This week we had the good fortune to join Dr. Vicki Magley and Prof. Anna Kirkland on an online panel discussion regarding workplace sexual harms of trainees and professionals in science and medicine, run by Assistant Professor Dawn Taylor for Women in Neural Engineering (WINE). The session began with a presentation by Dr Magley providing a brief overview of the iceberg model of sexual harassment and the incidence in STEM academic faculty and students, concluding with correlations between different types of sexual harassment, and between sexual harassment and negative outcomes.
The panel explored a number of questions over the course of the hour, including:
Why is the incidence of workplace sexual harassment in academic medicine is so much higher than other fields?
How can institutions improve reporting behaviours?
Do we think institutions are equipped to investigate and manage sexual harassment?
What do we know about the experiences of LGBTQIA+ people in STEM regarding sexual harassment?
Acknowledging that men also experience sexual harassment, what can be done by men who are bystanders, who want to be good allies?
It was such a privilege to be part of this panel, and to try to wrap our heads around the problem – and its solutions – together. The full recording of the forum can be watched here, and WINE can be found on Twitter here.
The MWIA Western Pacific 2021 conference has been and gone! I want to extend my thanks and gratitude to Dr Dabota Yvonne Buowari for volunteering to present a poster for the book, as the editorial team were unfortunately unable to attend. This year’s theme was “The Role of Medical Women in the Future”, and given the overwhelming courage and initiative of the women who have written, researched, or shared their stories for this book, this wass certainly the year we couldn’t afford to miss! The presentations and posters can still be viewed as video on demand here, and will remain available until September 27th.
I’m also thrilled and honoured to say our poster was considered for their Best Poster Presentation award! It provided a brief overview of how the book came about, the methods used by our authors, and a snapshot of where we are at with the project right now. You can find the video of the poster presentation below, along with references. There is also a transcript below the video, along with visual descriptions.
Of Doctors By Doctors: International Perspectives. Poster Presentation recorded for the MWIA Western Pacific Conference 2021.
Audio Transcript and Visual Descriptions
Audio transcript is on the left column, and visual descriptions of the slides is on the right column.
Slide 1 Audio
Hello everyone! My name is Liz and I am the project manager for a collaborative research anthology on occupational sexual harms in medicine, which is what I will be talking about today. One of our wonderful authors Dr Buowari has kindly offered to attend this conference on our behalf, but if you have any questions for the project lead or for myself, our contact details will be on the last slide along with our website. Before I begin, I would also like to acknowledge that I am presenting on the traditional land of the Kaurna people, and recognise their spiritual relationship with their country, culture, and heritage beliefs. I pay my respects to Elders past and present, and extend that respect to other First Nations people.
Slide 1 Visual
A Title Slide for the presentation, using the background provided by the Medical Women’s International Association (MWIA) Western Pacific Regional Conference 2021. Text in top left reads “Western Pacific Regional Conference 2021 of the Medical Women’s International Association. August 20-21, 2021. Virtual Conference”. Text in the centre reads “Of Doctors By Doctors: An International Perspective. Presenting Author: Dr Dabota Yvonne Buowari. Project Lead: A/Prof Louise Stone. Project Manager, Presentation Delivery: Mx Elizabeth Waldron.
Slide 2 Audio
Of Doctors By Doctors is the working title of our international, interdisciplinary research anthology about occupational sexual harms in medicine. Each chapter is contributed by an author or team of authors from all around the world. The book explores the many factors that influence the experiences of doctors who have been sexually harmed by other doctors. It asks questions about the sociocultural factors that influence survivors’ interpretations and understanding of their experiences, and about the approaches of different disciplines and institutions to understanding, preventing, and intervening in occupational sexual harms.
Slide 2 Visual
Slide title: “about “Of Doctors By Doctors”. In the centre are three bullet points. At the bottom of the slide are four boxes.
First point: “international, interdisciplinary research anthology about experiences of occupational sexual harms of doctors, by doctors”
Second point: “Focus: contextual factors shaping the ways doctor-survivors experience, interpret, understand these incidents”
Third point: “We use “occupational sexual harms” to encompass a range of single or recurring incidents of unwelcome and intrusive conduct by a coworker or colleague, including but not limited to:”
Box on far left, titled “sexual violence”: ““any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the survivors/victims, in any setting, including but not limited to home and work.”1“
Box second from left, titled “sexual assault”: “sexual activity with another person who does not consent. It is a violation of bodily integrity and sexual autonomy, and is broader than narrower conceptions of “rape”, especially because (a) it may be committed by other means than force or violence, and (b) it does not necessarily entail penetration”2“
Box second from right, titled “sexual harassment”: ““unwelcome conduct of a sexual nature, in circumstances in which a reasonable person, having regard to all the circumstances, would have anticipated the possibility that the person harassed would be offended, humiliated, or intimidated…conduct of a sexual nature includes making a statement of a sexual nature to a person, or in the presence of a person, whether the statement is made orally or in writing”3“
Box on far right, titled “sexual abuse”: ““actual or threatened physical intrusion of a sexual nature, whether by force or under unequal or coercive conditions””
Slide 3 Audio
The impetus for the book came from a qualitative study published in 2019 by some of our editorial board. Stone, Phillips, and Douglas conducted a narrative study about the impact of occupational sexual harms on doctors. They developed a narrative framework to articulate the ways doctor-survivors interpreted and were affected by these experiences, plotting the trajectory of their experiences through 5 discrete phases.
Prelude is the phase in which people try to make sense of their experiences by understanding the history.
Assault is the single or recurring incident of sexual harm, centred on the way the survivor interprets the assault, and the questions they still have around it.
Limbo is the period of elective or enforced silence after the event.
Exposure is the phase in which the survivor’s name becomes known, either in their workplace, in the courts, or in the media.
Aftermath is the phase in which the long-term impacts of the events begin to emerge, both in terms of their personal and professional life. While this framework aids in understanding the ways that survivors interpret their experiences, the stories of participants prompted yet more questions.
Slide 3 Visual
Heading: “2019 study by A/Prof Louise Stone, Prof Christine Phillips, Prof Kirsty Douglas: impact on doctors of sexual harassment and assault by other doctors in the workplace4“. In the centre of the slide are 4 dotpoints. At the bottom are 5 arrows each pointing to the arrow on its right. The arrows act as headers for brief quotes that illustrate potential questions a survivor would ask themselves during that particular narrative phase.
First dotpoint is followed by two sub-points. First point reads “participants”. First sub-point reads “doctors who had experienced inappropriate sexual behaviour by another doctor, causing ongoing distress.” Second sub-point reads “gender not specified in recruitment, but all participants women”
Final dotpoint reads “developed narrative framework to analyse interpretations/understanding of lived experiences in 5 phases:”
Arrow on far left reads “prelude”. Text below reads ““why did this happen to me?””
Second arrow from left reads “assault.” Text below reads: ““what do I think/feel about what happened to me? How do I interpret/understand the incident/s?””
Middle arrow reads “limbo”. Text below reads: “Should I tell anyone? What does it mean for me to be silent, and what happens when I am silent?””
Second arrow from right reads “Exposure”. Text below reads: ““what is it like for me at and outside of work, now that people link my name to this case? How do I negotiate these events in relation to my career?””
Arrow on far right reads “Aftermath.” Text below reads: “how have these experiences affected my personal and professional life, years later? How have they affected my personal and professional sense of self?”
Slide 4 Audio
What factors actually influence survivors’ interpretations and understandings of their experiences? What factors influence the paths they take, or even consider, during these journeys? What factors contribute to these incidents happening at all? Each of these questions is crucial to informing intervention strategies, which must target different factors depending on whether they’re attempting to minimise the risk of incidence, improve reporting rates, or mitigate harm and impact on survivors’ futures where incidents do occur. So Louise decided to expand this pilot study to explore the how of sexual harms, engaging with expertise from different cultural contexts as well as different disciplines. By taking an exploratory approach to mapping out the landscape of this under-researched field, we aim to explicate these contextual factors so that policymakers, educators, medical regulators, and clinicians and colleagues can make better decisions about prevention, intervention, and management of occupational sexual harms. The other main aim of this book was to ensure, as we build this community of practice, that a diversity of perspectives was woven into its core.
Slide 4 Visual
Two boxes are side by side at the top of the slide, with purple arrows associating dotpoints in the left box with dotpoints in the right box.
The box on the left is titled “questions arising from participants’ stories:”. The first dotpoint in this box reads “What factors influence survivors’ interpretations/ understandings of their experiences?”. The second dotpoint in this box reads “What factors influence survivors’ behaviour (especially during Limbo, Exposure, Aftermath)?” The third dotpoint reads “What factors contribute to incidents happening at all?”
The box on the right is titled “can inform intervention strategies depending on aim:” The first dotpoint in the left box is linked by a purple arrow to a dotpoint in the right box that reads “Mitigating betrayal trauma and harm (especially from report handling) after sexual harms” The second dotpoint in the left box is linked by a purple arrow to a dotpoint in the right box that reads “improving likelihood that incidents will be reported.” The third dotpoint in the left box is linked by a purple arrow to a dotpoint that reads “minimising risk of incidents occurring.”
The bottom half of the slide is a heading, “Aims”, followed by 5 dotpoints.
The first dotpoint has one sub-dotpoint and 2 sub-subdotpoints. It reads “to explore and articulate contextual factors that influence the ways doctors experience and interpret sexual harms by other doctors”. The sub-dotpoint reads “taking into account:”. The first sub-subdotpoint reads “Differences that arise in different cultural contexts.” The second sub-subdotpoint reads “Approaches of different disciplines to conceiving/solving the issue”
The final dotpoint reads “To protect the balance of diverse voices in the community of practice we build around occupational sexual harms in medicine”
Slide 5 audio
So the book as a whole has been designed with 4 main areas of inquiry in mind.
Section 1 provides a little background context for the ways that gender and medicine and marginalisation operate and interact in general, engaging expertise from disciplines such as history and gender studies.
Section 2 asks experts from a variety of disciplines to explore the ways different actors conceive their role in addressing occupational sexual harms in medicine, and how these different approaches impact survivors’ attempts to navigate pathways for reporting and justice.
Section 3 presents qualitative case study analyses based on the pilot study, conducted in different countries around the world.
Section 4 reflects on theoretical and historical approaches to advocacy, including the opportunities and conundra faced by leaders, grassroots activists, and medical students trying to build and sustain momentum towards change.
As the book enters its next stage of chapter reviews this month, we expect to see thematic similarities and differences emerge between disciplines and cultural contexts in the ways that people conceptualise, and aim to address, the issue. Still, there are 3 main take-aways that are already beginning to emerge.
Slide 5 visuals
The top of the slide has 4 purple boxes (describing the “sections” of the book) that each contain a number of green boxes (describing the chapter titles within that section).
The purple box on the far left reads “section 1: Context.” There are 4 boxes within, which read (from top to bottom) “introduction”, “the history of women in medicine”, “intersectionality”, and “gender in medicine and the role of men”.
The second purple box from the left reads “Section 2: Interdisciplinary lenses.” There are 6 green boxes within, which read (from top to bottom): “law”, “Medical education”, “organisational behaviour”, “regulatory bodies”, “therapy”, and “integrating interdisciplinary lenses”.
The second purple box from the right reads “section 3: International perspectives”. The single green box within reads “Qualitative case studies conducted around the world, based on the pilot study 4(full chapter list below)”.”
The purple box on the far right reads “section 4: the way forward”. The 3 green boxes within read (from top to bottom): “cultural change and accountability in leadership”, “everyday advocacy: from theory to praxis”, and “medical students”.
The bottom of the slide has green boxes detailing the chapters and authors of Section 3, the full list of which can be found here. These are superimposed on a world map. Countries which are being written about in the book have been highlighted in teal; all other countries are grey.
Slide 6 Audio
Firstly, that occupational sexual harms in medicine occur all around the world. Despite the dearth of literature, there remains an untapped wealth of lived experiences. While retrieving and analysing data from lived experiences of such a sensitive subject poses ethical and methodological challenges, they can still provide a fruitful basis for exploring the how and why of sexual harms in many different contexts. Future research should focus on exploring and understanding the contextual factors at play, and considering their cultural specificity.
Slide 6 Visuals
This slide is titled “Take-away 1: occupational sexual harms of doctors by doctors is pervasive.”
Below are three dotpoints. The first reads “Despite dearth of prevalence data, we know this happens around the world.” The second reads “Retrieving and analysing data from doctors’ lived experiences of sexual harm by other doctors poses ethical, methodological challenges.” The third reads “But still important to continue qualitative, exploratory work as we continue mapping the field”
At the bottom right there is a purple box, with a green arrow attached and pointing right. The purple box reads “future research directions”. The green arrow reads “Select and explore specific contextual factors in more detail, considering cultural specificity”
Slide 7 Audio
Secondly, this issue is deeply shaped by social dimensions, involving a complex interplay of factors both internal and external to the medical workplace that cannot be addressed through generalised simplistic measures. Resolutions will require nuance and flexibility. Future research should consider translatability when using pre-established interventions as case studies, taking care to recognise the degree of cultural specificity of these contextual factors.
Slide 7 Visuals
Slide 7 is titled “Take-away 2: occupational sexual harms have social dimensions.”
Below are 3 dotpoints. The first reads “They involve a complex interplay of factors both internal and external to medical cultures/workplaces.” The second reads “Simplistic measures, and measures non-specific to medicine, are likely to neglect key aspects of the dynamics at play.” The third reads “Resolutions, interventions, will require nuance, flexibility”
At the bottom right there is a purple box, with a green arrow attached and pointing right. The purple box reads “future research directions”. The green arrow reads “Explore global case studies of workplace interventions, analyse potential for translatability while accounting for cultural specificity of factors involved”
Slide 8 Audio
Thirdly, a multi-disciplinary, multi-layered approach will be required to generate the policy and cultural changes necessary to reduce incidence, improve reporting, and decrease trauma related to reporting, and a wealth of further research will be needed to form the basis of these responses. We will need the courage of survivors and future researchers, and the encouragement of their colleagues and peers, in order to make meaningful changes to sexual harms of doctors, by doctors.
Slide 8 Visuals
This slide is titled “Take-away 3: occupational sexual harms require multi-disciplinary, multi-layered, evidence-based approach.” Below are 4 main dotpoints
The first dotpoint reads: “Policy change and cultural change both necessary to:” This is followed by 2 sub-dotpoints, which read “reduce incidence” and “increase reporting”
The second dotpoint reads “We need survivors to be courageous about contributing their experiences to informed research.” The third reads “We need researchers to be courageous about engaging in more controversial/less prestigious types and topics of research.”
The fourth dotpoint reads “we need colleagues and peers”, and is followed by 2 sub-dotpoints, which read “to support survivors who do contribute their experiences” and “to support researchers who are attempting to address the dearth of research.”
Slide 9 Audio
We are currently in the final stage of recruitment, looking for contributors to write a chapter in section 3 from any countries in the region of the Americas, other than the USA or Mexico.
If you are interested in writing any of these, please reach out to us! We don’t have any requirements for minimum qualifications or publication history, and we are happy for you to write in whatever language you are most comfortable.
If you want to be part of this growing community of practice, but don’t fit into any of our chapter categories, reach out anyway! We are currently working on expanding this project beyond the book, to facilitate a continued dialogue and to encourage future research.
If you’re interested in learning more, you can visit our website, or you can email our project lead Louise at the address on the slide. Thank you once more to Dr Buowari for kindly facilitating this process on our behalf, and thank you for your interest in this project.
Slide 9 Visuals
This slide is split into two columns. The left column is titled “currently recruiting contributors.” Below is a map of the WHO region of The Americas, with all countries greyed out except the USA and Mexico, which are coloured in teal. The map is accompanied on the left by text reading “For a section 3 case study from any country in the WHO region of the Americas (except USA or Mexico).”
The right column is titled “contact us.” The text below reads “More details available on our website: ofdoctorsbydoctors.com. Full bibliography and notes. To contact Project Lead: A/Prof Louise Stone Louise.firstname.lastname@example.org“
We are so excited and grateful to Dr Dabota Yvonne Buowari for taking this show on the road and presenting a poster about the book at this year’s MWIA Western Pacific conference. This year’s theme is “The Role of Medical Women in the Future”, and given the overwhelming courage and initiative of the women who have written, researched, or shared their stories for this book, this is certainly the year we can’t afford to miss! It’s being held virtually on August 20-21, and you can attend here.
Our poster will provide a brief overview of how the book came about, the methods used by our authors, and a snapshot of where we are at with the project right now. It’ll be available as a video on demand for 30 days after the conference along with the other presentations, but I’ll also post a video of it in the coming days. See you there!
We were so excited to present a poster at AAAPC 2020 this year! Moving to an online poster walk presented its problems, but the AAAPC team rose to the challenge admirably, providing an ample and orderly space for each poster to be presented and discussed. Unfortunately, the session wasn’t recorded, so we were unable to capture the presentation or the discussions we had in the breakout rooms, but I can provide some insight into our poster.
At this point, we were still primarily in the recruitment stage of the project, and the poster does not give much information beyond the information available on our site here. Presenting the poster gave us an opportunity to further build the community of practice around this issue (and hopefully reach contributors from under-represented regions!), and to pursue consciousness-raising around the issue. Responses to our project are still divided between doctors who have personally encountered sexual harms in the profession (anecdotally or otherwise), and doctors who have rarely or never encountered them (some of whom have extensive experience working toward addressing sexual harms). The dearth of literature on doctors who have been sexually harmed by other doctors has also been problematic for decision-makers attempting to address the issue. We hope, by spreading awareness that research on this issue is global and ongoing, to facilitate the expansion of the body of research and the growth of our burgeoning community of practice.
I’m thrilled to announce that I’ll be presenting an oral paper at the 2021 Australasian Association for Academic Primary Care conference. I’ll be presenting in Papers 7: Using Different Methods to Tackle Challenges in Academic Primary Care, at 11am on Friday 13th August (AEST). My oral paper, titled Representation, Diversity and Ethics: Building an international community of authors to write around sexual abuse in medicine, uses an evocative autoethnographic approach to explore the pragmatic and ethical dilemmas that arose through the recruiting phase of the book.
Louise and I presented a poster at AAAPC’s 2020 conference to talk about the book and try to further build this wonderful community of practice that has been growing around the project (unfortunately, that digital poster walk wasn’t recorded, but the poster itself is available here). This year is going to be a little different. We’re at our final hurdles with recruitment for the book, so we’re turning our attention towards our dissemination and translation strategy, and towards questions around how we can expand this project to continue work beyond the book.
International recruitment has been an essential part of our project, both as an ethical consideration and as a means of fostering richness of research in an under-studied field. It has, however, been resource-intensive, and has required skills in building communities of practice as well as more straightforward skills in searching for researchers. With this paper, I hope to provide some insight into our process, particularly regarding the ethical and political considerations involved.
This year’s conference will be available online between 12-13 August, and the oral papers can be pre-recorded or delivered live, followed by a live discussion. While I may not be able to channel the live discussions, I will be pre-recording my oral paper so that I can post it here – so if you can’t make it to the conference itself, watch this space!
If you are able to attend the conference, Louise will also be running a workshop on designing good qualitative research projects at 2:45pm on Thursday 12th August (AEST). The editorial approach and design of the book has been deeply informed by her expertise in qualitative methodologies, and if you feel more sturdy on quantitative grounds but are curious to see how the other half lives, her Masterchef mystery box challenges are always a great way to explore the space.
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.