Sexual assault in surgery: a painful truth

 

Sexual assault in surgery: a painful truth

Abstract

Uncomfortable conversations are necessary for a safe work environment.
Surgery and surgical training have a problem with sexual harassment, sexual assault and rape. It is an uncomfortable truth, but the truth nonetheless. These issues are present in all spaces, including workplaces, and broadly range from small infringements of personal space to overtly criminal activity. However, in surgery we have a specific issue: our community is small.

This means that despite reporting abuse, a person may never be able to walk away from the experience or the community in which it happened.
To have honest and accurate conversations about sexual harassment, sexual assault or rape, we need to know what these terms mean. As there is often misunderstanding, the following definitions from UK law are important:
Sexual harassment is a form of unlawful discrimination under the Equality Act 2010. Sexual harassment is unwanted behaviour of a sexual nature.

To be sexual harassment, the unwanted behaviour must have either:
•
violated someone's dignity, whether it was intended or not
•
created a hostile environment for them, whether it was intended or not.1
Sexual assault is when a person is coerced or physically forced to engage in sexual contact against their will, or when a person, male or female, touches another person sexually without their consent. Touching can be done with any part of the body or with an object. Sexual penetration is when a person (male or female) penetrates the vagina or anus of another person with any part of their body or an object without that person’s consent.

A rape is when a person uses their penis without consent to penetrate the vagina, mouth, or anus of another person. Legally, a person without a penis cannot commit rape, but may be guilty of rape if they assist a perpetrator in an attack.2
Now, having read those definitions, the authors ask you to re-read, ideally out loud, the opening paragraph of this article.
From these definitions it is clear that this is a broad range of behaviour, from unintentionally creating a hostile environment to sexual penetration. The milder end of the spectrum is oftenunderestimated, underplayed and commonly excused: ‘everyday’ sexual harassment often involves ostensibly positive things like commenting on appearance. The defences of ‘but it’s a compliment!’ and ‘but she likes it!’ do not lessen the fact that, in the workplace, there are ways of paying a compliment that are acceptable, and ways that are very much not. Despite being positive remarks, they objectify the person rather than valuing them as a professional. Moreover, there are a variety of social reasons why ‘smile andsay thank you’ is the easier thing to do than to speak up against unwelcome behaviours or attitudes.
Surgeons and trainees are unlikely to report sexual harassment; thus, to date, much of the information we have on this topic is anecdotal. Anonymous surveys have often revealed the extent of the problem. Recently, the Rouleaux Club (the trainee body for vascular surgery) released data from their national survey. Of 120 vascular trainees, and with a 60% response rate, 46% reported experiencing or witnessing bullying, undermining or harassment. This prompted trainees to share their experiences on social media.
Many described physical and verbal behaviours that rekindled discourse in the surgical community around sexual harassment, assault and rape. Similarly, the recent independent review on diversity and inclusion from the Royal College of Surgeons of England highlighted that ‘jokes’ were made about rape and sexual assault, and revealed that of the 800 respondents who stated they had suffered harassment/abuse, only one quarter had reported it to someone.
The UK surgical community is just beginning to address these difficult conversations, but there is a great deal of global literature to support the fact that surgeons experience unacceptable behaviours in the workplace, both as trainees and non-trainees. In 2015, the Royal Australasian College of Surgeons commissioned a national survey of members, with 3516 individuals (47.8%) responding from all surgical specialties (81% male, 15% trainees). They found that harassment (19%), discrimination (18%) or sexual harassment (7%) all featured. Some 12% of trainees had experienced sexual harassment; the rate was strongly gendered (30% of women had experienced sexual harassment) and 56.1% had not reported.
When respondents were asked if ‘they have ever been the recipient of sexual harassment behaviours in the workplace’, there was an 8.1% rate of sexual assault and a 1.1% rate of rape (from a list of 10 options provided).4 However, the highest frequency of behaviours was sexually explicit or offensive jokes (59%), unwelcome sexual flirtations (56%), inappropriate physical contact (53%) and questions or insinuations about sexual or private life (52%).

Similar data have been reported in a Greek study, which found a 20% rate of sexual harassment.5 Colleagues in the United States have also conducted a variety of studies that echo these findings. In a large cross-sectional national survey (n = 7409) of general surgery trainees, sexual harassment was reported by 10.3% (19.9% of female trainees overall). Of those women that did report, the perpetrators were most frequently patients or patients’ families (31.2%) and consultant surgeons (30.9%), followed by trainees (15.4%) and nurses or staff (11.7%).6 The most commonly cited reasons for not reporting were believing that the action was harmless (62.1%), believing reporting would be a waste of time (47.7%), being busy (37.9%) or being uncertain whether they were experiencing sexual harassment (31.8%).7
In 2017, the General Medical Council survey found that 2908 (5.5%) of doctors in training had witnessed or experienced bullying in their current post. The vast majority (2721 trainees) said they did not wish to report via the national survey because they did not think that reporting would make a difference (944 doctors), feared adverse consequences (852 doctors), didn't think an issue was serious enough to report (613 doctors) or it had been reported locally (1505 doctors).

Reporting these incidents can lead to greater negative impact for the victim than the perpetrator, by being threatened with negative consequences for their career.9 Whether they choose to report or not, a victim’s career can be affected by their withdrawing from the work environment to avoid perpetrator or bystander colleagues.10 For UK trainees, it is fair to say that the lack of major third-party employers outside of the NHS makes a negative impact on career progression a risk not worth taking.
The debate about whether there is a culture of sexual harassment, discrimination and sexual assault should end. Instead, harder conversations need to begin. To move forward, we require acceptance that this issue exists, and that each member of the surgical community has a duty to attempt to address it, whether they have personally witnessed or experienced these behaviours or not. It is not enough to not be complicit. As a community, we should all be anti-sexual harassment, anti-sexual assault and anti-rape.
We are proud of the tight-knit community in which we work and the tremendous efforts by individuals and organisations to make our workplace inclusive. However, we must remember that for victims of harassment, discrimination and abuse, the notion that ‘everyone knows everyone’ can turn a welcoming community into something that feels like a prison. Many fear their story becoming known. The dedication required to achieve a career in surgery means leaving the profession is often unthinkable, and this can lead to burnout, depression and suicide.

To move forward we need to normalise challenging these behaviours, whether this is at a departmental, local or national level. For trainees in particular, the significant power that trainers have over career progression can silence even the most confident voices. This will require the creation of psychological safety at every level and mechanisms to report inappropriate or illegal behaviours, so that surgeons no longer feel that reporting will not make a difference, and will not have a negative impact on their careers or mental health.
Reporting behaviour is a first step to institutional awareness and action, yet it is one of the greatest barriers, with unclear reporting options that make victims fear repercussions.10 In a 2020 survey, a group of US residents were asked how they would feel most comfortable reporting these issues, and 67% of residents chose methods that were anonymous, with the second and third most preferred options being departmental reporting and reporting to another resident.7 Professional societies have a significant role in addressing this issue, by leading culture change, signposting reporting mechanisms and providing sanctuary to share experiences.

There is a role for senior leadership to set the tone and own the problem. In the New Zealand and Australia experience, a widely published apology by then President David Watters on YouTube was a critical turning point in the journey towards acceptance and ownership of the problem of bullying, discrimination and sexual harassment by surgeons. Equally, there is a role for bystander and upstander training. The standard we walk past is the standard we accept, and many of us hear and see behaviours every day which we know to be unacceptable.
The authors hope this paper is a call to action; that it sparks further uncomfortable conversations; that it begets an acceptance from the (mostly male) surgical community that this is not an attack, nor is this about blame. This is about how to move forward and to make things better and safer for all of us.
To make a safer workplace, every member of our community needs to refuse to tolerate these behaviours. This means taking action in the form of an informal conversation, an awareness intervention or, for the more egregious behaviours, immediate disciplinary action. We should be clear: an unacceptable joke may mandate a ‘cup of coffee conversation’, a pattern might mean remedial training, but sexual assault or rape are crimes. They should and must be treated as such.

Acknowledgments
The authors would like to thank the multitude of humans who advised, guided and shared their experiences to help form this piece. Without their candour, bravery and trust, it would not have been possible to write this. We acknowledge the victims who often remain unseen and unheard.

Authorship
Simon Fleming (SF) was invited to write this paper as a visible and outspoken advocate for culture change in healthcare, with a particular focus on surgery. He has written and spoken before on this topic and experienced first-hand the public discomfort with discussing how these issues are managed in the surgical workplace.
Rebecca Fisher joined the paper as a junior trainee with an academic interest in the experiences of women in surgery. She has not experienced the severe end of this spectrum but has counselled friends and colleagues who have. As a visible member of the medical Twitter community, she has previously been asked to anonymously report on cases of sexual assault where the victim felt unable to speak out themselves. Because of the sensitive nature of sexual harassment and assault in our surgical community, she chose not to speak out about these cases, due to concern of retribution.
One author of this paper (SF) reached out to over 20 women in surgery who have, in the past, shared with him via social media experiences of sexual harassment, discrimination, sexual assault and rape. Not a single one was willing to co-author, even with the guarantee of anonymity.

References
1.
Acas. What sexual harassment is. https://www.acas.org.uk/sexual-harassment (cited July 2021).
Go to Citation
Google Scholar
2.
Crown Prosecution Service. Sexual offences. https://www.cps.gov.uk/crime-info/sexual-offences (cited July 2021).

Google Scholar
3.
Royal College of Surgeons of England. We will put diversity at the heart of our strategy. https://www.rcseng.ac.uk/about-the-rcs/about-our-mission/diversity-review-2021 (cited July 2021).
Go to Citation
Google Scholar
4.
Crebbin W, Campbell G, Hillis DA, Watters DA. Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia. A N Z J Surg 2015; 85: 905–909.