Sex- and gender-based harassment: the toxic substrate of medical professional culture

This issue of CMAJ features research on sex- and gender-based harassment and discrimination perpetrated by physicians in Canada over a recent 5-year period.¹ Lithgow and colleagues searched media reports, Canadian legal decisions, and notifications from physician regulatory bodies from 2019 to 2024 to find cases in which 208 physician respondents were involved in concerns of harassment or discrimination involving an estimated 689 victims, most of whom were women or girls and the vast majority of whom were patients or their caregivers.¹ The findings help to highlight an important problem for the medical profession in Canada: the tendency of its leadership and regulators to conceal sex- and gender-based misconduct perpetrated by physicians.

Among those identified in the linked study as complainants or victims, only 2 were physicians and 3 were medical trainees. This doesn’t track with the findings of recent high-profile surveys of physicians and medical learners from the United Kingdom and United States, in which reported rates of experiencing sex- and gender-based harassment in clinical workplaces were as high as 65% and 23% among those identifying as women and men, respectively.^2,3 A 2022 survey of orthopedic surgeons in Canada with a low response rate found a rate of 74% (97.5% of women respondents).⁴

Every now and then, a story of sexual assault, gendered bullying, or harassment by a colleague in a medical workplace makes headlines, especially when the perpetrator or victim is someone important. “Isn’t this shocking?” the story’s tone implies. I know I am not alone among physicians in screaming inwardly each time, “This is not news!” Because it happens every day, so much so that many physicians experience a culture of gendered mistreatment as the toxic substrate of existence, the water in which they swim daily — tolerated, and largely undiscussed, unexamined, and unrectified.

I and many of my colleagues around the world have experienced more than one such incident during medical training or practice.⁵ Beyond hearsay, evidence confirms this. The vast majority of respondents of all genders in a 2023 survey of UK surgeons reported having witnessed such discrimination and harassment.² The same study underscored the profession’s sense of resignation, as respondents also expressed low faith in there being any adequate response by accountable organizations. In a 2024 survey of 454 physicians in Canada from more than 30 specialties, in which nearly 1 in 10 overall — about 1 in 5 women and 1 in 3 physicians younger than 45 years — reported personally experiencing sexual abuse, harassment, or misconduct in the workplace, 60% of respondents did not report it because they feared embarrassment or retaliation, or thought that nothing would change.⁶

When organizations that should hold perpetrators of sex- and gender-based discrimination and harassment accountable don’t, it makes the problem worse. Research in business settings supports a theory that organizational climates in which mistreatment is tolerated increase perceptions that such mistreatment is inevitable, leading observers to justify and maintain the status quo.⁷ Recent Canadian research showed that, without strong supports built in to the system, the act of making a complaint can fuel further harassment or bullying, because powerful agents often work to silence and smear those who speak out.⁸

Incidents of bad behaviour perpetrated by physicians are often handled quietly by organizations and regulators, particularly for cases of misconduct toward a professional colleague. One might argue that this protects the profession — for which high public trust is crucial — from being irreparably harmed by the actions of a few. However, secrecy in dealing with incidents also supports a culture of silence and a widespread perception that the profession tends to protect the reputations of perpetrators over the well-being of colleague-victims.

A professional culture like this — in which entrenched systems support an oft-repeating pattern of opaque consequences for perpetrators and inadequate-to-negligible support for victims, which further reinforces silence⁹ — creates outcomes detrimental to the profession itself, namely physician burnout, mental health concerns, and early exit from the profession.³

To begin to address this culture and its consequences, Canada’s regulatory colleges and legislators could emulate approaches taken in the UK following the high-profile 2023 survey.² Its findings prompted a report by a working party of the Joint Royal Colleges of Surgeons in the UK and Ireland that outlined 15 recommendations regarding the reporting and investigation of incidents, policies regarding education and improving workplace culture, and directives around data collection, and announced revisions to the college’s code of conduct.¹⁰ NHS England called for anonymous reporting of incidents, and general workplace legislation enacted in the UK in 2024 aims to ensure that all incidents reported are addressed by employers.

However, reports, statements, easier mechanisms for anonymous reporting of incidents, and even legislation, will not suffice to solve the problem of a culture of silence that leaves victims chronically unheard and repeatedly traumatized. Encouraging reporting of incidents in the absence of clear steps for action and accountability risks victims being assaulted twice — once by an individual and a second time by the system. Although Canada lacks a clear estimate of the size of the problem of sex- and gender-based discrimination and harassment among medical trainees and physicians, simply having academic institutions or colleges collect data through regular surveys could likewise be harmful without robust plans to use such data to improve systems.

The medical profession in Canada needs to address its poorly hidden problem of sex- and gender-based discrimination, harassment, and assault. To do so will take a culture change in which the profession openly acknowledges the importance of the problem, owns its failure to address it, and takes steps to change regulatory and academic systems to prioritize believing victims, remediating offenders, and setting enforceable standards for behaviour.

See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.251179