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.
Defining the problem
Despite a focus on developing a diverse and inclusive workforce, sexual misconduct in surgery remains largely hidden due to its nature as personal, sensitive and potentially destructive. The hallmark of sexual misconduct is an imbalance of power, in relation to employment, care or education. The action relates to a need for power and control, with dehumanising attitudes and psychological vulnerabilities in perpetrators. Doctors also fear false accusations which can range from misinterpretation, through to vexatious allegation.
This behaviour is common enough that most of us know someone who has experienced it, but personal stories remain known to very few. If you find 'Me too' terribly boring now, please check your privilege1 and consider whether sexual assault is something we should all just accept. Bullying and harassment have moved firmly into the category of unacceptable behaviour but sexual misconduct remains a shameful reality, with widespread acceptance, excuses and barriers to reporting. Great harm is delivered by a minority of individuals. The power gradient can have an unexpected psychological effect on otherwise assertive and confident people. Targets can find themselves unable to react to unexpected and sudden sexual advances from those in a position of authority2,3. This is described in the literature on sexual assault, with many examples in all walks of life4-6, but it is still surprising when we hear that senior doctors too, both male and female can commit assault and remain protected by their position.
An imbalance of power also makes it difficult for targets to express discontent. There are frameworks and organisations aimed at support and protection of individuals reporting unacceptable behaviour7. Unfortunately, the label of ‘victim’ has undeniable, wide-ranging visible and powerful effects in the workplace and on individuals, potentially every working day. One helpful concept is the shift away from hand-wringing ‘support of victims’ towards techniques which expose the truth and empower witnesses to effect change. There can be situations where an apology, expression of regret, acknowledgement that the behaviour was not welcome and concern for her wellbeing can be sufficient. Reporting at this point, with this response, is rare, but has the potential to conclude an incident with a demonstration of remorse and respectful intentions.
Sexual misconduct in healthcare is destructive and difficult to manage
Surgical training takes us to different hospitals and in about half of the 10 departments I worked in, in four regions of the UK, several women, usually a nurse, physiotherapist or trainee colleague would share unexpected incidents which had led to profound unhappiness. Older women would use softer terms such as
“He just wanted to have his way with me”
“He took advantage of me”
“I went along with it but it was not what I wanted”
Those younger than me would express shock that unwanted sexual behaviour was tolerated by the medical profession
“Why is this allowed?”
“Why do they tolerate him?”
“Why did nobody warn me, it turns out they all know what he’s really like?”
One recurring theme is that women in a social situation experience unexpected sexually aggressive behaviour, not from strangers but from trusted doctors in a position of responsibility, sometimes with a direct supervisory relationship. Alcohol is sometimes a contributing factor to vulnerability, aggression and difficulties in assessing consent. Other recurring themes in perpetrator behaviour are common wherever an imbalance of power is found. Typically, any challenge afterwards is met with an approach of entitlement and impunity, with direct or implied threats. Another theme is angry resentment by the perpetrator when the reflective response of their target was not as they would wish it to be. I heard about the unanticipated consequences women of all ages had faced which resulted in life-changing emotional distress, relationship breakdown, unwanted pregnancy, harm to their careers and suicide attempts. Most of the cases shared with me as a trainee were never reported formally; it is likely as many as one third of incidents were never shared with anyone4.
I empathised with the concept that I also did not want to live in a world which allowed people to be treated like this. This leaves us in a dark and difficult place whilst the regulatory framework and culture allow such behaviour to continue.
Characteristics of misconduct
A report commissioned by the professional standards authority8 defined four categories of response from those in healthcare found culpable of sexual misconduct.
Defined responses included denial of incident, denial of harm, victim-blaming and cognitive reconstruction. Cognitive reconstruction is a phenomenon in which perpetrators genuinely believe that their actions are acceptable. It is associated with personality vulnerabilities including difficulties with empathy and narcissism9, which can lead to the assault and this characteristic response. It is recognised in the literature relating to sexual misconduct10 with many public examples. It can be disarmingly unsettling to confront a colleague who is intelligent and high-functioning but believes they have done no wrong, even where there are independent witnesses or multiple victims. Informally, it can be difficult to establish any definite conclusion, often resulting in no further action. Acknowledging an incident and apologising did not occur in this series and arguably is a different issue.
Across a hierarchy of responsibility, the risk of damaging others is predictable and avoidable. Contemporary standards for the military describe this explicitly. Illicit sexual activity between colleagues in the workplace itself can generate a toxic work environment, is unlikely to be tolerated by employers and risks undermining the confidence of colleagues and patients. Informing managers and supervisors may seem boring and intrusive but could serve as an indicator of respectful and consensual intention. Some Trusts have processes in place which may come to represent a standard, for everyone’s protection.
In parallel with racism, discriminatory behaviour will continue whilst we tolerate disrespectful language. Men and women are often in the privileged position where this is grating, but not personally offensive to us. Challenge from a position of privilege is powerful, but can happen only if we have the interest and energy to face up to our responsibilities.
Bystander training has demonstrated success as a useful intervention in the military and in higher education11, 12. Participants rehearse how to intervene in situations where they suspect mismatched expectations, or obvious distress is being ignored. A similar approach within the health service could favour prevention of this difficult problem, for everyone’s benefit.
Sadly, the focus is more often on the fear of an environment where anyone can be accused and the perceived loss of personal freedom for those in a position of privilege. Understanding the right to challenge sexual misconduct keeps everyone safe and promotes our values of excellence, integrity and respect13.
It is difficult to legislate for sexual behaviour between colleagues. A failure to acknowledge a power gradient is hazardous and can lead to opportunities for sexual assault. The combination of sexual behaviour and alcohol (and/or recreational drugs) is also risky as it can lead to offensiveness, errors in assessing consent and an inability to give consent. It is hard to see how sudden sexual advances towards a colleague are compatible with the GMC’s Good Medical Practice standard of respect. The radical concept of listening to each other, regardless of gender and role, especially at times of distress, will help us build a respectful and inclusive profession. Establishing a genuine standard of respect will mean that eventually, this behaviour may disappear, as expectations and consequences will be widely known.
Section 74 of the Sexual Offences act 2003 defines consent:
“If she agrees by choice, and has the freedom and capacity to make that choice”
I use the common terms ‘victim,’ and ‘target’ whereas the regulatory framework refers to a ‘witness’ and those experiencing sexual assault are appropriately termed ‘survivors.’ This is written as ‘she,’ with an understanding that a target could also be ‘he.’
- Finch SD. Ever Been Told to ‘Check Your Privilege?’ Here’s What That Really Means. Everday Femism, July 2015.. Available at: https://everydayfeminism.com/2015/07/what-checking-privilege-means/ [Accessed 2020].
- Dziech BW, Weiner L. The Lecherous Professor: Sexual harassment on campus. University of Illinois Press; 1990.
- DuBois JM, Walsh HA, Chibnall JT, et al. Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases. Sexual Abuse. 2019;31(5):503-523.
- Reel JJ, Crouch E. # MeToo: Uncovering sexual harassment and assault in sport. Journal of Clinical Sport Psychology. 2018;13(2):177-9.
- Freischlag JA, Files K. Sexual Misconduct in Academic Medicine. JAMA. 2020;323(15):1453-4.
- Dobbin F, Kalev A. Why Sexual Harassment Programs Backfire. Harvard Business Review, May/June 2020. Available at: https://hbr.org/2020/05/why-sexual-harassment-programs-backfire.
- General Medical Council. How we safeguard whistleblowers in our processes. Available at: www.gmc-uk.org/about/how-we-work/corporate-strategy-plans-and-impact/supporting-a-profession-under-pressure/improving-support-for-doctors-to-raise-and-act-on-concerns/how-we-safeguard-whistleblowers-in-our-processes.
- 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.
- Widman L, McNulty JK. Sexual Narcissism and the Perpetration of Sexual Aggression. Arch Sex Behav. 2010;39(4):926-39.
- Greathouse SM, Saunders JM, Matthews M, Keller KM, Miller LL. A review of the literature on sexual assault perpetrator characteristics and behaviors. Santa Monica, CA: Rand Corporation; 2015.
- Aggarwal R, Brenner AM. #MeToo: the role and power of bystanders (aka us). Acad Psychiatry 2020; 44(1):5-10.
- Potter, S. Using a Multi-Media Social Marketing Campaign to Increase Active Bystanders on the College Campus. Journal of American College Health. 2012;60:282-95.
- British Orthopaedic Association (2021). BOA Values. Availabe at: www.boa.ac.uk/about-us/strategy.html.