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Imagine two neighbors, leaning over a backyard fence chatting. The scene looks comfortable, perhaps somewhat intimate if they have known each other a long time. Possibly, they are discussing their latest difficulties with their respective teenage children, or their feelings about the upcoming local elections. Now consider the fence that separates them—what purposes does it serve? Most obviously, it provides something to lean on, however, it also defines a geographic boundary that marks a recognizable "territory," for example, house, yard, driveway for each.

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There are also less obvious "boundaries" operating in this exchange that delineate each person's rights, duties, and obligations. These are neighbors, perhaps close friends; perhaps not. They are not lovers, doctor, and patient, relatives, or teacher and student. They could become these things, but if they did, the boundaries defining their relationship would change. In addition, there are boundaries around the kind of information and emotions they will share, based, in part, on their past history, who they are as people, and what feels comfortable and appropriate to each given the nature of their relationship.

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Boundaries are the lines we draw between and around things. They can be physical, defining where one country begins and another one ends; biological, differentiating cells, organs, and organisms from one another; or social; delineating norms or rules for what is appropriate or relevant in a particular relationship, conversational exchange, or individual behavior.

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Boundaries are necessary, but must be flexible enough to adapt to different situations, different cultures, and other factors. For example, there is a general social convention that limits or prohibits physical contact between strangers. The rule or norm applies in some but not all situations. In a crowded elevator or subway car at rush hour physical contact is the norm, and strangers must manage social relations while in bodily contact (e.g., by pulling in personal boundaries and avoiding eye contact). Boundaries allow for relationships to form, but if too rigid, can be inhibiting. Likewise, where boundaries are too porous and unclear, they can make relationships unsafe and conflicted. Confusion arises when boundaries are unclear, participants disagree on what they should be, multiple relationships with the same person (e.g., physician and friend) exist simultaneously and require different boundaries, or when one or both participants do not feel entitled to, or do not know how to create and maintain healthy boundaries.

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As in the crowded subway, providers and patients must be able to adapt and manage boundaries to maintain optimal relationships. For example, providers are permitted to ask intimate questions of relative strangers, and to touch and manipulate parts of the body that are generally thought to be "private" during the physical examination (especially genital and rectal examinations). Such acts would be serious boundary violations in other settings. To protect the patient (and ourselves) from boundary confusion it is important to be more careful about the other boundaries that allow for safety and comfort in the ...

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