Race and Gender

The Indigenous, or Aboriginal and Torres Strait Islander, communities that predated British colonial rule have been subject to continuing and brutal oppression and marginalisation by a colonial regime that has systematically eroded Indigenous individuals’ access and connection to culture, identity, land and their own ways of knowing and being. (5). Modern Australia has been imposed upon the traditional lands or Country of hundreds of Indigenous nations. Successive waves of immigration in Australia have led to complex cultural and racial dynamics. From the late eighteenth to the mid nineteenth century, migration to Australia consisted of a mix of British convicts and British ‘free settlers’. ‘White’ Australians descended from these and other generations of British migrants form the largest ethnic group of Australians to this day.

Figure 18.1

Infographic Australia. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 18.1 Long description

The infographic provides information about Australia, with a population of 26.4 million and 41 doctors per 10,000 people. It highlights several gender-related statistics. 62 per cent of women participate in the workforce. 37.8 per cent of women are in managerial positions. 23 per cent of women have experienced intimate partner violence. Maternal mortality is 2.9 per 100,000. Infant mortality under 5 is 380 per 100,000. 43.2 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Australia:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 14, and is stable.

In the later nineteenth century, growing agricultural and mining industries attracted more diverse migrants, including many from Asia and the Pacific Islands. (Reference McNeill and Marmo6; Reference Stead and Davies7) Non-white migrants experienced discrimination, abusive working conditions and exploitative labour practices, including indentured labour, and there has been race-based violence throughout Australian history. (Reference Stead and Davies7; Reference Mar8) For the first half of the twentieth century, the vast majority of non-white migrants were rejected, and some non-white residents were deported, in what is known as the ‘White Australia’ policy. The ‘White Australia’ policy was officially ended in 1973. Racism continues to be an unpleasant undercurrent in Australian culture and is a common political target. (Reference Elkin9)

Of note, ‘White Australia’ policies were never accepted by all Australians. Hodges describes the way Australian multiculturalism developed over time, and the complex race relations that have characterised Australian culture. He argues that although Australia had a series of policies, including ‘1901–1945 (bad white Australia policy); 1945–65 (not-quite as bad assimilationist policy); 1972–96 (trying-to-be-good multiculturalism policy); 1997–present (bad new regressive policy)’, these policies were continually challenged. The policies ‘ignore the complex connections people have always made in Australia, even before Federation’. (Reference Hodge10) Australians have a long tradition of championing diversity and human rights which runs in parallel to racist discourses. (Reference Tazreiter11–Reference Bottomley13)

There is a similar history of gender-based violence, with one in four Australian women experiencing intimate partner violence. (Reference Bottomley13) Aboriginal and Torres Strait Islander women are at higher risk. (Reference Bottomley13) Despite public protest, and a recent ‘Australian of the Year’ who championed this cause, (Reference Wheildon15) one woman dies every eleven days due to domestic homicide. (14) The prevalence appears to be rising.

Australia has important cultural myths that shape the experience and response to gender-based and race-based violence. Australians are generally proud of convict heritage, and the anti-establishment and anti-authority culture prevalent in Australia’s history and literature is represented in the so-called ‘tall poppy syndrome’, a description of the way high achieving or successful Australians are often seen as untrustworthy, arrogant and selfish opportunists who need to be ‘cut down to size’. (Reference Peeters16) This form of classist prejudice plays into rape myths, where doctor survivors may not be well supported or acknowledged because they are privileged, and therefore not seen as vulnerable. (Reference Krahé, Kury, Redo and Shea17) The narrative of ‘mateship’ and the myth of egalitarianism (a ‘fair go for all’) obscure the uncomfortable history of racism, sexism, harassment and interpersonal violence that shapes Australia’s history. (Reference Austin and Fozdar18)

Medical Workforce and Health Care Services

The so-called State–Federal divide in health care means financial and policy approaches to health can be confusing and contradictory. General Practitioner trainees are funded and managed through the Federal budget, while other doctors in training are funded and managed primarily in State government-run hospitals. The division between the two systems is one reason why cultural change is difficult.

GPs train and work in small community businesses, and their patients are partly or fully reimbursed through a fee for service insurance scheme called Medicare. Non-GP doctors generally train in salaried positions in State-run hospitals where patients are fully subsidised. Some service delivery models, and some kinds of health care workers, work with distinctive populations with distinctive needs in distinctive ways that are not necessarily encompassed by this description of the mainstream system. Aboriginal Community-Controlled Health Organisations (ACCHOs), for example, often offer salaries rather than fees for service.

The multiple management systems involved in health care make it challenging for doctors in training to understand their rights in any given workplace. Most doctors in training rotate through multiple workplaces, and may need to manage the policy environments of their workplaces, their training organisations and the civil and criminal legal systems of State and Federal courts. Understandably, this can be confusing and impede reporting of sexual harassment.

Australia has a long tradition of fly-in, fly-out (FIFO) services, including the Royal Flying Doctor Service, which has a century-long tradition of supplying health care to isolated communities; however, this does not fully compensate for a lack of rural services. Some remote communities, particularly those with high Aboriginal and Torres Strait Islander populations, have very poor access to health care services. Despite the narrative that Australia has ‘universal health care’, there is a deep divide between health experience access for rich and poor, and between urban, rural and remote populations. These divides exert a profound influence on the kinds of health care experiences an individual may have, and the kinds of experiences a health care worker may have in their ‘workplace’. There are also areas with their own microculture, such as mining communities and farming communities. Outer metropolitan communities are often highly racially diverse. Intersecting marginalisations can mean health care workers can have very different sociocultural experiences, depending on the location of their work.

International Medical Graduate Experience and Vulnerabilities

Over 40% of the rural medical workforce are International Medical Graduates. (19) International Medical Graduates who seek to obtain registration in Australia must complete an International Medical Graduate (IMG) programme to do so. (Reference Board20) In most medical disciplines, after attaining medical registration in Australia, IMGs must work for many years in a ‘priority area’ and obtain a permanent residents’ visa or citizenship in order to provide services covered by Medicare rebates. Theoretically, these conditions are designed to incentivise practising in locations, services, or communities that are under-served. In practice, these conditions appear designed to exploit skilled labour. (Reference Healey, Fakes and Nair21–23)

After undergoing the difficulty and expense of emigrating, IMGs face a range of personal challenges: they start on temporary residency visas, with limited rights, no access to Medicare for their own health care, and a future that is dependent on the immigration arm of the government and the medical training and regulation bodies working in concert with one another to facilitate their career. (Reference Healey, Fakes and Nair21) Doctors who previously held more senior positions must ‘prove themselves again’ under this system with little opportunity for recognition of prior professional expertise (23) and IMGs’ ability to continue to live and work in the country is partly contingent on continuing to work in services that, in rural and remote ‘areas of need’, often leave them profoundly isolated from formal and social systems to protect them from abuse by clients or colleagues. (Reference Board20–23)

Gender in Australian Medicine

Although women are evenly represented in medical graduates, they are not evenly represented across disciplines, or in leadership. (Reference Bismark24; Reference Shalit25) Sexual harassment has been an important dialogue in recent years, with several high-profile cases discussed in the national discourse and described in our discussion. (Reference White26–Reference Colenbrander, Causer and Haire32) High prestige disciplines are still seen as ‘boy’s clubs’, particularly in anaesthetics (Reference Carter33), surgery (Reference Lim34) and cardiology. (Reference Burgess35) Doctors from marginalised groups are at higher risk of discrimination and harassment. (Reference Pascoe36)

In surgery in particular, Australia follows the global trend of being relatively hostile to female surgeons, with less female representation in leadership, and persistent microaggressions towards female surgeons in practice. (Reference Sprow37) Qualitative research in this area suggests there are four types of implicit bias that restrict women from thriving in surgical training and practice: workplace factors such as access to parental leave and role models, epistemic injustices such as unfair assessments of women surgeons’ performance by patients and senior colleagues, objectification and the assumption that they will carry out more emotional labour in their work and life. (Reference Hutchison38)

There are assumptions about ‘Lady doctor’ work that are pervasive, and affect all disciplines. ‘Lady doctors’ are seen by the community to be more empathic, generous, self-sacrificial and interpersonally capable. (Reference West39) These widespread assumptions lead not only to shape the type of work women do, but also the remuneration. In Australia, the medical gender pay gap is wide, (Reference FitzGerald40; Reference Grossman41) and while procedural work is highly valued, cognitive and interpersonal work is not. (Reference Grossman41) Specialties characterised by high emotional labour extract a deep personal toll on contemporary doctors. (Reference Quadrio42–Reference Jenkins44) Doctors in high prestige disciplines, such as neurosurgery, often echo other forms of privilege, and these doctors are more likely to be white, male and Australian born. (Reference McAlpine and Drummond45)

Interestingly, there is often unease between female junior doctors and nurses, which has deep roots in Victorian history. (Reference McAlpine and Drummond45; Reference Heggie46) In our study, one of the participants commented that

The unease and fraught power relationships between female doctors and nurses alienates junior doctors from the women who could be their natural allies in the prevention of sexual harassment.

Women doctors also carry the burden of emotional labour outside of their profession. Professor Carolyn Quadrio, a child and adolescent psychiatrist in Melbourne, mentions in a podcast the legacy of domestic violence and emotional work carried by women. She describes her background in a Greek immigrant family, and the legacy of grief, pain and sorry women carry. ‘Women were the emotional organ of the family’, she says, ‘the work of grieving was done by the women’. (Reference Quadrio and Howpage48) She expresses concern that this generation of young doctors are busy managing immediate trauma and are therefore less able to manage longer term concerns around structural barriers: ‘You have to deal with the immediate wound before you think about the battle.’ (Reference Quadrio and Howpage48)

Law

Prosecuting sexual offences generally involves requiring the prosecution to prove the complainant did not consent, and while each state largely emphasises free or voluntary agreement in its definition of consent, each jurisdiction has slightly different definitions of consent as well as different legislation regarding the conditions under which consent may be considered ‘impossible’ or ‘non-existent’ (e.g. if the complainant was drugged or unconscious). (Reference Mathews and Bismark49)

In criminal cases, a jury must determine if the prosecution has proven beyond reasonable doubt that the complainant did not consent to the sexual behaviour in question, considering the complainant’s state of mind at the time. (Reference Mathews and Bismark49) Workplace sexual harms are comparatively rarely prosecuted in criminal court, (50) in part because workplace sexual harms often do not meet the threshold of ‘sexual offence’ definitions, and in part because criminal cases can be costly in relation to one’s time, energy, and finances. Cases often involve specific features that can be re-traumatising and difficult to endure for survivors.

The external bodies that may use civil courts or independent tribunals to receive and respond to allegations of workplace sexual harassment include anti-discrimination or human rights bodies, industrial relations or employment tribunals or the Fair Work Commission, or workplace health and safety bodies or regulators. (Reference Smith51)

Applications to the Fair Work Commission and Industrial Relations/Employment Tribunals

The Fair Work Commission (FWC) is a national workplace relations tribunal. Recent amendments to the Fair Work Act (2009) have empowered the FWC, from November 2021, to hear complaints of workplace sexual harassment and respond to applications for general protections, complaints of unfair dismissal and unlawful termination, and issue orders to stop workplace sexual harassment. (Reference Smith51) ‘Orders’ to stop specified behaviours are a kind of formal legal warning which, if violated, may be enforced by pursuing remedy through civil courts and may include a fine.

The Work Health and Safety Act 2011 (Cth) and Work Health and Safety Regulations 2011 (Cth) specify that employers or workplaces are obligated to prevent (or, if this is not possible, minimise) occupational risks and hazards that endanger the wellbeing of people in the workplace (employee or otherwise). The federal policy body responsible for developing workplace health and safety ‘model laws’, Safe Work Australia, interprets this obligation to include a duty to prevent workplace sexual harms, (Reference Smith51) including a duty for businesses to coordinate work health and safety responsibilities (and how they may be discharged) with other businesses with which they work or share premises.

Medical Education

Doctors in Australia train in universities, with extensive workplace-based learning occurring simultaneously in hospitals, community health centres and general practices. After an undergraduate degree, or an undergraduate and postgraduate degree, the medical students graduate and undertake a series of rotations as ‘junior doctors’, also known as interns in the first year, then residents. After a few years of generalist training, most residents apply to a specialty training scheme and become registrars.

Australian universities have a historical issue with sexual harassment on campus, particularly in residential colleges. In 2016, the peak body representing the thirty-nine universities of Australia (Universities Australia, or UA) launched the Respect. Now. Always. initiative to prevent sexual harms in universities and improve university responses to sexual harms, (Reference MacDermott52–55) including two national surveys of student safety (Reference MacDermott52–53) and culminating in agreements between universities on plans to address sexual harms of students over the next several years, including public accountability measures. (53–55)

Specialty training schemes are run by medical specialist colleges, where the profession is responsible for training and certifying doctors to practise in the discipline. On completing their requisite training, they become fellows of the relevant college, and are then registered by Australian Health Practitioners Regulation Agency as specialists in their relevant discipline.

Learning environments are accredited by the Australian Medical Council to ensure training occurs in high quality environments. General practice is a little different because GPs are funded through the federal government, and practice in private rather than public medical workplaces. Training is heavily subsidised by the federal government and is regulated differently to other medical disciplines. GP trainees are required to undertake some of their training in underserved communities to partially offset this cost, and form a significant workforce for rural and remote Australia. International Medical Graduates have additional training and certification requirements. (23)

Rapid turnover of placements means doctors rarely settle into teams, and may have difficulty acculturating to their context. Sexual harassment policies also overlap. A student, for instance, has a policy framework in their training hospital as well as their university, and a registrar reports to their college as well as their hospital or general practice. Add in legal options, and medical regulatory bodies, and doctors in training can be very confused about who to report to, and what will happen if they do.

Medical Regulation

Australian doctors, including medical students, are regulated by the Medical Board, a federal organisation that is managed by the Australian Health Practitioners Regulation Agency. This agency is responsible for registering health professionals, and the Board hears cases of potential professional misconduct. The Board can temporarily or permanently deregister a health practitioner, which means they are unable to practise their profession in Australia. There are a number of other less severe options for the Board, including education, remediation and supervision. (57)

The Medical Board’s aim is ‘to protect the public’. While the Board does hear cases where a doctor’s behaviour in their personal lives indicates a potential risk to patients (e.g. criminal behaviour, violence and fraud), reports of sexual harassment between colleagues have been relatively rare.

However, there have been some important decisions which shape our understanding of the Board’s stance on these issues. In one case, (58) a doctor had sexually harassed a patient and had consequently undertaken disciplinary action (including an educational course on professional boundaries), then two years later sexually harassed a nurse who worked with him in a hospital.

The Board took immediate action and suspended his licence during the investigation, and he appealed to the Tribunal, arguing that this action was too severe because his misconduct against a co-worker should not be considered equally as egregious as his misconduct towards a patient: ‘to equate conduct between a doctor and a colleague to a doctor and a patient erroneously diminishes the importance of the unique features of a doctor patient relationship’. The Tribunal rejected this argument, and responded:

In this response, the Tribunal indicated recognition that sexual harassment between colleagues in a medical workplace not only constitutes professional misconduct, but that it involves power dynamics through the hierarchy of the medical workplace that render workers vulnerable.

Prelude

Before and immediately after the assault, Dr Lee viewed her relationship with John Kearsley as a mentor. However, as time passed, she came to realise that his behaviour was deliberate and predatory. When she reflected on the vulnerabilities experienced by junior doctors, she commented that attrition of self-esteem, hierarchical power relations and lack of respect for interpersonal boundaries was enculturated early in medical school.

She also described the similarities between the supervisor–trainee relationship and other hierarchical and dependent relationships.

In retrospect, Dr Lee felt that medical training teaches junior doctors to suppress emotions, conceal problems, and strive for perfection, which ultimately makes them more vulnerable.

Assault

Dr Lee describes her experience in the foreword of this book, but in summary, she was invited to a professor’s home for dinner to discuss mentorship. He had a family, and as it is not unusual to have a dinner with a supervisor and their family in Australia, this was not an initial concern. Because she was drugged prior to the assault, she does not recall all of the evening, but she does recall waking up during the assault. She had difficulty putting on her shoes, so was obviously still cognitively impaired when she left his house.

The morning after the assault, she disclosed the situation to a medical friend, and this friend facilitated an appointment with a GP, advocating for her and insisting that they do a drug screen.

Dissociation is a common response to trauma, and reduces the victim’s ability to think and respond appropriately. It also impacts on their ability to function professionally. In her victim impact statement, Dr Lee discussed how she had changed from being open and engaging to being quite withdrawn and isolated. It was difficult in this highly traumatised state to speak at all, let alone to report behaviour that is often experienced as shameful.

Limbo

In Australia, legal and organisational processes require prolonged periods of confidentiality, because court cases take many months and even years to be heard. Like other victims, Dr Lee had to endure many months of silence, isolation and self-doubt. Dr Lee managed to complete her training, but the trauma impacted her professional and personal life deeply.

Although Dr Lee had similar confusing reporting avenues to consider, the benzodiazepines she was given decided her course of action.

She did have support from friends, family and some senior colleagues, which was essential. No restrictions were placed on his medical licence until he pleaded guilty two years after the assault, leading to his suspension. It was not until 2019, over three years after his conviction, that he was finally deregistered.

When Dr Lee reflected on the situation, she commented on the expectation that she manage interpersonal conflict herself:

Exposure

Although Dr Lee chose to keep her name confidential in the court case, she was aware that many colleagues knew what had happened. That loss of anonymity and gossip were painful, and made her workplace feel quite unsafe. As a doctor who was used to having a high degree of control and agency, the lack of control over the perceptions of others was unsettling.

She was also deeply disturbed by the number of character references supplied by her colleagues for the perpetrator, even after he pleaded guilty to the assault.

Aftermath

Dr Lee revealed that after the conviction, instead of feeling triumphant, she was engulfed by profound shame. She felt humiliated, believing that her own weaknesses had blinded her and made her vulnerable to being handpicked, groomed and victimised by a man she had trusted. Dr Lee found it difficult to re-establish her career and sense of self. She describes feeling vulnerable and exposed at work.

When she became a consultant herself, she questioned her role in supervising and mentoring junior staff. Do we teach in the hidden curriculum this sense of over compliance? Is professionalism about being unemotional, and in total control? Dr Lee sees her role as nurturing the next generation, arming them with the skills to self -protect. She is working on her biography, and continues to reflect on how this experience shaped her life as a doctor and a person.

Cumulative Microaggressions: ‘We’re Just Too Used To It’

Junior doctors learn in a hierarchy and are expected to be compliant with the needs of the team. Many junior doctors, particularly those who live with intersectional disprivilege, learn to tolerate sexist and racist microaggressions, from the profession, their multidisciplinary colleagues and the community. (Reference Herweck73–Reference Wheeler76) In this environment, it is unsurprising that junior doctors can become tolerant of unacceptable conduct. It is also understandable that managing repeated microaggressions leaves less cognitive and emotional capacity for recognising and responding to harassment. (Reference Wheeler76) International Medical Graduates in Australia practise under a moratorium, which binds them to a decade of service in an underserved community. (Reference Healey, Fakes and Nair21–23) It is highly unlikely that an IMG will risk a complaint when their visas are dependent on their supervisors, their college or hospital, the Medical Board and the Australian Government.

The Role of Invalidation and Shame

Doctors are also part of a community, and the community continues to blame survivors for their own trauma. Rape myths invalidate survivor experiences, minimising the impact of trauma, and leading to underreporting of sexual harassment. (77–78) It is surprisingly difficult to break the perception that rape only happens to those who ‘deserve’ it, due to their choice of clothing, behaviour, location or even their body types. (77–78) These myths are pervasive, and are reinforced in the media, (79) the courts (80) and the broader social world. (81–82) The recent treatment of Brittany Higgins, who was sexually assaulted in our Australian Parliament House, has provided a clear warning for survivors. Being a survivor, and making a story public, comes with deep personal and reputational consequences that can destroy personal and professional wellbeing.

For a survivor in medicine, rape myths cause cognitive dissonance. Doctors are privileged, and therefore do not fit the public image of either a survivor or a perpetrator. Whenever we present this work, we inevitably face the question, ‘How can sexual harassment occur in the cold, hard light of day in a busy hospital?’, closely followed by a suggestion that young doctors may benefit from resilience training. The narratives that survivors are ‘sensitive snowflakes’ (Reference Haslop, O’Rourke and Southern83) who misinterpret the behaviour of their senior colleagues is often matched with a similar narrative that perpetrators are merely ‘bad apples’ and therefore should be managed individually. Thinking this way means they see no need for systemic change. (Reference Searle84)

Career Impact: ‘Does Anyone Ever Report These Things and Come Out on Top?’

Sexual abuse in the medical profession is not just a personal trauma, it is also a professional betrayal. When the workplace, the courts, the colleges or the collegiate community fail to respond appropriately, the personal trauma of sexual abuse is compounded by institutional betrayal that threatens recovery. (85–87) In the last ten years, there has been a concerted effort by Australian colleges, universities, hospitals and the Medical Board to address the issue of sexual harassment. Most now have policies and processes in place for reporting.

The Australian Human Rights Commission recently published their landmark report, Respect@work, (85) and it is this report that led to positive changes in national legislation. (Reference Nawaz86) Australian law now requires that all workplaces have a positive duty to report, ensuring hospitals, universities and other medical workplaces comply with the Sex Discrimination Act around sexual safety at work.

However, reporting sexual abuse in medicine has profound consequences, since young doctors rely on senior colleagues for support. Like the military, the hierarchy of medicine diminishes the likelihood of reporting abuse. (87) Young doctors fear ‘whistleblowing’, feeling it may bias fair assessment for training, and also their continued access to collegiate networks that will sustain their careers in the longer term. (87–88) There is also confusion about the process of reporting. Sexual abuse in the workplace is managed by a series of institutions with overlapping roles and responsibilities (89–90).

It is unrealistic to expect a junior doctor to navigate this complexity. In our study, we found time and time again that there was a difference between written policies and expected behaviour, so survivors distrust the institutional response to reporting. (Reference Healey, Fakes and Nair21; 50; Reference Braid71; 90) The anti-harassment posters on the walls reflect a law that is not always enforced, and the written policies around the reporting of abuse do not always reflect what they see happening in their working environments.

Personal Impact: ‘My World Is Broken and Will Never Be the Same’

In our study, we found that participants not only experience personal trauma, but they also experience a profound shift in their world view and their professional identity. Such a shift is likely to junior doctors to lose confidence and agency. The cost of a court case is also prohibitive for a junior doctor, especially as the hope of a successful outcome is slim. The risk of re-traumatising is high. Many doctors reflect the views of Judge Madgwick when sentencing a person for sexual assault: he described the victim as a ‘heroine of fortitude’ for surviving the hearing. (89) Many women believe that taking a sexual assault to court provides no benefit to the victim, even if it may forward the cause of justice for others by serving as a deterrent. Taking a case to court involves surviving ‘a theatre of shame’. (90)

Betrayal Blindness: ‘Was It Really Abuse?’

Betrayal trauma theory suggests that underreporting may also be linked to a purposeful, if unconscious, method of ‘not-knowing’. (91) Freyd and colleagues found that a close and dependent relationship between the perpetrator and victim predicted memory impairment for physical and sexual abuse. (92) After abuse, betrayal trauma theory suggests that victims may dissociate to maintain important relationships, by unconsciously not-knowing about information that would threaten it. (92; 93) Victims who have survived childhood trauma are more likely to suffer betrayal trauma and are more likely to dissociate, (93) reducing their capacity to register and respond to betrayal. (94; 95) Given prevalence estimates of 8–31% for girls, (96) it is likely that some victims of sexual trauma in medicine are also survivors of childhood trauma. In betrayal trauma, ‘the best way to keep a secret is not to know it in the first place; unawareness is a powerful survival technique when information is too dangerous to know’. (Reference Walton29)

‘Betrayal blindness’ can also be experienced by bystanders. This may involve consciously pretending not to know to avoid consequences in social relationships (the ‘Emperor’s New Clothes’ phenomenon) or may mean that bystanders remain truly unaware of the trauma. Bystander blindness protects the bystander by helping them avoid seeing and responding to risk. Acknowledging trauma threatens their own interpersonal, physical and moral security. (97)

Betrayal trauma has also been linked to poorer outcomes in mental health, including depression, anxiety, and PTSD. (98) This is particularly evident when institutions fail to protect victims or negatively respond to them. Therefore, it is essential that we understand how both abuse and betrayal influence the narratives of victims of sexual abuse in the medical profession – their understanding of causative factors, their initial response to the trauma, their experience of suffering, their decisions around reporting, and their longer term recovery. Survivors may not report because they genuinely have been consciously and unconsciously silenced. (99)

In Australia, the importance of bystanders was raised by the military. In 2013, an investigation was launched into sexual violence and gendered abuse in the Army. (100) The Chief of Army, Lieutenant General David Morrison gave a powerful speech that is still cited as a turning point in the national consciousness around sexual harassment and gendered workplace relations. Morrison was already known for his stance on gender equity, and this speech was written by his speech writer, Lieutenant Colonel Cate McGregor, who is transgender.

The speech was a masterclass in cultural leadership, with a visibly angry Morrison delivering a powerful directive. The most quoted phrase from this speech is the call to bystanders, where he stated, ‘the standard you walk past is the standard you accept’. However, there are other important messages in this speech that shaped not only the dialogue around sexual harassment, but also the role of men and male leaders in particular in eradicating it.

Restorative Justice

Institutional trauma needs institutional healing. Part of this healing involves understanding and responding to failures in the system that contribute to vulnerability. In 2023, we held an Australasian Summit on sexual harassment in medicine, and focused on the trajectory of health promotion, from primary to quaternary prevention.

Australia has made a significant effort over the last ten years to eradicate sexual harassment, but the problem undoubtedly persists. In medicine, the greatest weapon a perpetrator has is the tendency of the survivor to shut down and be silenced. Until we understand how to enable the survivor to speak, we suspect the behaviour will continue, perhaps in more subtle ways that are difficult to challenge.

Gender in Society

Austria is a democratic state and member state of the European Union (EU). To date, Austria has a population of about nine million people, with the majority of the population ranging from nineteen to sixty-four years of age. Austria is often described as a conservative welfare state. (Reference Riederer and Berghammer18; Reference Schmidt19) Regarding gender equality, Austria is marked by formally providing equal access and treatment on the one hand, and traditional and conservative role allocation on the other. For example, access to social services and individual health care is granted by law to all citizens irrespective of their gender; however, some gender inequality persists, for example regarding the allocation of power (in terms of political, social, and economic power and decision-making positions to the disadvantage of women) and unpaid labour affecting women disproportionally. Compared to the EU-average of 70.2, Austria has a gender equality index of 71.2 (100 is full equality), but is lower than the EU-average regarding the dimension of power and gender equality in decision making. (20) Such a result means that gender equality has not yet been reached regarding representation in political positions (e.g. parliament, government), economic positions such as corporate boards of large national corporations or social positions in large research funding organisations. However, compared to the EU-average, Austria has a higher percental share of women in such positions, except for board members of the central bank and in decision-making positions of the national Olympic sport organizations. (21) Increasing gender equality was listed as one of Austria’s three main challenges towards achieving the Agenda 2030 SDG (Sustainable Development Goals) targets. (22) Education is an important aspect, and it can be observed that tertiary education levels are increasing for all genders, (23) with more women than men completing tertiary education. (24) Despite this development, overall employment rates (paid labour) consistently have been more than 10% lower in the female population with more than four times as many women being part-time employed. (25) Women are spending almost 4% more time doing labour each day than men, with paid labour accounting for less than half of it, while the same figure for men is a little below three quarters of their time. (26) These factors contribute to a national gender wage gap of 12.2%, ranking above the OECD-average. (27) Working part-time often turns into a long-term arrangement (Reference Riederer and Berghammer18) and appears strongly connected to women with children and childcare responsibilities, (Reference Schmidt19) representing a major form of unpaid labour. Schmidt (Reference Schmidt19) also refers in this context to the creation of an ideal working norm for women with children/childcare responsibilities.

Figure 19.1

Infographic Austria. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality

Figure 19.1 Long description

The infographic provides information about Austria, with a population of 9 million and 54.6 doctors per 10,000 people. It highlights several gender-related statistics. 57 per cent of women participate in the workforce. 33.2 per cent of women are in managerial positions. 15 per cent of women have experienced intimate partner violence. Maternal mortality is 5.2 per 100,000. Infant mortality under 5 is 320 per 100,000. 48.1 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Austria:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law mandates equal remuneration for females and males for work of equal value.

S D G Gender Index global ranking is 6, and there has been some progress.

Intimate relations and founding a family with children are often marked by traditional gender role allocation. An Austrian study on three cases of differently shared parental leave in heterosexual couples (Reference Schmidt28) showed that negotiating parental leave is father-led, thus focusing on father’s parental leave as a bonus. Simultaneously, masculinity ‘remains hegemonic in being superior to femininity’ (28, p. 382). Pursuing non-normative, more gender-equal, care and parental leave arrangements was also found to be associated with relationship challenges. (Reference Mauerer and Schmidt29) Additionally, some restrictive gender roles are represented in several aspects of everyday life. For example, Kollmayer, Schober and Spiel (Reference Kollmayer, Schober and Spiel30) argue that teachers should be better equipped with knowledge about gender roles and gender bias and should reflect on gender differences in students’ performance and motivation to prevent (unintentional) reinforcement of limiting and restrictive gender roles and gender beliefs.

In the EU-wide study on violence against women, physical and /or sexual violence from a partner or a non-partner was experienced by about 20% of adult women in Austria. Thirty-eight per cent of women reported having experienced psychological violence in adulthood. (31) A more recent survey on gender-based violence in the EU has shown even higher numbers of physical and/or sexual violence by a partner or non-partner: about 35% of adult women in Austria reported these. Additionally, this survey included violence in the workplace and showed that almost 27% of working adult women experienced sexual harassment at work. (32) The numbers indicate that harassment and violence are considered more or less acceptable. But higher numbers of reported violence and harassment also indicate less acceptability of violence and harassment. (33) Austria has several pillars to respond to violence, including legislation, inter-agency collaboration, and non-governmental and governmental actors. The second GREVIO report on addressing violence against women in Austria has shown that Austria has made progress regarding improved legislation to prevent and respond to violence, increased funding of activities and interventions, training of specific professional groups (e.g. medical doctors) and creating specialized counselling services throughout Austria. Further recommendations target, for example, long-term action plans and evaluation. (34)

Gender in Medicine

Overall, the medical profession attracts women in increasing numbers. Currently, more women than men study medicine in Austria. (35; 36) However, change in gender composition in medical personnel is not true for all qualification levels and ranks in academic medicine. Despite quotas, which are implemented in national legislation and at EU-level, affirmative action plans and monitoring committees in hiring processes, gender gaps persistent in higher ranks. The gender gap in high-ranking positions in medicine is discussed with reference to parenthood, lack of (female) role models and the need to improve working conditions towards a better work-life balance and more individualized career paths. (Reference Steiner-Hofbauer and Holzinger37) Currently, women are (and expect to continue to be) underrepresented in higher ranks and in specialist careers (Reference Kuhlmann38) despite the increasing numbers of female medical doctors.

Structures of academic medicine are embedded in historical, cultural, social, and gendered contexts and processes. These contexts and processes intersect. In Austria, academic medicine is described as having gendered structures that also determine different career outcomes to the disadvantage of women. In this context power was mostly ascribed to and accumulated by men. (Reference Siller6) Such a setting enables the accumulation of power over others, but also results in maintaining a system of disadvantaging those perceived as ‘weaker’. Strict hierarchies, decision-making as individual – but not collaborative – responsibility and privilege, non-transparent communication, competition at the cost of collaboration, and mistrust may occur in medicine and strengthen such a system. It can be hypothesized that safe learning environments may counter a transgenerational repetition of a system that disadvantages some over others. (Reference Kumagai, Jackson and Razack39; Reference Torralba, Jose and Byrne40) However, ‘old boys’ clubs’, gendered structures in (academic) medicine and gender stereotypes discriminating against women in advancing in their careers are still noticeable in studies on medicine and medical structures. (Reference Siller6; Reference Komlenac41) Humiliation and harassment of medical students in medical education is also occurring in Austria (Reference Siller4) – a finding which is reflected internationally, as bullying, harassment and discrimination are found in several studies. (Reference Scott42; Reference Averbuch, Eliya and Van Spall43)

Medical Education

Medical education starts with an undergraduate degree with, mostly, twelve semesters (six years at public universities), including internships, and completed by a year of clinical rotations as well as a diploma thesis. Thereafter, postgraduates who want to practise as a medical doctor complete nine months of basic training in different specialties, comprising at least three months in surgery and internal medicine each, followed by several years of specialty training and one or more exams. Whereas the undergraduate programme is anchored at medical universities or medical faculties, practical and postgraduate training may be completed at general hospitals or specialized institutions as defined in the Hospital Act. The contents and requirements of the training are regulated by the Austrian Medical Chamber. (Reference Ärztekammer44)

The considerable duration of training prolongs the time trainees are dependent on evaluations and having to progress in training. According to legislation, a person responsible for training, either a specialist or family practitioner depending on the type of training, oversees progress in training. (45) The perception of being exposed to extensive dependency is also underlined by students’ reports. (Reference Sarcletti and Schäfer46; Reference Kelm47) Additionally, in a study on medical students at the Viennese medical university in Austria, students reported the highest stressor to be performance pressure and self-set standards. (Reference Steiner-Hofbauer and Holzinger37) Another study on medical students in one Austrian teaching hospital has shown that about half of the students were reluctant to speak up when having a concern about patient safety. The authors connected these findings with hierarchical structures in hospitals and low perception of an encouraging environment to speak up. (Reference Schwappach48)

Law

In the context of the workplace, sexual harassment, discrimination based on sex/gender, equal treatment and equal pay are covered by equal treatment legislation. (Reference Thomasberger49) Austria has also introduced legislation to fight violence against women in the private sphere (in 1996) and has signed and ratified the Istanbul Convention Action on violence against women and domestic violence. (50) Sexual rights and gender equality are still marked by ambivalence. For example, conservative parties and groups have also subjected processes of liberation to protests, for example regarding decriminalization of abortion, and marriage and child adoption rights for same-sex couples, as well as gender-inclusive language. (Reference Mayer, Sauer, Kuhar and Paternotte51) Additionally, Thomasberger (Reference Thomasberger49) has summarized that ‘(t)he ratification of the Istanbul Convention did not result in any major changes in the existing legislation’, (49 p.49) which signals that Austria is already equipped with equal treatment and violence prevention legislation, but that there is also opportunity for further improving legislation. Thus, despite strong achievements in legislation and policy on violence prevention, discrimination and harassment, there is still the potential to improve gender equality and violence prevention, particularly regarding, for example, adopting comprehensive approaches or closing gaps and barriers for survivors to receive support. (52)

Sexual harassment and sexual discrimination are subsumed as discrimination based on sex/gender and are regulated in equal treatment acts – thus containing a non-discrimination rule. Sexual harassment and discrimination may also be criminal offences and be covered in the criminal code. (Reference Thomasberger49) Within the academic context, the University Act prescribes that public universities have an equal treatment committee, which monitors discrimination based on gender, sexual orientation, religion/worldview, ‘race’/ethnicity or age. To promote gender equality and equal treatment at universities, additional policies, such as the affirmative action plan for the promotion of women and equal treatment policies, are published in universities’ statutes. (53)

Sexual harassment is one form of discrimination based on gender and is prohibited at the workplace. It encompasses any sexual(ized) behaviour that denigrates a person and is not wanted, is inappropriate or is offensive. (54) If an employee is reporting sexual harassment, the employer has to act. These actions can be manifold but have to prevent further sexual harassment and must not be of disadvantage for the person reporting harassment (see e.g. Gleichbehandlungsanwaltschaft). These legal and regulatory frameworks are only some aspects to counteract sexual(ized) harassment and sexual(ized) violence. Other aspects may include the organizational culture, awareness of the prevalence of sexual harassment, safe spaces to report incidents and a supportive environment for the survivor.

Medical Regulation

As per the Federal Doctors’ Law, the Austrian Medical Chamber has to establish a mediation committee in every state in Austria. The main task of the committee is to solve disputes and to reach agreement between parties. If a disciplinary offence is suspected, the disciplinary council of the Austrian Medical Chamber should be involved. (Reference Ärztekammer55) Disciplinary sanctions range from a written reprimand to being removed from the professional register. (45)

Several councils (e.g. Ethics and Complaints Council; Working Group on Patients’ Safety) are in place to protect patients’ rights and to ensure that medical doctors comply with the doctor’s law and professional code. When medical errors occur, they are treated as an organizational issue, and not as an individual issue. (Reference Ärztekammer56)

Legal regulations, particularly regarding sexual harassment and discrimination, have been discussed in the previous section on law in this chapter.

Prelude

Maria studied medicine because she wanted to help others and to interact with people. However, during her medical education she noticed that the profession was also about power displays in the workplace. For example, she experienced the pressure to show an impeccable performance, to compete with others, and to adhere to a strict hierarchy. Additionally, medicine was gendered in terms of women being seen as ‘the others’, whereas men were often displayed as the norm or as an example of how to perform or act. Thus, career paths were mostly presumed to follow a linear path, which was most often associated with men’s career trajectories.

Maria often noticed that sexualized harassment in academic medicine was not seen as acceptable. Nevertheless, she hardly overheard others talking about such incidents; if it happened it was tabooed and hushed.

When Maria was in her final year of medical education, she already knew about strict hierarchies and the requirement to comply with instructions. She knew that as a student and as a medical doctor in training, she would be on the lower end of the food chain. Criticizing and complaining about a senior doctor might come with a cost – she told herself that she would not jeopardize her training spot and be compliant so she could learn and finally practice as a medical doctor in the specialty of her choice. After successfully completing her medical education, Maria found a training spot for her postgraduate basic training at a university hospital including her desired specialty as the final rotation. It was a small team which had a strong and competitive research strand as well as a patient care strand. The senior doctor had vast experience in research and a very good reputation in his field. Maria was happy to learn from him and to be supervised by him.

Assault

After some time, Maria noticed rumours and remarks being spread within her team. The women in her team were more often assigned to patient care, whereas the men spent more time in the lab to conduct research. If one of the female staff spent time in the lab, she heard others muttering about the ‘tyranny of quotas’, that women are better with patients than with cells, and that they would get pregnant anyway. One day, Maria was assigned to go to the lab instead of spending her time at the ward. She shared the lab with two of her colleagues, who were already more advanced in their training than she was. Maria was already nervous about coming to the lab, because of the remarks about women’s (in)ability to do research or pursue a career in research, or comments hypothesizing a sexual affair with the senior doctor, so they (the women) get assigned to the lab.

In the lab she felt her male colleague standing next to her, watching her every move. He looked up and down at her, telling her that he could help her whenever she needed it. Maria felt very uneasy, as the words by themselves sounded harmless, but him standing so very close to her and whispering with a coarse voice left her feeling dirty. When she got home that day, he called her asking if she wanted to get together to celebrate her day in the lab. She declined. The next evening, he called and asked her to meet because he was lonely, and he felt that there was a spark between them. She declined again. After that she got text messages and voice messages saying he missed her or that he was looking forward to meeting her in the lab. At work she felt increasingly tense, dreading to see him again. In the lab he kept his distance, but whenever she looked at him, he smiled and winked at her. Wherever she was, he was there too. The next day, she walked up to him, telling him to stop harassing her. He laughed and asked her if she was so tense because she ‘hadn’t gotten any in quite some time’ and to loosen up. Maria felt unsure if she overreacted. Nobody appeared to have seen or noticed anything as everyone kept working quietly.

Limbo

A few days later, Maria talked to one female colleague in her team, and told her about her interactions with said male colleague. The female colleague shrugged it off and reported that this particular colleague always tries to push the boundaries with the ‘new ones’. She told Maria to forget about it as he was harmless, and it was some kind of rite of passage every woman in this team must go through. She also told Maria that there is not much she could do and that it might also just be a misunderstanding. After talking to her, Maria felt unsure if she should talk to the senior doctor. She did not want to embarrass herself if it was indeed a misunderstanding.

At first Maria tried to let it go, but even after weeks she felt tense at work and startled when her phone rang. She sought out the equal treatment committee at the university. Unfortunately, she had deleted all texts and voice messages, and there were no witnesses in the room with her when he talked to her. The committee took her report and provided her with first steps that could be taken, which included talking to the head of the team, or talking to the accused aggressor.

Exposure

Maria felt unsure if she wanted any actions being taken. At work, everyone appeared to keep a distance from her. She felt that everyone avoided her. One day she overheard how the male colleague told another person that she, Maria, hit on him, and that she was now embarrassed about his rejection. Maria felt increasingly insecure. She told the equal treatment committee that she renounced her accusations and that she did not want any steps being taken. Maria feared retaliation by her male colleague and that this might impact her career opportunities. Her contract was only for a few more weeks so she decided to sit it out.

Aftermath

After her contract ended, Maria sought another training position, which was further away from this hospital. She felt embarrassed and powerless about what happened. After some time, she talked to close friends about it. They encouraged her and told her that it was not her fault. They also named it sexual harassment, but Maria had difficulties accepting it as sexual harassment. It did not fit her assumptions of sexual harassment.

Raising Awareness and Knowledge on Sexualized Harassment

Global awareness raising was also activated by the #metoo movement, which helped spark discussions on sexualized harassment, discrimination, and abuse. (Reference Brunner and Partlow-Lefevre8) The movement can be a basis to build interventions. Every student and all staff should be aware of sexualized harassment, discrimination and abuse, its signs, facets, and its impact and they should know how to counteract it. Obligatory workshops that are offered repeatedly should be tailored so they are relevant and useful for anyone working in academic medicine.

Promoting Collaboration, Connectedness, and Participation

Deconstructing hierarchies is one necessary step to overcome abuse of power and barriers due to dependency and fear of retaliation. These strict hierarchies can be deconstructed by promoting a collaborative working environment with shared decision-making processes. Even though individual accountability in patient care still exists, such individual accountability is not needed in other contexts relating to, for example, teaching, publishing, or doing research. However, this approach is not equated with suspending leadership, but focuses on including all members of the organization in everyday processes.

Uncovering Systems of Abuse

Sexualized harassment, discrimination and abuse thrive in silence and neglect. Publicly demonstrating that sexualized harassment, discrimination, and abuse are serious issues, and that the organization should pursue a zero-tolerance approach, is needed to render this phenomenon visible. Also, others (62; 67; 68) have emphasized the need for visibility and a clear approach to uncovering systems of abuse.

Zero-Tolerance

Visibility should also be reflected in the consequences of sexualized harassment, discrimination, and abuse. Sanctions should be applied without exception. They can be manifold but must focus on the perpetrator and not on the survivor. For example, terminating the perpetrator’s contract or withdrawal of their resources should be chosen over ‘fixing’ the survivor. Additionally, visibility of such actions prevents gossip and misinformation.

Active Support by Contact Points

Committees and contact points that are not bound to directives are essential tools to operate in this field, and should be empowered to ensure action is taken. The head of the organization must be committed and in full support of actions taken. The contact points should also actively provide information on sexualized harassment, discrimination, and abuse, on contact details and on the process if sexualized harassment, discrimination, and abuse are reported. Currently, there are further initiatives on university campuses that focus particularly on sexualized violence.

Background

I come from Brunei, but ethnically I’m mostly Chinese. Brunei is a funny, little country. It’s so little that almost everyone knows everyone in one way or another, to the point where we recognize their car number plates. And people talk … a lot … about everyone. Probably because there’s not much to do. It is a Muslim country. Alcohol is not available for sale anywhere in the country, but you can bring your quota into the country for private consumption as long as you are not a Muslim. So there are no bars or clubs, and there is not much in the way of night life.

Brunei’s main resource is oil, so a lot of the expats in Brunei work in the oil and gas industry, just like my dad, though he’s not an expat. I hung out with a lot of my dad’s colleagues’ kids. Kids from England, Holland, France, USA, Australia, New Zealand, and the list goes on. There’s a little community of us, us families of the oil and gas industry, who are all members of a recreational club which has a few restaurants, pools, a gym, tennis courts, a golf course, basketball courts, badminton, squash, football fields, and a sailing club, and it’s on a beach. Spouses of the employees often ran particular social and enrichment groups such as aerobics, performing arts, silk painting, crochet, etc. Within this club, it seemed as if the rules that people normally follow in Brunei didn’t exist. I didn’t have to worry about wearing short shorts or a bikini because everyone else was dressed the same and no one looked at you twice. Outside though, that’s a different story. It is frowned upon for women to expose their decolletage, back, shoulders, midriff and thighs. Even if you cover up, people still stare at you because you might have a pretty face, nice hair or a desirable body shape. Interestingly though, most Bruneians are respectful and reserved.

You could say that I grew up in a mixed culture. I had ‘white’ friends who would greet you with a kiss on the cheek, and Asian friends who would greet you with a wave or a handshake. I adapted to both and changed my demeanor and accent depending on the company I was with. There is a certain behaviour that is expected of you as a child in the company of adults. You would always call an older person auntie or uncle, even if they are not related to you in any way. It’s just respectful. Back chatting, raising your voice or swearing is forbidden and will be met by physical punishment at home.

Now, why is this relevant? Because what you see on the outside is a far cry from what happens behind closed doors. I clearly recall many instances of domestic violence between my parents from the time I was about six years old. None of which I was allowed to speak of. I had to ‘save face’. But I was desperate. I needed my mum to get out of there. I honestly thought she was going to die at the hands of my dad. I came up with all sorts of ideas such as her moving back to Singapore and taking me and my brother with her, but she said she couldn’t financially support us and had to endure more of my dad’s abuse, just to give us the life she wanted us to have. I eventually told my paternal grandmother’s maid. I figured that she’s no relation to the family and therefore could find a way to help discreetly. She told my paternal grandmother and my dad’s sister who spoke with me about it. Unfortunately, my mum denied it and told me off about it saying I should never tell anyone anything.

Some time before I turned ten, my brother molested me. What I understood at the time was that he was ‘teaching me’. This included French kissing, what pubic hair looks like, finding my ‘hole’ (vagina), and how a penis gets hard. It felt wrong but I didn’t know it was wrong until a few years later. I didn’t know what it was called. I later learnt that it was really bad and I would get into a lot of trouble if anyone found out so I kept my mouth shut, out of embarrassment.

There aren’t any positive adjectives to describe my teenage years. I got into a lot of trouble with my parents as I rebelled. I was manipulated by my brother to think that he was the only person in the world who had my back so I took the blame for a number of things to protect him. I lied to my parents. My dad lost trust in me, but I never trusted him after seeing what he put my mum through. It was a terribly confusing time for me.

Medical Education

I knew from a young age exactly what I didn’t want in life. I had to leave Brunei. My parents were living a double life. A life that was perfect from the outside, but so, so horrible on the inside. We were playing pretend and I couldn’t be myself. I vowed to become financially independent from anything and anyone, so that I would never find myself in a situation similar to my mum’s. Doctor. That’s what I would be. Doctors are respected. It’s a prestigious profession. I would be untouchable. I had my first excuse to leave Brunei. I applied to London universities, the furthest away from Brunei my parents would let me go to, and I got in. I left Brunei alone with one overweight suitcase and one backpack. I brought my favourite pillow, a ridiculously large duvet because my mum was worried I would get cold, a tiny, one-cup rice cooker and slow cooker my mum bought me, and essential clothes and toiletries. I had only been to London once before to attend interviews for entry to medical schools, but I was confident that I would find my way to the halls of residence and uni with a map of London and the London Underground. I was on my way to be free from pretending. To be me.

Finding me, now that was one hell of a journey. What I discovered was that I yearned for acceptance by any means possible. I did what I thought would make people like me, from doing ridiculous dares to paying for meals or rounds or drinks. I had a father, but I didn’t have a father figure, someone I looked up to and could rely on, so I had boyfriends instead. Oh, and I clung on to them. I needed to be loved so badly. I met my most significant boyfriend at uni, and he is still a good friend of mine today. I have him and his family to thank for saving me when I was probably the most mentally unstable. He protected me when I was so vulnerable. We weren’t meant to be, but we still care deeply for each other.

I knew exactly what I didn’t want in a man. He had to be the exact opposite of my dad. He had to be non-Asian, a Christian or Catholic, open-minded and have a less prestigious profession to mine.

Sexual Harassment

Working as a junior doctor in London was character-shaping. A huge learning curve. On the first Wednesday in August every year, all the junior doctors move up a rank. For all med school leavers, this was the first day as an intern, and the previous interns to become a junior house officer, and so on. We were allowed to select our hospital preferences, but we were not guaranteed to get our first preference. I ended up in a hospital in northeast London. It was a beautiful, brand new hospital at the time and they put us interns up in lovely new apartments not far away. I didn’t know anyone. My external persona of confidence was built to hide my utter lack of it. I wanted to please people and to be liked. I was friendly with everyone and went to as many social gatherings as I could. All the interns and most junior doctors were lovely. The more senior doctors, on the other hand, they were, in general, scary people. I was certainly intimidated by them. There was a bullying culture because they had done the hard yards and felt they had the right to treat us the way they were treated.

On my surgical rotation, the specialist registrar on my team was doing some sort of study. It involved reviewing patients’ charts and collating data. He asked me to help, which I was more than happy to do. There was a little room full of patients’ charts and both of us went in. Everything happened so quickly. He locked the door behind us and pushed me down on the bench, started kissing me, licking my face and touching my body. I froze. Then rattling and a knock on the door. I pushed him off, jumped up and tried to open the door. You know how in movies, you see the poor victim trying to get away from the bad guy, and she can’t even put the key in the ignition of the car, and you’re screaming at the TV telling her to just slow down and the key would go in? That was exactly what it was like. I could not turn the lock and push the handle. I was fumbling. Panicking. I eventually got out after a few seconds, but it felt a lot longer than that. My friend was outside and I just ran in the opposite direction of that room and she followed me. Far enough away, I told her what happened. She immediately told me to report it, but I just wanted to go home. I tried to process what happened and work out what to do. I had to go back the next day and work with this guy. I wondered whether I would be taken seriously. I mean, this guy was a specialist registrar. He was basically the second in charge to the consultant. No one who needed to believe me would believe me. And even if they did, would they even class this as a reportable event? He didn’t rape me. He just kissed, licked and touched me. Was I being a sissy? Maybe it was my fault. Yes, that’s what it was. I was friendly with him and joked around, and maybe he got that vibe from me. It must be my fault. I will learn from this and try to be less friendly next time. So I didn’t report it. I acted like nothing happened and it was bloody awkward. He spoke to me the following day and apologized, saying that he didn’t know what came over him and to please not tell anyone. I shrugged it off and said, ‘Meh, no big deal. Forget about it’, but inside I just wanted to scream at him. I had to work under him for the next few months, which was really hard. Thankfully, I had the support of a colleague whom I had grown very close to as we worked on the same ward.

I moved to Brisbane in 2008 and worked at several different hospitals as part of the training process. I thought that there wouldn’t be much adapting to do as both countries speak English, cultures are pretty similar and medicine is medicine, right? Wrong! The culture shock moving from London to Brisbane was huge compared to the move from Brunei to London. Who would have thought? I struggled to understand Australian English because of the accent and the slang. Older Australians had a hard time understanding my British accent, so I forced myself to learn common Australian phrases, slang and eventually spoke with an Aussie accent. Medicine was hard too because guidelines, protocols, reference books, processes and procedures were different. Heck, even the use of brand names for medications was new to me. I looked like an idiot on a cardiology ward as an SHO asking what Cartia was. Oh, it’s just aspirin, but at 100 mg, not 75 mg? So I did what I felt I had to do and clinged to more senior doctors who would non-judgmentally guide me. Did they? Not really. Ridicule was commonplace. There were a handful who I thought were really helpful, but little did I know this was a recipe for assault.

There were many instances of inappropriate behaviour by more senior male doctors such as touching my inner thigh during grand rounds or meetings, sniffing my hair and neck, touching or squeezing my buttocks in the presence of a patient so I couldn’t do anything, undoing my bra clasps as a joke and many inappropriate text messages including one from a professor late at night asking to sleep next to me because his wife was on her period! After I refused, he treated me totally differently at work. He didn’t look at me and didn’t speak to me, instead of sharing jokes and laughing together which we used to do. I kind of felt guilty and almost sorry for him. It wasn’t long before he left the hospital suddenly and unexpectedly.

At one stage, I was working as Principal House Officer in an emergency department. I was seriously considering joining the training programme so I spent eighteen months working there and improving my skills and knowledge. My husband had been hobby home brewing for a number of years. One of the emergency consultants who had just resigned to return to his home country knew about this and asked if my husband could provide a keg for his son’s end of school party at their house and join in the fun, which he was more than happy to do. The emergency consultant’s wife and other kids were already overseas. We arranged to spend the night there with our three kids, knowing that we were going to be drinking. We had a ball. Our kids enjoyed swimming and playing games; then it was their bed time. We showered and put our kids to bed upstairs and we continued with the party. When the night was over, we headed to bed in our designated room. I fell asleep quickly with my husband next to me, but then I woke up to someone touching me. It was the consultant. He was kneeling on the floor beside me, stroking my buttocks and vulva and he put his fingers inside of me. I couldn’t move. I don’t know why. I felt sick. I know I said ‘Stop’ a number of times, but my voice was so weak. I heard him say, ‘Oh c’mon, you know you want this. You know I’ve always had a thing for you and I know you want me. Well, now you can.’ In my head I was thinking … Um, no! I thought we were just colleagues. You were my boss. I could hear him saying, ‘Mmmmm you are so fucking gorgeous and your pussy just gets me so fucking hard’, while he grabbed my hand and put it on his penis and with his other hand he continued molesting me. I elbowed my husband to try to wake him because my weak voice asking him to stop or asking for help didn’t get me anywhere. He just kept going. Again, I said, ‘Stop’, and elbowed my husband, told him to get out. It stopped. My husband fell back asleep. But my heart was pounding. Confused. Scared. Dirty. Disgusted. Angry. Asking myself what I did to make him think I felt that way towards him, or what I did to make him think he could do that to me.

Our kids came to our room in the morning and I had to act like normal Mummy. My husband had to transport his equipment back home. There wouldn’t have been enough space for all of us and his equipment in the car. He brought the equipment home and came back to get me. In the time he was gone, I was scared out of my mind. My kids desperately wanted to go for a swim again so I headed out of my room, down the stairs to watch them as they swam. I couldn’t believe it. The consultant acted like nothing happened. Nothing at all! I ignored him. It was so awkward. When I left with the kids, I was so relieved but yet I burst into tears almost as soon as I got in the car.

The consultant tried to keep in touch by sending me text messages and emails, but I never responded. Even his son tried to get in touch. I assume he didn’t know what happened and was confused as to why I didn’t want to have anything to do with them anymore.

This was a turning point for me. After this point, I stopped being friendly to any male doctor, I smiled less and I stopped attending social events organized by hospital colleagues.

I couldn’t stay in the hospital system any longer. In Australia, an International Medical Graduate is under a ten-year moratorium, where they have to work in a district of workforce shortage for ten years. This is scaled depending on how rural your placement is. The further away from the city you go, the less time you have under your moratorium. London to Brisbane was tough, but moving out to the country … man, that’s something else! Who would have thought that all you had to do to gain the trust of the local farmers as their doctor is to talk about the weather! So not only was I speaking differently and using words that don’t exist in the English dictionary, but the content of my conversations also had to change quick smart!

I specialized in general practice. I put everything I had into passing those exams: all my energy, time, and what felt like all the money I had. I turned all my anger and frustration into becoming a GP and I made it. I was my own boss. I took control.

I put everything behind me and moved on. I put on a hard, headstrong exterior so that I would never find myself in a similar situation again. I compartmentalized my past experiences and didn’t own them. Me writing this … this is me starting to own my experiences. It’s been such a difficult process. Until now, I didn’t recognize those events as assault. I recently asked my best friend from the London hospital I first worked in if he thought I came across as a slut. He was surprised and wondered why I would ask such a question. I told him about this book, which has made me reflect on my past. I did wonder why it kept happening to me because I was the common denominator. Surely there’s something in my persona or a big sign saying ‘slut’ on my forehead, I thought. My friend reassured me that I did nothing wrong, except maybe trust people too easily. I also learnt through the process of writing this that I’m really not alone, that this happens to so many people.

Brunei is a very safe country and the people are generally respectful. My trusting personality may have stemmed from this false sense of security, not truly understanding that there are real predators out there. My insecurity from growing up without a father figure, believing my brother that he was the only person who would look out for me and that we had a secret only he and I knew, and truly thinking I was ugly made me want to make up for these insecurities by being overly friendly and overly generous, which most likely led others to take advantage of this. As a foreign-trained doctor in Australia, I was further disadvantaged in a system I did not yet understand, and in a country where the culture and language were so unfamiliar.

Being a young, female, Asian GP, I filled my appointment book quickly. Managing mental illnesses in my patients is a big part of my day. For the most part, my past experiences helped me understand what my patients were going through, but there were times when I was guilty of thinking, ‘If only I could tell you that I get it because I’ve been there’, or ‘Oh, cry me a river! I’ve had to go through way worse’, or even a bit of jealousy that they are getting the help they need from their family and a doctor like myself, which I didn’t have access to. There were many, many other consultations that did bring up some painful memories and I had to act my way through it. Imagine trying to support someone when you haven’t had the support yourself. I have said goodbye to patients, shut the door, and just cried in my room, then get myself together before I run too late, and call my next patient in with a smile on my face. By the end of the day I’m pooped. I have nothing left to give to my family. I’ve become pretty good at leaving work at work so much so that when my husband asks how my day was, I will often reply with, ‘I can’t remember. Must have been okay.’

I had to do better. I learnt more about mental illness and available resources that may help my patients, which I used myself. Although my past experiences were traumatic, I don’t think I would be the doctor I am today otherwise. What strikes me as odd is the lack of support given to International Medical Graduates for their own mental health and wellbeing. As it is, we come into the country with nothing but a medical degree and we’re told to go forth and work in this health system, as long as it’s in a rural area where the availability of support, on-the-job training, and connections is limited and the spoken language and culture is different.

I wish for medical educators to encourage all doctors and medical students to read this book. Know that this happens. Don’t be a predator. Don’t let yourself fall victim to a doctor who thinks they have power over you and the ability to silence you. If you do, know that you’re not alone and it’s not your fault. It never was.

Gender in Society

With its currently 83.1 million citizens, Germany is the most populous country in the European Union. The traditional role model with women being the main providers of unpaid care work continues to exist in German society – with predictable negative consequences. Concerning their lifetime income, women earn only half as much as men. (Reference Boll, Jahn, Lagemann and Puckelwald1) In 2020, reactions to severe traumatic stresses and adjustment disorders were identified almost three times more often in women than in men – experts say mainly due to the double coping burden women carry. (2)

Concerning sexual harassment, several events in the last decade led to a wider public discussion about the topic. In 2013, the journalist Laura Himmelreich reported being sexually harassment by a politician. In the aftermath, thousands of women publicly shared their own experiences with sexual harassment under the hashtag #aufschrei, Geman for outcry. The debate that followed led to the first broad social debate about sexual harassment in Germany. (Reference Eddy and Cottrell3)

On New Year’s Eve 2015, hundreds of women were sexually harassed, some even raped, near the main train station in Cologne. More than 500 cases of sexual violence were officially reported, whereas only three of the perpetrators were convicted. (Reference Bosen4) The ensuing debate, again, brought focus to the topic and generated momentum for changes of the relevant laws. In fact, the events resulted in a reform of the law covering sexual offences, which now deems sexual harassment a criminal offence that can be pursued and punished under the law. (5)

Data on sexual harassment of women in Germany is scarce, but the existing data suggests that they are highly affected. Most of the available studies cover harassment in the workplace and report incidences as high as 70–80% depending on the type of harassment. One representative survey of the general population reported that 58.2% of German women had been affected by sexual harassment. (Reference Müller, Schröttle and Lebenssituation6)

Gender in Medicine

Approximately 63% of the nearly 98,700 medical students in Germany are women, with no significant drop until residency. (Reference Berufstätige Ärzte7) However, women are far less likely to hold higher ranked and leadership positions. In 2016, only 31% of senior physicians at thirty-four German university hospitals were women. (8) The situation becomes even worse for senior leadership positions such as university chairs, clinic directors or department heads: in 2019, women only held 13% of the leadership positions of the aforementioned hospitals. (9) Additionally, the German clinical workforce is less diverse than in other Western countries, with approximately 15% of the practising physicians holding a non-German passport, as recently reported by the German National Medical Board. (10)

Figure 21.1

Infographic Germany. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 21.1 Long description

The infographic provides information about Germany, with a population of 83.3 million and 45.2 doctors per 10,000 people. It highlights several gender-related statistics. 56 per cent of women participate in the workforce. 29.4 per cent of women are in managerial positions. 21 per cent of women have experienced intimate partner violence. Maternal mortality is 4.4 per 100,000. Infant mortality under 5 is 360 per 100,000. 48.1 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Germany:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law mandates equal remuneration for females and males for work of equal value.

S D G Gender Index global ranking is 21, and is stable.

However, these facts are not always met with reflection about systemic barriers that women might face in medicine; rather, the high numbers of undergraduates are used by some critics to try to limit access for women into the medical profession. (Reference Freyschmidt11; Reference Dordowsky12). For years, there has been an ongoing debate in the community about the percentage of women entering medicine, some deeming it ‘too high’. The impending shortage of senior physicians and the need for more and better part-time models are paternalistically called ‘gender-based’ problems – according to the critics women would take up the majority of training positions only to afterwards drop out to have children and work part-time to be able to look after them. (Reference Freyschmidt11; Reference Dordowsky12)

Sexual harassment in the workplace is an important factor in the systematic discrimination that women doctors are facing in the medical profession. First, women are consistently more affected than men. (Reference Sojo, Wood and Genat13–Reference Mclaughlin, Blackstone and Uggen17) In Germany, only one representative study exists thus far, but it shows a very high prevalence among female physicians working in a large university hospital: 76.1% had experienced at least one form of sexual harassment at work. (Reference Djermester18) Second, sexual harassment has far-reaching negative consequences on health and work capacity of the affected person. (Reference Lindquist and McKay15; Reference Parker and Griffin19–Reference Victor, Wichman and Malakkla23). In the aforementioned study, 77.1% of the sexually harassed women doctors experienced negative consequences like emotional turmoil, negative health impacts or work deterioration due to the harassment. (Reference Djermester18) Third, sexual harassment as a display of power can help maintaining existing power structures (Reference Johnson, Widnall and Benya24–Reference Menon26) and strengthen the ‘glass ceiling’, which prevents women from access to leadership positions in a male-dominated environment. In fact, if a woman physician’s work performance decreases due to repeated sexual harassment at work, this could make her seem less qualified for a leadership position and therefore add to re-establishing antiquated gender stereotypes. (Reference Bursten27; Reference Fitzgerald, Shullman, Bailey, Richards, Swecker and Gold28). The German medical system is still very hierarchical and slow in its accommodation of flexible work structures and non-linear careers, which is also reflected in its struggles to integrate diverse career models due to personal choice or structural barriers. Gender-related harassment displays intersectional dimensions in Germany as well; however, these are poorly researched in the biomedical field. A recent survey of students and lecturers enquiring about discriminatory experiences beyond sexual harassment highlighted multiple sources of discrimination, with sex/gender still being the dominant one. (Reference Ludwig, Jenner, Berger, Tappert, Kurmeyer, Oertelt-Prigione and Petzold29)

Medical Education

Studying medicine in Germany involves at least five years of university education. Before taking the final exam, students have to work for one year in a hospital, taking one trimester in surgery, one in internal medicine and one in another specialty of their choice. After successfully passing the final exam, young doctors start their training as residents to become a specialist. It takes at least five years of training to become a specialist, in most cases up to eight years full-time. The medical specialist training in Germany is structured according to the general education guideline created by the German Medical Association. In accordance with this national guideline, the federal states define their own specialist training guidelines, which residents have to fulfill in order to become a specialist in the specific region/state. The guidelines include a detailed description of the skills, knowledge and number of operations/procedures a candidate has to participate in or lead, in order to become a specialist. Senior doctors are responsible for the supervision, creating a situation of dependence for the residents.

Law

In Germany, sexual harassment in the workplace is forbidden by law, according to the General Equal Treatment Act (AGG – Allgemeines Gleichbehandlungsgesetz). Regarding sexual harassment, the AGG states that employers are responsible for taking appropriate measures to protect their employees. If the employer does not fulfill their duty to do so, employees have the right to refuse to continue working. The law, moreover, states that employees who speak up against sexual harassment at work and file an official complaint must be protected from any disadvantages because of it. Additionally, sexual harassment can also be a criminal offence. According to §184i of the Criminal Code, perpetrators of sexual harassment can be imprisoned for up to five years, the same punishment which can be enacted for sexual assault or rape (§177 Strafgesetzbuch [StGB]). (5)

Medical Regulation – What Happens to Doctors Guilty of Misconduct?

In Germany, all doctors are obliged to register at the German Medical Association. In case of a severe form of professional misconduct, doctors can lose their license to practice as a doctor. According to public court rulings, there is one documented case in which a doctor lost his medical licence because of sexual harassment at the workplace, since he harassed several female trainees. (Reference Köln30)

The medical board of the region of Nordrhine-Westphalia (Ärztekammer Nordrhein) was the first and only of the German federal medical chambers so far to establish a central contact service, consisting of three women lawyers, to which all doctors of their federal state can turn to for help concerning sexual harassment in the workplace. Systematic promotion of bystander intervention is only about to begin in the German medical environment. So far, there is no real tradition of colleagues helping each other. To the contrary, an advisor working in the equal opportunities consultation office of Charité-Universitätsmedizin Berlin explains that a lot of her daily work revolves around the lack of solidarity between team members and everyone’s fear of harming their own careers by supporting survivors of sexual harassment. One project aims to address these unhealthy cultures by fostering effective bystander interventions addressing sexual harassment in academic medicine among students of the same institution.

Prelude

Sabrina had already worked two years as a resident in the field of plastic surgery when she took a new job at a large academic hospital.

She describes the team atmosphere as friendly, although she recalls the relation between the colleagues as quite detached. The only exception was Dr T – he was her supervisor, only a few years older than her, and she quickly felt comfortable around him due to his friendly manners and informal interaction. Being the main supervisor for the residents, he oversaw their training and assigned who would do which operation.

After a while Sabrina noticed that he seemed to favour her over her colleagues when it came to interesting cases and rare interventions that every one of the residents was keen on getting their hands on to complete their training catalogue. He also missed no opportunity to stress that he could help her to complete her training in a shorter time and to promote her research ambitions. As he offered her a position on his research team, she was over the moon.

In retrospect, she identifies his grooming behaviour as one of the main reasons why it was so hard for her to recognize and fend off the harassment that followed.

Another reason which made it hard for her to correctly identify his behaviour was that it shifted only gradually. Slowly, he started to search for more physical contact with her, sitting or standing very close to her and sometimes casually laying his hand on her shoulder or her thigh while they were going over some patients’ records.

However, his behaviour got more and more intrusive. He started making ambiguous comments, suggesting to ‘do some research together, just the two of us, without the others’. Although she felt more and more uncomfortable around him, she still couldn’t tell him to stop. Asked about the reasons for her reluctance, she stated that she still feared to offend him, damaging their – as she thought – amicable relationship. Moreover, he held a position of power over her, as he was the one assigning the tasks and operations and who got recognised on scientific papers.

Sabrina tried to avoid him at work, spending a lot of time and energy thinking about how best to keep away from him. This constant pondering took a lot of her mental capacity, and she recalls problems concentrating on her actual work. She thought about telling a colleague about her situation but didn’t dare because she feared the consequences of the harassment becoming public.

Sabrina was worried that her colleagues would despise her for reporting Dr T, so she didn’t. Moreover, it reinforced the idea in her that she might be the one being overly sensitive.

His harassment didn’t stop, however, and the more she tried to keep her distance, the more he became intrusive. He started to pressure her to meet him after work for drinks, implying he would withdraw his support should she refuse. She declined, desperately searching for excuses.

Eventually one day as the two of them were performing a surgical intervention, he stepped behind her and pressed himself against her.

Limbo

Sabrina called in sick for the following days, feeling deeply humiliated and overwhelmed by the necessity to navigate the situation. She reproached herself for not speaking up, telling him to stop and unmasking the harassment, and she was shaken by the thought that eventually she was incapable of standing up for herself.

Now being able to label her experiences as sexual harassment eventually helped her to go to the Women’s and Equal Opportunity Commissioner and file a complaint against Dr T.

Sabrina also learned that it would be best if some of her colleagues would be able to confirm the harassment and be willing to testify publicly.

Exposure

So, she finally spoke to some of her colleagues about the incidents. Unfortunately, she had to find out that none of them was willing to appear as a witness against Dr T.

To experience this lack of solidarity hurt Sabrina deeply, and it was only of small consolation that she didn’t have to go back to work. He continued working in the same department and in the same position he held before. On Sabrina’s side, even colleagues she had considered friends shunned her from then on. The legal process only led to a warning letter to Dr T, issued by the hospital. More extensive measures against him could have only been taken had another witness confirmed her allegations.

Aftermath

Two years after the incidents, Sabrina is still struggling with its impacts on her life and career. She recalls still getting overwhelmed sometimes by the thought that he just carried on as if nothing had happened, whereas it left her with a shattered career, searching for a new job and a feeling of self-loathing. She experiences thinking that if she had had the courage to confront him earlier this might have never escalated.

Gender in Iran

Iran, officially the Islamic Republic of Iran, located in Western Asia, is a nation with Persian as its official language and divided into thirty-one provinces. (Reference Zeighami, Mangolian Shahrbabaki and Dehghan8) Even though Iranian women have made significant progress in recent years, they still face many challenges in various fields. Although the rate of female literacy in Iran is 90 percent, the number of educated women has increased significantly through the years and they constitute 56% of the students of Iran’s public universities, (9) they continue to face significant obstacles in the job market. The 2023 Global Gender Gap Index highlights Iran’s challenges in gender equality: its score for economic participation and opportunity and the labour force participation rate are low (see figure 22.1). Iranian women are less likely to have roles as legislators, senior officials, and managers. (1; Reference Zeighami, Mangolian Shahrbabaki and Dehghan8–10)

Figure 22.1

Infographic Iran. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 22.1 Long description

The infographic provides information about Iran, with a population of 89.2 million and 15.1 doctors per 10,000 people. It highlights several gender-related statistics. 14 per cent of women participate in the workforce. 18.9 per cent of women are in managerial positions. 31 per cent of women have experienced intimate partner violence. Maternal mortality is 22 per 100,000. Infant mortality under 5 is 1200 per 100,000. 36.6 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Iran:

• – a woman cannot get a job in the same way as a man.

• – there is no legislation on sexual harassment in employment.

• – there is no legislation specifically addressing domestic violence.

• – the law does not prohibit discrimination in employment based on gender.

• – there are no criminal penalties or civil remedies for sexual harassment in employment.

• – there is no law that mandates equal remuneration for females and males for work of equal value.

S D G Gender Index global ranking is 104, and is stable.

The High Council for Human Rights in Iran indicates that women make up 25.2% of public managers across all executive levels, with a total of 19,597 female managers reported in 2020. (9–10) Additionally, Iran’s score for women’s political empowerment is low. (Reference Zeighami, Mangolian Shahrbabaki and Dehghan8) These statistics underscore the profound gender inequalities faced by Iranian women. Despite making up half of the population and outpacing men in literacy and educational achievements, women continue to struggle for equal participation in the labour market and face systemic barriers in political and economic leadership. The disparity remains stark, as discriminatory policies at all levels impede their societal advancement.

Recent Change

The compulsory hijab law in Iran, implemented in the wake of the 1979 Islamic Revolution, mandates women to wear the hijab in public. This regulation has become a focal point of contention and emblematic of broader gender-based restrictions within Iranian society. In recent years, resistance against this mandatory decree has markedly intensified. The tragic death of Mahsa Amini in September 2022, reportedly occurring during enforcement actions by the moral police regarding her hijab, catalysed extensive protests under the banner of ‘Women, Life, Freedom’. This incident provoked widespread outrage within Iran, where existing public discontent towards the government was already pronounced, further galvanizing a sustained and widespread protest movement. Amini’s death resonated profoundly across the nation, precipitating an unprecedented surge of demonstrations against the government. These protests swiftly gained traction, primarily spearheaded by young women advocating for fundamental rights. Significant participation was observed from both men and women, challenging not only the hijab mandate but also broader issues concerning freedoms and rights in Iran. Despite heightened government enforcement of hijab laws and increased penalties for non-compliance, numerous Iranian women persist in their resistance. This ongoing struggle underscores a pivotal facet of the broader campaign for women’s rights and freedoms in Iran. The situation serves as a poignant reminder of the enduring struggle for personal liberties and gender parity amidst stringent societal and legal constraints.

Gender in Medicine

While women have historically comprised the majority of the workforce in health care sectors, primarily as nurses, caregivers, and midwives, their roles have significantly diversified in recent years. According to the Medical Council of Iran, there are approximately 161,000 physicians in the country, with women representing about 71,000 of these. Human rights reports from Iran indicate that 52% of physicians are men and 48% are women.

Furthermore, women dominate certain specialties, comprising 98% of obstetricians and gynecologists, 40% of specialist doctors, and 30% of subspecialist doctors. In the academic sphere, women make up 34% of faculty members in medical sciences. Within the Ministry of Treatment and Medical Education, there are 13,531 women, with 12,883 serving as basic managers and experts, 647 as middle managers, and only one as a senior manager. (9) Despite the increasing number of female physicians and faculty members in medical sciences, leadership roles and higher positions in education remain predominantly male-dominated, reflecting a significant gap in achieving gender equality. (Reference Zeighami, Mangolian Shahrbabaki and Dehghan8; Reference Mosadeghrad11)

Medical Education

In Iran, the integration of health service delivery and health professional education is overseen by the Ministry of Health and Medical Education. This body coordinates with over sixty affiliated universities of medical sciences that provide health care services and are responsible for the education and training of 77% of the health workforce. (Reference Zeighami, Mangolian Shahrbabaki and Dehghan8; Reference Zeighami, Zakeri, Mangolian Shahrbabaki and Dehghan12) The undergraduate medical training in Iran spans seven years, culminating in an MD degree. This programme includes two years of Basic Science Training followed by an examination required to progress to the next phase, three and a half years of clinical training (incorporating theoretical education and hospital placements), followed by ‘Pre-Internship Examination’, which is a requirement to proceed to internship, and an eighteen-month internship period during which students must also complete a research dissertation. Medical students receive hands-on training in specialized hospital wards, under the supervision of board-certified faculty specialists. Upon successfully completing medical school and the dissertation, graduates must register with the Iranian Medical Council and obtain a Licence to Practise. This process also involves fulfilling a government service requirement, which includes military service for male doctors and service in remote areas for female doctors, lasting up to two years for general practitioners and between four to twelve years for specialists.

Sexual Harassment Law in Iran

Iran faces significant challenges regarding legal frameworks that address sexual harassment. The absence of specific laws criminalizing gender-based harassment in the workplace and inadequate enforcement mechanisms often prevent victims from filing legal complaints against their harassers. This lack of criminalization and insufficient enforcement measures, combined with ineffective and non-deterrent punishments, undermine the obligations of employers and the government to prevent sexual harassment and provide necessary training to inform victims of their rights. This education is crucial for preventing workplace harassment. (Reference Rizvani13)

Although Iranian law includes provisions criminalizing certain sexual offences and harassment, these provisions are limited to public disturbances, excluding private settings or work environments. Additionally, Article 637 of the Islamic Penal Code specifically addresses physical sexual intercourse and the implications of physical sexual harassment. According to this article, any sexual act between a man and a woman outside of marriage is considered a crime, and the perpetrators are punished. If a sexual act (sexual harassment) is committed through force or coercion, only the harasser is sentenced to punishment. However, the law requires the accused to confess before a judge, or the victim must present male witnesses to substantiate the claim, complicating the prosecution of such cases, since sexual harassment typically occurs in private places without witnesses. A critical issue is that sexual harassment, particularly in the workplace, lacks a clear definition. Existing laws are inadequate and do not directly address sexual harassment in the workplace. (Reference Rizvani13; Reference Mesri, Farajiha, Azadfallah and Azari14) Notably, existing laws do not cover verbal, non-verbal, or quid pro quo harassment in non-public settings such as workplaces. (Reference Rizvani13; Reference Bagheri15) Therefore, accurately defining and criminalizing sexual harassment in the law is crucial, and organizations should be legally obligated to train, prevent, and protect victims against sexual harassment.

Medical Regulations in Iran

In Iran, doctors who intend to practise must be legally registered with the Iranian Medical Council (IRIMC) and receive a membership/licence number. This licence is valid nationwide, recognizing the individual as a qualified doctor of medicine throughout the country. After successful registration, doctors receive a Membership Card. The IRIMC rigourously verifies each doctor’s identity and qualifications upon registration and maintains up-to-date records of all changes to ensure the accuracy of the medical register. IRIMC members must periodically update their profiles, including photos and contact details, and renew their membership cards every five years.

Additionally, all licensed medical staff must demonstrate their continued competence and ability to provide high-quality care through a relicensing process that also occurs every five years. To be relicensed, doctors must provide evidence of their participation in Continuing Professional Development (CPD) courses approved by the IRIMC or other accredited medical organizations, earning at least 25 CPD credits annually. The IRIMC also supervises doctors’ practices to ensure adherence to medical regulatory requirements and takes disciplinary action if these standards are not met. Actions can range from issuing warnings to suspending or placing conditions on their registration, or even removing a doctor from the register. Furthermore, the IRIMC issues Certificates of Good Standing (CGS) or Certificates of Professional Conduct to active registered members upon request. These certificates are required when doctors seek licensing in other jurisdictions and are issued after assessing the doctor’s disciplinary records, ensuring they are provided in a signed and sealed envelope to maintain confidentiality and integrity. (16)

Prelude

Case 1 is about a cosmetic dermatologist who experienced sexual harassment during her internship in a public hospital. Experiencing sexual harassment caused her to eventually leave the hospital and prefer working in a private office where such dynamics were less pronounced.

Assault

The survivor, who experienced sexual harassment while she was a medical intern in a public hospital, recounted her harrowing ordeal. Despite facing sexual assault from multiple individuals, her main harasser was an anesthesiologist in the operating room. She attributed the prevalence of such behaviour to the power dynamics and hierarchical relationships inherent in hospital settings. The victim believes that younger women and medical students are particularly vulnerable to sexual harassment because they have less power and authority within the hospital. Additionally, their relative lack of influence and status makes them prime targets for harassment, exacerbating the challenges they face in these professional environments.

One common form of harassment she encountered involved a group of male colleagues, including an anesthesiology specialist, who made inappropriate jokes about a patient’s private parts. She described the situation:

She felt unable to object to their behaviour because it would only worsen her situation. ‘I decided not to say anything and just pretended I wasn’t listening to their conversation, instead focusing on the patients’ medical reports’, she explained.

She had a worse experience. The primary perpetrator was the anesthesiologist, who was in his forties and married. He frequently asked her personal questions about her private life. She recounted,

Eventually, he began physically harassing her. Whenever they were alone, he found excuses to come close and touch her. ‘He touched my back and backside or stood too close to me, and his hand touched my body whenever he wanted to explain something. He sometimes told me how beautiful I was’, she stated. She tried to avoid him, giving him the cold shoulder and not answering his questions directly to convey her discomfort, but he remained undeterred.

Feeling trapped, she knew that reporting such incidents often led to victim-blaming and gossip, which would further isolate her. She explained,

Moreover, she believed even if she reported his behaviour, it would not lead to any positive outcomes due to the power imbalance in the hospital.

She noted that this disparity in handling harassment cases contributes to significant underreporting among women. Many do not report incidents due to the lack of meaningful consequences for perpetrators and the fear of being blamed by colleagues. Moreover, ‘students and interns have no power in hospitals, and other staff don’t care about them and often place blame on them’.

Desperate, she eventually confided in her classmates and a few female colleagues whom she trusted to avoid blame or gossip. ‘After I told my colleagues and classmates, they didn’t leave me alone with him and protected me’, she said gratefully. After some time, she finished her internship and left the hospital.

She lamented the toxic hospital culture, stating,

Her experiences underscore the need for systemic change within medical institutions to protect interns and staff from sexual harassment and foster an environment where such abuses of power are no longer tolerated. The reluctance to report harassment is often compounded by the perception that no punitive action will be taken against the harasser, coupled with the fear of exacerbating the situation or facing victim-blaming.

Limbo

At first, the victim believed the anesthesiologist’s touches were accidental, but as the behaviour persisted, she became certain it was intentional and felt increasingly distressed. ‘I just wanted to leave and never come back’, she admitted. Overwhelmed by her situation and the lack of support from hospital management, she doubted that they would act against a well-positioned doctor. She feared that the blame would inevitably fall on her, as it often does on women in similar situations. She described grappling with self-doubt and blame:

These questions reflect the internal turmoil and guilt that victims of sexual harassment frequently endure, further worsening their emotional distress. The victim identified the absence of a formal reporting system as a significant barrier to addressing sexual harassment.

She believes that the lack of a clear, supportive pathway for addressing such harassment left her vulnerable to further incidents, extending the period during which she was harassed. This scenario highlights a critical gap in many organizational cultures and structures, where inadequate support and unclear reporting mechanisms significantly worsen the impact of such experiences on victims.

Exposure

The survivor in this case managed to disclose the incidents of harassment to a few close colleagues without immediate negative repercussions. She carefully chose whom to confide in, limiting her exposure and potential fallout by sharing her experiences only with those she trusted within her department. Despite this controlled disclosure, the ongoing harassment significantly impacted her wellbeing and professional satisfaction. She experienced a profound sense of job dissatisfaction, feeling that the discriminatory environment was intolerable. Ultimately, these feelings drove her to contemplate leaving the hospital entirely, seeking a workplace where she could feel safe and respected. This decision highlights the emotional and professional toll that sexual harassment can take, even when the immediate circle’s response is not overtly negative.

Aftermath

After enduring sexual harassment in the hospital, the survivor made a significant career shift, leaving the hospital setting to establish herself in the beauty industry and work as a cosmetic dermatologist. Now working from her private office, she feels empowered and in control of her professional environment. Despite this positive change, the residual effects of her past experiences continue to influence her attitudes and behaviours. She expressed a strong aversion to hospital environments and remains cautious in her interactions with male colleagues and coworkers. This cautious approach underscores the lasting impact that such traumatic experiences can have, affecting trust and comfort in professional settings long after the incidents have ceased.

Prelude

In Case 2, the victim, after experiencing sexual harassment from a specialist, shared her ordeal with colleagues and classmates, only to discover that they too had suffered similar mistreatment. Together, they reported the incidents to the head nurse. Unfortunately, despite their collective efforts and testimonies, the harasser faced no consequences. This lack of action from the hospital administration led to widespread feelings of depression and job dissatisfaction among the victims. Feeling disillusioned by the ineffectiveness of the reporting system and the apparent impunity enjoyed by the harasser, the victim resolved to never formally report such incidents again. The survivor is a specialist in a private hospital now.

Assault

The victim was a medical student when she experienced sexual harassment from one of the physicians in a public hospital. She describes that the hospital was rife with sexual harassment, ranging from verbal comments and jokes about women’s bodies to inappropriate physical contact. She recounts how sexual jokes, comments about physical appearances, and lewd messages were common, coming from various individuals including male nurses, students, patients, and caregivers. Despite her efforts to confront these behaviours, she often found that her protests either were ignored or exacerbated the situation, leading her to either remove herself from the environment or try to ignore the comments.

Her most troubling experiences involved an internist specialist during her internship. This perpetrator not only made sexual jokes but also demeaned women who objected by calling them old-fashioned. His behaviour escalated from verbal harassment to physical actions, particularly during times when fewer staff were present, such as night shifts. He would make comments about women’s bodies and inappropriately touch female staff under the guise of compliments or observations about their weight. The victim vividly recalled the first time this internist commented on her body, suggesting her uniform was fitted to accentuate her figure, which left her feeling shamed and angry. When she objected, he ridiculed her response, intensifying her frustration.

On one occasion, when they were alone, he used the pretense of explaining something to inappropriately touch her back and other parts of her body, prompting her to quickly leave the situation. The survivor explained ‘he wanted to explain something to me about a patient’s medical report and he started to touch my back and other parts of my body. I was shocked and terrified and made an excuse to leave. I felt disgusted and I just wanted to cry.’ The victim explained ‘I got anxious and did not want go to work because of him.’

At first, when he verbally harassed her, she could not understand if it was sexual harassment or not because based on some of her colleagues’ reactions it was ‘normal’ behaviour for men and the victim doubted her feelings, thinking perhaps she was overreacting to what was considered ‘normal’ behaviour. However, the physical harassment was a turning point that made her realize the severity of the situation. She felt depressed and unsure of what to do. After a while, when he continued his harassment, she reached out to other interns and nurses, discovering that many had similar or more severe forms of physical harassment experiences.

Limbo

In a state of limbo, the victim initially struggled with her negative feelings towards the harasser, unable to pinpoint why she felt this way. She recounts that upon reflection, she realized he often made derogatory jokes about women and inappropriate comments about patients and colleagues, which many seemed to dismiss as normal or ‘manly’ behaviour. This normalization within the workplace made her feel confused about her discomfort. When the harasser first physically touched her and made explicit comments about her body, she knew she needed to take action. She expressed regret over her inability to react more assertively in the moment, questioning why she didn’t confront him directly or even retaliate physically. ‘My biggest regret is why I did not do anything, screaming at him or even physical attack, but I did not do anything and just left him to continue his harassment’, she lamented. This paralysis was partly due to not knowing how to handle the situation or where to report his behaviour.

Exposure

Together, the survivor and her close colleagues approached the head nurse, who was sympathetic and advised them to formally report the behaviour so she could escalate it to hospital management. She explained, ‘Because the head of department was a man and his friend, we decided to talk with the head nurse, she told all of us should report his behaviour and she will talk with the managers of the hospital.’

Despite their reports, the outcome was deeply disappointing: the perpetrator was merely transferred to another department without any formal punishment, leaving the victims shocked and concerned that he might continue his behaviour elsewhere. This outcome highlights the challenges victims face in environments where the hierarchy protects the perpetrator rather than supports the victims, illustrating the need for more robust mechanisms to handle such complaints effectively and protect employees from repeated abuse.

Aftermath

In the aftermath of the management’s decision not to discipline the harasser, the victim felt deeply betrayed and became depressed. The lack of consequences for the harasser, despite numerous reports from multiple victims, left her disillusioned with the formal complaint processes. As a result, she resolved to never formally report sexual harassment again, opting instead for a more direct approach: confronting any future harasser verbally and physically. She rationalized this decision by stating, ‘When there is no punishment for harassers and you cannot even sue them in court or other places, the better solution is to defend yourself and make the situation worse for the harasser.’ Determined to empower herself and prevent further incidents, the victim pursued further education and became a specialist, now working in a private hospital. This career advancement was partly driven by her desire to create a professional environment where she could establish clear boundaries. She explained,

By adopting a more assertive and serious demeanor at work, she aimed to deter inappropriate behaviour and establish herself as someone who could not be easily harassed. This shift in her professional approach reflects a broader strategy of self-empowerment and boundary-setting, illustrating how individuals might adapt to protect themselves in environments where institutional support and justice are lacking.

Gender in Japanese Society

In a detailed analysis of Japan’s gender dynamics as of January 2020, the population stood at 60.94 million men and 64.36 million women, reflecting a nearly balanced sex distribution. Yet disparities emerge in the workforce: men outnumber women by roughly 2:1 in full-time roles, while the ratio inverts to about 1:2 for non-regular and part-time positions, constraining women’s participatory role in the labour market. Consequently, women’s average income remains significantly subdued, approximately 40% lower than that of their male counterparts. (6)

Cultural Background

A detailed description of changes in women’s roles in Japan’s cultural context in recent years follows. Historically, Japan endorsed practices such as ‘retirement upon marriage’ or ‘retirement by age 30’, exclusively applying to female employees. (7) This unequal employment condition was seen as a problem; thus, the Labour Standards Law was enacted in 1947. This law was designed to consider the physiological and physical characteristics unique to women and establish the ‘principle of equal pay’, which prohibits gender-based wage disparities. Between 1985 and 1999, the following labour laws were enacted: the Equal Employment Opportunity Law (1986), which prohibited dismissal due to pregnancy, childbirth, or maternity leave; the Convention on the Elimination of All Forms of Discrimination against Women (1985); and the Child Care Leave Law (1991), which supports workers with nursing or childcare so that they can smoothly balance responsibilities and continue work (now the Child Care and Family Care Leave Act, 1999). (Reference Iki8)

Figure 23.1

Infographic Japan. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 23.1 Long description

The infographic provides information about Japan, with a population of 123.3 million and 26.1 doctors per 10,000 people. It highlights several gender-related statistics. 55 per cent of women participate in the workforce. 14.8 per cent of women are in managerial positions. 20 per cent of women have experienced intimate partner violence. Maternal mortality is 4.3 per 100,000. Infant mortality under 5 is 230 per 100,000. 10.2 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In (country):

• – a woman can get a job in the same way as a man- the law prohibits discrimination in employment based on gender.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – there is no legislation on sexual harassment in employment.

• – criminal penalties or civil remedies for sexual harassment in employment do not exist.

• – there is no law mandating equal remuneration for females and males for work of equal value.

S D G Gender Index global ranking is 35, and is stable.

Awareness about discrimination against women has also gradually increased. Between 1999 and 2022, there has been a shift in policies for women to improve gender equity. The Basic Act for a Gender Equal Society (1999) and the Law for the Promotion of Women’s Activities (2015) have been enacted, and the policy axis today insists on gender equality, inclusive of both men and women, rather than only for women. (Reference Iki8)

Changes in the Status of Women

Statistical data indicates changes in the status of Japanese women in recent years. It suggests that the number of women in the workforce has been increasing steadily, (10) and the percentage of female full-time employees (27.2%) has also increased. (9) However, the percentage of women in management positions remains low. (10) According to the Global Gender Gap Report 2021, women hold 14.7% of managerial positions, 9.9% of parliamentarian positions, and only 10% of all ministerial positions, with a score of 0.061 for ‘politics’ (0 being complete inequality and 1 being full equality). (11; 12) In 2016, the first female governor of Tokyo was finally elected, but there is yet to be a female prime minister in Japan. (13; 14)

Selective Dual-Surname System

A recent case highlights the issues Japanese women face: the selective dual-surname system. Under the current Civil Code, married couples are required to have the same family name when they marry, and to our knowledge, Japan is the only country in the world with such a requirement. (15) Hence, most women change their family names upon marriage. (16) With the advancement of women in the workforce, some advocate for the need to introduce a selective separation of the family names of married couples. However, the Supreme Court did not approve such a system. (17)

While the prevailing Japanese stereotype dictating that women should predominantly remain at home has evolved since the 1950s, gender-based discrimination persists. Women’s societal participation remains markedly unequal. Consequently, it is challenging to assert that Japan has achieved gender parity.

Gender in Medicine

In 2018, the total number of Japanese physicians was approximately 300,000, of which 21.9% were women. (18) The percentage of female physicians in Japan is the lowest in the OECD, (19) and many of them work as part-time or short-term regular employees rather than full-time employees. (20) As for the composition of each specialty by gender, the percentage of men engaged in internal medicine was 20.6%, orthopedics 8.5%, and surgery 5.3%, while the percentage of women engaged in internal medicine was 14.9%, pediatrics 8.9%, and ophthalmology 7.6%. (21) Men are more engaged in surgical specialties. (Reference Burgos and Josephson22)

Women Leaders in the Medical Community

According to Dr Kono et al., the number of female assistant professors has increased to 30% between 1980 and 2018, while the number of female professors has remained stagnant at less than 10%. (Reference Kono, Watari and Tokuda5) According to a 2011 survey by the Japanese Surgical Association, women comprised 14.6% of physician medical subcommittees and 6.3% of surgical societies. The current situation reveals the difficulties women face in getting promotions. It is rare for women to take on leadership roles in business or the medical world.

Sexual Harassment in Hospitals

According to Japanese surveys, nurses, administrative staff, and doctors answered that they had ‘sometimes’ been sexually harassed. (26) Thus, the frequency of sexual harassment occurring in hospitals varies for several types of health care workers. Nurses tend to be more susceptible to sexual harassment, as compared to other health care workers. (Reference Amano27) Female physicians in Japan face both sexual harassment and pressure to sacrifice their jobs (their careers) because of life events such as marriage, pregnancy, childbirth, and child rearing. Therefore, it is difficult for female physicians to maintain an excellent work-life balance in Japan.

Medical Education

Japanese Laws for Women

Laws such as the Equal Employment Opportunity Law (1972) and the Child Care and Family Care Leave Law (1992) contribute to the prevention and management of harassment for life events such as pregnancy and childbirth. (34) These laws also prohibit dismissal and other disadvantageous treatment due to pregnancy, childbirth, and childcare, and have been promoted to provide an environment where women can easily take appropriate leave. In addition, victims can also ask a neutral third-party organization to resolve harassment disputes against the offenders. With the enforcement of the revised Law for the Comprehensive Promotion of Labour Policies (i.e. the Power Harassment Law) (2018), employers’ measures against harassment have become an obligation. Companies are obligated to set up consultation services and implement measures to prevent recurrence. (35; 36) These laws are similar in their form to those of many developed countries in this area.

Medical Regulation

Setting

The characters are a male attending doctor A and a female Resident B, Resident C and Attending D. Attending A is educated, conscientious, and trusted by the residents. Among the three female residents, Resident B was particularly well supervised by Attending A. Neither Resident B nor others felt that this was a problem.

After one of my study sessions, Resident B received a message on social media from Attending A, saying that she was attractive and wanted to meet her in an empty room.

As soon as Resident B received this message, she discussed it with her trusted resident classmate C and her attending doctor D. When she did not reply to the message, she received another message from Attending A, saying that he did not want her to worry about it, and things were fine. After that, she did not receive any messages from Attending A.

Later, this incident became known to the others. Colleagues and junior staff made fun of Resident B, saying that she was invited because she was beautiful, that she must have been flirting with Attending A, and that Attending A was a womanizer, contrary to appearances. There were no other female residents in the room except Resident B. She felt frustrated that she could not say anything back and could only laugh along with them.

Prelude

There is a latent perception that men are superior in ability and position in a male-dominated environment in terms of numbers and status, and in a hierarchical relationship between attending doctors and residents. Such perceptions foster a culture in which women are evaluated not for their abilities but based on their appearance and charm.

Resident B thought that she had been treated by Attending A without any arbitrary intentions. However, from Attending A’s point of view, Resident B’s behaviour might have made him think that she loved him. She tried to remember each of their interactions to pinpoint which behaviour made him think so, but nothing came to mind.

Assault

Resident B was not physically harassed by Attending A. However, she was psychologically and socially harassed. She was afraid of what Attending A might do to her if she met him behind closed doors, and she was worried that her future career would be negatively affected if she rejected her supervisor. In addition, the comments of her colleagues and junior staff who found this incident amusing made Resident B feel uncomfortable at work and angry with them.

Some people may say that this is not sexual harassment because nothing was done. However, sexual harassment can cause indelible psychological scars on its victims, regardless of whether they are physically harmed.

Resident B suffered double sexual harassment, not only from Attending A but also from her colleagues and juniors who treated her unkindly. Since this incident was a one-time event, it is not worth remembering for the person who perpetrated this sexual harassment. However, for the victim, the suffering continues even now, and any trigger can suddenly recall the memory of the event.

Limbo

Resident B immediately consulted her trusted attending doctor and peers after receiving Attending A’s message. She knew she would not be able to resist Attending A if he harmed her behind closed doors. She also knew she would not be able to ignore what he did and continue working. However, she did not want all her colleagues or juniors to know about this. It was enough for Resident B to confide in someone who understood her suffering. She did not know how people found out about it later, but Resident B thought that she could confide in someone she trusted and then continue her work without telling anyone the whole story, and she did just that.

Exposure

When her name became known at work, and she saw her trusted colleagues talking about her with amusement, she was disappointed. She lost her trust in them and became angry.

How do I cope with this sense of betrayal when colleagues talk about me behind my back? At that time, she had to laugh it off. She did not want to say anything back to her colleagues or juniors and worsen her relationship with them.

Are the critics correct? Am I to blame? Resident B does not think so. While there was a comment that Resident B might have invited her superior, she did not remember misleading Attending A. She almost thought she was at fault, but she did not feel guilty. She did not feel guilty about what she had said or done, but she did not want to blame Attending A.

How do I keep working when everyone is talking about me? Resident B tried to think of the people who were likely to gossip or talk about her behind her back. She worked to keep a psychological distance from them by not socializing with them beyond work.

Aftermath

Resident B is now a senior resident working at a different hospital. Attending A continues to work in the same hospital. She positively reflected that she would now be able to deal with similar events if they occur in the future. She also thought that she would be able to advise other female doctors or medical students with similar experiences.

For Resident B, this incident triggered a strong desire to not want other women to go through the same thing. Rather than going public with her own experiences, she would first help the women near her.

Current Problems

Causes of Failure to Achieve Gender Equality

Gender in Society

Malaysia is in South-East Asia with a population of 32.5 million in 2020. Malaysia’s population is mainly divided into three categories: Bumiputera which has 69.3% of the population (Malay and Indigenous people); non-Bumiputera (non-native), which has mostly Chinese (22.8%) and Indian (6.9%) people; and others (1%). The current sex ratio is 106 males per 100 females for citizens and 156 males per 100 females for non-citizens. (1)

Gender equality has improved slightly in Malaysia, with the Malaysia Gender Gap Index (MGGI) increasing from 0.709 in 2019 to 0.714 in 2020. (1) MGGI measures the differences between men and women in fours sub-indices: political empowerment, health and survival, educational attainment, and economic participation and opportunity. A score of 1.0 (100%) indicates that the equality of women and men has been achieved. Women have surpassed men in the educational attainment sub-index with a score of 1.059 but not for the health and survival sub-index recorded (score of 0.956) nor for economic participation and opportunity (score of 0.738). A women’s labour force participation rate (LFPR) of 55.3% in 2020 was far behind neighbouring countries such as Singapore (69.7%) and Thailand (66.8%). There is no barrier for females to enter any industry or occupation in Malaysia. However, there are differences between the number of males and females in different sectors, reflecting the choices and aspirations of Malaysian females. (Reference Lim2) In 2015, 8.6% of females were involved in ‘human health and social work activities’, compared to 1.3% among males. In addition, females contributed to 48.5% of the medical doctors, 38.4% of the obstetrics and gynaecology specialists and 42.4% of psychiatrists. (Reference Arrizabalaga, Abellana, Vinas, Merino and Ascaso3)

Based on the Institut Public de Sondage d’Opinion Secteur (IPSOS) 2018 survey on gender equality, the top three issues facing Malaysian women were sexual harassment, sexual violence and sexualization of women in the media. (4) These findings are similar to women globally, except that the third issue worldwide has been physical violence. Gender equality is still challenged by negative cultural values and misconstrued religious beliefs around power, privilege and control held by men. These differences significantly drive sexual discrimination, gender-based violence and sexual harassment. Despite the government’s commitment to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and SDG5, and while in-roads have been made into education, health and labour, relatively few women hold positions in decision-making roles.

Figure 24.1

Infographic Malaysia. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 24.1 Long description

The infographic provides information about Malaysia, with a population of 34.2 million and 22.3 doctors per 10,000 people. It highlights several gender-related statistics. 52 per cent of women participate in the workforce. 23.2 per cent of women are in managerial positions. 19 per cent of women have experienced intimate partner violence. Maternal mortality is 21.1 per 100,000. Infant mortality under 5 is 780 per 100,000. 53 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Malaysia:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law does not prohibit discrimination in employment based on gender.

• – there are no criminal penalties or civil remedies for sexual harassment in employment.

• – there is no law that mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 59, and there has been fast progress

Gender in Medicine

Gender disparities can occur in medical specialities, although these disparities may vary by country. Generally, females make up the majority in fields such as general practice, obstetrics and gynaecology, and palliative medicine, while men dominate in specialities such as cardiology and most surgical areas. (Reference Moberly5; 6) The reasons for this are unknown, but it could reflect women’s role in society, where they are seen as warm caregivers. Proportion-wise, a study conducted in 2014 found that far fewer female doctors attained consultant status compared to their male counterparts within a similar timeframe. (Reference Arrizabalaga, Abellana, Vinas, Merino and Ascaso3) There is limited up-to-date statistical data on gender distribution in the Malaysian health care workforce, but available figures suggest that the number of female doctors is rising in Malaysia. While 63.6 per cent of medical specialists were male in 2010, analysis within age groups revealed that Malaysian doctors were gradually shifting from a male-majority workforce towards a female-majority workforce. (6) The data showed that while medical specialists over sixty had an 85:15 male-to-female ratio, this ratio gradually progressed in the opposite direction with younger age groups. For medical specialists under thirty, the gender distribution was 39:61, favouring females. The trend was reversed with more senior specialists. The Ministry of Education of Malaysia reported that the proportion of female medical students enrolled in public universities was 63.3% in 2014. However, a lack of more recent data suggests that it remains uncertain whether these higher numbers of female medical students were translated into higher numbers of female clinical specialists and consultants. (Reference Arrizabalaga, Abellana, Vinas, Merino and Ascaso3; Reference Wan7)

Medical Education

Medicine is a very challenging field, and selection into medical school was only available for a select privileged few before the mushrooming of private medical schools. Medicine is a very desirable career among Malaysians. Many Malaysian parents aspire for their children to study medicine, which is perceived as a noble, honourable, and well-paid profession. The entry points into medical school are generally very competitive. Surviving medical school for five to six years can be gruelling. Furthermore, things do not get easier upon graduating as house officers. House officers have to wait a long time for a posting, which can be competitive, as permanent posts are limited. The remaining doctors may be offered positions working with the government under contract, which comes with significantly fewer benefits, such as access to speciality training.

There are a few pathways of study to become a doctor. Students can opt to train after completing a pre-university programme such as Form 6 (government schools), matriculation (in local colleges/universities) or other internationally recognized programmes such as A-Levels. (8) After a recognized pre-university programme is completed, a student can opt to study medicine at a public or private university. Currently, there are eleven public universities and twenty-two private universities offering medicine as a course that the Malaysian government recognises. (9) The curriculum in medical schools may not include modules on gender-based violence. Similarly, post-qualification training may not provide training on this topic.

An undergraduate medical course typically takes five years to complete before graduation. (8) After graduation, a medical graduate must complete two years of compulsory service as a house officer or intern at a designated tertiary-level public hospital anywhere in the country. Training includes postings in six compulsory departments, and each department has an appointed supervisor for house officers. Any medical graduate must be employed in a government hospital for house officer training and a further two years as a medical officer. At present, private hospitals in Malaysia do not offer house officer training. A medical officer can opt to pursue postgraduate training after serving another two years of compulsory service in a government hospital. (Reference Yong10). Postgraduate training typically takes four years, and fellowship training can range from three to four years. This can also be done at a government hospital or overseas. (Reference Yong10)

Legal Framework

Malaysia has different legislative instruments which can be used to address sexual harassment cases, but a standalone comprehensive sexual harassment law does not exist. The Penal Code requires proof beyond a reasonable doubt and is therefore rarely enforced in the case of sexual harassment. The following key legislations are referred to or used for sexual harassment cases. They include the Code on Prevention and Eradication of Sexual Harassment in the Workplace (1999); the Employment Act 1955 (amended 2012), Part XVA on sexual harassment, which provides guidelines on prevention in workplaces; and Tort of Sexual Harassment for civil action since 2016. (11) The draft of specific sexual harassment legislation was by the joint action group against violence against women (JAG-VAW). Currently, it is known as Joint Action Group on Gender Equality (JAG-GE) and has fourteen active women’s groups.

Women’s groups first proposed a draft sexual harassment bill in 2001. It was further developed by a Special Project Team on the Sexual Harassment bill and first presented to Parliament in 2021. Several provisions from the original Bill were dropped, including that of organizational duties, which would have provided provisions for organizations to have a duty to prevent and address sexual harassment. A Coalition on Advocacy of Sexual Harassment Bill 2021, comprising the JAG-GE, Engender Consultancy and Young Women Making Change, advocated for an initial comprehensive Sexual Harassment Bill. However, when the Sexual Harassment Bill 2021 was passed in 2022, it only defined sexual harassment, the setting up of a Tribunal to address sexual harassment cases and a committee to work on the guidelines and implementation of the new Act. Moving forward, women’s groups are intending to continue to work with the Ministry of Women, especially on guidelines for the new Sexual Harassment Act, including positive organisational duties. The Ministry of Women, Family and Community Development has announced that the Act will be implemented in stages, including the setting up of the Tribunal. We hope that this new Sexual Harassment Act will provide protection for all and prevent sexual harassment in the country.

Medical Regulation

All medical practitioners in Malaysia, regardless of whether they are in the public or private sectors, are regulated by one body, the Malaysian Medical Council (MMC). (12) All medical practitioners are required to abide by and comply with the Code of Professional Conduct of the MMC, and this is mainly to ensure propriety in professional practice by medical practitioners and to prevent abuse of professional privileges. The Code of Professional Conduct emphasises the health and welfare of the individual and family under the care of a practitioner as of the highest importance.

The council is comprised of medical professionals and was established under the Medical Act 1971 (amended 2012). The Medical Act is legislation related to the registration of medical practitioners and the practice of medicine. Together with the Medical Regulations 2017, the Medical Act deals with all disciplinary matters involving registered medical practitioners. If there are transgressions made of the expected norms of practice, it can result in punishment after a due process of inquiry.

The MMC has disciplinary jurisdiction over registered medical practitioners and will exercise it over anyone who has, for example, committed serious professional misconduct as outlined in the Code of Professional Misconduct or any other guidelines issued by the Council. Serious professional misconduct here refers to ‘a failure to meet the minimum standards of professional medical practice’ and ‘sufficiently immoral or outrageous or disgraceful character’. When a complaint is made in accordance with the Act, it is forwarded to the Complaint Management Committee (CMC), which comprises five council members who usually hold office for one year at a time. The CMC scrutinises each complaint, and if it meets their requirements, it is forwarded to a Preliminary Investigations Committee (PIC) and/or Disciplinary Board (DB). The PIC and DB members are selected from the Disciplinary Panel, which comprises council members and/or fully registered medical practitioners with at least ten years of registration under the Council. The Council then reviews the investigation of the mentioned panels and determines the next course of action. Depending on the offence, medical practitioners can be reprimanded, suspended, or struck off the registry. (13)

Prelude

This is about a specialist who viewed her experiences as trivial, though unacceptable and uncomfortable, and led to the experiences being lost in her memory. Recent discussion on the topic sparked her memory of the incident and made her realise the intensity of her experience.

Assault

The survivor has had a few encounters with sexual harassment. Her first encounter was when she was a house officer (intern) doing her surgery rotation at a tertiary hospital. It was the norm for consultants to shout at surgeons during ward rounds and surgeons to regularly shout at medical officers (MOs) and house officers (HOs). However, stories of sexual harassment were rarely heard of or spoken about. There were, however, frequent rumours of surgeons pairing up with medical officers and house officers or fraternising outside work.

She assisted a surgeon in the operating theatre one day with a scrub nurse present. While the surgery was progressing, the surgeon asked her personal questions that made her uncomfortable. She was startled to be asked whether she had a boyfriend. Despite stating having one, he further asked whether she would go out clubbing and dancing during the weekends. She replied uncomfortably, ‘Not really …’, but was startled to get his statement that he would like to see her dancing and see her moving. ‘I felt very uncomfortable then and did not respond to his remarks. I looked pleadingly to the scrub nurse who was present for a reaction, but she appeared not to have noticed what had happened and was absorbed in her work.’

Her subsequent encounter was as a post-graduate trainee doing hospital rotations. She was assigned to an internal medicine ward and described her working experience as enriching but challenging sometimes. She enjoyed working with most of her colleagues in the department, who were supportive and willing to teach. One physician was exceptionally attentive and helpful. Although he was not the physician in charge of the ward, he occasionally came to the ward to help do rounds when the physician in charge was unavailable. He was professional in his conduct with patients and other staff. Still, the trainee noticed that he paid more attention to her and often asked her how she was coping in the posting and how she was doing her studying sessions outside the hospital premises.

He asked her personal questions, such as whether she was single and how often she travelled back home to her hometown. He even offered to coach her privately over lunch or dinner outside work. On a few occasions, he asked her if he could travel with her back to her hometown whenever she planned to. She felt strange about the inquiries and the offers since they were not close to begin with. She declined all his requests as she felt uncomfortable and suspicious of his intentions. In addition, it was known that he was married with a child, and his family was based in another state. A more unacceptable behaviour occurred a few times during ward rounds where he would put his hand on her shoulder or back while saying, ‘it’s ok, don’t worry’. Not knowing how best to react, she pretended not to notice as these incidents were in front of patients. She was confused about whether he was trying to be friendly, but she did know that his behaviour made her increasingly uncomfortable.

Limbo

The survivor related,

In the second incident, as a trainee, she confided in another MO about her situation. She discovered that the perpetrator did have a history of similar behaviour with other MOs who were no longer in the posting. The other MO offered to inform the physician in charge of rosters not to slot her and the physician together in future. She faced no further problems throughout the duration of that posting.

Exposure

The survivor, in this case, did not encounter any issues when disclosing the incidents to others. Not many people knew of the incidents, as she revealed the details to a few close friends who were her colleagues in the concerned departments. She thought of the incidents as trivial, not realising at the time that she experienced sexual harassment. She believed there was insufficient concrete evidence to justify making a report and felt uncomfortable dealing with any scrutiny. Until now, she questioned herself if she had done something to provoke these advances. Her strategy was to go under the radar and continue working without causing fuss or disruption.

Aftermath

The survivor is now a specialist at a local university, and the incidents she experienced did not appear to hamper her career progression. She is, however, more empowered now and intends to work towards creating a safer working environment for other health care workers, such as working with this book chapter.

Prelude

Case 2 involved a compilation of events experienced by ten survivors with a history of sexual harassment from a similar perpetrator and received national coverage in 2018. The information was retrieved from newspaper reporting and those handling the case, including officials who investigated the case. None of the survivors agreed to be interviewed when approached by a third person who assisted their case.

Assault

This case was a high-profile case involving a senior orthopaedic consultant who was also the head of the department (HOD) at a tertiary-level hospital. The perpetrator had a long-standing reputation for sexually harassing new house officers in his department, but complaints were either not made or did not make it to investigations by higher authorities. (Reference Zainal and Chung14) The perpetrator was a very senior consultant and a very influential and well-connected person in his discipline. House officers (HOs) who were exposed to his misconduct were terrified of making any official complaint for fear of being penalized. They are concerned that the heads of departments, who are responsible for deciding whether the HOs have completed a posting successfully, may discriminate against them. Failure to successfully complete any postings would then disrupt their career progression.

A survivor’s account was reported in the Star newspaper, where she was summoned to meet the HOD in his office. She said,

Another HO detailed her account where she received advances during work and spotted a dark vehicle parked outside her apartment for an extended period. The HOD had texted her, saying he had found out where she lived and was waiting for her outside. (Reference Zainal and Chung14)

Limbo

The sexual harassment incidents had spanned many years, but many HOs who were affected did not come forward to complain. This changed when one of those affected did come forward to make an official complaint at the institution. The discussion spiralled into the national agenda when it came to the attention of the Ministry of Women, Family and Community. This Ministry then alerted the Ministry of Health and the then Minister of Health ordered an immediate investigation into the case. This resulted in several other HOs coming forward to make official complaints.

Exposure

Those affected grappled with all the possible outcomes of making a complaint, such as the HOD not signing them off to the next posting or receiving an unsatisfactory report resulting in a permanent blemish in their personnel files. In this case, no police reports were initially made. Some who did lodge reports within the organisation were left disappointed by the inaction. When news of the reports had broken, the perpetrator was told to go on leave and more survivors stepped forward with reports of his transgressions. (Reference Radhi15; 16)

An independent inquiry body was formed to investigate the matter. As the HOD was put on leave, he drafted a letter of support addressed to the inquiry body vouching for his good character and noting that under his leadership, his department achieved an excellent track record and that he was respected by many. He then pressured specialists, medical officers (MOs) and nurses in his department to sign it, going to the extent of identifying who had not done so and personally contacting them to request their signatures. (Reference Zainal and Chung14)

Aftermath

Based on the interviews with investigators, many of those who came forward had left the medical fraternity. They considered the challenges they faced, and decided they couldn’t focus on their job after such an ordeal. We were informed that at least one of the doctors has not recovered from the impact of the experience and is still receiving ongoing psychological support. The fate of those who went through similar experiences but did not lodge complaints is unknown.

There was also collateral damage in this case. After one month of investigations by the independent inquiry, the body recommended that the HOD be suspended from his duties. When investigations were completed months later, the HOD was terminated in all services upon the consent of the King of Malaysia. At around the same time, specialists from the same department were informed that the entire department (including fourteen specialists, twenty-five MOs and fifteen paramedics) would be getting transfer letters to different hospitals. Questions to top officials for reasons of the en-masse transfer were met with responses like, ‘It was to dismantle the toxic environment’, ‘the department was guilty by association and inaction’ and ‘it was collateral damage’. The transfer plan was eventually shelved after much opposition. (Reference Foon Fong17)

Medical Fraternity

Sexual harassment seems to be a commonplace occurrence in the medical fraternity but is not usually reported. This was until a high-profile case came into light involving an eminent and senior orthopaedic surgeon who was also the head of his department at a leading tertiary-level hospital in the country. A house officer had lodged a formal complaint against him for sexual harassment, and the Ministry of Women’s Affairs raised the alarm and called for an investigation. It was then that the Ministry of Health opened investigations into the wrongdoings of the surgeon. This triggered a domino effect which saw several other junior doctors coming forward with complaints of harassment by the surgeon dating back several years.

While it was good that investigations into this surgeon had finally begun, it begged the question of why it took the intervention by not one but two ministries to initiate investigations. A system already exists for incidences such as this, but it was not utilised in this case(s). Another question raised is what the role of the surgeon’s hospital is in dealing with harassment. Were no complaints made at all to the hospital authorities? There appear to have been weaknesses in a system that should have functioned to provide a safe space for employees. There is also an apparent lack of deterrents in an existing system, which ideally should be built into the reporting system, the investigation processes, the provision of support for the survivor/perpetrator, and the actual redress or inquiry.

Several factors involving the health care environment may explain the reluctance of victims of sexual harassment to come forward. What was noted in the cases reported is that perpetrators of harassment are usually in a more senior post than the victim. Junior doctors are typically reliant on the assessment of senior doctors to progress within a posting and on to other postings. Hence, when harassment happens, junior doctors may be reluctant to lodge a formal complaint in writing for fear of jeopardising their careers. Compromises in a junior doctor’s career can range from minor actions such as not being included in the operating theatre for critical surgeries, to more major ones, like receiving a failing grade in an end-of-posting exam. It is this hierarchical nature of the medical community, the existence of ‘senior’ and ‘junior’ doctor labels, and fear of consequences to their careers that causes its members to enable predatory behaviour in a way to ‘save their necks’. To further aggravate this is the issue of power dynamics in the workplace, which is prevalent in the Malaysian working culture. Hofstede’s Power Distance Index was developed to measure power distribution between individuals in a business, culture, or nation. Malaysia scored the highest in this among countries all over the world, which means that Malaysia has the most significant power distance between employers and employees. (Reference Hofstede18) Hence, it is not surprising that junior doctors would be hesitant to call out harassing behaviour by their seniors.

The medical fraternity exists within a relatively small circle. This means that even when transfers occur due to disciplinary problems, there is still the tendency for a victim to run into a perpetrator later, as the circle is a small one. Another question that has arisen is whether the workplace is a safe space considering the potentially many (unreported) cases of harassment or bullying. Is there any safeguarding in place and is it given priority in the health care system? If there is a written policy in place, it is essential to ensure that the policy gets implemented. Looking back at these cases, awareness about sexual harassment and ways of getting help may need to be addressed. Junior doctors go through an orientation process when they begin their careers, and awareness of sexual harassment may be a useful component to add to their training.

Survivors

We examined how victims from two different perspectives dealt with their situations and how they ultimately carried on with their careers and lives. In the first case, the survivor experienced relatively minor but still significant encounters of sexual harassment. While instinctively knowing that something was off but unsure if what she was experiencing was sexual harassment, she went into survival mode and got out of the situation(s) by saying ‘no’ in a good-natured way by laughing it off rather than stating it assertively. It is not unusual for survivors to face confusion about the types of behaviours that fall into the category of sexual harassment and the perceived severity that warrants legal action. In contrast, the survivors from the second scenario suffered for months or years in fear and shame until one of them took a fateful step to lodge a report. While the public classifies the case as a triumph as the perpetrator was eventually found guilty and punished, with his practising licence revoked, this could not reverse the damage faced by survivors. The perpetrator is still a free man and was not convicted under a court of law for his crime because none of the survivors were keen to make a police report.

Ideally what should have been done in both cases was to immediately document in writing either in a book or electronic device what had transpired and with whom, when and if there were any witnesses present. The next step would be to report their experiences to a higher authority. That higher authority would then be responsible for investigating or appointing someone suitable to do so before appropriate action is taken. The survivor should then take note of the action taken by the investigating authorities, where keeping a timeline of events would be helpful.

In the short term, talking to someone, albeit a friend or counsellor, would help immensely in relieving a huge burden and getting clarity. This is provided when an appropriate response is given. Ignorance of others on sexual harassment matters can cause harm when the listener invalidates the experiences with reactions such as ‘you are being so sensitive’, discouraging the survivors from pursuing further action and speaking up. There is also the issue of normalising certain seniors’ ‘acceptable behaviours’, leading to a workplace culture of sexual harassment.

All health care workers should familiarise themselves with the available protocols (if any) for sexual harassment. While making a report is the idealistic approach to dealing with an encounter of sexual harassment, it is important to consider several issues that have plagued the minds of our survivors here. Firstly, the time between making a report and eventually taking action can be lengthy. As if the incident of harassment were not traumatising enough, the victim would be subjected to reliving the episode repeatedly while making the report and during the investigation. To top that off, victims often face retaliation in the form of intensified bullying as their perpetrators roam freely and blame victims. Victims often get blamed for the harassment they experience and are accused of provoking the attack in the first place.

On the other hand, when a report is made, action is not always taken. This is mainly the case when the perpetrator is in a position of power and influence. Hence, not only is no action taken to reprimand the perpetrator, but the victim is placed in an even more vulnerable position. The perpetrator, being a HOD, can exert power by not allowing the victim to complete the rotation within the department, jeopardising the completion of housemanship, which is compulsory to be confirmed in service.

The organisations here have an essential role in ensuring the workplace’s safety for all. Its policy in supporting its employees needs to be clear and solid. It also needs to take reports of sexual harassment seriously and take the necessary steps to investigate them and take action. This will ensure that all health care professionals feel safe at the workplace and act as a deterrent to perpetrators of sexual harassment. This would add further value to the organisation in the long run. These organisations (clinics, hospitals, ministries) would not be able to function without good leaders. Leaders need to place appropriate emphasis on sexual harassment, and politicians need the political will to emphasise the implementation of the newly approved Anti-Sexual Harassment Bill. (19)

Legal Issues

An issue with reporting sexual harassment is the high burden of proof that falls on the victims. Sexual harassment is, unfortunately, usually difficult to prove in the absence of physical evidence such as bruises or witnesses. Often the victims look like their complaints were made based on misunderstandings. There are also limitations in the availability of current legal remedies. The definition of sexual harassment itself is not very clear under Section 509 of the Penal Code, where it is stated ‘to insult the modesty of any person’ and ‘intrudes upon the privacy of such person’. (20) There is also no specific coverage of online sexual harassment in the Communications and Multimedia Act of 1998. (21)

There is also limited coverage of situations in the workplace. The Employment Act 1955 only applies to employers and employees in Peninsular Malaysia. (22) The Public Service Department Circular also mentions sexual harassment but is only restricted to the workplace in the public sector. Apart from that, there is an absence of legally mandated obligations by the public and private sectors to establish in-house policies and mechanisms to prevent and address sexual harassment. Presently, the Code of Practice on the Prevention and Eradication of Sexual Harassment only recommends that employers set up policy statements prohibiting sexual harassment in the organisation, protective and remedial measures (including complaint measures), as well as educational programmes (including training) to raise awareness of sexual harassment at all levels within the organisation. (19)

When a case goes to court, hearings are often time-consuming and expensive. The processes deprive survivors of their privacy. There is also a high burden of proof on the victims of sexual harassment as it is complicated to prove, and judges have to ascertain beyond reasonable doubt that the case is indeed one of sexual harassment. It is not surprising that many victims do not come forward due to this and the possible repercussions where the perpetrators do not usually get more than a rap on the wrist. Monetary compensation is only possible if a civil suit is to be pursued under the tort of sexual harassment. While this is not the most effective form of a deterrent for some perpetrators as it can be quickly paid off, it is also not what victims often seek, such as an apology or acknowledgement from the perpetrator that an offence has been committed.

Gender in Society

Mexico has a total of 126,014,024 inhabitants, of which 51.2% are women. In the case of Mexico City (CDMX), the population is 9,209,944 inhabitants, of which 52.2% are women. Furthermore, the adult population of CDMX between 25 and 69 years old is 5,516,642 inhabitants, 53% of whom are women. All the above data is reflected in the population census conducted by the National Institute of Statistics and Geography (INEGI). (1)

Figure 25.1

Infographic Mexico. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 25.1 Long description

The infographic provides information about Mexico, with a population of 128.5 million and 24.4 doctors per 10,000 people. It highlights several gender-related statistics. 47 per cent of women participate in the workforce. 36 per cent of women are in managerial positions. 24 per cent of women have experienced intimate partner violence. Maternal mortality is 59.1 per 100,000. Infant mortality under 5 is 1280 per 100,000. 43.9 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Mexico:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – there is no law that mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 67, and is stable.

Considering the above data, we can affirm that there is a slight difference between the number of men and women in the country; however, this gap is exacerbated when we talk about the presence of women and men in positions of power and decision-making. A clear example of this difference and its prevalence was observed when, in 2014, the obligation of political parties to guarantee gender parity for the registration of candidacies to different elected positions was raised to Constitutional rank (INEGI-INMUJERES). (1) In Mexico City, the governor was appointed by the republic’s president, and the position had been assigned only to men. However, in 1999–2000, democratic election was established, and a woman was appointed interim governor. In the 2018 elections, Claudia Sheinbaum Pardo was elected as head of a government of science, and there was likewise a considerable increase in the participation and election of women for the mayoralties of the city. (Reference Fernández Poncela2)

According to INEGI 2020 statistics, 15.1% of the total population in Mexico is indigenous, and half are women. They are doubly discriminated against, first because of their indigenous status and second for gender reasons. Opportunities for indigenous women in labor, political participation, or schooling are very scarce and may even be non-existent in some ethnic groups. In the most challenging situations, some indigenous women who have not reached the age of majority are the object of transactions in exchange for some material good for their families. These acts are shielded using arguments about the uses and customs of various indigenous peoples. (Reference ChandomÍ3)

Gender in Medicine

In Mexico, there has been an increase in the number of women in the medical field. For example, in the last school year, 2019–20, the General Directorate of School Administration (DGAE) of the National Autonomous University of Mexico (UNAM) reported that 33% of the 1,930 students accepted for the career of a medical surgeon were women.

Since the 1990s, the gender breakdown in medical schools has been reversed, and to date, the female sex is predominant. This phenomenon has been dubbed the ‘feminization of medicine’. One projection suggests that by 2027 the percentage of women enrolled in medical schools will reach 60% nationally. (Reference Graue-Wiechers, Alarcón-Fuentes, Guevara-Guzman, Ostrosky-Wegman, T, 372ME, P, E and P4)

The presence of men stands out within management positions in health institutions and medical schools. However, the last decades have seen increased participation of women as leaders, mainly in medical education and some health institutions. Within medical education, the UNAM School of Medicine is one of the most representative of this change since more than half of the managerial positions, including secretaries and heads of academic departments, are held by women. In the research division, seven women head their departments, and the positron emission tomography/computed tomography (PET/CT) services, research, and teaching unit is headed by a woman.

Regarding medical specialties, a report published in 2022 found that from 2006 to 2015, the surgical specialties that showed an increase in female students graduating were otolaryngology (55%), cardiothoracic surgery (23%), coloproctology (21%) and pediatric surgery (17%). Regarding clinical specialties, those with an increase were pediatric cardiology (52%), allergy/clinical immunology (30%), pediatric neurology (28%), genetics (25%), and pediatric endocrinology (23%). (Reference Sepúlveda-Vildósola, González, López-Sepúlveda and Martínez-Escobar5) For instance, only three of the thirteen institutes that make up the National Institutes of Health have had or now have female medical directors. However, the remaining institutes’ general directorates have never been led by a woman. (Reference Rivera-Romano, Fresno, Hernández-Lemus, Martínez-García and Vallejo6) In our country, data regarding gender violence in medical students has been reported from 15.5–69%, more towards women than men. To mention a couple of examples, it was reported to have been performed through sexist insults (F: 11.5%; M: 3.4%) and personal academic favoritism (F: 9.0%, M: 2.9%). (7)

Sexual harassment has been reported to occur more frequently in clinical cycles (73.66%) than in primary cycles (26.34%). In both, women are the most affected, and occurrence increases with the number of years of study, being significantly higher during the fourth and fifth years of the degree course. Harassment manifests as unwanted invitations to go out on a date, inappropriate jokes, leering, questions to female students about their sexual habits, unwanted sexual conversations, obscene flirtatious comments, insinuations of sexual relations, unwanted sexual attentions, or academic blackmail. Sexual abuse affects 7–28% of students; 46–54% are women and 19–39% are men. The forms of abuse include being spied on in bathrooms, being forced to undress, showing sexual organs, observing masturbation, being pressured to perform oral sex, and fondling, among others. (7)

Medical Education

In Mexico, the body in charge of evaluating and certifying the quality of medical education is the Mexican Council for the Accreditation of Medical Education, (8) which establishes the standards to evaluate the quality of education. (Reference Salud9) The figures reported by COMAEM for the second semester of 2022 are ninety-one accredited programs, eleven with expired accreditation, one without accreditation, twenty-five in self-assessment, two unfavorable opinions, and twenty-four without the accreditation process. (Reference Salud9)

The accreditation considers standards from the administrative process to the evaluation of the students and the monitoring of graduates. COMAEM’s challenge is to certify medical education because of the increase in medical schools and students in the country (133,000 students in 2018). (Reference Rillo, Martínez-Carrillo, Conteras-Mayén, Valdéz-Ramos and Castillo-Cardiel10) On the other hand, medical education in Mexico is heterogeneous; there are more than 140 public and private medical schools with different programs and characteristics. (Reference Blancas and Bárcena11) In addition, about 50% of specialty students are enrolled in postgraduate training at UNAM. Although the school environment seeks to be free of violence, a factor that can substantially increase the risk of violence is social service. The social service component is integrated into the program to ensure students gain practical experience and develop a sense of social responsibility before becoming practicing physicians. However, it is unpaid and unregulated and the government does not offer safeguards for physicians. (Reference Blancas and Bárcena11)

Resident doctors do not have labor rights since their professional activity is considered a postgraduate scholarship. These factors increase the susceptibility of physicians to unsafe and violent environments. (Reference Machado, Ramírez, Sepúlveda and Márquez12) A resident physician in Mexico is a medical professional who enters a receiving medical unit to perform a specialty characterized by academic, assistance, and research activities that must be carried out during the time stipulated in the related academic and operative programs. In addition, these must be endorsed and supervised by a university institution.

Law

The Federal Labor Law, in article 133, states that ‘Employers or their representatives are prohibited from carrying out acts of harassment and sexual harassment against any person in the workplace or allowing or tolerating such acts.’ (13)

Public hospitals and clinics received at least 118 complaints of acts of harassment and sexual and labor harassment from workers, residents and intern medical students, and beneficiaries, from December 1, 2018 to June 2019. The complaints range from acts of workplace harassment (unjustified workload, mistreatment, threats, and physical aggression) to sexual aggression (verbal and physical). Some women even report having been drugged to be later sexually abused by medical personnel. (Reference Universal14) Workplace harassment in the hospital environment occurs mainly in administrative areas; in the medical area, it is little reported. (Reference Aldave, Hernandez-Garnica and Puga-Murgia15) In a study of professional burnout in the hospital environment, psychological harassment, the medical specialty area of participants and the year of residency contributed to professional burnout by 23%, while the gender of participants and the intensity of harassment did not. (Reference Tafoya, Jaimes-Medrano, Carrasco-Rojas, Rodríguez-Machain and Ortiz-León16)

Medical Regulation

The General Law for Equality between Women and Men (2006), the General Law for Women’s Access to a Life Free of Violence (2007), and the Regulation of the General Law for Women’s Access to a Life Free of Violence, to name a few, stipulate rules on sexual harassment and gender violence in the workplace in Mexico. However, unfortunately, the applicability depends on the institution. Since so few institutions have a Gender-Based Violence Committee, there is currently little control over cases of gender-based violence in hospitals. One example is the Mexican Institute of Social Security (IMSS). In its ‘Code of Conduct and Prevention of Conflicts of Interest of Public Servants of the IMSS’, section 7.2 calls for respecting human rights, equality, and non-discrimination and enforcing measures to stop any form of violence, harassment, or sexual or labor harassment towards any person in the workplace. (17) On the other hand, during their training as medical specialists, university students can be encouraged to learn about the various forms of violence and, more importantly, reliable reporting channels. (Reference Olivares Olivares, Gómez Zapata, Flores Félix, Castañeda Prado, Turrubiates Corolla, Esperón Hernández and Valdez-García18)

Prelude

The isolation experienced by medical students occurs from the moment they enter medical school, as educational demands prevent them from maintaining the family, social roles, and social relationships they had outside of medicine up to that point. Then they are cut off from university life. From the third year of studies, they are sent to a hospital where they take classes and begin to get involved in hospital medical care activities, especially in the morning but also in the afternoon and at night with ‘on-call’ hours. This isolation takes the form of long days of study-work inside the hospital from the fifth year of the career, called Medical Internship, and reaches its maximum during the specialty studies, called Medical Residency, where the short time outside the hospital is used to sleep and study.

The so-called ‘teaching hospitals’ have in common a hierarchical structural design characterized by the isolation of their doctors in training, who have little or no contact with the outside world. This strips them of their belongings, roles, and social positions before entering. Isolation is reinforced by impersonal treatment such as calling them by their grade of training instead of by name: the students, the MIPS (medical interns in the fifth or sixth year of their career), the interns, the R1, 2, 3 (first, second, third or subsequent resident physicians).

Doctors in training also break with the ordinary spheres of life – sleep, work, and recreation – and everything converges in the same physical space, always in the company of the same people and under a hierarchical organization that imposes rigid schedules and plans. Moreover, the work assigned to students (undergraduate and graduate) tends to be alienating, as they receive minimal payments in exchange for long and exhausting workdays laden with high professional responsibility and sometimes without the necessary inputs. The medical profession’s isolation and inflexible hierarchical order place students under a strict surveillance system designed to ensure their cooperation and obedience, through systematic harassment and the imposition of rules that endorse their subordinate role (the MIP cannot speak directly with the person on secondment but only with R1 and the latter with R2 and so on), or through the imposition of diffuse and changing rules whose purpose is to endorse the power of authority over students. Some laws violate their autonomy by forcing them to ask permission to carry out basic activities such as going to the bathroom or eating. Or through the systematic application of punishments, which include verbal aggressions such as obscene nicknames or swearing, cursing or humiliating them by highlighting their mistakes, making fun of them or talking about them as if they were not present, and forcing them to participate in activities that disqualify them, such as performing unnecessary, meaningless or menial tasks (e.g. mopping the office, buying dinner in the early morning). In turn, it is common for interns or residents also to receive ‘punishment guards’, which prolongs their confinement and isolation within the hospital.

On the other hand, a system of privileges is also included. Their obedience is rewarded with a degree of restitution for what is lost within the hospital; therefore, students adapt to the extent that they obey the rules, avoid punishment, and accept the privileges granted. The differential treatment that female medical students receive protects them from the mistreatment and abuse to which their male colleagues are subjected. This apparent protection enables male students to achieve triumphs in the competitive world of medical training, because they can’t earn the same privileges if they do not endure the same ‘punishment’.

In addition to the above, gender-based violence among medical students is also manifested by the following:

1. 1) Gender discrimination. Physicians and residents often target female medical students based on their physical attractiveness. As a result, their teaching responsibilities are often skewed towards flirtation or condescending protection of female students, stripping them of their role as students and thus excluding them from intellectual competence within the field.

2. 2) Sexual harassment. The intensity of harassment experienced by female medical students ranges from subtle advances to explicit sexual harassment. It is thus a known pattern within the medical profession that operates with impunity and gives rise to a culture of sexual harassment within teaching hospitals.

Assault

When Sara was a MIP, she attended to a patient with a periodontal abscess during a night shift. In her hospital, an otolaryngologist would typically handle such a procedure, so Sara called the doctor. However, while the doctor was on the way, she left the patient and a family member in front of the office and went to see another consultation because the emergency room was overfull with patients that day.

Following the incident, the student said that the doctor would make remarks in the corridors:

Exposure

Sara remembers commenting with her classmates that they should report the aggressors but that many of them mentioned several cases where negative consequences ensued for the students and not the aggressors. Some minimized the abuse or blamed the victims: ‘it is also your fault, you are always smiling, and they see it as an invitation, they are men, they like to compete for attention, you should feel flattered to have the attention of the handsome and successful doctor [aggressor otolaryngologist]’ (Sara recalls).

In the case of the male colleagues, they often argued errors in the interpretation on the part of the female doctors:

According to Sara, she once saw how they ‘punished’ an inmate who complained about verbal abuse from the doctor. ‘They had a dilator that they used to call it (the “Oh my god”), and they made the joke of raping him with this object in the doctors’ office while they told us that this happens to those who gossip; that dog does not eat dog, and that we are their pets and we owe them obedience’, she says.

Aftermath

Sara says that these experiences throughout her professional training modified her way of addressing patients and the concept she had of certain health professionals.

Currently, Sara belongs to a gender commission of her university to generate a change and propose ways to support the doctors to report and accompanies them during the process of avoiding revictimization.

Gender in Nigerian Society

Nigeria is the most populous black nation in the world, the most populous country in Africa, the third most populous country in the world, and the biggest country in West Africa. (Reference Ogundare1) According to the 2006 population census, Nigeria has a population of 140,431,790 people with 69,086,302 females and 71,345,488 males. Nigeria occupies 923,769 square kilometres, where 909,890 square kilometres makes up the land mass and 13,879 square kilometres are water. (2) It is bounded by the Republic of Benin, Niger, Chad, Cameroon and the Gulf of Guinea. Of the Nigerian population, 17.50% of doctors were women in 2008. (3) The Federal Republic of Nigeria was divided into three divisions as at 1951. (Reference Ayate and Akwa4) These have given birth to thirty-six states with a capital territory at Abuja. Nigeria is also divided into six geopolitical zones namely North-East, North-West, North-Central, South-East, South-West, and South-South zone. Nigeria is a country where about 250 languages are spoken, with English acting as the lingua franca. Pidgin English is a creole language widely spoken in Nigeria, which is English mixed with words from the local languages. The tenses do not follow British, American or Australian English.

Figure 26.1

Infographic Nigeria. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 26.1 Long description

The infographic provides information about Nigeria, with a population of 223.8 million and 4 doctors per 10,000 people. It highlights several gender-related statistics. 52 per cent of women participate in the workforce. 30.3 per cent of women are in managerial positions. 24 per cent of women have experienced intimate partner violence. Maternal mortality is 1050 per 100,000. Infant mortality under 5 is 10700 per 100,000. 65.4 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Nigeria:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law does not prohibit discrimination in employment based on gender.

• – there is no law that mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 130, and is stable.

In Nigeria, there is preference for the male child as families will prefer to have a son than a daughter, and this has affected girl-child education. It also affects the training of children, including the way females are treated from cradle to adulthood. Sons are given better feeds as children, and better education and health care. This is a problem where the girl-child may not be given formal education and may not be allowed to attend school. (Reference Tyeakaa, Amaka and Nor5) Some of the reasons for preference for the male child are religious misinterpretations, cultural beliefs, economic crisis, poverty, early marriage and teenage pregnancy. Women are expected to be at home and look after the children. Some people believe that educating a girl is a waste of resources as she will take the education to her husband’s house when she gets married. This is gradually changing as more parents are enrolling their daughters in school. Women are now occupying leadership positions in government. In some Nigerian cultures, women have traditional ceremonies they perform as rites of passage, celebration of womanhood and coming of age of the girl child. An example is the Iria ceremony performed by the Ibani people of Grand Bonny and Opobo of southern Nigeria.

Gender in Medicine

Choosing medicine as a career has increased among Nigerian women, (Reference Amadi6) though some specialties tend to be dominated by men. There remains a large gender difference in the choice of specialty. (Reference Jefferson, Bloor and Maynard7) Traditionally, women have assumed the responsibility for raising families and maintaining the household. (Reference Mobilos, Chan and Brown8) The gender roles defined by Nigerian society may affect the choice of medical specialty.

There are more Nigerian women doctors and medical students compared to earlier years. (Reference Amadi6) According to the Nigerian National Bureau of Statistics in 2015, 2016 and 2017 the proportion of doctors in Nigeria that were females was 34.1%, 34.1% and 34.6%, respectively. (Reference Diderichsen, Johansson, Verdonk, Lagrojanssen and Hanberg9)

Women have occupied leadership positions in health institutions, the Ministry of Health, hospital management boards and also politics both at the state and national levels. Dr Elizabeth Abimbola Oshodi was the first woman to be elected as president of the Nigerian Medical Association in 1988 for the 1988–1990 tenure. The Nigerian Medical Association is the umbrella association of all doctors and dentists practising in Nigeria. Prof Adenike Grange was the first Nigerian woman doctor appointed as a Nigerian minister of health. Other Nigerian women doctors have been provosts of medical colleges, deans and deputy vice-chancellors of universities and deputy governors of Nigerian states. Some of the reasons for the disparity in the proportion of male and female doctors are family and societal norms and beliefs which are being transferred to the health sector. (Reference Abdulgadir10)

Gradually, women doctors are penetrating the highly dominated male medical specialties such as orthopaedics, general surgery, burns and reconstructive surgery, obstetrics and gynaecology and urology. (Reference Amadi6; Reference Jefferson, Bloor and Maynard7; Reference Flyckt, White, Goodman, Mohr, Dutta and Zanotti11–Reference Yusufu, Ahmed, Odigie, Delia and Mohammed16). In Nigeria, females have dominated some specialties such as paediatrics, anesthesiology, internal medicine, ophthalmology, radiology, family medicine and community medicine. This reflects the cultural expectation that women will specialize more in fields of medicine that express the natural caring and nurturing nature of women as related to preventing diseases, helping and taking care of children (Reference Amadi6; Reference Abdulgadir10; Reference Chukwumah and Unweni17). There are few studies on sexual harassment among doctors practising in Nigeria and fewer on how women doctors are affected.

Medical Education

Medical education can be categorized into undergraduate and postgraduate medical education and continuing medical education. (Reference Malu18; Reference Ezeanolue19) Medical schools in Nigeria are known as colleges of medicine, colleges of health sciences or faculties of medicine, and are charged with the responsibility by law to train medical doctors (Reference Malu18; Reference Ezeanolue19) Undergraduate medical education takes six years and is regulated by the National University Commission (NUC) and the Medical and Dental Council of Nigeria (MDCN). (Reference Malu18; Reference Ibrahim20) After graduation, the young medical graduate undergoes internship followed by the National Youth Service Corps (NYSC). NYSC is a one-year compulsory programme which every Nigerian graduate thirty years and under must undergo irrespective of the course of study. Medical residency in Nigeria is largely sponsored by the government as only few missionary and privately owned hospitals offer residency training. Postgraduate academic degrees are awarded by the universities, (Reference Malu18) including postgraduate diplomas in some clinical specialties, for example anesthesiology. Residency training is regulated by the postgraduate medical colleges, which are the National Postgraduate Medical College of Nigeria (NPMCN) and the West African Postgraduate Medical College through its component colleges the West African College of Surgeons and the West African College of Physicians (Reference Malu18; Reference Ezeanolue19). These colleges periodically visit residency training accredited centres and medical colleges to see if they meet the approved guidelines for residency training. On completion of the residency training, the new consultant may be retained in the hospital where the residency training was done or asked to seek a job elsewhere. Junior doctors and medical students are vulnerable at every stage of their training to sexual harassment.

Law

Previously there was no legislation against sexual harassment at the workplace or in educational institutions. However, the National Industrial Court of Nigeria (NICN) in 2017 made an amendment of its civil procedure rules in which provision was made through Order 14, (21) titled ‘Sexual Harassment and Discrimination at the Workplace’. (22; 23) Sexual harassment is defined by the National Industrial Court of Nigeria as consisting physical conduct of a sexual nature, verbal and non-verbal forms of sexual harassment including quid pro quo harassment. (23) In 2019, a bill was proposed by the Nigerian Senate titled ‘Prevention, Prohibition and Redressal of Sexual Harassment in Tertiary Educational Institutions 2019’, which also defines sexual harassment and punishment for offenders if it occurs in higher institutions. (21) The law covers all students in tertiary institutions including medical students. Some medical schools and hospitals have their various guidelines and policies against sexual harassment. In institutions where there is no formal reporting system, the survivor reports to her supervisor, hospital management or authorities of the medical school or files the case in court. The supervisor may be a supervising consultant, head of department, faculty chair, dean, provost of a medical school, director of medical services, chairman of a medical advisory committee, head of a residency training programme or the chief medical director. A panel of enquiry is constituted to investigate the matter and make recommendations. Depending on the petition, the recommendations may or may not be considered by the hospital or medical school.

Medical Regulation

The practice of medicine and dentistry in Nigeria is regulated by the Medical and Dental Council of Nigeria (MDCN). (24) The MDCN ensures that medical and dental practice is conducted in an efficient way in Nigeria, safeguarding the health of its citizens. (Reference Ezeanolue19) Once a medical and dental student graduates from any Nigerian medical school, the new doctor is inducted and a temporary practising licence is issued, which is valid for two years to enable the doctor to practise medicine and dentistry as an intern under the tutelage and supervision of a consultant. At the end of the internship, the doctor applies to the MDCN, submitting the necessary assessment forms duly signed by the supervising consultants and the head of the hospital, which is the medical director or chief medical doctor of the hospital. Then a permanent practising licence is issued, which is renewed annually after attending the prescribed continuing medical education units. Medical and dental graduates from foreign universities sit for an examination conducted by the MDCN to enable them to practise in Nigeria.

The MDCN has published the ‘Code of Medical Ethics in Nigeria’, which guides medical practice in the country. (Reference Nwaohuocha25) Members of the public who feel aggrieved by any professional misconduct can report to the hospital management, the MDCN or the Nigerian Medical Association (NMA). If a report is made to the MDCN, a panel sits to investigate the allegation. Depending on the offences, the erring doctor may be suspended from medical or dental practice for a stipulated period of time or have his or her name permanently struck from the MDCN register.

Different hospitals have different policies and guidelines for disciplining erring doctors. A panel is set up to investigate any petition of misconduct and recommendations made to the hospital management. Punishments of doctors found guilty include apology to the patient, suspension for a number of months during which the salary of a doctor is withheld, removal from the workplace, and issuance of a query or warning letter. However, the health care sector includes a number of people and organisations with different expectations, opinions and backgrounds. Therefore, sometimes doctors who behave unprofessionally may be cautioned without any formal letter by their supervisor or fellow colleagues.

Prelude

This case study involved interviewing a survivor of sexual harassment in which the perpetrator is a male doctor in a Nigerian teaching hospital. The survivor describes in her words what made her vulnerable:

She identified single women in Nigeria as vulnerable to humiliation in the family, at the workplace and also in the community. Also, being a junior doctor is another factor of vulnerability to sexual harassment at the workplace. She was even confronted by male and female colleagues that she should deny the harassment and be quiet.

Assault

Dumebi is a female ophthalmology resident doctor at a Nigerian teaching hospital. She was happy about her job and was carrying out tasks assigned to her dutifully. In the department, they work in teams comprised of registrars, senior registrars, and consultants. When she joined the department, there was a senior registrar named Tosan who travelled to the United Kingdom for subspecialty training in a field whose training was not available in Nigeria. Tosan’s course lasted for six months, and he had already spent three months in the United Kingdom before Dumebi joined the faculty. Dumebi had not passed the primary examination which is the entry requirement for residency training in the postgraduate medical colleges in Nigeria.

Three months after Dumebi joined the department, Tosan returned from the United Kingdom. One day Dumebi and Tosan met at a taxi rank on their way to work and boarded the same taxi to work. While in the taxi they exchanged pleasantries and were engaged in a conversation. Tosan told Dumebi about a regional conference scheduled later that year overseas with sponsorship from the government. Dumebi told Tosan she was not interested as she just joined the department and was still familiarizing herself with the specialty and learning its rudiments. Tosan pressurized Dumebi to send a text message to the consultant in charge coordinating the trip and he forwarded the consultant’s number to Dumebi. After much pressure, Dumebi sent a text message to the coordinator of the trip. Tosan never mentioned to Dumebi that she would have to repay him after the conference.

One day, Tosan asked Dumebi for her USB drive, saying that he wanted to give her some academic resources to enable her to pass her residency primary examination. Dumebi gave Tosan her USB drive, and Tosan returned it back with his own USB drive of a higher capacity, as Dumebi’s could not contain all the resources. Dumebi thanked Tosan and took both drives, returning Tosan’s equipment in the next couple of days.

After the conference, Tosan started making sexual advances at Dumebi which she turned down, but he persisted. Tosan told Dumebi she had to pay him back for informing her about the conference. Tosan later reported Dumebi to their faculty chair, stating that Dumebi was disrespecting him. At this time, Dumebi had been sent for a three-month rotation in the surgery department and had been there just one week. Dumebi was recalled from her surgery rotation and told that a panel would be set in the department to investigate the issue. Dumebi was never sent back to complete her rotation in the surgery department.

At this time, Tosan was a candidate for the position of president of the junior doctors association of the hospital. Dumebi informed the association about what was going on. Her fellow junior doctors, both male and female, forced her to withdraw her complaint. Tosan sent a text message to Dumebi which read: ‘I do not think that life is all about squabbles. I still wonder why you would want to ridicule me.’ After some time, Dumebi’s name was removed from the departmental duty roster. Queries were issued to Dumebi titled, ‘insubordination to superior authority’, and a letter requesting Dumebi to seek medical help and send a report that she was medically fit. Dumebi had a mentor in the hospital who was a consultant in another department. One of the consultants in the hospital who was part of the hospital management committee sent Dumebi’s mentor a text message which reads: ‘Thank you madam good morning, please can you confirm if your girl Dr Dumebi has started treatment’. At this time, Tosan won his election and became president of the junior doctors’ association.

There was an offer for the purchase of land. Dumebi was interested and submitted the necessary documentation. After paying for the land, Tosan refused to give proper documents to Dumebi as her name was written in initials in the deed of conveyance. When Dumebi requested Tosan to write her name in full and not in initials; he refused. Instead he sent a text message to Dumebi: ‘Who knows why all the typists make the same mistake in your name. I did the right thing for all the allottees but the evil in your heart will not allow you to know good. Posterity will judge me but the evil in your heart must hunt you for life.’

Limbo

The survivor in this case never had the intention of reporting; worse is that there was no formal reporting system nor policies against sexual harassment in the hospital. This is an interesting case because usually it is the victim that reports first, but here the perpetrator reported that his victim was disrespecting him. When Dumebi was reported by the perpetrator, a panel was set up in the department to investigate the issue and it included both a male and female consultant. She and the perpetrator were interviewed separately and later together. At the end of both sessions, Dumebi was told that what she was claiming never happened as she had no evidence and was just making up stories against her perpetrator. Before then the perpetrator told Dumebi that once they got into the panel, she should start apologizing to him. The survivor said she was strong enough to face whatever it is as she will not give into any pressures mounted on her. A second panel was also set up by the hospital management, made up of professors and doctors from other departments. She attended the panel, but the recommendations of the two panels were never communicated to her. In her own way, she met with several senior doctors to intervene in the matter, but nothing was done.

Exposure

This case was different as her name was known from the beginning. There were a lot of gossips and false accusations as a result of the sexual harassment. Even a female ophthalmology senior registrar told the survivor that she was the cause of the sexual harassment and should apologize to the perpetrator. Reporting to female doctors did not save the situation as they all supported the perpetrator. She was never concerned about the grapevines (gossips and rumours at the workplace) as they are common in any workplace. Dumebi never blamed herself for what happened as she never saw anything wrong with her action. The only thing she thought was wrong is that she should not have given in to the pressure mounted on her by the perpetrator to joining the trip for the overseas conference, as there are two Nigerian proverbs that say, ‘free things can purge the stomach’ and ‘nothing goes for nothing’. She never argued with anyone since within her she knew she was sexually harassed even though she never saved all the discussions and text messages received from Tosan. She kept her cool and encouraged herself.

Aftermath

The abuse that occurred impacted on the personal and professional life of the survivor positively and negatively. The impact was positive on her personal life as she leant not to be subject to any form of pressure especially when it is coming from the opposite sex and someone of a higher cadre. She also learnt to avoid receiving favours that she does not merit as it may be bait. In this case, if she had not attended the conference, the perpetrator would not have had any opportunity of asking her for payback. The negative impact was that she was not allowed to complete her residency training in her specialty of choice. She experienced career retrogression and was tagged a ‘troublemaker and troublesome person’. It did not bother her. She is still a medical doctor practising her profession in another hospital. She was able to recover fully and never had any emotional and psychological breakdown because she never allowed it to disturb her and she self-encouraged herself. She had the will power and determination to become an ophthalmologist. Her incident became an eye opener in the first hospital where she worked, as other male doctors were surprised that with everything done to Dumebi, she never compromised her integrity, morality and self-esteem. She hopes to write a report about her experience to the United Nations to bring this problem to light, so that an international day can be dedicated to sexual harassment at the workplace. She also wishes to have a movement and foundation to help women doctor victims of sexual harassment by providing counselling and legal protection, and by helping them secure residency placement elsewhere if necessary. A part of her plans is to provide stipends to other victims if their salaries are stopped or their appointment terminated.

Current Situation in Nigeria

Culture affects the way women are treated wherever they are. Survivors of sexual harassment should have self-encouragement and strong self-esteem. They should not rely on anyone as even female doctors cannot be trusted when it comes to issues of sexual harassment. They should not allow the incident to disturb them emotionally and psychologically. They should develop deaf ears to all grapevines (gossips and rumours) in the hospital about the matter.

Sexual harassment at the workplace leads to a hostile work environment and career stagnation. This takes different forms, which includes retaliation, false allegations, demotion and stigmatization. One of the barriers to getting justice for sexual harassment is the stigmatization that follows it. In this case study, some women doctors approached the survivor, forcing her to keep quiet. Some were even angry with the survivor, saying that she was making false accusation against the perpetrator, that it is a common thing that happens at the medical workplace, and therefore there is nothing wrong even if it ever happened, as it is a normal thing for men to flirt even with their subordinates at the medical workplace and male doctors are not exceptions. As the perpetrator is a married man, letting people know about the incident may get to the ears of his spouse, and therefore it may disturb his marriage. A female consultant who was a member of one of the panels of enquiries told the survivor that she wants to put fire into another woman’s marriage. One begins to wonder if the survivor invited another woman’s husband to sexually harass her, yet she is blamed for being sexually harassed. Survivors do not report because they are ashamed and afraid of termination of their appointment if the incident of sexual harassment is reported to the hospital management and medical school authority. (Reference Johnson30) The case discussed is different as it was the perpetrator that reported his victim to a higher authority; this shows the level of injustice women doctors get when they are victims of sexual harassment.

Directions to Prevent Sexual Harassment in the Nigerian Health Sector

Strategies can be taken to prevent and manage sexual harassment of female doctors by male doctors in the Nigerian medical workplace:

1. 1. A formal reporting system in all health institutions and medical schools with an office in the Federal Ministry of Health and Women’s Affairs dedicated to sexual harassment, where women can lodge such complaints. The Ministry of Justice should also provide legal aid to survivors. This will encourage survivors to come forward and lodge their complaints.

2. 2. Establishment and implementation of policies against sexual harassment at the medical workplace and in medical schools to protect women doctors and female medical students.

3. 3. Panels set up to investigate allegations of sexual harassment of doctors by doctors should have no bias. There should be justice. Survivors should be protected from any form of retaliation, victimization and discrimination, including making employment decisions and benefits dependent on unwelcomed sexual activity.

4. 4. Perpetrators should also be disciplined appropriately no matter their rank or the position they occupy in the hospital.

5. 5. Policies and strategies should be established against trainer–trainee bullying in all health institutions and medical schools irrespective of whether they are accredited for residency or not, to protect junior doctors, especially women doctors, resident doctors and early career doctors, from any form of trainer–trainee bullying by doctors.

6. 6. Counselling should be made available for survivors who develop emotional and psychological breakdown following incidents of sexual harassment.

Recommendations

Various stakeholders in the health sector have roles to play in the management and prevention of sexual harassment against medical practitioners. This includes:

• Supervisors and consultants

• Hospital management, which includes the hospital management board, primary health care board and the hospital management committees

• Heads of departments, deans, provosts of medical colleges and faculty chairs

• The Nigerian Medical Association

• The Medical Women’s Association of Nigeria

• The National Association of Resident Doctors of Nigeria (NARD), which is the association of early career doctors/junior doctors in Nigeria.

Gender in Society

The Islamic Republic of Pakistan, located in South Asia, has a population of over 241 million, making it the world’s fifth-most populous country. (1) Pakistan has a young population, with approximately two-thirds below the age of twenty-nine. (1) About half of the population of the country are women. The 2023 population and housing survey revealed that only 48% of females are literate compared to 70% of men, with only 8.3% of women have access to tertiary education. (1) The female contribution in the paid workforce is only 20%. (2)

Pakistan has gender inequalities within its patriarchal society, where men are traditionally considered the primary breadwinners and decision-makers, while women are expected to fulfil domestic roles. The Global Gender Gap Report, 2022, published by the World Economic Forum, ranked Pakistan 145 out of 146 countries, (Reference Schwab, Samans, Zahidi, Leopold, Ratcheva and Hausmann3) higher than only Afghanistan. Women lag in every sphere of life, such as education, economic opportunities, access to health care, and political representation.

Gender inequality in health is evident from a high maternal mortality ratio of 186 deaths per 100,000 live births in 2019. (4) Women’s lack of autonomy in reproductive health decisions contributes to high fertility, poor health outcomes, and higher infant and maternal morbidity and mortality. (Reference Ali, Ali, Nadeem, Memon, Soofi and Madhani5) In many regions of the country, early marriages are common, which further exacerbates women’s health challenges. (Reference Ali, Ali, Nadeem, Memon, Soofi and Madhani5)

Pakistan, as the first Muslim country with a female prime minister (Benazir Bhutto in 1988), inspired greater female involvement in public life. During her tenure, a substantial female workforce, exceeding 100,000 female health workers, was established to deliver essential health care services in semi-urban and rural areas. These women played a pivotal role in altering societal perceptions of working women, contributing to the empowerment of women in rural Pakistan. (Reference Ahmed6)

Recent years have seen progress in gender equality, especially in urban areas. There has been a gradual increase in female education access, coupled with a decline in child and early marriages. Urban regions, marked by improved literacy rates and increased workforce participation, exhibit more diverse and progressive attitudes towards gender roles. Challenges persist in rural areas and lower economic strata, where conservative values and limited educational access contribute to traditional gender norms. (Reference Lohana, Alizai and Ahmed7)

Figure 27.1

Infographic Pakistan. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 27.1 Long description

The infographic provides information about Pakistan, with a population of 240.5 million and 10.8 doctors per 10,000 people. It highlights several gender-related statistics. 24 per cent of women participate in the workforce. 4.9 per cent of women are in managerial positions. 29 per cent of women have experienced intimate partner violence. Maternal mortality is 154 per 100,000. Infant mortality under 5 is 6300 per 100,000. 46.7 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Pakistan:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – there is no law that mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 123, and there has been some progress.

Legislation

In recent years much legislation has been approved to support women in cases of sexual harassment and assault. There is national legislation as well as some specific to provinces. Some of them include:

1. 1. Prevention of Anti-Women Practices (Criminal Law Amendment) Act 2011 (pertaining to forced marriages and inheritance deprivation in the name of custom)

2. 2. The Women in Distress and Detention Fund (Amendment) Act 2011

3. 3. Right to Ownership (Women) Act 2011

4. 4. The Acid Control and Acid Crime Prevention Act 2011

5. 5. The Protection Against Harassment of Women at the Workplace Act 2010

6. 6. Domestic Violence Prevention and Protection Act Sindh (2013) and Balochistan (2014)

7. 7. Child Marriage Restraint Act (Punjab Marriage Restraint Amendment Act 2015, Sindh 2014)

8. 8. Criminal Law (Amendment) (Offences relating to Rape) Act 2016

9. 9. Criminal Law (Amendment) (Offences in the name or on pretext of Honor) Act 2016

10. 10. Punjab Protection of Women against Violence Act 2016

11. 11. Prevention of Electronic Crimes Act (PECA) 2016

12. 12. Khyber Pakhtunkhwa Domestic Violence Against Women Act 2021

13. 13. Anti-Rape (Investigation & Trial) Act 2021

Despite this legislation, the implementation of these laws is an issue due to reluctance of victims to lodge a complaint, poor police practices to collect evidence and support the victim, and a slow and inefficient legal system.

Role of the Legal System in Sexual Harassment Cases

Proving sexual harassment in court is difficult. Even if witnesses are available for sexual harassment, the court cases drag on for years. If the perpetrator is a person of influence or has connection with some person of influence, they may use their influence to malign and harass the victim and their families to drop the charges. In a patriarchal society such as Pakistan, women are often blamed as the ones who led the perpetrator to commit the crime, perhaps by wearing revealing clothes, inviting behaviours, or even being at the wrong place at the wrong time. There are some organizations who provide legal support to victims of sexual harassment, for example Asma Jehangir foundation and Hina Jilani law firm.

Courts may suggest psychological support for the victim; however, in most cases victims have to pay for those services.

Role of Police and Other Law Enforcing Organizations in Sexual Harassment Cases

People do not have faith in the police. The Pakistani police, with some exceptions, have deep rooted problems of corruption. Although there are now women police officers, generally women do not feel safe and would refrain from involving the police. In most cases, evidence is not collected properly or may even be tampered with to benefit the perpetrator. Women are also scared of negative publicity by involving the police. Involving the police means that the police can visit the house of the victim or call them to a police station at any hour. If the perpetrator is powerful, there are chances that the police will side with them due to being bribed or under the orders of some influential person. In many cases, the police tell the victim to patch things up with the perpetrator as such matters bring media coverage and shame to the family.

Role of Medical Organizations in Providing Legal Representation to Doctors in Civil or Criminal Cases

There are no formal medical organizations which represent doctors legally in cases of sexual harassment or other similar cases. The Pakistan Medical and Dental Council (20) is the only statutory publicly led organization that may address such grievances and may cancel licensure of doctors involved in sexual harassment. Doctors do not have insurance to cover their expenses in case they are involved in civil or criminal cases. The government may provide a defence attorney if they are unable to afford one. However, in most cases they organize these services themselves.

Navigating Justice: A Case Study on Workplace Sexual Harassment from Pakistan

Overview

In the UK, the definition of sexual harassment was clarified by the 2010 Equality Act. It centres on behaviour that makes an individual ‘feel humiliated, offended or degraded’ and on ‘unwanted behaviour of a sexual nature’, which encompasses sexual jokes, touching, and sending emails of a sexual nature or putting up pornographic pictures; a claim that a comment was made in jest or as a compliment is not a defence.

The essence of sexual harassment is that:

1. a) the conduct is of a sexual nature

2. b) the conduct is unwanted.

Figure 28.1

Infographic United Kingdom. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 28.1 Long description

The infographic provides information about the United Kingdom, with a population of 67.7 million and 31.7 doctors per 10,000 people. It highlights several gender-related statistics. 58 per cent of women participate in the workforce. 36.8 per cent of women are in managerial positions. 24 per cent of women have experienced intimate partner violence. Maternal mortality is 9.8 per 100,000. Infant mortality under 5 is 4100 per 100,000. 48.6 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In the United Kingdom:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 18, and is stable

Certain hallmarks repeat themselves over and over again in cases of sexual harassment, sexual assault, rape and domestic violence – women and children are made to feel complicit by their abuser; the entirely rational fear of not being believed; the humiliation of coming forwards with an account of what happened; the knowledge that reporting an abuser in a position of authority – given the power he wields not just over the victim but those around them – may only make things worse.

Quoting American author Ursula Le Guin, ‘The power of the harasser, the abuser, the rapist depends above all on the silence of women.’

In 2016, the Trades Union Congress (TUC) in the UK issued its report ‘Still a bit of banter?’, which concluded that 52% of women at work suffered sexual harassment and that 80% of them did not report it. (1)

In June 2019, Unison published its NHS survey ‘It’s never OK’, which disclosed that the vast majority of those targeted were women (81%) and the incidents mainly involved perpetrators older than their target (61%), who were often in more powerful roles (37%). Nearly a third (31%) of those who had been sexually harassed said it occurred on a regular basis, and more than one in ten (12%) said it occurred weekly or daily. (2)

At the start of the #MeToo movement in 2018, many men expressed surprise at the number of women who had been the victims of sexual harassment. In 2017/18 a survey done by the Medical Women’s International Association revealed that 34% of women doctors suffered sexual harassment at work. For 22% of these, their job or future job depended on performing unwanted sexual behaviours. Fifty-two per cent said that someone was coming unnecessarily close in a physical or sexual way, and 62% received comments on appearance in an unwanted or sexual way. In 15% of cases, the women doctors were coerced to have physical contact that was unwanted or sexual, and 5% were coerced to have more serious sexual encounters, including rape.

In the UK, the gradual increase in the proportion of licensed doctors who are female has continued towards parity with male doctors but has slowed in recent years (figure 28.2). (3)

Figure 28.2

Women in medicine in the UK.

Figure 28.2 Long description

'The graph shows Percentage from 42 to 58 on the y-axis, and years from 2012 to 2021 on the x-axis. Line 1, Male: Starting at approximately 56.5 percent in 2012, the male percentage shows a steady decline over the years. The line decreases gradually, reaching about 51.5 percent by 2021. Line 2, Female: Beginning at around 43.5 percent in 2012, the female percentage demonstrates a consistent increase throughout the period. The line rises steadily, approaching 48.5 percent by 2021.

There is currently in the UK an almost equal balance of men and women joining the workforce each year. More women are entering medical school (64% of the medical student intake was female in 2021). This is largely counterbalanced by the increase in the number of international medical graduates (IMGs) whose primary medical qualification is from outside the UK and European Economic Area, who are mostly male. All specialties had an increasingly female composition between 2012 and 2021. The highest proportion of female doctors is seen in obstetrics and gynaecology (60%), followed by paediatrics (58%), general practice (57%), and public health (55%). The lowest proportion of female doctors is seen in surgery, which was 15% female in 2021, up from 9% in 2012. (3)

The number of IMGs in the UK has increased by 40% in the last five years (from 58,222 in 2017 to 81,457 in 2021) at a time when the number of UK graduates in the workforce has increased by 10% (from 162,634 to 178,173). The number of associate specialist doctors has grown at almost six times the rate of general practitioners in the last five years and four times the rate of consultants.

Medical Regulation

Data obtained by the Independent newspaper in 2022 showed that between 2016 and 2020 an average of twenty-eight doctors have been sanctioned each year by the General Medical Council (GMC), which regulates more than 350,000 doctors in the UK, after allegations of sexual misconduct were proven against them. These figures probably reveal ‘the very tip of the iceberg’ in terms of the actual levels of sexual assault within health care (12; 13).

The majority of these doctors were erased from the register, meaning they lost their licence to practise. Of the proven allegations, forty-one were made by another health care professional, forty-two by a patient, and the remainder were unknown.

A doctor who has been erased cannot apply to be restored to the medical register for five years. At that stage, a tribunal will have to decide whether the doctor is fit to resume unrestricted medical practice.

In addition to the erasures, several doctors were suspended from the register after hearings for alleged sexual assault. The maximum suspension is twelve months. In deciding the length of the suspension, the GMC considers the seriousness of the findings of the investigation. A warning is issued if a doctor’s behaviour departs significantly from the GMC’s Good Medical Practice but restriction on registration is not necessary.

How Easy Is it to Bring a Case of Sexual Harassment to an Employment Tribunal in the UK?

Leaving aside sexual assault, which would be dealt with in a criminal court, harassment cases are brought under the Equality Act. Unfortunately, that tends to be one person’s word against another. It is then a case of looking at corroborative evidence, for example email correspondence or diaries, and asking whether the victim contacted human resources and raised a grievance. A lot of cases settle before they get to court, a level of compensation might be paid, other measures might be put in place. There is a great deal to be gained by resolving it as soon as possible. It is now the job of institutions to take responsibility for this.

Living Our Values (LOV) and the Resolution Process

‘Living Our Values’ was incorporated in a Code of Conduct and a disciplinary procedure, now known as the Resolution Process, at the BMA in 2017. The Code was introduced to deter and also to deal with bad behaviours. It was rolled out to BMA committees to raise awareness of the union’s core values and expectations of staff in terms of behaviour.

The Code of Conduct should have dealt with the issues raised by the women GPs. However, it was abused and weaponised and not used as it should have been. Had it worked properly we would not have needed the Daphne Romney Report.

The Resolution Process has been used successfully to resolve many informal complaints, and to resolve some substantial complaints through the formal route, with adjudication by a panel of three doctors. However, the process has been undermined; there is a perception that the process is not effective (because its operation is shrouded in secrecy), and many perceive its application to be partial, which has deterred them from using it. Others have chosen not to use it because they are frightened of repercussions, and in the case of some staff, of losing their job.

Daphne Romney made thirty-one recommendations. The recommendations include education on equality, diversity and inclusion, a helpline for staff facing sexism or discrimination, an external independent complaints service, bespoke face-to-face training for all committee members, and mandatory training for committee chairs.

There must be a policy of zero tolerance, and there must be consequences for the perpetrators, once proven ‘guilty’. The BMA must have proper sympathetic reporting structures, and good collection of data. The current systems in place, including Codes of Conduct and the inappropriate acronym ‘LOV’ (‘Living our Values’), are inadequate. They are felt to be intimidating and unsupportive. Institutions should convey that reporting sexual harassment is important and courageous.

BMA committees should introduce quotas or minimum numbers of women in order to better reflect the percentages of men and women in each branch of practice. Daphne Romney accepted that quotas are very unpopular with some, but years of diversity reports and recruitment attempts have not managed to even out the gender balance on the major committees, particularly on the Staff and Associate Specialist Committee. She regarded this as a temporary measure to change the culture, perhaps for ten years, when hopefully the balance will change.

Members of committees should be prevented from standing for re-election for that committee after twelve years unless they hold an executive position. This will allow new members onto the committee. Members may seek re-election to that committee after three years. When I was on the GPC, some committee members had been in post for twenty-five years!

BMA members should be restricted in the number of committees they can sit on.

The BMA must ensure that there is adequate support, counselling and protection for the complainant and ensure that he or she is not victimised for having made a complaint. I have personally tried to speak with the GPs involved in the initial revelations, but most are reluctant to discuss the matter at all.

Existing strategies to tackle bullying, undermining behaviour and harassment focus on changing behaviour in the victim. It is more useful to focus on prevention, rather than mitigating strategies.

In spite of all the initiatives that have been introduced, the current methods for tackling mistreatment are perceived as ineffective and potentially damaging to victims.

The BMA Network of Elected Women (NEW) was set up in 2019. It is a group of BMA-elected medical women who aim to champion and strengthen female leadership and advance diversity for the benefit of the Association. The collaboration of different voices at all levels and from all backgrounds is key to unlocking women’s collective potential. There is now an informal WhatsApp group, a formal list server, a book club, and an after-school club, and webinars are planned.

A parallel and informal group of male allies (Active Allyship) has been established, which is separate but complementary. They advocate for greater gender equality at the BMA. Bystander training (see later) is planned as one of their activities, with a national programme carried out at a regional level.

What Has Been the Effect of the Daphne Romney Report?

Some senior members of the BMA said ‘How dare you raise this?’ when the women GPs went to the press. It was said that the BMA Code of Conduct should have been used, but the women doctors involved had no faith in the current processes.

It is now easier to acknowledge that sexual harassment is an issue. The Report has given women the support to speak up. It is interesting that there was resistance to setting up the Report in the first instance.

The current mandatory online training models are seen as ineffectual – people look up ‘correct’ answers and unthinkingly comply. Existing training sessions in diversity and equality are not taken seriously, especially by those who need them. I remember well when I was on the GPC from 2007 to 2012 the ‘nudging’ and jokes made during the equality and diversity sessions that we were required to attend. During a discussion on perceived lack of gender balance, there were eye rolls, and uncomfortable grunts in the GPC chamber.

Although doctors agree that some progress has been made since the Romney Report, more needs to be done to improve the situation. (Reference Limb16; 17) Since the publication of the Report, several women doctors have risen to leadership positions on committees, including the first ever female Chair of the GPC, and have had a very difficult time. The problems are far from over.

Bystander Training

It has been suggested that the profession must also articulate the ethical obligations of individuals who witness harassment and inequitable treatment. (Reference Mello and Jagsi18) In their New England Journal article in 2020 ‘Standing up against gender bias and harassment – a matter of professional ethics’, Mello and Jagsi stated that health professionals have a moral duty to intervene as bystanders (‘upstanding’). (Reference Mello and Jagsi18) This obligation should be described in codes of medical professional ethics and supported with institutional training. Bystander intervention is especially useful for conduct that is not severe or sustained enough to trigger institutional investigations. Witnessed incidents abound in the profession, and upstanding is therefore critical. Bystanders are more likely to intervene if they believe their organisation has effective mechanisms for addressing the problem.

Bystanders often have multiple, idiosyncratic, and conflicting interests, and experience painful dilemmas. How can they be supported to be more effective when faced with unacceptable behaviour? Rowe has some practical advice in ‘Fostering constructive action by peers and bystanders in organisations and communities’. (Reference Rowe19)

Potential responses to observed instances of sexual harassment and gender bias:

1. 1. Document details of behaviours in a diary for possible future use. For example ‘10/3/19, 11.00: JB stated during surgery that female surgeons “are never good under pressure”.’

2. 2. Remove the target from the situation. For example, ‘Mr King, I’m going to have Dr Target assist with another patient.’ ‘So sorry to interrupt – I really need Dr Target’s help in exam room 5.’

3. 3. Provide support privately to the target of the behaviour. For example ‘I thought what he said was unacceptable, and I’m really sorry it happened. How are you doing? What can I do to support you?’ ‘I wanted to check in with you. Has Jim caused any further problems for you?’

4. 4. Ask civil but pointed questions of the perpetrator in the moment. For example, ‘Do you really mean that?’, ‘What do you mean by that?’, ‘It sounded like you were saying … .’

5. 5. Deflect the behaviour using humour.

6. 6. Express disapproval of the behaviour to the perpetrator in a private setting.

7. 7. Engage others to help deal with the behaviour if it recurs.

8. 8. Name the behaviour as unacceptable on the spot.

9. 9. Report the perpetrator to the institutional sexual harassment officer.

10. 10. Remove the perpetrator from duties that might prompt a recurrence of the behaviour.

True culture change will occur more quickly if combating harassment is recognised not just as an institutional responsibility, but also as a personal ethical obligation of every health professional.

Prevention

Unfortunately, it is difficult to demonstrate that preventive measures are effective. Schemes therefore receive little or no investment.

The key is to start in schools.

Girls and young women aged between ten and twenty-four are more likely to be victims of sexual offences recorded by the police than older women. (Reference Jones, Farrelly and Barter20) According to a 2020 Government report, one-third of all female victims recorded by police were under fifteen years old.

Sexual harassment of girls is rife in schools but largely goes unreported and unaddressed. A 2017 report revealed that 37% of female students in mixed sex schools have personally experienced some form of sexual harassment, 24% have experienced unwanted touching of a sexual nature compared to 4% of boys, 58% of female students have experienced or witnessed sexual harassment at school, 66% have experienced sexist language. (21; 22) Many teachers feel ill-equipped to tackle the issue. Female teachers also experience harassment by pupils.

In 2020 the government introduced compulsory age-appropriate Relationship and Sex Education in all primary and secondary schools. (23) This is definitely a step in the right direction, but much remains to be done to improve it.

Sexism and Misogyny

Laura Bates founded the Everyday Sexism project in 2012, (Reference Bates24) inviting women on social media to detail sexist encounters they had had. In 2014 she published the book Everyday sexism: the project that inspired a worldwide movement. Bates was surprised at how many of the accounts came from girls in their mid-teens. She herself received torrents of abuse, including graphic rape and death threats.

Over the last five years she has concentrated her efforts on her work in schools. In 2018 ‘something changed’.

This began her journey into the manosphere, posing as ‘Alex’, a confused young man looking on Reddit, and elsewhere, for answers. This took her from the Incels (Involuntary Celibates) to the MGTOW (Men Who Go Their Own Way). She went undercover to an MRA Conference (Men’s Rights Activists). It was a chilling experience. ‘The reality was that these are men you might walk past in the street’. The list of MRA grievances is long. They include the low attainment of some boys in schools; male suicide as a leading killer of men under fifty in the UK; higher levels of women entering higher education in some countries; male circumcision, or MGM; and the lack of provision for male victims of domestic violence. Other big issues are child custody, and false accusations of rape and sexual assault. Bates writes that these grievances are interpreted as attempts by feminists to control men’s lives. ‘At its simplest, the argument goes like this: if women’s sexual autonomy has given them wicked and tyrannical control over men’s lives, then women’s liberation is at the root of all male suffering. Therefore, the obvious remedy is to remove women’s freedom and independence and to use specifically sexual means … to do so.’ (Reference Bates25)

What came out very clearly in her research was that we were looking at hundreds of thousands of people, millions of views, so many different websites and forums. We are talking about a massive network.

The point Bates makes is both stark and subtle: there is a live community of violent extremists, operating online without censure, with a guiding ideology of misogyny, and with an aim of radicalising young boys. Her book, Men who hate women was published in 2020.

Existing stereotypes encourage boys to join misogynistic groups. Boys do not cry. Men do not talk about their feelings. There is a harking back to women staying at home. Feminism is the great evil and the root of all their problems. The men are often victims of sexual violence. They spout extreme rhetoric online. They have tried to de-fund women’s refuges.

Around 70% of boys in schools have come in contact with these groups. Almost none of the parents have heard of them.

We need to start taking extreme misogyny seriously rather than writing it off as a community of oddballs: not to do so is to utterly fail to keep this generation of boys and girls safe. We need to develop our understanding of how to help those boys at risk of going down this path and prevent it happening in the first place. As Bates says, ‘failing to act is the mark of a society that devalues not just women, but men.’ (Reference Bates25)

How Can Men Help in Prevention of Sexual Harassment?

There are many men who are supportive. We need men to call other men out. There must be disciplinary procedures for people who ‘cross the line’. The temptation to keep the matter private, as happens at present, is very great.

The Good Lads project is active in many universities and further education colleges. It includes mandatory sexual consent workshops for all freshers. (26) Active solidarity from groups of men such as football or rugby clubs is helpful. The White Ribbon Alliance (27) has a youth programme for schools, and the BMA’s Active Allyship is a definite step in the right direction.

We have to teach everyone the importance of consent and we have to start as early as possible.

Gender in Society

In 2020, the United States (US) population was estimated to be 331 million people, of which 51.1% were women. (1) Although most Americans (72%) are white, the race and ethnicity of the US population is diversifying. The 2010 Census revealed the following racial demographics: 12.8% reported being Black; 5.7% Asian; 0.9% American Indian; 0.2% Native Hawaiian; 3.4% multiracial; and 18.4% Hispanic. (2) The modern role of women in the workforce first dramatically changed in the 1920s with two major events: new employment during World War I and the ratification of the Nineteenth Amendment to the US Constitution granting women the right to vote. (Reference Jones3; Reference Carnes, Morrissey and Geller4) Subsequently, social and cultural changes in the 1960s and 1970s prompted legal protections for women in education and the workplace, (Reference Carnes, Morrissey and Geller4) with women increasingly allowed to obtain post-secondary education. By 2018, women comprised 57% of college students and students, 49.5% of medical students, and 46.8% of the workforce. (5)

Cultural stereotypes continue to characterize women as ‘communal’ (e.g. kind, dependent, nurturing) while men are characterized as ‘agentic’ (e.g. logical, independent, strong). (Reference Heilman and Okimoto6) These stereotypes disadvantage women (and men) in domains such as science, medicine, and leadership, as competence can be viewed as a violation of a gender role. (Reference Carnes, Morrissey and Geller4; Reference Ashton-James, Tybur, Grießer and Costa7) Despite increased representation, women continue to be underrepresented in traditionally male-dominated professions, comprising 21.3% of protective service employees, 15.1% of architects and engineers, and 5% of CEO positions in S&P500 companies. Conversely, women remain clustered into ‘pink collar’ jobs, constituting 87.6% of health care support occupations, 94.5% of secretary and administrative assistant positions, and 95% of teaching assistants, kindergarten and elementary school teachers. (Reference Berdahl, Cooper, Glick, Livingston and Williams5) Occupational segregation, largely stemming from a continued cultural devaluation of work performed by women, contributes to a persistent gender wage gap. To enumerate, on average, women in the US earn 81.6% of what men earn, with the gap widening to 75% with increasing levels of education. (Reference Leisenring8) More concerning, gender-based discrimination, including sexual harassment, is reported by 50% of women in the US workforce, with few reporting the abuse to an authority. (Reference Das9) In 2017, the #MeToo movement brought awareness to sexual violence against women by advocating for survivors and encouraging them to speak out about their experiences. TIME’s UP Now, which had several industry-focused initiatives including TIME’s UP Healthcare, followed by bringing awareness of sexual harassment and discrimination in the workplace. TIME’s UP Foundation has expanded their mission to advocate for safe, fair, and dignified work for all women of all kinds, creating a society free of gender-based discrimination in the workplace and beyond. (Reference Kearl10; Reference O’Neil, Sojo, Fileborn, Scovelle and Milner11)

Figure 29.1

Infographic United States of America. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 29.1 Long description

The infographic provides information about the United States, with a population of 340 million and 35.6 doctors per 10,000 people. It highlights several gender-related statistics. 57 per cent of women participate in the workforce. 41.1 per cent of women are in managerial positions. 26 per cent of women have experienced intimate partner violence. Maternal mortality is 21.1 per 100,000. Infant mortality under 5 is 630 per 100,000. 34.8 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In the United States:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – there is no law mandating equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 38, and there has been some progress

Gender in Medicine

The Women’s Health and Feminist Movements of the 1960s and 1970s served as an inflection point for US women to embark on careers in medicine. (Reference Carnes, Morrissey and Geller4) With admissions restrictions removed by laws enacted at the end of this cultural movement, a surge of women graduating from medical school was observed, with 20,000 women matriculating from 1970 to 1980, compared to 14,000 from 1930 to 1970. (Reference Braslow and Heins12) By 2003, women in the US applied to, entered and graduated from medical school at similar rates as men. However, the percentage of full-time women faculty that identify as underrepresented by race or ethnicity (URiM) has been essentially unchanged from 12% in 2009 to 13% in 2018. (Reference Lautenberger and Dandar13) This is particularly true for most surgical specialties in the US, which remain predominantly occupied by men. In 2017, 20.6% of general surgeons in the US were women, (Reference Aziz, DuCoin, Welsh, Paramo, Andreone, Butsch, Smith, Pories and Baxter14) with Black women surgeons representing just 1% of the academic surgical workforce. (Reference Berry, Khabele, Johnson-Mann, Henry-Tillman, Joseph and Turner15; Reference Aggarwal, Rosen, Nehemiah, Maina, Kelz, Aarons and Roberts16)

Increased representation of women physicians has not correlated with workplace equity. Although the overall percentage of full-time women faculty in US medical schools continues to rise, the majority of women faculty held the rank of instructor. (Reference Lautenberger and Dandar13) Moreover, there has been no narrowing of the gender gap over time. Women physicians employed by academic centers are less likely than men to be promoted or appointed department chair. (Reference Richter, Clark, Wick, Cruvinel, Durham and Shaw17) Women physicians face a persistent wage gap that cannot be explained by hours worked, skill or experience. (Reference Jena, Khullar, Ho, Olenski and Blumenthal18) Furthermore, women physicians perceive gender-based discrimination 2.5 times more frequently than men, with reported rates of sexual harassment as high as 80%. (Reference Stephens, Heisler, Temkin and Miller19–Reference Heisler, Stephens, Temkin and Miller21) The structural acceptance of these abusive behaviors adversely impacts physicians, surgeons, and patients and contributes to burnout and voluntary and involuntary departure from the medical profession. (Reference Aggarwal, Rosen, Nehemiah, Maina, Kelz, Aarons and Roberts16; Reference Nunez-Smith, Pilgrim, Wynia, Desai, Bright, Krumholz and Bradley22; Reference Linzer and Harwood23) Tragically, 40% of women reduce their hours to part-time or leave medicine entirely within six years of finishing training. (Reference Paturel24) With this percentage of attrition and reduction in the workforce (see figure 29.2), Government and Academic Medical Centers, and the health care system as a whole must start viewing attrition as a sentinel event that has the potential to threaten public health and safety. (Reference Lautenberger and Dandar13)

Figure 29.2

Seven-year promotion outcomes for US full-time academic faculty, 2008–2009.

Figure 29.2 Long description

The horizontal axis represents promoted, not promoted, and left academic. The vertical axis ranges from 0 to 60 in increments of 10. The graph shows the following approximate data for: women assistant professor, n equals 3,588; men assistant professor, n equals 4,441; women associate professor, n equals 1,036; and men associate professor, n equals 1,977; respectively. 1. Promoted: 19, 24, 27, 32. 2. Not promoted: 44, 44, 52, 47. 3. Left academia: 39, 31.5, 21, 21.

(13)

Medical Regulation

Sexual misconduct in academic medicine is prevalent. A 2018 report of the National Academies of Sciences, Engineering, and Medicine (NASEM), entitled ‘Sexual harassment of women: climate, culture, and consequences in academic sciences, engineering, and medicine’, found that 45% of women in medicine experienced gender harassment before completing medical school and more than 50% of women faculty and staff have experienced gender harassment during employment. This rate for medical students is higher than for science or engineering students. (32)

In a study of early-investigator awardees, approximately 30% of women academic medical faculty in the US reported sexual harassment; among those reporting sexual harassment, 59% reported that it negatively impacted their professional confidence and 47% reported that it negatively impacted opportunities for career advancement. (Reference Jagsi, Griffith, Jones, Perumalswami, Ubel and Stewart33) Rates are even higher in some sub-specialties, as 67% of women vascular surgeons reported sexual harassment; only 7% of these incidents were reported to supervisors. (Reference Smeds and Aulivola34) Barriers to reporting, including fear of reprisal and retaliation, have been well-documented. (Reference Smeds and Aulivola34; Reference Binder, Garcia, Johnson and Fuentes-Afflick35)

Despite a high prevalence of sexual misconduct and significant negative outcomes for physicians and surgeons, most research on physician sexual misconduct focuses on acts against patients rather than between colleagues. (Reference AbuDagga, Carome and Wolfe36–Reference Gulrajani39) US state medical licensure boards and the Federation of State Medical Boards (FSMB) have the authority to investigate and discipline physicians who commit sexual misconduct by restricting, suspending, or revoking licensure to practice; (40) however, physician-on-physician sexual harassment is often investigated as a workplace misconduct issue. Furthermore, health care organizations have flexibility in reporting physicians accused of sexual misconduct to medical boards. (Reference AbuDagga, Carome and Wolfe36) Consequently, few academic medical faculty or physicians who are accused of sexual misconduct are sanctioned by medical boards. (Reference Espinoza and Hsiehchen41; Reference Liu and Hyman42) For example, an analysis of sexual misconduct-related reports indexed in the National Practitioner Data Bank from 2003 to 2013 revealed that a small number of physicians (N=1,039) were reported during that time period, and 70% of those reported were not disciplined by a medical board. (Reference AbuDagga, Wolfe, Carome and Oshel43) In the US, peers may be involved in reporting sexual misconduct but are rarely involved in disciplinary processes for physicians accused of sexual misconduct. Some US professional societies (e.g. American Association for the Advancement of Science) have created new policies and procedures for addressing sexual misconduct among their members, with those who violate these policies subject to removal from annual meetings and bans from attending future meetings. (Reference Bates, Jagsi, Gordon, Travis, Chatterjee and Gillis44) However, few professional societies provide publicly available statements or policies pertaining specifically to gender. (Reference Heisler, Miller, Stephens, Ton and Temkin45) Actions of individual organizations are unlikely to prompt significant, widespread change. To this end, recent publications emphasize a need for large-scale organizational and institutional change, (Reference Heisler, Miller, Stephens, Ton and Temkin45; Reference Fairchild, Holyfield and Byington46) as well as grass roots efforts to enforce codes of conduct, education, and training within academic institutions, health systems, professional societies, and private practices. (Reference von Gruenigen and Karlan47)

Prelude

As an intern covering minor surgical cases under direct supervision of my attending physician, I was fairly insulated from the egotistical behavior of this anesthesiologist. The stories and warnings from senior residents, nurses, scrub technologists and those same attendings were that he was difficult and could be hard on people. In truth, he was arrogant, condescending and rude. My encounters with him became more frequent and more inappropriate as I became more independent through residency and received a more substantial surgical caseload. He leaned into the power differential without overtly crossing a line into harassment. These interactions were not rare, nor specific to me. Rather, they were illustrative of an oppressor allowed to bully and intimidate anyone to maintain perception of power and an ineffectual organization that permitted it, unfettered.

After completing fellowship, I returned to my former residency program – now as an attending surgeon employed by a health care system. I would have the opportunity to train the residents in my surgical sub-specialty and to build the division which I now led. I was excited to work among the very talented attending surgeons who had trained me years ago. The only concern was that he was still there. As a member of the contracted group of anesthesiologists, this narcissist continued to reign the operating room (OR) suites, infecting the space with his arrogance and derision. His menacing presence continued without a specific direct incident. He was allowed to embed negativity throughout the surgical space without reprimand or consequence.

Assault

I had a major surgical case scheduled to start at 0730. I went to meet the patient in the pre-operative area, and he was behind a curtain talking with her and her family. He peered in my direction, informing me that he was talking with her and needed more time. I acknowledged his request, shut the curtain and stood by, waiting for my turn to talk with our patient. As his conversation turned from relevant medical history to social conversation and laughter, I again opened the curtain to signal I was ready to talk with the patient. He snapped at me, saying that he wasn’t done talking. I explained that I still needed time to talk with the patient before we proceeded to the OR, and he sharply and condescendingly replied that he would be done soon. I closed the curtain and stepped back a few feet. He finally emerged from the room and walked past me, indifferent. I met with the patient and her family to review our plan for surgery, the process of recovery and when she would see her family again.

I knew I needed to address the interaction in order to resolve the conflict. I approached him and asked to speak with him. I acknowledged the importance of his time to meet the patient and review the anesthesia plan for surgery, and noted that I did not appreciate his aggressive response nor his dismissive attitude about my time with the patient. He replied with a sharp tone that he was meeting the patient and developing a rapport with her and her family; my entering the space was disruptive to his time with her. I noted that his socializing with the patient continued, even after I specifically expressed my need to speak with her. I did not appreciate his blatant disregard of my time, nor his behavior in front of my patient, which was hostile and unprofessional. He rolled his eyes and told me to ‘Just calm down’. He reached behind me, patted me on the buttock and squeezed as he walked past me.

My instinct was to yell out or physically fight back at him for what he did to me. Instantaneously, I was reminded of my environment and my need to maintain professionalism, to control my emotions and my response. I was humiliated and embarrassed, left wondering if anyone saw this interaction or his action; yet I maintained integrity and continued on with the responsibilities that lay ahead.

In those subsequent few minutes as the patient was being wheeled from the pre-operative holding area to the OR, my mind was racing with the prior events. Eventually, I was in the OR with the team attempting to regain my focus on the case, but as my patient was prepped and draped, the harassment persisted. This anesthesiologist stood up behind the drapes, watching the surgical steps, and proceeded to comment on the case with nit-picking, criticism, condemnation, ridicule, and biting sarcasm. It was a totally inappropriate barrage of unnecessary negativity that did nothing but distract. My attempts to politely redirect him were futile. Finally, I sternly looked at him and requested that he stop his unprofessional behavior in front of the OR team. He then recoiled to his chair.

Limbo

I had no intention of reporting him. He was a prominent anesthesiologist in the institution and his reputation, though extremely despicable and reprehensible, was ingrained in the fabric of the OR and accepted by the institutional leadership.

I spoke with a male colleague later that day: ‘You won’t believe what happened to me …’ I blurted out the entire story. This colleague, a trusted confidant, was horrified to hear how I had been treated and unsurprisingly, immediately guessed the identity of the perpetrator. My colleague was unrelenting and said, ‘You have to report this. Dr Jarma crossed a line. He assaulted you!’ I explained that it wouldn’t matter. Nobody would believe me. It would be his word against mine. He offered to report on my behalf, to be my voice. I reluctantly agreed to allow him to report the event.

Shortly thereafter, I was called to a meeting with Human Resources, my department chair and two members of the Medical Staff Office. They requested details of the allegation, which I provided. Two profoundly imperative themes emerged from that meeting.

First, I was told that I had handled the situation incorrectly. I created a safety concern for my patient and my team by proceeding to the OR. I should have requested another anesthesiologist so I could focus on my job without additional distraction. Though there was no process available to guide me in this circumstance and the means of requesting another anesthesiologist would have resulted in questions and delay, my experience of being sexually harassed was distorted to imply that I was in the wrong by continuing with the case. In essence, I was potentially endangering my patient, my team, and my organization by doing the job: performing the scheduled operation. It was irrelevant that I had been sexually assaulted by a key member of the team.

More importantly, Dr Jarma was protected under the guise of ‘due process’. He would be allowed to work while they met with him and additional staff. As a physician, he shouldn’t suffer financial penalty just because I alleged inappropriate behavior. He would be treated fairly. In order to protect me, however, I was provided the option of paid leave. This would ensure I would not experience further interactions with him.

Exposure

I was bullied through the ongoing investigation process after the sexual harassment, which caused additional distress. Once, I was confronted by the Human Resources representative, who openly discussed my case in a busy cafeteria. She desired to update me as to the status of the investigation – Dr Jarma is aware, of course, and cooperating fully. Her attempt at timeliness was usurped by the lack of confidentiality. Worse, the rationale for this impromptu meeting was a request that I provide my story in writing.

While the investigation only took a few weeks, time seemed to stand still for me, as I was continually reminded of Dr Jarma’s presence. He was instructed to avoid direct contact or conversations with me, with which he complied. However, he was everywhere – the recovery room, the surgeon’s lounge, the hallways, and outside other operating rooms. He demonstrated complete lack of regard for my discomfort, and in fact seemed to revel in the awareness that he was abiding by the rules without being constrained by them.

At the final meeting with the investigation team, I was informed that, despite this assault occurring in a populated place during the busiest time of day, nobody could corroborate my claim. However, they learned through staff interviews that Dr Jarma had a pattern of unprofessional behavior including sexual harassment that violated organizational standards and was unlawful. As a result, the anesthesia group and hospital leadership agreed to reassign Dr Jarma to another hospital where he already worked, but now on a full-time basis. The final decision did not include any sort of serious punishment: revocation of hospital privileges, termination, suspension of medical licensure, or legal action.

Removing him from the OR environment resulted in excessive gossip occurring around me. ‘Did you hear what happened to Dr Jarma?’ ‘Yeah, I heard he was just being himself and it upset a sensitive surgeon.’ Occasionally, I was confronted with direct questions like ‘Did something happen between Dr Jarma and you?’ ‘Are you really the reason Dr Jarma was reassigned?’ ‘Are you doing okay? I heard about Dr Jarma and you.’ I maintained a professional demeanor and politely played dumb, or deflected the questions, acknowledging that these conversations were inappropriate, regardless of whomever they involved. Though the outcome removed this perpetrator from my hospital, he was allowed to work in another environment, thereby subjecting others to his abusive behavior. I didn’t feel like the outcome was satisfactory. I wanted to disclose everything – the indignities, the hostility, the abuse. This anesthesiologist sexually assaulted me in public in the presence of witnesses but was protected by this institution and allowed to maintain his professional standing and financial security. On the other hand, I suffered from threats, ridicule, disbelief, exposure, antagonizing behavior and revictimization.

Aftermath

Ideally, this sexual assault would have ended with vindication and institutional support; however, that was not the case. Eventually, I resigned from that health care institution; this incident and the institutional culture were the basis of my resignation. The resentment I carried from that situation, and how it was handled by hospital administration, still lingers, though it does lessen with the passage of time.

This experience is unfortunately not unique to attending surgeons, nor is it situationally rooted in one health care system. Through my educational and other leadership roles, I continue to help others navigate these emotional, professionally challenging, and unlawful situations. I have the great fortune to have developed a network of strong women colleagues that are similarly focused on creating an equitable, safe and dignified workplace environment for everyone in health care. Through our collaboration and collective passion for this cause, we strive to make this the new culture in medicine and surgery for future clinicians.

Gender in Society

Zambia is a landlocked, resource-rich country with sparsely populated land in the centre of Southern Africa. It shares its border with eight countries (Angola, Botswana, Democratic Republic of the Congo, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe) that serve as an expanded market for its goods. Its population, much of it urban, is estimated at about 17.9 million and growing rapidly at 2.8% per year, partly because of high fertility, resulting in the population doubling close to every twenty-five years. (1) Girls and women continue to remain vulnerable because of many age- and sex-specific social barriers and gender inequalities. High Gender-Based Violence (GBV) prevalence in Zambia, particularly in rural areas, is due to existing cultural norms and unequal power relations at the household level. The 2013/14 Zambia Demographic Health Survey (ZDHS) reports that from all women who had experienced any type of physical or sexual violence, only 43% sought help to stop the violence, 9% never sought help but told someone, and 42% did not seek help and never told anyone. (2) Where help was sought, GBV survivors most frequently sought it from their own family (69%) or from the husband or partner’s family (43.2%), while formal structures of support were hardly approached for help (e.g., police – 7.8%; medical staff – 1.5%; social work – 2.2%). Unfortunately, there are no cases of sexual harassment in the workplace from any sector which have been referred to the National Prosecution Authority (NPA), except for one in the recent past.

Figure 30.1

Infographic Zambia. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 30.1 Long description

The infographic provides information about Zambia, with a population of 20.6 million and 3.1 doctors per 10,000 people. It highlights several gender-related statistics. 52 per cent of women participate in the workforce. 40.5 per cent of women are in managerial positions. 41 per cent of women have experienced intimate partner violence. Maternal mortality is 135 per 100,000. Infant mortality under 5 is 5560 per 100,000. 81.6 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Zambia:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 124, and there is some progress.

Gender in Medicine

There has been a notable change in the number of women in medicine in Zambia, from one female medical student entering medical school about fifty years ago to some universities recording over 50% female medical student entry recently. Despite this great achievement we have great underrepresentation of women at the leadership level in the health sector in general. Over almost sixty years of independence, there has been no female doctor who has ever served as Minister of Health. Those doctors that have been ministers are male. Zambia has ten provinces: all provincial health offices are headed by male doctors. It is almost the same picture at the district level, where we have less than 10% representation in the 110 districts. Women remain underrepresented at the various levels of leadership in the health sector in Zambia in research, academia and hospital management.

On the other hand, in the private sector, including private hospitals, non-governmental organisations and international organisations, female doctors are heading these organisations, some with more than 100 employees. One of the reasons women abstain from leadership positions in Zambia is because workplace policies do not support the parental and family roles that women have. Women are slowly getting more support from partners in our society but women in leadership roles need more than just supportive partners. Our workplace systems need to be more inclusive and diverse for us to see a meaningful change. Women in the health sector in Zambia continue to be underrepresented in positions of authority. They are merely restricted to lower ranks of management.

A recent study showed that firms with female CEOs experience 48.3% less sexual harassment. An increase of one female director is associated with a 18.2% decrease in the sexual harassment rate. (Reference Au, Tremblay and You3) Of course, more is involved in reducing sexual harassment in workplaces. Increasing female leadership in the health sector is one way to start through deliberate collaborative and innovative leadership.

Medical Education

For a long time, there was just one public medical school in the country, but in the recent past we have seen an increase in the number of both public and private medical schools. The duration of training for a medical doctor varies between six and seven years depending on the institution. There are also a number of medical students that train in other countries like China and Russia, after which they come back home to practise medicine. The faculty under these universities are responsible for assessing competencies both at undergraduate and postgraduate levels. All newly trained and inducted medical doctors have a mandatory one-and-a-half-year internship as junior resident medical officers. On completion they may choose to undergo specialty training for another four years on average in their field of choice or remain as general medical officers. Certain fields tend to attract more women for specialisation, like paediatrics, and obstetrics and gynaecology, although the overall number of males is always higher. Other than a few private hospitals and non-governmental organisations (NGOs), the government, through the Ministry of Health, is the main employer of all medical doctors in Zambia. However, at the hospital level, the hierarchy in the department starts with the head of department, consultants, senior registrars, registrars, then the interns, and learning in the clinical environment is by apprenticeship. Therefore, the seniors play a major role in the career progression of the junior colleagues because they impart skills and knowledge, and complete the appraisals of students and junior doctors’ performance, in the form of logbooks. This, unfortunately, means doctors in junior positions, including students, are vulnerable to hierarchical abuse. Culturally, a junior may never offer criticism or any form of feedback to the superiors regarding their clinical learning environment for fear of jeopardising their career progression. Even though there no actual studies to indicate the level of abuse in the Zambian context, other studies have found that inappropriate behaviour, harassment, and belittlement of physicians-in-training was perpetrated mostly by fellow physicians in superior positions. (Reference Szafran, Woloschuk, Torti and Palacios Mackay4)

Law

Zambia has laws which prohibit sexual harassment in the workplace. These are the Gender Equity and Equality Act no. 22 of 2015, the Anti-Gender-Based Violence Act no. 1 of 2011 and the Penal Code. These acts provide criminal and civil sanctions. (5) The law generally deals with cases of sexual harassment very seriously, as the offence has a very strict punishment with a minimum of three years’ imprisonment and a maximum of fifteen years’ imprisonment. However, the evidentiary rules in offences of a sexual nature are quite onerous as they require corroboration. The evidence of the victim has to be corroborated by independent evidence which tends to establish the identity of the perpetrator and the commission of the offence. These corroborative rules are in place to guard against the danger of false implications. These rules are onerous as most incidents of sexual harassment occur in private, and in the absence of evidence such as text messages or an eyewitness it becomes difficult to prove a case beyond reasonable doubt.

There are specialised police, prosecution, and judiciary departments mandated to deal with cases of sexual harassment; however, the evidentiary requirements are the major impediment that may lead to perpetrators not being charged. Victims can receive support from One Stop Centres, which offer multi-disciplinary support in the form of counselling and legal advice. The police and the prosecution service also provide counselling and legal support as do non-governmental organisations. There are risks of retaliation and further harassment on a victim who reports, as most institutions both private and public do not have safety mechanisms that protect a victim from backlash. The medical doctors do not have an institution mandated to defend them in civil or criminal cases nor do they have insurance which would cover such costs. Women who report sexual harassment are often viewed as weak or are blamed for having seduced the man, for example, by their way of dressing. Additionally, many panels to resolve such issues are led by men who are less knowledgeable about sexual harassment.

Medical Regulation

In order for medical doctors to practise in Zambia, they have to register with the Health Profession’s Council of Zambia (HPCZ). The Council has the mandate to register and regulate all health facilities in Zambia, both public and private, and training institutions teaching health sciences. The HPCZ is a statutory regulatory body established under the Health Professions Act No. 24 of 2009 of the Laws of Zambia. The functions of the HPCZ as enshrined in the Act, among others, include the registration of health practitioners and regulation of their professional conduct. (6)

Professional misconduct may warrant disciplinary action, as spelt out in the organisation’s ethical code of conduct which states in part that personnel (health practitioners) exhibiting dishonest behaviour or corrupt practices, and indecent or violent behaviour, may lead to disciplinary proceedings even if the offence is not directly connected with the health practitioner’s profession. Some of the disciplinary measures include cancellation of registration, censure or counsel to the practitioner or otherwise imposition of fines. (7) Clearly there is no mention of sexual harassment of colleagues in this document. The role of colleagues and other professional bodies is not clearly spelt out in how an erring member should be disciplined. On the progressive side, the Public Service Management Division (PSMD), which is the regulator of all public workers doctors, including doctors, has recently revised the disciplinary code and procedures for handling offences in the public service, as of May 2023. Any form of sexual harassment on first breach results in instant dismissal from public service. (8)

Prelude

Following ethics approval (#1652–2021), a survey using Google form documents that did not capture any personal information or identifiers was sent to the membership of the Medical Women Association of Zambia. Eight responded to the questionnaire and reported to have experienced sexual harassment, which happened between one to more than ten years ago. The sexual harassments which have been experienced by the survivors include inappropriate texting (3), inappropriate touching (3), inappropriate comments (7), physical contact (2) and rape (1). Three of the survivors are currently working in the same department as the perpetrators. Only one perpetrator was the same rank as the survivor, while the rest of the perpetrators were senior to the survivors at the time of the harassment.

Most survivors attributed organisational culture, followed by social context and personal vulnerabilities, as factors they thought contributed to the sexual harassment. Below are quotes from the survivors’ perspectives on what they consider put them at risk of such horrendous acts.

The Assault

Here we highlight the narratives given by two of the survivors.

One of the respondents (S5) narrated this.

However, this was plain simple: it was rape.

The second survivor (S6) explained an incident as having brewed from ward rounds.

At the end of each rotation, junior residents get signed out before rotating through another specialty. As this junior officer went to the head of department’s office to be signed off, he grabbed her and started touching her breasts and asked for sex; but she found a way to escape and never looked back.

Limbo

An analysis of the responses reveals an alarming trend of systemic sexual harassment by male doctors of female doctors who were in the majority of the cases subordinates of the perpetrators. More than half of the respondents considered reporting the case; however, only two did report. Reports were made to the immediate supervisor and to the Ministry of Health. In both cases nothing came out of the reports, one respondent was told that it was normal for new young doctors to be approached by seniors and in the second one the complaint report went missing. There were no sanctions, nor was accountability meted out on the perpetrators for the reported cases. The only satisfaction that respondents got from reporting was that they experienced no further acts of harassment.

The major challenges faced by the respondents which prevented reporting were fear of reprisals and of being labelled difficult, in addition, respondents thought they would not be believed. Previous attempts by other female doctors to report had resulted in the whole hospital knowing of the incident: the lack of confidentiality and protection against retaliation were major deterring factors for non-disclosure. Other key considerations were that respondents did not want to create work tensions with perpetrators with whom they still had to work. Moreover, the lack of documented evidence of incidents of harassment contributed to the non-reporting, as respondents believed their word alone would not suffice. Knowledge of whom to report to was not known to all: only half of respondents knew where to go. Some respondents hoped for the incidents of sexual harassment to naturally go away, and half of the respondents stated that they did not have the personal strength to report as the process of doing so would be cumbersome and emotionally draining.

Exposure

Two of the survivors reported that they had experienced retaliation from the perpetrators and colleagues. And as a result, the survivor had to leave that hospital and find employment elsewhere. Three survivors had actually experienced thoughts of how they would cope with a sense of betrayal in the event that colleagues talked about them, and one of these narrated that she did not care only for her career. On the other hand, another survivor narrated the ordeal her friend went through when she reported a rape case at her institution, and we infer here that this friend unfortunately did not participate in our current survey, and hence we cannot comment on the specifics of the experience. This loss of anonymity and gossip has some repercussions on how the survivors would cope with the sense of betrayal. This survivor did not report her case, and she does not think she would recommend anyone to report a rape case at her hospital.

None of the survivors in this survey ever thought they needed to respond to critics or people talking about them if it came to light that their cases were exposed. One of the survivors alluded to thoughts of self-blame and said people have often misunderstood her friendliness. On the contrary, another survivor knew she would be criticised but the critics would not be correct to blame her for being female around men who are ill mannered. Some of the survivors did consider how they would cope working in an environment amidst the gossip and would have preferred to get a transfer. While another actually moved:

Aftermath

After the incidents, the respondents expressed different feelings; some respondents felt the incident made them stronger. ‘I feel strong as I had a clear plan on how to gather evidence about the harassment and to report it.’ Another one responded, ‘A strong doctor.’ There was self-blame as well. ‘I always think I am a coward. I should have fought.’ Not reporting the incident meant they could go on without anybody knowing.

The impact the incident had on their personal and professional life was profound. It has led to suspicion and mistrust of male colleagues: ‘I am suspicious of male colleagues. I always prefer to work with female doctors on projects.’ A loss of respect as well:

Avoidance of male colleagues as well: ‘I am distant with male colleagues, and I am not usually comfortable in situations where I find myself alone with a male colleague.’

Respondents also described recovery in various ways that meant some state of forgetting, forgiveness or feeling comfortable about themselves and feeling comfortable in the company of male colleagues. Agonisingly, some have failed to recover. One described recovery as ‘Not happening as I see him with his smirk on his face.’ Others reached a place of recovery through counselling and prayer. Sadly, most have not fully recovered, and this remains a work in progress. Some respondents have used their experience to counsel others and raise awareness on the issue, seeking the benefit of others.