How many more people will be abused before we act on sexual violence in healthcare?

A new investigation by The BMJ and the Guardian provides further evidence of the prevalence of serious sexual violation and assaults in the UK’s NHS.1 The investigation offers some explanation of why sexual harassment and abuse remain enduring concerns, finding a lack of sexual safety policies in many organisations and failures to record and then investigate such cases. Collecting and recording data are central to organisational understanding of these phenomena.2 The investigation highlights failures to take sexual violence seriously and to value gaining a more sophisticated understanding of three distinct sanction mechanisms—self, social, and legal sanctions—that are required to reduce these violations in workplaces and society.

Sexual harassment and abuse do not occur in isolation. Our research has associated these behaviours with workplaces that are already hotspots for bullying and harassment from both patients and staff.3 Perpetrators exhibit aggressive, goal directed behaviours for their own satisfaction and to enhance their feelings of power and control, with little or no regard for their targets.4 Research shows that this behaviour is habitual—once started, it is difficult for the individual to self-reflect and control it.567 Perpetrators often test how others react to their transgressive activities and whether their behaviour is tolerated in that environment. They use cognitive reframing and behavioural strategies to overcome their inhibitions, denying or downplaying the consequences of their behaviours.89

Perpetrators select locations for privacy and access to suitable targets—especially people who are vulnerable, powerless, or might be considered unreliable witnesses. Jimmy Savile’s crimes showed the vulnerabilities of healthcare workplaces and the attraction for abusers10—people can move around largely unchallenged by both staff and the visiting public.

Perpetrators are found to use specific career choices such as agency or locum work to improve their access to targets.10 Some workplaces, notably mental health facilities, are hotspots for perpetrators as they are the location of a wide range of professions including psychiatry, nursing, and psychology staff.111213 There are also issues with family medicine14 and obstetrics and gynaecology,15 although these vary by profession and access. Focusing on such locations to ensure data are gathered is valuable, especially as the investigation indicates that data collection is inconsistent.

Given that perpetrators’ self-regulation is impaired, two other mechanisms should be used to help deter and prevent their behaviours.8 Social sanction is an important means of inhibiting perpetrators, but only if the perpetrator fears the negative reactions of others. Considering ongoing issues of recruitment and retention in health workforces, having fewer staff reduces the means to notice other’s abusive behaviours and then the capacity to intervene.8 As perpetrators often hide their activities, only subtle clues might be available to indicate that something is not quite right.

More insidiously, perpetrators can deliberately subvert workplace norms and culture, often relying on ambiguity.8 They might only make sexualised comments to junior female staff, for example, masking it as a joke to make it easier to disregard. Yet what is occurring is boundary shifting, desensitisation of bystanders and targets, and reduction of social sanctioning.8

Clear policies of sexual safety and mandatory staff training on these policies are important in re-establishing social boundaries, reducing the ambiguity of what is acceptable behaviour from staff and patients, and raising awareness about reporting. For those who are experiencing sexual harassment and violence to feel confident about reporting, they must trust that senior and responsible role holders are willing to listen and act on their concerns. Yet such roles are often held by perpetrators or those more focused on protecting the organisation.16 Building a trusted organisation requires the application of sanctions,17 showing justice for the targets of abuse and that safeguarding of staff and service users is a priority. The current investigation indicates what could be interpreted as a wilful disengagement manifest in the failure of controls to detect or prevent sexual abuse. Not collecting data on sexual harassment and violence does not change its occurrence—rather, it suggests that the organisation is incompetent and lacking in good intentions.

Effective legal sanctions and punishments are the final means to inhibit perpetrators.8 This investigation again shows shortcomings in the NHS, with inconsistent and inadequate recording making early detection impossible, and inconsistent sanctions leading to further ambiguity. Early evidence of sexual transgression is often discounted.18 These failures fuel perpetrators’ moral disengagement and sense of exceptionalism8 and permit abuse.919 They pervert justice and support for targets. Downplaying incidents of sexual abuse, especially those perpetrated by patients, reduces staff wellbeing, job satisfaction, and workplace safety, and increases staff intentions to quit the workplace and profession.202122 The culture of silence that follows supports the decline of moral, financial, and care quality in the organisation and the erosion of public trust, permitting abusive activities.2324

2022 saw the highest level of sexual violence reporting in the UK. When these events occur at work, they undermine the safety and integrity of that workplace. Specific sexual harassment and violence policies need to be developed and used2 if we are to have the means of changing the lives of perpetrators, targets, and bystanders.