Seeing the Unseen: A Theory of Sexual Misconduct Perception in the Surgical Workplace

INTRODUCTION: Sexual misconduct in surgery is recognised as widespread, yet individuals within the same departments report markedly different perceptions of prevalence. Quantitative data show gender differences in experiences, but reasons for this remain unclear. This study explored perceptions of sexual misconduct in the UK surgical workplace and developed a heuristic framework. METHODS: Qualitative analysis was undertaken of free-text responses from 742 participants in a 2022 nationwide UK survey. Respondents included students, trainees and consultants. Inductive, reflexive thematic analysis within a constructionist paradigm was conducted, with iterative coding by two researchers and team discussions to refine themes and develop an explanatory framework. RESULTS: Accounts diverged. Some participants described respectful workplaces with little misconduct, while others reported pervasive harassment, assault and inaction. Using an X-ray metaphor, the "Lateral View X-ray" theory was developed to explain this. The "AP View" reflects unawareness or minimisation, sustained by limited exposure, normalisation as banter, defensiveness, and seniority-related distancing. The "Lateral View" reflects heightened awareness from personal or witnessed experiences, hypervigilance, frustration at inaction, and informal warning networks. Male victims described additional barriers to recognition and disclosure. Drawing on standpoint and epistemic injustice theory, this work demonstrates how social position, power and language shape whether misconduct is recognised or obscured. CONCLUSION: The Lateral View X-ray theory explains how sexual misconduct can be simultaneously pervasive and invisible within surgery. Awareness depends on vantage point, where those least exposed perceive little problem, whereas those affected perceive structural harm. Embedding this framework in surgical education may widen perspective, improve responses and support cultural change.