Addressing gender violence in medicine

In medical school, we learn about Broca’s area, the region of the brain that when injured prevents a person from translating their thoughts into spoken word. When this area is damaged, from a stroke or traumatic injury, the person can hear a partner declare their love or a child cry, but are unable to vocalize a response. Silenced by their injury, their voice is trapped.

In a similar way, as medical students, like the consequences of an injury to Broca’s area, we may hear and intimately know the experiences of gender violence, but we are unable to share. Our voices are trapped and silenced, exacerbated by the hierarchical and apprentice-based training environment, further constrained by a complex policy and regulatory environment.

An unspoken epidemic

An alternative to using our voices is to use data, public health statistics and numbers may tell our stories more safely. But in medicine, those numbers by and large don’t exist. The recently published report from the National Academies of Science, Engineering, and Medicine (NASEM) on sexual harassment in academia unveils the pervasive issue of gender violence in medical training. The findings from the report found that women medical students were 220 percent more likely than non-science students to experience sexual harassment and that nearly half of women medical students experienced sexual harassment from faculty.

And yet this study — essentially the only published of its kind — is limited in scope. The data were collected at only two medical schools and does not include peer-to-peer or patient violence. In effect, medical schools have failed to survey students about gender violence during training with the rigor necessary to understand the topic.

What we do know about gender violence is largely from the general population. Gender violence occurs along a continuum — from harassment, obscenity, stalking, sexual assault, to trafficking — and is pervasive in the U.S, with 23 million women reporting an experience with rape or attempted rape in their lifetime, and one in four female college students are sexual assault survivors. Gender violence is a public health epidemic.

Medicine is approaching its own #MeToo moment, as seen by recent events, including: the criminal charges of sexual misconduct by prominent physician leader, Dr. Thomas Frieden; the prestigious promotion and subsequent demotion of Yale professor Dr. Michael Simon; and the sexual harassment lawsuits at academic health centers: Dartmouth, University of California San Francisco, and the University of Maryland. Federal laws—Title VII, Title IX, the Clery Act — have long mandated institutional responses to remedy gender violence at federally funded institutions; however, few of these mandated processes are survivor-centered, and institutional violations are all too common.

Further, proposed changes to Title IX guidance, which is undergoing the public “Notice and Comment” process, would weaken an already frail system for addressing gender violence in academic settings. The new rules would give institutions the option to demand a higher evidentiary standard to adjudicate investigations and would not require the investigation of off-campus offenses. This is particularly problematic for medical trainees because our training requires us to travel for residency interviews, away rotations, and conferences.

Addressing gender violence in medicine

As we look for solutions to address gender violence in medicine, in a rapidly evolving federal context, one stop-gap option is the use of privileged or confidential advocates. Advocates do not exist at every institution, and their specific protections vary by state. Advocates provide people who have experienced gender violence with information about institutional, criminal and civil actions, as well as non-reporting alternatives. Importantly, advocates are protected from subpoenas and exempt from Title IX reporting.

This year, Oregon Health and Science University (OHSU) took steps to improve resources for students, residents, faculty, and staff experiencing gender violence by building an advocacy program. In February, OHSU held its first community listening session on sexual harassment, convened by prominent women-identified institutional leaders. During the listening session, we drafted and read a letter to a filled lecture hall, outlining how to improve access to gender violence resources. With support from faculty champions and the Title IX office this effort led to the funding and establishment of a campus-wide gender violence program.

Although there is certainly more to do, an early win like this sends a powerful message to the house of medicine that experiencing gender violence during training should not be the price of admission to the profession. We urge the medical education community to take four fundamental steps:

Research. Medical schools and regulatory bodies — including the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education and the American Osteopathic Association — fail to collect data on gender violence using evidence-based tools, such as the ARC 3 campus climate survey. Each year, thousands of medical students, residents, and fellows receive surveys that fall below the scholarly standards of sociology, criminology and gender studies.

Resources. Institutions must invest in support services for students who experience gender violence, such as advocates. Institutions must look to the lessons learned in other contexts (e.g., college campuses) and invest and translate evidence-based prevention interventions to medicine.

Regulation and policy scan. Medical education leaders must assess how organizational and national policies impact trainees who are gender violence survivors and offenders. There are many policy domains to study, including federal grant funding, medical specialty organizations and honorary societies, academic conferences and educational protection policies for clinical students.

Reconceptualize. Many contemporary solutions to addressing gender violence focus on the criminal justice system. Although that may work well for some, students would benefit from additional options. Institutions should learn about other models — like restorative justice — for resolution. Leaders and researchers at UC Davis are using this modality to address learner mistreatment in medical school.

Healing this system will take time and effort from those with the power to create change. Like the stroke survivor who seeks to use her voice, we are using the tools available to us, albeit limited, to translate the stories that we hear into action. Together, we can and should expect medicine to be a violence-free learning environment.

Support services

Title IX of the Education Amendments of 1972 (“Title IX”) and the Clery Act are federal laws that require educational programs to address and remedy any known sex and gender discrimination, including sexual assault and harassment on campus. All institutions that accept federal financial support are required to stop discrimination, prevent the recurrence of the behavior and mitigate its effects. Contact the Title IX Coordinator at your institution for more information about your rights and resources.

Some institutions have non-reporting, private resources on campus, such as privileged or confidential advocate programs (resources will vary by institution and state). If you need help navigating issues related to sexual assault or harassment, the National Sexual Assault Telephone Hotline is a free, 24/7 resource: 1-800-656-HOPE (4673).

Kelsey Priest and Caroline King are medical students.

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