By Homa Arshad
Consultant Arthroplasty, Pelvic and Acetabular Surgeon, Barts Health NHS Trust
Corresponding author e-mail: [email protected]
Published 25 May 2021
Comment from the BOA
A recent survey published by UNISON in June 2020, “It’s Never OK”, reported that 1 in 12 staff had suffered sexual harassment in the workplace in the last 2 years. The acknowledgement of all sexualities as worthy of respectful and inclusive acceptance and celebration has enhanced our humanity in general; especially as to acknowledge that this must apply to men as well as women challenges discriminatory behaviour.
The BOA is committed to a change in the culture within the profession to illuminate, report and to prevent such behaviours which are detrimental to the well-being of individuals, compromises patient safety and is a barrier to creating an inclusive environment. Whilst the majority of reported cases are from women, the issue of sexual harassment of men is recognised as equally unacceptable.
The following article is written with the perspective of the sexual harassment of women, with the understanding that men may also be subjected to this destructive behaviour.
Tremendous courage is required for victims to tell anybody about an incident of sexual misconduct and formal reporting in Trauma and Orthopaedics remains rare. Bullying and harassment in our specialty continues to take its toll through absenteeism, poor health and worse outcomes for patients 1,2 . An environment of excellence must be free from abuse, with a thorough understanding of the management of poor behaviour. One of the most complex and controversial of these is sexual misconduct.
I have some colleagues with a highly-developed awareness of this issue and who have developed a thorough understanding of a seven step approach to the problem. I have also encountered disappointing responses from others, of all levels of seniority and age, male and female, from around the country, including some with extended responsibilities. An examination of our regulatory processes, a review of the literature and discussion with colleagues holding different views can help to achieve competence.
1. Acknowledging and believing an account of misconduct
Many victims fear they will not be believed or will be blamed for their vulnerability or compliant response. Any account is often received by others with an interpretation of events in the best possible light. The alternative is unpleasant, unsettling and frightful. If victims persist, people often default to victim-blaming or denial of harm3. I found this to be the case even when contacting a professional bullying and harassment agency on behalf of a colleague. A sexual context to the problem revealed a lack of specific training and effectiveness.
Being married lends a further layer of respectability to perpetrators, with an expectation of respect towards women and care over their own position. However, in a review of confirmed sexual misconduct cases in healthcare4, of the 81 doctors, almost all were married men. What if the accusation is false? You are not in a position to decide, and cannot immediately know all the facts. Responding with humanity is an option which is commensurate with the real world.
Another factor which prevents a supportive response is the fear of legal action or recrimination from those in a position of power. The threat of this is real and potentially troublesome. It can be difficult to identify anyone with integrity and courage who can understand the problem and respond with effective support.
2. Avoiding ridicule or amusement
Sometimes people laugh when they don’t know how to react. This response risks an impression of emotional immaturity and disinterest in the suffering of others, including the devastating effect of sexual acts upon those who ‘freeze then yield 5,6.’ Those who are consistently respectful towards others are least likely to offend.
3. Expression of regret and sympathy
Although sexual misconduct is common, it is not acceptable. Racism is a useful analogy and similarly, it can be difficult for someone who has never considered this behaviour to understand the harm it causes. It is better to avoid expressing disgust or shock, as further drama is unhelpful.
An expression of regret and sympathy “I am so sorry to hear that” is often helpful, as is acknowledging the humanity and hurt of the victim. Avoid promising extended support which you cannot actually commit to; this would be rare in a work relationship. Listen if she wants to talk and if you can bear it. Normalising the appropriateness of professional support is helpful ‘most people would be shaken by what you’ve been through.’
4. Recognition of the pervasive power gradient between consultants and colleagues with other roles
“They’re both adults” but only those in a position of privilege who haven’t thought it through believe that we are all equals. We still have a steep power gradient in surgery, particularly between consultants and everyone else. This doesn’t disappear outside the workplace. The failure to see this applies particularly when the powerful would like to indulge themselves, or believe it is right to protect the position of privilege of a colleague over the human rights of another individual. Sexual behaviour can be considered as abuse in a relationship of trust, particularly when associated with aggression, deception, ‘grooming’ behaviour, the effects of alcohol or a significant difference in age7. This is embedded within the General Medical Council (GMC) framework relating to sexual behaviour with patients and those close to them8, but complaints from colleagues, trainees and students are managed on a case-by-case basis.
Complaining on behalf of a colleague without their consent could demonstrate strong support but could be unhelpful; without evidence, there is no case. Victims may be unwilling to embark on a potentially gruelling formal process, with isolating confidentiality requirements, intrusive and challenging formal questioning, gossip and judgement in the workplace and the fear of repercussions. However, for historical scenarios where everyone knew about child sexual abuse and turned away from it, in hindsight this was never a reasonable defence.
Feeling safe and respected as a human being in work or education is a universal right, reflected in policy documents. Generic policies for harassment and complaints may suggest informal or at least internal resolution. It can be possible to mediate an apology and an acknowledgement that this behaviour is inappropriate and cannot be repeated. This, together with concern for the victim’s wellbeing may lead to genuine resolution for the victim. A concern remains over the perpetrator’s future behaviour. In contrast with some other sexual offences, there is no evidence-based intervention known to be effective for the rehabilitation of those committing workplace sexual misconduct9. This makes a case for a formal disciplinary record for the protection of the employer. It does not, however, guard against or warn potential future victims.
Local resolution must be carefully managed to avoid collusion with the usual defences of denial of incident, denial of harm, victim-blaming and cognitive reconstruction. Should this happen, it is extremely difficult for the less powerful complainant to explain the problem with any confidence, conviction or detail. The problem is considered to be dealt with; this is known colloquially as ‘sweeping it under the carpet.’ Victims can be terminally demoralised and damaged by failed local processes. This fits the narrative of ‘she didn’t want to take it further.’
5. An understanding of how to provide support
Support includes colleagues, friends and family in their usual roles, reinforcing the humanity of the victim in her role as a colleague/friend/partner and centred on her expression of her needs. It does not include curiosity, demands for information or inexpert advice.
Accessing professional counselling support and development is helpful and can be done through our professional organisations including the Royal College of Surgeons and the British Medical Association. Unexpected sexual advances from someone in a position of power can be shockingly disempowering and lead to sexual assault, with the victim feeling suddenly and unexpectedly unable to say or do anything10. This is an extremely sensitive area and any discussions should be led by the person reporting the incident. We may provoke severe trauma by imposing our own opinions and unconscious bias or probing for information whilst failing to provide a safe response.
Suggesting that victims tell all to their partners and families can be surprisingly toxic; the compartmentalization of a horrendous work-related experience enables coping mechanisms which can be ripped out by involving those closest. This is a personal decision to be taken sometimes with professional support. It can seem like defusing a bomb or the sharing of poison.
6. An understanding that there are obligations but also limitations to a consultant’s pastoral role towards trainees and students
This is a difficult area as victims may look towards Training Programme Directors, Clinical Leads and Managers for action, whilst few of us have any specific training. We may be poorly equipped to address these issues informally or to substitute for a counsellor or therapist. We can offer the extremely important task of ensuring robust support for reporting. I heard of examples where the more extensive involvement of such individuals, whilst well-intended, was ultimately unhelpful or damaging.
7. A recognition that an abuse of power carries consequences which can be addressed by the GMC or the police
Any individual can report an incident of concern to the GMC or the police.
Survivors of sexual assault can be supported by experts and may choose to report the incident to the police. Acknowledging this as a valid and courageous course of action is helpful. Avoid expressing views that reporting to the police is somehow extreme or in contrast, the duty of the victim; both stances are profoundly unhelpful and inappropriate. The GMC framework considers rape and sexual assault by doctors to be serious issues relating to professional misconduct. Where they consider that a crime may have been committed, they will of course suggest reporting to the police as well, although this is not easy11. The police, GMC and employing Trusts will seek to share information. These are large organisations each with their own governance and rules; there can be challenges in managing communication in a way which is timely and relevant.
Being investigated by the GMC or the police is traumatic, and the majority of investigations end in no further action; hence some individuals believe it is wrong to report sexual misconduct. Advising for tolerance of abuse or assault colludes with the disempowerment of victims and adds to the inertia against organisational learning and progress. Sadly, many victims do decide that tolerance is their best option.
Reporting to anyone requires the courage and persistence of victims who deserve the best support we can offer. Reporting on behalf of someone or coercing her to report risks causing destructive emotional trauma, a loss of evidence or an angry backlash if the process is not as she would want it to be.
Alternatively, a belief that if anything untoward has happened ‘it should be reported’ allows us to step away from the victim, sometimes with no understanding of the process or pitfalls involved and a complete lack of support. Reporting becomes less likely, the assault goes unchallenged and the perpetrator sees that his sense of entitlement was well-founded.
The destructive and distracting effects of discrimination, harassment and undermining behaviour are amplified by a sexual context. We have risen to the challenge of actively promoting values of respect and appropriate behaviour in Trauma and Orthopaedics. Understanding and supporting survivors of sexual misconduct is essential for the wellbeing of our colleagues, patient safety and high quality care.
- Balch Samora J, Van Heest A, Weber K, Ross W, Huff T, Carter C. Harassment, Discrimination, and Bullying in Orthopaedics: A Work Environment and Culture Survey. J Am Acad Orthop Surg. 2020 Dec;28(24):e1097-e1104.
- Zuckerman JD. CORR Insights®: What Proportion of Women Orthopaedic Surgeons Report Having Been Sexually Harassed During Residency Training? A Survey Study. Clin Orthop Relat Res. 2020;478(11):2607-9.
- Nielsen A. Victim Blaming and Natural Reactions to Trauma in Cases of Sexual Assault and Natural Disaster (2019). Master's Theses 3141. Available at: https://scholars.fhsu.edu/theses/3141.
- Searle R. Sexual Misconduct In Health And Social Care: Understanding Types Of Abuse And Perpetrators’ Moral Mindsets. Report for Professional Standards Authority. September 2019. Available at: www.professionalstandards.org.uk/docs/default-source/publications/research-paper/sexual-misconduct-in-health-and-social-care-understanding-types-of-abuse-and-perpetrators-moral-mindsets.pdf?sfvrsn=630f7420_2.
- Chivers-Wilson KA. Sexual assault and posttraumatic stress disorder: a review of the biological, psychological and sociological factors and treatments. Mcgill J Med. 2006;9(2):111-8.
- McAdams CJ. Perspectives on Sexual Power, #MeToo. Acad Psychiatry. 2020;44(1):26-8.
- NHS England. What is consent? Available at: https://www.nhs.uk/about-the-nhs-website/professionals/healthandcareprofessionals/child-sexual-exploitation/documents/consent-information-leaflet.pdf (Accessed Jan 17 2021)
- General Medical Council. Sexual behaviour and your duty to report colleagues. Available at: www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/sexual-behaviour-and-your-duty-to-report-colleagues/sexual-behaviour-and-your-duty-to-report-colleagues.
- Carey B. Therapy for sexual misconduct? It’s mostly unproven. The NY Times, Nov 2017. Available at: https://www.nytimes.com/2017/11/27/health/sexual-harassment-addiction-treatment.html.
- McKinney C. Sexual coercion, gender construction, and responsibility for freedom: A Beauvoirian account of me too. Journal of Women, Politics & Policy. 2019;40(1):75-96.
- Topping A. Just one in seven rape survivors expect justice in England and Wales. The Guardian. October 2020. Available at: www.theguardian.com/society/2020/oct/20/just-one-in-seven-rape-survivors-expect-justice-england-wales.