Sexual misconduct in surgery ‘calling it in’ – together we can shift culture

https://doi.org/10.58974/bjss/azbc028

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When was the last time you heard someone say something at work that made you feel uncomfortable?

What did you do in the moment?

How did you feel at, or after that moment?

All too often we are exposed to comments, conversations, so-called ‘banter’ that makes us feel uneasy.

In England and Wales, the legal definition of sexual harassment is when someone carries out unwanted sexual behaviour towards another person that makes them feel upset, scared, offended or humiliated¹.

By definition, sexual harassment is, behaviour characterised by the making of unwelcome and inappropriate sexual remarks or physical advances in a workplace or other professional or social situation.

Victims and survivors of sexual harassment are often told that they are being ‘unreasonable’, ‘too sensitive’, or that they ‘can’t take a joke’. The effects of sexual harassment are not only distressing at the time, but can have long-lasting effects.

Earlier this month, an article published in the British Journal of Surgery, highlighted the stark realities of life as a woman in surgery in the UK.

Begeny et al ² showed that compared with men, women were significantly more likely to report witnessing, and being a target of, sexual misconduct. Of the women interviewed, 63.3 per cent reported being the target of sexual harassment versus 23.7 per cent of men. Additionally, 29.9 percent of women had been sexually assaulted versus 6.9 percent of men, with 10.9 percent of women experiencing forced physical contact for career opportunities, versus 0.7 per cent of men. Being raped by a colleague was reported by 0.8 per cent of women versus 0.1 per cent of men. On top of this, people’s perceptions of organisations adequacy of handling sexual misconduct were much lower among women than men. Ranging from a low of 15.1 per cent for the General Medical Council to a high of 31.1 percent for the Royal Colleges (men’s evaluations: 48.6 and 60.2 percent respectively).

We are not surprised by these figures. In fact, during our conversation around framing this article, we both re-lived experiences from our training years and more recently:

• The senior surgical consultant who insisted on rubbing himself against me at any opportunity in theatre.
• The lewd comments – Noticing a pair of pearl-style earrings I was wearing, the same Consultant leant over the operating table, staring at my chest and winking he said, ‘They’d go well with a pearl necklace’.
• The consultant anaesthetist who would always find a way to tie up my gown, who then proceeded to pat me on the bottom as I walked towards the operating table.

Did anyone who witnessed these behaviours say anything? Did we say anything?

No, we ignored it, feeling uncomfortable, degraded, humiliated, and in the moment burying it and focussing on the patient in hand. We didn’t necessarily have other female colleagues to share these experiences with. We were only aware of the rumours that were always circulating, about more serious sexual misconduct, and labelling of women who were ‘willingly using their sexuality’ to advance their careers.

Why didn’t we say anything?

Quite simply because we felt our career depended on these men and the ‘power’ they wielded over us. They were our surgical trainers, our referees for our next job; they had worked many years in the hospital we were training in and we were merely there on rotation. Would they ruin our reputation? Would they write an unsatisfactory reference? Would they remove precious training opportunities? Would they prevent us from getting our Consultant post? Because we feared for our hard-fought surgical rotation, our hard-earned training number, our dream Consultant post.

Who could we tell? Who would listen anyway? and even if they did, who would be prepared to rock the boat?

These examples are just the tip of a much bigger iceberg, the depths of which lie in a sea steeped in patriarchal hierarchy.

These experiences are not unique to women in surgery or even women in medicine, they are the symptoms of a culture aligned with a masculine paradigm where independence, productivity, busyness, achievement, pushing through, winning and ‘power over’ are celebrated.

Think about the language we use in medicine; it is so often hierarchical. We talk about patients being under a consultant, we talk about the juniors who work for or under a consultant.

We use stereotypes to describe specialties, pigeon-hole people depending on their gender. All of these subtle descriptors become ingrained in our subconscious to the point that even as women we start to use them. We join in the banter, because at the end of the day what we crave as humans is connection and feeling part of a tribe. Even if, deep down, the values, beliefs and actions of that tribe do not align with our own.

Our ability to show vulnerability is wrung out of us and yet who do patients want to see?

They want to see a doctor who shows compassion, who is kind, who is confident in their abilities but knows their limitations, who will ask for help, who is able to say, ‘I don’t know, but I will try to find out’.

Now is the time for us to stand together as a surgical community, no matter our gender, to shift the culture.

Whilst this might feel like a mammoth task, we have to start somewhere. And it requires everyone to speak up and call in or call out this not only unacceptable, but illegal behaviour. It is of paramount importance that all people feel safe in their environment of work and can enjoy learning, training and helping patients, without fear.

So what can you do if you are a victim, witness or active bystander of sexual misconduct?

First of all, remember that the behaviour is not acceptable and is in fact illegal.

You can always speak to your clinical supervisor, educational supervisor, tutor, clinical lead or programme lead, for example.

All organisations have freedom to speak up leads and champions as well as methods for anonymously reporting this type of behaviour. Other channels for highlighting bullying and harassment should be clearly signposted on your organisation’s intranet.

Document the incidents; one option is to write yourself an email and file it. Ensure you document the facts and if possible the language used, verbatim. Identify witnesses.

You have probably heard the phrase ‘calling it out’ which is defined as bringing public attention to an individual, group, or organisation’s harmful words or behaviour. For example, in the moment saying

“I don’t find that funny. Tell me why that’s funny to you.”

There is also an alternative approach ‘calling it in’ which is an invitation to a one-on-one or small group conversation to bring attention to an individual or group’s harmful words or behaviour, including bias, prejudice, microaggressions, discrimination and sexual harassment. Supporting the perpetrator to change their behaviour, not ostracising them. For example

“I’m curious. What was your intention when you said that?”

Harvard University has created a helpful document which describes this in more detail and is well worth reviewing³.

The reality is that it can be very difficult to respond to the perpetrator in the moment.

One strategy is to speak to them (but not alone) after the event. This is an example of a coaching tool used for difficult conversations or asking for what you need.

1. Arrange a mutually convenient time to have a conversation, and explain why you want to talk (not in detail). For example,

“I would like to talk to you about something I noticed in theatre the other day”.

• At the start of the conversation clarify what you heard/saw and explain how it made you feel.

“When we were in theatre last week I noticed that you used a lot of sexual innuendos. This made me feel very uncomfortable”.

• Explain what you need going forward

“I ask that you not use this kind of language and if you do, I will ask you to refrain, in the moment”.

• Share what is in it for them.

“It is important that everyone feels safe in theatre, this kind of behaviour reduces concentration, trust and safety for both staff and patients”.

• Now ask Is there anything they need to be able to support this change in behaviour?

“ Is there anything you need to support this change in behaviour?”

Recognise that it might become worse during periods of stress or as a perceived way of building rapport rather than destroying respect and rapport.

• Collaborate on a way forward.

Another option is for staff members to have a private peer-peer ‘cup of coffee’ conversation. Vanderbilt University has described how to do this. They emphasise that any poor behaviour creates a bad culture that should be changed⁴. The Royal Australasian College of Surgeons has an app for such ‘cup of coffee conversations’. This is part of being an active bystander⁵.

These are just some examples of how as individuals, we may start to tackle the problem and the recent BMJ article ‘What should I do if I am sexually assaulted at work?’ provides a comprehensive narrative on the actions you should take⁶.

What we also need are robust strategies to shift the culture. This requires collaboration across organisational boundaries, with involvement  and ownership by all relevant stakeholders with both a top down and bottom up approach.

One such example is the recent publication of the Sexual Safety in Healthcare – Organisational Charter⁷ which has already been signed by a number of organisations. This provides an overarching philosophy, but not practical ways of nudging change.

On a practical level we suggest that conversations and invitations to challenge behaviour should be offered at every opportunity. For example, in the same way that we encourage people to speak up as part of the WHO surgical safety checklist, could we also take this pause to remind people of decorum in theatre and zero tolerance for banter?

Specific conversations should occur during induction and supervision meetings, explicitly describing expected behaviours and what to do if sexual misconduct is encountered.

Communication strategies need to be in place to highlight methods of reporting and challenging behaviours.

The anaesthetist, who describes a ‘snowflake generation’ who need to toughen up, because they should expect their training to be brutal, demanding, stressful, with bullying and sexual harassment thrown in for good measure⁸, would do well to recognise that these so-called ‘snowflakes’ are now joining together to create a snowball, the like of which have not been seen since the suffragettes fought and won ‘votes for women’ 95 years ago.

It is no longer time to be silent nor to look away or shamefully laugh; the time is now to speak up for ourselves and others. The Medical Women’s Federation is still required to set the standards because women have a different experience.

If you have been affected by this article please feel able to reach out to us, peers, colleagues, friends and family. You are not alone and it is ok to not be ok.