swallowing disorder. Speech-Language Pathologists andAudiologists should have the discretion to treat their spouse.Health Professions Regulatory Advisory Council 6112

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions) Please explain the rationale for your position.You may include evidence and/or citations where applicable.If you require more room than the space provided, please attach a separate page.A. No - the appropriate alternative that OSLA has proposed better achieves the objective of the provisions. The legislation was toprotect the patient from sexual abuse. OSLA supports "zero tolerance" for sexual abuse of a patient.B. Yes - as the provisions currently stand - if you are a spouse and receive treatment from your health care provider spouse - itequates to sexual abuse and a mandatory revocation which undermines the intent of the provision.At a minimum, if treatment preceded the spousal relationship, allow the regulatory College to assess and set various disciplinarymeasures on a case-by-case basis.Health Professions Regulatory Advisory Council 8113

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)If you require more room than the space provided, please attach a separate page.This provision minimizes and detracts from the real purpose and intent of the legislation which is to protect the patient fromunwanted sexual activity when the health care professional is in a position of power and trust.Also there first has to be a finding of sexual abuse as defined in law. Currently the provisions automatically assumes that if aspouse is treated there is sexual abuse. Treatment of spouse does not automatically infer sexual abuse.If a spouse has been consenting to sexual activity prior to the beginning of a professional relationship, there is no reason toassume that the consent has changed once treatment is received.Also, the term patient is not defined in the RHPA and therefore the term spouse and patient does not mean the same person.Therefore a spouse who receives treatment or an assessment by the therapist cannot be interpreted as being a patient.Health Professions Regulatory Advisory Council 10114

Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:College of Opticians of Ontario115






Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:College of Psychologists of Ontario121













Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Dental Hygienists’ Association134






Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Dental Hygiene Practitioners of Ontario140


Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario College of Social Workers and SocialServices Workers142




Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Association of Optometrists146






Spousal Treatment Submissions (Organizations - PDF/Fax Submissions)Submission from:Ontario Association of Medical RadiationTechnologists152









lB"*odl rf Dinecfo*u of Do*gn*uu "]fherepyNATUROPA"]TF{YI l2 Adelaide Street EastToronto, Ontario MsC l KgEmail : office@BDDTN.on. caTelephone: 4 I 6-a66-8383Facsimile: 4 16-a66,-2| 75TOll trree: l-877-361-1925January 18,2012Health Professions Regulatory Advisory Council56 Wellesley St W., l2th FloorToronto, ON M5S 2S3Re: Mandatory Revocation Provisions and Treatment of Spouses by Health Care ProfessionalsIntroductionAs HPRAC is aware, the Board of Directors of Drugless Therapy-Naturopathy (BDDT-N) is the statutoryregulator of the Naturopathy profession in Ontario under the Drugless Practitioners lcl (DPA). Uponproclamation of the Naturopathy Act, 2007,the Board will be wound up and its operations assumed bythe College ofNaturopaths of Ontario. The transition is currently scheduled on or about March 31,2013.ln the meantime, the Board continues to regulate the profession with its full authorities. Since theNaturopathy Act obtained Royal Assent, the Board has implemented a policy of regulating the professionconsistent with the Regulated Health Professions Act GHPA) as much as is possible within thelegislative framework of the DPA. The Board's Policy on Prevention of Sexual Abuse, insofar as itrelates to the treatment of spouses, closely tracks the provisions in the Procedural Code. Specifically, thePolicy prohibits sex with a "client" under any circumstances, imposes a two-year "cooling off' periodbefween the cessation of the practitioner-patient relationship and commencing an intimate relationship,and requires NDs to report any instances of abuse by another ND or health care practitioner. The Policystates that "if counseling has been a major component of the professional relationship, sexual contact isprohibited for all time". The Policy does not define "client", but there is no exemption for spousaltreatment.The DPA does not authorize the Board to prescribe automatic revocation of registration or any otherpenalties with respecto any disciplinary action. Penalties must be determined on a case-by-case basis. Acopy of the Board's Policy on the Prevention of Sexual Abuse is attached as Appendix A.STIBMISSIONThe Board unequivocally supports the government's "ze-ro tolerance" approach to sexual abuse of patientsby health care practitioners. The Board would not condone any liberalization or backing away from thatapproach. Nevertheless, the Board is uncomfortable with the Leering formulation that any spousaltreatment equates with sexual abuse under the RFIPA, regardless of whatever circumstances may apply.Accordingly the Board is not convinced that a blanket prohibition againstreating spouses and includingautomatic registration revocation are necessarily in the public interest.

The Board agrees with an absolute prohibition against health care practitioners counseling their spousesand understands that such a prohibition would be consistent with current practice in many otherjurisdictions, however the Board recommends that the blanket prohibition against the treatment of spousesbe removed from the procedural code.The Board also agrees that there should be a prohibition against health care practitioners (including NDs)providing ongoing care to their spouses, other than in the most exceptional of circumstances. The Boardrecommends an explicit statutory spousal exemption for treatment in cases of emergency, assisting withactivities of daily living, or in instances of minor or incidental care.With the foregoing in mind, the Board recommends an approach to the treatment of spouses by healthcare practitioners that contains the following elements:eeMandatory revocation should not be triggered automatically in instances of spousal treatment.The Disciplinary Panels should be granted discretion to consider circumstances on a case-by-casebasis, such as the nature of the treatment provided, the circumstances under which the decision totreat was made, whether the patient was in a vulnerable situation or state of mind at the time andso on.The Procedural Code should continue to contain a blanket and absolute prohibition against healthcare practitioners providing professional counseling services to their spouses, includingmandatory revocation of registration for noncompliance.. Whether a prohibition against the treatment of spouses is in the patients' and in the public interestshould be considered on a profession-by-profession basis and, when such a prohibition isnecessary, should be included in the profession-specific act, or in the College's MisconductRegulation. The onus should be on individual Colleges to justify a complete or partial spousalexemption and prohibition should be the default position. In the case of NDs, the Board wouldrecommend an amendment to the Naturopathy Act prohibiting NDs from being the primary healthcare providers to their spouses.oWhere the profession-specific act or Misconduct Regulation contains a prohibition againsthetreatment of spouses, it should also contain an explicit exemption for emergency, minor orincidental treatment and for assistance with activities of daily living.The Board of Directors of Drugless Therapy - Naturopathy is grateful for the opportunity toparticipate in this review.SincerelyAngela M. Moore, NDExecutive Director

Appendix ABoard of Directors of Drugless Therapy - NaturopathyPolicy on Prevention of Sexual AbuseThe goal of these guidelines is to:o Protect the publico Respond promptly and sensitively to a complainant while protecting the rights of theaccused Naturopathic Doctor to a fair hearingo Safeguard the privacy of the complainant and the Naturopathic Doctoro Avoid delays; complete the investigation within a reasonable time frameo Have as non-confrontational an investigation as possibleSexual Abuse includes, but is not limited to:. Sexual intercourse or other forms of physical relations between a NaturopathicDoctor and a client. Sexual touching of the client by the Naturopathic Doctoro Behaviour or remarks of a sexual nature by the Naturopathic Doctor towards theclientExamples of inappropriate behaviour include:. Sex between a Naturopathic Doctor and a client, whether it is initiated by the client ornot. Engaging in any conduct with a client which is sexual, or may be reasonablyinterpreted as sexual, including but not limited to sexual intercourse, genital to genitalcontact,.genital to anal contact, oral to genital contact, oral to anal contact, oral to oralcontact except for CPR, touching breasts or genitals except for the purpose ofappropriate physical examination or treatment or where the client has refused orwithdrawn consento Encouraging the client to masturbate in the presence of the Naturopathic Doctor ormasturbation by the Naturopathic Doctor when the client is present. Any behaviour, gestures or expressions that are seductive or sexually demeaning to acliento Inappropriate procedures including, but not limited to, inappropriate disrobing ordraping practices that reflect a lack of respect for the client's privacy or deliberatelywatching a client dress or undress instead of providing privacyo Subjecting a client to a genital, breast, anal or rectal examination in the presence ofmedical students or other parties without the explicit written consent of the client, orwhen consent has been withdrawno Examination or touching of the genitals without glovesSA page l'of 3

Appendix ABoard of Directors of Drugless Therapy - Naturopathyo Inappropriate comments about or to a client including, but not limited to, makingsexual comments, or comments that could be interpreted as sexual, about a client'sbody or clothingo Making sexual or sexually demeaning comments to a client, sexual innuendo or jokes,or criticism of the client's sexual orientationo Making comments about sexual performance during an examination or consultation,except when the examination or consultation is pertinent to the issue of sexualfunction or dysfunctiono Requesting details of sexual history or sexual likes or dislikes, when not clinicallyindicated for the type of consultation, other than the normal questions associated withgathering information during a history or homeopathic consultationo Making a request to dateo Initiation by the Naturopathic Doctor of conversation regarding the sexual problems,preferences or fantasies of the Naturopathic Doctoro KissingAny conduct will be considered'sexual in nature' if it is inherently sexual conduct, e.g.touching the client's sexual organs other than when warranted or called for in the courseof an examination; or it is potentially neutral contact done with a sexual motivation, e.g.patting the client's knee.'Sexual in Nature' does not include touchins. behaviour or remarks of a clinical natureappropriate to the service provided.The penalty for infractions could include revocation of the Naturopathic Doctor's license.Naturopathic Doctors are required to report any instances of abuse by a colleague or otherhealth care provider. Complaints will be acted upon but the name of the complainant willbe kept confidential until formal charges are laid.To avoid unintentional transgressions, Naturopathic Doctors are required to:o Have someone else in the examination room when doing examinations of the genitals,breasts or anus, unless the client specifically requests otherwise (this might include asupport person of the client or a member of the Naturopathic Doctor's office staff andshould be handled in such away that the privacy of the client is protected as much aspossible)o Explain all procedures in detail prior to the examination, no matter how routineNaturopathic Doctors should:o Ask permission before asking questions of an intimate nature, or before touchingoCreate a climate of open communication to reduce the power imbalance inherent inthe practitioner/client relationshipo . Encourage clients to ask questions, express any discomfort, and to take personalresponsibility in making health care choicesSA page 2 bf3

Appendix ABoard of Directors of Drugless Therapy - NaturopathyWhen a professional association and a friendship exist at the same time, the NaturopathicDoctor should ensure that they are kept quite separate.If a more intimate relationship is to develop, the Naturopathic Doctor is responsible forterminating the professional relationship and providing appropriate referral. After suchclosureo a cooling off period of at least two years must be respected before proceedingwith any further relationship. However, if counseling has been a major component of theprofessional relationship, sexual contact is prohibited for all time.t999/06SA page 3 of3

Health Professions Regulatory Advisory Council55 St. Clair Avenue WestSuite 806 Box 18Toronto, Ontario, Canada M4V 2Y7Telephone: 416-326-1550Toll-Free: 1-888-377-7746Fax: 416-326-1549Website: www.hprac.orgTwitter: www.twitter.com/hpracontarioEmail: hpracwebmaster@ontario.ca

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