Which Factors Fuel Sexual Violence in Healthcare?

Mônica Tarantino

August 11, 2022

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and led to the assailant, Giovanni Quintella Bezerra, being arrested on the spot. He's a 32-year-old, White, successful physician, and he's now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, Medscape interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo School of Medicine (FMUSP). Daniela Pedroso, MA, is a psychologist who has 25 years' experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC (UFABC), São Paulo and at the Department of Health, Life Cycles, and Society at the University of São Paulo School of Public Health (FSP-USP). Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).

Accusations and Investigations

Not all incidents of sexual violence in healthcare institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014–2019), 1734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states' Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state's regional council of medicine, police stations, and public prosecutor's office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number also includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

"Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: it may turn out that there was no truth to the accusation after all, and yet someone's career may already have been destroyed," explained Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

"We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened," Scardoelli told Medscape.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — "Where It Hurts" — a campaign that was launched to raise awareness about sexual violence committed by healthcare professionals. When she was 16, her pediatrician sexually abused her. It wasn't until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4000 posts online. Most of them were people's accounts of acts of violence committed by physicians during appointments in their office or during treatment in the hospital. These are available on Twitter under the hashtag #ondedoi.

Inadequate Sex Education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words "healthcare professional" and "sex attack" in the same sentence. "One of the most disturbing aspects is that healthcare professionals are committing these acts of violence against women who are in a vulnerable state, typically when they're under anesthesia, they've fallen ill, or when the healthcare professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way," said Drezett.

As Cohen sees it, to perpetrate these acts of sexual violence, physicians — as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust — make use of their power to take advantage of a person's vulnerability. He explains, "Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands — the people who commit sexual abuse all have something in common. In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person." Indeed, anyone who knocks on a physician's door seeking a diagnosis or treatment, anyone who knocks on a lawyer's door seeking assistance, is putting themselves in a fragile situation. "The abuser considers the other person an object, not a human being who has rights," said Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these "powerful" professions and in the circumstances and opportunities these professions provide a means to fulfill their desire. In medicine, however, there is yet another imbalance, one involving consent to touch a person's body.

The age of the recently arrested anesthesiologist is something that caught Cohen's attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

"When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties — a time when sex is at the forefront of one's life — nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience — as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people's well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room." As for the findings of Cohen's review, the majority of the 150 cases were dismissed because of lack of evidence.

To Pedroso, who has treated more than 12,000 victims of sexual harassment, it's the questioning and intimidation that women feel in relationship to the male physician — a person who is viewed as holding knowledge about her body — that leaves them vulnerable and more subject to acts of violence, especially in more remote places. "We're speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women's bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so."

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. "We are long overdue. We live in a country where there's this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don't teach boys not to rape."

Another point highlighted by Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won't be caught. This is what may have happened with Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender's Office, Thaísa Guerreiro, stated that although the Women's Hospital in São João do Meriti — one of the places where the assailant worked as an anesthesiologist — had adopted protocols to protect patients, it failed to enforce them. Another observation was that the healthcare professionals normalized violations of a woman's right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Guerreiro went on to say that the hospital's chief of anesthesia and the state's health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Bezerra would ask the patients' husbands to leave the room in the middle of the procedure.

It should be clarified, Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. "There are two sets of situations that we term 'obstetric violence.' One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to healthcare professionals' attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things."

Early Education Crucial

How are healthcare institutions dealing with this problem? "Very poorly. Sexual violence perpetrated by physicians and other healthcare professionals is a taboo subject that people are still afraid to talk about," Cohen observed. "Regrettably, sexual violence happens all too often. Before, maybe we weren't talking about it much because, from our viewpoint, healthcare professionals, such as physicians and nurses, weren't likely to commit acts of violence while performing their duties," noted Drezett.

Drezett also spoke about schools and what role they can play. "Of course, schools should discuss violence against women, especially in the field of healthcare. This has been done for a long time now, though it's not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology," said Drezett. For example, in the bioethics classes taken in the third and fourth years of FMUSP's medical degree program, Cohen asks students to reflect on the significance of being in a position where you ask a patient you've never met to undress so you can perform an exam, and the patient promptly and readily complies. "This is not about the physician, it's about the power of the institution," the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Drezett thinks it's very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. "We're talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier — parents talking to their children, teachers talking to their pupils." He also doesn't believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. "If they were, the Roger Abdelmassih case would have done away with the problem."

On the other hand, Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth — two clinical practices that are recommended the world over.

"Healthcare professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice — they remove themselves from situations like those described in the Bezerra case; they don't practice medicine in a reckless manner," said Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. "Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule," he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

"This is not true. These incidents can happen in any doctor's office. It all depends on the physician — whether he or she has designs on committing a criminal act," Drezett noted. He did point out that there are few sexual molesters among healthcare professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. "Of course, we're speaking again about the exceptions, but in my experience of treating victims, I've seen, for example, more cases where it's been a police officer, not a physician, committing an act of sexual violence against a woman," he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn't gathered the evidence to back up their accusations, it's possible that the physician wouldn't have been caught in the act and that the case would have taken a different course — including pressure being put on them and their becoming the target of retaliation. In light of these possibilities, the group demonstrated the profession's highest ideals. Their fearlessness is inspiring.

This article was translated from the Medscape Portuguese edition.


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