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    Ending gender harassment in medicine

    Women medical students now outnumber men, yet they still face significant levels of gender harassment, contributing to increased rates of burnout and dissatisfaction. How do we improve the learning environment for our future doctors?

    woman with hand up

    The email seemed innocuous on its face. An administrative assistant at the University of Michigan Medical School sent around a note to schedule a meeting. The note referred to all the male physicians as “Dr. Surname” and the lone female department member by her first name. 

    “Not my title, which is of course equal to theirs, and not my last name — just ‘Reshma,’” says Reshma Jagsi, MD, a professor in the department of radiation oncology at Michigan.

    “And I am the Deputy Chair of the department.”

    Gender harassment — what Jagsi refers to as the “daily series of indignities” — is a type of sexual harassment where members of one gender are targets of unwanted verbal or nonverbal behaviors. In fact, the seminal 2018 National Academy of Sciences, Engineering, and Medicine (NASEM) study, “Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine,” found that half of all women in medical school have experienced some form of sexual harassment, with gender harassment being the most common. Examples include sexist stories and jokes; offensive remarks about someone’s appearance or body; gendered comments, such as suggestions that one sex is not suited to a particular type of work; and mistreatment, slights, or being ignored or patronized.

    While both men and women may be on the receiving end of gender harassment, research suggests that women are victimized more often than men.

    Esther Choo, MD, associate professor of emergency medicine at Oregon Health & Science University, tells a story from her own training years about how an attending physician, in a misguided effort to lighten the mood, required everyone in the operating room to tell a dirty joke. Choo can still recall how uncomfortable and distracted this made her feel.

    Choo’s experience highlights one of the challenges to ending this type of harassment: like the doctor who thought he was “lightening the mood,” men and women often have vastly different perceptions of appropriate and inappropriate behavior. Indeed, a recent study in Academic Medicine found that women recognize inappropriate behavior at far higher rates than men.

    "It’s fairly well-established that there are career impacts from experiencing harassment and measurable physical and mental health sequalae."

    Esther Choo, MD, Oregon Health & Science University

    Another substantial impediment to righting these wrongs? The general reluctance of victims to report offenses. National data estimates that less than 8% of victims report harassmentin large part because they fear retaliation.

    Harassment happens frequently in STEM

    BethAnn McLaughlin, PhD, a neuroscientist and the 2018 co-winner of a Disobedience Award from MIT Media Lab, believes that the frequency of inappropriate behavior is especially toxic to women medical students and other scientists.

    Examples of consistent affronts appear on the website for “MeTooSTEM,” a nonprofit McLaughlin created to help victims of gender harassment. A. Bee reports that a “big name in my field” stares at her breasts and looks her up and down in front of other men and colleagues in social settings. “This humiliating and degrading behavior causes me to feel insecure and as if I am not a worthy scientist … I feel humiliated,” she writes.

    On the same website, Sue reveals that she consistently faced gender discrimination as a PhD student. Her supervisor helped John and James find a postdoc position but told her, “You have a husband to look after you.” Later, as a researcher, she was provided with fewer resources than male colleagues of similar rank “despite bringing in more grant funding.”

    “It’s fairly well-established that there are career impacts from experiencing harassment and measurable physical and mental health sequalae,” Choo notes.

    Gender differences and recognition of harassment

    Though national research and anecdotal evidence affirm the prevalence of gender harassment in academia, abolishing the behavior is complicated by the stark differences in how men and women view certain interactions.

    The Academic Medicine study outlined these gender disparities in detail. Researchers identified 21 common forms of harassment and then created videos depicting the behaviors: sexism; pregnancy and child care related bias; having abilities underestimated; sexually inappropriate comments; being relegated to mundane tasks; and feeling excluded or marginalized. The study authors also made control videos that depicted similar scenarios to those in the treatment video minus the offending behavior.

    The researchers then shared the videos with faculty at four academic medical centers.

    Compared to men, the female faculty members reported much higher frequencies of gender harassment in 33 of 34 videos that showed examples of inappropriate behavior. Generally, men reported such episodes to be uncommon. Meanwhile, no differences were seen in response to control videos among men and women participants.

    Linda Chaudron, MD, co-author of the study, professor, and vice president and senior associate dean for inclusion and culture at the University of Rochester Medical Center, said the research supports the hypothesis that people who experience harassing behaviors more frequently “are more likely to recognize them.”

    Why victims don’t report

    Recognition of harassment may be one stumbling block in the abolishment of gender harassment, but a more substantial hurdle is the difficulty some victims face in speaking up about their experiences.

    Only a small percentage of those who are on the receiving end of harassment make an official complaint — and one study of the issue explains why: many who are harassed believe nothing will be done. McLaughlin says many victims and whistleblowers find themselves twice wronged, first from the behavior itself and then again when the harasser retaliates or an institution fails to support them.

    Nancy Chi Cantalupo, co-author of a recent study that analyzed more than 300 cases of faculty harassment of students, found that the targets of harassment do not report incidents that they assume will not be “winnable” in court.

    "Training is important — to be able to recognize [inappropriate behaviors] when you are not the person experiencing them and understand how they may be impacting others and intervene when appropriate."

    Linda Chaudron, MD, University of Rochester Medical Center

    A 2018 study in Academic Medicine of harassment in medical school suggests that “covert retaliation” — vindictive comments made by the accused about the accuser in confidential settings such as grant reviews, award selection meetings, or search committees — is a frequent response when medical student victims report a faculty offender. The study authors propose two possible solutions: encouraging senior faculty to intervene when they are aware of harassing comments or behavior, and, in cases that involve multiple instances of sexually offensive behavior, banding together to file a joint complaint.

    Training to solve the problem

    Acknowledging that gender harassment occurs is a first step, but it is not enough, Chaudron says. “Training is important — to be able to recognize [inappropriate behaviors] when you are not the person experiencing them and understand how they may be impacting others and intervene when appropriate.”

    The message conveyed to students also needs to change, Choo believes: “How do we treat these problems like they’re not odd unusual one-offs, but really recognize that they’re common and students are likely to encounter them. So instead of saying, ‘if’ inappropriate behavior happens, we should say, ‘These behaviors are common. When they do happen, inevitably, to many of you, here’s what you need to do and here’s how you can be a good ally if you see it happen.’”

    One training program that appears to get it right is WE SMILE (We can Eradicate Student Mistreatment In the Learning Environment), created by the Renaissance School of Medicine at Stony Brook University in 2009. Prior to WE SMILE, Stony Brook ranked below the national average for awareness of university harassment policies, explains Howard Fleit, vice chair for education at Stony Brook. 

    WE SMILE is presented to students at three transitional moments in their medical school careers and consists of video vignettes, interactive seminars, and workshops that explain Stony Brook’s policies and procedures.

    Since implementation of WE SMILE, a study of the program found that student awareness of policies and procedures increased to almost 100%, compared to pre-program levels of 67%. The same study indicates that nearly 80% of students reported never being subject to offensive sexist remarks in 2012, and only four years later, 87% of students reported the same — a 7% improvement.

    Elizabeth Petty, MD, senior associate dean of academic affairs and a professor in the department of pediatrics at the University of Wisconsin School of Medicine and Public Health, says her university launched an awareness campaign in 2016 that required everyone on campus — all faculty, staff, and students — to participate in a sexual harassment course. Independently, the medical school also launched its own campaign outlining “what kind of behavior we expected of our own faculty, students, and staff to help the medical school be respectful and inclusive.” Town halls, seminars, and summits followed to disseminate awareness of policies and procedures for reporting offenses.

    The result? The Wisconsin medical school improved on 14 out of 16 measures of student mistreatment.

    In 2017, nearly 90% of the university’s medical school students said they were never denied opportunities for training or reward based on gender, while two years later, 96.6% said the same. The national average is 93.8%.

    Likewise, in 2017, 55% of students who did not report mistreatment said the reason was because they did not think anything would be done, Petty says. In 2019, only 22% of students who did not report said the same. Nationally, the average for all medical schools in 2019 was 39%.

    Petty says the school also now includes professional criteria as part of faculty appointment letters and faculty reviews. “It makes people understand they are being held accountable,” she says. Furthermore, more than half of the medical school’s department chairs are now held by women. “Having that visibility of women changes the environment in a positive way,” she says. 

    Moving beyond training to attain gender equity

    Cantalupo says the solution to prevalent gender harassment in medical schools is “broad-based cultural change that goes beyond individual cases. That requires recognizing that sexual harassment is a cause and a consequence of gender inequality and that solutions to sexual harassment need to address inequality more broadly.” To start, she suggests creating and coordinating committees and interventions to fit into a comprehensive prevention plan.

    "The onus is on us. What can well-meaning faculty do to give more agency to students — to be able to complain without it leading to some form of retaliation. The onus should not be on the learners. By definition, harassment doesn’t occur unless there’s a power dynamic."

    Esther Choo, MD, Oregon Health & Science University

    Choo suggests “case-based discussions” as is done in clinical medicine. For example, a discussion of the attending physician who required dirty jokes to lighten the mood in the operating room might begin with: “Here’s an example of someone skirting the line. It’s easy to say they’re doing nothing illegal, but it’s harder to say that they’re creating an atmosphere where patient safety can happen effectively.”

    “The onus is on us. What can well-meaning faculty do to give more agency to students — to be able to complain without it leading to some form of retaliation,” says Choo. “The onus should not be on the learners. By definition, harassment doesn’t occur unless there’s a power dynamic.”

    Routine anonymous assessment of everyone in each department would create opportunities for people to say, “There’s a bad culture here,” she says.

    McLaughlin also hopes that funding institutions will reform the ways in which they recognize contributions to scientific research by granting money not just to the principal investigator but also to the junior scientists on a project. This would weaken the rigid hierarchical power structures where students depend on one authoritarian figure to reach the next phase of their education and careers, she says.

    Addressing gender harassment will take a culture shift, but for now, those who bravely take a stand still face professional risks both large and small.

    Asked why she is willing to risk it all, Jagsi does not hesitate in her response: “This needs to be called out. I do this because it is the right thing to do.”