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Background Sexual harassment has become a national concern and one that is increasingly recognized in the field of medicine. Although there are reports of the sexual harassment of medical trainees, there is little information on the prevalence of this problem and whether it is adequately addressed by training institutions.
Methods Surveys with descriptions and examples of sexual harassment were mailed to 133 internal medicine residents in a university training program. The residents were asked to report anonymously whether they had encountered sexual harassment during medical school or residency, the frequency and type of harassment, its effect on them, whether they chose to report it to a person in authority, and the factors that influenced this decision.
Results Surveys were returned by 82 residents (response rate, 62 percent) -- 33 women and 49 men. Twenty-four women (73 percent) and 11 men (22 percent) reported that they had been sexually harassed at least once during their training. The women were more likely than the men to have been physically harassed, and the women's harassers were of higher professional status. Among those harassed, 19 of the women (79 percent) and 5 of the men (45 percent) thought that the experience created a hostile environment or interfered with their performance at work, but only 2 women and no men reported their experiences to an authority. The women cited a lack of confidence that they would be helped as the main reason for not reporting the experience, whereas men most commonly said that they had dealt with the problem without the need for outside assistance.
Conclusions Many medical trainees encounter what they believe to be sexual harassment during medical school or residency, and this often creates a hostile learning and work environment. Training institutions need to address the adverse effects this may have on medical education and patient care.
No comparative studies are available, but a number of factors suggest that medical students and residents are trained in a setting that may predispose them to sexual harassment. The many years of training required to become a physician mean that the stakes are high if trainees choose to challenge a supervisor's behavior. The quality of trainees' educational experience and many aspects of their day-to-day life are controlled by their supervising residents and attending physicians -- a fact that may further discourage a trainee from confronting a harasser. Students and residents often move to a new work environment each month and encounter many supervisors and peers in settings where they are unfamiliar with the resources available to them should they be harassed. The team structure characteristic of inpatient medical care requires trainees to spend long hours in small groups doing difficult, emotionally taxing work; this may contribute to the breakdown of social barriers that would otherwise preclude unwelcome sexual overtures3,4. The nature of physicians' work is often sexually charged, requiring the physical examination of naked bodies and discussions of contraception, marital infidelity, sexual abuse, and similar topics rarely discussed in other professional settings. Finally, many young trainees are women, whereas the majority of supervising physicians are men5,6,7.
Several recent studies in the medical literature have addressed medical trainees' experience of sexual harassment. A large percentage of medical students (36 to 52 percent) report experiencing some form of sexual harassment during medical school,8,9,10 with reports by women students being much more frequent than those by men8,9,10,11. A study of female physicians that included some residents reported that 27 percent had been sexually harassed in the preceding year12. Among both students and residents, such harassment creates a high level of stress10,11,12,13. However, none of these studies have examined the frequency and type of sexual harassment residents experience, the professional status of the harassers, the range of negative effects, or the likelihood that the harassment will be reported.
To address these questions, we asked residents in internal medicine about their experience of sexual harassment during medical school and residency. We undertook the study to help design a program to address this problem.
Methods
This study involved a cross-sectional written survey of medical residents. The study population included 139 interns and residents enrolled in the residency program in internal medicine at the University of California, San Francisco, in 1992; 6 residents were excluded because they had recently transferred into the program. The survey was mailed to the 133 eligible residents. Approximately 75 percent of the residents had been trained at medical schools at other universities. Although the survey was anonymous, those who responded were asked to return a postcard showing their name so that surveys not returned could be followed up.
Residents were asked their sex and year of training, but no other demographic data were requested out of concern that such data would make it possible to identify individual respondents. To help the respondents recall and categorize episodes of sexual harassment, they were given a list of types and examples of behavior that might be perceived as sexual harassment (Table 1). They were asked to report whether and how often they thought they had been sexually harassed during medical school or residency, the types of behavior they had encountered, the sex and status of the harasser, and their response.
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Results
Of 133 residents, 82 (62 percent) responded to the survey, including 33 eligible women (72 percent) and 49 eligible men (56 percent). Overall, 35 respondents (43 percent), including 24 women and 11 men, reported a total of 83 episodes of sexual harassment. Forty-one episodes occurred during medical school, and 42 during residency.
Harassment of Women
Nearly three quarters of the female residents (24 of 33) said that they had been sexually harassed, more than once in many cases (Table 2). Of the 56 episodes the women reported, more occurred during medical school than during residency. All but one of the women reporting harassment said that the harasser had been a man (Table 3). Most of the harassers were attending physicians or other physicians. The women reported nearly three times as many instances of nonphysical harassment as of physical harassment (Table 4). Among the 24 women, 3 reported that sexual harassment had interfered with their ability to work, 16 said that it created an intimidating, hostile, or offensive environment, 2 reported that it made them uncomfortable, and 3 indicated that there were no negative effects.
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Harassment of Men
About 1 man in 5 (11 of 49) reported having been harassed. Unlike the women, the men noted more such episodes during residency than during medical school (Table 2); about half the harassers were other men (Table 3). Most of the harassers in the men's reports were nurses, and none were attending physicians. The harassment was exclusively nonphysical, except for one report of unwanted physical advances (Table 4). Among the 11 men who reported harassment, 1 man said it interfered with his ability to work, 4 said it created an intimidating, hostile, or offensive environment, and 6 said there were no negative effects.
Responses to Harassment
Five women and two men reported that they had confronted their harassers directly; except for one woman, they all said this action had stopped the harassment. Only two respondents, both women, indicated that they had reported the harassment to someone in authority; both reported that their complaint had been resolved satisfactorily. A larger percentage of men than of women (42 percent vs. 16 percent) said that they had not discussed the harassment with personal friends or colleagues.
One of the most common reasons the women gave for not reporting harassment was that they were not confident they would be helped (18 women, or 77 percent), whereas the most common reason given by the men was that they had dealt with the problem without needing outside help (9 men, or 82 percent). A female second-year resident who reported having received unwanted physical advances and explicit sexual propositions during medical school commented, "I never reported sexual harassment because I felt that it would never help me in any way to do so." The women were much more likely than the men to report a fear of retaliation (14 women vs. 1 man, or 64 percent vs. 9 percent) or a feeling of shame or guilt (6 women vs. 0 men, or 27 percent vs. 0 percent) as an important reason for not reporting harassment. A female intern noted, "As a woman looking to avoid delicate situations or more harassment, I may not avail myself of the resources men have in their colleagues and mentors."
Discussion
We found that 73 percent of the female residents (24 of 33) considered that they had been sexually harassed during their training. To interpret this finding, we need to consider the limitations of the study, the definition of sexual harassment, and the difficulties that arise in the effort to apply this term in practice.
The small sample limits our ability to generalize from the study's findings, as does the fact that it was conducted at a single institution. However, the fact that residents reported experiences occurring at medical schools throughout the country suggests that this problem is not confined to a single institution. Second, although our response rate of 62 percent was similar to those of most other studies addressing these issues, it is possible that those who responded were more likely to have experienced sexual harassment than those who did not. Even if none of the women who did not respond to the survey had been harassed, however, harassment would still have been reported by more than half of all female house staff in the study population. It is possible that the respondents' recall of episodes may have been facilitated by the publicity given to sexual harassment in the year before the study and by the list of types of behavior that we provided in the survey. Finally, in this study we chose to focus on the perspective of the person who experiences the harassment, rather than that of the alleged harasser. This is in accord with the newly established legal emphasis on the victim's perspective in defining sexual harassment, but it captures only one aspect of a complex picture.
The Legal Approach
The law on sexual harassment is still evolving14. There are two legally recognized forms of sexual harassment15,16. The first type is quid pro quo harassment, which occurs when a sexual relationship with an employer is made an explicit condition of obtaining or retaining employment or benefits of employment; we designated this sexual bribery. The second type is behavior that creates a hostile, intimidating, or offensive work environment for the employee. In our survey, unwelcome verbal advances or offensive body language were examples of such behavior.
Traditionally, determining that sexual harassment has occurred has involved a consideration of "the record as a whole and . . . the totality of the circumstances"15. In 1991, an appellate-court ruling held that sexual harassment must be judged from the perspective of a "reasonable woman" (when the victim is a woman), since "conduct that many men consider unobjectionable may offend many women"17. This emphasis on the victim's perspective, particularly that of a female victim, represents a dramatic departure from the prevailing standard; it is not yet clear whether this approach will be upheld by other courts.
Whose Perspective Is the Right One?
The practical application of the definition of sexual harassment is difficult. By its nature, sexual harassment is an interaction between two people. The perceptions of the person being harassed are often quite different from those of the person accused of doing the harassing, and it is not immediately obvious which perspective is the appropriate one for determining whether sexual harassment has occurred. The differences in perceptions may derive in part from generational and sex differences6,7,18. For instance, if a male resident tells a female student in front of the medical team that he likes it when she wears skirts because she has great legs, she may feel angry and humiliated, even though he genuinely intended his remark as a compliment.
If the intentions of the alleged harasser are used to determine whether harassment has occurred, many episodes will be found not to constitute harassment at all, but even behavior free of malice may leave a trainee feeling demeaned and intimidated. On the other hand, if the perspective of the person who feels harassed is used to determine whether harassment has occurred, then the potential harasser may not be able to know how his or her behavior will be judged until after it has occurred. One student may feel flattered by frequent compliments on her dress and hair, whereas another may feel demeaned. Different perspectives may be important for different purposes; the alleged harasser's intentions should be considered in examining the merits of a particular complaint, whereas the perspective of the harassed trainee is central in attempts to improve a hostile environment.
Difficulty of Establishing Explicit Criteria
Rather than rely on the different perspectives of the parties involved, we could consider defining sexual harassment according to explicit criteria. For instance, we might agree that episodes of physical contact are more likely to qualify than other episodes. Yet it is easy to imagine exchanges that do not involve physical contact but are clearly intimidating or offensive to the student, such as the Deep Throat example described earlier. Certain types of physical behavior, such as hugging or putting an arm around a colleague, may be viewed as sexual harassment in one professional context but be entirely appropriate and inoffensive in another. In our study, the descriptions of the types of behavior that respondents were asked about were likewise qualified; for example, instead of asking whether respondents had ever received verbal sexual advances at work, we asked whether they had ever received unwelcome verbal sexual advances in the workplace. Mutually enjoyable flirtation is not the same thing as sexual harassment. The circumstances surrounding the event are crucial in determining whether sexual harassment has occurred19.
The Role of Power
Another approach to sexual harassment is to think of it as an abuse of power in the workplace. Although it is possible for a trainee to harass a supervisor sexually, it is much more likely that the person with more power will harass the person with less. The behavior of people in powerful positions may be perceived as being more threatening than the same behavior by a trainee20. A medical student who repeatedly asks an intern for a date may seem annoying, whereas a department chairman who pressures the same intern may be viewed as a threat. In our study, men tended to have less negative reactions to sexually harassing behavior. Since men traditionally have more professional power, they may be less likely than women to see such behavior as harassment or to feel threatened by it. When they are in less powerful roles, however, they may also be subject to sexual harassment, whether from women or other men.
Defining the Problem in Medicine
We are just beginning to address the problem of sexual harassment in medicine21,22,23. Although the legal guidelines clearly bear on this issue, we need to make our own decisions about the sort of behavior that is desirable in the medical field, instead of simply worrying about which behavior will expose us to liability.
We need to be prepared to respond to formal complaints of sexual harassment, but we may be more effective if we concentrate on improving the training environment. It would be difficult to address the overall problem adequately merely by investigating and assigning blame for each episode. Relying on litigation is likely to create defensiveness and further resentment instead of improving the training environment, and it may result in retaliation or a backlash that excludes women from professional socializing24,25. As our study illustrates, sexual harassment is too pervasive and too rarely reported for legal action to be a viable approach. Preventing harassment is likely to be more effective than trying to erase its effect after the fact.
A hostile training environment can have serious consequences for medicine. Trainees who feel harassed may be distracted from their education, and patient care may suffer; they may feel alienated by the educational process and decide against further training; in extreme cases, they may even be influenced to leave the field11. Physicians whose trainees feel intimidated or offended may inadvertently affect their own patients the same way, creating barriers to communication and good medical care26.
How can we address the problem of sexual harassment in our own institutions and training programs? A number of authors have described specific interventions25,27,28,29,30. The main goal of any program dealing with sexual harassment should be prevention15. Ideally, a single coordinator should be in charge; this can increase visibility for the program and allow the coordination of education, training, and complaint resolution31. It may be difficult, however, to find a person powerful enough to enforce behavioral standards, willing to take on this responsibility, and readily accessible to trainees.
The most important parts of a prevention program are education and training. Leaders within an institution need to establish a strong policy on sexual harassment and to demonstrate their commitment to establishing a comfortable working environment so that powerful faculty members and attending physicians will be persuaded that this is an important issue25,32. It may be helpful to have a forum to discuss types of behavior that constitute sexual harassment, both to heighten awareness of the issue and to develop community standards. Trainees need to be taught to recognize behavior they should not have to tolerate; they should be taught to give prompt responses about the unwelcome nature of such behavior and to seek help if it persists. Complaints should be kept as confidential as possible, both to protect the privacy of the complainant and to protect the person accused of harassment from being considered "guilty until proved innocent." It may be helpful to compile a periodic report outlining the complaints about sexual harassment that have been received and the nature of the actions taken; such publicity reinforces the importance of the issue and may help prevent further harassment32.
There is potential for abuse in any complaint-resolution process in this area. Because sexual harassment is usually not witnessed and there is rarely any physical proof, judgments about whether it has occurred depend on the credibility of the parties involved and the internal consistency of their accounts. This is a difficult issue, which may be approached by requiring a scrupulously fair and unbiased approach to the investigation of complaints, as well as by providing an appeals process to both parties.
Our study of the experiences of trainees reveals that many students and residents in medicine are trained in environments they perceive as hostile. We need to consider the effect that such environments may have in preventing trainees, especially women, from benefiting fully from their education, achieving their professional goals, and playing an active part in the leadership of our profession.
Supported by the Department of Medicine, University of California, San Francisco.
We are indebted to Cynthia Lynch, J.D., Nicole Lurie, M.D., Molly Cooke, M.D., Amy Levine, the Robert Wood Johnson Clinical Scholars, and the participants in the writing seminar at the Institute for Health Policy Studies for editorial comments; to the residents of the Department of Medicine at the University of California, San Francisco, for completing the surveys; and to Dorothy Drady for administrative support.
Source Information
From the Robert Wood Johnson Clinical Scholars Program (M.K.), and the Division of General Internal Medicine (A.B.B., R.J.H.) and the Department of Medicine (M.A.S.), San Francisco General Hospital -- all at the University of California, San Francisco.
Address reprint requests to Dr. Komaromy at the University of California, San Francisco, Suite C-126, 521 Parnassus Ave., San Francisco, CA 94143-0903.
References
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Related Letters:
Sexual Harassment in Medical Training
Farley M. M., Kozarsky P., Jensvold M. F., Mackey B., Young-Horvath V., Donaldson D. H., Frankel S. S., Laverson S., Komaromy M., Bindman A. B., Haber R. J., Sande M. A., Conley F. K.
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Full Text
N Engl J Med 1993;
329:661-663, Aug 26, 1993.
Correspondence
This article has been cited by other articles:
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