Abstract
Anecdotal evidence suggests sexual harassment by seniors still affects doctors and medical students; a deeper understanding is needed of its prevalence in the NHS. Hierarchal structures, unequal power dynamics, cumbersome reporting systems and fears for career progression act as permitting factors and barriers to reporting. Initiatives to counter sexual harassment have been implemented in medical workplaces and other industries. The effectiveness of these initiatives to bringing culture change and reducing the incidence of harassment needs to be evaluated, as well-intended initiatives may backfire.
The Harvey Weinstein scandal confessed to an appalling catalogue of sexual harassment and assault, abuse of power within hierarchal structures, silencing of victims and bystanders turning a blind eye. The #MeToo campaign that spread like wildfire through social-media, revealed that this is not a phenomenon confined to Hollywood.
To what extent do the same issues exist in the medical environment? There is anecdotal evidence to suggest so, but a deeper understanding is needed of the prevalence, consequences and enabling factors in the environment, to allow formulation of practical and effective preventative solutions.
‘Just Banter?’
When does ‘workplace banter’ or ‘harmless flirtation’ become sexual harassment? When do friendly gestures become inappropriate touching? Behaviour that is deemed unpleasant or intimidating from the perspective of the victim is harassment. It can be physical, or verbal; such as offensive or demeaning comments, unwanted prepositioning or gestures of a sexual nature. Defined by the Equality Act as unwanted conduct related to a ‘protected’ characteristics (sex, race, age etc) or unwanted conduct of a sexual nature(6).
“I was told by a senior consultant to sit on his lap when I asked him to help me interpret an X-ray” – junior hospital registrar(7). “…the ‘privilege’ of being allowed to scrub in meant I had to politely smile to questions such as ‘I bet you like it dirty’, ‘you like to be dominated? or whilst shaving the patient ‘how’s your state of affairs down there?’…it was humiliating and degrading”.
Prevalence & Normalisation
Several studies have found medical student harassment and discrimination to be prevalent and a widespread phenomenon, not limited to a certain country or programme(1). A study of medical schools in the US found 92.8% of women experienced, observed or heard about at least one form of gender discrimination or sexual harassment(3). The association of American medical colleges graduation questionnaire in 2011, found approximately 1 in 6 US medical students experience some form of harassment or discrimination.1 There is less research focusing on the UK, but a recent (yet to be published) study of UK medical students found 63.3% experienced harassment or discrimination(2). They were more likely if they were female or in their clinical years.
“A consultant made sexual advances towards me…nothing serious came of it but I felt I couldn’t say anything to anyone”.
Harassment was perceived as normalised behaviour;
“there’s a culture of sexism and belittlement of women as banter”. “…so normalised and ingrained that you’re not sure if you’re overreacting”(2).
In working life, it appears the issues are the same. In the 2017 MWIA survey of 1150 female doctors from across the globe, 46% reported sexual harassment in the workplace(5). A 2016 survey of surgical trainees in Australia, 50% reported bullying, discrimination or sexual harassment(4). 7% had been subject to sexual harassment, in 75% of the cases the perpetrators were consultants.11 Within the NHS, there is ample anecdotal evidence suggesting this is an issue, but there are no recent studies that focus solely on gender discrimination or sexual harassment of UK doctors. The NHS England staff surgery in 2016 stated 22% of doctors and dentists had experienced bullying, harassment or abuse from another staff, in the preceding 12 months(9). How much of the was sexual or gender-related was not specified.
The invisible problem
‘Under-reporting’ of sexual harassment is a commonality of all the studies. A study of UK medical schools found reporting systems inaccessible and cumbersome;
“logistical hassle of having to do it… not worth it”.
Only 5% reported incidents, many students stated that personal consequences would stop them from reporting, fears of the impact on their education and being labelled,
“I didn’t want a reputation of a whiner”(2).
Fear of the impact on career progression is a common factor,
“…advised against pursuing an investigation in my sexual harassment case, because it would “harm my career” as a woman in science.’(7).
NHS England staff survey showed only 33% reported the incident. It found that trainees were the least likely to take action. Only 1% were willing to submit details of incidents to the GMC NTS survey so that they could be formally investigated by the deanery(9). These studies show that despite the regular supervision, pastoral support, and multiple other initiatives that have been introduced to support juniors; it has not been enough to address the fears and barriers doctors face to reporting harassment.
Hierarchy, power dynamics & ‘by-stander silence’
It is important to consider, that like Hollywood, there are significant power dynamics at play within the NHS. Cannot ignore that in the majority of these incidents, the inequality of power between the abuser senior and the victim (often the senior and a trainee/student), is a causative factor and also acts as a significant barrier to reporting. The hierarchal nature of the profession increases the perception of ‘impunity’ of seniors, and also increases the likelihood of the ‘bystander silence’.
“...he kept making lewd and humiliating jibes, there was at least 7 staff in the theatre, no one said anything...”
The personal and wider consequences
Sexual harassment has personal consequences on the doctor affected and wider consequences on the working environment, patient care, and the profession as a whole. It creates stressful and intimidating environments, which can impair performance. Trainees who frequently experienced harassment are less likely to complete projects or provide optimal patient care(1,10). Other studies have shown they are more likely to have depression, anxiety, insomnia, appetite loss and were more likely to drink alcohol for escape(1,16).
There is also evidence to show it can affect career choice. In a US study, 45.3% of women stated gender discrimination and sexual harassment influenced their specialty choice. It found that women choosing general surgery were most likely to experience gender discrimination and sexual harassment during residency selection.3 In the UK there is anecdotal evidence to support this,
“my supervisor laughed when I told him I wanted to be a surgeon, he said I’d do better to stick to ‘female’ specialities”.
Gender disparity and unconscious bias
The issues identified cannot be isolated from the larger context of gender disparity that unfortunately still exists within aspects of the NHS. The pay gap; figures from the Office of National Statistics showed that in 2016 female doors working full time earned 29% less than their male colleagues. This is higher than the pay gap seen in other professions such as solicitors (12%) or accountants (19%) (17).
Although the number of women on boards has increased in recent years, a report by Exeter business school states there needs to be another 500 women sitting on NHS boards to achieve gender balance. Their analysis shows some roles such as chief nurses tend to be female dominated, whereas other roles such as chief exec, finance director and medical directors remain male dominated (57%, 74%, 75% respectively)(11).
Data published by the advisory committee on clinical excellence awards in 2014 showed men received 85% of the national excellence awards within England and Wales. It is likely that gender bias still impacts on women’s overall representation in the workforce. A 2015 study showed how inherent assumptions about gender can impact a women’s professional prospects. The randomised double-blind study saw applications for science-based jobs sent to research universities. The CVs were identical, except carrying female or male names. The study revealed that recruiters rated the ‘male’ applicants as ‘significantly more competent and hireable’ than the identical ‘female’ applicants. They also offered the ‘male’ applicants a higher starting salary and were more likely to offer them career mentoring”(18).
Positive Initiatives
The ‘Women in surgery’ initiative was introduced in the UK to combat the ‘masculine’ stereotypes of the speciality, provide female surgical role models and networking opportunities to provide support and mentoring for the junior female doctors. In Australia, following a media uproar when a female surgical trainee published her experience of widespread sexual harassment in the profession, the Royal Australasian College of Surgeons has launched multiple initiatives to combat the issue. They appointed an expert advisory group that launched a comprehensive internal enquiry, which was published in 2015 and revealed the extent and depth of the problem to all. Following that they introduced a 3 year education and awareness campaign, a mandatory new training module on discrimination, bullying and sexual harassment, an updated code of conduct explicitly identifying these behaviours as breaches, and an anonymous complaints process and free confidential counselling(4). This is a commendable and comprehensive effort to stamp out the problem, analysis will be needed to evaluate the effectiveness of the initiatives, to allow other countries or programmes to follow suit.
Outside healthcare other industries have a longer histories of implementing initiatives to combat sexual harassment. Many American firms have introduced no-dating policies. Employees that start a relationship with each other are supposed to notify management. However, workplace sexual harassment is generally not an issue within mutually agreed relationships, and there is no evidence of the effectiveness of such intrusive policies. Other industries have introduced mandatory ‘anti-harassment’ training, which may involve attending a talk, online videos defining what sexual harassment is, or online questionnaires involving identifying instances of harassment. Studies into their effectiveness have been inconclusive(19). There is some evidence to show that it can increases sensitivity of trainees to identify what constitutes as harassment(12). However, poorly designed training can backfire. A study showed that ‘anti-harassment’ material presented to men activated stereotypical ideas of men as powerful and women as vulnerable, worryingly, as such ideas are often associated with the propensity to commit sexual harassment(19). Other unintended negative consequences include making senior men fearful about mentoring young professional women, or creating resentment on the part of those who are mandated to attend(13,14).
Initiatives that have been shown to be useful include anonymous ‘environment surveys’, which include questions about whether employees have experienced sexual harassment, on the condition results are are noted and acted upon by employers. Many studies have shown that men and women often hold different perceptions as to what constitutes as sexual harassment(15). There is evidence that mediated conversations between small groups of men and women can be useful to forge consensus(12).
Key points
Prevalence and normalisation of sexual harassment within the medical workplace needs to be countered.
Trainee doctor surveys require specific questions on sexual harassment and gender-related bullying.
Reporting systems need to be logistically simple and transparent.
Interventions needs to be evaluated for their effectiveness in reducing incidence.
Reflection
The recent #MeToo campaign has shown sexism, harassment and abuse are rooted in every aspect of society. Unfortunately, the medical world does not seem to be isolated from this.
But this cannot excuse the appalling levels of harassment still affecting students and doctors. We must provide the exemplary working environment, where every member of staff is valued, treated with dignity and respect and empowered to achieve their full potential. As medical professionals, we must strive to always act as role models. We must be aware of our own unconscious bias, as we all have prejudiced tendencies. We must be aware of the language we use when mentoring juniors. We must all challenge when our colleagues or seniors act inappropriately, and not be complicit in ‘normalisation’ or ‘by-stander silence’.
Not to end with doom and gloom, occasionally sexism can be rather amusing. A tweet from a radiographer:
“Nice young women don’t ‘play with science’ ….‘It’s an fMRI scanner, not a Tonka truck”7
Competing interests: I have read and understood the BMJ’s policy on declaration of interest and have no relevant interests to declare
References
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