Sexual harassment experienced by medical students can have a measurable impact on mental health, leading to burnout, anxiety, or even a career change [4, 22]. A 2014 meta-analysis which found that 59.4% of medical trainees had experienced at least one form of harassment or discrimination during their training, with more than two-thirds of the included studies reporting SH specifically [5]. Although much of the prior literature on SH focuses on harassment from faculty/staff, a Canadian national survey found that 40% of SH incidents were perpetrated by patients [8]. Our findings support that SH/SA by patients is a common experience encountered by medical students.
We found that SH behaviors are twice as likely to be experienced by students identifying as female, consistent with multiple previous studies that female students experienced SH two to three times more often than their male peers [4, 23, 24]. Similar frequency for experiencing SH (most commonly 1–3 times in the past year) was reported by both sexes, suggesting that though incidents are more likely to ever occur for females, incidents are infrequent in any given year. Our data demonstrate no significant difference between frequency of experiencing SA behaviors based on sex of the student. This could be due to the relatively small number of SA events reported in our cohort, but warrants further examination. Additionally, we found that students identifying as male are not immune from SH by patients, with 31% of male students having experienced SH. This prevalence is slightly higher than reported in prior studies which ranged from 12 to 29% [11, 25, 26]. The #MeToo movement has brought awareness of SH against females to the forefront. Greater dialogue and movement needs to occur to include men in the discussion, reducing the stigma associated with male sexual harassment and potentially increasing their reporting rates [27,28,29].
We hypothesized that medical students experience more SH compared to senior trainees (i.e., residents or fellows) and attending level physicians because of larger perceived power differential of hierarchical roles within academic medicine. However, we found the prevalence of SH among students in our cohort to be lower in comparison to our previous study of residents and attending physicians where we found that 83% reported experiencing SH and 31% SA behaviors from a patient [30]. This difference may be due to the greater number of cumulative patient encounters that residents and attendings have experienced. Our finding of a higher prevalence of experiencing SH from patients among clinical students compared to preclinical students likely also reflects increased time to accumulate SH incidents from patients, consistent with previous literature suggesting that SH and gender discrimination are higher in the clinical environment than in pre-clinical education [15, 31].
Since the inception of Title IX in 1972, medical schools and organizations have adopted a zero-tolerance policy on SH [12] including laws protecting victims from retaliation [13]. Despite this safety net, reporting of SH remains low. According to the Association of American Medical Colleges’ (AAMC) 2020 Medical School Graduation Questionnaire, only 26% of students who had experienced harassment or other offensive behaviors reported these incidents to faculty or medical school administrators. The most common reason for lack of reporting was that the incident did not seem important enough to report [32]. We confirmed that medical students who experienced SH from patients were unlikely to report SH in an official capacity.
In our cohort those who identified as female were more likely than their male counterparts to select reasons for not reporting that downplayed the episode, including “not sure if serious enough”, and “did not think the patient intended to harass”. In some environments, downplaying SH/SA may be a way for women who have experienced these incidents to transform them and lessen their impact [33]. Those who identify as female were also 3 fold more likely to report that they did not think reporting an incident would have productive consequences. This aligns with the concept that women perceive a greater risk in reporting SH than do men [4]. Some additional reasons students may fail to report include fear of reprimanding from attendings, humiliation from staff and peers, negative patient satisfaction or removal from a clinical rotation [13]. While we did find that fears of retaliation were also reported by our cohort as reasons for not reporting an incident of SH/SA, we did not see significant differences by sex. In order to ensure a safe learning environment, barriers to reporting must be lowered, there must be transparency about the outcomes of reporting, and safety and support must be ensured for all medical students who experience SH/SA.
One-fifth of our respondents noted that experiencing SH/SA by a patient made them feel burned out, with females reporting feeling burnout due to SH/SA more than males. Burnout has a higher prevalence among trainees and women in particular [34]. The connection between discrimination/harassment and poor mental health outcomes (e.g., depression, anxiety, burnout) has also been well-documented [35, 36], including in students who experience gender discrimination or harassment [22]. Men academic faculty members report burnout from experiencing direct harassment, whereas women report increased burnout with direct and indirect harassment experiences (i.e. witnessing or hearing about someone being directly harassed) [37]. The additional impact of indirect experiences of harassment may serve as an amplifier of the effects harassment and burnout for women in medicine.
Limitations
There are several limitations to this study. The smaller sample size and survey population limited to a single public medical school may limit the generalizability of our findings. Due to the electronic methods utilized to distribute the survey, our data may be subject to selection and/or response bias. Another limitation that may cause bias is the relatively low response rate of 26%. Our sample had an overrepresentation of students identifying as female (68%) when compared to the percent of medical students who identify as female in the school overall (58%). The majority of our respondents were between the ages of 25–29 years, which is consistent with the national mean age of 24 years at time of matriculation to medical school [38], but narrower than the age range of matriculated students (21–37 years) in this school.
We did not specifically examine the prevalence and impact of SH/SA by race/ethnicity or among gender minority students. Existing literature about the rates of SH/SA experienced by people of different races/ethnicity is mixed, though data overall suggests some differences among groups. The Stop Street Harassment survey was a large (n = 2009) survey of adults that found no overall significant differences in the experience of SH/SA by race/ethnicity, although the authors did report a trend toward higher odds for SH for Hispanic women relative to white women [39]. In a study of Ob/Gyn residents, Hispanic/Latinx and white or Asian trainees reported higher incidences of sexual harassment compared to Black resident trainees [40]. Future studies are needed to investigate and address these potential race/ethnicity disparities of the experience of SH/SA. In addition, we did not perform analysis of non-binary students due to the small number of respondents identifying as such in our cohort. Given the high frequency of stigma and discrimination faced by transgender and gender non-binary medical students [41], further investigation of SH experienced by these students should be prioritized in future studies.
Preventing and responding to SH/SA
It is clear that more needs to be done to reduce medical students’ exposure to SH/SA. Medical school leadership should prioritize the prevention and reduction of SH/SA. As suggested by Binder et al., one first step by medical schools is the public declaration of zero tolerance for harassment in addition to mandatory sexual harassment training programs [13]. Zero tolerance policies are especially important for those who supervise medical students. Allowing those in positions of power to commit or tolerate SH/SA could contribute to a culture of acceptance around SH/SA, including from patients, as work environments with a perceived organizational tolerance of SH tend to have higher overall rates of SH,(48) and SH is less likely to occur if sexually harassing behaviors are not accepted by authority figs [42]. Efforts to create diverse and inclusive environments may also help, as work environments which are male-dominated and with large power differentials between levels tend to have higher overall rates of SH [43,44,45].
Despite efforts and zero tolerance policies, it’s likely that we will never be able to prevent all SH/SA from patients. Inappropriate sexual behaviors can result from medical conditions, including delirium and dementia [46]. Given the likelihood of SH/SA occurring, it’s essential that those who supervise and/or work with medical students have formal training in bystander intervention [13]. Bystander intervention allows action be taken to call out and identify witnessed SH/SA behavior towards medical students, particularly if the witness is a supervisor or senior to the student (such as an attending or resident). Similar to microaggressions, allowing witnessed SH to occur without intervention or discussion implicitly suggests that the behavior is acceptable. Students should be educated on and empowered to report incidents, so that reporting is normalized, and the culture improves for future learners. Access to counseling and other support services and time off to utilize these services should also be readily available and easily accessible for affected students.
