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.