We must confront sexual violence in the NHS to prevent further institutional harmBMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p2118 (Published 18 September 2023) Cite this as: BMJ 2023;382:p2118
- Philippa Greenfield, co-presidential lead for women and mental health, consultant general adult psychiatrist, named doctor for adult safeguarding and trauma informed lead
The recent “Me Too in Medicine” investigation by The BMJ and the Guardian1 is an important reminder of the sheer scale of sexual violence experienced by NHS staff—35 000 reports of rape, sexual assault or harassment, stalking, or abusive remarks were identified though a freedom of information request to all NHS trusts and police forces from 2017 to 2022. As highlighted in the investigation, this is likely just the “tip of the iceberg” of sexual violence in the healthcare system. Last week we similarly saw the publication of a report by the Working Party on Sexual Misconduct in Surgery (WPSMS) showing the alarming levels of sexual violence perpetrated by our surgical workforce.2 This shouldn’t surprise us—sexual violence persists in every country and culture and mostly affects women and girls but can affect anyone.3
Survivors of sexual violence in the healthcare workforce have been silenced and neglected, and we have failed to acknowledge the devastating harm caused. Public and professional attention brought to this issue by the “Me Too” investigation and WPSMS report has resulted in a welcome call to action against sexual violence to our health organisations, institutions, and regulating bodies.4
Any new initiatives or legislation must confront the headlines clearly stated in the WPSMS report—that the real challenges faced are not tackling external threat, but rather fundamentally changing the culture that lies in the fabric of the NHS. The “Me Too” data show that incidents of sexual violence were mostly perpetrated by service users.1 But they also tell us that 4000 NHS staff were accused of perpetrating sexual violence, with few cases resulting in any repercussions.1 This is particularly concerning because these figures are likely a vast underestimation of the scale of sexual violence perpetrated by staff. Meaningful data on rates of NHS staff perpetration are difficult to find because incidents are rarely recorded. The WPSMS report, however, asked surgeons directly about their experiences of perpetration of sexual misconduct from colleagues. It found that sexual misconduct (ranging from sexual harassment to sexual assault and rape) over the past five years was widespread and disproportionally affected female surgeons.2
No formal NHS systems are in place for staff to safely raise or record reports of staff-on-staff sexual harassment and violence. Most NHS organisations do not have a sexual violence policy, and training to build awareness and expertise in the workforce to respond appropriately to disclosures is woefully lacking.5 We currently do not have a system that supports survivors who disclose their experiences of violence.
Institutional harm can refer to an individual act of harm or poor care experienced in an organisation but more meaningfully describes the risk posed by organisational cultures that tolerate, downplay, and even perpetuate harmful behaviours.6 This has been seen in cases in health organisations including those of Jimmy Savile,7 Winterbourne,8 and in other institutions. These cases exposed critical governance flaws in the prevention and detection of sexual misconduct and abuse and failure to bring perpetrators to account. Institutional hierarchies reinforce power imbalances between survivor and perpetrator that allow greater harm and disbelief of the survivor.
In healthcare our main responsibility is patient safety. To protect patients, we must act on reports of staff perpetrators. Sexual harm has serious and long term implications on health and is therefore an issue for many patients seeking healthcare, particularly in mental health services.9 A report in 2018 by the Care Quality Commission, Sexual Safety on Mental Health Wards, described the extent to which service users experienced sexual harm while accessing care. It showed that, over a three month period, “1120 sexual incidents involving patients, staff, visitors, and others were described in 919 reports, occurring within healthcare, some of which included multiple incidents.”10 The trauma and barriers to disclosure and seeking help are compounded when this harm is perpetrated by a person in a position of trust. Failure to tackle the prevention and detection of sexual misconduct and abusive behaviours in health organisations therefore has serious effects on patient safety, trust, and credibility.
We must be galvanised to enact the cultural change that is needed to prevent further institutional harm in the NHS. NHS England has asked all organisations with a role in delivering healthcare or training of healthcare professionals to sign up to their charter that commits to actions to move towards a culture of “zero tolerance” to sexual violence.4 This will be supported by further national guidance and governance to support implementation. This is a matter of protecting our workforce and patient safety, both inextricably linked to abuses of power. Effective solutions to tackle sexual violence require an institution-wide approach that is underpinned by trauma informed principles.11 Through sustained education and training of our workforce and senior leadership we must act to create a culture that understands the true damage caused by sexual violence. We must develop clear policy—such as the Preventing Sexual Violence policy in my own NHS organisation,12 a “first responder” policy to support a safe, timely, and trauma informed response that mitigates further harm.
Meaningful change will only be possible if supported by tangible actions from our professional bodies. The General Medical Council’s update to the Good Medical Practice guidelines13 for the first time explicitly states that doctors must not behave in a way that constitutes sexual harassment. Standards of professional conduct should include responsibilities on us all as “bystanders” to respond to observations of sexual violence. Professional responsibilities must be supported by formal structures such as clear national guidance that enable confidential reporting and encourage the recording of all incidents to easily identify repeated patterns of behaviour. There must be national agreement of process that ensures that sexual violence perpetrated by healthcare staff is immediately acted on with a safeguarding lens and with clear actions and accountability to mitigate further harm. Specialist support must be available externally to promote learning and decision making and to overcome the risk of defensive or closed cultures developing.
Only by recognising that it is our individual and collective responsibility can we achieve the cultural change needed to offer services that are truly safe to work and receive care in.
I would like to acknowledge the following for their contribution to the ideas and sentiments of this article: Shirley McNicholas, women’s lead and founder of Drayton Park Women’s crisis house and chair of the Camden and Islington NHS Foundation Trust Awareness and Response to Domestic abuse (C&I ARDSA) network; Julie Redmond, lived experience practitioner for the Camden and Islington NHS Foundation Trust Trauma Informed Collaborative and member of the C&I ARDSA network; Andie Rose, lived experience lead and activist and member of the C&I ARDSA network; Holly Elgood Curtis, project manager for the Trauma Informed Collaborative Camden and Islington NHS Foundation Trust and member of the C&I ARDSA network; Stella Kingett, chair of the Royal College of Psychiatrists Women and Mental Health Special Interest Group (WMHSIG) and consultant psychiatrist.
Competing interests: none declared.
Provenance: Commissioned; not externally peer reviewed.