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.