Approach

At the start of this book, we wanted to ensure that readers have the opportunity to familiarise themselves with current thinking about sexual harassment, gender in medicine, and the historical context of sexual harm and its prevention, regulation and management. We are aware that readers will come to this book with particular learning needs and particular areas of expertise. We are expecting that some readers will be survivors; others will have policy responsibilities for managing sexual harms in the workplace or responsibilities. Some may have advocacy roles in teaching, research or policy, and many will come from other disciplines or contexts different to our own.

Medicine is not unique in its respect for hierarchy, and sexual harassment did not begin with the #MeToo movement. We are often asked why we chose to focus exclusively on medicine, given the contemporary emphasis on interprofessional learning and practice that is common in contemporary health care. We have attempted in this part to demonstrate the way medical culture has developed and is maintained, focusing on its history, current challenges and sociocultural contexts around the world. Like any profession, it has its own cultural expectations, and these impact the way sexual harassment is experienced, discussed and managed.

In each chapter, we have asked authors to provide an overview of the field, so that readers can address areas where they need to update their knowledge and understanding. Although these chapters are brief, we have provided appropriate readings to assist those new to the field to explore the problem in greater depth.

Structure

In chapter two, Phillips provides an overview of the issues around gender in medicine. Medicine has a highly gendered history, and although women are well represented in medical school, medical leaders are still predominantly men, particularly in disciplines of high prestige, such as surgery. The author considers medicine as a hegemonically masculine institution, and reflects on the complex embodiment of a woman doctor in such an environment. They describe how sexual discomforting of women – patients and clinicians – can become routinised under hegemonic medical masculinity. Performing gender in a professional way often involves women doctors distancing themselves from the troubling fact of their own bodies. The authors propose that this contributes to heightened sexual risk in the medical workplace.

In chapter three, Roberts and Ahluwalia bring their expertise in education, management, policy and leadership to examine the role of men. Although the evidence suggests that the perpetrators of sexual harassment are usually male, survivors are from all genders. Male survivorship is not well represented in the literature, and their voices are rarely heard. The role of men in allyship, leading and supporting teams in the prevention and management of sexual harassment is highlighted in this chapter, and the authors emphasise the critical role of bystanders in preventing and managing sexual harms.

In chapter four, Waldron and Stone tackle the difficult challenge of outlining changing concepts and approaches to sexual harassment in the workplace, beginning from a historical position where sexism tended to be normalised, to a much more challenging and complex sociocultural environment where workplaces are expected to provide a psychologically safe environment. This chapter attempts to capture how workplace harassment, gender-based violence and gender-based discrimination have been challenged in different global contexts and in different times in history.

Chapter five outlines the variety of medical workplaces in which doctors work, from relatively solitary situations (e.g. primary care in remote communities) to highly institutionalised large companies, such as tertiary hospitals. Medical work is also diverse, ranging from clinical roles, to teaching, education, research, policy and leadership. Some medical workplaces are highly hierarchical, while others promote interdisciplinary working, where health professionals work in partnership with individuals and the community. The diversity in the nature and structure of medical work changes how misconduct can be prevented and managed.

In chapter six, a team of medical educators, academics, clinicians and doctors in training collaborate to describe how doctors are trained around the world. Although there is significant variation in the approaches to medical training, there are also significant similarities. In this chapter, the team explore the way hierarchy is managed, the approach to teaching the science, art and craft of medicine, the choices around making curriculum globally consistent or locally relevant, and the management of learning environments to ensure doctors in training are safe. This chapter pays particular attention to the hidden curriculum, and how learners are enculturated into the social world of medicine, shaping who they are as doctors, not just what they do.

In chapter seven, Botha and Bismark explore the impact of sexual harassment on colleagues, on the workplace as a whole and on patients. In the past, there has not been a particular focus on the behaviour of professionals towards other professionals, as professionalism has tended to be more concerned about behaviour towards patients. However, it is now known that interprofessional communication and relationships have an impact on patient safety. This chapter explores that impact.

Finally, the team of authors for chapter eight look at what is known about the type of workplace interventions that have been used to prevent, reduce the impact and minimise the harms of sexual harassment. This chapter summarises the evidence behind potential strategies using the framework of primary, secondary, tertiary and quaternary health promotion.

Introduction

On 7 November 1869, thirty-nine medical students from the Women’s Medical College of Pennsylvania attended a medical lecture at Pennsylvania Hospital. The teaching session had been negotiated some months in advance and was intended to expand their clinical exposure. Instead, the visit was hijacked by a heckling mob of over 200 male medical students from two local medical schools. Over the course of an hour, the students harangued the ‘she-doctors’, spat tobacco juice on them, and after the lecture followed them and harassed them on the street. (Reference Tierney1)

The men behind the ‘jeering episode’ were roundly criticised in the press for their ungentlemanly behaviour. (Reference Blackguardism2) In a published letter, a male medical student responded that it was men who had been affronted by ‘this shameless herd of sexless beings who dishonor[ed] the garb of ladies’. The women students had forfeited the right to gentlemanly treatment by being ‘beardless neuters’, afflicted with the kind of ugliness ‘only seen in hell’. (3) Not being ladies, they were appropriate targets for the sexualised attention shown by the medical students. They were both sexless, and ripe for sexual humiliation.

There are no published accounts by the women who were targeted in the jeering episode. However, the first generation of women medical students adhered to a strict code of female demureness. As the men spat and cat-called, the women remained seated without flinching. They may have reflected on the flimsy protection provided by a ladylike demeanour.

The jeering episode is more than a moment in the history of pioneering women doctors. It laid bare the institutional fissures about sex and gender that have persisted in medicine to the present day. In varied ways, women doctors over generations have noted or contested the attention paid to their bodies, and performed a certain type of doctorly womanhood in order to minimise sexual risk and gender-based marginalisation in the profession.

Why should it matter now? In most countries, women entered the modern medical profession over a century ago. Women have moved into every medical subprofession. There would be few medical schools where medical students are not instructed by female professors and female clinicians. Yet women doctors remain anomalies in the global health workforce. In nearly two-thirds of the countries which report their health workforce statistics to the World Health Organization, more than half of all doctors are men. (4) In the hierarchies of medical subprofessions, medical research and medical academia, women continue to be clustered in more junior positions. Women in the profession continue to occupy a position of difference, defined by and in relation to male doctors.

The medical profession has been persistently troubled by the meanings and actions attributed to gender. For the male students and their professors behind the jeering episode, gender was dichotomous. There were men, and there were not-men: a category which included women and the beardless neuters who had no business trying to be doctors. Beneath their invective there seethed an unsettling concern that these new women doctors represented a challenge to the existing gender order. In this chapter we set out the case that women in medicine continue to negotiate their way through a profession that reflects and enforces masculine power. Although this chapter focuses on women, the same processes are in play against people subordinated by hegemonic masculinity – people with diverse sexualities or gender identities – and the disadvantage is further intensified for those who also hold minority ethnic or religious identities.

Hegemonic Medical Masculinity

To state the obvious: the medical profession remains a place dominated by men. Both medical education and hospitals – the pre-eminent medical workplace – are structured around what the gender theorist Raewyn Connell calls hegemonic masculinity. (Reference Connell5) Connell argued that masculinity is not a fixed attribute of any individual, nor is masculinity necessarily confined to men. (Reference Connell and Messerschmidt6) Rather, masculinities are patterns of practice through which individuals engage with the position of men in society. Individuals (men, and to a lesser extent women) move through and produce masculinity by engaging in masculine practices, working in groups or societies or institutions. These practices structure the distribution of resources and of power in the form of authority, and the production of meaning and values. (Reference Schippers7) Masculinity therefore is fundamentally relational; masculinity exists in relation to femininity.

Hegemonic masculinities may not be the most common form of masculinity practised by individuals, but they tend to be the most admired in a society, and often represent an idealised state for men. Hegemonic masculinities legitimate and perpetuate the gendered order of a society. They are supported by masculinities which interact with one another in complex ways. Complicit masculinities are those practices and systems which enable individuals to benefit from men’s social dominance while not directly themselves oppressing women. (Reference Connell5) Individuals who embody subordinate masculinities represent a subversive contrast to hegemonic masculinity – typical examples include sexual diversity in heteronormative cultures – which may nevertheless still consent to the dominance of hegemonic masculinity. (Reference Hennen8) Individuals who embody marginalised masculinities include those who belong to non-dominant racial or class groups. They too may support hegemonic masculinity through being suborned through exemplary examples (e.g. exceptional performance by a black athlete) or through controlling metaphors connecting blackness and criminality. (Reference Yang9)

The practices of hegemonic masculinity – being action-oriented, authoritative, ‘rational’ and independent of thought – were salient in the evolving profession of medicine in Europe through the eighteenth and nineteenth centuries. It took a well-funded philanthropic foundation to cement them into medical education internationally. In 1910, Abraham Flexner produced his enormously influential report on North American medical education. To correct what he saw as the inconsistent, under-regulated, unscientific training of doctors, he proposed a science-based, rational, university-led education, based on the German model of education. (Reference Flexner10–Reference Bailey11) He saw no reason for proprietary medical schools for women, and considered most of the medical schools for black students to be inadequate and unnecessary. The American Medical Association was highly supportive of his efforts to professionalise medical education by increasing barriers to entry. (Reference Bailey11) Compliance requirements resulted in the closure of all women’s medical schools, and two of the nine medical schools for black medical students. As a result, medical graduates in the USA became more homogenised and the profession of medicine was increasingly white, male and upper class. (Reference Wooster12) The actual number of graduates fell, and the proportion of women graduates in US medical schools did not rise above 6% until the 1960s. (Reference Barkin, Fuentes-Afflick, Brosco and Tuchman13)

Flexner’s rational, science-based curriculum has become the global standard. (Reference Bleakley, Brice and Bligh14) Most medical readers of this book will be familiar with the model through their own training. (Reference Weisz and Nannestad15) Even advocates of different models of education, such as the Cuban and Brazilian place-based, community-oriented medical programmes, continue to cite their respect for the Flexnerian approach. (Reference Antunes Dos Santos and MDPT16–Reference Vela-Valdés, Salas-Perea, Quintana-Galende, Pujals-Victoria, González Pérez and Díaz Hernández17) Flexner – like many of the Progressives who supported medical education reform in North America – held a strong view that society would work best if controlled by a benevolent elite. (Reference Wooster12) That benevolent elite was in his time almost entirely comprised of men in positions of power and influence. Hegemonic medical masculinity reflects both the influence of Flexnerian education and the organisational hierarchy of hospitals, both of which in turn reflect the prevailing gender order.

The markers of masculine medical hegemony can be difficult to discern. Many men and women will argue that there is no specific male privilege in medicine, that any woman with sufficient dedication can forge their own path within the profession. To illustrate oppression, Marilyn Frye (Reference Frye18) used the metaphor of the birdcage. A bird, Frye says, may not recognise the bars of the cage as interlocking mechanisms constraining their freedom; instead it sees the bars as just part of their known world. Our notion of the ideal professional doctor can function as a birdcage. We may not be able to recognise hegemonic masculinity, but still it is there. In her analysis of changing concepts of ‘the good doctor’, Whitehead (Reference Whitehead19) charts a discursive shift from character to competencies. This has had the effect of obscuring the gendering of the ideal doctor. The Flexnerian scientist-physician was a person of character – intellectual, incisive, authoritative, reasoned, upright – which matched the male ideal of the time. In the 1970s, the new discourse on competencies emerged, focused on role performance. The good doctor could be produced through a pre-determined set of values, attitudes and behaviours. Framing professionalism around competencies or entrustable professional activities encourages doctors to view the professional ideal as independent of gender.

Hegemonic medical masculinity can be seen in entry systems to medicine which privilege men. Between 1979 and 2002, the National University of Singapore capped women’s enrolment to one-third of the cohort, on the grounds that female doctors had a higher rate of attrition through their career. (Reference Tambyah20) The nine Japanese universities found in 2018 to be rigging the entrance exams in favour of male applicants advanced the same excuse: ageing woman doctors would leave to care for their husband, children or elders. (Reference Schieder21) In both these cases, attrition of women professionals was normalised as a response to their role as birthers and carers, and less capable male students were advanced at their expense. For the profession, losing capable women, skewing the profession to men, was not seen to represent a substantive problem. Structurally, men benefitted from the patriarchal dividend. (Reference Connell22)

Hegemonic medical masculinity is a global phenomenon. Even in countries where women comprise most of the medical workforce, the most prestigious positions in academia and medical organisations are held by men. In Latin America, the higher echelons of medical leadership where decisions are made about health care systems, medical education and health policy, are largely male. (Reference Knaul, Arreola-Ornelas, Essue, Nargund, Garcia and Acevedo Goméz23) Although women comprise more than 70% of the medical workforce in Russia, they are clustered in the least prestigious professions, those which bear a metaphoric relationship to mothering, such as primary care or paediatrics. (Reference Harden24) In Estonia, during the Soviet occupation, women doctors received lower salaries and received comparatively little benefit from the informal or black market economy for medical services. (Reference Barr and Boyle25)

People who embody what Connell termed complicit masculinity have key roles in supporting an institution’s masculine hegemony. Complicity requires that a group agrees to the procedures through which domination and subordination occurs. It is a ‘cautious conspiracy’ that sanctions the processes and planning that enable hegemony to occur (Reference Gómez26, p. 118).

A senior male specialist tells a homophobic joke at the expense of another male doctor, in front of two of his peers. One of them laughs at the joke and the one who doesn’t later counsels the targeted doctor not to take the joke personally. Each doctor witness in this case demonstrates complicit masculinity. The witnessing doctors have directly allied themself with power, and by joining in or discounting the meaning of the joke, reinforce the fragile status of the subordinate. In this story the complicit doctor witnesses could be either male or female. The fact that women can and do become engaged in complicit masculinity indicates the fallacy of thinking that representation of women in the career structures of medicine is sufficient of itself to overturn hegemonic masculinity.

The increase in women in medicine has given rise to a particular anxiety of masculine hegemony: that women may reduce the status of the profession. (Reference Biringer and Carroll27) In 2004, Carol Black, the president of the Royal College of Physicians in the UK, asserted in a newspaper interview that medicine, a profession which had been ‘dominated by white males’ risked losing its influence as it became dominated by women. (Reference Laurance28) In her view, women were unable to take up leadership positions because of their responsibilities to family. Black advocated gender parity in medical school entry through strategies to increase male entry. As only the second female president of the College of Physicians in its history, Black said she was able to talk about this sensitive issue ‘because no man can bring it to the fore’. As a woman in authority in a system of masculine hegemony, Black here gives a textbook example of masculine complicity, as performed by a woman.

Is there such a thing as hegemonic femininity in medicine? If hegemonic medical masculinity in practice is recognised through assertiveness, authority, and rationality, hegemonic medical femininity, as the other in this idealised relation, is recognised through submission, self-effacement and intuition. In medicine, hegemonic femininity characterised in this way is typically attributed to the nursing profession. (Reference Davies29) This is not to say that individual nurses are submissive, or that submission is a professional characteristic of nursing. Rather, the institution of medicine – particularly in hospitals – is enacted through regimes of submission manifested in the organisational practices of nurses in relation to doctors. In hospitals the most experienced nurse often needs to submit to the authority of the most inexperienced of doctors to obtain medications for patients, advocate a procedure or advance a diagnosis.

A woman doctor has little use for hegemonic medical femininity. Their challenge is to negotiate hegemonic masculinity without being harmed by it. They might do this through adopting a range of masculinities, or they might adopt what Schippers (Reference Schippers7) calls alternative masculinities and femininities. Alternative masculinities and femininities may embrace traits and practices that do not privilege a hegemonic relationship between men and women. In medicine, such a project might be demonstrated outside of the large institution or in particular medical disciplines that are emerging, or do not have an established career structure. Doctors and nurses working in the early days of the HIV epidemic recount actively seeking to develop new masculinities and femininities in medicine, often through actively countering masculine hegemony. (Reference Bayer and Oppenheimer30)

Hegemonic medical masculinity finds itself under the spotlight at present. The disclosure of sexual harassment and gender discrimination in the medical workplace has thrown light upon its troubled gender relations. In response, those in authority and those enacting complicit masculinity have sought to shore up masculine hegemony. One strategy is to exceptionalise people’s experiences of harassment. Many inquiries into sexual harassment in medicine have advanced the ‘bad egg’ argument, that the perpetrator of harassment is an outlier, rather than a predictable outcome of a system of masculine domination. Another strategy is to trivialise harassment practices. After attending a course designed to counter sexual harassment in medicine, a male anaesthetist said, ‘What’s wrong with telling a woman she looks nice in her dress?’ He had distilled the message of the course to this: he should exercise caution against women’s unaccountable sensitivities to compliments.

Performing Gender as a Woman Doctor

The Professor was respected for his dedication to teaching of students. He did not discriminate between them, and was punctilious in ensuring equality of opportunity for male and female doctors and students. No doubt the female student had expected a recommendation about textbooks to read, videos to watch. Instead, he casually recommended a beauty regime.

While Connell’s theory of hegemonic masculinities offers a productive way to understand the workings of the medical system, it skirts around gender and the daily negotiation of difference. Judith Butler (Reference Butler31; Reference Butler32) proposes that a key feature of the hierarchical relation between men and women is a naturalised gender dialectic, in which heterosexual desire assumed to be grounded in biology, is the ontological basis of gender difference. Masculinity and femininity are the product of this fundamental relation; heterosexual regard for the female is masculine and the object of masculine regard is feminine. The Professor in our example is not sexualising the student with intent. Rather he is operating within a system of relations, signs and practices in which a woman is reconstructed through heterosexual regard as the one who is seen, rather than the one who sees.

Women doctors may also embody pariah femininities. Pariah femininities are defined by Schippers as ‘the quality content of hegemonic masculinity enacted by women’, and which are apprehended not as feminine but as not-masculine (Reference Schippers7, p. 95). Pariah femininities are typically enforced in relation to masculinity, and are noted by both men and women. Epithets indicating pariah femininities in medicine may include being a demanding bitch (taking the masculine quality of authority), being uncollegiate and disrespectful (being independent), or being a cock-teaser (exhibiting sexual authority).

The ‘beardless neuters’ who were the victims of the jeering episode – and many of the pioneering women doctors – embodied a pariah femininity, defined as not-masculine but not feminine. This was even more so when they explicitly wore men’s clothes or behaved in masculine ways. The first Chinese-American woman doctor, Margaret Chung, called herself Mike at medical school and wore a man’s suit and tie. (Reference Wu33) Gertrude Stein appalled her peers at Johns Hopkins Medical School by smoking cigars, challenging professors and taking boxing classes. (Reference Bliss34) Mary Edwards Walker, a decorated military surgeon and advocate of dress reform, seems to have posed a lifelong challenge to traditional binary categories of gender. Early in her professional life she wore the dress reformer’s garb of bloomers and simple skirt. Later in life she wore men’s clothes, claiming to do so for the freedom they offered. ‘I don’t wear men’s clothes, I wear my own clothes’, she magisterially explained to the police arresting her on the made-up charge of illegal cross-dressing. (Reference Fischer35)

These women were explicitly engaged in performance. All people perform gender. Butler points out that gender is materialised through regulatory conventions and norms, which are ‘forcibly reiterated’ though our institutions (Reference Butler32, p. 2), and realised through performance. A doctor performs their gender (usually one of a binary) in relation to normative obligations and expectations within systems and relations of power. (Reference Butler36) A doctor’s gender is imputed to them through their performance of it.

Medicine is a highly performative discipline, and doctors are conscious actors. They are taught to take a consultation in a structured fashion, using a patterned flow of conversation gambits to elicit the information they need to diagnose and treat. They learn how to approach a person, and how to initiate the intrusion of an examination of another person’s body. They learn communication strategies which help them to ingratiate, to placate, to demonstrate empathy, and to engage in difficult discussions. Patients often distinguish a good doctor from a bad doctor on the basis of this performance. (Reference Grundnig, Steiner-Hofbauer, Katz and Holzinger37)

The Professor’s advice to the medical student to wear lipstick is really advice about how to perform her gender in an acceptable manner. The student may be concerned that she is being asked to perform femininity in a way that inevitably positions her as subordinate to masculinity. She may consider if refusal to wear lipstick may be regarded as an act of pariah femininity. She may toss up attempting to engage in hegemonic masculinity. In all of these she will be negotiating her embodiment in the act of performance.

The Body of a Woman Doctor

How does a woman doctor negotiate her own embodiment? In her famous conjecture, Simone de Beauvoir proposed that one is not born, but becomes a woman. (Reference De Beauvoir38) Taking this insight further, Monique Wittig (Reference Wittig39) argued that a person’s sexual characteristics also inform a presumed social destiny. For Wittig, gender is a category made malleable by the biological category of sex, reflected in cultural ideals of the ‘inner essence’ of woman. Rather than becoming a woman, a woman is obliged to perfect their womanhood according to social apprehensions of what sex entails.

In medicine, the clinical eye often constructs the female body as vulnerable, obscure and governable in ways that men’s bodies are not. (Reference Schildrick40) De Beauvoir observes that as a girl matures she faces an increasingly hostile and threatening society; her maturing body becomes a source of shame or the subject of threats from others. (Reference De Beauvoir38) Like any woman, the female medical student is aware of her self as seen by others. In becoming a woman doctor the female medical student learns to distance herself from her embodiment. All doctors do this to some degree. We can trace some of this broadly back to the socialisation of doctors. The student schools themself to develop a ‘clinical eye’ through the study of the scientific elements of the body – disintegrated, depersonalised, and subject to their gaze. If we participate in the fiction that we have no body, the physical intimacies of medicine – touching the bodies of others, viewing and learning about the body in group settings with other adults – become abstracted and less overwhelming.

Adopting the clinical gaze may be experienced as a relief by young women. Nawal El Sadaawi entered medical school in Egypt at the behest of her parents in the 1950s. In Memoirs of a Woman Doctor, the fictionalised account of her medical training at Cairo University (Reference El Sadaawi and Cobham41), she writes of stepping outside of her gender as she enters medical school:

For Nawal El Sadaawi, this is a moment of liberation. She provides a compelling account in The Hidden Face of Eve (Reference El Sadaawi42) of the fraught journey of young Egyptian women to womanhood in a culture where girl’s bodies are a source of shame and a site of assault. Carrying out a death sentence on her body was both a professional act but also a source of relief.

For many women doctors, their own disembodiment is the essence of professionalism: the ideal state of becoming Dr No-Body. At the same time, a woman cannot really eschew her physicality: she is always to others a person in a woman’s body. Women’s bodies are constantly presented as a problem in a way that men’s bodies are not. The dress code for women medical students entering the University of Queensland/Oschner Louisiana medical programme is ‘a professional proper fitting blouse with slacks or skirt (avoid excessively low-cut necklines or revealing clothing)’. Male students are advised to wear ‘a proper fitting dress shirt and tie with appropriate trousers (no jeans or shorts)’. Women’s bodies need to be desexualised to be professional. Men just have to cover their knees.

To illustrate the impossibility of the ideal of Dr No-Body, consider the case of pregnancy. The physical fact of pregnancy is an assertion of the body. The pregnant body becomes large, unwieldy. The person’s centre of balance changes. They may no longer be able to walk or stand as easily. Nevertheless, most pregnant doctors and medical students strive to function as if they were not pregnant. They do not seek special consideration – nor is it likely to be granted. University policies around pregnancy frequent state no specific leeway is to be provided to the student, unless they have medical complications, such as hyperemesis. The woman is obliged to struggle against the fact of her pregnant body to continue functioning as a professional, and be perceived as such.

Sexualised discomforting of women in medicine has been described since women walked into the medical classroom. Sophia Jex-Blake, one of the first women to receive a medical education in Great Britain, described male students from the University of Edinburgh shouting anatomical epithets at her in the street. (Reference Knox43) She understood their meaning, even if the police did not. In the USA, Emily Barringer, the first woman doctor to hold a hospital surgical training appointment, was the subject of sustained harassment by her fellow residents. Over the dinner table they discussed rape cases in gynaecological detail, pointedly enjoying her discomfort. (Reference Barringer44)

Flexner viewed the co-educational Johns Hopkins Medical School, opened in 1893, as the ideal for his new model of medical training. (Reference Flexner10) Women students commended the respectful demeanour of their fellow male students. (45) That respect didn’t continue into the men’s private conversations. The female cohort of one year were referred to as Battle Ax, Buffalo Bill, Strawberry Blonde and Karyokinesis. (Reference Bliss34) All of these can be read as sexualised epithets: two highlight the women’s perceived lack of sexual attractiveness, and two involve sexualised appreciation. A celebrated textbook on the relatively new concept of karyokinesis had just been produced by two Johns Hopkins graduates, using – for the first time – photographs of the fertilised ovum. (Reference Maienschein46) The Johns Hopkins students who gave their colleague a name associated with sexual fertilisation were employing the same tactic of demeaning a woman in coded scientific language as the Edinburgh students who shouted rima pudenda at Sophia Jex-Blake.

Although the proportion of women in medical schools has increased, students and young doctors continue to report the practice of clinicians engaging in generalised sexualised banter. This is often accepted by young female doctors as just part of the general ambience. Their role is to not pay attention, to let it fall off their backs. In a study of sexual harassment in five US medical schools, Wear, Aultman and Borges (Reference Wear, Aultman and Borges47) report one student commenting on a degrading comment made by male doctors in an obstetrics and gynaecology term. They had expressed collective shock that a patient they thought was too fat and unattractive to be sexually active was pregnant. As it was ‘not in reference to me’ the student was unbothered by the comment. In becoming a woman doctor, the young woman learns to step outside her body while at the same time recognising that within the profession her body is considered degradable and shameful.

The situation is even more challenging for those existing in a matrix of oppression, as explored by Patricia Hill Collins in her treatment of intersectionality. (Reference Collins48) Virginia Alexander, a black medical student in the 1920s, repeatedly complained of a professor who pointedly told ‘every discreditable, dirty and insulting story he could think of’ about black people in classes attended by black women students. When the women complained to the Dean, they were advised to rise above their race (Reference Du Bois49, p. 33) – in fact, this was an injunction to set aside their race and their gender. In the USA, reports of widespread harassment in medicine directed towards women of colour, compared to men, women, and men of colour, were extensively documented in the National Academies of Science Education and Medicine consensus study. (50) The same intersectional disadvantage is also reported by queer women. In a large survey of US surgical residents, LGBTQI+ women were found to have higher rates of sexual harassment than non-LGBTI+ men and women, and LGBTI+ men. (Reference Heiderscheit, Schlick, Ellis, Cheung, Irizarry, Amortegui, Eng, Sosa, Hoyt, Buyske, Nasca, Bilimoria and Hu51)

In highly patriarchal cultures, becoming a woman doctor involves navigating public spaces where sexual harassment is normalised – as in the case of ‘eve teasing’ in South Asia. In order to practise, women doctors in Pakistan need to find ways to commute safely from home to work sites independently. Failure to find ways to navigate the sexualised public space can result in women giving up their careers. In these circumstances, learning to drive offers a way to create a safe space around their bodies in the public space between home and work. (Reference Masood52) The risk of harassment does not stop at the door of the hospital, however. In an article on everyday harassment of female workers within Pakistan’s hospitals, a doctor in her early thirties described how she had lost her perspective on it as abnormal:

The doctors recount running a gauntlet of staff casually leering as they walk in the open spaces between wards in hospitals, targets of sexualised innuendo while trying to keep themselves aloof through the portrayal of a professional stoic demeanour: a contemporary echo of the thirty-nine women in the jeering episode of 1869.

Conclusions: Gender and Sexual Risk

Masculine and medical hegemonies arise from two systems of structuring of power relations which mutually reinforce one another. The problem for women doctors under masculine medical hegemony is the one-two punch of being obliged to be complicit within the hegemony, while remaining vulnerable to personal sexualisation within it. As a result, women doctors face a heightened risk of sexual harassment and abuse in the workplace.

Masculine medical hegemony is unavoidably sexually inflected. If stepping outside their bodies is a marker of the woman doctor’s professional self, they may become inured to language and practices which in another workplace might be recognised as subtle grooming, as in the following example of a senior surgeon in a US hospital who habitually made explicit sexual remarks to medical students:

The senior doctor in question was later formally accused of sexual harassment. Behind every doctor who engages in public sexual discomfiture and private sexual harassment are a lot of people who have been complicit in supporting masculine hegemony – from the people who repeatedly employ him as a lecturer knowing his language, to the other staff who make light of his behaviour, to the people who advise female students not to be alone with him.

When a doctor is harassed or assaulted by a fellow doctor, she may be taken by surprise. No matter how much she has blown off a comment, she finds that she is in fact reducible to a sexual object by one or many doctors. Some may freeze in the moment of assault, particularly if it occurs in the presence of patients. Some may not have discerned grooming behaviours, especially if they are couched around acts of professional benevolence, such as offering extra training or special opportunities. Most will experience a fundamental loss of faith in the professional contract they believed they held with their peers. Many may lose confidence in their performance of gender. ‘What message was I sending?’ a woman doctor asks, a question which individuates hegemony and locates the blame in the wrong place.

Medical hegemony and masculine hegemony are not inevitable. The realisation and countering of masculine hegemony requires conscious focus and awareness of its existence and the ways in which it is propagated (Reference Connell54). To use Frye’s metaphor, the bird should study its cage. It is possible that the realisation that sexual risk is endemic in its profession may be a realigning moment for masculine hegemony in medicine. It is possible that alternative masculinities and femininities may emerge in medicine and be imbricated through its authority structures. What would a medicine that is not structured around masculine hegemony look like? We might imagine that it would have a more flexible, more open approach to career development, and that women and men would be equally represented across subdisciplines and in positions of authority. We could imagine that this would mean more openness to people who faced intersecting marginalised positions, including people from minority ethnic positions and people who did not come from backgrounds of wealth and privilege.

At the same time, medical hegemony may be facing its own reckoning, with the devolution of medical knowledge and technological capability to patients afforded by technology. If a person can manage their own medical needs with little medical oversight, then there may be a decreasing role for the professional hegemony. We might imagine a less hegemonic medicine would be evidenced in a more patient-led medical practice, sharing more of its practices with other disciplines. But we should be wary. The profession is likely to resist any moves that may be interpreted as counterhegemonic. Medicine is a global project, and masculine medical hegemonies are emerging in many post-colonial contexts. Somewhere, everywhere, a doctor is learning to perform their gender. Somewhere, everywhere, a person is becoming a woman doctor. They have just begun the project of negotiating medical masculinities.

Introduction

In this chapter we consider the role of men in relation to the sexual abuse of doctors by doctors internationally. Any observations should consider gender at every level, whether it be victim, bystander, perpetrator, supervisor, employer, case manager or leads in regulatory and legal organisations. We also specifically expand on the potential for change which could be afforded by the systematic engagement of male leaders as allies and mentors. We review the evidence for effectiveness of bystander and male allyship programmes, (1) considering potential impacts of its widespread adoption in health services. We consider facilitators and barriers to men taking up the role of ally in prevention of gender-based harassment or violence.

To understand the implications of gender and the role of men, we will provide an overview of what is known in relation to the incidence of sexual abuse in medicine, and the demographics of both perpetrators and victims. We make reference to the impacts of sexual abuse, as they must always be considered when proposing strategies to assist victims or prevent abuse.

Sexual abuse is defined as unwanted sexual attention, which can range from persistent sexualised comments to requesting sexual favours – sometimes in relation to career progression – and coercion through to violent assault. (Reference Lim and Cortina2; Reference Burke3) The #metoo (Reference Burke3) campaign has given voice to victims, including within medicine, (Reference Bhattacharyya4) leading to an increased understanding of the prevalence in a range of professions. This has accelerated research into sexual harassment and abuse in medicine. (Reference Ceppa, Dolejs, Boden, Phelan, Yost, Donington, Naunheim and Blackmon5; Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi6)

Sexual abuse has significant negative impacts on physical and mental health (Reference Stasenko, Tarney, Veith, Seier, Casablanca and Brown7) as well as confidence at work. Even the mildest form of abuse (persistent verbal sexualised attention) can impair career progression, health and feelings of self-worth. (Reference Stasenko, Tarney, Veith, Seier, Casablanca and Brown7) Perceptions of negative reactions from colleagues, fear due to power differentials between perpetrator and victim, and concerns that confidential access to supportive systems may be lacking can impede disclosure of abuse. Therefore, it is incumbent upon organisations and systems such as health care employers, postgraduate medical education bodies and regulators to listen, offer a safe space to disclose and then act effectively.

Gender and Victims of Sexual Abuse

Men as victims of sexual abuse may be targeted by same sex or opposite sex perpetrators, and it is possible that under reporting is even more common in this group than with female victims and is worthy of further research. The general male population has been reported in the US to have had a one-in-six chance of a past history of sexual abuse, (Reference too8) and disclosure is particularly difficult for men, with increased concern that they will not be believed. In our discussions to date, it is clear that the culture of medicine needs to become more open and that victims of sexual abuse of all types need to be made to feel safer in disclosing, as well as more confident that appropriate supportive actions will occur. Furthermore, studies of US medical clinicians responsible themselves for investigation of child sexual abuse disclose a 13% past history of personal sexual abuse if they are male, and 20% if they are female. (Reference Nuttall and Jackson9) There may be many reasons for such high incidence among clinicians with this specific remit; one could postulate that this may be to promote self-healing by taking the role no longer as victim but as one with power to heal and help others. More broadly, a motivation may be to fundamentally change systems to increase effectiveness and address current organisational deficits.

Overall, however, victims of sexual abuse in society and within medicine are far more likely to be women or have other protective characteristics. We consider a range of international systematic reviews in relation to medical sexual abuse to understand who the victims may be. Halim and Riding’s (Reference Halim and Riding10) review of surgical specialties found that of 970 nurses in one included study, (Reference Park, Cho and Hong11) 25.2% reported sexual harassment, and that of medical students from fourteen US medical schools, (Reference Nora, McLaughlin, Fosson, Stratton, Murphy-Spencer, Fincher, German, Seiden and Witzke12) 83% of female respondents had suffered sexual discrimination or harassment, while 41% of male medical students also had this experience. Effects on this group of wider bullying and harassment included stress, poor work satisfaction, depression, and suicidal ideation. Victims of abusive experiences avoid those specialities where it occurred, and the incidence is higher in women, ethnic minority groups and LGBT students. Fnais et al.’s (Reference Fnais, Soobiah, Chen, Lillie, Perrier, Tashkhandi, Straus, Mamdani, Al-Omran and Tricco13) international systematic review revealed statistically significant increased harassment of women compared to men. Sexual harassment was the most common form of harassment in medicine in twelve of their studies, while in the remaining four studies the difference in incidence of different types of harassment and discrimination (e.g. verbal, physical, sexual etc) did not reach statistical significance. More broadly, risk factors identified by Bhaji and Altomare (Reference Bahji and Altomare14) for all forms of discrimination and harassment included training status, gender, ethnicity, culture, sexual orientation and language spoken, in that order.

Gender and Role in Managing Sexual Abuse

The role of men as investigating officers in cases of sexual abuse in the UK has been studied by Chowdhury-Hawkins et al., (Reference Chowdhury-Hawkins, McLean, Winterholler and Welch15) who found that 76.8% of all victims (male and female) preferred a female officer to provide care in the sexual assault referral centres. Clearly this is likely to also have relevance for choice of confidante or case manager within medicine for victims. In parts of the profession where there remains gender disparity, a choice of case manager including gender choice is likely to be imperative. This would be important for organisations to consider when determining their policies.

Gender and Perpetrators of Sexual Abuse

If we are to progress the prevention and early detection of sexual abuse in the medical workplace, then we also need a much greater understanding of the role of men as perpetrators in 88% of cases (Reference Searle, Rice, McConnell and Dawson16) than simply knowledge of the statistics. This can be gained by considering the mindsets of men who are perpetrators of sexual abuse, including psychological factors that may predispose to this. (Reference Ceppa, Dolejs, Boden, Phelan, Yost, Donington, Naunheim and Blackmon5, Reference Launer17) Use of such knowledge of personal as well as organisational risks may allow development of effective educational and interventional programmes.

Who, therefore, are the perpetrators of sexual abuse in medicine, and how do they interact with victims? In her 2019 UK report, Searle et al. (Reference Park, Cho and Hong16) considers the 275 cases of a range of clinical health care professionals where sexual misconduct with either colleagues or patients was reported to the health care regulators. Eighty-eight per cent of the perpetrators were male. Of those in the study who were doctors, 100% of the perpetrators were male. Colleagues were the target in 32% of cases, and in 54% the location of abuse was the workplace.

There are a range of theories to explain why sexual abuse in the workplace may occur, including the four factor theory, (Reference O’Hare and O’Donohue18) which postulates that the elements which allow such abuse include a perpetrator with motivation which may relate to power or sexual attraction, who then also overcomes internal moral and external organisational restraints, as well as the resistance of the victim. Some scales such as the ‘likelihood to sexually harass’ (Reference Alderden and Ullman19) may be utilised in studies which profile the psychology of perpetrators.

The UK literature offers evidence that increased prevalence of sexual abuse within medicine occurs where predisposing vulnerabilities of the victim exist, (Reference Park, Cho and Hong11) whether the victim is a doctor or a patient. Of all patient groups, increased risk is found for mental health patients. The literature describes a pre-phase of grooming, (Reference King and Greening20) and during that time power imbalance is a predisposing factor to abuse. The power disparity is commonly in seniority and in gender. The professional status most commonly associated with being a perpetrator is the most senior clinician, such as a consultant. (Reference Ceppa, Dolejs, Boden, Phelan, Yost, Donington, Naunheim and Blackmon5) Sadly, in educational terms often the allocated workplace role of perpetrator is that of supervisor or mentor. Hence the relationship commences with assumed trust. This may delay the recognition of the victim regarding the intent of the perpetrator in the grooming phase. The position of relative power of the perpetrator also places the victim in a more difficult position in trying to prevent or halt the abuse. We therefore know that there is significantly more likelihood that perpetrators of sexual abuse in medicine are male, but also that there is significant interplay with other elements that create power disparity, such as seniority at work or holding a supervisory status. Any interventions to detect, prevent or respond to such abuse therefore need to be targeted appropriately considering such demographics.

Men as Advocates and Roles in Systems Change

We now move to the ways in which men can assist at an individual and system level to prevent abuse, assist workplace culture change, and sympathetically and effectively manage individual cases. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi6) The inclusion of the male voice as a proponent for justice and prevention is also paramount if we are to progress within medicine, as in other professional groups. (Reference Fabiano, Perkins, Berkowitz, Linkenbach and Stark21) Active listening when a peer, a supervisee, or a student shows signs of distress and begins to disclose is paramount. There is no doubt that this can be very uncomfortable listening, and if the disclosure reveals the perpetrator to be male, uncomfortable feelings can be generated in the mind of the (male) listener, who may often be a longstanding colleague of the perpetrator. Being able to sit with the discomfort, identify at a human level, and offer support but without bias will free the colleague up to take supportive and decisive action. Certainly, evidence has shown the assumption that women will be more sympathetic (Reference Alderden and Ullman19) in the legal investigation of sexual abuse or will show less bias has in some settings proved unfounded. (Reference King and Greening20) Therefore, although the likelihood of being a perpetrator or a victim of sexual abuse is clearly influenced by gender, the solutions, it seems, are not necessarily so.

If we are to develop the culture within medicine to one where abuse of any kind is rarer, and where doctors, especially juniors, feel safer, we need both men and women to fully engage with the development of self-regulatory systems, and act as positive role models. The idea of the ‘not so innocent bystander’ (Reference Flynn22) takes the notion of positive role model further. Searle et al. (Reference Ceppa, Dolejs, Boden, Phelan, Yost, Donington, Naunheim and Blackmon16) describe the deterioration from incivility in the workplace to abuse. Therefore, if bystanders act on incivility at an early stage, the assumption is that culture would not degenerate to the level of sexual abuse. It may be more likely that a male potential perpetrator of sexual abuse or harassment would share ideas or sexual comments about the potential victim(s) with another male colleague than a female one, which again provides an ideal opportunity for men to champion the cause of reducing incidents of abuse by acting at the first point of hearing these warning signs. In terms of systems change, senior leaders (who may or may not be men) need to be willing to call out and report suspected abuse within their organisations. Research and case studies have shown a reluctance of victims to report, but also some inertia on the part of medical employing organisations, educational institutions, regulators and legal systems. (Reference Halim and Riding10)

This leads us to consider whether male advocacy is effective in preventing sexual abuse either in society or the workplace, and whether systematised training programmes have a place in creating such allyship. Facilitators to becoming allies are hearing a disclosure of sexual abuse, witnessing such behaviours or narrative in the workplace and having a desire to promote social justice. (Reference Tolman, Casey, Allen, Carlson, Leek and Storer23) Potential barriers can include adverse underlying attitudes towards gender-based issues, a fear of loss of privilege in the workplace or indeed fear of being a male mentor to women, which is described as a minority backlash to the #metoo movement. Feelings of vulnerability or reluctance that a minority of men express when stepping into a one-to-one mentoring role of a woman are explored through the lens of change theories by Soklaridis et al. (Reference Soklaridis, Zahn, Kuper, Gillis, Taylor and Whitehead24) Clearly, if we are to progress with equal opportunities for career progression, as well as to assist in organisational change to prevent sexual harassment, such fears need to be addressed. Even more importantly, the majority of men who do not express such fears may not understand their potential value as mentors and advocates, and this must also be addressed for maximum benefit. This potential positive impact of men is greatest in systems where men hold the majority of senior leadership positions and are therefore in a position to effect transformational change. (Reference Wood25)

There are a range of ways in which society (26) and organisations in particular (Reference Johnson and Smith27) can effectively engage in gender inclusion programmes, with 96% of organisations involved in such programmes showing benefit, against 30% of organisations improving in relation to perceived employee gender inclusion where there is no deliberate policy of directly engaging men in such programmes.

The benefits in terms of reach and potential influence of engaging men with prevention programmes are clear, especially in male-dominated professions or departments. Reviews and recently published work advise some caution in relation to methods used, especially if male allies are unaware of their inherent privilege and if schemes lack accountability to feminist principles. (Reference Pease28) Strategies to encourage effective and supportive accountability include awareness of such privilege, listening, developing trust and alliances, as well as holding other men to account. (29) One of the threads in this book is that of power, and it is important to refer directly to power in this chapter on the roles of men. The themes include abuse by those in positions of power, loss of power of victims through abuse, the inability to effect systems change without engaging those in power, and any unintended risks or adverse dynamics that sometimes ensue when groups are given power in this arena. These themes can speak to gender power imbalance, but also the imbalance of victims working within large, seemingly unresponsive or unbelieving health service organisations. (Reference Halim and Riding10) Other power dynamics such as age, role status, and sometimes ethnicity or predisposing vulnerabilities are also shown to come into play. (Reference Bahji and Altomare30)

Broadly in society two main types of engagement with groups of men to prevent violence against women occur: social movements and public health programmes. (Reference Messner, Greenberg and Peretz31) Public health programmes can involve volunteers or paid roles as champions and allies. Both approaches could be applicable within the health sector, potentially within staff groups at all levels of seniority.

Social movements can be exceptionally effective in raising awareness, encouraging disclosure and generating empathy to the cause of prevention of sexual abuse in the workplace, as seen by the #metoo (Reference Burke32) and ‘time’s up’ (33) movements. High levels of publicity and the engagement of high-profile figures willing to disclose abuse have brought the issue of sexual violence and discrimination at work into sharp focus. Social movements specifically to engage men in gender equality issues worldwide include the #heforshe movement, (1) which aims to achieve gender parity both at home and work. These same principles are also imperative within medicine, (Reference Fnais, Soobiah, Chen, Lillie, Perrier, Tashkhandi, Straus, Mamdani, Al-Omran and Tricco13) and especially male-dominated specialties such as surgery. Wood describes the negative impact on the specialty of failing to draw from the full pool of talent across the gender spectrum, as well as the moral imperative of tackling gender bias, discrimination and sexual harassment using the #heforshe link to signal allyship and increase publicity to this cause within surgery. (Reference Wood25)

Public health programmes within medicine have occurred in some areas to assist in the prevention of harassment at work, and also examples exist in other sectors or populations from which we could learn, including cognitive behavioural models aiming to develop strategies for change in order to prevent violence against women in the general population. (Reference Crooks, Goodall, Hughes, Jaffe and Baker34) Separately, a systematic review was undertaken of 706 American and Canadian studies on the effectiveness of bystander interventions to prevent sexual violence in a range of populations. (Reference Mujal, Taylor, Fry, Gochez-Kerr and Weaver35) Actions taken in these programmes included presentations, discussions and active learning exercises. Thirty-two per cent of the studies included in the systematic review had pre- and post-intervention assessments of effectiveness. Of these, the greatest evidence for benefit was in the ‘Bring in the bystander’ and the men’s programmes, which would again support the interest we show in developing the role of men as part of the solution.

Beyond this, we look to evidence for the effectiveness of male allyship programmes, and strategies underpinning these in workplaces generally, (Reference Madsen, Townsend and Scribner36) as evidence from studies in the medical workplace are rare. Madsen, Townsend and Scribner (Reference Madsen, Townsend and Scribner36) describe strategies of forming developmental relationships, HR processes, leadership development, treating women as equals and challenging sexist behaviour. There is therefore an early evidence base around interventions, but little so far within the medical profession.

Conclusion

In summary, it is clear that sexual abuse in medicine is not rare, has severe negative impacts on individuals and hence reduces the ability of the medical profession to thrive. In order to achieve the types of open, supportive organisations in which we and our most junior colleagues can have confidence we need to act. Being open and transparent about the risks of abuse and sexual harassment occurring in the medical workplace is step one in prevention. However, this chapter suggests we can go much further and instigate gender awareness and male allyship programmes as well as ensuring all health service organisations have well-formed and responsive systems to act effectively in prevention and management of sexual abuse. The literature also tells us we need far more research on the effectiveness and impacts of such programmes. Therefore, we recommend a plan of action and research on the ability to prevent and effectively act on sexual abuse in the medical profession.

Acknowledgements

Thank you to Katie Nicholas, Knowledge Specialist, Knowledge Management Team, Health Education England, for assistance with the literature review underpinning this chapter.

Introduction

One of the unexpectedly pernicious challenges the authors of this chapter have encountered when presenting our research on workplace sexual harassment has been deciding how to ‘tell the story’ so that our audiences can hear and acknowledge the problem. We have presented our work in a range of contexts, from private consultations to conference presentations, talking with intelligent, empathic, passionate people who care deeply about making the world a better place. Nevertheless, it has been our experience that individuals can struggle to accept that sexual harassment can occur in the cold, hard light of day in a busy teaching hospital.

There is a wealth of evidence that doctors do sexually harass other doctors in a variety of working relationships and contexts, at a range of career stages, across diverse specialties and roles, and even in the presence of formal interventions and prohibitions aiming to eradicate the problem. (1–6) Yet it has been our experience that this evidence is often discounted, because of the cognitive dissonance and rape myths surrounding the sexual harassment and abuse. ‘My story is not the right story’ said one of the participants in our original study, (Reference Stone, Phillips and Douglas7) ‘I mean these things happen in a hospital. It’s not a dark alley.’

Medical audiences have normative expectations about the sequence a narrative of empirical inquiry should follow, the questions that ‘should’ be asked first in any research story. They expect presentations and publications to start with the question: ‘based on prevalence, is this problem a real and serious one?’ This is the first question that is asked by ethics committees when assessing a research proposal, deciding if the project has merit. If we were to follow this expected narrative arc, we should present prevalence statistics first, demonstrating the significance of sexual harassment in medicine, leading the audience to engage in the problem. However, in this case, we find that prevalence statistics are marred by more fundamental questions around what sexual harassment really is. Is it an extension of sex discrimination, or similar to physical assault? Is it only about women? Is it a problem of safety, or just a personal problem transplanted into the workplace? Health professionals have been taught to critically appraise data, and can and do disengage from a discussion if they feel the data is flawed in the way it is collected, measured or applied. In this case, we have to work with competing narratives that are embedded in policies and processes, and differ significantly. Different people in different contexts hold strong views about what sexual harassment is, and this shapes their understanding of how to measure and address it. Because the beliefs around sexual harassment in medicine are so strong, we have found it necessary to understand and address these hidden beliefs using different narrative structures. In doing so, we reference some of the fundamental differences in the way sexual harassment has been understood in the past, and how it has changed over time.

What Are Narratives and Why Are they Important in this Field?

Narratives offer conceptual frameworks structuring the way people understand and approach phenomena. (Reference Alcoff8–Reference Scott10) It can be difficult to understand which narratives we need to address (and how one might attempt to do so) in a given context, particularly where some narratives have become so normalised or ingrained that people adopt specific positions unconsciously. However, language can inform our understanding of positionality. The particular words a person chooses to utilise when talking about workplace sexual harassment can give us some insight into what kinds of conceptual frameworks and positions they are bringing to bear on the topic. As a social process, the meaning or significance of language can also be context-sensitive: people may use the same word or phrase in different ways depending on the narratives and positions they use to craft their messages. (Reference Scott10)

In a similar way, there are a range of ideas and priorities shaping potential ‘solutions’ for the problem of doctors sexually harming other doctors. This book presents a diverse but non-comprehensive collection of narratives brought to bear on this issue from a variety of positions. The editors have consciously preserved many variations between chapters: the book does not adopt a unified position on the language used to operationalise ‘workplace sexual harassment’; the theoretical or bureaucratic frameworks that offer the most complete understanding of the phenomenon; why workplace sexual harassment exists, how it persists, and what to do about it. This chapter will further muddy the waters by exploring historical perspectives in a non-linear fashion, teasing out conceptualisations of the term ‘workplace sexual harassment’ in context to interrogate how this term developed, what kinds of problems and frameworks it has been used to describe, and how this term has been used to agitate for social change.

We wrote this chapter to equip readers for the road ahead – through the book, and more broadly. This chapter situates the book’s non-consensus positions within the ebb and flow of broader discourses on workplace sexual harassment, laying out the unique positions, goals, resources, and approaches embedded in the contexts in which these frameworks developed. In doing so, we are attempting to sensitise readers to the notion of ‘workplace sexual harassment’ as an ongoing dialogic negotiation within and between social groups and across society, to equip them with tools to attend to the narratives and positions being adopted in a given context, to critically consider their significance and meaning, and to tailor the narratives and positions they use in context to communicate effectively to a broad audience. We believe this narrative understanding is essential if cultural change is to be achieved.

How Is ‘Workplace Sexual Harassment’ Understood around the World

It is likely that sexual harassment has been experienced throughout history, but the term itself, and the ideas behind it, are relatively recent. There have been a number of international commitments to the elimination of workplace sexual harassment over the last sixty years. In 1992, the UN formed a committee to implement the Convention to Eliminate All Forms of Discrimination Against Women (CEDAW), stating that ‘equality in employment can be seriously impaired when women are subjected to gender-specific violence, such as sexual harassment in the workplace’. This committee called for ‘effective legal measures, including penal sanctions, civil remedies and compensatory provisions to protect women against all kinds of violence, including … sexual assault and sexual harassment in the workplace’. (12) More recently, the International Labour Organization (Reference Carlson13) included a clause that required countries to ensure ‘protection against victimization of or retaliation against complainants, victims, witnesses and whistle-blowers’. (Reference Heymann, Moreno, Raub and Sprague14)

There have also been regional approaches to addressing sexual harassment in employment. The European Union Directive on the equal treatment of men and women at work explicitly defined sexual and sex-based harassment as discrimination, urging employers to take preventive measures against it. (Reference Masselot15) In Africa, the 2003 Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa – commonly known as the ‘Maputo Protocol’, calls for governments to increase transparency around recruitment, and address sexual harassment. (Reference Budoo-Scholtz, Lasseko-Phooko, Durojaye, Nabaneh and Adebanjo16)

Each of the charters adopts different definitions and conceptualisations of sexual harassment. This framing of sexual harassment may invoke any of several core ideas, which can lead to quite different understandings of the problem. For example, some differentiate harassing behaviours into types. This often includes distinguishing between ‘quid pro quo’ situations, where the powerful demand sexual favours as ‘payment’ for employment benefits, and ‘hostile environment sexism’, in which sexual harassment can be more subtle or diffuse. Sexual harassment can also be seen as a form of gender discrimination and an assertion of unequal power with the workplace (Reference McCann17). Another approach is to frame workplace sexual harassment as a problem of occupational health and safety. Risk mitigation approaches to sexual harassment are common internationally, (Reference McCann17) drawing on narratives commonly used in industrial settings. The concept of psychological safety (Reference Newman, Donohue and Eva18) in the workplace is gaining momentum, basing its approach on the work of industries like manufacturing, farming and health care and their efforts to reduce physical risks. For example, the NHS in the UK has used this framing to develop its sexual safety charter for patients and staff. (Reference Rimmer19) This approach has led to some workplaces discussing ‘sexual safety’ as a concept (Reference Rimmer20) or incorporating sexual harassment into a safety framework, either explicitly or by implicitly conceptualising sexual harassment to align with prohibitions against other forms of misconduct (Reference McCann17). Some legislative frameworks set out a ‘positive duty to report’. The positive duty is a legal obligation on organisations and businesses to take proactive and meaningful action to prevent relevant unlawful conduct from occurring in the workplace or in connection to work. (21) This positive duty is embedded in national legislation for more than 50% of high-income countries, and less than 30% of lower income countries. (Reference Heymann, Moreno, Raub and Sprague14)

The following part of the chapter will outline an ‘origin story’ of the term ‘workplace sexual harassment’ that describes key developments in theorising sexual harassment in relation to power and discrimination. This part also contextualises these frameworks by highlighting their roots in feminist theorising, grassroots activism, and advocacy for legal changes in the US of the 1970. (Reference McCann17; Reference Backhouse22–Reference Baker23).

Sexual Harassment as an Emerging Field of Interest and Action

In the US, activist movements of the 1960s precipitated significant shifts in the sociocultural, politico-legal, and economic structures of society. (Reference Siegel, MacKinnon and Siegel11; Reference Borstelmann24) By the mid-1970s, the idea of a ‘working woman’ had changed and diversified. There were shifts in women’s employment conditions, the diversity of women who were able to work, the roles they played and the workplaces they occupied. Shifts in women’s work were accompanied by discursive changes in what it meant to be a working woman and broader challenges to binary and hierarchical gender roles and norms. Meanwhile, feminist theorising and organising began to focus increasingly on new theories and methods of organising around sexual violence and sexualised economic coercion. (Reference Backhouse22; Reference Borstelmann24)

In this environment of social change, there was increasing community and legal pressure on institutions to respond to injustice. The ‘origins’ of the term ‘sexual harassment’ in grassroots advocacy have been attributed to Lin Farley, Susan Meyer, and Karen Sauvigné’s work in Cornell University’s working women’s programme, with significant theorising occurring through their independent consciousness-raising efforts. (Reference Siegel, MacKinnon and Siegel11; Reference Backhouse22; Reference Baker23; Reference Beiner, Brake, Chamallas and Williams25)

Responding to Sexual Harassment: A Complex Problem with Multiple Intersecting ‘Solutions’

This chapter highlights that the concept of ‘workplace sexual harassment’ is a moving target. Legal, social science, and feminist activist spheres offer evolving and often-diverging approaches to theorising and taking action on sexual harassment, and the sociocultural narratives that make meaning from workplace sexual harassment are constantly negotiated and contested. If we want to develop effective interventions – if we want to make a change in the world, to address sexual harassment – we have to develop some kind of understanding of the problem that lies in front of us. This tends to include asking questions such as:

• How do you decide that an incident qualifies as ‘sexual harassment’?

• What causes sexual harassment? What are the functions or purposes of the phenomenon? What motivates discrete incidents or behaviours?

• Should sexual harassment be seen as a problem between individuals, as a problem within a collective or group, as a problem within society, or a mix of all three?

• Who are the actors with the relevant power and scope to address the specified cause, at the specified level, to reduce the specified behaviours?

• What, exactly, is the part of sexual harassment that makes it ‘wrong’?

Approaches to answering these questions can vary between jurisdictions, and between workplaces. These differences don’t necessarily signify an ‘incorrect’ approach. Sexual harassment is a complex problem, and it’s not ‘wrong’ to try to understand and respond to the problem from multiple angles. It is, however, important to understand that any proposed theoretical framework, proposed solutions or interventions, and even narratives framing and defining the ‘problem’ are specific ways of approaching the issue: they highlight and target specific aspects of the problem in specific ways.

For example, a campaign to promote sympathetic narratives about women responds to an understanding of workplace sexual harassment as being caused by culturally endorsed antipathy towards women. However, a problem of antipathy towards women doesn’t necessarily produce solutions that can also address sexual harassment motivated by or targeting other factors or populations. Not all people who are sexually harassed are women, and some sexual harassment (such as ‘intersectional sexual harassment’) targets marginalised identities or characteristics other than ‘woman’. (Reference Cortina and Areguin33)

Specific and targeted interventions can be effective, but approaches should fit the context. Effective action requires thinking critically about how the problem is being framed. What part of the problem are you being presented with? How does that problematisation ‘match’ certain kinds of solutions over others? What parts of the problem may be more or less effectively addressed through those solutions? It’s important to attend to the specificity of narratives we encounter, to ensure our response is effective.

Newer Grassroots Methods: Hashtag Activism

Social media tagging systems have increasingly been used to mobilise around political goals. ‘Hashtag activisms’ such as #MeToo can perform consciousness-raising functions: they afford socioemotional support structured around sharing lived-experience narratives of marginalisation and oppression, which can then be transmuted to developing a feminist consciousness to understand these experiences as structural rather than personal, which can then motivate action to contribute to social change. (Reference Gash and Harding31; Reference Mendes, Ringrose and Keller42; Reference Gleeson, Turner, Fileborn and Loney-Howes43)

The functions of hashtag activism are inherently shaped by technology. Social media can create a sense of public access to private lives, imbuing it with symbolic and practical significance for consciousness-raising and mobilising around ‘unspeakable’ issues. (Reference Mendes, Ringrose and Keller42; Reference Mendes, Ringrose, Fileborn and Loney-Howes44) Social media technologies can expand the potential reach of a movement beyond a physically located community (Reference Mendes, Ringrose and Keller42; Reference Gleeson, Turner, Fileborn and Loney-Howes43), but factors like tagging systems also allow for increased efficiencies in censorship policies and practices that suppress speech and restrict reach. (45)

Online platforms also necessitate new priorities and strategies for collectives to protect members and promote the integrity, longevity, and political efficacy of the movement as a whole. (Reference Mendes, Ringrose and Keller42; Reference Mendes, Ringrose, Fileborn and Loney-Howes44) The ‘digital labour’ of moderating content is essential, but the necessity and real costs of moderation often go unrecognised. Identified persons adopt responsibility to promote a supportive group environment, acting as socioemotional ‘buffers’ that enable group members to be vulnerable, to enable mutual support and bonding and thereby promote group efficacy and longevity. This can be labour intensive and emotionally draining, and can expose moderators to vicarious trauma and targeted abuse; furthermore, online activist environments often lack structured support or exit strategies used in other collective action environments to protect against burnout. It can create further vulnerability to moderator burnout and undermines group capacity to ‘stay the distance’. (Reference Mendes, Ringrose and Keller42; Reference Gleeson46)

Exposing the soul-baring processes of private disclosures to a public sphere also means the public can bring to that disclosure their own interpretive frameworks and expectations. (Reference Gleeson, Turner, Fileborn and Loney-Howes43) Even when groups are not being actively targeted for online abuse, they may experience challenges in managing internal supportive group dynamics alongside the social dynamics of their outward-facing advocacy efforts. For example, best practice ‘private’ responses to disclosures within consciousness-raising groups are to non-judgmentally receive and believe the disclosure, which fosters a trauma-supportive environment that performs therapeutic and theorising functions. (Reference Kelland30)

However, public allegations have a different normalised narrative trajectory: public disclosure is interpreted through a pseudo-legalistic paradigm of ‘verifying claims’. (Reference Gash and Harding31) Groups or disclosures made through social media can thus become the site of tensions between ‘publics’ of the medium and the more ‘private’ group needs, norms, and expectations around disclosure. (Reference Mendes, Ringrose, Fileborn and Loney-Howes44) This can pose challenges for collective action in which hashtag activism plays a dual role as simultaneously offering support and developing public awareness.

Thus, hashtag activism can involve negotiating layered complexities in social dynamics, both for members of campaigns and for ‘outsiders’ encountering and interacting with it. It can be as specific and targeted as any other intervention or strategy, and engaging with or responding to these efforts requires consideration for the most appropriate response in the context in which disclosures – and broader movements – are being brought to light.

Positionality and Competing Narratives

The stories we have told in this chapter include a narrative about the term ‘workplace sexual harassment’. The position of this story as an ‘origin story’ of the term ‘workplace sexual harassment’ (Reference Siegel, MacKinnon and Siegel11; Reference Backhouse22) shouldn’t be understood as the ‘first’ kind of efforts to address workplace sexual harassment, nor as the genesis of the concept.

What was left in or out of this ‘origin story’ are narrative choices, and they serve a purpose. (Reference Bacchi and Jose38) We have highlighted individual ‘trailblazers’ to ‘lead’ the movement, included the story beats about one individual’s lived experience catalysing broader action, situated the story in spaces accessible to institutionally empowered actors, and described a narrative trajectory of linear progress: the law didn’t work well, people worked hard to change that, and now it works better. Simply put, it’s an academic hero’s journey.

Some histories of feminist organising emphasise ‘unity through sameness’: a narrative that bonding over shared, similar experiences of injustice and oppression empowered people to work collectively to effect change. This ‘sisterhood’ narrative is critiqued for seeking to strengthen collective voice by subsuming or marginalising ‘divergent’ concerns and points of difference between members of the collective, in favour of ‘focusing on women’s issues’ in ways that reify a particular notion of what a ‘working woman’ is. (Reference Scott10; Reference hooks29; Reference Brown47) In short, the ‘sisterhood’ narrative normalises a specific perspective and implies it to be universal.

Axes of power and domination shape dynamics of oppression in ways that deeply influence social life. However, some of these axes are not necessarily visible or of central concern from certain positions in society.

For example, some contemporary strains of feminist theory on workplace sexual harassment problematised ways that economic relations structured gender and sexual relations. (Reference Siegel, MacKinnon and Siegel11) The dominant, simplified narrative to explain that framework often draws on white, middle-class, heteronormative notions of the home and family: men are ‘breadwinners’ and women are ‘housewives’, and these positions in society confine women’s labour, sexual lives, and social lives to the home, inextricably entangling women’s labour and economic power to their sexual relations in the home and subjugating them relative to men. Work empowers women by liberating them from the home and from economic dependency and subjugation; workplace sexual harassment puts women ‘back in their place’ by reinstating sexual subjugation within women’s working lives. (Reference MacKinnon34)

Brown highlights the specificity of this narrative by exploring the meaning and significance of workplace sexual harassment for Black women. What it means to be a ‘working woman’ differs where intergenerational knowledge and practices for keeping oneself safe in exploitative workplaces were developed through a history of ‘domestic service’ and chattel slavery; theorising workplace sexual harassment as a problem of ‘male dominance’ is a risky strategy for a community that remains vulnerable to racialised harms in the face of enduring narratives that villainise Black men’s sexuality as posing inherent, uncontrollable danger of sexual violence specifically to white women. (Reference Brown47)

Different positions also produce different approaches. For example, some feminists contemporary with WWU drew on their theorising, but had to adapt it to facilitate legal reform in their own countries. (Reference Backhouse22) One contemporary collective, the Alliance Against Sexual Coercion (AASC), was relatively more service-oriented than the WWU (later, the WWUI), in part due to its genesis in rape crisis centres; (Reference Baker23) the AASC, while still publishing prolifically, focused less on legal reform relative to the WWUI, reasoning that the existing legal system (particularly enforcement) reproduced oppressive patterns such that anti-harassment laws would be unlikely to afford justice to ‘a poor, Third World or lesbian woman, particularly if harassed by a “respectable” man’. (Reference Baker23)

Engaging with diverse standpoints, particularly at intersecting axes of marginalisation, can highlight expanses of marginalising and oppressive structures of society and rich, highly situated strategies and scholarship, (Reference Richardson and Taylor48) that may otherwise go un-attended by the movement. It does not make sense to conceptualise all instances of workplace sexual harms as stories of ‘men sexually abusing women’. There are many kinds of power in society, and the stories we tell attend to particular axes of power to make sense of them; the ones we neglect to attend to tend to become invisible. For example, the needs and safety of precarious workers and workers in stigmatised or illegal employment conditions are still rarely centred in discussions of workplace sexual harassment. Understanding workplace sexual harassment through the lens of multiple interacting axes of power offers nuance and flexibility to respond to the conditions of workers experiencing multiple marginalisations. Sexual harassment tends to increase where working conditions are exploitative, where there are dependent aspects of workplace relations that enable coercion, and where rigid hierarchies produce steep power differentials within the workplace. Obviously, these characteristics are common in professions, including law, the military and medicine.

Furthermore, the universalising narrative obscures the ways that differences are mutually constituted or relational, thereby potentially reproducing oppressive and marginalising patterns that silence the voices of people experiencing multiple intersecting forms of marginalisation and oppression. (Reference hooks29; Reference Brown47) In short, perpetuating a single universalising narrative can foreshorten the vision of a movement and inhibit effective responses to complex sociopolitical environments.

In this chapter, we have not discussed many details about the people in the ‘origin story’. The story was stripped of much of the context necessary to understand how specific and situated the definition of ‘workplace sexual harassment’ developed really was. The work of the WWU was informed by the histories, skills, social capital and resources that Farley, Meyer and Sauvigné developed through their activist backgrounds and their academic backgrounds; it was informed by Cornell University’s priorities and initiatives that contextualised the programme, and by the American legal and sociocultural landscape the WWU and Catherine MacKinnon navigated. Another way to frame the origin story is a working women’s organisation, drawing on the ideas, resources and precedents of diverse communities of working women before them, theorised through experiential knowledge generation and engaged actively in dissemination and translation of that knowledge back into community, as well as institutions like law and the academy. (Reference Baker49) Farley’s, Meyer’s, Sauvigné’s, and MacKinnon’s class positions and connections to institutions enable the story to adopt a sense of legitimacy for people with institutional power, but constructing them as figurehead-theorists erases the labour of the workers whose experiential knowledge was fundamental to developing the language of workplace sexual harassment – the labour was inescapably a collective effort. (Reference Baker49)

By laying out a range of ways of thinking about and approaching this ‘origin story’, we are highlighting another kind of contextualisation that shapes the narratives we encounter, beyond broad categories like ‘culture’ and ‘discipline’. We are on a completely different side of the world from many of our contributors; we each may look at the Earth and see different features, and while our views don’t invalidate each other, none of us are necessarily seeing the whole celestial sphere. (Reference Haraway50) Positionality involves reflecting on one’s position, and particularly how that may shape one’s perspective. This is the final layer of context we offer in this chapter: this chapter was written by a white queer person on unceded Kaurna country and, later, unceded Awabakal country. We drew on texts in English accessible as determined by intellectual property agreements between academics, publishers, universities, associations, and international bodies. Our educational background affords us some fluency in academic dialects across a range of social sciences and humanities disciplines, though this too has been shaped by the contexts in which we grew up and entered our learning life. We have chosen, in this chapter, not to explore sexual harassment movements or law across different countries or times. Instead, we offer a specific story as a framing device to highlight the ways that workplace sexual harassment is conceptualised as a form of highly situated and contextually specific problematisation of a social phenomenon.

Medicine and the Role of Power and Agency in the Medical Hierarchy

Collectively, doctors have layers of institutional power: they have academic power to generate ‘legitimate’ knowledge, they have direct and epistemic power over patients’ bodies, and they often have some form of legal power through legislative frameworks. People tend to struggle to understand that doctors can and do experience sexual harassment at work: if sexual harassment is ‘about’ power and hierarchy, and if doctors have power, it logically follows that doctors must perpetrate sexual harassment, but can’t be vulnerable to it. When confronted with a case of sexual harassment between doctors, they may offer alternative narratives to reconcile the dissonance: perhaps the ‘victim’ can be seen as flawed or weak or complicit, and therefore not worthy of being seen as a ‘doctor survivor’. This social narrative is pervasive and challenging to navigate when trying to develop momentum to address sexual harassment in medicine.

The realities do not fit this social narrative. Power is not unidimensional and concrete: empowerment in one way or one context doesn’t protect people from disempowerment or vulnerability in other contexts or other ways. The structures constituting medical hierarchies are not ahistoric, immobile, and quarantined from all other social hierarchies and discourses.

Power is better understood as a social dynamic than a category. Doctors can be disempowered in their workplaces while simultaneously being empowered relative to others in their workplaces. As discussed in this chapter, social realities are dynamic and contested. Analysing sexual harassment requires accommodating more than one axis of power, and may require accommodating power dynamics unique to a particular context. This could include considering the rigidity of hierarchies within the medical profession or within specific kinds of workplaces like hospitals; it could include considering the ‘invisibilising’ effects of enculturating an expectation of ignoring or suppressing one’s embodied experiences in the course of work; it could include attending to working conditions that create dependent dynamics such as rotations or working visas.

Power dynamics could also include intersecting marginalisations on broader social hierarchies. How does a doctor with disabilities navigate work-based pressures to ignore or suppress embodied experience, particularly in inaccessible workplaces? How do International Medical Graduates experiencing racialized violence in isolated rotations manage tensions in their working relationships when their external avenues are constrained? (Reference Pascoe4) Other forms of positionality that aren’t necessarily axes of marginalisation may also be important to account for. For example, doctors can experience profoundly different realities of work than other workers even in the same workplace, and if the positions of doctors are different from those of nurses or administrators or janitorial staff, it may be helpful to tease out what those positions mean in order to anticipate and account for differences in the ways a given strategy or approach may affect different workers.

Balancing Consensus and Complexity: The Importance of a Narrative ‘Toolkit’

There is clearly a lack of consensus around what sexual harassment is, and how it should be addressed in the medical workplace. We have discovered in our research that although there may be some consensus in the policies around sexual harassment, discussions rapidly reveal that people using those policies have different conceptualisations around what sexual harassment actually is. We are often questioned about our definitions of sexual harassment, and the language in those questions indicates that there are different narratives at play. For instance, some will focus on discrimination in the workplace, questioning whether women in the workplace are as vulnerable as we suggest. Others will debate the ‘edges’ of the narrative, questioning whether an act can be considered harassment if there is no assault. In doing so, they often talk about young doctors being ‘over-sensitive’ or ‘insufficiently resilient’.

These arguments are based on three narratives that have been foundational for much work on sexual harassment over the years. Sexual harassment can be seen as an extension of discrimination, an extension of physical assault, and/or an extension of occupational harms. Because these narratives are so powerful, it is impossible to offer a universal consensus statement on why sexual harassment persists, and how it should be managed. This chapter offers narrative tools to critically engage with discourses and positionality, which can be crucial components of effective and strategic communication and advocacy.

When reading this book, it may be helpful to consider what narratives are dominant in the reader’s context. There has been a deliberate attempt by the authors and editors to highlight how sexual harassment is framed, understood and managed in different contexts, and it may be helpful for the reader to consider how these contexts shape the way sexual harassment is understood. Like many social processes, there is no one ‘right’ way to address the problem, because there is no one ‘right’ type of experience. Advocacy for doctors who experience sexual harassment by other doctors requires a lexicon of narratives and counter-narratives in order to make the phenomenon seem possible. Narratives that make the behaviour visible, as well as invisible, need to be considered before advocates can craft effective strategies to manage it. To do so, the community needs an effective narrative toolkit, which must account for different positions in the medical social world, as well as the different stories to which they respond.

Introduction

Medical workplaces help frame a doctor’s identity. Where a doctor works operates as shorthand for the type of work they do, the teams they may work in, the types of patients they see and the conditions they treat. Some workplaces represent long-sought career goals, while others are places doctors have been allocated without choice, or have entered through happenstance. Medical workplaces can engender a profound sense of belonging, where workers feel valued and supported to work to their best, and where their personal values are aligned with the institution. Many doctors do sustain over the long term a sense of belonging to their workplace. Sometimes, however, the workplace can function as a trap for doctors. Its physical spaces can be places of physical risk. The emotional affinity many doctors feel towards the workplace may enable them to be exploited, suborned or subverted.

Typically, medical workplaces are characterised by their service mission, the challenges and responsibilities of the work, and the frequent expectation of extended work hours. Although not all workplaces are hierarchical, the institutions in which almost all doctors train, and in which they spend their formative years, are deeply hierarchical. The requirement to be a good fit in the workplace can have a profound impact upon one’s expectation of what it is to be a doctor.

Hospital Workplaces

A hospital reflects the culture of its community, but it also creates its own culture. It is a total institution in the sense meant by Goffman. (Reference Goffman1) A total institution physically separates its residents from the rest of society, imposes a bureaucratic order upon them, and regulates their activities. A defining characteristic is the way junior staff are acculturated to the mores and rules of the total institution. (Reference Goffman1) In total institutions some of the power relations in the outside society are heightened and difficult to resist. Junior staff are most likely to be ‘batch living’ in hospitals, and thus are the most vulnerable to the impacts of the hospital as a total institution.

Hospitals were constructed historically to provide accessible nursing and doctoring to groups of sick people, and later to concentrate and support specialised functions such as surgery or pathology. The institutions which founded the first hospitals – military and religious organisations – were experienced in human logistics. Nursing became increasingly regimented, reflecting the Nightingale influence, in part to protect the emerging middle-class cohort of nurses from sexual harassment. (Reference Bullough2) Nightingale’s ambition was to create a decentralised nursing cadre which could function through outreach into people’s homes. Hospitals were ‘but an intermediate stage of civilisation’. (Reference Nightingale3) She was concerned to protect her nurses from being ‘morally and bodily destroyed’ (Reference Nightingale4, p. 184), a risk she felt was particularly acute when nurses fell under the sole purview of male hospital authorities (Reference Nightingale4). To prevent this, nurses lived in designated accommodation near hospitals, and were supervised by on-site nursing managers responsible for their workloads and their moral safety.

The traditional hospital workforce thus separated (female) nurses from (male) doctors. Doctors had freedom of movement to move across all hospital spaces and enter different wards; nurses were assigned to, and supervised in, wards or teams. When women in the West started to graduate from medicine in the mid to late nineteenth century, they often found themselves structurally separated in their careers from men. In career surveys of women doctors undertaken in 1881 by the Women’s Medical College in Pennsylvania and the New England Hospital in Boston, women doctors described working almost entirely separately from male doctors – in women’s hospitals, or in private clinics, women’s asylums or schools. (Reference Drachman5) English, Australian and Canadian women doctors of this era experienced the same gendered separation, with women unable to find positions in the public hospitals where they had trained. (Reference Elston6–Reference Godfrey8) After the Flexner report recommended co-education of doctors, the women’s medical programmes and women’s hospitals went into a decline. (Reference Barkin, Fuentes-Afflick, Brosco and Tuchman9) In the early twentieth century, women doctors in countries as diverse as the US (Reference Drachman5) and China (Reference He, Luesink, Schneider and Zhang10) were increasingly employed in male-run hospitals, but usually in ‘female’ specialities, such as obstetrics and gynaecology.

Women doctors moved into spaces constructed by and for male doctors, and in many respects this has never changed. Women doctors adapt to these environments; the environments rarely change for them. Hospital working schedules may not be adapted to the needs of workers who have other caring responsibilities outside of work. The working structures for doctors are usually based on seniority hierarchies which shape the working cultures of those lower down the hierarchy, and which in turn reflect the historical patriarchal relations of power in hospitals.

One of the ways women doctors in hospitals demonstrate their capability is by asking to be treated no differently to men. We can see this most radically in the ways that women doctors in hospitals negotiate their own embodied experience as menstruants. Women medical students and doctors are often loath to publicly discuss their own menstruation. (Reference Maity, Wray, Coffin, Nath, Nauhria, Sah, Waechter, Ramdass and Nauhria11) Yet menstruation is part of the regular experience of most women doctors. Hiding menstruation is a denial of the facts of women’s bodies in the workplace. Women surgeons have recounted the difficulties of managing the pain and fear of flooding due to menstruation through long operations. (Reference Dean12) Despite women constituting the majority of operating theatre staff, they tend to have less changeroom and toilet space allocated to them than men. (Reference Dean12; Reference Mudgway, Hariri, Olmedo-Temich, Lee, Wu, Nam and Lum13) Leaving the operating theatre to change a menstrual product or to take analgesics involves holding up the procedure and having to scrub in afresh, all while publicly acknowledging what may be seen to be a female vulnerability. (Reference Alvarado14) Women doctors going through menopause also describe not asking for consideration of its impacts, again citing concerns about appearing frail. (15)

Being silent about menstruation and menopause reinforces women’s shame about their bodies. In a ground-breaking study, Schooler et al. (Reference Schooler, Wark, Merriwether and Caruthers16) demonstrated the links between menstrual shame, bodily shame, and sexual decision-making. Women who are ashamed, and distanced, from their bodies are more likely to be less assertive, more vulnerable and less assured in situations of sexual decision-making. Women doctors in training in hospital thus face a trifecta of vulnerabilities. They work in a hierarchical structure usually under male authority; they are taught to think of their bodies as things to be silenced; and their work brings them into contact with multiple places of risk.

Early career doctors even now are ‘itinerant workers, moving from ward to ward’. (Reference Rapport, Francis-Auton, Cartmill, Ryder, Braithwaite and Clay-Williams17) The spaces a doctor traverses are often the hidden parts of hospital: the underground corridors linking different wards, the unmonitored service lifts, the fire-escapes linking different floors. Rostered overnight, they may doss down in makeshift places such as tea-rooms, spare hospital rooms, or cordoned-off beds in the emergency department.

The association between shiftwork and sexual harassment is difficult to assess, as sexual harassment is often obscured in surveys which use the analytical categories of ‘non-physical’ or ‘physical’ violence. Shiftwork does not confer an added risk of sexual violence to women doctors in Serbian emergency departments (Reference Nikolić and Višnjić18) and Chinese hospitals. (Reference Wu, Zhu, Li, Lin, Chai and Wang19) This is in contrast to studies in Pakistan, (Reference Hussain, Rehman, Bashir, Begum and Jehan20; Reference Masood21) Egypt (Reference El Shakhawy and Mondoor22) and Sudan (Reference Kheir, Khair, Mapayi and Patwa23) where the already high rates of sexual violence towards female physicians are increased on overnight shifts. The perpetrators in all these studies are most likely to be fellow or more senior physicians. When the site of assault is recorded, closed spaces are frequently mentioned, such as examination rooms, (Reference El Shakhawy and Mondoor22–Reference Stone, Phillips and Douglas24) operating theatres, (Reference Kheir, Khair, Mapayi and Patwa23–Reference Chaudhuri25) and doctor’s offices (Reference Kheir, Khair, Mapayi and Patwa23; Reference Chaudhuri25; Reference Cox, Jewitt and MacIver26).

Hospitals can also create risk through sexualising working spaces, through unofficial actions for which the institution may disavow responsibility. (Reference Searle, Rice, McConnell and Dawson27) A senior doctor who regularly invites health workers to his office to watch pornographic videos (Reference Chaudhuri25) may be presented as the one bad egg of the institution. The practice of group sexual bantering may be rationalised as team-building. (Reference Searle, Rice, McConnell and Dawson27) In their collection of accounts of sexual harassment in the NHS, Cox, Jewitt and MacIver (Reference Cox, Jewitt and MacIver26) include many stories of groping and frottage by senior doctors of more junior doctors in public places like ward rounds, or operating theatres, which indicate that even in surveilled spaces molestation can happen. (Reference Cox, Jewitt and MacIver26) As noted in chapter 8, clinicians often find it difficult to counter these instances of molestation by more senior doctors in patient-facing spaces in real time.

At other times, institutional actions may be read as direct endorsement of sexual harassment. Liang, Doman and Nestel (Reference Liang, Doman and Nestel28) cite the case of a picture of sexual positions displayed on a wall in a shared staff-in-training office. An example from my own experience: I once worked as a junior doctor in a hospital which had a lease arrangement with a cable company whose range of options included pay-to-view soft pornography. For a small fee, a patient could watch grainy porn on the television fixed to the wall in front of their bed. Other patients or hospital orderlies would saunter over to watch. Behind the scenes, colleagues were amused by the female staff members’ concerns about negotiating such an environment to examine the patient. The hospital administrators were probably unaware that pornography was one of the cable company’s television options. Nevertheless, neither the administration nor senior colleagues thought that disabling the pornography option on the in-hospital televisions was a priority. For the women doctors and nurses, this decision created a sexualised environment which, not surprisingly, set the scene for sexual harassment from patients.

Ambulatory Care Workplaces

Hospitals function in similar ways the world over. Ambulatory care workplaces are different. They are a diverse set of small enterprises that range from small private businesses to corporatised entities or government-owned multidisciplinary polyclinics. Stuck for a descriptor, an Australian government website warned readers ‘You can’t stay overnight in a clinic’. In other words, a clinic is the opposite of a total institution; no one is rostered around the clock, and the patients come and go, generally of their own volition and wearing their own clothes.

These features reflect heightened agency for all people in the workplace, and create a complicated landscape for sexual harassment and assault. In hospitals, sexual abuse of doctors is perpetrated most frequently by other doctors. In ambulatory care, the landscape of sexual harm navigated by doctors also includes sexual misconduct by doctors towards patients, and sexual harassment by patients towards doctors. For female doctors, the primary care setting is colonised by sexual risk, (Reference Rothstein, Huber and Gaskell29) even if the personal risks of experiencing or witnessing these forms are not always high, and are moderated by the spatial and organisational structure of the workplace.

In the ambulatory sector, the overall level of sexual abuse and harassment perpetrated by doctors on doctors, and doctors on nurses, appears to be lower than in hospitals. (Reference Searle, Rice, McConnell and Dawson27) This is not to say that doctor-on-doctor sexual harassment does not exist. In Surviving in Scrubs, (30) a collection of accounts by women doctors of sexual harassment, there are multiple accounts of doctors being sexually harassed by other doctors in primary care, usually doctors in more senior positions. The authors point out this sector’s workplace organisational systems may be insufficient to respond to reports of sexual abuse made by one staff member about another staff member. Most primary care services are small businesses with limited HR capacity. (Reference Cox, Jewitt and MacIver26) Sexual harassment by doctors of health workers may be underestimated in the primary care sector as it is underreported by those who experience it.

The second type of sexual harm that can occur in the ambulatory sector is by doctors to patients. Sexual abuse of a patient is considered an offence which should be notified to the regulatory authorities, and so it has a public accounting trail. Although reports of sexual misconduct towards patients are rare, family physicians and psychiatrists are over-represented in national registry data. (Reference Dehlendorf and Wolfe31–Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk33) Both these disciplines tend to have longitudinal treatment relationships and consult on a one-to-one basis – a set of circumstances in which patient–doctor boundaries may be violated and patients’ vulnerabilities exploited. In Australia, general practitioners constitute 23% of the profession, but 45% of the notifications to the national regulator for sexual misconduct with patients, while psychiatrists constitute 3.2% of the medical workforce but 8.7% of notifications for sexual misconduct. (Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk33) The doctor-perpetrators of sexual assault against patients in notification data are almost all men, and the victims women. (Reference DuBois, Walsh, Chibnall, Anderson, Eggers, Fowose and Ziobrowski32; Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk33)

Is there a relationship between sexual harming of patients and sexual harming of other doctors? It is sometimes posited that since both relate to enactments of power, a doctor who victimises a patient is more likely to victimise a vulnerable doctor. Such a suggestion emphasises the psychological characteristics of the abuser doctor. Using the workplace as lens, we propose that the workplace environment may modulate the risk of abuse of doctors by doctors in ambulatory clinics. Most primary care clinics have relatively flat organisational structures, and do not have the level of power asymmetry that occurs in hospitals between senior and junior doctors. The most frequent site of sexual misconduct by doctors with patients in community clinics are the consulting rooms. (Reference Searle, Rice, McConnell and Dawson27; Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk33) These consulting rooms are sites of solo practice. Doctors interact with other health workers in communal spaces like tea-rooms or waiting rooms. Thus, the material spaces which may be exploited for sexual harming of patients by doctors do not have the same affordances for sexual harming of other health workers.

The third type of sexual harassment in this sector is sexual harassment by patients, particularly of younger female doctors. While sexual harassment by patients and their families is reported in hospital settings, it seems to be more frequent in ambulatory care. This may be related to patient characteristics. Clinics with a high patient throughput and more patients with substance abuse and mental illness have higher rates of reported patient-on-doctor sexual harassment. (Reference Magin, Adams, Joy, Ireland, Heaney and Darab34) Sexual harassment of doctors by patients may also be related to spatial and organisational factors. The practice of one-to-one consultation, or home visits, provides more opportunities for sexual harassment. (Reference Miedema, Eastley, Fortin, Hamilton and Tatemichi35; Reference Joa and Morken36)

Rural and remote clinics for underserved populations pose their own challenges. In countries with inadequately resourced rural populations, doctors are often posted to a rural community service for at least a year. Many countries issue specific visas to doctors on the requirement that they are bonded to serve in rural towns. Indeed, immigrant doctors have become the mainstay of rural medical care in Australia, Canada and the US. (Reference Nightingale3Reference Russell7; Reference Moazzam, Wodesenbet, Munir, Alaimo, Lima, Ashraf, Endo and Pawlik38) Despite this, there is a dearth of research on the experiences of female immigrant rural doctors. Many of the oral histories focus on fish-out-of-water accounts of women overcoming racism, though there have been layered accounts indicating that these women also faced gender discrimination. (Reference Baer39, Reference Wright and Mullally40)

The practice of rural bonding of doctors who may come from a different background raises the possibility of intersectional harassment. In one rural clinic in the US, for example, the female clinicians who belonged to minority groups described gender and racial harassment by their male co-workers. (Reference Ko and Dorri41) Many felt they had little recourse but to leave the community. Such incidents pose a risk to sustainable service delivery in underserved populations.

Temporary Workplaces

This category includes locum (or fly-in/fly-out) arrangements and mobile medical units. These are challenging workplaces. By their very nature they are not sustainable, and workplace supports are fragile.

In locum employment, clinicians work for themselves, usually contracting their labour through a medical recruitment agency. These arrangements are instituted because the workplace has been unable to secure the workforce it needs, or because the workplace is so challenging that it can only be undertaken on short visits. For the doctors themselves, local arrangements have the advantage of self-employment and the ability to make decisions about their own workload and workplace. However, locum doctors in a health service are often treated with disengagement by hospital management and depersonalised as the stopgap solution. In their interviews with locums in the NHS, Ferguson et al. (Reference Ferguson, Tazzyman, Walshe, Bryce, Boyd, Archer, Price and Treddick-Rowe42) noted that locums were subject to repeated questioning of their legitimacy as doctors, both excluded from professional development activities, such as training and case presentations, and cast as a clinical governance risk. In 2010, the British Medical Journal reinforced this everyday discrimination against locums when it ran a front cover headlined ‘Misfits: the problem with locums’ for a simple story on the difficulties of recruiting locums. Being on the outer edge of the medical workforce in a hospital places junior locums at risk of harassment, and reduces their ability to protest about it through the hospital’s formal channels. For more senior locum doctors, sitting outside the governance arrangements of a hospital can provide a cover for sexual harassment of other staff. (Reference Dyer43; Reference Dyer44)

If fly-in/fly-out arrangements are used for an entire workforce, as they are in the mining industry, they can be associated with a marked risk of sexual harassment for women, reflecting the itinerant workforce, the lack of oversight, and a macho culture. (Reference Parker45) Mobile medical units or teams have been touted as a way to improve service delivery in underserved rural and under-resourced urban populations.

In richer countries, many mobile clinics are funded through philanthropy or faith-based organisations, and run with a volunteer workforce of clinicians. (Reference Singh, Baig and Singh46; Reference Coaston, Lee, Johnson, Weiss, Hoffmann and Stephens47) In other settings, they usually operate through vertical staffing where staff are brought in from another facility. (Reference Khanna and Narula48) These models are expensive and frequently rely upon external funders such as universities or philanthropists for funding.

There has been little evaluation of the staffing, safety and sustainability of mobile clinics. Mobile clinics can operate outside of formal governance structures or oversight, as in the case of US-based anti-abortion pregnancy support clinics. (Reference Thomson, Levitt, Gernot and Spencer49) In one of the few studies of a mobile medical unit programme in a fragile humanitarian setting, senior doctors were reported to be moving the arduous responsibility onto younger doctors, with women being underrepresented. (Reference Abujaber, Alajlan, Jordan, Abjuaber and Vallieres50) The respondents also noted the emotional and financial investment of donors into this model, when a transition to place-based care might be preferable. The literature on mobile clinics often emphasises the moral worth of their project, othering the population being served and elevating the mission of the clinic. The management model for mobile clinics is generally fairly flat, and there seem to be few recourses for complaint for workplace bullying and harassment. A harassed person may be more likely to simply take themselves off the volunteer work roster than to make a formal complaint about workplace safety.

Precarious Workplaces

Some years ago I taught a course to humanitarian medical aid workers. The students had spontaneously divided themselves into constituencies: the inexperienced workers who viewed the course as an entrée to global humanitarian work, and a heckling claque of old hands who sat at the back of the class often deflating the enthusiasm of the novices with their accounts from the field, which were literally war stories.

After an unappreciated discussion on international guidelines, a novice asked the experienced hands, ‘What do you think we should learn about?’

‘Sex at work’, replied an experienced health worker. ‘The things no one tells you about until you’re in the field.’

In 2018, the humanitarian sector had its #MeToo moment. Oxfam was accused of covering up sexual abuse and harassment by its staff in Haiti after the 2010 earthquake. In the wake of the scandal, Médecins Sans Frontières (MSF), one of the world’s largest medical aid agencies, announced that it had concluded an investigation into sexual harassment and abuse by its staff and had fired twenty people. (Reference Arie51) Since then, it has become clear that sexual harassment is common among many international humanitarian aid organisations. (Reference Sauter52) In a large, representative survey, 6% of men and 17% of women had experienced sexual harassment while on their previous assignment, (Reference Martinmäki, de Jong, Komproe, Boelen and Kleber53) almost entirely from their peers.

Humanitarian aid is a precarious workplace. The work setting is complex and fragile, and clearly distinct from the person’s home. Workers are often encouraged to separate themselves from the local people, and to socialise only with other aid workers. Workers are driven by the mores and buy into the mission of the humanitarian aid organisation. It is common for missions to be led by older males, with younger females working the entry-level roles. (Reference De Koeijer, Parkinson and Smith54) Added to this combustible mix is the desperate and chaotic crisis of humanitarian aid work, the weak rule of law in these settings, and the hyper-masculinity that characterises much of the humanitarian aid work. (Reference Mazurana and Donnelly55)

Since MSF began publicly reporting incidents of unacceptable behaviour by its staff, there has been a steady increase in the number of local staff reporting bullying and sexual harassment by international aid workers. (Reference Sauter56) This increase suggests growing comfort in the organisation with reporting and responding to abuse. It also points to intersectional power plays. While early career women aid workers are at higher risk of sexual abuse in humanitarian organisations, lower-paid local women face the highest risk of sexual abuse.

Virtual Workplaces

Telehealth, a virtual workplace, provides the clinician with freedom from some of the constraints of ambulatory care or hospital workplaces. However, the emerging literature suggests that sexual harassment by patients remains an uncomfortable possibility. (Reference O’Daffer57) This phenomenon has already been described in call centres. In a survey of a German call centre, three quarters of the women respondents had been sexually harassed by telephone in the course of their work. Being subjected to sexual harassment over the telephone was a more stressful experience if the call operator worked from home. (Reference Sczesny and Stahlberg58)

Telehealth usually involves the use of a video-link, which expands the possibilities for sexual harassment. The extent of sexual harassment by telehealth of doctors is unknown. The Times of India (Reference Nagarayan59) reported concerted sexual harassment by patients of doctors on twenty-four-hour telehealth sites – from genital exposure to sexual soliciting – noting that systems to prevent and ban patients who harassed doctors were not robust. This kind of sexual harassment in the workplace is criminalised in most countries, but prosecuting may be difficult if the patients are not in the country or have given false identities.

The virtual workplace should be a safe workplace. Management approaches need to be proactive and responsive, and have firm mechanisms to prevent e-consultation harassment, to respond to it if it occurs, and to support the clinician who has experienced this kind of harassment.

Conclusion

Different medical workplaces create different conditions of possibility for sexual harassment and abuse. Of all the workplaces discussed in this chapter, hospitals are the most cited as places of risk for sexual harassment of doctors, usually by peers or more senior doctors. In hospitals, the hierarchy of the workforce, the long hours on premises, and the structure of the building itself poses a particular risk for sexual harassment. Ambulatory care workplaces overall are less likely to be sites of sexual harassment, but the forms of sexual harassment that may occur in these settings are manifold, including peer harassment and harassment by and of patients. Temporary workplaces, such as those occupied by locum clinicians, intensify some of the vulnerabilities of clinicians in hospitals, while simultaneously providing less oversight and support for clinicians. Workplaces such as international humanitarian aid settings are considered precarious in that their settings are fragile, and the workplaces are temporary, intense, and remote from the home life of the aid worker. The virtual world of the telehealth worker requires forward planning and response by businesses and managers to prevent online sexual harassment.

Introduction

Medical training is physically, emotionally and ethically demanding. (Reference Smith1–Reference Yavari4) Medical students train in a rapidly changing world, and educators constantly face the challenge of adapting training to meet the needs of today’s students and tomorrow’s patients. This means responding to evolving community expectations, expanding population needs, evolving teaching tools and techniques, and diminishing economic resources. Globally, governments are grappling with rapidly rising health care costs, rising demand, increasing inequity and threats to patient and health professional safety. (Reference Gantayet-Mathur, Chan and Kalluri5) There are also global challenges to health, with climate change being the most obvious. (Reference Philipsborn, Sheffield, White, Osta, Anderson and Bernstein6)

Many patients now expect to be treated as partners in care, forming their own ideas of what constitutes good treatment based on their interpretation of available data. (Reference Grover, Fitzpatrick, Azim, Ariza-Vega, Bellwood and Burns7–Reference Elwyn, Frosch and Kobrin10) There are shifts in what constitutes ‘evidence’ in a ‘post-truth’ world, (Reference Brashier and Marsh11, Reference Chinn, Barzilai and Duncan12) an issue that became abundantly clear during the COVID-19 pandemic. (Reference Barzilai and Chinn13) The community want safer care, with more dignity, autonomy and compassion, and this means that consumers and carers are becoming more integral to medical training. (Reference Cochrane, Ritchie, Lockhard, Picciano, King and Nelson14, Reference Singh, King-Shier and Sinclair15) Public expectations of doctors continue to grow. (Reference Grover, Fitzpatrick, Azim, Ariza-Vega, Bellwood and Burns7, Reference Miles, Asbridge and Caballero16)

At the same time, there is diminishing trust in institutions and experts, (Reference Miles, Asbridge and Caballero16) with increasing risk of occupational violence towards professionals like doctors. (Reference Liu, Gan, Jiang, Li, Dwyer and Lu17, Reference Mento, Silvestri, Bruno, Muscatello, Cedro, Pandolfo and Zoccali18) The need to train new health professionals must be balanced with service obligations in health care settings, with doctors in training experiencing increasing levels of burnout as they attempt to meet both training and service obligations. (Reference Dyrbye and Shanafelt19, Reference Galaiya, Kinross and Arulampalam20) Governments are taking a greater role in the regulation and governance of health professionals. In many countries, ideas around professionalism and professional conduct have evolved from systems where the profession itself had significant autonomy to codes of conduct with ‘tightly enforced rules devised in a culture of suspicion about doctors’. (Reference Bernabeo, Holtman, Ginsburg, Rosenbaum and Holmboe21) Around the world, doctors are training in environments where there is diminishing trust.

At the same time, shifts in community expectations have made learning to become a doctor more complex. Curriculums are constantly being rewritten, and trainers need continuous professional development to keep up with the latest requirements and expectations. (Reference Daneman and Benatar22–Reference Odongo and Talbert-Slagle24) Cohorts of senior doctors, who are medicine’s traditional trainers, learned their own skills at times and in places where professional values and competencies were different or less explicit. Interprofessional learning and working is now expected, (Reference Gantayet-Mathur, Chan and Kalluri5) adding additional competencies in team work, communication skills and leadership to an already overcrowded curriculum. (Reference Gantayet-Mathur, Chan and Kalluri5) Worldwide, there are significant variations in medical training. In an increasingly globalised world where medical migration is common, (Reference Botezat and Ramos25, Reference Adovor, Czaika, Docquier and Moullan26) it can be challenging for a country to decide what competencies an immigrant doctor may hold and what training they require to meet the medical needs of their new local context. (Reference Shiffer, Boulet, Cover and Pinsky27, Reference Mohammed Ahmed, Syed Moyn and Kadambari28)

The medical workforce has always faced rapid shifts in knowledge, but the pace of change is increasing. Technological innovations, including Artificial Intelligence (AI), are changing how medical work is learned and enacted. (Reference Zhang, Cai, Lee, Evans, Zhu and Ming29, Reference Chan and Zary30) The COVID-19 pandemic has accelerated pedagogical and clinical change, as clinicians, managers, educators and students found ways to adapt their practice to better meet the needs of their populations during a time of unprecedented demand for health services, coupled with the need to maintain quarantine restrictions. (Reference Daniel, Gordon, Patricio, Hider, Pawlik and Bhagdev31–Reference Binks, LeClair, Willey, Brenner, Pickering and Moore35) These fundamental shifts in medical work have impacted training and altered the ways doctors teach and learn.

In this chapter, we examine medical training in all its complexity, and describe the professional environment that makes doctors in training vulnerable to sexual harassment. In doing so, we recognise different forms of power and privilege, conscious and unconscious, (Reference Walsh36) and present contemporary challenges to the design and implementation of medical education strategies to address the problem.

The Structure of Medical Training

Although the way doctors train varies considerably across the world, medical training generally occurs in three stages.

First, medical student training includes an undergraduate degree, or an undergraduate and postgraduate degree. Training generally occurs in a medical school within a university. These schools can be public or private, and provide on-campus teaching as well as workplace-based learning using a range of hospital and community-based medical teams to supervise and teach. (Reference Wijnen-Meijer, Burdick, Alofs, Burgers and ten Cate37)

The emphasis on workplace-based learning in medical school differs significantly around the world. Many medical schools, like in Argentina, introduce clinical training late in the learning cycle, after biomedical training. (Reference Falasco and Angel Falasco38) Other schools have built their curriculum around early clinical exposure, believing this approach enhances clinical competencies. Countries adopting this approach include Ethiopia, (Reference Wijnen-Meijer, Burdick, Alofs, Burgers and ten Cate37) Indonesia, (Reference Shah39) India, (Reference Rawekar, Jagzape, Srivastava and Gotarkar40) Iran, (Reference Mafinejad, Mirzazadeh, Peiman, Khajavirad, Hazaveh and Edalatifard41) and many countries in Europe. (Reference Simmenroth, Harding, Vallersnes, Dowek, Carelli, Kiknadze and Karppinen42) However training occurs, medical students enter the workforce as doctors at the end of this stage of training. (Reference Wijnen-Meijer, Burdick, Alofs, Burgers and ten Cate37)

Second, an internship and/or residency is undertaken between medical school and speciality training. Doctors at this stage may be called interns (in their first year), house officers, medical officers or residents. During this time, doctors may need to complete a period of mandatory clinical service. Residents usually follow a generalist curriculum, which may or may not include an academic component, such as a Masters or Doctoral degree. (Reference Strout Kemper, Cavallario, Walker and Welch Bacon43, Reference Giesler, Boeker, Fabry and Biller44) At the end of their residency, doctors may apply for specialty training. In some countries, doctors can remain as generalists without further training, and work in hospitals or in the community. (Reference Wijnen-Meijer, Burdick, Alofs, Burgers and ten Cate37)

Third, speciality training is undertaken. This varies between disciplines, medical contexts and countries. (Reference Weggemans, van Dijk, van Dooijeweert, Veenendaal and Ten Cate45) Doctors at this stage of training are called registrars or senior residents and take senior roles in hospitals or community practice. Their supervisors are usually specialists, who are known as attendings, consultants, specialists or physicians, or by their speciality title (e.g. paediatricians, surgeons or general practitioners). Specialists may or may not be employees of health care institutions. Often they will only be available at certain times of the day, leaving the bulk of the decision making to their registrars.

Training, assessment and curriculum vary, but once qualified, registrars become specialists themselves. Most doctors train for at least ten years to gain their specialist qualifications and may train for longer if they enter a particularly challenging specialty. Specialty training may take place in universities, hospital networks and/or specialty colleges. The assessments at this stage are often expensive, arduous and lengthy. Registrars often form deep relationships with their supervisors that are essential to their career progression.

Continued professional development is also a requirement for all health professionals. Part of the role of medical training is to drive a commitment to lifelong learning, but also to normalise lifelong teaching. Every health professional teaches and learns from a range of people, including patients and their families.

Future medical educators are often identified early in training, when they are performing the teaching role appropriate to their own stage of learning. (Reference Gordon and Karle46) Like other roles in medicine, mentorship is critical, and this can be why unconscious bias can mean some doctors have more opportunities for career progression than others in medical education. (Reference Kramer, Heyligers and Könings47) Over time, this may lead to a faculty of teachers that does not reflect the diversity of learners they teach, a common problem in medical training. (Reference Boatright, London, Soriano, Westervelt, Sanchez and Gonzalo48, Reference Verdonk and Janczukowicz49)

The Regulation of Medical Training and the Challenge of Medical Migration

Doctors train to serve the needs of their communities. This means medical schools set different curriculums, accommodating their social, political, cultural, and health contexts. There is significant variation in the way doctors are trained across the world and the variety of workplaces in which they learn (see chapter 5). In an increasingly globalised economy, this can pose some challenges when doctors migrate.

Medical migration is growing. The Organisation for Economic Co-operation and Development (OECD) estimates that one in six doctors in 2016/17 were overseas trained, with many more locally trained but born overseas. This figure has risen by 70% since 2000. (Reference Socha-Dietrich and Dumont50) There have been calls to embed globalised standards in medical education, (Reference Karle51) as qualifications are rarely comparable between countries, meaning doctors who immigrate need to update their qualifications to meet local requirements. Training variations pose a challenge for the educational and regulatory systems of the countries involved.

Over the last twenty years, the International Association of Medical Regulatory Authorities has encouraged sharing of international approaches to training and regulation.(Reference Reid, Leistikow, Paniagua, Udekwu and Letlape52) Those interested in a more global approach to standards of competence argue that this will drive best practice educational design (Reference Tackett, Zhang, Nassery, Caufield-Noll and Van Zanten53) and facilitate medical migration. (Reference Karle51) However, there are concerns that sociocultural differences between countries optimise curriculums and training for their own context. There is some concern that homogenising medical training across the world could lead to imperialist standards that don’t meet the needs of all communities they are meant to serve. (Reference Rashid54) This is not merely an academic concern; it impacts the way international medical graduates (IMGs) from one country are perceived and treated in another. IMGs already experience high levels of discrimination and harassment. (Reference Ulusoy, Swigart and Erdemir55–Reference Fnais, Soobiah, Chen, Lillie, Perrier and Tashkhandi57) Differences in professional culture, expectations and training make IMGs more vulnerable and increase their cognitive and emotional load. (Reference Chen, Curry, Bernheim, Berg, Gozu and Nunez-Smith58, Reference Kehoe, McLachlan, Metcalf, Forrest, Carter and Illing59)

The regulation of medical training varies considerably across the world, and within individual countries. Some countries have consistent standards for specialty training, which are monitored by medical councils or other regulatory bodies, and some seek accreditation through the World Federation of Medical Education (WFME). (Reference Weggemans, van Dijk, van Dooijeweert, Veenendaal and Ten Cate45, Reference Perez and Cuff60, 61) However, there are countries where training is highly variable. Lack of globally consistent training means that IMGs often face a lengthy and expensive assessment and accreditation process in their chosen country before they are able to practice.

China is addressing this challenging by seeking WFME accreditation. China has the world’s largest medical education system with 420 undergraduate institutions graduating over 480,000 doctors in 2019. (Reference Wang62) Achieving consistent educational outcomes across such a broad range of institutional settings is challenging, but China has now achieved accreditation status with WFME. China also sponsors students to undertake their studies abroad, with annual budgets reserved for sustaining students’ mobility. (Reference Jiang, Sun, Yuan, Duan, Wu and Liu63)

Other countries report difficulties maintaining consistent training across their networks, often due to limited resources available for accreditation. Brazil is an example of a country with lower resources, where the rapid expansion of medical education facilities outstrips the resources available to ensure universal quality of training. (Reference Antunes dos Santos and Nunes64) The regulation of learning environments is challenging, and this has an impact on the mastery of curriculum by learners.

Curriculum

There are two types of curriculums, and both are over-crowded. (Reference Slavin and D’Eon65, Reference Slavin and D’Eon66) The formal curriculum is often grounded in national standards, ensuring certain competencies are achieved by all learners. This curriculum is hotly contested, (Reference Wong, Gishen and Lokugamage67) partly because emphasis in the curriculum is associated with academic prestige. (Reference Wong, Gishen and Lokugamage67) More teaching can mean more funding, more status, and attraction of more students to the discipline itself.

The Formal Curriculum

Space in the formal curriculum is at a premium. Most educators bemoan the fact that while it is easy to argue for inclusion of a subject, lecture or experience, it is much more difficult to remove one. (Reference Slavin and D’Eon65, Reference Slavin and D’Eon66) This is not simply an academic problem. The overcrowded curriculum leads to overload in the students and academic staff. Student mental health is clearly declining, a worrying trend which has direct relevance to their risks of bullying and harassment. (Reference Rotenstein, Ramos, Torre, Segal, Peluso and Guille68–Reference Wasson, Cusmano, Meli, Louh, Falzon and Hampsey70) Students who are struggling with their mental health may have difficulty focusing on learning interpersonal skills, including recognising and responding to interpersonal aggression. (Reference Richman, Flaherty and Rospenda71–Reference Tuckey, Chrisopoulos and Dollard74) Overloaded staff may also lack the capacity to respond appropriately to interpersonal issues, ‘turning a blind eye’ to harassment. (Reference Nassar, Waheed and Tuma75)

One challenge with the written curriculum is commonly described in general practice, where ‘the curriculum walks through the door’. (Reference Strasser, Hogenbirk, Minore, Marsh, Berry, Mccready and Graves76, Reference Strasser77) This means that a supervisor has little opportunity to curate the learning experience for a doctor in training, because students’ exposure to different patient demographics and disease presentations may be highly variable across training. For most students, the relative chaos of workplace-based learning is a deep challenge, as they are unable to discern the ‘skeleton’ of their learning. They do not have a matrix on which to ‘hang’ learning experiences, and can feel like they are building this as they go, an experience similar to building a plane while already in flight.

Many medical schools, including in Egypt, (Reference Strasser77) India, (Reference Chacko78) the US, (Reference Albanese, Mejicano, Anderson and Gruppen79; Reference Iobst, Sherbino, Cate, Richardson, Dath and Swing80) Brazil and Germany, (Reference Roland, Hannah, Lilian, Heidrun, Cláudia and Luiz Vianna81) are shifting to a competency-based curriculum, focusing on developing the skills needed to transition from learning to practice. Canada (Reference Nousiainen, Caverzagie, Ferguson, Frank and Collaborators82) has been instrumental in designing a broad curriculum framework that focuses on organising these competencies into a structured curriculum, called the CanMEDS framework. (Reference Frank and Danoff83) CanMEDS introduced curriculum objectives related to the various roles a doctor takes in their professional career: Medical Expert (the integrating role), Communicator, Collaborator, Leader, Health Advocate, Scholar and Professional. (84)

Figure 6.1 The CanMEDS framework.

The international shift to competency-based curriculum has had significant ramifications for the teaching and assessment of professionalism. There are concerns that by breaking down training into measurable competencies and ‘atomising’ the curriculum (Reference Huddle and Heudebert85), essential and important professional skills that cannot be captured as competencies are being lost. (Reference Frank, Snell, Cate, Holmboe, Carraccio and Swing86) Competencies in professionalism, systems organisation and leadership have been added to various competency frameworks including those of Israel, (Reference Frank, Snell, Cate, Holmboe, Carraccio and Swing86) the US (Reference Frank, Snell, Cate, Holmboe, Carraccio and Swing86; Reference Combes and Arespacochaga87) and Singapore (Reference Frank, Snell, Cate, Holmboe, Carraccio and Swing86). Some countries are introducing individualised learning plans that focus on personal development to capture these professional competencies. (Reference de Heer, Driessen, Teunissen and Scheele88) Nevertheless, there remains concern that competency based medical programmes designed around analysis of tasks and roles may not address tacit knowledge, context specific skills or inter- and intra-personal knowledge, skills and attitudes that support appropriate professional identity formation. (Reference Combes and Arespacochaga87)

Professionalism has been codified in regulatory frameworks. (Reference Bird and Gilligan89) The problem with codes, however, is that it is easy to incorporate aspirational goals that are poorly defined, resulting in standards that are difficult to interpret and impossible to meet. For instance, the Medical Board and Australian Health Professionals Regulatory Agency (AHPRA) provide a code of conduct for all medical doctors and students. (90) This code requires doctors and medical students to provide ‘constructive and respectful feedback to colleagues, trainees, international medical graduates and students, including when their performance does not meet accepted standards’. (Reference MBo91) This statement is almost impossible to operationalise unless there is a recognition of established hierarchies, acceptable modes of communication (including interprofessional communication) and a high degree of existing psychological safety, none of which are likely to be present for junior members of the team.

The Hidden Curriculum

Underneath this overt curriculum is a curriculum that is less well defined but equally powerful, the so-called ‘hidden’ curriculum. The hidden curriculum is built into the training culture and professional relationships they experience. Professional identity is about who they are as doctors, not just what they do. Doctors in training develop their professional identities by absorbing values, norms and behaviours unconsciously through cultural immersion (the hidden curriculum) and consciously (the overt curriculum).

Students need to assume shared professional attitudes, behaviours and values to effectively function in their sociocultural roles as doctors. (Reference Wren92) Unfortunately, this means professionalism training can easily replicate existing ideologies and stratified relationships that further marginalise the most vulnerable members of the profession, worsening unprofessional attitudes and behaviours. (Reference Michalec and Hafferty93–Reference Chuang, Nuthalapaty, Casey, Kaczmarczyk, Cullimore and Dalrymple95)

Although medicine is changing, the professionalism codes present what Michalec and Hafferty see as a ‘nostalgic’ view of professionalism, with doctors expected to deliver highly individualised, bespoke care in resource-poor environments. (Reference Michalec and Hafferty93) The growing distance between what is taught in the formal curriculum and what is learned in the hidden curriculum, what is said and what is done in policy, and what is expected and what is achievable in clinical practice can result in doctors distrusting organisational statements, policies, processes and codes. When there is a gulf between what is expected and what can be delivered, moral distress worsens and the willingness of a doctor to report professional misconduct is significantly reduced, because the survivors lack confidence in the processes of the organisation. (Reference Musto, Rodney, Ulrich and Grady96) The hidden curriculum and its relationship to professionalism and professional identify formation is explored in further depth in chapter 14.

The Art of Medicine and the Role of Reflective Practice

Reflection is a metacognitive process that creates greater understanding of self and situations to inform future action. (Reference Sandars109) Reflective practice has been enshrined in medical training for decades, particularly in disciplines such as general practice and psychiatry, where doctors have prolonged and extensive relationships with their patients. (Reference Akhigbe and Monday110–Reference Thompson and Thompson113) Medical educators use reflective practice to help learners build the values, knowledge and skills necessary for the ethically, socially and cognitively complex situations that characterise clinical practice. Moderated reflection is particularly helpful when learners face situations that are confronting or emotionally charged. (Reference Sandars109) This includes interpersonal harassment, abuse or violence.

Medical practice in hospitals has become increasingly transactional, rather than relational. The language around evidence-based care, outcome measurement and quality improvement encourages a view of medicine that privileges interventions over interactions. The focus on skills and competencies has created a market for simulations in areas such as communication, professionalism and teamwork. However, there is concern that this may create doctors who can simulate empathy but have no authentic connection with their patients. (Reference Dagnone, Takahashi, Whitehead and Spadafora114; Reference Whitehead, Selleger, van de Kreeke and Hodges115) Performative empathy bears a strong resemblance to what the Dutch call ‘monkey tricks’, the capacity to mimic empathy without experiencing an authentic connection with patients. A lack of authenticity can impoverish therapeutic relationships. (Reference Whitehead, Selleger, van de Kreeke and Hodges115)

In order to authentically experience, understand and manage the traumatic and confronting interpersonal experiences that are common in medicine, learners need to be comfortable learning from reflection, alone or with peers or educators. (Reference Sandars109) Without a vocabulary to discuss their discomforts and emotional needs, junior doctors are left isolated and vulnerable, hidden in a culture of silence that protects abusers and suggests that their experience is not valid or not real.

It is difficult to create opportunities for protected time for reflection, and it is equally difficult to incorporate reflection into a curriculum that is competency based. Some Canadian authors, particularly Whitehead, have questioned whether CanMEDS has removed the important role of ‘Doctor as Person’ in creating the existing framework. (Reference Dagnone, Takahashi, Whitehead and Spadafora114; Reference Whitehead, Selleger, van de Kreeke and Hodges115) To be effective, reflective practice needs to be authentic, normalised and safe. With insightful educators, and time to teach and reflect, hidden assumptions can be examined, named and managed. Without reflection the doctor in training may lack the words and concepts to make sense of their experience and cannot question the cultural assumptions they have absorbed, (Reference Schön116; Reference Schön117) including the idea that abuse is an expected part of medical training and practice.

The Culture of Medical Training

Medical training may vary around the world, but health care workplaces have cultural elements in common. Doctors train in hierarchical organisations with dependent relationships. (Reference Crowe, Clarke and Brugha125; Reference Braithwaite, Clay-Williams, Vecellio, Marks, Hooper and Westbrook126) Medicine is a competitive industry, and training can be brutal, with long hours and high expectations. (Reference Rios127) Doctors tend to be perfectionistic and self-critical, with high rates of anxiety, (Reference Gerada128) and help-seeking tends to be discouraged.

Although there is increasing emphasis on patient-centredness in training, doctors experience declining empathy over the time of their training, partly due to moral distress, burnout and crippling workloads. (Reference Samra129) They also experience increasing levels of occupational violence from patients and their family members. (Reference Vento, Cainelli and Vallone130) In short, there are multiple ways in which doctors in training experience discrimination, harassment and inter- and intra-personal conflict.

Conclusion

Doctors in training learn in teams and within medical education systems with hierarchical power dynamics and high stakes assessments. Contexts and roles change throughout training, and doctors in training can be faced with goals that seem to act in opposition.

On the one hand, medical training is trending towards tightly defined competencies that meet well-defined standards. At the same time, communities expect individualised care that requires significant interpersonal skill. Doctors are exposed to discrimination, harassment and occupational violence, but must demonstrate equitable care that is empathic and patient-centred. There is often a discrepancy between encoded policies and enacted behaviours, and despite public commitment to equity, diversity and inclusion, doctors in training frequently experience a highly discriminatory workplace.

In an environment of high workload, resource constraints and escalating regulatory standards, doctors in training can struggle to meet the multiple and often contradictory requirements of their chosen profession. Doctors have high expectations of themselves, and this can affect their confidence. Unfortunately, this makes them vulnerable when they are subject to discrimination, harassment or abuse.

Introduction

Sexual harassment harms health care. It has a profound effect on the victim, disrupts the medical workforce, and is linked to poor patient care. (Reference Cortina and Areguin1–Reference Houck and Colbert4) Doctors who experience sexual harassment at work are at an increased risk of depression and burnout. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2; Reference Linos, Lasky-Fink, Halley, Sarkar, Mangurian and Sabry5) It is also detrimental to the doctor’s performance, as they may avoid colleagues and become less engaged with work. (Reference Commission6; Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7) In this way, individual trauma ripples into the workplace.

Hospital teams can become fractured due to poor team culture, and survivors and witnesses may leave. (8) Productivity is lessened, with an increase in absenteeism. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7) This imposes a financial burden on both the victim and the organisation. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7; 9) The destructive impact of sexual harassment on the individual and the hospital leads to poorer patient care. Doctors with deteriorating mental health or burnout are more likely to make medical errors, (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7; Reference Aghighi, Aryankhesal and Raeissi10) lowering patient satisfaction. (Reference Balch, Freischlag and Shanafelt11–Reference Templeton, Bernstein, Sukhera, Nora, Newman and Burstin13) Toxic workplace culture erodes effective workplace communication, which is essential for a culture of patient safety. (Reference Aghighi, Aryankhesal and Raeissi10; Reference Veltman14)

Impact on the Doctor

Impact on the Medical Workplace

Impact on Patient Safety

Conclusion

Sexual harassment is destructive. It harms the doctor, damages the hospital environment, and can lead to substandard patient care. Victimised doctors have worsened mental health and general wellbeing. Following harassment, they are more likely to experience burnout and associated working fatigue. Their careers can be curtailed as they become absent from work, while they may sidestep professional events to evade the perpetrator. Specialist trainees and medical students are among the most vulnerable to sexual harassment due to potential power imbalances between them and the perpetrator. Compared to men, woman have a broader definition of sexual harassment, make up most victims, and may be more adversely affected when harassment occurs. As sexual harassment ripples out into the workplace, communication and trust can break down within teams, and colleagues are likely to leave the workforce.

Following sexual harassment, productivity and quality of work decrease. Staff become more difficult to retain, and hiring new doctors increases costs that could be used elsewhere. As the health of survivors and hospitals decreases, so too does patient care. Burnt-out doctors are more than twice as likely to make a medical error, with higher rates of prescribing errors and near-miss events. As sexual harassment breaks down relationships, health care teams become more prone to making errors.

Sexual harassment is corrosive to the victim and the health care system. It should not be tolerated in any setting, let alone one with an ethos of care and healing.

Introduction

Sexual harassment and assault (SHA) is an enduring and chronic workplace health concern. (Reference Quick and McFadyen1) Studies confirm its prevalence in medicine. (Reference Galletly2–Reference McNally4) It disproportionately affects women doctors, those from minority-ethic and -gendered groups, and those in subordinate positions. (Reference Begeny, Arshad, Cuming, Dhariwal, Fisher, Franklin, Jackson, McLachlan, Searle and Newlands5–Reference Sterud and Finne10) In contrast, research shows the perpetrators of SHA are predominantly older males, notably those in more senior levels, and including both patients and colleagues. (Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk11–Reference Viglianti, Oliverio and Meeks13) In this chapter we outline how this latter group causes harm to their targets, but also include those whose attitudes and beliefs are the antithesis of medical values and principles – to do no harm. Further, we consider the costs to the organisations of this latter group.

SHA comprise three behaviours: gender harassment, which comprises verbal and nonverbal hostility, exclusion and objectivation on basis of gender; unwanted verbal and physical sexual attention including assault; and sexually coercive professional and education treatment. (Reference Johnson, Widnall, Benya and Washington14) In most countries these are included in laws, as is the case, for example, in the UK. (15; 16) The actions are conscious or unconscious attempts to maintain a status quo through exerting power and control over their targets to remind them of their position in a hierarchy. (Reference Schneider and Phillips17) In addition, more insidious harassment strategies can also be used, often anonymously, such as making obscene phone calls or postings, vulgar comments, and destroying property at a level insufficient to be clearly harassment. (Reference Schneider and Phillips17) These ‘low-level’ antics are frequently misattributed to social awkwardness, ignorance, or ineptitude, yet this enables their instigators to persist in efforts to undermine those they regard as threatening their position or status. Overarching all of these actions is hostile sexism that is predictive of SHA. (Reference Begany and Milburn18)

The consequences of these actions for their targets are immediate and enduring, including: reductions in job satisfaction, decrease in work performance, increasing withdrawal from the organisation and previously valued work and careers, and mental health decline that can involve post-traumatic stress disorder and even death by suicide. (Reference Cortina and Areguin19; Reference Willness, Steel and Lee20) The harms, however, are not confined to the direct targets but also witnesses. (Reference Pina, Gannon and Saunders21) These two groups can feel silenced due to fear about their future career and employment, (Reference Hart22) but also due to the ineffectiveness and untrustworthiness of institutional responses. (Reference Begany and Milburn18; Reference Hart22–Reference Bell, Street and Stafford25) Thus, underreporting is a significant matter. (Reference Pustolka and Paludi24; Reference Spittal, Bismark and Studdert26) These decisions to not report the events, however, have significant subsequent health and wellbeing consequences. (Reference Altman27) They also have consequences for perpetrators, greenlighting their actions, which can result in escalations to their scale and scope. (Reference Searle12; Reference Spittal, Bismark and Studdert26) These can also be aided by counterproductive organisational responses to reporting using SHA non-disclosure agreements that, while designed to reduce negative publicity and reputation loss, increase risks to further targets who are deprived of important information about perpetrators and workspaces. (Reference Altman27) Through these pathways, discriminatory and toxic workplaces become normalised (Reference Pololi, Brennan, Civian, Shea, Brennan-Wydra and Evans7) and undermine efforts towards workforce equality and diversification are undermined, (Reference Mansour, Tamirisa, Lundberg, Sharma, Mehta Laxmi, Mehran, Volgman Annabelle and Parwani28) and with this, important means to change the demographics of workplaces and the environment that sustains SHA. (Reference Cortina and Areguin19; Reference Willness, Steel and Lee20)

A public health approach has previously been applied to generic sexual violence. (Reference Becker and Reilly29) In this chapter we make three contributions. First, we extend the scale and focus of Becker and Reilly’s work, to delineate evidence-based SHA interventions. Second, we advance current understanding about SHA and its detection, deterrence and amelioration within the health workforce. Finally, we make the case for a multi-level and multi-stage SHA prevention approach that collectively could effect significant up- and down-stream changes for this workforce.

Public health prevention strategies are designed across five levels (primordial, primary, secondary, tertiary, quaternary), reflecting the five stages of disease (underlying, susceptible, subclinical, clinical, and recovery/disability/death). (Reference Kisling and Das30) The first level – primordial prevention – when applied to SHA identifies the wider social and cultural context risk factors that may promote SHA. The inclusion in law contributes to the primordial context. In this western context SHA research attests to a pervasive gender hostility and stereotyping that has positioned SHA as a ‘female issue’. (Reference Quick and McFadyen1; Reference Pina, Gannon and Saunders21; Reference Fitzgerald31; Reference Fitzgerald, Drasgow, Hulin, Gelfand and Magley32) Yet evidence shows men too are targets for SHA. Media coverage of high profile SHA cases, e.g. Russell Brand, imply male peer support for these actions, and reveal the enduring rape myths that either deny or seek to mitigate perpetrators’ actions (Reference Cortina and Areguin19; Reference Collibee, Rizzo, Bleiweiss and Orchowski34) and cause a secondary betrayal of targets in their vilification (Reference PettyJohn, Kynn, Anderson and McCauley35).

Recent UK government statistics report that 29% of employees experienced unwanted gender-based verbal and physical attentions over the last twelve months, and highlight distinct experiences between men and women. (Reference Adams, Hilger, Moselen, Basi, Gooding and Hull36) While workplaces are the main location for SHA, the next most frequent arise through off-site socialisation. Results confirm men as the dominant perpetrators, with women less frequent harassers. They show underreporting as endemic.

Primary Prevention

This level focuses on more susceptible individuals and populations, in order to minimise these experiences from ever arising.

SHA involves specific individuals because it arises in a context in which there are significant power imbalances between the perpetrator and their targets. Disproportionately targets are women doctors, those from minority-ethic and -gendered groups, and those in subordinate positions. (Reference Begeny, Arshad, Cuming, Dhariwal, Fisher, Franklin, Jackson, McLachlan, Searle and Newlands5–Reference Sterud and Finne10) Recent studies show men are also targeted. (Reference Begany and Milburn18; Reference Cortina and Areguin19) Their targeting is due to their reduced status and perceived perpetrator power over potential future employment and career progression that creates silence or delay in reporting until they are sufficiently outside of the perpetrator’s scope of influence. (Reference Fitzgerald, Swan and Fischer37)

Primary prevention efforts can also be improved through more awareness of the perpetrator. Studies show an increased threat posed by males in positions of power and authority, especially those in training, supervision and director roles (Reference Searle12; Reference Crebbin, Campbell, Hillis and Watters38). It is the exploitation of their power and position differentiation that is used to achieve their own goals. (Reference Begany and Milburn18) Focusing SHA prevention efforts on those in senior and influential positions is important, as these individuals set the tone of their working environment, are pivotal in creating psychologically safe workplaces, and act as role models signalling an acceptance of SHA if it is not addressed. (Reference Crebbin, Campbell, Hillis and Watters38) Further, there are disproportionately more instances within some specialities: obstetrics and gynaecology, psychiatry, surgery and general practice (Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk11; Reference Spittal, Bismark and Studdert26; Reference Crebbin, Campbell, Hillis and Watters38–Reference Veness, Tibble, Grenyer, Morris, Spittal, Nash, Studdert and Bismark46). These specialities are important hotspots to increase awareness raising and reporting for those in training and supervision.

Those at risk of perpetrating SHA have individual traits in common. These include low empathy, (Reference Regher and Glancy47) hostile sexism, traditional sex-role beliefs and social dominance needs. (Reference Cortina and Areguin19; Reference Pryor, LaVite and Stoller39) The aforementioned misuse of the hierarchal position is indicative of a wider sense of entitlement, and demonstrates an underlying male ‘proprietariness’ towards others, especially women, who are regarded as objects to be owned and controlled. (Reference Bouffard48) Specifically, they include sexual proprietaries, with these individuals viewing themselves as entitled to having their own uncontrollable sexual needs and desires met by those under their sphere of influence. This entitlement is a trait of narcissism. (Reference Raskin and Terry49) Sexual narcissism is characterised as being preoccupied by sex, with a compunction and entitlement in their interpersonally exploitative actions. (Reference Wryobeck and Wiederman50) Aside from having more traditional views of gender roles, these men lack the capacity for empathy and emotional intimacy and have lower self-esteem, which they compensate for through their feelings of entitlement. (Reference Hurlbert, Apt, Gasar, Wilson and Murphy51) Their need for ego-enforcement can lead them to use sex to feel powerful over others. The fragility of their ego makes this a constant and compulsive quest to boost their self-esteem. Sexually coercive men have an excessive need to be admired, and use exploitative sexual actions to achieve this. (Reference Baumeister, Catanese and Wallace52) Perceived threats to their masculinity and dominant position are important antecedents to SHA. Further, sexually aggressive men share distinct hypermasculine cognitions, including beliefs about male superiority and entitlement towards women, preoccupations about sex and rape myths. (Reference Ryan53) There have been ongoing calls for mandatory education from undergraduate level on SHA and unprofessional behaviours. (Reference Veness, Tibble, Grenyer, Morris, Spittal, Nash, Studdert and Bismark46) Those with these attitudes could be identified and de-selected from entering education and training. In addition, study shows the capacity for these individuals to self-regulate is reduced by high levels of alcohol consumption. (Reference Orchowski, Berkowitz, Boggis and Oesterle54) Therefore, removing alcohol from environments would be a simple means to avoid depleting further self-regulation capacity.

In contrast with these aforementioned individuals, review has highlighted the importance of empathy in general as a characteristic that improves the medical workforce. Results show those with empathy not only have better accuracy in their diagnosis and outcomes for patients, but also reduced levels of burnout and malpractice risk. (Reference Han and Pappas55)

Secondary Prevention

This level involves early detection with populations susceptible to sexual harassment and abuse attempting to avoid its onset. It requires demonstration of a transparent and fair response by the organisation to detection of SHA that signals these incidents are important, unacceptable, and taken seriously. Attention here can comprise two elements: towards individuals and environments. Early detection involves detection and challenge of those who demonstrate unwelcome SHA attitudes and behaviours. (Reference Spittal, Bismark and Studdert26) Challenging inappropriate attitudes and behaviours of those coming into the profession offers a means of upstream intervention to reduce subsequent events. Raising awareness among educators and students of the role of moral disengagement as an antecedent may be of value here in both detection and self-awareness. (Reference Bismark, Studdert, Morton, Paterson, Spittal and Taouk11) While such efforts may place universities in a difficult position in training and supporting their staff to identify and manage out such students, it would signal the focus on safe study and workplace from the onset. Regulators, while in the main not registering those in training, can support these efforts through attention on their quality assurance of medical training. For example, the UK’s General Medical Council’s ‘generic professional capabilities framework’ could be deployed here concerning professionals’ values and behaviours.

Prior study shows that SHA is often part of a wider array of anti-social and sexually coercive attitudes and behaviours that would be problematic in medicine, including manipulative and exploitative behaviours, irresponsible and immature actions, and an omission of social conscience, particularly directed towards women. (Reference Pina, Gannon and Saunders21) Recognising contexts that are depleting and can promote SHA through reducing perpetrator’s means of self-regulation includes those with high workloads. (Reference Searle, Rice, McConnell and Dawson56) Further study shows associations between verbal aggression and SHA, (Reference Crebbin, Campbell, Hillis and Watters38; Reference Park, Cho and Hong58) and that interpersonal incivility is part of a continuum that escalates to SHA. (Reference Halim and Riding57) Early provision of training towards reducing verbal aggression can be an upstream intervention that contributes to better work environments.

Further, secondary prevention includes awareness and action in the allocation of supervision roles and leadership promotion to avoid unsuitable individuals progressing in positions that increase their means to exploit others. (Reference Crebbin, Campbell, Hillis and Watters38) Specifically, two types of harasser are common: (Reference Pina, Gannon and Saunders21) public harassers, who overtly use amicable and articulate personas to deliberately intimidate and control targets, and private harassers, whose more conservative approach avoids attention and uses covert means to access and control potential targets. The latter is far harder to detect. Study of educators shows a categorisation comprising persistent and risk-taking perpetrators, those who perceive an emotional attachment to their targets as distinct from perpetrator who persistently seek sexual experiences with their trainees, from those who escalate risk by perceiving themselves as beyond reproach, and those who become infatuated with their trainee and mistake academic interest as something else. (Reference Dziech and Weiner78) Trainee and staff surveys are useful tools to provide early detection of high-risk situations and targets. Regular monitoring of trainees’ experiences in different workplaces can provide important insights over time and maintains attention on this high-risk group. Items, however, should include robust measures that capture tactics including those designed to humiliate, isolate, etc., (Reference Chawla, Gabriel, O’Leary Kelly and Rosen79) and the use of more compact self-labelling rather than behavioural experience measures; these measures collect a wider array of behaviours of concern and of their progression, and may also avoid further victimising respondents. (Reference Notelaers, Van der Heijden and D’Cruz80) Future capture can include positive experience, such as respect and care towards others, to rebalance awareness of positive actions. (Reference Dodson, Goodwin, Graham and Diekmann63)

As SHA is a distinct form of professional wrongdoing with high risks of recidivism, (Reference Spittal, Bismark and Studdert26) at the heart of secondary prevention is the decision to safeguard vulnerable groups compared to protecting the privacy of potential perpetrators. Secondary prevention requires the recording and monitoring of incidents to allow the potential for something to later become significant and necessitate immediate action. (Reference Notelaers, Van der Heijden and D’Cruz80) Early detection uses evidence to identify patterns of concern.

A tool to support secondary prevention is ongoing education and awareness, specifically self-care and self-reflection that supports early detection and improves raising of concerns. (Reference Bandura60) Those exposed to trauma arising from their medical practice on an ongoing basis can become depleted just from this exposure, and this reduces over time their capacity to manage and self-regulate. (Reference Van der Kolk82) Supporting health professionals to understand their experiences and actively process the losses and traumas that comprise their working lives are important for workforce retention as well as reducing SHA and other unhelpful responses. (Reference Murray83) There should be increased recognition of mid-professional life as a stage where previous shortcomings or omissions can become overwhelming, and individuals need more support. Reminding senior staff of the values they have in their practice and helping them to be more mindful through observing, rather than being defined by, their emotions are useful resources for self-reflection. (Reference Harris84) Study has shown the inadequacy of support for doctors who self-refer. (Reference Bradfield, Bismark, Studdert and Spittal81)

While we have focused on colleague SHA, patient targeting of staff is also a significant source of SHA. (Reference Viglianti, Oliverio and Meeks13; Reference Schneider and Phillips17) These incidents are part of the workplace and so need attention. They should be recorded as with staff-initiated events, allowing them to be added to workplace hotspot maps. Reporting should include the staff role targeted, alongside the perpetrator’s gender, age, ethnicity, profession and organisational role in order to help identify patterns, and inform interventions and support. Critically, such incidents should be addressed by managers to ensure staff feel they are being supported and show coherence to the organisation’s SHA policies. Cross-staff task forces can be useful in identifying and monitoring effective responses. These groups can help to support staff to surface and process the sense of betrayal and disappointment these events can create. (Reference Bradfield, Spittal and Bismark85)

Secondary prevention includes identifying SHA contexts, which can include off-site conferences and learning events. (Reference Begeny, Arshad, Cuming, Dhariwal, Fisher, Franklin, Jackson, McLachlan, Searle and Newlands5) These spaces often include alcohol, which is known to degrade individuals’ means of self-regulation. (Reference Orchowski, Berkowitz, Boggis and Oesterle54) Prevention strategies here, aside from reducing access to alcohol, include clear communication about SHA and how to report in order to remind delegates of the importance of self- and other monitoring in spaces where self-regulation can be reduced, alongside the need for social support. In this way everyone is co-opted to ensure potentially vulnerable delegates can remain safe.

Further SHA awareness training can raise awareness for investigators and organisational leaders using the outrage management model, which identifies five common perpetrator responses to try and manipulate others. (Reference Scott and Martin87) These strategies are: efforts to cover-up their SHA; moral disengagement from their actions though either denial, minimisation of their injurious effects, or shifting their responsibility; target denigration and deflection through criticising their integrity or competence; performative use of official channels by contending grievance processes have been resolved in a just and fair way with nothing further required; and finally, intimidation and bribery though threats of poor references, unwelcome job assignments or dismissal, alongside rewards of more favourable references, comfortable job assignments or/and promotions for those who support and enable their SHA. These efforts are designed to reduce the hearing of targets’ concerns, as well as their silencing support instead of the development of conducive networks that reward others’ silence. They include questions for medicine and other professions about overidentification for those in a profession and their exploitation by those in senior positions. (33)

Targets may delay reporting, which is known to increase the likelihood of more significant consequences. (Reference Cortina and Areguin19) For example, SHA comprises a violation that extends beyond the physical, impacting the emotional and socially defined sense of self. (Reference Petrak, Petrak and Hedge88) They also are not confined to the target and extend into their families and friendship networks. They can produce long-term psychological consequences arising from maladaptive coping responses following trauma that stem from the individual’s unwillingness to engage with their adverse internal experiences, including intrusive thoughts and memories, emotions and sensations, and efforts to reframe and reduce these experiences. (Reference Burrows89) These reactions are very common following SHA, and over time the experiential avoidance becomes deleterious to their further relationships and mental health. In response, interventions including Acceptance and Commitment Therapy (ACT) have been shown to be of value. (Reference Bean, Ong, Lee and Twohig90)

Tertiary Prevention

Shifting to this next level, efforts here aim to reduce the severity of ongoing concerns once an individual has become a harasser and abuser. However, SHA is a goal directed behaviour. (Reference O’Leary-Kelly, Paetzold and Griffin91) Therefore, this behaviour has already involved supressing both internal (moral) and external (professional codes) inhibitors as well as the resistance of their target. (Reference Park, Cho and Hong58) It is thus unsurprising that having suppressed these factors once, it is easy to repeat. Critically, evidence shows SHA is not only likely to be repeated but that its severity increases over time, with sanctions appearing to reduce the escalation for some but not prevent its occurrence. (Reference Lucero, Allen and Middleton92) Lucero, Allen and Middleton found two types of harassers with different pathways: those who engage in gender-based violence, who require more severe sanctions and are likely to engage in other violent actions, and those who undertake unwanted sexual attention, who were found to respond to counselling and training interventions. (Reference Lucero, Allen and Middleton92) It is, however, important that managers clearly and unequivocally respond to SHA, as inaction will result in a growing problem.

There remains a paucity of study of perpetrators and effective interventions, with current evidence showing significant interventions are important. (Reference Pina, Gannon and Saunders21; Reference Maben, Aunger, Abrams, Wright, Pearson, Westbrook, Jones and Mannion93) Those who undertake sexual harassment have low empathy, negative attitudes towards women, blaming those they target, and problematic perspective regarding power and sex. Those who are sexual offenders are found to be more adversely impacted by negative events and have reduced capacity to self-regulate. Overall, the effectiveness of intervention is questionable in offering assurance that these individuals can re-enter the workplace. Study of doctors shows these individuals are significantly more likely to deny their actions, or fail to acknowledge their injurious consequences, and as a result they may lack the means to engage with their behaviour and change. (Reference Searle12) They are using cognitive processes to help them to disengage and disinhibit them from seeing their actions as a cause of concern. (Reference Page and Pina94) They fail to recognise that their jokes denote these attitudes and their moral disengagement. (Reference Page, Pina and Giner-Sorolla95)

These more entrenched harassers and abusers have a persistent failure to control their sexual impulses, suggesting they have compulsive sexual behaviours, which includes their failure to regulate emotions and actions, and an impairment to their motivation that drives their self-serving actions. (Reference Lew-Starowicz, Lewczuk, Nowakowska, Kraus and Gola96) Such impairments are associated with depression, with SHA used as a means of improving their self-esteem and elevating their negative mood. These goal-directed actions drive an escalation to the threat they pose, with the frequency and riskiness of their behaviours often accompanied by a divergence from societal norms as a means of achieving the same satisfaction. (Reference Toates97) It is this escalation of risk that is central to its addictive quality. Therapeutic interventions include the Dual Control Model (Reference Bancroft, Graham, Janssen and Sanders98) that seeks to shift the weight from excitation to inhibition, and to avoiding stimulating spaces. A recent scoping review found 20% of men as having prior history of sexual aggression, including verbally pressurising, or coercing, another for sex. (Reference Janssen and Bancroft99) It showed positive association between this aggression and higher levels of risky sexual behaviours and alcohol use.

Tertiary prevention focuses on supporting these individuals to remain at work, and requires monitoring and recording of their behaviours. This evidence outlines the merit of punitive responses required to either remove or very closely monitor these individuals in order to reduce the potentially growing threats they pose to women and other vulnerable people. The tertiary prevention strategies are limited as they rely on fear-based solutions that necessitate the perpetrator’s concern to avoid others’ adverse reactions, or legal sanction to ensure their compliance. (Reference Bandura60) However, their low empathy reduces the effectiveness of social sanction. Efforts therefore are better focused on early detection before these behaviours become engrained.

Quaternary Prevention

In medicine this level is defined as ‘Action taken to protect individuals (persons/patients) from medical interventions that are likely to cause more harm than good’. (Reference Martins, Godycki-Cwirko, Heleno and Brodersen100) When applied to SHA in a medical context, we consider this to reflect the development and implementation of ‘appropriate’ levels of support for those impacted to enable their reintegration into the workplace, as well as ‘proportionate’ punishment for those identified as undertaking SHA within a medical context. Fundamental to these is the premise of avoiding harm in the application and use of interventions, with the objective of avoiding future negative events and impacts arising from the present actions, for all parties involved. (Reference Janssen and Bancroft99) Consequently, quaternary prevention includes a clear policy and practice focus on longer-term harm reduction strategies and workplace reintegration approaches.

Study of medical students shows undergraduate incidents can have significant consequences in shaping future career decisions. (Reference Stratton, McLaughlin, Witte, Fosson and Nora45) It can profoundly impact an individual’s sense of self and their career identity. (Reference Stone, Phillips and Douglas102) These experiences affect professional confidence, job performance and wellbeing, and are predictors of burnout and career exit. (Reference Wang, Tanious, Go, Coleman, McKinley, Eagleton, Clouse and Conrad103) Given SHA is disproportionately experienced more by ambitious women, (Reference Raj, Freund, McDonald and Carr68) who are likely to be more invested in this professional identity. The responses from the organisation and colleagues can result in feelings of betrayal and disappointment. (86; Reference Stone, Phillips and Douglas102) These responses are indicative of a far more profound loss of trust. Thus the return to work is a critical event, where further trauma emerges, such as discovering colleagues did not want you to return or facing a very different perspective of their profession and the organisation in which SHA occurred. (Reference Wang, Tanious, Go, Coleman, McKinley, Eagleton, Clouse and Conrad103) These experiences can be profoundly disorientating, throwing up everything.

Concurrent with and subsequent to their return can be ongoing court cases, with the associated requirement of public silence that can complicate communication transparency and relationships with colleagues. The ensuing reporting can challenge and threaten others who have chosen not to support the target. These events are accompanied by the further stress of managing unwanted media attention. Thus the individual has a lot of competing draws on their personal resources. In these spaces the support of colleagues can be profoundly positive in validating them as viable as health professional and as a person. It can provide support for recovery and reintegration, with mentoring an important direct strategy. Senior professionals outside the workplace can also have significant positive impacts, again facilitating personal recovery and professional reintegration. Indeed, study of SHA in medical academia found one in three targets were also more likely to remain in medicine and continue their progression to the top despite these events. (Reference Raj, Freund, McDonald and Carr68) Such outcomes reflect a drive to success despite these initial set-backs. They also reveal the tolerance of SHA within the profession.

Study shows the value of timely prevention, with strategies focusing on three areas – communication, management and monitoring. (Reference McDonald104–Reference McDonald, Charlesworth and Graham105) Specifically, the organisation should avoid the use of victimisation, which can derail SHA policy. They should engage with both the individual and their line managers, as both are likely to require support during these events and their aftermaths. There are important organisational tasks to be undertaken that include actively reflecting and learning where to change to reduce the likelihood of future instances. These should be undertaken with senior leaders, and the results communicated to the organisation to allow further self-reflection and development at individual, department and organisational levels.

Conclusion

This chapter draws on preventative medicine to outline five evidence-based levels for SHA intervention. Through adopting this approach, more effective means to detect, deter and ameliorate these events can be achieved. Collectively, they provide a multi-level and multi-stage response to SHA prevention that provides the means for significant up- and down-stream change. They recognise that SHA is the source of deep and ongoing harm chains in health with impacts beyond the initial targets, with negative consequences for witnesses, colleagues, employing organisations, regulators and ultimately patients and the quality of care they receive.