The Fear

I remember meeting with the head of the of the LIHPC, the internal organization responsible for the mental well being of residents. He told me “residency is like a marriage.” At the time I had not pieced together how residency training was anything like a marriage. It would not be until years later when I read about women’s history, that it was clear what he was referring to.

Historically marriage is the legal institutional entity that oppresses women and subjects them to no rights to even their bodies. It is has only been just recently that the laws around marriage have been changed to protect women more in their marriages. The first so called domestic violence law in the US said that husbands could not beat their wives on Sundays. It would not be until 1920 that all states in the US would make wife beating illegal, and not until the 1970s that states would start considering it as a crime and not until 1984 that the Federal Attorney General would recommend arrest of the abuser as part of standard police practice. It had not been until 1993 that all 50 states had removed their marital rape exemptions. Basically rape within marriage was legal until 200 years after the The United States Constitution was enforced in 1789. The US Constitution provides the language of the legal frame work by which our Federal Laws are created.

What is important to note is that our US Constitution’s language does not equally protect womens’ civil rights. The Equal Rights Amendment which was first brought to Congress in 1923 has still to this day, not been incorporated into our constitution. The purpose of ERA was to give men and women equal legal rights by the U.S. court system. The Constitution only explicitly states women’s right to vote. ERA’s language when it was finally proposed by Congress in 1972 (50 years later) is “Equality of rights under the law shall not be denied or abridged by the United States or by any State on account of sex.” Congress gave the states 10 years to approve the amendment, so the deadline to pass ERA was back in 1982.

ERA failed to get incorporated into the constitution in the 1980s due to a female lawmaker Phyllis Schlafy Esq., who used the military draft, war, the position that women were already being treated equally, and that working women with job skills would threaten the economic security of house wives with no job skills. Firstly, the military draft is not a civil right, nor is it even constitutional according to the 13th Amendment which states that “neither slavery nor involuntary servitude shall exist in the United States, except as a punishment.” Finally, why is the economic security of women who either decide to or who have been coerced to accept the gender role to delegate their economic security to men being prioritized over women who want independent economic agency? The only time men really need to take over becoming a breadwinner in a marriage is when a woman is experiencing the demanding biological challenges of pregnancy, motherhood and the attachment mechanisms of a young child. Schlafy’s position made it more difficult for women to leave marriages to become economically independent by giving economic priority not to wives but to their husbands over single working women. She was an enabler of domestic violence by making it more difficult for women to be able to leave abusive men and making young uneducated women without economic agency more vulnerable to being married off to abusers to obtain economic security. All of this trade of women being tied to and creating future economic poverty.

One could argue that Schlafy’s position was based on how far women had gotten integrated into the work force by the early 1980s.  However even in January 2019, ERA was blocked from being incorporated into our Constitution by the state of Virginia’s lawmakers and since 1982, 5 states have since rescinded their ratification of ERA. This is just one of several examples in U.S. history which suggest that there is something far more deeply subconsciously ingrained in humanity’s view of women and women’s place in the world with regards to their civil rights and value as a human beings outside a wife and mother.

https://www.equalrightsamendment.org/faq

Attorney Barry Goldstein dedicated his entire 30 year legal career to protecting Domestic Violence and Child Abuse victims and is a member of NOMAS (National Organization for Men Against Sexism). He is a teacher, author and leader in the movement to stop Domestic Abuse. In his interview, he states “for thousands of years we [human societies] have tolerated behavior [from men] that we would now call domestic violence and child abuse.” What he was referring to is typically termed “human rights violations.” But labeling them human rights violations takes away the specificity of what type of humans are disproportionately affected and they are women and children. Human rights violations are in fact the same behaviors and power dynamics within domestic violence but at a global level. More adult men will experience human rights violations when there is some form of war (either social or military), in which competing social groups, whose cultures are defined by men, will try to destroy each other to get access to natural or economic resources. But even when there is no war between different societies, there is always present, domestic violence which is basically a psycho-social war of devaluing women.

http://nomas.org/

https://www.barrygoldstein.net/

https://wappp.hks.harvard.edu/human-rights

This global historical context of domestic violence is very much relevant in the discussion of how to improve the experience of women physician trainees during their medical training and beyond especially in male dominated specialties. Male residents could argue that they experienced much worse than their female colleagues because they were physically assaulted or yelled at or screamed at publicly experiencing humiliation and that the human rights violation within medical training are equally experienced by both sexes. They could argue that at least female residents could trade sexual relationships with attendings for work protection or props, gaining the upper hand. This is most likely a form of projection because many men would have sex with their female attendings or chiefs to get protection and gain an edge so they do not think it’s fair women get that “advantage”. The reason they subconsciously make that assumption is because they do not experience the day to day fear that women have throughout their lives and especially the fear women experience around men. Men do not know what it is like to not be seen as equal human beings and when they do experience violation of their personal boundaries, they are the first to reassert them because it has been socialized in them to set those boundaries. Women are socialized to have their personal boundaries be porous because they are socialized to be victims of abuse. It is not the type of abuse itself that causes the trauma but the intensity and duration of fear that does. Fear is a killer.

The Adverse Childhood Experiences studies started by Dr. Vincent Felliti at Kaiser, pursued by the CDC, and advocated for by California’s first Surgeon General Dr. Nadine Burke Harris, showed that it was the fear and stress in the anticipation of acts of abuse that was one of the strongest risk factors for the future development of medical disease in adulthood. These adulthood diseases include cancer, autoimmune conditions, ischemic heart disease, diabetes, obesity, chronic pain, COPD, addiction and liver disease. ACE showed that it is the intensity and duration of fear/stress itself experienced by the victim, not necessarily the specific type of abuse in childhood that was the strongest predictor of these diseases in adulthood.

While the ACE studies were specific to trauma in childhood, there are still significant similarities between the power differential of abusers and victims in a domestically violent household and residents when they enter a training program. The huge economic debt, lack of lateral mobility and steep power differential between junior levels, senior residents and attending physicians in residency training place young adults into a situation where they are extremely economically and psychologically vulnerable like wives or children with no job skills and cannot leave the abuser. That psychiatrist was right “residency is like a marriage.” That level of economic vulnerability allows for abuses of power and large amount of fear in victims, especially in women.

Child abuse is a gendered experience in which 20% of girls and 5% of boys in the U.S. reported childhood sexual abuse per the Department of Health and Human Services.  It is also well known that the most common form of domestic violence abuse is not rape or physical assault, but emotional and psychological abuse. Yet our media and legal system give more attention and validity to rape, sexual harassment, and physical assault as markers for true abuse. This is because the sexism of our society expects women to put up with emotional labor and psychological abuse on a day to day basis, which is why ERA should be included in our constitution. The reason is because sexism is more than just about men are good at math and women are good at reading, sexism is the reason why human rights violations exist 70 years after the UN passed human rights laws. Sexism is the subconscious psychological mechanism that allows domestic violence and child abuse to survive and thrive at a global scale and persist in medical training, which is a profession about healing trauma not creating it. Sexism is also extremely costly.

As quoted from his very well researched book “The Quincy Solution. Stop Domestic Violence and Save $500 Billion” : “ [a]s discussed at the start of this book, most DV is neither physical nor illegal.. [v]erbal, emotional, psychological abuse are forms of abuse far more common than physical abuse. They serve to reduce his victim’s self-esteem and punish her for failing to obey.”

In order to create an effective zero tolerance policy for sexual harassment within medical training programs, the conversation needs to go well beyond the simple discussion of the immediate technicalities of what happened. The global history of sexism and how it has allowed domestic violence to thrive at a global level as seen in human rights violations, has to be incorporated into educating away the attitudes of people in the medical profession who have grown up in our sexist societies and which cause sexual harassment to happen in the first place unnoticed.

The term financial abuse is used when describing the control of money within a domestically violent intimate relationship, however this same dynamic occurs at a much larger scale with women working in the US economy. Sexual harassment and women residents having sex with superiors for work props or protection is a symptom of how many women manage the patriarchy. They know they will lose their jobs if they do not cater to these mens’ power trips which men have been conditioned for generations to believe they are entitled to. Women who do not play that game, are not protected and get kicked out, loose their source of income and are therefore forced in some other way to become economically dependent on men as you have to spend time and money to make career changes.

The Saunders Studies showed that unconscious gender bias by the court system and lack of understanding of the dynamics behind domestic violence including women attorneys, allowed male abusers a way out of accountability. The Quincy Model showed that when police force and court system focused on victim safety and abuser accountability, that domestic violence and child abuse rates dramatically dropped. ACE showed that the fear of abuse in children leads to future chronic medical diseases in adulthood costing the US billions of dollars annually.

https://www.sciencedirect.com/science/article/pii/S0145213411003140

https://www.avahealth.org/resources/aces_best_practices/biological-impacts.html

It is time that men stop interpreting their entitlement and social privilege as some vague distant behavioral concept they are oblivious to, but as the cause of fear and stress in women and children that leads to generations of medical disease, economic poverty and enormous economic cost to the tax payer. Men need to step up in their behavior and society needs to hold them to that standard not simply because it will make them “better men” but because the future health and evolution of our society depends on it. It is time that medical education leaders, the majority of whom are men, recognize that unless the bad behavior of men is held accountable for at an institutional level, women are not even going to survive in those institutions, they will leave like they try to leave an abuser in a marriage. If leaders in medical education want women physicians to thrive in the medical profession, then sexism itself must be overtly diagnosed and treated as the social disease it has been for at least the past 3 thousand years. If a zero tolerance policy is to be designed, then the group designing it must not consist only of people in the medical field but also women studies academics, attorneys specializing in domestic violence, and social economists. If a culture of training future female physician leaders is to happen, then the history of domestic violence and how that influences day to day behavior in the workplace today needs to be taught at every single ACGME approved residency program in the United States.

NOMAS was formed 40 years ago and yet today women are still being faced with the same sex based abuses of power at work, as a result, the #metoo movement  happened. Human Rights laws were created in 1948, yet the world’s legal systems have not been able to extinguish child brides, child slavery, the sex trade, and poverty. Those economies, which are psychological extensions of the domestic violence dynamic, are thriving both domestically and internationally. The reason is because the male based economy and the women who have to buy into it, prevent women from being seen at a societal level as being entitled to their civil rights outside of some reproductive advantage for men. Until women are valued as equal human beings, poverty, disease, incest, war, child brides, the sex trade and social dysfunction overall are never going to be minimized; they will be amplified.

https://stopabusecampaign.org/

https://hbr.org/2018/06/whats-holding-women-in-medicine-back-from-leadershi