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Over the last decade, I have worked with a team of editors and authors on an international book on sexual harassment in medicine, which has been published by Cambridge University Press. It has been a long, sometimes surprising and deeply disturbing analysis of a complex problem with world-wide ramifications.
From the beginning, we believed that sexual harassment was a cultural problem, deeply embedded within larger social worlds. There are features of medicine that are unique to its own culture, and this is the reason why we took a deep dive into a narrow field.
Medical workplaces are diverse. Harassment can occur with doctors, nurses, managers, other health professionals, patients and family members becoming either perpetrators or targets. Doctors arrive in medicine steeped in deeply gendered cultures, and often bring their own histories of trauma. Predators pick positions of power, where vulnerable targets are available. This is not an individual problem. It is always easy to attribute a systemic problem to individual “bad apples”, but we found there were bad orchards, bad farming practices, and, to extend the metaphor further, a variety of toxic herbicides causing unintended damage to crops. Medical culture is influenced by all the organisations and individuals that engage with it, and influence it. Therefore, it is not only medicine’s problem to solve.
It is therefore not surprising that the simplified ‘solutions’ proposed to address this complex problem don’t work. I have spoken to many leaders of many institutions around the world, and they often quote that there are laws preventing sexual harassment. This is true, but law is not enough. “It may be illegal” said one survivor wryly “but so is rape, and law hasn’t fixed that yet.”
Culture trumps strategy every time. You can legislate, regulate and educate, but none of that will fundamentally change “the way we do things around here”, at least not on its own.
“Zero tolerance” is an aspiration, not a policy.
Managing harms
During our work on the book, we learned that there were a plethora of laws, policies, organisations and institutions all too willing to collaborate to reduce sexual harassment. However, for the survivor this meant complex, intersecting policies and a bewildering variety of options.
A medical student, for instance, can report to police, medical regulators, their university, the staff of the hospital they are in, or the lead hospital in the network, and a number of informal networks that claim to provide “support and advice”. We found it almost impossible to find out what was behind the “doors” leading into the various institutions, meaning targets couldn’t find critical information to help them decide how to proceed. The questions they wanted answered weren’t difficult, but few were publicly available. Simply put, they needed to know:
- What would reporting it cost?
- How long the process would take?
- What were their risks of harm?
- Whether their name could be kept confidential?
- What would/could happen to the perpetrator?
- And what would the process actually involve?
Reporting is not the simple action it is often portrayed to be. It is a long, arduous, lonely and challenging process that can be a full-time job. Being a survivor is an exhausting addition to an already challenging career pathway, so it is no wonder that reporting is comparatively rare.
Sexual harassment and its prevention across the world
Every representative from every country we discussed, from Austria to Zambia, had stories of sexual harassment and gendered discrimination, and told us how gendered bias was woven into their contexts. The mechanisms may have been different, but sexual harassment seems to be a common experience for many doctors. While targets are of all genders, perpetrators are commonly male. People who live with intersectional disprivilege, including international medical graduates, are at higher risk.
Consciously or unconsciously, predators choose professions that have deep hierarchies, gendered workplaces, itinerant workers and masculine cultures. Medicine, like law, politics and education, is therefore attractive to those who seek to dominate others for their own gain. Although medical educators, managers, regulators and others committed to cultural change will do their best using the tools they have to select appropriate candidates, remove learners who demonstrate unprofessional conduct, and address inappropriate behaviour, there are entrenched organisational and cultural barriers to change. Many of them surprised us.
Our authors from Japan described that, until recently, women had a handicap applied to their selection scores in medicine, because “their social skills gave them an unfair advantage”. A young surgeon from the UK described reporting her sexual abuse to the medical regulator, but after many months of relentlessly giving stressful evidence, tried to withdraw due to a decline in her mental health. “I was told that I was under mandatory reporting obligations to report my abuser” she said “but if I was too unwell to do this, I may face restrictions on my registration until I recovered.”
Chinese doctors explained the tradition of Yi Nao, where the majority of the health workforce were exposed to physical violence from hired gangs, employed by disgruntled patients and their families to intimidate the staff into reducing hospital costs. The proffered solution — asking healthcare workers to “demonstrate more empathy” — is a classic example of an individual approach to a systemic problem that places the burden firmly on the shoulders of the victims.
We were also surprised when sexual harassment was less obvious. Our contact in Egypt explained that sexual harassment was less common in her context “because medicine is predominantly a profession for women, and you are more likely to find perpetrators in other areas, like business.” Despite years of searching in multiple languages, we were unable to get anyone from Scandinavia to speak, but our contact in Iran was keen to share the experiences she had documented in her research. This surprised us, as we expected to have more difficulty speaking with people in more conservative cultures.
We found that while all of the countries that wrote for us had addressed, in some way, the breadth of preventive strategies needed, there were gaps.
Prevention strategies included:
- Primary: teaching and training about sexual harassment, with practice in recognising and responding to inappropriate conduct.
- Secondary: identifying and respondingto high-risk targets, perpetrators and contexts.
- Tertiary: Managing policies so that those who are harmed are effectively managed to reduce the impact of trauma and prevent recurrence. This includes return to work strategies
- Quaternary: reducing the impact ofthe process on the target, including breaches of confidentiality and media exposure.
Medical training and professional identity formation
Medicine, and healthcare more generally, is an intense profession where juniors rely on others for career progression, and often operate as itinerant workers in a variety of subcultures throughout training.
While their professional identities are still forming, they are vulnerable. Medicine, by its nature, involves structured breakdowns in personal boundaries which medical students usually find challenging. It is difficult for them to learn how to perform intimate examinations, discuss sexual symptoms and endure the multiple sensory and bodily discomforts of close physical work with team members in surgery, emergency and other hands-on disciplines. It is understandable that as they adapt to these environments, it is hard for them to distinguish disinhibited behaviour by stressed and unwell patients from intentional harm. This is different to other settings, where physical touch and discussions about sex and intimacy are unlikely to be part of the job. Structured breakdowns in barriers to intimate touch are part of the acclimatisation of students to the job of medicine. It is understandable that they are vulnerable to misinterpreting signals in this new social environment.
Similarly, close physical contact with other workers is part of some disciplines like surgery, and junior doctors can question the intent of inappropriate touch, or even sexualised banter in tea rooms. In residential settings, targets often berate themselves for “inviting inappropriate attention” or “misconstruing behaviour”, despite the fact that they believe it is inappropriate when considering the situation in the abstract. This tendency to assume another person’s behaviour can be modified using your own communication skills leads perfectionistic personalities to take on blame that is not warranted, and silence themselves.
All this means that while workplaces are meant to be safe, the reality of medicine is that challenging interactions are far more complex and nuanced than might be expected in other settings. We wonder whether the situation is much more clear in professions like Law, where physical contact is less common.
Trustworthy institutions
Institutions have their own personalities, expectations and rules. However, there is often a difference between stated and enacted policy, what we would call the “hidden curriculum” in education.
In a way, institutions echo transportation planning, where there are formal paths through a problem, and also “desire paths” which are “the way we really do things around here”. Desire paths are unplanned, small trails formed by erosion and human or animal traffic that represents the shortest or most easily navigated route. They often cause damage to the habitat. Desire paths typically emerge as convenient shortcuts where more deliberately constructed paths take a longer or more circuitous route, have gaps, or are non-existent. Eventually, a clearly visible and easily passable path emerges that humans and animals alike tend to prefer.
Policies can be the same, with formal policies existing, but perhaps not acting the way they are meant to act. The further apart written policies and enacted policies are, the less trust health workers have in institutional rules and frameworks. This means that policies around issues like unpaid overtime, or organisational respect, reduce the trust people have in institutional attitudes and processes. Without trust they are unlikely to feel safe to report any inappropriate conduct.
Why medicine?
The rates of sexual harassment in medicine in Australia seem similar to other workplaces, but the measurements of prevalence vary, making quantitative comparisons difficult. However, medicine has opportunities to address the problem because of its unique capacities and strengths. Doctors are committed to healing, and deeply familiar with complexity. Within the profession, there are experts in deconstructing complex problems on a micro-, meso- and macro- levels. Surgeons and ED physicians are masters of critical incident debriefing. Occupational physicians have plenty to tell us about return-to-work strategies. Psychiatrists understand the impact of trauma on internal knowing as well as reporting trauma. Physicians evaluate complex processes for their efficacy. GPs like me are holistic and external, understanding medical cultures, but usually separate from the culture that caused the harm. We are therefore less vulnerable to the actions of powerful perpetrators.
Medicine should be able to tackle the problem within their own culture the way medical error was tackled in the past, creating safe spaces to honestly and openly deconstruct a problem and proffer potential solutions, setting aside defensiveness, blame and stigma. Doctors should be able to understand the trajectory of trauma, from the prelude that predisposes a doctor in training to abuse, to the restorative justice that sees a survivor return as a valued member of the profession they love. In doing so, they should draw from the expertise of many others, including experts in law, social science, therapy, and management.
As a profession, medicine has done its best work when it has provided moral and cultural leadership. Facing this problem frankly and openly is part of that leadership.
It is time to stop performative policy, the type that offers simple solutions to complex problems. There is no value in another compulsory workshop, aspirational statement or media campaign. Instead, we hope this book enables the reader to engage meaningfully with the interpersonal, interdisciplinary and international complexities of workplace sexual safety.
Sexual trauma should never be the price a doctor pays to work in the medical profession.
Dr Louise Stone is a Canberra GP with clinical, research, teaching and policy expertise in mental health. She is an associate professor in the Social Foundations of Medicine group, Australian National University Medical School.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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