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.