Intended for healthcare professionals

Opinion BMJ Investigation

With sexual harassment or assault, what you permit, you promote

BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1117 (Published 23 May 2023) Cite this as: BMJ 2023;381:p1117

Read Me Too investigation series of articles

The BMJ will be hosting a webinar on this topic on 8 June 2023

  1. Simon Fleming, orthopaedic surgeon
  1. Barts Health NHS Trust
  1. @orthopodreg

It is everyone’s responsibility to hold sexual predators in the NHS accountable or risk becoming complicit bystanders, writes Simon Fleming

Growing evidence shows that healthcare in the United Kingdom and worldwide has a problem with sexual violence. Increasing numbers of people who have faced sexual violence, predominantly women, are coming forward to share their experiences.1234

When it comes to sexual predators, what we permit, we promote. Think of people at work who “gave you the ick,” “were walking, talking red flags.” Many of us will be aware of people who fit this description, and some of us will have experiences of sexual harassment, assault, or rape by such sexual predators.

In England and Wales, evidence indicates that, by the age of 16, one in 20 women will have experienced attempted rape or rape. Moreover, 98% of the perpetrators of rape or assault by penetration are men.5 In healthcare specifically, the best data we have, allowing for under-reporting, indicates up to a 60% rate of sexual harassment of nurses, with data for doctors reporting endemic, if lower, rates.6 Rates of 10-15% for sexual assault and 1% for rape have been reported for surgical staff.7

Rape culture and the hierarchical and patriarchal structures we work in silence and dismiss the voices of people who have been harassed, assaulted, and raped. Rape culture describes the normalisation and underplaying of sexual violence in society. Writer Rebecca Solnit explains, “Rape culture asserts that women’s testimony is worthless, untrustworthy . . . who is heard and who is not defines the status quo.” The NHS has such a culture of hierarchy, patriarchy, and power.

So here is a question—if reading about sexual violence doesn’t fill you with either fury or disgust, why not? This might be due to familiarity with these experiences or normalisation and acceptance of what is toxic, at best, and criminal, at worst. Or it is simply denial, a freedom afforded to those in a place of privilege, because the truth is too uncomfortable?

Sexual Assault in Surgery: a Painful Truth was published in 2021 and was followed by further impactful publications.789 It highlighted a global culture of silence, of patriarchy, and of normalising sexual harassment, assault, and rape in surgery. It was the first paper of its kind in the UK. In the two years since, many healthcare organisations have released statements denouncing the attitudes and behaviours described. Many more NHS organisations have remained silent, watching from the sidelines, perhaps hoping that others will take the heat, bring about change, and that it might all simply go away. Some have set up working groups, although the finite timeline of these groups is a concern because it risks performative and pacifying action. Suggesting that the work of changing and maintaining culture will one day be finished shows a fundamental lack of understanding of the scale and severity of the problem we are facing. Making healthcare a safe, fair, respectful, and diverse place isn’t the job of a working group alone. It should be a core value, a uniting thread that runs through the fibre of everything we do.

Numerous stories of predatory behaviour in healthcare have been shared with me. Since August 2021 I have heard the following from people working in the NHS. One shared that they work with a consultant who played with the nipples of patients while they were under anaesthesia—the theatre team have started taping down patients’ nipples before surgery and removing the tape before they wake up. I’ve heard someone saying that they think there is no rape or sexual assault in the NHS, and that most sex is consensual, arguing that people who say there is have misunderstood or “don’t have a sense of humour.” Another complained that they shouldn’t have to worry that someone is going to “cry rape” if they put their hand on their thigh, especially if they are laughing or smiling. I’ve heard a staff member recounting that their colleague is a “well known sexual predator” and that everyone is aware, but if he is kept away from students, “everything will be fine,” adding: “You know how it is.”

But it doesn’t have to be this way. Again, if reading these doesn’t fill you with fury or disgust, why not? We do not need any more surveys to see whether there is a problem—evidently there is. We do not need any vague general statements or more silence on the issue. We need decisive action. This means anonymous reporting systems, active bystander training, systems that allow growth and learning but also demonstrate accountability and not reinventing the wheel, and using superlative resources that are still out there, like the Operate With Respect materials from the Royal Australian College of Surgeons.

The culture of healthcare and our attitudes must change. We must face the extent of the problem and tackle it directly. That means not shying away from the fact that it makes us uncomfortable, embarrassed, ashamed, or guilty and acknowledging when we have failed to listen to people who have experienced sexual violence. Nobody is above reproach or challenge, no matter who they are, who they know, what strings they can pull, or how many friends they have. Right now, the hierarchy we exist in allows these incidents to go unchecked and, when reported, allows them to be hushed up and brushed under an increasingly threadbare carpet.

We need to recognise that some people showing predatory behaviour might need a “cup of coffee conversation” and some might need an awareness intervention, but also that some have committed explicit crimes. These conversations can be had by the person experiencing the behaviour, a bystander, a peer, or an ally.10 Criminal behaviour should be dealt with seriously, regardless of who has committed the crime. Failure to challenge, individually or organisationally, these attitudes is akin to accepting them as “just how things are.”

We all have a part to play in changing the culture of healthcare. As many more of us have uncomfortable conversations about how to make the NHS a safer place for patients and healthcare workers and we accept the premise of “what we permit, we promote,” ask yourself—what side of history do you want to be on?

Footnotes

  • Competing interests: none.

  • This article has been funded by the BMJ Investigations Unit. For details see bmj.com/investigations.

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