Establishing a Foundation for Change

Workplace culture strongly affects your organisation’s ability to achieve its strategic goals, which is why creating a respectful environment should be a defined part of your organisation’s strategy. When you spend time getting the fundamentals right, you lay the foundation for long-lasting and meaningful change. Start by providing direction, setting expectations and establishing accountability for results. Your employees need to know that eradicating sexual harm is a leadership priority.

Dimension 1: The Kinds of Evidence Needed to Advocate

When we present this work, we often face a series of questions. Over time, we have come to recognise these recurring questions as attempts to reconcile the gap between people’s perceptions and the realities we are addressing. Common questions include:

• Is this problem real, and if so, how significant is it?

• If it is real, is it relevant to me?

• If it is relevant to me, is it truly my problem or someone else’s responsibility or fault?

For audiences to engage with our message meaningfully, they first need to believe in our credibility as advocates and in the reliability of the data we present. This credibility is crucial in overcoming the cognitive dissonance that often arises when considering the occurrence of sexual harassment within their own contexts and under their watch.

This book aims to synthesise different types of evidence to create a series of compelling arguments for change. The editors recognise that advocacy involves engaging with different audiences, each of whom may respond differently to the types of evidence presented. One significant barrier in addressing sexual harassment is the scarcity of robust quantitative data that demonstrates prevalence. Gathering accurate data on such a sensitive issue, marked by shame, stigma, and invisibility, is challenging, yet it is essential to substantiate calls for change. For governments and policy makers, one area of interest is assessing the costs and benefits of policy action and inaction, (Reference Petticrew, Whitehead, Macintyre, Graham and Egan6; Reference Nutbeam and Boxall7) which in this field may include quantitative estimates related to workforce attrition, absenteeism or patient outcomes (see chapter 7). Such data answers whether the problem is ‘real’ and significant. Furthermore, it strengthens our credibility as advocates and reinforces the legitimacy of our message.

It is equally crucial to consider how these data-driven narratives can be communicated and enriched. (Reference Marmot, Friel, Bell, Houweling and Taylor8) This is particularly challenging when the data contradicts long-held opinions among advocacy audiences. Relying solely on quantitative data is often insufficient to drive engagement, as there will never be ‘enough’ evidence to satisfy everyone, and the data is likely to be criticised as ‘weak’. (Reference Farrer, Marinetti, Cavaco and Costongs5) In medicine, which values scientific rigour, there is a tendency to privilege precise data – yet ‘accuracy’ can be difficult to achieve when measuring complex social phenomena like sexual harassment. Hence, the tendency to endlessly debate prevalence statistics.

Quantitative data is most impactful when enriched with personal stories. Brief stories or ‘cameos’ can vividly illustrate specific situations or interventions to stakeholders. (Reference Priest, Waters, Valentine, Armstrong, Friel, Prasad and Solar9) Well-chosen and skilfully communicated stories can effectively challenge people’s tendency to dismiss the data, helping to address questions around whether the problem is real, relevant to them, and whether they bear some responsibility for addressing it. Narratives of lived experience counteract dismissive attitudes that label survivors as ‘overly sensitive’ or frame perpetrators as merely ‘bad apples’ whose behaviour can be managed individually rather than systemically.

However the data story is conveyed, it should be locally relevant and summarised for policy makers in a digestible format – often as a ‘one-pager’. (Reference Izumi, Schulz, Israel, Reyes, Martin and Lichtenstein10) Creating a clear, one-page narrative for change is an essential tool not only to communicate findings and recommendations, but also to focus the team on obtaining the right data to anchor key messages. This also keeps messaging consistent, ensuring that the various people and agencies working to create change remain aligned and goal-focused.

Good communication requires people with the right skills and tools, able to convey data clearly and meaningfully, avoiding unnecessary complexity and ensuring that the audience understands the message. This often involves difficult but necessary discussions about what constitutes effective data. For instance, while policymakers may be more persuaded by economic arguments that highlight the financial burden sexual harassment places on hospitals, survivors on the team may feel uncomfortable about reducing their experiences to cost figures or data points on a page. Given there are likely to be multiple stakeholders in any meeting or presentation, it is often a challenge to determine which arguments to present, and the timing of each.

In Table 33.1, Dabota Yvonne Buowari describes her work gathering evidence in Nigeria and other countries in Africa to drive change. She illustrates the importance of community-based participatory research, a particularly effective method in advocacy programmes. (Reference Hawe and Shiell11–Reference Davis, Lindberg, Cross, Lowe, Gunn and Dillon14) This approach empowers local participants through active involvement in the research process, enabling them to translate findings within their communities and ensuring the data genuinely reflects local experiences. (Reference Ingram, Sabo, Gomez, Piper, de Zapien and Reinschmidt12; Reference Stack and McDonald15)

In their work on sexual harassment, the editors of this book have discovered that trends are often more readily accepted than individual statistics. Therefore, we often present simplified graphs that illustrate findings across multiple studies in diverse contexts, acknowledging that each study may have its own methodological limitations. This approach mitigates the tendency of stakeholders to sidestep the issue by focusing on the methodological flaws of individual prevalence studies. As we often say, knowing that prevalence is well above zero should be sufficient data to ground our advocacy work.

The team from ‘Surviving in Scrubs’ discusses in chapter 35 how they have gathered and communicated lived experience narratives to advocate for change. One common issue they highlight is the importance of having clear reporting pathways for survivors. It is essential that the person or organisation receiving and managing the report is independent enough to assure the survivor that their report will be heard objectively and without impact on their future career. While providing options for survivors is important, there must also be transparency, so they are fully informed about what will happen next, the boundaries of confidentiality, potential costs (including time), and possible outcomes. Holding organisations accountable for their processes and outcomes is one way advocates can help survivors be heard and appropriately supported. Analysing and communicating gaps in these processes requires in-depth policy analysis, ideally presented as a diagram accompanied by a story that illustrates the real-life impact of these gaps on survivors. Although constructing these visual narratives can be complex, they provide a focused pathway for driving change.

Lived experience narratives are powerful tools to persuade and inspire change, especially when survivors share their stories themselves. However, presenting these stories requires a trauma-informed approach to avoid retraumatising survivors who may be in the audience. One effective way to handle this is by providing these narratives as supplementary material, allowing participants to engage with the content on their own terms. The goal is to empower survivors to own their stories while protecting them from potential exploitation, a frequent concern for survivors of sexual harm when engaging with media.

Ideally, a policy argument combines multiple forms of evidence. Whitehead et al. recommend advocacy organisations present a ‘jigsaw of evidence’, which is ‘not one single piece of evidence, but rather many different bits, of varying quality, creatively pieced together’. (Reference Whitehead, Petticrew, Graham, Macintyre, Bambra and Egan16) This collection of varied pieces, each with different strengths, can be assembled to form a comprehensive argument. In Table 33.2, Dabota Yvonne Buowari discusses her approach for creating change in Nigeria.

Dimension 2: Who Advocates for Change and Who Should Hear their Message?

Every stakeholder has the potential to be either an advocate or a target of advocacy, making it essential to map the field at the outset. Working in teams allows communication to be managed by the best-suited team member for a given situation and context. (Reference Farrer, Marinetti, Cavaco and Costongs5) Ideally, the advocacy team should include representatives from the organisations and individuals who will be integral to enacting change. Farrer et al. suggest each stakeholder should be considered with the following questions: (Reference Farrer, Marinetti, Cavaco and Costongs5)

• who has the power to effect change?

• who is most vulnerable to pressure?

• who holds the power that is necessary to change the system?

• who is an ally?

• who is likely to actively oppose efforts?

This mapping process is invaluable for crafting narratives tailored to specific audiences. It is equally important to map the team involved in advocacy work. In chapter 14, we discussed VeneKlasen’s four types of power. (Reference VeneKlasen and VeneKlasen17) Understanding the sources of power within the team – including their formal, institutional roles (‘power over’), their social capital and potential for collective action (‘power with’), their individual capacities (‘power to’) and own self-knowledge, sense of agency and personal qualities (‘power within’) – can help leverage team strengths effectively.

Betty Yeoh Siew Peng, an advocate for women’s rights in Malaysia, reflects on the principles that guide her activism. She describes how she developed these principles through her personal and professional life and through her work with a range of groups, from grassroots movements and unions to dedicated advocacy organisations.

Dimension 3: Advocacy Messages

There are core narrative arcs frequently used in advocacy. While not universal, these familiar narratives offer stakeholders a recognisable structure. In medicine, audiences often expect a certain format – such as a literature review, method, results, and discussion. Changing this narrative arc demands greater cognitive effort work for the audience, so it is essential to structure the story carefully and logically.

Common advocacy narratives are often built around themes such as:

• Values and social justice

• Human rights

• Legal obligations

• Economics

• Self-interest (e.g. reputation as an employer of choice)

The chosen narrative, mode of communication, and presenters may vary considerably and should be selected thoughtfully. Presenters and participants bring different forms of influence, whether it is the authenticity of survivors, the authority of senior colleagues, or the enthusiasm of medical students. For example, Surviving in Scrubs shares stories, including anonymous ones, to help other survivors find language and voice to address their own trauma. (Reference Cox and Jewitt18) The Time’s Up movement in the US emphasised collecting defensible data on workplace harassment – an essential advocacy tool for organisations. (Reference Chawla, Gabriel, O’Leary Kelly and Rosen19) In contexts like hospitals, one of the most compelling narratives to engage health care professionals in addressing harassment is its direct impact on patient outcomes and the overall quality of care. Harassment not only harms individuals but also disrupts teamwork, communication, and morale within medical teams, ultimately affecting patients. The CanMEDS framework emphasises advocacy as a core competency for physicians, encouraging them to ‘respond to the needs of the communities or populations they serve by advocating with them for system-level change in a socially accountable manner’. (Reference Poulton and Rose20) In this context, addressing harassment is not only about creating a respectful workplace but also about fulfilling a professional duty to advocate for safe, high-quality patient care.

An important aspect of delivering advocacy messages is not just the content, but the tone. It is our experience that presenters need to ‘calibrate outrage’ – while outrage can be mobilising, it can also cause audiences to disengage. There have been moments in the narratives around sexual harassment in medicine that have used shocking content to draw attention. For example, the initial push to address this type of harassment in Australia involved a female surgeon, Dr Gabrielle McMullin, sharing a case where a registrar was propositioned by her supervisor. After recounting the case, Dr McMullin remarked, ‘Her career was ruined by this one guy asking for sex on this night. Realistically she would have been better to have given him a blowjob on that night and to have left it at that.’ (Reference Newlands, Cuming and Jackson21) Predictably, this statement divided the surgical community, but it ultimately led to significant change, including the ‘Operating with Respect’ campaign. (Reference Tobin and Truskett22) This narrative was effective because Dr McMullin used her status as a senior surgeon to deliver a powerful message to the right audience at the right time.

Louise Stone recalls meeting a senior bureaucrat to request research funding to explore the experiences of international medical graduates in Australia. The bureaucrat responded, ‘Well, I’m prepared to read a proposal as long it doesn’t take a victim mindset with more whining women’. In situations like these, the tone must be highly objective and data-based. We have found that it is crucial to keep the message within ‘the zone of proximal development’ – challenging enough to stretch the audience’s thinking, but not so confronting that it causes them to disengage.

Dimension 4: Tailoring Arguments to Different Political Standpoints

Advocacy messages must be tailored to the audience, which requires understanding where the advocate’s goals align with the organisation they are addressing. This includes recognising and addressing unhelpful narratives, such as the idea that a perpetrator is merely a ‘bad apple’ and the target of harassment needs to build resilience because they are ‘over sensitive’. (Reference Searle, Rice and McConnell23) These misconceptions often need to be confronted directly.

A common issue is the belief that sexual harassment and its management are individual rather than collective responsibilities. People vary in the extent to which they attribute responsibility to individuals versus systems, as seen in health care debates. For instance, in the United States, right-wing groups are more likely to hold individuals accountable for their own behaviour and social standing, (Reference Farrer, Marinetti, Cavaco and Costongs5) while those with left-wing views are more likely to attribute issues to inequitable social and economic systems. (Reference Knight24) Depending on the audience, advocacy narratives should be shaped in a way that ensures that organisations do not evade their obligations by placing responsibility solely on survivors.

The Working Party on Sexual Misconduct in Surgery was formed in the UK in 2022 and published their groundbreaking paper titled ‘Sexual harassment, sexual assault and rape by colleagues in the surgical workplace and how women and men are dealing with different realities’. (Reference Begeny, Arshad, Cuming, Dhariwal, Fisher and Franklin25) It has been insightful to observe this team develop an advocacy strategy using a combination of research, workshops and publications. (Reference Newlands, Jackson and Cuming26) One of their effective strategies involved working with, rather than opposing, the Royal College of Surgeons of England, beginning their advocacy with a scientific paper – a strategic choice that resonates with doctors who prioritise evidence-based approaches. Their report integrates diverse forms of evidence, with lived-experience quotes, research outcomes, evidence of organisational support and a solution-focused series of recommendations, all presented in a concise and impactful manner. (Reference Newlands, Cuming and Jackson21)

Dimension 5: Barriers Impeding Effective Advocacy in Medicine.

There are a several ingrained social assumptions about the medical profession that make it difficult for many to accept that sexual harassment is a significant issue. Hospitals are often seen as safe, controlled environments, and people may find it hard to accept that sexual harassment occurs in these settings and that doctors – typically viewed as dedicated professionals – can be perpetrators. Additionally, doctors are generally seen as privileged and therefore immune to risks of sexual harassment or abuse.

Medicine is a conservative field, characterised by lengthy training periods and steep hierarchies. Those at the top of these hierarchies may be reluctant to change, as they hold privileged positions with considerable power. Beyond individual resistance, broader societal barriers also impede progress. The current political and economic climate emphasises individualism and neoliberal values, both of which create obstacles to systemic reform. Short-term political cycles and the high-output, low-investment model of many academic institutions further delay necessary changes.

Both medicine and contemporary society have deeply entrenched, gendered cultural norms that create barriers to addressing harassment and promoting effective advocacy. Dominant gender norms shape social and professional hierarchies, reinforcing power dynamics that protect the status quo. (Reference Connell and Messerschmidt27) Additionally, the high prevalence of childhood trauma and gender-based violence can normalise harassment, making it harder to address these issues in adulthood. (Reference Anda, Felitti, Bremner, Walker, Whitfield, Perry and Giles28)

Biomedical training and research approaches often do not incorporate or prioritise social science perspectives, which can hinder the profession’s ability to respond effectively to complex issues like harassment. Furthermore, with multiple actors operating in this space, each with differing priorities and goals, aligning advocacy efforts requires significant coordination and collaboration.

Despite these barriers, there are promising developments at both the national and global levels. States and multilateral organisations are increasingly committed to advancing Sustainable Development Goals (SDGs) that focus on gender equality, safe work environments, and accountability.

In the health care sector, specific initiatives address the protection of doctors from harassment by colleagues. For instance, the International Labour Organization (ILO) adopted the Violence and Harassment Convention (C190) in 2019, which applies to all sectors, including health care. This landmark convention establishes the right to a workplace free from violence and harassment, emphasising employer accountability and preventive measures. (29) As of the end of 2024, forty-five countries had ratified the Convention, though its impact will only become evident once it is translated into local legislation and fully implemented within the sector.

Additional professional efforts have also been introduced. In 2015, the Royal Australasian College of Surgeons launched the Operating with Respect (OWR) programme in response to evidence of bullying and sexual harassment in surgical environments. This programme includes mandatory training on respectful behaviours, reporting mechanisms, and support systems. While an initial survey indicated moderate effectiveness in reducing bullying, findings also underscored the need for a broader, sustained strategy to build a respectful, safe, and inclusive environment. (Reference Gretton-Watson, Oakman and Leggat30)

The American Medical Association (AMA) has similarly developed guidelines to promote a respectful workplace, with the AMA Code of Medical Ethics providing specific guidance on addressing harassment and maintaining professional conduct among colleagues. These guidelines aim to foster a culture of respect and accountability in health care settings. (Reference Shanafelt and Noseworthy31)

The UK’s National Health Service (NHS) has implemented the Civility and Respect Framework, which aims to improve workplace culture by tackling harassment and bullying across all levels of medical hierarchies.

While these initiatives indicate a growing recognition of the need to protect health care practitioners from intra-professional harassment, achieving sustained change requires a comprehensive approach. Isolated initiatives have shown limited impact, emphasising the need for a coordinated strategy that includes policy reforms, robust accountability mechanisms, and cultural shifts within medical institutions. (Reference Gretton-Watson, Oakman and Leggat32)

Dimension 6: Practices and Activities that Increase the Effectiveness of Advocacy Efforts

Coordinated organisational efforts can create a multiplier effect, amplifying the impact of advocacy initiatives. It is essential to identify and mobilise advocacy leaders across all levels of the health care profession to raise awareness and drive sustained change. This includes engaging medical colleges, health boards, trusts, education bodies, and unions. (Reference Mahase33) Mobilising these diverse stakeholders ensures a comprehensive approach that can address harassment more effectively.

In Table 33.5, Dabota Yvonne Buowari showcases the range of stakeholders she has targeted in her advocacy efforts in Nigeria, demonstrating the importance of a multi-stakeholder approach.

Finally, there is an art to using media to create change. Simon Fleming is a fierce advocate for cultural change in medicine, and has written an article about his approach, with the intriguing title ‘A lot of people just wish I would shut up, but I won’t – how a surgeon has made it his mission to stand up to bullies and discrimination’. (Reference Fleming34) Simon is known for his social media advocacy, and in Table 33.6 he describes his approach.

Where Harm Begins

Doctors don’t arbitrarily begin acting inappropriately once they are handed their degree; the seeds of their behaviour are planted in medical school and before, forming strong thick roots by graduation. These students who say inappropriate things or make unwelcome advances are often recognised by their peers, they are spoken about in groups, avoided at parties, on placements, or alone in rooms, but rarely are complaints escalated to the medical school. Even when a student’s inappropriate behaviour is reported, they’re usually given second chances, an opportunity to prove they didn’t mean what they did/said, and sometimes they take those opportunities to change and improve themselves, but sometimes they’re clever enough to know they have to get smarter about how they perpetuate this behaviour. Those are the students that become the doctors we are worried about. Those are the doctors that know how to get away with comments or behaviour, pretending it’s a joke, intimidating their victims, or using their status as leverage.

Students aren’t blind to the insidious professional culture that allows for unrelenting sexual harm. However, we are taught, although maybe not explicitly, to allow comments because reacting to them may be considered oversensitive. Similarly, we learn to accept a ‘reasonable’ level of discomfort. After all, we’re acutely aware of the variable power dynamics in medicine, and the weight of a senior’s word against our own. We’re taught to seek out and accept feedback. This is not a bad practice, as it allows us to grow as doctors.

However, with the power dynamics at play, feedback can and does turn dark and dangerous, and yet we’re told to accept it, and more specifically we depend on it to further our careers. We’re not taught how to critically appraise the feedback we receive, nor to question the authority figures around us. Students are enculturated early on to exhibit ‘professional’ behaviour, to rigidly adhere to the social/cultural hierarchy, and to understand that speaking out can jeopardise your standing and label you as difficult. This enculturation is compounded every additional year in medicine, as you begin to see the repercussions of non-adherence to these standards. Unless actively internally resisting, which comes at great emotional and psychological cost, year by year you are disempowered, silenced, and slowly broken to fit the mould that medicine wants you to be.

Reporting Harm in Medical School

Early on in my medical degree I had already begun wondering about the processes of reporting sexual harassment and assault, as have many students in medical schools around Australia. Through my many conversations with students, we’ve each wondered about what to do if a fellow peer makes inappropriate comments or displays inappropriate behaviours. Our thoughts turn to the long days spent in hospital, wondering whether we would dare mention to a colleague, let alone report, if a superior crossed the boundaries we each set.

I’ve had conversations with countless women and men about where the ‘threshold’ should be for reporting sexual harassment and assault in medical school – is it when we feel uncomfortable, after we’ve told them to stop, after rumours have begun, or after it’s happened to someone else? In medical school harmless chatter is interspersed with rumours of harm, making it a difficult landscape to navigate, as students wonder if there is truth to whispered discussion, because surely action would be taken if there was. So for a while these conversations exist as general warnings, with the hope that one day a voice can be strong enough, loud enough, or there are enough voices to create action. In my discussions with medical students around these issues, I’ve encountered the phrase ‘I’d only report in case it happens to someone else’ or ‘… to try and stop it happening to someone else’, more than I had ever anticipated.

Medical students seem to tolerate, and even expect, a level of discomfort, inappropriate behaviour, or assault. Each student seemed to note that they anticipated varying degrees of harassment, and accepted it as a reality, for which they would not report if it affected only themselves, but that if that same harassment or behaviour was targeting or affecting someone else, they’d be far more willing to report it. That greater will to protect others around them is perhaps because of the selfless nature of some entering medicine, or perhaps it is because of a failure of the system to create a space that allows someone to stand up for themselves. Notably there is not a lack of desire to report, to say something, to have a conversation about inappropriate or uncomfortable behaviour, or to change the culture of reporting. There is simply a lack of ability for people to ensure their own safety while reporting.

Although the processes for reporting malfeasance vary from medical school to medical school, and hospital to hospital, the need to be able to report incidents, from microaggressions to assaults, is critical. However, the many conversations I’ve had with students highlight how many failings there are within these processes. Most notably two topics are brought up in each of my conversations: anonymity, and the ability to write down and acknowledge an incident, for future evidence. The need for anonymity in reporting, or even talking about, individuals higher up in the hierarchy who have acted inappropriately is crucial to creating an environment that students feel safe in. Simply being in medical school carries additional quandaries, as the schools are a part of the universities they operate under, in conjunction with varying health services, and are independent entities as well. The interaction of many different external stakeholders creates a confused landscape with differing pathways and systems, meaning medical students are often unsure of what, how, or who to report to, and whether there is anonymity or space to have a conversation about incidents without actioning those conversations.

The lack of clarity, and feelings of safety, in reporting processes during medical school all exacerbate the harm experienced by students who are already some of the most vulnerable in the medical hierarchy. With no stakeholder willing to step forward and claim responsibility over safety (physical or psychological), it teaches students that they are immediately powerless in their careers, that their future is filled with immense uncertainty, because if there is no protection to be given when you’re most vulnerable, why would there be protection later on? Universities and hospitals need to work symbiotically to create an environment that is safe to have conversations about incidents that occur throughout our medical training. Additionally, creating a space where incidents can be acknowledged, either verbally or in writing, without needing to escalate any decisions, is important to establishing a culture where conversations are key to change.

The barriers that exist in medical school around reporting are only intensified once students enter placements. There are fears around retribution; there are concerns of the emotional labour, time, and stress that comes with reporting; there’s consideration of how that report will impact the perpetrator and thereby impact teaching, especially in rural communities where teaching opportunities may be sparser. Mostly there are concerns about how it may impact our future careers. Due to the nature of medical school and training, a lot of the study and work between doctors and students is done in small groups or one-on-one. So, if behaviour is reported, even anonymously, it can be easy for the perpetrator to trace back who did so, even with prolific or serial abusers.

Even still, the students that feel capable, willing, and safe to report quickly learn of the immense time (both in writing the reports, and in the large periods of waiting) reporting requires, alongside the emotional burden of recounting your story multiple times. Rural students are faced with additional challenges where there is not only social and physical isolation, but they must consider the immediate and longer-term impacts of reporting on teaching. Reporting perpetrators in small communities, some of whom may be good teachers, mean there is a decreased quantity and quality in the teaching that is made available to students on placement. These impacts can have long-lasting effects beyond the rotation, especially to long-term rural students. Students begin to internalise personal responsibility for occupational hazards because these barriers all amount to a sense of learned helplessness where students feel that no one can be bothered with them or their safety, so are simultaneously trapped and disempowered by each component of the system.

Ultimately being a medical student is a unique training experience, where you are caught between finding your footing in a densely competitive career, maintaining a sense of ‘professionalism’, feeling like you are learning the entirety of medicine, all while trying not to burn out before you’ve truly begun. This, coupled with the burden of being responsible for your own safety (and sanity), is increasingly difficult in a system that, to students, isn’t necessarily focused on creating reporting processes that are safe. With the structure of medical education being its own barrier to progress and positive change and alongside navigating the workload of study and life (with burn out always looming), even students who haven’t personally experienced or witnessed sexual harm are left with few personal resources to fight for change.

The Future of Medicine

It must be recognised that medicine suffers from institutional sexism, on every level, that was purposefully built into its framework, which contributes to a derisive and insidious culture that historically benefits and fosters opportunity predominantly for straight, cisgendered, white men. Changing this is not an easy task, but it is a necessary one. It can only happen from within, and with that, we require a new generation of medical students, primed with the skills to identify and call out gender bias and inappropriate sexual behaviours from day one. One that fosters opportunities for diverse leadership, that values bystander advocacy and people in positions of privilege using their positions to encourage change, and one that amplifies the voices of the consumers who bear witness to harm which does not instil faith in medicine and doctors to provide compassionate care. The whispers about the sexual predators in medicine, the doctors that students dread to be on placements with, become louder conversations because of strong and courageous women and men who decide that silence serves no one.

We need to build a culture where individuals are willing to stand up and denounce the behaviour, to ask for consequences, and to establish a culture where if anyone was uncomfortable, they are empowered to speak up, for themselves, and not just ‘in case it happens to someone else’. We want to strive for a culture where we actively encourage students to value their own wellbeing and safety and to be able to navigate the delicate skill of changing culture and disrespecting the rigid hierarchy that does serve some purpose in medicine. Culture is changed, in part, through conversation. These conversations about sexual harm in medical school, and in medicine, need to continue, and they need to continue openly and not in the shadows. We need to discuss the multi-layered barriers in reporting and the lack of anonymity while simultaneously having transparency in conversation. We need to discuss what sexual harms are in protected forums, because when a collective comes together to share a safe space, it is easier to mention the leering doctor, the student who touches his peers in inappropriate places, the supervisor who makes uncomfortable comments. Once those conversations begin happening, we recognise the prevalence of the issue, and that it shouldn’t be occurring this often, we begin to talk louder, to call for action from our peers, to ask for accountability from those in charge, and to change the culture.

The sick patient that is Medicine sits in front of us and needs help: it’s our job to ensure they receive the treatment they need. We need to hold our multidisciplinary team meeting to discuss our diagnoses, to consider the comorbidities, to write out our problem lists, and to discuss our short-term and long-term management plans. Not everyone in medicine will believe that the culture is sick enough to warrant treatment; some will cross their fingers and take a ‘wait-and-see’ approach; some will see this as a problem beyond their scope as a practitioner; but some will understand the urgency of treating the patient in front of them. As the medical student standing in the corner of this consultation, I’m desperately hoping the doctor sees what I do and is willing to consider me and my future colleagues’ opinions, perspectives, and ideas, so we can collaborate for effective coordinated care and give our patient the best chance to heal.

Surviving in Scrubs: Using Narratives and Lived Experience to Create Change (Becky Cox and Chelcie Jewitt, perspectives from doctors in training)

Surviving in Scrubs is a grassroots organisation that advocates for the survivors of interprofessional sexual misconduct within the health care workforce, campaigns for cultural change through the engagement of key stakeholder organisations nationally within the UK, and provides training services to educate anyone who works clinically or in health care education or management. The organization was formed in June 2022 by Dr Becky Cox, an academic GP with specialist interests in gynaecology, and Dr Chelcie Jewitt, a specialist trainee in emergency medicine, both of whom have lived experiences of sexual misconduct while working in health care.

The core of the Surviving in Scrubs campaign is its website (www.survivinginscrubs.co.uk). This platform enables anyone who works within health care – regardless of their job role, their location, their specialty, their level of seniority or even their gender – to submit an anonymous testimony of their own personal experiences of sexual misconduct within the health care workplace, or incidences that they have witnessed. There is no doubting the power of this collective narrative – with over 200 stories published online at the time of writing – as it has been monumental in ensuring that the sexual safety of health care staff has been frequently reported on by medical and mainstream media since Surviving in Scrubs began.

The need for Surviving in Scrubs to exist as a group is very telling of the cultural issues facing health care workers. There is a lack of support for victims within the reporting mechanisms currently in place throughout the NHS. This often leaves victims feeling isolated, alone and powerless. One of the main motivations for the co-founders in forming the campaign group was to empower the survivors of sexual misconduct by making their voices and their stories heard, as both have firsthand experience of sexism, misogyny, sexual harassment and assault throughout their career, starting as medical students.

Its amplification of survivor voices is what has made Surviving in Scrubs so successful. This grassroots movement has brought the voices and experiences of the many victims to those who are in power. Those stories have evoked emotions of distress in the masses, and it has made many of those in power think beyond the numbers and the statistics that have proved the prevalence of this issue for years (91% of female doctors have experienced sexism; 30% of female surgeons have been assaulted at work). Surviving in Scrubs speaks truth to power, which has enabled representation from the disempowered victims who have been silenced for too long.

Since its inception, Surviving in Scrubs has been invited to speak at several meetings for key stakeholders within health care – NHS England, NHS Education for Scotland, the General Medical Council (GMC), the British Medical Association (BMA), multiple royal colleges, the Medical Schools Council and several medical schools, to name a few. Health care has had an awakening to the fact that there is an issue of sexual misconduct within its ranks, but there is little knowledge or understanding of what needs to be done in order to rectify this issue.

In November 2023, Surviving in Scrubs published its first report – ‘Surviving healthcare: sexism and sexual violence in the healthcare workforce’. This report consists of the summation of the experiences recounted in 150 stories describing sexism, sexual harassment and sexual assault within the health care workforce submitted to the Surviving in Scrubs website anonymously between 2022 and 2023. The stories were submitted voluntarily by survivors and describe incidents of these behaviours, challenged faced and their impact. The key findings are described in Table 34.1.

This report includes stories from a variety of health care professions, working in a multitude of specialties and health care environments, demonstrating that the damaging culture of sexual misconduct permeates through the whole of health care. A key role of Surviving in Scrubs is to ensure that the discourse around these themes is inclusive of all professionals working within health care, as is the case in clinical practice.

As part of the report, the authors have outlined a set of key recommendations for health care organisations to implement in order to bring about positive change (Table 34.2).

Education

There is a need for effective mandatory education and training for all staff members who work within health care to ensure there is an awareness of what sexism and sexual misconduct is and how it can be recognised within the health care setting. Active bystander and allyship training should be available to all staff as well as training on how to prevent sexual misconduct and promote positive culture change.

There needs to be tailored education for managers, supervisors, and human resource staff groups on how to respond to first disclosures of sexual misconduct and how to support survivors through the reporting process, with particular attention focusing on how they should respond to reports of sexual violence. There is also an argument to provide trauma-informed consultation skills training to anyone who might act as peer or near-peer support for victims of sexual misconduct, or would be in a role where disclosures fall within their responsibilities.

Research into the Impact

Sexual misconduct within health care has only been discussed openly in the past few years, despite the behaviours and attitudes having always been endemic within health care. As such, the research regarding its prevalence and its impact is very much in its infancy. The data relating to the UK NHS workforce is so far very doctor- and, in particular, surgeon-specific, despite these professional groups not working in isolation. The ‘Surviving healthcare’ report contains stories from doctors, nurses, paramedics, psychologists, administrators, dentists, carers, optometrists, pharmacists, managers, health care assistants and health care students, proving that research needs to incorporate other professional groups. Further research needs to be through an intersectional lens, again as there is minimal data looking into how other protected characteristics are affected.

Moving on from defining the prevalence of sexual misconduct, there needs to be research looking into evidence-based interventions to address the culture effectively, and preventing the attitudes and behaviours that lead to sexual violence. It is important to note that the need for this research should not hinder the development of intervention implementation. It would be appropriate for continuous evaluation of any implementations as they occur. The criteria for assessment will also have to consider that an improvement in culture surrounding sexual misconduct would likely increase reporting of incidences as more survivors feel empowered to raise complaints.

When it comes to the impact of sexual misconduct, this could result in research from multiple angles – the psychological cost to staff, the impact to patient care, the financial cost of staff sick days, staff quitting or even the cost of legal proceedings against health care employers.

Independent Inquiry

Surviving in Scrubs is calling for an independent inquiry at a national level to investigate the prevalence, impact and drivers behind the culture of tolerance relating to sexual misconduct within health care. It would also be of paramount importance to evaluate current reporting practices and how this affects survivors, whether they decide to report or not, and if they do what barriers they face. It is important that any such inquiry is independent, removing any influence of party politics on the outcome.

Improved Support for Survivors

Alongside effective training and education for managers, supervisors and human resources staff members to improve the experience of survivors of sexual misconduct raising complaints, there needs to be improved psychological support for survivors. Ideally, this would be via dedicated access to specialist sexual violence support from independent sexual violence advocates provided by the health care employers, who will help survivors navigate the reporting process if they wish to proceed down that route.

Another intervention would be the introduction of peer or near-peer support, either through nominated advocates for sexual safety in the workplace or through in-person or virtual support groups. These interventions would work towards providing a supportive community for survivors, minimising the feelings of isolation that can occur when being a target of sexual misconduct.

Review of Current Policy

A recent investigative article from the British Medical Journal and the Guardian found that 90% of NHS Trusts in England did not have a sexual safety policy applying to interprofessional sexual misconduct. Of the 10% that do have a policy, there is need to review if they are fit for purpose. The recommendation is that the policy should act to prevent sexual misconduct from occurring with education and open discussion forming part of the workplace culture, but also when such incidents do occur, there should be an easy-to-navigate reporting system that offers psychological support for survivors. There should be clear guidance on what warrants reporting and the formal channels of doing so.

Introduction of Specialist Sexism and Sexual Misconduct Policies

At present, most trusts will incorporate issues of sexual misconduct underneath the umbrella of a bullying and harassment policy. Though it is recognised that sexual misconduct does overlap with some of the issues relating to bullying and harassment, there are nuances to sexual misconduct that warrant a specialist policy in its own right. This links back to the need for specialised support for victims.

Another aspect of these policy reforms is that all trusts should provide an honest and transparent record of the number and types of incidences that are being reported within the trust, and what action was taken. All records should be published within the public domain. The aim of this is to encourage a culture of accountability within health care organisations, and for them to demonstrate they are taking staff safety seriously.

Independent Anonymous Reporting System

Surviving in Scrubs, along with the Working Party for Sexual Misconduct in Surgery (WPSMS), is lobbying towards the implementation of an independent anonymous reporting system, available across the whole of the NHS. This is to ensure that there is a standardised reporting system so that nobody working in health care is at a disadvantage if they wish to pursue a complaint against their perpetrator.

Though there is a need for local reporting mechanisms, a national system would be beneficial for everyone. In particular, it would help the individuals who work within small teams where anonymity and therefore psychological safety of the victim could be compromised. This is particularly pertinent within some general practice settings.

Another benefit of a national reporting system is that the data would be centrally stored, enabling pattern recognition of where sexual misconduct behaviours are prevalent, which would alert the need for interventions in terms of education, training and review of policies.

Reform from Health Care Regulators

Currently, the threshold for investigating complaints of sexual misconduct submitted to regulators is too high. A vast majority of cases are dropped at the triage stage of the complaint, meaning that when survivors are brave enough to relive the trauma by raising a complaint, it is often dropped with little to no explanation. This can lead to repercussions for the survivor, such as feelings of helplessness and feeling as though they are not being believed or that their experience does not matter.

Health care regulators need to realise that they have a responsibility to staff safety as well as patient safety, and that should start with them increasing the number of complaints that they investigate. This would also warrant the need of improved support for survivors during the investigation and tribunal processes, with transparency around the tribunal process and psychological support from advocates with specific training relating to sexual misconduct.

Improved Communication

Trusts, GP practices, health care regulators and the police need to improve their communication links in cases of sexual harassment and assault. At present, if a survivor wants to pursue a criminal complaint, they need to report to the police; however, this information is not automatically shared with the NHS Trust involved, nor the regulator of the perpetrator. In a similar fashion, if the survivor reports to the regulator, this information is not shared with other organisations.

These links of communication need to be strengthened as there is a propensity for organisations to pass the buck when it comes to investigating issues, with regulators often refusing to investigate criminal issues (sexual harassment and assault), or stating that complaints do not reach their threshold for investigation and should be dealt with locally. In not communicating these issues, they are adding another burden onto the survivor, making the process of obtaining justice more complicated, forcing them to relive and retell their trauma more times than would be necessary if organisations communicated effectively.

These recommendations are not exhaustive, and as some interventions are introduced, the evidence base of what will be beneficial for survivors will increase, along with further recommendations. There is little information presently about what works best for survivors of interprofessional sexual misconduct within the health care setting. The conversation about the prevalence of sexual misconduct occurring in this space has only opened up over the past few years, so there are a lot more questions than answers about how pervasive sexual harassment actually is.

Surviving in Scrubs will continue to ask the questions about what can and should be done in order to advocate for survivors and protect potential survivors from experiencing sexual misconduct at work. However, it is the responsibility of every individual who works within health care, or within an organisation that supports health care, to strive towards a culture free from this misconduct. Changes must occur across all levels of health care: GP surgeries, community services, hospitals, universities and health care education providers, integrated care boards, NHS England, Wales, Scotland and Northern Ireland, health care colleges and representative bodies, health care regulators with support from the professional standards authority, and the Department for Health and Social Care.

Surviving in Scrubs will continue to speak truth to power, ensuring the voices of survivors are heard. However, ultimately it is these organisations that need to change as they have a responsibility to protect the safety of their staff members, even when it is from other workers.

Next Steps: Leading from Within

When asked to explore the ‘what now/what next’ question, in the context of gender-based violence, it is hard not to be struck, nearly immediately, with moral injury. It feels a little like, if we are having the conversation now, it’s already too late. The harms have already happened, are still happening. Plus it feels so … big. So unwieldy. Having someone ask how to change hundreds of years of patriarchy, hierarchy, power and silence is like having someone ask to just … tweak gravity. But that is kind of the point. The reality is, sure, the best time to change the world we inhabit was hundreds of years ago. But the next best time to change things is today.

So when asked how to change culture and what next, it feels like there are three very distinct questions there – how do we get rid of the normalisation of toxic behaviours and beliefs, how do we excavate the entrenched attitudes of the status quo and then, once we have a dug big ol’ cultural void, what do we fill it with? It’s all well and good to cry ‘burn it down’, but you need a plan about what to build on the ashes.

Most organisations or systems we exist in have survived thanks to certain tacit assumptions. They are a source of strength, a source of reassurance, a cultural blanket to wrap oneself in when things are uncertain. However, the truth is that many of these assumptions do not quite align with the values that might performatively or rhetorically be spoken about. Therefore, when thinking about culture change, many need to overcome the cognitive dissonance between what they espouse and what really happens. This places people and their (albeit anthropomorphised) organisations in a state of anxiety. ‘We must change. We must change now. Oh no. We haven’t changed yet and we don’t even know how. Or what. Or …’. This anxiety state tends to lead to a variant on the grief cycle: fear, anger, denial, more denial, a tons more denial, scapegoating, and then often some more fear and denial.

Instead, we have to lean into our culture. It’s not all bad. In fact, culture gives us strength, it gives us the ability to highlight the bits within our culture that need highlighting for change. It also gives a reassuring sense to those experiencing a fear of, or sense of, loss; we aren’t changing everything, just some bits. Just the bad, toxic, harmful bits.

So what’s next? Next we change the pieces of our culture that need change. We grow, we learn, we make mistakes and then we grow some more. We bring people along with us, as we identify those things that need changing and what we want them to change into. Whether its anonymous reporting systems, ways of declaring relationships in the workplace, websites where people can share their stories, changes in legislation or educational pieces helping people recognise issues, be a bystander or an ally, how to actively listen or any other of the myriad of ways of changing the status quo, the first step is the hardest. Accepting that there is a ‘what’s next?’ and starting to build it. Together.

Wellbeing Curriculum

Medical students and doctors in training are more likely to cope with challenging interactions if they are well. (Reference Byrnes, Ganapathy, Lam, Mogensen and Hu1) Unprofessional behaviour can be a marker of distress within training, noting that student perceptions about what is ‘unprofessional’ can differ markedly from that of faculty. (Reference Reddy, Farnan, Yoon, Leo, Upadhyay, Humphrey and Arora2) Medical training is arduous, and even high performing students with a history of impressive resilience can struggle with the workload and stresses of medicine. However, many strategies used to promote wellbeing in medical students and doctors in training are informal, including voluntary self-care activities, non-specific support mechanisms and the provision of designated pastoral care staff. While these strategies are important, they don’t require students to think critically about wellbeing for themselves or for their patients. This means some students and doctors in training will avoid the curriculum altogether, feeling these strategies are trivial, performative offerings that are not relevant to their situation or their learning.

In New Zealand, medical schools now include curricular content aiming to improve student wellbeing (Reference Moir, Usher, Wilson, Molodynski, Farrell and Bhugra3) with Auckland medical school initiating a longitudinal ‘Health and Wellbeing Curriculum’ in 2013. (Reference Yielder and Moir4; Reference Curtis, Jones, Tipene-Leach, Walker, Loring, Paine and Reid5) The curriculum is based on a framework known as ‘SAFE-DRS’ (Self-care skills, Accessing help, Focused attention, Emotional intelligence, Doctor as patient) and includes assessment, a reflective portfolio and observation by clinicians of how students are managing their stress on the wards. (Reference Yielder and Moir4) The students are encouraged to consider how these principles can be applied to themselves as well as their patients. The inclusion of patients as a focus for wellbeing improves outcomes for both (Reference Moir, Patten, Yielder, Sohn, Maser and Frank6; Reference Frank, Breyan and Elon7) and, frankly, helps to overcome the resistance some students still have to ‘soft skills’ development.

Self-care is an important skill for patients to learn, so they are able to manage their own illnesses more effectively and independently. The World Health Organization has a curriculum of self-care tools, which can provide a basis for learning in this area. (8) Giving students the language of empowerment and agency is important if they are to be able to retain their voices and their agency.

Training includes other challenging topics like diagnostic uncertainty, suicide prevention, and death and dying. Medical training is full of discomforts. Some are quite visceral (like disgust with certain smells, and fainting in the operating theatre) and others are relational, like the dislike or anger that may arise during patient interactions. Learning to name and manage these feelings, and use them as information, are critical parts of becoming a good doctor. Students will also experience ethical discomforts, which are hard to tolerate. By using reflective groups, the medical schools increase students’ ability for self-reflection (Reference Gold, Bentzley, Franciscus, Forte and De Golia9) but also acclimatise the students to talking about feelings and perceptions, in a safe environment. Reflective groups can enable students to talk honestly about their observations and experiences of clinical practice and workplace culture, including negative role modelling and disruptive clinician behaviours. (Reference Villafranca, Hamlin, Enns and Jacobsohn10; Reference Noort, Reader and Gillespie11) These moderated groups can break down silencing, enabling students to normalise conversations about difficult professional conduct in their workplace. It also trains and supports students to speak up for colleagues. (Reference Moir12)

Managing Moral Distress

Moral distress results from ‘physicians inability to act in accord with their individual and professional ethical values, due to institutional and societal constraints’. (Reference Moir13) Many students come into medicine with altruistic aspirations, but the workload and the contrast between their expectations, the values they are taught and the reality of the clinical workplace can be profoundly unsettling. (Reference Gaufberg, Batalden, Sands and Bell14; Reference Warmington and McColl15) Moral distress is associated with a sense of shame, guilt, low self-worth and poor mental health, as well as unhelpful coping mechanisms like overuse of drugs and alcohol. (Reference Dzeng and Wachter13) Managing the inevitable moral distress of working in a workplace under considerable pressure and recognising the early signs of burnout are important skills for students and doctors in training. Students who witness unprofessional behaviour can feel alienated from medical culture, especially if they live with intersectional disprivilege. (Reference Bynum, Varpio, Lagoo and Teunissen16; Reference Romanski, Bartz, Pelletier and Johnson17) In this context it is easy for students to feel they are not valued, and lose trust in their organisations and profession. (Reference Wallace, Lemaire and Ghali18) These students are less likely to report unprofessional conduct, because they do not trust the culture in which they work and the people to whom they must report.

There are two obvious ‘antidotes’ to moral distress and burnout. The first is creating authentic and meaningful roles for students, appropriate to their stage of training and professional development. (Reference Curry19; Reference Grumbach, Lucey and Johnston20) Meaningful work is essential to maintaining wellbeing, but it also helps students use their voices and their opinions. (Reference Helmich, Derksen, Prevoo, Laan, Bolhuis and Koopmans21; Reference Warmington, Johansen and Wilson22) Silent students are vulnerable, and less able to manage or report professional misconduct. The second is reflective practice, which can include reflective writing, (Reference Yielder and Moir4; Reference Wilson and Ayers23) small group discussions about student experiences, and individual or group mentoring. (Reference Uygur, Stuart, De Paor, Wallace, Duffy and O’Shea24) Reflective activities can enable students to discuss the many physical, emotional and ethical discomforts that doctors must learn to manage. To be effective, these groups should be facilitated by an expert who is not involved in grading or assessment, because the dual roles can mean students may not feel the environment is safe. (Reference Reddy, Farnan, Yoon, Leo, Upadhyay, Humphrey and Arora2) Reflective groups can strengthen the bonds between students, improving empathy and shared agency. (Reference Neff25) In the event of misconduct towards them, it may mitigate against isolation, stigma and shame, through having peer allies who can encourage reporting to supportive staff. (Reference Reddy, Farnan, Yoon, Leo, Upadhyay, Humphrey and Arora2) It can also protect against the attrition of empathy that is often seen in early training.

The Trauma Curriculum

Trauma-informed care has become an expectation of clinical practice in many jurisdictions. In medical education, we are only beginning to consider what this means. Many students and doctors in training come to medicine with vulnerabilities and past experiences that will inevitably raise discomforts during training, and even the most robust student will have experiences during training and practice that they will find traumatic. (Reference King, Steenson and Mulholland26–Reference Finkelstein and Mathers28) After all, it is not ‘normal’ or within most students’ experience to dissect a human body, or to cause pain or discomfort to others, even if these activities are authorised within the profession.

If there is one thing medical educators can bring to training, it is the ability to make the implicit, explicit. Medicine is a science, a craft and an art, and there are different skills in teaching these different aspects of the job at hand. While science is familiar, and is generally tackled easily, kinaesthetic skills are taught well by some educators, including interdisciplinary educators like nurses and physiotherapists. However, teaching the art of medicine, including professionalism, is a difficult task. It involves ‘outing’ the feelings and discomforts of others, and modelling appropriate management.

The two disciplines that have a lot of experience in this space are general practice and psychiatry. General practice has a long and proud history of teaching difficult areas of practice, including tolerating uncertainty, managing challenging interpersonal interactions and maintaining appropriate boundaries. Psychiatry has a long tradition of supervision, and good educators in this space have a range of theoretical frameworks to draw on when discussing difficult concepts like trauma. For this reason, these two disciplines are key to the teaching of trauma.

It is our view that students and doctors in training learn best when they see their learning is situated in practice. (Reference Cho, Yu, Lee and Jung29; Reference Shinkaruk, Carr, Lockyer and Hecker30) While some students accept that self-care is part of their role as doctors, others do not, perhaps due to their personal developmental trajectory. Medical educators are well aware of the theory of proximal development: the idea that to teach effectively, concepts must not be already mastered (because the student will disengage) or out of reach (because students will not be able to grasp the idea, and will become demoralised). Ideally, teaching builds on concepts already mastered and ‘stretches’ the student into areas they have not yet understood. (Reference Groot, Jonker, Rinia, Ten Cate and Hoff31; Reference Gillespie, Conn and Dornan32) Teaching skills around wellbeing, trauma and teamwork is best attempted starting with their roles in patient care, and then extending them into self-care, so the student or doctor in training can begin to incorporate personal application when ready.

Like wellbeing, students need a model and language to begin to conceptualise what is happening to them and to their patients when trauma is experienced or re-experienced. There are many ways to undertake this teaching, but one approach to trauma-informed medical education uses the framework detailed in Table 34.4. (Reference McClinton and Laurencin33) It is useful, because it holds individuals and the institution responsible for modelling and managing a trauma-informed approach to curriculum, pedagogy and clinical exposure. It is our belief that students and doctors in training will again be more able to communicate their personal trauma if the language and concepts are normalised in teaching and practice.

The Teamwork Curriculum

Finally, teamwork needs a similar approach, with the teaching of models of professional interaction and teaching and practice of language around appropriate and inappropriate behaviour in clinical teams. There are many models available to teach, but one useful model has been provided by Belbin. (Reference Belbin34) Belbin asserts that people take different roles in a team, partly due to their inherent characteristics, and partly due to team requirements. Team membership is not static, but fluid, and this can be a reason why a previously functional team becomes dysfunctional. The model taught is less important than the discussions that are facilitated, again in reflective learning spaces. Learners who do not have a language or a model to understand and describe interpersonal dysfunction are left without an ability to understand or respond to toxicity in the team, and again, may withdraw and become disengaged.

Dissociation Is Another Form of Silencing, Where Trauma Is Wordless, and so Becomes Unspeakable.

The identification with the aggressor as described by Ferenczi also captures the way in which the victim takes in the imagined guilt and shame of the perpetrator. This process has often already begun in the grooming process leading up to an assault. Nathanson (Reference Nathanson, Stubley and Young6) writes of sexual abuse as a relational trauma which is a form of oppression and tyranny. He suggests that it is at the time of grooming that victims begin to lose their capacity to resist. He says:

It is this corruption that is central to the oppression, stealing away the freedom to say no and to reach out to others, to disclose and to break the silence, asking for help and companionship as an essential step in any struggle for freedom. The victim feels implicated, isolated and alone.

Thus, Herman’s description of disconnection from others in trauma relates to the grooming process, the isolation in the moment of the event and the consequences and repercussions of the assault. Silencing, shame, stigmatisation, guilt and despair separate the victim from the rest of society. This is further compounded by the avoidance that is a part of the post-traumatic response, a shutting down from self and others to avoid re-triggering, dissociation and hyperarousal states.

In these multiple ways the survivor may struggle to speak out, to disclose what has occurred. Caught in their isolation and feelings of guilt and shame, lacking the words to have a narrative, or lacking the memories due to dissociation, frightened by the potential loss of the attachment figure and the consequences this will bring – silencing may take many forms.

Survivors who do manage to disclose are likely to have different needs, but general principles for healing, whatever is offered, apply.

Laub and Auerhahn (Reference Laub and Auerhahn7) suggests that trauma therapy involves the communication of ‘testimony’ to a witness willing ‘to be totally present to the survivor, and to receive as well as experience what he / she wants to transmit’.

Trying to bear what is being communicated, without action or attempts to be rid of it, is the beginnings of containment. Wilfred Bion (Reference Bion8) described this notion in terms of mothers and babies, when in the normal course of development, a baby is filled with the early, powerful anxieties, and employs projective identification to communicate what is unbearable to the mother. It is her role to try to take this in, to think about it and attempt to understand what might be going on in the baby’s mind so that she might relieve him of his distress. Over time this gives the baby the experience of someone who can bear what they feel is unbearable and thus can lessen the need to rid oneself of distress.

Traumatic experience may be understood as a rupture of the container so that knowledge is attacked, the ability to link associated experiences is lost, and the capacity for thought which allows an experience to be recognised and owned is lost. As Alford (Reference Alford9) describes in the quote above, love wants to know, and hate would break what we know into pieces to save us the horror of knowing. Not knowing empties the world of the connections that give it meaning and life its vitality.

Bion’s model of containment highlights the need for another mind to know, to be open to recognising, feeling and thinking about unbearable experiences. This includes all of the complex emotional responses to what has occurred and the mourning process that is needed to heal. Mourning involves working through sadness, despair, guilt, shame, and rage.

There is a moment in the television adaptation of Margaret Atwood’s The handmaid’s tale that captures a central question for those who have been abused, violated and oppressed by a cruel patriarchal system. June, the main protagonist, asks a group of traumatised women who have been talking about how to find a way forwards after such violence and degradation. She says: ‘Why does healing have to be the only goal? Why can’t we be as furious as we feel? Do we have that right?’

June’s suggestion that survivors may need to feel the fury – to have the right to do so – alongside the healing, brings in a broader question than the therapeutic treatment of traumatised individuals. To feel the rage is to allow this aspect of the necessary grieving that is a part of the healing process, to allow the feelings that were cut off through dissociation when it was too dangerous to feel. It is also empowering, and this is a vital aspect of its function when disempowerment is so central to oppression trauma.

Psychoanalyst Beverley Stoute (Reference Stoute10) describes Black Rage arising out of repeated acts of injustice without opportunities for redress that is at the heart of racism. This form of oppression leads to moral injury – inhumane behaviour experienced as a betrayal of what is right. Stoute suggests that indignant rage – in this case Black Rage – is an appropriate response to such injury, that it is an adaptive mental construct and a powerful and necessary defensive psychic force which serves to preserve dignity and self-worth and mitigate the impact of racial trauma.

This links with the need for justice, acknowledgement of what has happened and reparations. Herman (11) emphasises the necessity of a political movement alongside the practices of studying and treating psychological trauma. She argues that:

The thesis put forward in Herman’s book, Trauma and recovery (Reference Stoute10) is that the process of healing from trauma is essentially embedded in a wider socio-political framework that must always be taken into account. Within this particular context, a robust process of responding to disclosures and supporting doctors in the process of ensuring safety (for themselves and their careers), healing and justice is vital.

Learning to Speak: Overcoming Silence to Manage Trauma and Shame

The problem of employee silence is widespread in hospital-based health care, (Reference Peadon, Hurley and Hutchinson12) and new professionals, including junior doctors, are especially prone to silence. (Reference Donovan, O’Sullivan, Doyle and Garvey13–14) In management and organisational research, employee silence occurs when employees individually or collectively ‘withhold ideas, information about problems, or opinions on work-related issues’ including those where they ‘do not speak up about errors, unfair treatment, or behaviours that violate personal, moral, or legal standards’. (Reference Morrison15, p81)

Junior doctors are inducted into the medical profession via formal and hidden curricula imparted during medical education and training. (16) The implicit messages they receive communicate their place in the medical professional hierarchy and let them know they are to be ‘seen and not heard’ and that the views and preferences of senior colleagues are to be privileged. (Reference Lister, Spaeth, Edwards, Martin and Ashkanasy17) They also experience and witness negative behaviours such as incivility, bullying, harassment and discrimination (Reference Llewellyn, Karageorge, Nash, Li and Neuen18) that are typically perpetrated by doctors higher in the hierarchy (Reference Talash, Corfield, Latcham, Lavelle, Williams and Machin19) and reinforce the silent status quo. (Reference Rai and Agarwal20)

The messages junior doctors receive are effective to the extent they frequently fail to speak up for patient safety and care, (Reference Brennan and Davidson21; Reference Dendle, Paul, Scott, Gillespie, Kotsanas and Stuart22) subverting their professional commitment to do no harm (Reference Loewenbrück, Wach, Müller, Youngner and Burant23) and the organisational obligation to report adverse events and errors. (24) Those who do voice concerns can become victims of symbolic violence, (Reference Bourdieu and Wacquant25) a type of reputational harm that ensures they are effectively blacklisted, unable to secure ongoing employment or progress their training, in which they have invested significant time and resources.

In an environment where speaking up about professionally and organisationally mandated issues can lead to bullying and harassment as well as tarnished reputations and stalled careers, junior doctors are even less likely to voice concerns related to their working conditions and wellbeing. Issues related to hours, pay, rosters, leave and fatigue are therefore also left unsaid, (Reference Creese, Byrne, Matthews, McDermott, Conway and Humphries26) and those related to abuse are even harder, if not impossible, to raise.

In the military, female soldiers who were victims of workplace rape lapsed into two forms of employee silence, acquiescent and quiescent silence. (Reference Pinder and Harlos27) The former is characterised by a sense of futility (speaking up is useless and nothing will change if I do). The latter is associated with suffering in silence – with hopelessness and a lack of self-efficacy to voice that makes speaking up at any point unlikely. Acquiescent silence, however, holds the promise of voice: some victims spoke up about their experiences years later, when similar reports surfaced in the public domain.

The problem of employee silence is, however, a compounding one, and left unchecked it leads to organisational silence, defined as the group-level belief that it is not safe to speak up or it is futile to do so. (Reference Morrison and Milliken28) This creates widespread ‘climates of silence’ in which silence at work becomes the self-perpetuating norm (Reference Morrison and Milliken28, p. 708).

Breaking the Vicious Circle of Silence: Restoring Agency and Confidence to Voice

Much of the literature on employee silence focuses on addressing organisational and structural barriers to voice, and in health care research professional factors have also been identified as significant. Solutions include improving mechanisms for voice, for example via protected reporting programmes such as the Freedom to Speak Up Guardians initiative in the NHS in the UK; (Reference Hughes29) programmes that teach health care professionals how to speak up (see Reference Jones, Blake, Adams, Kelly, Mannion and Maben30 for a review); and attempts to improve organisational or professional culture, the Royal Australasian College of Surgeons’ Operating with Respect programme (31) being one example of professional accountability training designed to reduce bullying and harassment.

Little attention has been paid, however, to ways employees might be supported to address the problem of silence themselves – an oversight that perpetuates the kind of individual inertia Pinder and Harlos (Reference Pinder and Harlos27) identified in their study on silent soldiers. Yet their conceptualisation of acquiescent silence hints at two ways junior doctors, who also work in highly stratified and oppressive environments, might progress from silence to voice.

That victims spoke up after someone else had suggests collective voice could be one way for junior doctors to break their silences. Associated with unions and other forms of employee representation, (32) collective voice has recently been exercised by junior doctors in several jurisdictions in Australia on the topic of systemic unrostered and unpaid overtime. The doctors joined forces in the form of class actions against their hospital employers and the first case was recently found in their favour. (Reference Yu, Jeuniewic and Brook33) Finding ways to connect junior doctors who are victims of work-related sexual assault, via class actions or other means, could provide a safer way to speak up.

That some of the soldiers in Pinder and Harlos’ (2001) study (Reference Pinder and Harlos27) eventually broke their silence, despite long-term fear and inertia, suggests interventions that enhance individual agency could also be useful, workplace coaching being one example. Coaching is an agentic activity that empowers individuals in several ways. (Reference Jones, Woods and Guillaume34) First, it provides a space where they are listened to and heard. Second, it uses questions that prompt people to find solutions to work-life problems. Third, it uses goal setting to enable people to develop accountability and track their performance.

Research on junior doctor silence, conducted by one of the authors of this chapter, suggests the movement from silence to voice occurs on a spectrum as individuals develop agency, and that the journey takes place in stages (Figure 35.1). In the first or wounded stage, junior doctors are at the silent end of the spectrum, overwhelmed by their circumstances and hurt by their experiences to the extent voice (on any topic) is impossible. In the second, pragmatic stage, junior doctors are aware of their plight but continue to believe voice is not welcome. Highly functional, they accept their situation with stoicism. In the third stage, junior doctors become critical – and cynical – about their situation. Anger can propel them to speak up about the things that matter most to their wellbeing, such as the inability to obtain parental leave. In the final, confident stage, junior doctors are more likely to raise concerns. They have learnt how to navigate the complex systems in which they are immersed, established allies who can support their efforts to raise concerns and have greater self-efficacy to voice.

Figure 35.1 The transition from silence to voice.

(Reference Yu, Jeuniewic and Brook33)

This trajectory supports the notion that increasing junior doctors’ sense of personal and professional agency is required if they are to break free of their deeply held beliefs that speaking up – be it about sexual harassment, other working conditions concerns or patient safety and care – is neither permitted nor welcomed. Coaching encourages individuals to become active leaders of their own lives rather than the passive recipients of life. Focused workplace coaching that aims to develop communication skills could offer junior doctors a path to voice. As the ability to speak up has also been linked with increased employee wellbeing, (Reference Brooks, Wilkinson, Brough, Gardiner and Daniels36) workplace coaching could also be a path to recovery.

Designing a Curriculum that Incorporates the Tools for Recovery

We are no longer in an era where doctors are expected to be relentlessly objective. The symbolic separation of doctors from their patients, in the form of white coats, special obscure language and other symbols of power, is breaking down. It has been interesting to watch doctors return to special clothing in the form of scrubs during the pandemic, perhaps as a way to re-establish appropriate infection control and symbolic therapeutic distance.

Doctors are taught to relentlessly suppress their personal and emotional needs. Medicine demands sacrifice. It chooses the elite thinkers, who dedicate their early lives in achieving high academic goals. It then expects over a decade of commitment to higher learning, and this includes lengthy hours, including hours that are never captured in a timesheet. In addition, doctors in training still tolerate and may expect ‘beneficial mistreatment’, the years of harsh expectations and feedback which they believe will make them better doctors.

Medical training and practice may come at considerable expense. Doctors have high rates of mental illness, alcohol and other substance misuse and relationship breakdowns. Suicide rates are high. Doctors live with high and often unachievable personal expectations. At this time in history, they also live with growing occupational violence, in workplaces that are becoming psychologically unsafe.

In order to survive the brutality of medicine, the painful procedures that must be carried out on vulnerable patients like children, the bad news that must be delivered, and the witnessing of appalling trauma that must be endured, doctors need to learn to moderate their empathy. In difficult consultations, and during difficult procedures, doctors will often revert to objective, theory-based thinking, partly to protect themselves from the trauma, and partly to ensure the patient gets what they need without the doctor being distracted by their own distress. It is therefore understandable that doctors may not have the language, experience or frameworks to manage their own trauma. Although there have been moves to destigmatise mental illness in medicine, to encourage the sharing of feelings, and to provide non-specific support mechanisms for doctors, often these are couched in terms that imply the doctor is responsible for managing their own distress. It is even a requirement in some codes of conduct that ‘doctors maintain their own wellbeing’. Some now describe this as ‘wellbeing washing’, the illusion of care that is a light dressing over a deep wound. One cartoonist described this well, when talking about the NHS. In response to a request for more support for doctors, the manager responds, ‘we’ve given them a room to cry in, what more do they want?’

In this environment, doctors who experience their own trauma may lack the words, let alone the theories, to understand what has happened to them, and to communicate it to others. Their defences have been shattered, the personal and the professional selves are no longer walled off, and underneath their thick layer of protective objectivity, they may lack the capacity to make sense of the experience. The injunction ‘it’s good to talk about things’ doesn’t help if there are no words to describe the feelings experienced, or no-one who the survivor feels is safe to hear the message.

As educators, colleagues, therapists, leaders and regulators, we need to consider how we can use the frameworks doctors already have in place to manage this wordless trauma. One way, of course, it is to teach trauma theory and trauma management early in training. Doctors revert to theory if a situation is distressing. We need to supply theory they can use. Psychological trauma should also be debriefed in a formal, objective way, perhaps with structures like root cause analysis that are already well known, so doctors have appropriate scaffolding to discuss difficult challenges. When trauma occurs, it is naïve to assume that all doctors need is kindness, compassion and non-specific support. Although these are helpful in themselves, trauma-based therapy is a difficult skill that requires expert practitioners. Assuming this form of trauma can always be managed with non-specific kindness and empathy underestimates the impact this form of trauma can have on a survivor. Doctors deserve well-trained and capable trauma-based practitioners who can help them name their experience, understand it and find ways to move beyond it to return to practice if they choose to do so.

Training for Employees to Ensure Everyone Has a Common Understanding of their Obligations

The start of sexual harassment prevention is making sure all workers can recognise sexual harassment and understand their obligations under law and the organisational policy to prevent it. In some countries, there is no legal precedent for this work, as sexual harassment is not defined in law, which can make this process challenging.

To prevent sexual harm, employers need to provide all workers with clear and consistent information, instruction and training. One of the biggest issues is that different people will have different understandings of what sexual harassment is (see chapter 4) and so may respond, or not respond, to different situations. This is especially the case where staff come from different cultural backgrounds where understanding and tolerance of sexual harassment can diverge.

Common approaches to this type of health promotion are to mandate educational programmes and to ensure the knowledge is mastered using a variety of assessment tools. In doing so, organisations can guarantee that their employees are informed about sexual harassment, and can define it, but there is no such guarantee that they will recognise it when it occurs in the workplace. These approaches are compliance focused and fail to include attention of the informal systems of how such policies will be utilised in situ.

Skill Development to Recognise and Respond to Sexual Harassment

While people may recognise sexual harassment in theory, they may not recognise it in practice. Some of our editors have had experience running scenarios of discrimination and harassment, role-played by professional actors. Even when primed and supported, we have been surprised at how difficult it is for medical students to respond to these situations.

Knowledge of sexual harassment is not the same as the capability to recognise and respond to it in context. There is a clear difference here between knowledge and professional skill. There is a body of research work needed to underpin this form of training to ensure it translates into action in the workplace.

Assessing and Managing Risk

In order to manage issues around sexual harassment in medical workplaces, it is necessary to understand risk. We are still learning about individual and team risk, but initiatives like HOTSPOTS in New Zealand (described in chapter 14) attempt to map risks over time, based on a dynamic analysis of learners’ feedback. Using this model, we expect it will become possible to identify high-risk teams, and potentially high-risk individuals. Hopefully, we will also be able to detect and communicate features of highly functional and psychologically safe teams, so these skills can be transmitted to learners and educators in the future.

However, doing this work requires much more granular data about interpersonal behaviour than we have in practice. We trust that education and skills development will create a common language around sexual harassment, and therefore provide more accurate and predictive data. We also expect that further research in this area, particularly ethnographic research, may inform responses to particular workplaces, such as emergency departments, surgical theatres and mental health facilities, where sexual harassment seems to be more common.

Developing Safe Work Policies

Policy development seems to be central to providing a safe workplace. However, it should be recognised that sexual assault has been illegal in most jurisdictions for decades, and yet even extreme forms of abuse, such as rape, continue to occur. There are two important aspects of policy to consider. Firstly, the policies must be known, and this is a question of education. Secondly, they must be accepted, respected and followed. The problem here is that written policies may not reflect the hidden rules that are accepted by staff, more commonly described as ‘the way we do things around here’.

There is a parallel in urban planning, to describe the way humans (or animals) may create an alternative path to the one created for them. One phrase for these paths is a ‘free will way’, an unplanned small trail caused by human or animal traffic that shows us where we choose to travel. It is usually the shortest or the most easily navigated route to the destination, the short cut, or preferred route to a destination, and the depth of its surface erosion is often an indicator of the traffic level it receives, relative to the official route. In other words, a free will path reflects ‘the way we do things around here’.

Despite building formal policies, laws, and educational materials that look effective, predators continue to use these preferred routes and use cultural, hidden rules that leave survivors abandoned. The work that needs to be done is to understand how these hidden paths have been used, how policies have succeeded (or failed) to meet their objectives, and how inappropriate attitudes and behaviours can be challenged and changed.

Performative policies need to be changed. Employees view workplace policies as genuine when they are motivated by care and concern for employees, and are thoughtfully and consistently implemented. Insincere or inequitable policies can lead employees to question the overall ethics or values of an organisation and trigger a lack of trust. In this way, policies can actually impede reporting. Unfortunately, employees can base their trust in the organisation on the implementation of the entire policy suite. This means that when a hospital claims to value their employees, but continues to expect unpaid overtime from its junior staff, or use other exploitative practices, it undermines trust in their entire policy framework. Over time, such abuse can transform into distrust.

Finally, it should be recognised that policies intersect. A doctor in training who has experienced sexual harassment may report to a number of organisations and disciplines, described throughout Part 2. Inconsistent policies, policies that overlap or contradict each other, and policies that are deeply opaque mean that survivors distrust the process, and do not report.

Identifying High-Risk Situations

There have been prevalence studies in many medical workplaces across different countries and different contexts. There have also been studies of medicine relative to other health and social care professions that specifically identify the greater frequency of this issue for and within medicine. However, at the time of publication, there have been few high-quality studies that have compared prevalence across contexts using the same methodology and the same criteria.

We know that doctors are at risk of sexual harassment from nurses, carers and patients, as well as colleagues. One of the issues in medicine is that patients may, at times, lack capacity to regulate their behaviour. For instance, surgical patients may behave quite differently while recovering from anaesthetics. Patients with dementia or mental illness may be unable to regulate their behaviour due to illness or disability. Emergency departments can seem quite chaotic, and may have patients who are still under the influence of drugs and alcohol. In these environments, inexperienced doctors can have difficulty distinguishing the sexually aggressive patient from the unwell patient, and may therefore tolerate behaviour that would be unacceptable in other contexts.

Supporting High-Risk Targets

This is a difficult area, because population risks and individual risks are not the same. For instance, certain communities may be particularly intolerant towards doctors of a certain race. Identifying those doctors at risk is difficult. We do know that international medical graduates are at particular risk, and in the training of these doctors to manage expectations of medical practice, there needs to be similar training to help these doctors respond to racism, harassment and discrimination. Racism can also lead to witnesses discounting the experience of International Medical Graduates.

Throughout the book, authors have highlighted the importance of training everybody to respond to inappropriate behaviour. Normalising good bystander behaviour as well as strategies to manage harassment as a target is essential to ensure doctors living with multiple marginalisations are well supported. This is vital to fostering and maintaining trust within these teams and workplaces.

Managing High-Risk Perpetrators

There is little written about perpetrators in medicine. Researchers from the University of Melbourne have analysed risks to identify the higher risk from repeat perpetrators in doctors and thus the value of distinct sanction. (Reference Bismark, Spittal, Gurrin, Ward and Studdert1) Professor Searle’s work suggests there may be a difference between the predator, who chooses medicine to access targets, and the doctor whose behaviour becomes disordered over time. (Reference Searle2) While there is little written about early identification of high-risk individuals and the effectiveness of remediation, we have seen in multiple chapters of this book that perpetrators are rarely removed from the medical workforce, resulting in escalating scale and frequency of sexual assault. This is one area where more research is needed, to better understand not only how to exclude potential perpetrators from the medical workforce, through selection and assessment processes (see chapter 14), but also how medical culture supports and enables sexual harassment and abuse. Senior medical staff may lead a very socially restrictive life, with extensive work commitments precluding the development and maintenance of personal and social support. The rates of alcohol abuse, mental illness and death by suicide are disproportionately higher in doctors, and we are yet to acknowledge and understand how medicine as a culture can actually drive professional misconduct. This is a difficult, but necessary, area to research.

Reducing Reporting Barriers and Streamlining the Processes of Reporting

Strategies in this area involve writing processes that are clear and understood. It is important to get multiple stakeholders to identify gaps, and omission and conflicts in these process, or confusing content. This includes seeking advice from survivors, who may identify barriers to reporting. It also should include ongoing monitoring and review of policies and their review to ensure information contained is accurate and current. Organisations should ensure when and how other organisations may be involved in reporting, to ensure survivors are not confused by intersecting and contradictory policies. There should be a well-informed support person available who can advise on these processes. Ideally, this person should not be involved in teaching or management, to avoid potential conflicts and enable the survivor to consider their options independently. Whether the survivor chooses to report or not, they should be offered independent support. The process should minimise re-tellings by the survivor.

Communicating Investigation Outcomes to the Workforce

It is necessary to balance transparency and confidentiality. De-identified information should be released in a way that respects confidentiality, but ensure the workforce understands that allegations of sexual harassment are taken seriously and that there are consequences. These controls and provision of information are critical to maintaining trust.

Analysing Critical Incidents

Throughout the book, we have seen examples where policies and processes can be harmful. Policies have failed, and processes have been unexpectedly ineffective. One particular challenge is when a survivor withdraws their report.

Throughout this process, there are usually multiple, consecutive failures. The harassment has not been prevented and it may have not been recognised or reported by the survivor or the bystanders. When reports have been received, the process may not produce a satisfactory outcome. Because these processes are so complex, it is essential that they be examined carefully with a view to improving policy and process. There are, of course, processes to examine clinical failures in medicine, and a similar root cause analysis can be followed.

Providing Rehabilitation for Survivors

For the survivor, there is the difficult decision to remain within the culture that harmed them, to change speciality, or to exit the profession entirely. The loss of doctors to the profession when they are unable to re-enter the workforce has received little attention. Medical training is an extraordinary investment of resources, not only for the survivor, but also for patients and the community. Survivors who have invested heavily in their professional identities feel lost and isolated when they are no longer able to practice. They not only lose the capacity to work, they also lose the collegiality of their peers. These derailed careers also have consequences for employers, impacting their equality and inclusion policies, and efforts to attract and retain more women and those who live with intersectional disprivilege into medicine. It is important that rehabilitation emphasises the repair of wider relationships that will have been damaged in these cases and their subsequent reporting processes. This wider group might include both colleagues and patients.

Given that sexual harassment and sexual abuse constitute a failure of governance, it should be a collegiate responsibility to help the survivor regain as much function as possible. If they return to the workplace, re-entry is challenging. The workplace may seem the same, but the survivor may be changed. As Dr Dominique Lee wrote in chapter 18 ‘When I went back to work, I found myself hugging the walls because the floor no longer felt safe’. There will also be others for whom her treatment makes this a distrusted workplace.

Managing Privacy and Confidentiality

Exposure, loss of anonymity and gossip are all painful, especially when the case is high profile and the media is involved. The people involved in any investigation should know who has been informed about the case, and who has not. Communication needs to be carefully managed, and the workforce needs to be reminded of their obligations to respect the confidentiality of the people involved. Workers’ rights to confidentiality should be protected.

Reducing Victimisation

When survivors report, their team can easily ‘take sides’, expressing their support for either the survivor or the perpetrator. The siding with individuals can create further betrayal, and damage other relationships. If the media becomes involved, both parties are harmed through the airing of opinions, and the judgments of others, including those they thought were colleagues or friends. Survivors can experience inappropriate interpersonal communications in their team, including gossip, bullying and further harassment, which limits their capacity to focus, including on their work. It is essential that teams around the survivor and the alleged perpetrator are monitored to ensure each is protected from this form of harm.

There is a particular type of victimisation which involves the adversarial nature of investigations. We are aware of survivors who have reported to regulatory bodies, and have been unable to withdraw from the process when it became deeply traumatic. Regulatory bodies need to ensure they have clear processes to manage ‘victim whisteblowers’. When mandatory reporting for professional misconduct is required, it is unacceptable to force a survivor to report their perpetrator when the report itself causes deep harm. This is a complex problem, but mandatory reporting should not override a survivor’s health and wellbeing.

Reducing Re-traumatisation

Although it is critical that reporting processes establish essential facts, it is also important to minimise discussion of the harassment to what is necessary to achieve outcomes. Multiple, unnecessary re-tellings can deepen trauma.

Restoring Safe Culture

The principles of restorative justice include preventing further harm by working with those involved to set relations right. All people impacted by the wrongdoing – survivors, perpetrators, witnesses, patients and community members – have a voice in the justice process. However, in order to make this process work, we need to actively repair trust and create safe spaces to have difficult conversations, where people can share freely without judgment.