Today I delivered a brief, tailored overview of some of the Australia chapter for the Royal Australian and New Zealand College of Psychiatry Congress 2022. In less than 15 minutes, it’s difficult to capture the scale of the problem in all its complexity, and I am deeply grateful to the attendees for being so open and willing to engage with such confronting and challenging material. The discipline of psychiatry plays a crucial role in managing the consequences of occupational sexual harms, and collaboration is critical for addressing the pervasive structures that enable gendered harms in our shared habitat of medical workplaces.
I’m going to do something a little unusual for this presentation and enclose a suggested reading-list below the presentation transcript and references. In such a limited time frame there was a lot of material that didn’t make the final cut; these readings, while not the sum total of our research, may at least begin to aid those who wish to develop their understanding of the state of the problem in Australia, beyond the 12-minute mark.
In 2014, I looked after an intern who was raped by her boss while on her way to the carpark after a night shift. That therapeutic relationship led to 8 years of research, teaching, policy and education around the vexed issue of sexual harm of doctors, by doctors
In 2019, Liz and I started working on an edited book capturing lived experience and policy responses from experts around the world.
We included expertise from a variety of salient disciplines. Today, we would like to bring you a small snapshot. As we do so, we are indebted to one of the doctor survivors who we’ll call Stephanie. She’s been brave enough to share her experience of sexual assault in an Australian hospital.
This issue will come to you, because you will hear these stories from a variety of perspectives. The CANMEDS framework describes the multiple roles we may take as clinicians, and all are relevant to the difficult problem of sexual harm in medicine.
Perhaps you come as a colleague, a manager, a teacher in the professionalism curriculum, a researcher of sexual harm, an advocate for others, a medical regulator or a survivor. Regardless of the roles you carry, you probably still inhabit the role at the centre of this model. Like me, you are likely to come across the vexed dilemma of establishing a therapeutic relationship where the perpetrator, the survivor and the therapist share the cultural context of medicine.
As you can gather, we don’t think a simple educational module for senior staff, or an edict encouraging survivors to report is enough. The problem of sexual harm in medicine is a complex one, and deserves a thoughtful and multilayered solution.
Psychiatrists are part of that solution.
So, what is sexual harm and how do we define it for the purposes of this presentation and the book?
Let’s start with an example from Stephanie. “Time is supposed to heal all wounds, but I am still waiting. Every time I’m reminded of the incident, I still feel the same rage, shame, and desire to just disappear.”
We use the term “sexual harms” very specifically for two reasons:
We want to account for the way sexual harms escalate, and the recidivist nature of perpetration. We also want to encompass the entire spectrum of harm, from the factors that raise risks to the aftermath for the survivor, the profession and the patients.
Secondly, we wanted to avoid getting bogged down in overlapping and contradictory legal frameworks around the world. For us, the focus should be on the experience of the survivor. If there is harm, there is a problem, regardless of the definition or rape, sexual assault, gender based harassment or discrimination operating in your sector.
Nevertheless, discussing prevalence is hard. We know it’s hard to estimate prevalence with any hidden criminal behaviour. Every time we present, we get these questions about prevalence. So we wanted to share some of the data we DO have in Australia, with all it’s contradictions, overlaps and flaws, to give you a snapshot of what we know.
So, here are some of the relevant studies, and yes, we will give you a link to the references at the end.
Yes, doctors experience sexual harms.
One in three workers in Australia have been sexually harassed at work over the last five years. The rate of sexual harassment in healthcare was also 33%.
12% of ACT staff indicated they had been subjected to physical harm, sexual harassment or abuse at work in the last 12 months.
In NSW, one third of all doctors had experienced sexual harassment at least once in their careers;
55 % of female doctors
and 61% of female doctors in training reported that they had experienced sexual harassment in their workplace.
Yes, junior doctors experience sexual harms.
Around 14% of NSW and ACT junior doctors reported sexual harassment,
and 29% of females reported sexual harassment during their employment at their health service.
Nationally 9% doctors in training experienced sexual harassment in the last 12 months.
Medical students experience sexual harms.
14.5% of students had been sexually harassed since starting at University. 5% had been sexually assaulted since starting University. Woman, and LGBT plus had much higher risk.
Yes, it is probably occurring in your specialty
3% sexual harassment in the last two years .
7% have ever experienced sexual harassment in the workplace.
6.2% had ever experienced sexual harassment in the workplace .
Yes, doctors perpetrate sexual harms against other doctors.
For junior doctors, it is mostly their senior colleagues.
For all doctors, it is mostly other doctors causing harm.
Doctors can be a greater threat against doctors in training. than patients and patient families.
And yes, they may be supervising the survivor. At least 45% of the perpetrators of bullying, harassment or discrimination were supervisors.
No matter how we swing the data, we need to concede that the risk is well above zero.
Under-reporting is a problem across all forms of gender-based violence. We have a problem with the risk-benefit equation. The risk is gaining a reputation as a difficult person who is “unprofessional” or a “troublemaker”. The survivors fear losing their reputations, their training positions and their careers. The personal benefit is usually negligible.
Many survivors just want someone to hear and validate them. They don’t want to start an extended combative litigation process. But once their situation is reported, many lose control of their own stories
These are the instrumental reasons. There are other, less conscious reasons that are more insidious. In order to understand them, it is important to think across the whole trajectory of trauma from the prelude to the aftermath
So let’s start before the abuse. What makes you vulnerable? For Stephanie, it was all about power, status and agency.
“When I went through med school, we got into theatre and I was told to stand in a corner and not speak. And often we’d join the team, and we’d be ignored and we were okay about that. And it wasn’t surprising if the consultant who you’ve worked with for six weeks didn’t know your name. I think all of that [affects] your self-esteem and makes you think that they’re really important and you’re nothing.”
Medicine normalises or even valorises self sacrifice. It’s the “theory of beneficial mistreatment” we see in many hierarchical professions from the military to the missionary. What doesn’t kill you makes you stronger. Microaggressions reduce your capacity to recognise and respond to boundary violations. And of course, trauma survivors and those with intersectional disprivilege are at higher risk.
Sexual harassment, of course, can exacerbate this need to fade into the background.
Five years after the assault, Stephanie still says this:
“The perpetrator used to hold a high position in a well known hospital and he was a respected member of the community. I on the other hand was still a trainee.”
Stephanie talks about how that mantle of respect impacted her capacity to detect and manage the risk of harm.
When assault happens, it is hard for survivors to recognise and name it. These things happen in the cold hard light of day in institutions that the public and the workforce need to trust. Survivors and anyone who hears their story have to manage their own cognitive dissonance. We think it has the same feel as family secrets: Mum’s alcoholism or Dad’s violence.
Known but unknown, Seen but unseen. Which is why there is often a long time where the survivor fades into a form of limbo.
During this time, survivors have to decide whether to take action.
If they do, there are a LOT of “formal” options. We had difficulty finding clear pathways and any information about what might happen. Survivors will have a lot of considerations to juggle with little information available. Questions like:
- Will my report be anonymous?
- Will the process harm me further?
- How long will I have to wait for a resolution?
- What will it cost me in time, money, emotional energy, to pursue the process?
- Will I be told when a resolution is reached? Will I be told what it is?
- What are the chances I can manage my current situation until I can leave this rotation?
- How will I manage my fear of working with the perpetrator and managing sense of responsibility to protect other people in the workplace?
- What will happen to my training if my College finds out?
When people do find out, rape culture is alive and well. Loss of anonymity and gossip is painful, and the exposure can feel like a second assault.
Regardless of the journey, most survivors choose to re-enter the profession. When I interviewed Stephanie, I remember her telling me that when she returned to a hospital after five years of leave, she felt like she had to hug the walls, because the floor no longer felt safe. I don’t think we put enough emphasis on the trauma of re-entry.
We’ve talked a lot about the trajectory of trauma, but as we finish, I wanted to mention two theoretical frameworks that can help us understand and respond to this rift in our community.
Here’s Stephanie again, talking about the relational basis of trauma in the profession.
“Being a trainee can be like being in an abusive relationship. There are many of the same things happen, the same psychological techniques… A lot of boundary transgressions, like expecting somebody to come in all weekend when they’re not paid for it. It’s a weird parental, patriarchal kind of relationship.”
In Stephanie’s case, the perpetrator held a senior position in a well-known hospital and was a respected member of the community. She was “just a trainee.”
Sexual harm within this relationship is not just a trauma, it is also a betrayal.
Freyd’s betrayal trauma theory suggests that under-reporting may be linked to a purposeful, if unconscious, method of “not-knowing”. If there is a close and dependent relationship between the perpetrator and survivor, acknowledging trauma threatens our interpersonal, physical and moral security. We respond by developing an unconscious betrayal blindness. Bystanders can do this too.
Michael Salter writes about how this can create gaps in individual and collective narratives. “In effect, the disallowance of traumatized knowledge at the individual level is reproduced at the collective level, such that, even where sexual abuse survivors are able to formulate and share a narrative of their experience, this narrative struggles to find a public register of meaning that would lend it significance.”
So to close, I’d like to share some insights we’ve gained presenting this work that lends weight to Freyd’s and Salter’s theories.
When we present this work, many people find the data difficult to accept. These are not bad people, we just recognise the strength of the forces keeping us all from seeing trauma in our own profession. Here are some common comments you may well recognise from other hidden trauma contexts:
- “well I never saw a single case and I’ve been managing professional misconduct in medicine for decades, so the problem probably isn’t as big of a deal as you’re saying it is”
- “well I never did anything and neither did my esteemed colleagues and frankly this is a difficult time for medicine, so now is not the time to make mountains out of molehills”
- “well I think your logic is sound but I never saw a quantitative study that suits my specific requirements, so you should do more surveys and syntheses of formal complaints first before you start asking people why they don’t respond to surveys or submit formal complaints”
- “well I never saw any men in your data therefore your data must be flawed and you must be biased”
- “well I never saw a single case, I believe you that it’s a problem but I’m astonished and confused why nobody ever came forward”
This is not an easy conversation. It’s confronting, and its complex. The theory, expertise and experience you have as psychiatrists means you have a lot to contribute in this space, and I know many of you are already working to reduce sexual harm in a variety of contexts. If you’d like to continue the conversation with us, here’s my email address, and the QR code link to our website. Thank you for all the work you to reducing the impact of sexual harm in our community.
On the rippling effects of sexual harms of doctors by doctors
- Oertelt-Prigione, S. (2019). Sexual Harassment is an Occupational Hazard. Journal of Women’s Health, 29(1), DOI: 10.1089/jwh.2019.8113.
- Jenner SC, Djermester P, Oertelt-Prigione, S. (2020). Prevention Strategies for Sexual Harassment in Academic Medicine: A Qualitative Study. Journal of Interpersonal Violence, Jan 30. DOI: 10.1177/0886260520903130
- Cortina LM, Areguin MA. Putting People Down and Pushing Them Out: Sexual Harassment in the Workplace. Annual Review of Organisational Psychology and Organisational Behaviour. vol 8 pp. 285-309. DOI: https://www.annualreviews.org/doi/abs/10.1146/annurev-orgpsych-012420-055606
- Searle R.H. Sexual Misconduct in Health and Social Care: Understanding types of abuse and Perpetrators’ Moral Mindsets. Report for Professional Standards Authority. 2019. Retrieved from: https://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
- Searle, R. H., Rice, C., McConnell, A., & Dawson, J. (2017). Bad apples? Bad barrels? Or bad cellars? Antecedents and processes of professional misconduct in UK health and social care: Insights into sexual misconduct and dishonesty. Retrieved from: https://www.professionalstandards.org.uk/docs/default-source/publications/research-paper/antecedents-and-processes-of-professional-misconduct-in-uk-health-and-social-care.pdf
Statistics on sexual harms in Australia (non-specific to medicine)
- Australian Human Rights Commission (2018). Everyone’s Business: Fourth national survey on sexual harassment in Australian workplaces. Retrieved from: https://humanrights.gov.au/our-work/sex-discrimination/publications/everyones-business-fourth-national-survey-sexual
- Heywood, W., Myers, P., Powell, A., Meikle, G. & Nguyen, D. (2022). National Student Safety Survey: Report on the prevalence of sexual harassment and sexual assault among university students in 2021. Melbourne: The Social Research Centre. Retrieved from: https://assets.website-files.com/61c2583e4730c0d5b054b8ab/623ba530bc6676dfcdb1d5dc_2021%20NSSS%20National%20Report.pdf
Statistics on sexual harms in Australia between doctors (or of trainee doctors by doctors): Prevalence, reporting behaviours, reporting outcomes
- Australian Salaried Medical Officers’ Federation NSW (2019). ASMOF Sexual Harassment and Gender Equity Survey: Doctors-in-Training Report. https://www.asmofnsw.org.au/images/ASMOFNSW/ASMOF%20Sexual%20Harassment%20and%20Gender%20Equity%20Survey-%20DiT%20Report.pdf
- Australian Salaried Medical Officers’ Federation Submission to the Senate Education and Employment Legislation Committee Inquiry into the Sex Discriminaiton and Fair Work (Respect at Work) Amendment Bill 2021 (2021)). https://www.asmof.org.au/images/ASMOFNational/ASMOFSub_Respect@Work.pdf
- Medical Board of Australia and Ahpra (2022). Medical Training Survey 2021 Annual Report. Retrieved from: https://medicaltrainingsurvey.gov.au/Results/Reports-and-results
- Australian Medical Association (WA) (2016). Shattering the silence. Medicus, 56(3), April 2016, 18-23.
- Independent Review into the Workplace Culture within ACT Public Health Services (Final Report). March 2019. Retrieved from: https://www.parliament.act.gov.au/__data/assets/pdf_file/0006/1344903/Independent-Review-into-the-Workplace-Culture-within-ACT-public-health-services-Final-report-March-2019.pdf
- Victorian Public Sector Commission (2022). People Matter Survey 2021. Retrieved from: https://vpsc.vic.gov.au/data-and-research/people-matter-survey-data-2021/negative-behaviour/
- Crebbin, Campbell, Hillis & Watters, 2015. Prevalence of bullying, discrimination, and sexual harassment in surgery in Australasia. ANZ J Surg, 85, 905-909. DOI: 10.1111/ans.13363
- Australasian College for Emergency Medicine (2017). ACEM Membership Consultation Paper: Discrimination, Bullying and Sexual Harassment. https://acem.org.au/getmedia/6e60dba9-7ee3-4524-bde4-82b1535bea17/ACEM_DBSH_Action_Plan_Consultation_Paper.aspx
- Venkatesh B, Corke C, Raper R, Pinder M, Stephens D, Joynt G, Morley P, Bellomo R, Bevan R, Freebairn R, Varghese B, Ashbolt M, Hawker F, Jacobe S, Yong S.: Prevalence of bullying, discrimination and sexual harassment among trainees and fellows of the college of intensive care medicine of Australia and New Zealand. Critical Care and Resuscitation, 18 (4). 01 Dec 2016. DOI: 10.3316/INFORMIT.515237365457343
- Llewellyn A, Karageorge A, Nash L, Li Wg, Neuen D (2018) Bullying and sexual harassment of junior doctors in New South Wales, Australia: rate and reporting outcomes. Australian Health Review, 43(3), 328-334. http://dx.doi.org/10.1071/AH1722.
- AMA, 2015. Submission to the Expert Advisory Group on Discrimination, Bullying, and Sexual Harassment Advising the Royal Australasian College of Surgeons. Retrieved from: https://ama.com.au/sites/default/files/documents/FINAL_AMA_Submission_to_RACS_EAG_on_Discrimination_Bullying_and_Harassment.pdf
The nature and power of betrayal trauma and cultural narratives around sexual harms in Australia
- Smith CP, Freyd JJ. Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress. 2013;26(1):119-24.
- Smith CP, Freyd JJ. Institutional betrayal. American Psychologist. 2014;69(6):575.
- Smith CP, Freyd JJ. Insult, Then Injury: Interpersonal and Institutional Betrayal Linked to Health and Dissociation. Journal of Aggression, Maltreatment & Trauma. 2017:1-15.
- Minter, K., Carlisle, E., & Coumarelos, C. (2021). “Chuck her on a lie detector” – Investigating Australians’ mistrust in women’s reports of sexual assault (Research report, 04/2021). ANROWS.
- Salter, M. (2020). The transitional space of public inquiries: The case of the Australian Royal Commission into Institutional Responses to Child Sexual Abuse. Australian & New Zealand Journal of Criminology, 53(2), 213–230. https://doi.org/10.1177/0004865819886634