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Monthly Archives: April 2015

Island of no consent – maternity care and bodily autonomy in Ireland

Posted on April 26, 2015 by Sinéad Redmond

This piece was previously published in the print version of the Irish Anarchist Review

On the last day of August 2014, in a ruling the country and the media barely noticed, Mr Justice Ryan in the High Court in Kerry found against Ciara Hamilton and for the HSE in an utterly terrifying moment for every person pregnant or giving birth in Ireland from here on out. Ciara Hamilton had taken a case against the Health Service Executive after the birth of her second child, during which a midwife had, without obtaining consent, broken her waters, leading to an umbilical cord prolapse and an emergency caesarean section.

 

The breaking of waters during labour, in medical terms amniotomy or Artificial Rupture of Membranes (ARM), is not recommended best practice precisely because it can lead to a cord prolapse, which is a serious emergency when giving birth as it cuts off the blood flow and air supply to the baby. If the person giving birth is a Strep B carrier (as Ciara Hamilton was) it can also carry an increased risk of Strep B transferring to the newborn and causing serious damage to the baby (as happened to Ciara Hamilton’s child). It is listed as a Do Not Do under NICE recommendations. Despite this, and despite ARM being known to carry dangers and risks to both birthing woman and baby, it is still a widely carried out procedure in many Irish maternity hospitals. In the case of Ciara Hamilton’s birth, it was a procedure carried out by a midwife without seeking consent to do so.

 

This, too, despite being obviously grossly unethical and a fundamental violation of both human rights and bodily autonomy, is something which routinely occurs in Irish maternity hospitals. In the spring of 2014, AIMS Ireland carried out a survey of those who had given birth in Ireland between 2010 and 2014. The survey was available to be filled out online, and was spread through various social media channels, as well as through media coverage. The pool of respondents was a self-selecting one, and numbered 2,836. It found that only half of all those giving birth – 50.2% of respondents – were given an opportunity to refuse tests, procedures or treatments being carried out on them. This is a truly frightening figure. What is, however, more frightening, was the wording of Mr Justice Ryan’s finding against Ciara Hamilton.

 

“Mrs Hamilton would have seen the hook and would have known what was going to happen because of the sheet that was put under her in bed. Since, on the evidence, this was a routine procedure that Ms Kelliher was carrying out for the purpose of diagnosis to see if her fear of foetal distress was justified or not, it does seem strange that she would not have mentioned to the patient what she was going to do and have obtained her consent. The very fact that it was so routine suggests that the midwife would have done so. I am satisfied that the probability is that Midwife Kelliher obtained the plaintiff’s consent and informed her about the ARM that she was going to perform.”

 

What the judge has here concluded is that the midwife obtained consent because she should have done so – and that a woman giving birth who had consented only to a vaginal examination, NOT an ARM, should have known that ARM would have happened because of the presence of an amnihook and a sheet. This is a truly bizarre conclusion. Why would a person giving birth be assumed to be able to identify an amnihook – a specialised piece of medical equipment – and further be assumed to know that it would mean an ARM would be carried out on them without having been consulted or informed about the risks and benefits of the procedure? Again, this judge with no evidence to prove this assumption – and indeed the more recently published evidence from AIMS shows that not giving women a chance to refuse procedures is a large part of normal practice – asserts that a health care provider would have obtained consent because they should have done so, with no onus on the healthcare provider to prove evidence of informed consent being obtained. The fact that Ciara Hamilton testified to the fact that she was not given an opportunity to consent to an amniotomy is not even mentioned by the judge in this decision. Even more disturbingly, he goes on to say:

 

“The patient’s co-operation was needed in terms of re-positioning on the bed, the procedure might take some time and the implement was quite long, so it is not something that a person would or could do without the knowledge of the patient. The plaintiff got into position, was co-operative and consented to the vaginal examination. Ms Kelliher used a hook and gel and of course surgical gloves. She put a sheet under the plaintiff and got her to move down in the bed and discussed with the plaintiff what she was going to do. Midwife Kelliher said that she “would have discussed”, but in my view that was a matter of usage and she clarified that she actually meant, not that she would have in the sense of describing a practice in a conditional sense, but that she did with Mrs Hamilton.”

 

Mr Justice Ryan is here saying that Ciara Hamilton positioned herself in such a way as to consent to an ARM. She consented to the vaginal examination and moved down the bed. Is this really so different from the “short skirt” argument put before courts in trials of other forms of violation of women’s bodies? Yet again, with no proof, he asserts that an ARM could not be carried out without the knowledge of the person giving birth, despite the evidence of a woman who had undergone it that indeed it had been. AIMS Ireland has heard from many, many more women around the country who have had nonconsensual amniotomies – and indeed many other procedures – performed without their knowledge. This is a far from rare occurrence; yet the voice of the woman upon whose body this was perpetrated is once again, in the arena she sought redress for her exclusion from the decisions being made about her body and her birth, being spoken over, ignored, and deemed uninformed, inconsequential, and irrelevant.

 

But by far the most frightening aspect of all in this case is that, despite clearly stating in his ruling that Ciara Hamilton had “underwent a frightening and disturbing experience that would leave long term troubling recollections”, Mr Justice Ryan punitively awarded the full costs of the HSE’s defence against her and her family. This was unarguably a move designed to discourage other women and people who have experienced violations of their consent during pregnancy and birth from pursuing legal action against those responsible. A move meant to punish a woman and her family who did dare to speak up against the unacceptable, indefensible treatment AIMS Ireland hear of in Irish maternity wards all too often, and whose experiences, as before during their birth, were once again ignored by the State and its enforcers, quite literally judged to be meaningless. The truth of what happened to Ciara Hamilton and her recounting of it and its consequences for her and her son was callously dismissed by a judge who simply refused to believe it because he thought it shouldn’t happen.

 

What this ruling means is that it is now legally not a requirement for any Irish maternity ward or healthcare provider to prove either that a procedure is necessary for the person giving birth or the baby they’re giving birth to, or that they obtained informed consent from the person giving birth to carry out that procedure. In a country in which pregnant women are specifically excluded from the HSE’s National Consent Policy as being the final arbiter of what happens to their own bodies, with the High Court cited instead as the appropriate decision maker for these cases, this ruling is a further reminder to anyone with a uterus that if they are, or if they should become pregnant, they are no longer in control of their own body. They are lesser; they do not own themselves. Instead the State owns them.

 

This, of course, is in part a consequence of the 8th amendment; but it’s also in part a consequence of a larger prevailing attitude in maternity care in Ireland, that women in general and specifically women who are pregnant and giving birth are not trustworthy decision makers and cannot be allowed to make choices around their pregnancies and births as they cannot be trusted to be concerned with a safe outcome for their baby. This is bizarrely at odds with the State and HSE attitude to those who have given birth; they become at once the only possible caretaker for that child, not in need of any support or care in so doing, left entirely alone to do so with no formalised system of support around them even when they look for the assistance of one. Again, Ciara Hamilton and her family are an example of this; a family who need specialised supports for their son, damaged due to the poor management of his birth, they live in a state that will do its utmost to avoid shouldering the cost of it and avoid recognising Ciara Hamilton’s son as a valued member of our society who should be provided with all that he needs in order to allow him to participate in that society in a just and equal way. Now both they and he have been further punished for their attempt to right that balance and address the wrong done to him and his mother during their birth. For a family to be faced with the crippling financial burden that is the HSE’s extravagant legal costs of defending a birth claim will further deepen the gap between what their child needs and what they can afford to give him. Their situation is a haunting and horrific one that should never have been allowed to happen, and in many other jurisdictions never would have.

Contrasting the judgement in the Hamilton vs HSE case with a recent UK Supreme Court judgement, Montgomery v Lanarkshire Health Board, is an exercise designed to induce both heartbreak for the Hamiltons and rage on behalf of all pregnant women in Ireland. In this ruling, the Supreme Court held there exists for those giving birth an explicit right to information  about ‘any material risk‘ in order for them to make fully informed decisions on the process; without this information being provided, informed consent cannot be said to have been given. In this instance, Nadine Montgomery was pregnant, diabetic, carrying a large foetus and was not informed by her doctor of her increased risk of shoulder dystocia, which is, in the words of an expert witness of the case, “a major obstetric emergency associated with a short and long term neonatal and maternal morbidity [and] an associated neonatal mortality”. She did indeed experience a shoulder dystocia during birth, which was a horrendously traumatic experience for her and caused severe long term brain damage to her son.

 

Despite the fact that Nadine Montgomery had repeatedly expressed concerns about giving birth vaginally, her doctor said that she as a matter of course chose not to explain the risk of shoulder dystocia to diabetic women because the risk of serious injury to the baby was very small and that if she did, “then everyone would ask for a caesarean section”. The doctor makes no mention of the risk to women’s health and wellbeing of shoulder dystocia in her decision making.

 

A key and obvious difference here between the Montgomery case and the Hamilton case already is that the very concept of explaining risk of interventions, or of not performing interventions, to women is discussed at all in the Montgomery case. It does not appear at all in the Hamilton vs. HSE judgement. Given Mr Justice Ryan’s discussion of how Ciara Hamilton was treated it is probably safe to assume that informed consent is completely outside his frame of reference – again, a terrible but unsurprising indictment of the Irish maternity system as well as the Irish court system. The idea of informed consent literally does not make any showing here. Extensive discussion of the idea of informing women and how that should best be performed by healthcare providers takes place in the Montgomery case and yet the Hamilton judgement does not mention this concept even once.

 

In stark contrast, not only was the concept of informed consent discussed at length during the hearing of the Montgomery case itself, but it is also given a strong legal definition and set of requirements in the ruling itself.

 

“An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and her consent must be obtained before treatment interfering with her bodily integrity is undertaken. The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.”

The final and deepest cut of bitter envy from the Montgomery judgement to those of us in Ireland forced into the maternity system here, comes from Lady Hale’s part of the judgement, thus making it case law in the UK from the highest court in the land. It is as follows:

“In this day and age, we are not only concerned about risks to the baby. We are equally, if not more, concerned about risks to the mother. And those include the risks associated with giving birth, as well as any aftereffects. One of the problems in this case was that for too long the focus was on the risks to the baby, without also taking into account what the mother might face in the process of giving birth.”

Could any paragraph and context more succinctly highlight the appalling gap between the treatment of pregnant women in Ireland and the expected sheer basics of human rights of pregnant women elsewhere in the world?

For more on this see AIMS Ireland – www.aimsireland.ie, also on Facebook and Twitter.

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Posted in Health, Reproduction. Bookmark the permalink.

Don’t go anywhere: Risk management for women

Posted on April 17, 2015 by Stephanie Lord

You leave your house very early in the morning. It could be anywhere between 6am and 8am, but it’s mostly around 6.30am. You take the bus to work. The streets are deserted. Most mornings, your boyfriend walks your dog down the road beside you to the bus stop. Some days, you are on your own. On your days off work, you would like to walk your dog across town at 6am, the route you would take in the daytime when there is hustle and bustle, but maybe it isn’t safe enough when it is early. There aren’t enough people about.

There are shady looking characters that lurk around the streets in the morning. You get nervous when you see them. You wonder should you alter your route to the bus stop but each route you would take would require you to walk down a street that might be a little bit too desolate at that hour. You need to weigh up the risk more.

You love the summer, because when you are going to and coming from somewhere, the days are lighter and longer and it means that you can see further ahead and further behind you. You used to only walk with your keys in your hand if you were alone at night.

You do it in the daytime now too – ever since you read about that woman who was attacked in broad daylight in the park. A 19 year old man pushed her in the river. She fought him off. You would like to walk your dog in the park at the back of your house but it is too quiet, too empty and too risky. A man told you on the beach last week about how he lets his dog off-lead at 5.30am in the morning when there’s no one around so she can get a good run. Your leashed dog is jealous of his dog. You are jealous of him.

You would not go to a deserted beach at 5.30am in the morning.

It would be too dangerous. What is it like to be completely alone on a beach and not be scared?  You do not know. You could go to the beach on your own of course, but if something happened people would say “that really wasn’t wise” and “what was she doing on a beach on her own at half five in the morning?”

You do not really go anywhere alone between 10pm at night and 6am. There is an unspoken agreement between you and your boyfriend that he will meet you from the bus or train if it is after 8pm, but definitely if it is after 10pm. You are jealous of the time that your boyfriend has with his thoughts when he wanders alone through empty streets before coming to meet and/or protect you on the way home.

You are jealous but you are glad he is there.

Your house is a ten minute walk from the nightclub, but you take a taxi at 3am. You use an app to take the taxi, because you don’t know who you are flagging down on the road. You text your Mam who is a bad sleeper and probably awake anyway to let her know you are in a taxi and on the way home. You are glad there is cctv outside the pub across from your house. You text your Mam again and tell her you are in your house. You wait for the texts from your friends to tell you that they’re home. Your boyfriend comes home from football and pints with the lads. He walked. He kisses you goodnight and goes to sleep but is not woken by the ping ping of his friends whatsapping him to tell them they are home ok. You envy their carelessness. They will not feel guilty for coming home and falling asleep straight away and forgetting to text their friend. They do not have to.

You lie in the space between sleep and wake until the last message is received from your friend to let you know she’s home ok. Her battery had died so you were panicking over nothing. That taxi driver was fine after all.

You take the bus to work but it’s busy so you can scan the seats for a space beside a woman. There are none, so you sit beside the man who looks the least creepy but you know that even that might not be a safe bet as you recall the time a friendly old man who did not look weird at all sat beside you on the bus when you were 19. You are in the window seat. He asks you about university and keeps touching your arm, but you feel he would think you impolite if you told him how uncomfortable it is making you. He gently places his hand on your left breast as if it is no big deal while he is talking to you and you are so shocked you have to get off the bus twenty miles from your house and ring your friend to collect you. While you are waiting you ask yourself over and over again, did that really happen? It happened.

Now you sit as close to the driver as possible but it sometimes means a split-second judgment call on whether the man in the seat beside your prospective seat looks like a weirdo. You wonder which seat is the safest. You text your friends to let them know you made the last bus.

Ten years later, you feel an uninvited hand brush your bottom as you stand waiting to cross at the lights. He looks you in the eye after and crossed the road. You wonder if that was an accident but you know that you do not accidentally touch someone with the palm of your hand while waiting for the green light that indicates it is safe to cross the road. You sit beside Molly Malone and watch him until he disappears and wondered if you should run after him but what would you say if you caught up? Would anyone believe you anyway? Something similar happened to your friend recently while walking her dog beside the canal. You are all running the gauntlet. Molly stands still. She has seen it all.

You wear longer cardigans and longer shirts now. You wear longer coats like a flimsy shield. Summer is good because the days are longer, but the coats are shorter or not there at all so it’s a catch-22 really. You remember how these things happened during the daylight and wonder why you ever thought daylight was a defence in the first place.

You go home and make dinner. You feel safe. Your house is your fortress. You remember when it wasn’t. You think of a time, in a former life, when someone else lived there. You hear the names he called you and the sound of the walls he punched. Daylight was no use to you then and you try not to think about it. There is a knock at the door but you aren’t expecting anyone so you ignore it. It could be anyone really. You wonder why pepper spray is illegal in Ireland but remind yourself to get the small tin of wasp-killer spray from under the sink and keep it in your handbag. You read that it does the same thing. You wonder is there a point to any of these Oprah magazine safety tips at all. You feel you should be more defiant. You double check the doors and windows are locked.

When you wake, you quietly wake up your boyfriend.

You need to get the bus to work.

7 Comments

Posted in Equality, feminism, Violence against women and tagged , , . Bookmark the permalink.

A favourite piece of research for Swedish model advocates throws up a few surprises

Posted on April 13, 2015 by feministire

Guest post by @pastachips

“Does legalized prostitution increase human trafficking?“, a 2012 study by Cho, Dreher and Neumayer, is cited everywhere as evidence that ‘legalised prostitution’ increases trafficking into the sex industry. This article from last month is a recent example. The study’s conclusions have already been called into question, basically because the paper doesn’t distinguish between different meanings of the word trafficking, either in terms of taking account different countries’ laws – are we comparing like with like? – nor in terms of making a distinction between something-that-might-be-legally-trafficking-but is-essentially-undocumented-migration, and something more like cross-border kidnapping. Making that kind of distinction is pretty important if you’re trying to say something coherent! As is comparing like with like! The papers’ authors caution against treating its conclusions with too much weight, noting that “the quality of data is relatively low”, and that more research “will require the collection of more reliable data to establish firmer conclusions” (p26), but I think their data is actually way worse that they’re letting on.

They focus in on comparing Denmark, Germany and Sweden, and tell us: “in terms of human trafficking victims, the ILO estimated the stock of victims in Germany in 2004 to be approximately 32,800 – about 62 times more than in Sweden” (p25). I looked up their reference for that 32,800 figure, and found that the ILO paper cited as the source – Danailova-Trainor & Belser, 2006 – doesn’t even mention Germany. I discovered that by reading it, but you can also test it by clicking through and doing a command-f search for the words “German” or “Germany”, which you might reasonably expect to occur in a document that mentioned Germany.

The same 2006 paper is also cited as the source for the numbers on Denmark, where the claim is made that “… the ILO estimates the stock of human trafficking victims in Denmark in 2004 at approximately 2,250, while the estimated number in Sweden is about 500”, and the bracketed reference reads: “Global report data used in Danailova-Trainor and Belser, 2006” (p24). Again, I looked for those numbers (or any mention of Denmark) in vain in the Danailova-Trainor & Belser 2006 paper. I also checked out the “Global Report” mentioned as the source for Danailova-Trainor and Belser’s data, which I figured was probably a reference to the ILO’s 2005 report titled ‘A Global Alliance Against Forced Labour’ – there’s nothing else published that it plausibly could be; I checked. The 2005 Global Report doesn’t contain any country estimates, let alone numbers like those cited by Cho, Dreher and Neumayer.

I assumed that the 32,800 figure regarding Germany must have come from somewhere, so I dug around for ages on the ILO site, and found that the ILO seems to mostly resist giving country-specific numerical estimates (cf this 2005 report on trafficking in Germany, which really won’t be drawn on numbers). The only figures I could find for trafficking in Germany in 2004 were these official lists of identified victims that put the 2004 number at 972 (for all officially identified trafficking victims, not just sex trafficking victims). Obviously a list of ‘officially identified’ victims is unreliable – for instance, surely everyone knows these lists massively under-represent the number of men trafficked into agricultural work. But I feel like at least that list has an available methodology, which you could for instance replicate to see if you would get a similar number, or critique or challenge (as I would). How do you assess the validity of the process which produced an unreferenced 32,800, that appears to have come from nowhere?

It’s probably worth noting that I’m not invested in “defending” Germany’s record on ‘sex trafficking’ (scare-quoted because I think a lot of what is referred to in that phrase is more complicated that is generally allowed). I’ve focused in a bit on Germany because the study does. I don’t support Germany’s legal model in terms of sex work, and nor do any sex worker-led organisations in Ireland or the UK that I’m aware of; sex workers are perfectly capable of articulating why and how laws like those in Germany harm us, and disproportionately harm the more marginalised of us. I just feel like having references that go somewhere is quite a low bar in terms of the social sciences – especially when you’re citing very large numbers that apparently don’t appear anywhere else! – and I’m pretty surprised that the Cho/Dreher/Neumayer study seems not to clear that bar.

I also noticed that the study’s info on sex work laws around the world (167 countries! such big study wow!) is from, uh, 1995. (See p46.) The authors of the study are aware of some potential problems with this, noting: “for some countries, prostitution law changed during the 1996-2003 period: … Germany (2002), Denmark (1999) … Netherlands (2000), New Zealand (2003), and Sweden (1999). Our results are robust to the exclusion of these countries” [emphasis mine; some countries removed because if you want to see the full list you can follow up my reference] (p37). Norway implemented the sex purchase law in 2009; Iceland in 2007. In short, the effects of the ‘Nordic model’ are not actually included in the data of this study, and nor is the effect of the New Zealand model. “Our results are robust to the exclusion of these countries”. This might arguably make the study a not-totally-solid citation for you, if you’re looking to argue that the Swedish model is great and the New Zealand model is 💩. Here’s maybe the most interesting surprise. Cho, Dreher and Neumayer include a handy list of all the countries they’ve “looked at” (scare-quotes because hmmm), sorted into categories according to whether those countries have “very high”, “high”, “medium”, “low” or “very low” trafficking ‘inflows’. (See p44.) Sweden is listed in the “medium” category, along with … New Zealand.

Now, I don’t think that’s actually meaningful! Because I think that the data used to produce the conclusions of this study was 🌸 garbage 🌸. In general I think you get information that’s meaningful about sex work, trafficking, migration and exploitation by asking migrants who sell sex about their experiences and their policy suggestions. This study is a good example of that. But if you do think the conclusions of the study are meaningful – for example, if you’ve cited this paper as part of your argument in favour of laws like Sweden’s – then it should probably concern you that a study-you-apparently-consider-reliable ‘reveals’ Sweden is actually no ‘better’ at tackling trafficking than New Zealand. Whoops!

I know “the point” of this study is that it’s not “just about” individual countries; it’s trying to see patterns on a macro scale. But – that’s kind of a design problem with the study? In order to have relevance to policy debates, you have to organise your data in a way that is coherent with the terms of the debate – or at least, not egregiously incoherent. The global sex worker rights movement isn’t arguing for the (massively varied!) laws that this paper puts in the pile it calls “legalisation”; we’re not campaigning for “oh, laws that look something like the ones they have in Nevada, or Amsterdam, or Germany, or New Zealand; the details don’t matter, we don’t really mind”. We do mind! We’re trying to work towards (and improve on) the sex work laws they have in New Zealand. Sorry if this idea is complicated, but: aggregate data from Germany, Denmark, New Zealand and the Netherlands doesn’t make sense if no one is arguing in favour of the legal system in Germany, Denmark or the Netherlands, and when people who are pro-criminalisation refuse to understand this, they don’t derail us so much as make it obvious that they don’t care about the detail of the laws because they won’t be affected by them. Which isn’t that great an advocacy look, tbh. My focus on comparing New Zealand to Sweden in this study’s (broken and out-of-date) data isn’t because I’m scared of what will be ‘revealed’ by the aggregated global data (except in the sense that I’m finding this study scarily incompetent); but because I think it makes sense to talk about legal systems in a way that’s precise enough to be coherent.

Plenty of people have cited the Cho/Dreher/Neumayer paper as if it closes the argument, or as if it has some kind of weight or meaning. People who have been using it (presumably without reading it) probably need to decide whether the study – once read beyond the abstract – shows that New Zealand and Sweden have pretty much the same outcomes in terms of ‘sex trafficking’, or whether it’s actually so unreliable and badly put together as to be functionally useless (ding ding ding). While they decide which angle to take, I’m gonna write to the journal that published this paper and raise a few concerns.

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Posted in Dodgy stats, Sex work and tagged , . Bookmark the permalink.

Sexism in Medicine: Try not to talk about it

Posted on April 7, 2015 by Dr. Madeleine Thomas

*Dr. Madeleine Thomas is the pen name of a GP working in Ireland.

When asked to write a piece in reaction to comments made recently by Dr. Gabrielle McMullins, an Australian Vascular Surgeon on the topic of sexism in Medicine, which attracted much controversy, I must admit I had to stop and think carefully before agreeing to do so. I am an Irish, Irish educated female doctor. I graduated from Med School nearly 7 years ago. I have never before written about my experiences working as a female medic, I simply vent to poor unfortunate friends & family instead.

To recap, Dr. McMullins, who Irish media pointedly referred to as having studied in Trinity College Dublin, for reasons I’m not sure why, (was it there that her view of gender in the workplace was meant to have been corrupted?) was attending the launch of her book entitled ‘Pathways to Gender Equality: The role of Merit & Quotas’ when she made comments that referenced the case of Dr. Caroline Tan, an Australian surgical trainee who, after successfully winning a sexual harassment case against her boss at the time, Dr. Chris Xenos, subsequently failed to secure work in her chosen area of speciality in any Australian public hospital. Dr. Tan herself, in an interview made to an Australian paper, in light of the furore surrounding the comments made by Dr. McMullins, reported that she had been shunned by her fellow colleagues following the case and had been overlooked for positions, she feels as a direct consequence of speaking out. Her previous boss, Dr. Xenos continues to work in the hospital where Dr. Tan was sexually harassed.

But what did Dr. McMullins actually say? Ok, admittedly it doesn’t sound good on first reading: “What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request.” I confess, I initially read this quote as presented, almost entirely out of context and was shocked. But is that what she really was trying to say? She went on to further clarify her comments after the headlines had been grabbed and condemnation had come from everywhere. “Of course I don’t condone any form of sexual harassment, and the advice that I gave to potential surgical trainees was irony, but unfortunately that is the truth at the moment, that women do not get supported if they make a complaint. It’s not dealt with properly: women still feel that their careers are compromised if they complain, just like rape victims are victimised if they complain.”

The reactions of condemnation from Australian Medical Training Bodies to her comments were swift and predictable. Michael Grigg, President of the Royal Australasian College of Surgeons (RACS), said the idea female surgical trainees should “silently endure sexual harassment (was) disappointing and quite appalling”. He said complaints about sexual harassment were taken seriously by the college and “investigated and acted upon at the highest level”. Kate Drummond, chair of the RACS Women in Surgery committee, told ABC that sexual harassment does happen, but she said the idea that speaking out is a career-ending move is incorrect. So was this simply a case of a doctor with a book to sell overstepping the mark and encouraging a culture of silence and submission or was she trying to call out the sexism that she feels still clearly exists within Medicine? It’s all very well to encourage women to be vocal about cases of sexual harassment in the workplace, but if there is no practical, robust response to such complaints, nor adequate support for those who have been victims, how could anybody have any confidence in the systems that are meant to ensure equitable working conditions and career opportunities? Is there a fear that by speaking out, you’ve effectively isolated yourself professionally and irreversibly damaged your career in the process? In other words, can we honestly say that case of Dr. Tan is an isolated event? Sadly, I believe it not to be.

Of course sexism exists in a variety of workplaces, but Dr. McMullins specific reference to sexism as experienced in medicine resonated with me as a female doctor. Have I ever encountered examples of sexist behavior in medicine? Of course I have. Have I personally ever experienced sexual harassment? Straight up, no I have not. Have I made career decisions that have been in some way influenced by expectations of gender? I don’t believe so. Do I know others who have? Certainly. Have others said to me on numerous occasions that my chosen area of speciality training, General Practice, was a good choice for reasons of starting a family, that “it’s less hardcore than surgical training” or “hospitals are tough for women”? Yes, many times.

Where are these attitudes born out of though? There are more women in medicine than ever before, yet still there are few women holding senior medical academic posts and completing training in disciplines such as surgery in proportion to their male colleagues. There is a growing debate, albeit mostly from UK based media sources, about the feminisation of medicine. In an article by Professor J Meirion Thomas, a self described feminist, (probably part of the ‘but I love women! Some of my best friends are women’ club) “Why having so many women doctors is hurting the NHS: A provocative but powerful argument from a leading surgeon”, he argues that because there is now a gender imbalance within the NHS, continuity and delivery of service is being steadily hampered by female doctors having the temerity to choose part time work in order to facilitate selfish lifestyle choices like, raising a family and pursuing post graduate academic careers, among others. He even states that “Women in hospital medicine tend to avoid the more demanding specialities which require greater commitment, have more anti-social working hours, and include responsibility for management.” Of course, he also references the great British taxpayer in his piece, questioning whether they should accept such a flagrant waste of their money in training these female doctors, only for them to go off and have families and not want to spend every waking hour entrenched at the coal face of hospital medicine, the very cheek. As it happens, female doctors often do spend every waking hour working in hospitals, it’s called being ‘on call’. We even work weekends, just like our fully dedicated male colleagues.

The reality is that his is not a singular opinion. The face of the Medical Workforce in Ireland is changing, just like in the UK. In a report by the Medical Council of Ireland, the proportion of female doctors registered on the Medical Register has risen from 37% in 2008 to just over 40% in 2012. Interestingly, amongst graduates from Irish medical schools, there is a higher proportion of female versus male graduates in all age groups up to the age of 45. There is no doubt that this will present challenges for workforce planning in the future, but is it necessarily a bad thing that the status quo, which in some cases has previously taken the form of a boys club arrangement, will stand to be changed?

Is there really a boys club mentality still in existence? Surely not, it’s 2015 and female doctors, as Professor Thomas has indicated are basically ruling the roost, right? Well, not quite; In terms of where women fit into the medical workplace, there are still huge barriers to female doctors working in the specialities they have chosen. Undeniably the training path of a surgical trainee, for example can at times be arduous and punishing, with demanding workloads, 36 hour shifts on a regular basis and the pressure to maintain academic pursuits. Many, if not most trainees will be expected to complete Masters degrees and PhDs in order to be considered for Consultancy posts. The notion of achieving any form of work/life balance after all this can, for the most part be just that, a notion. But hey, this is the life we signed up for and sympathy is hard won at any rate. What really stings, is when it can transpire that at times, you’re just not really on the same playing field as everybody else when it comes to long term career prospects. Not only did you not get to tog out to go on the pitch, but you’re not even going to be invited for the post match drinks.

Of course Ireland is a small country, the Irish medical community is even smaller and job interviews can sometimes take the form of a casual word of mouth process. It is for this reason that I fear doctors of both genders can often be reticent to call out mistreatment or inappropriate behavior by a colleague or superior. People need solid references in order to progress unhindered in their careers and when you have people striving to gain a position that they have spent anything up to a decade or more of their lives working and studying to achieve, when they have families to support or student loans to pay off, the stakes are undeniably high. Nobody wishes to become the difficult member of the team, to be spoken about in hushed terms, to not be considered for a post because of their attitude and thus often behavior that on paper would be considered to be reprehensible often goes unchecked. I think this is really what Dr. McMullins was trying to highlight, although I feel she, as a Senior Medic would have preferred to have conveyed her argument more constructively.

As a GP trainee, I have overall had incredibly supportive male colleagues and mentors, but nearing the end of my training I am faced with the prospect of interviewing for GP jobs for which I may not be considered as equal as some of my male peers. Irish GP practices are primarily run as Small or Medium Enterprises, or in other words, as businesses. A female GP is more likely to work on a part time basis than a male colleague for reasons such as maternity leave and family commitments. I’m not saying my male colleagues are any less dedicated to raising their children, but the creche or child minder probably has Mam on speed dial and as for the maternity leave, well, I know I’m the doctor here, but you don’t need me to explain that to you right? GP practices can often have to arrange expensive locum doctor cover to replace any doctor that is on leave and this can affect the running of the business and concurrently the income generated. Whilst you could never question a job candidate openly about her family life for fear of being hauled in front of an employment tribunal, there’s no law preventing you from thinking that it may. As a Practice Manager once told me, it would be easier just to hire the male candidate.

A female colleague I met at a conference told me how she had recently discovered that a male doctor who started work at her practice at roughly the same time as her, was at the start of his employment, offered a three year contract with the prospect of partnership in the business. She, who was equally qualified, was offered just a one year contract. Whilst women’s presence in medicine is stronger than ever before, the glass ceiling for women, just like in other careers, definitively exists. With still relatively few women in senior positions, especially in leading academic roles in universities and colleges, is there any hope of meaningfully challenging gender bias and the status quo? Will we, in years time be reminiscing over Dr. McMullins comments and denying that there was any basis to what she was saying, or will we have acknowledged that an open discussion about issues such as sexual harassment, discrimination against female doctors, and the career paths open to women in Medicine needed to be had? Being a doctor is tough enough, but try not to be difficult about it, ok?

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