I was honoured to be invited by SHaME to speak at this year’s Sexual Violence, Medicine, and Psychiatry online academic symposium. Although the symposium was initially scheduled for 2020, it was delayed until March 2021 due to the pandemic and consequently moved to an online format.
Sexual Harms and Medical Encounters (SHaME) is an interdisciplinary research hub focussed on the interlinks between sexual violence, medicine, and psychiatry. Their projects explore historical, contemporary, regional, and global perspectives to understand the role of medical professionals in understanding and addressing sexual harms. While SHaME does not focus solely on doctors who have been sexually harmed by other doctors, their approach to researching and making visible the complexities of sexual harms has been inspiring for our own editorial team, particularly as we began to contemplate the dissemination and translation of our research and the potential to continue building a community of practice in this space.
For this symposium, I delivered a presentation that explored. In the first half of the presentation, I explain a little of the background of my research into occupational sexual harms in medicine, including a brief overview of the narrative framework developed by myself, Prof Kirsty Douglas, and Prof Christine Phillips in our 2015 qualitative study (and its findings). The second half of the presentation is more about addressing the complexities and dilemmas involved in making workplaces safe. I use CANMEDS to provide a conceptual framework to tease out the different dimensions of professional responsibility (for individuals and institutions) involved in addressing workplace sexual harms, beyond “zero tolerance” policies.
The other symposium recordings, including roundtable discussions, presentations, and keynote papers, are all still available and free to access here. It’s a rich collection of expertise, exploring topics ranging from prevention of violence against women with disabilities to the changes in conceptualising trauma in the field of sexual assault service provision, and I highly recommend taking a look. I’m honoured to have had the opportunity to participate, and I’m on tenterhooks watching for their next events!
Hi everyone, my name’s Louise Stone, I’m from the Australian National University and I’m grateful to be involved in this conference.
In 2014 I looked after a young intern who was raped by her boss while on her way to the carpark after a night shift. In the process of caring for her, I realised that the therapeutic relationship felt very different, and I felt I needed resources to help me manage her trauma. After all, she was a doctor, the perpetrator was a doctor, and I was a doctor, so there was no wonder there were complexities in the consultation. However, at the time, there was nothing in the literature about sexual abuse in the medical profession.
I’m a GP with expertise in mental health and qualitative research, so it seemed the time to step up and do something. I joined up with Kirsty, who’s a professor of general practice and an expert in health services, and Chris Phillips, who’s a GP and anthropologist, to develop a qualitative research project around this difficult issue.
Although we know little about the experience of qualified doctors, we do know a little about harassment and discrimination in medical training. This international meta analysis makes it clear that harassment is common, and unfortunately sexual harassment is very common, particularly amongst women.
Still, despite the fact that I talked to a number of senior GPs who cared for junior doctors who were victims of abuse, little is known about the prevalence of such abuse, or the lived experience of the survivors.
We do know that the medical workplace can be quite toxic. There are high rates of depression and alcohol abuse, high rates of secondary traumatic stress, and feelings that admitting to any of this is a sign of weakness that can ruin your career. Healthcare occurs in a community, and community values are not always pleasant. Racial or sexual diversity can lead to microaggressions, comments that add up over time and can make you more vulnerable to trauma. Unfortunately, suicidal ideation is very common, particularly amongst medical students – so common that 4% of our colleagues attempt suicide at some stage in their career. So I knew that stepping into this deeply challenging area was going to be methodologically and ethically challenging, and so I invited a broad group of experts in law, medical education, organisational psychology, ethics, psychiatry, and research methodology to help me on a reference group. And having spent considerable time designing the study and getting the ethics right, I was ready to recruit. And this story broke.
Caroline Tan is a neurosurgeon who won a case of sexual harassment as a registrar, and essentially lost her career. Then another registrar visited Professor John Kearsley at his home when he invited her to discuss a fellowship opportunity. She was drugged and assaulted, and his is the first criminal conviction we have in Australia for sexual assault of a doctor, by a doctor. Suddenly I didn’t have a problem with recruitment any more.
I recruited participants through social and mainstream media. We didn’t specify gender in the study, but 6 women volunteered. I’ll call them Stephanie, Claire, and Emily (who were specialist registrars at the time of abuse and won their cases in a civil or criminal court), Helena, Alice, and Kate didn’t report their abuse (they left the hospital system and entered general practice). I interviewed them over 2 years, for 1-6 hours in total, and all were registrars at the time of their abuse. We analysed their interview transcripts, their victim impact statements, legal documents, and media reports.
We found that there were 5 critical periods in the experience of abuse. The Prelude is the time before the abuse where the victims try to work out why the trauma happened to them. Helena and Kate felt they needed to be less open and friendly. For Helena, this meant “being professional” and “not smiling as much”. She commented that female doctors walk a tightrope, balancing the need to be strong and make decisions and be a good girl who is approachable and nice to the nursing staff. Some participants had already experienced abuse in school and had been taught not to speak up. They all felt the culture of bullying and harassment in the hierarchy of medicine didn’t help. In Emily’s case, the phone calls, the comments, the touching went on for months. She felt a responsibility to “be professional” and “manage this on her own”. “Being professional” seems to mean not reacting to bad behaviour, retaining your dignity and your poise – and in these circumstances, it just doesn’t work.
In this study I defined sexual abuse as a single event or escalating harassment that is unwelcome and distressing. The women questioned themselves and were ambivalent about their role. The helplessness is horrible, so it’s not surprising that many would rather feel responsible and at least retain some sense of power and agency. Helena was a young registrar when she was assaulted while on a rural term after a team dinner. 5 years later she still questions whether being held against a wall and touched was abusive. In her words: “sex with patients is never okay. Sex with nurses is not okay either”, but like all the participants in this study, she felt like “fair game”. These women might not report because they don’t recognise the abuse – they expect it.
This is the phase that surprised me. Limbo is the time between the abuse, and the resolation of the inquiry around it (when the abuse becomes public). 3 of the women in my study did not report: they left the hospital system and abandoned their specialist careers, and entered general practice. And it’s not surprising. As Emily said: “does anyone ever report these things and come out on top?” For Emily, Stephanie, and Claire, though, Limbo meant years of silence while the courts, the regulatory bodies, and human resources considered the case. These legal and organisational processes require prolonged periods of confidentiality. Victims endured many months of silence and isolation. Some still worked in teams with the perpetrators. Stephanie saw the court case through only because she wanted to protect other women.
At some point the victim’s name becomes known: in their workplace, in the courts, or in the media. Feelings of betrayal are common, and loss of anonymity and gossip are very painful. Rape culture is also alive and well. There was an article about Claire that said: “if you can’t get a neurosurgeon to fix your brain tumour, it’s because people like Claire have ruined the senior surgeons.” Stephanie still struggles with the fact that John Kearsley pleaded guilty, but had a hundred testimonials saying what a wonderful man he was, and had his sentence truncated to 7 months on appeal because he was so important to the community. Emily was told she was no longer welcome in the hospital because she caused her perpetrator to become suicidal. Claire never found work in a public hospital again. Emily took years before someone was prepared to give her a job. For these women, the Exposure was a second assault, and the women they expected to support them caused the worst of the betrayal. For Stephanie, though, there was some light. Her college was deeply supportive, and it was the senior men who rang to ask her what they could do to help. She says that’s the only reason she’s finally able to return to her job 4 years after the assault.
In the Aftermath, these women still struggled to make sense of things. The women who won their case in court all had difficulty re-establishing their careers and their sense of self. Emily still panics when her phone rings. Stephanie still struggles to speak to other professionals at work. And Claire talks about losing faith in her profession. In this context, justice is elusive. These women are now profoundly different. As Stephanie put it: “the world is broken, and will never be the same.”
So where do we go to next? It’s easy to talk “zero tolerance”, but harassment is illegal and that hasn’t stopped it happening. I didn’t do this study to tell sad stories in medical journals. It seems to me it’s up to all of us to work together to change our community. But the problem is not an easy one to solve.
So this is the CANMEDS framework, which defines all the roles we take as professionals with our clinical role in the centre. This study started with me asking a clinical question, but that’s not the only question we have to answer. To me, it seems there’s 8 dilemmas we have to resolve if we’re going to make our workplaces safe.
We have a responsibility to mentor the next generation of practitioners. In our study, we found that mentorship was manipulated into grooming. Some of the women were singled out, praised, given good cases to manage. One factor that facilitated this process was the deep respect in which junior doctors often hold their seniors. The CANMEDS definition of professionalism requires doctors to put the needs of the dependent person first, in a supportive and protective environment. The dependent person in these relationships is definitely the trainee. Unfortunately, not everyone is good at reflecting on their own feelings and behaviour. Keeping mentoring relationships safe means ensuring mentors have the skills of personal insight and reflection. We need to incorporate this discussion into supervisor training.
In this study, there were failures in moral leadership. Harassment occurred despite supposed “zero tolerance”. As one of my participants put it: “There were anti-bullying and anti-harassment posters everywhere in the hospital, but when I actually asked for help I was the one who lost out.” At the medical board level, there is mandatory reporting if a doctor has sex with a patient, but there’s no mandatory reporting for a trainee. Participants, therefore, felt unprotected at the highest level. Having already experienced the normalisation of sexual harassment in medical teams and the routine humiliation of junior doctors, it’s not surprising that 3 women in this study chose not to report their experience. Several participants commented on the stigma associated with being “too assertive”, afraid of being seen as a “feminazi” or a “troublemaker”. It’s hard for anyone to confront powerful or aggressive senior colleagues. Medical managers have a a role to play in setting up an impartial process and a network to support them to manage any difficult situations. Someone has to be prepared to sack the senior surgeon, or “zero tolerance” means nothing.
One common form of communication within organisations is gossip: the inevitable fallout of a complaint of sexual harassment or assault. Three of our participants in our research experienced not only internal gossip, but public exposure. When the case of one trainee was made public, several female colleagues minimised her experience. “I haven’t come across any of it,” they said, “and it’s no more common in medicine than anywhere else. This is all overblown.” The same person had feedback that people were saying “oh, she used to sleep around.” One particularly distressing type of formal communication occurred as letters of support from senior colleagues for a perpetrator who pleaded guilty in court. Privileged individuals without similar experience may fail to understand just how hurtful their unguarded comments can be. However, the inability to imagine what it must be like to be bullied, harassed, or assaulted is a serious failing when one considers how important accurate empathy is in medical practice. Public scandal can undermine community and professional confidence in an individual, a profession, and an institution, but institutional silence can contribute to betrayal trauma in the victim. It is an extremely complex challenge to decide who should make statements, what messages should be conveyed, and what information and opinions are appropriate, either formally or informally.
Collaboration is based on trust and respect, but it was clear from our studies that victims can be denied collegiality and locked out of their professional communities as “troublemakers”, even when they win their case. As doctors we’re often required to manage ambiguity in patient care, for instance by treating patients well regardless of their moral flaws. The ability to come to terms with our own negative feelings applies to colleagues as well as patients. It’s easy to take sides and break down our communities. Whatever the circumstances, and especially if the accuser and the accused are part of the same team, doctors need clear institutional guidance on how the situation can be managed, and they need to manage their own opinions very carefully.
All the participants in this study were in training, and were reliant on the assessment of senior colleagues to progress. They all believed that the assessment of their performance was likely to be influenced by the choice to report sexual harassment and abuse. Part of the role of assessors is assessing “soft skills”, like interpersonal skills and professionalism. Unfortunately, these are the assessments most prone to bias. Claire and Emily both had their assessments for professionalism plummet as soon as they reported their abuse. Senior colleagues and training programs can take action as medical educators. We need to assess fairly, and this is harder than it looks. Discrimination can be quite dangerous.
One of the trainees I interviewed was isolated in a rural rotation and had no idea who to approach for help. Another turned to a lawyer and received poor advice. It is possible that an advocate within the profession might have saved her from additional distress. On the other hand, one trainee felt that her senior colleagues managed the whole thing extremely well. Doctors are familiar with their role of advocate on behalf of individual patients, and of specific categories of patients. They are less familiar with the idea of advocating on behalf of their colleagues. Nevertheless, the same principles apply as those outlined in CANMEDS. This includes using one’s influence, mobilising change, speaking up for those in need, engaging relevant others, and improving organisational quality.
We seldom discuss the parallels between the role of advocate in patient care, and in collegial care. Advocacy can involve stepping out of line, with the risk of being unpopular or losing your place in the Old Boys’ network. Advocacy among junior doctors can mean standing up for someone with whom one’s in competition. As colleagues, we need to support our whistleblowers and the decisionmakers who sit in positions of power at the college, the medical board, and in hospitals. It’s a tough job, and we need to support our colleagues who do it.
All the features of the CANMEDS configuration meet at the heart, in the professional role. But we found that it was difficult for our interviewees to find the right person to help them; that GPs were not always knowledgeable and skilled in management; that acute care (such as the collection of forensic specimens) was limited by concerns about anonymity. No-one was advised to contact formal support agencies, such as the Doctors’ Health Advisory Service. The interviews highlighted a therapy dilemma. Doctors can help victims of sexual trauma to recover, partly because they are deeply experienced in medical culture. However, doctors share their professional position both with the victim and the perpetrator, and we need to consider what this means.
We need wise leaders in all these roles if we as a community are going to address this really wicked problem. It’s time that we realised that this is a complex community problem that needs a complex community solution. We’ve moved this project forward and are currently editing a book on this topic, with authors from Argentina to Zambia, and experts on everything from international law to organisational psychology to medical education and to therapy. If you’re interested in this work, please contact us by emailing me at ANU on the address shown on this slide. If you are from the Middle East or from South-East Asia we would be particularly delighted, as despite 18 months of serious effort we are struggling to find authors in your region. We know solutions will only be found if we work together. Please join us if you can.