"In my second year of residency, I was being bullied by a senior female resident. One of my chief residents knew about the bullying and paged me to the call room one day. He told me that he could help keep her under control. He then proceeded to pull his pants down and told me that if I had sex with him he would protect me from her. He pushed himself on me and I basically just made an excuse to leave." — Colorectal surgeon now working in Southern California

"I was a trainee and was told that if I wanted to be a consultant, I had to comply with the physician's wishes." — General physician in the United Kingdom

Sexual harassment has long plagued the healthcare field, as it has the rest of society. And it is hardly an American phenomenon; harassment among physicians and healthcare workers takes place in different cultures and countries.

Two recent Medscape Medical News surveys asked physicians in the United States and the United Kingdom about their experiences with sexual harassment. The Sexual Harassment of Physicians: Report 2018 included more than 6200 physicians and clinicians in the United States. The UK report has results from more than 1300 physicians there.

The two countries have very different healthcare systems, as well as many cultural differences. Not surprisingly, there were similarities and differences in the responses. One powerful point in both surveys is that sexual harassment is alive and well in medicine, and the vast brunt of it is aimed at female physicians. "There is growing appreciation on both sides of the Atlantic that female physicians are often the targets of sexual harassment, not only from coworkers and superiors but also from patients and their families," said Reshma Jagsi, MD, DPhil, professor, deputy chair, and residency program director in the Department of Radiation Oncology at the University of Michigan, Ann Arbor. Jagsi spent time in the UK when she shadowed a medical student and then conducted research there during a sabbatical. "Whether in the form of sexist remarks and crude behaviors — the so-called gender harassment — or in the form of unwanted sexual advances, sexual coercion, or sexual assault, such experiences can be incredibly corrosive to women's physical, mental, and professional well-being," said Jagsi.

Rob Hicks, MD, a general practitioner (GP) and well-known medical commentator and contributor to a wide range of media platforms in the UK, told Medscape Medical News, "Here in the UK, the issue of sexual harassment is increasingly being discussed, and steps are being taken to address the problem, to prevent it from happening, and to support those affected."

A Tale of Two Countries

Overall, 10% of US clinician respondents reported that they had been sexually harassed within the past 3 years. Among physicians specifically, 7% said they had experienced some form of sexual harassment during the period.

In the UK, overall, 3% of doctors said that they had experienced some form of sexual harassment during the past 3 years.

Women were far more likely in both countries to report harassment. The percentages reporting harassment were lower in the UK Medscape report than in the US report. In the United States, a higher percentage of female physicians reported having personally experienced sexual abuse, harassment, or misconduct in the past 3 years compared to men (12% vs 4%). In the UK, 5% of women physicians reported that they had been harassed, compared to 2% of men.

Some have said that the percentages of women harassed seems low, but that may be due to the fact that the survey asked about more recent experiences. "The survey asked people to report their experiences over the past 3 years, so the situation may have changed in the past decade, for example," Hicks speculated. "Also, it might be the case that people are more aware of the consequences of their actions and that they now understand how behaviors that may have been thought of as being acceptable in the past no longer have any place in the workplace, or anywhere else for that matter."

Who Is Doing the Harassing?

Among US physicians, 47% said the perpetrators were other physicians, and 16% reported they were harassed by nurses. A little more than a quarter (28%) reported that they were harassed by primary care physicians, and 72% said that they were harassed by specialists. Emergency medicine (11%) and general surgery (9%) were among the specialties in which there was a higher percentage of perpetrators.

In the UK, more than half of doctors (56%) said harassment came from a colleague in a superior position, 24% from someone in an equal position, and 20% from someone in a subordinate position. In the UK, specialties in which a higher percentage of doctors were harassed by other doctors were anesthesia (12%), general surgery (10%), psychiatry (7%), and plastic/cosmetic surgery (5%). In both countries, sexual harassment from patients creates problems for physicians. US physicians were more often sexually harassed by patients than were UK physicians. In the US, more than a quarter (27%) of doctors reported that they had been sexually harassed by a patient.

In the UK, sexual harassment by patients was less common (17%) than in the US. But it was still higher than misconduct by colleagues (17% vs 3%). "The anecdotal experiences I most frequently hear about from my colleagues are comments from patients about their appearance, things like, 'You have such nice legs, you should wear short skirts more,' and other uncomfortable innuendos," said Jagsi. "I had a patient who kept perseverating on my name, insisting on calling me 'Dr Sexy' instead of 'Dr Jagsi.' Sometimes harassment from patients can also involve unwanted or coercive sexual advances or even assault."

In the US, the most common form of harassment by patients included acting in an overtly sexual manner toward physicians (17%), repeatedly asking the physician to go on a date (9%), and attempting to touch, grope, or grab them (7%). In all three categories, harassment was far more common toward female doctors.

Dermatologists experienced the highest percentage of patient harassment (46%), followed by emergency medicine physicians (43%) and plastic surgery/aesthetic medicine physicians (41%).

UK physicians faced similar types of harassment from patients. Of physicians who had been harassed by patients, the most common behavior was the patient acting in an overtly sexual manner (53%), followed by requesting a date (29%) and attempting to touch, grab, or grope them (24%). In both the US and the UK, female doctors encountered overtly sexual behavior (11%), being asked out on a date (2% vs 8%), and attempts at physical contact far more frequently than men did.

The specialties in which harassment by patients was most likely to occur differed in the UK: general surgery (25%), psychiatry (23%), emergency medicine (23%), and general practice (22%) were the specialties in which harassment was more common.

"It may be that UK patients are now less likely to see it as being inappropriate. In the past, the doctor was perceived as being in a more authoritative or superior position within the doctor-patient relationship," said Hicks.

"However, over recent decades this relationship has become less formal and a more equal relationship, and increasingly, first names are used rather than titles, so perhaps these changes play some part," he added.

Over recent decades, [the doctor-patient] relationship has become less formal and a more equal relationship, and increasingly, first names are used rather than titles, so perhaps these changes play some part. Dr Rob Hicks

Physicians in Both Countries Don't Report the Bad Behavior

A large proportion of misconduct goes unreported. Among US physicians who in the survey said that they had been harassed, only 40% reported the behavior. Among UK physicians, that proportion was even higher: more than half (56%) did not report the incident. Still, more than a third (37%) told the perpetrator to stop, and 20% told the perpetrator how they felt.

Why did physicians remain silent? The UK survey didn't ask the reasons for not reporting the incident. In the US survey, physicians cited fear of being accused of overreacting (49%), belief that no action would be taken (45%), and fear of retaliation from the perpetrator (36%) as the top three reasons for remaining silent. "Speaking up is scary," said Alex Granovsky, JD, who runs an employment law firm with a subspecialty in physician employment, with offices in New York City and Cleveland, Ohio. "I think there are plenty of people who do not report sexual harassment for fear of retaliation."

Failure to report harrassment harms the victim downstream, he emphasized. "The harassment continues, gets worse, and makes the workplace unbearable," he told Medscape Medical News. "The employee's work suffers or is terminated for 'performance' issues."

Is the Sexual Harassment Situation Improving?

Because of media attention and public outrage over sexual harassment, there is less tolerance of these behaviors. Two pivotal reports regarding sexual harassment were recently published, one in the US and one in the UK.

Last June, a sweeping report from the National Academies of Sciences, Engineering, and Medicine found that sexual harassment in academia is significantly more common among engineering and medical students than among those in fields outside of science and technology. The highest rates of harassment were in medicine, with 40% to 50% of medical students reporting harassment by faculty or staff.

The report set off a torrent of publicity and triggered responses from professional and government organizations, including medical organizations. The project, which began in 2015, took on greater urgency as the #MeToo movement drew attention to the pervasiveness of harassment of women, explained the study's director, Frazier Benya, PhD, a program officer with the National Academies' Committee on Women in Science, Engineering, and Medicine, during a webcast of the public release of the report.

"We didn't know the eyes of the nation would be on this study with all that has transpired since," Benya said.

In the UK, the British Medical Association (BMA) undertook an independent investigation in response to allegations of sexual misconduct that were made by senior female doctors. As reported by GP Online, the doctors said that within the association's GP committee (GPC), there was a culture of "institutional sexism," and they reported having to endure "belittling, crude and sexist comments, being frozen out of meetings or ignored and facing sexual harassment."

Zoe Norris, MD, GPC sessional subcommittee chair, told GP Online, "I have never experienced the level of sexism and discrimination in my entire career that I have in the GPC."

In April of this year, the BMA commissioned a fully independent review of the allegations. The report found that for the most part, the allegations were true. According to the author of the report, Daphne Romney, QC (Queen's Counsel, a senior barrister) there is "an 'old boys' club' culture for some that lingers on without proper challenge, which treats women as of less importance and ability."

Romney made 31 recommendations for consideration by the BMA council as part of a BMA-wide governance review. "The board has broadly accepted all of the recommendations," said Helena McKeown, MD, a chief officer at the BMA and representative body chair. She noted that there are some technical glitches and details that need to be ironed out. "We have to get it voted through because we are a trade union, and we have to comply with our articles and bylaws," she told Medscape Medical News. "I hope we can get on with it and all of the recommendations approved, and I will be doing my part to see that they are implemented."

Culture is notoriously difficult to change, McKeown added. "But as one of the chief officers at the BMA, my intention is to try to influence the culture by my own behavior, and I seek to address these issues."

What Is the Status of Action Against Sexual Harassment?

Across US industries, including medicine, there has been an uptick in the filing of harassment complaints. The US Equal Employment Opportunity Commission (EEOC), which investigates complaints of workplace sexual harassment and discrimination, has reported that it received 7500 from October 2017 to September 2018, which is a 12% increase over the prior year. In addition, the EEOC filed 41 harassment lawsuits during the past year, which is a 50% increase from the year before.

In the UK, Employment Tribunal fees, which were introduced in 2013, caused a sudden, sharp decline in the number of claims being issued. These were fees levied on those seeking to bring an employment claim. "Since the abolition of fees in July 2017, there has been a continued rise in the number of tribunal claims," said Danielle Parsons, LPC/LLB, a senior associate in employment law at Slater and Gordon, a London-based law firm. "Individual claims in the period April to June 2019 rose by 14% from the same time last year."

However, Parsons added that as an employment lawyer, she has seen the number of complaints increase, and recent statistics from Unison, the UK's largest health union, suggest that a "shocking 8% of healthcare staff have been sexually harassed in the past year."

In both countries, it appears that there is increasing recognition of the problem, and tolerance for it may be waning. "It's certainly worth trying to understand whether differences in culture, healthcare systems, or other factors might lead to greater frequency of certain behaviors in one country or another," said Jagsi. "We know, for example, from decades of research in organizational psychology that the single strongest predictor of harassment in organizations is a perception that such behavior is tolerated.

"I imagine that if a particular culture or society fosters a sense of acceptability regarding inappropriate behaviors, those behaviors will be more common in that environment," she added. "But the bottom line here is that sexual harassment is far too common everywhere we look. Time really is up."

But the bottom line here is that sexual harassment is far too common everywhere we look. Time really is up. Danielle Parsons, LPC/LLB

Roxanne Nelson, RN, BSN, is a freelance writer based in Bellingham, Washington.

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