By Dr. Esther Choo and Dr. Reshma Jagsi, director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan

In January, Evelyn Yang, the wife of Democratic presidential candidate Andrew Yang, spoke out about experiencing sexual assault at the hands of New York obstetrician Robert Hadden during her pregnancy. (Hadden has denied Yang's charge but eventually pleaded guilty to a single criminal sexual act in the third degree and one misdemeanor count of forcible touching in a separate case; he no longer practices medicine.) Hadden and the hospital system where he worked is now being sued by Yang and multiple other women for alleged assaults including ungloved vaginal touching, penetration and licking his patients.

How could a health system expose itself and its patients to extraordinary risk by failing to take definitive action against a physician who had been accused of such egregious abuses?

Disturbingly, Hadden was permitted to continue practicing even as complaints accumulated and was allowed to see patients again after an initial arrest. How could this happen — how could a health system expose itself and its patients to extraordinary risk by failing to take definitive action against a physician who had been accused of such egregious abuses?

In fact, the health care system generally offers plenty of blind spots for potential abusers; its traditional structures overlap with the impulse of most organizations to preserve their public reputation. In the case of sexual assault, these factors relegate patient and employee safety to a secondary consideration.

Without major changes, such abuses will continue unabated.

The “traditional structure” of health care includes steep, vertical hierarchies — those who serve in more junior roles generally report to a single person who functions as a gatekeeper to ongoing employment and advancement. This power dynamic is one in which assault, abuse, harassment and coercion can flourish, sheltered from complaints or disciplinary action. In the Yang case, there is evidence of this: Clinic workers allegedly knew or at least had heard rumors of Hadden’s behavior and did not speak up, a strong signal of a punitive environment where individuals were not free to intervene.

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Written policies and passive, standardized (and typically ineffective) trainings may meet legal requirements but fail to address the root causes of these “never events” — incidents that cannot be tolerated, even if infrequent. The “never event” is a concept from the broader field of patient safety and is used to describe mistakes that should never occur, such as surgery on the wrong body part. Health care institutions, however, have not tended to consider the assault of patients one the same level as unintentional medical errors when developing approaches to ensure patient safety.

Although unintentional behaviors are far more common than egregious predatory acts like those that Yang describes, the same types of interventions need to be created and protected in both cases. Indeed, such interventions are needed to ensure that fear of sexual assault does not add to the already too-long list of barriers to high quality care for women.

The Joint Commission, a major accrediting body for health care facilities, has recommendations for the prevention of violent events, including sexual assaults, in such facilities. The ethics committee of the American College of Obstetricians and Gynecologists recently updated its own guidelines for preventing sexual misconduct. For example, the committee now recommends the routine use of chaperones during patient examinations of the breasts or genitals.

However, it is difficult to know if such guidelines are being used. The adoption and implementation of such rules are not tracked and incentivized. There is little common knowledge about what an adequate institutional response to incidents of assault or harassment even looks like; thus, health care organizations have little benchmarking or pressure to meet thresholds of quality or safety in this area.

Even for those with the desire and the courage to report, reporting pathways for sexual assault are notoriously obscure, complex and inconsistent from institution to institution. Sometimes the human resources department, sometimes Title VII, sometimes Title IX, sometimes a hospital ombudsperson, sometimes the hospital chief of staff, sometimes an anonymous online form — the point of contact depends on who the assault or harassment happened to (patient, hospital staff, student) or who suffered the assault/harassment. And when these systems are not well coordinated, as is the case at many institutions, a serial aggressor has a greater chance of slipping through the cracks.

As in other organizations, reports go to those employed by the hospital or health care system and invested in its welfare, creating a conflict of interest from the outset that favors the person who committed the assault. Further, it is often difficult for those reporting to know ahead of time what to expect after placing the report — what the processes will be like, the timeline, the supports and protections in place for those who report — uncertainties that add further to the anxiety of reporting.

Compounding the challenges to effective responses to assault is the silencing of incidents. Once an investigation is underway, those who reported the assault are typically prohibited from speaking about the incidents. At the same time, any complaint triggers social and professional retaliation, in which those reporting the assault are shamed and subject to criticism (“a liar,” “a mental case,” or “an opportunist”) and those who are reported are defended (“he’s the target of a hit job” “I’ve known him for 20 years and can’t imagine him doing any of those things”).

The pattern of eroding the legitimacy of those who experience the assault and protecting the assaulter is so well recognized it has its own name: DARVO (deny, attack, reverse victim-offender). Overall, the emerging narrative invariably casts doubt on the reliability of the storyteller.

Settlement and separation payouts, too, are conditioned on nondisclosure agreements. Those who experience sexual assault ultimately quietly slip away — disempowered so that their voices cannot effectively impugn the reputation of the institution, and sometimes blocked from advancement or further employment. Meanwhile, those who commit the assaults slip away as well, but having blocked any public disclosure of the details of their offenses, institutions are able to provide a “warm handoff” to other employers to allow them to continue to thrive. The process is so common as to have its own name in the business: “passing the trash.”

Sexual assault in health care is, thankfully, rare. However, cases like Hadden’s remain and flourish for too long — they are echoed in cases like those of Larry Nassar, David Newman, George Tyndall and too many others. We should have health systems designed with multiple safeguards in place so that sexual assault does not occur to begin with; like deaths due to medical errors, we need high reliability systems with zero tolerance for assaults against patients. Yet, until we have eliminated assault, we also need sensitive reporting systems; training to empower bystanders; swift, standardized, safe, thorough and transparent processes for addressing incidents once brought to light; and public accountability for excellence in this area. Those who experience assault and bystanders who report it should not experience shame or retaliation.

Yang’s courage opens the door for a discussion of how the health care system can allow sexual assault to occur. For women to access the health care they need and deserve, we must turn patient sexual assault into the “never event” it should already be.