Sexual violence in medical students and trainees in Flanders: a population survey

3 Background: Sexual violence has globally been recognized as harmful to young people’s health. In 4 medical school, which is a highly competitive environment, the risk is supposedly even bigger. In this 5 study we firstly aimed to investigate the magnitude and promoting factors of sexual violence in medical 6 students and trainees in Flanders. Secondly, we wanted to assess the reactive behaviours as well as 7 the knowledge of possible types of bystander reactions as well as potential support resources for 8 victims of sexual violence. 9 Methods: This study was initiated and coordinated by the Flemish medical student representation 10 organ (VGSO). A survey containing demographic and behaviour-specific questions based on the UN- 11 MENAMAIS and SAS-V questionnaire was sent to all undergraduate, graduate and postgraduate 12 students of the 5 medical schools in Flanders. Participants were asked to limit their responses to 13 internship-related events. Further questions concerning reactions to sexual violence, perpetrators, 14 bystander reactions and general knowledge concerning support after sexual violence were asked. 15 Results: We received 3015 valid responses to our survey, obtaining a response rate of 29% in the 16 potential target population. Within the total study population, 1168 of 3015 participants (38,73%) 17 reported having been victim of at least one type of sexual violence as explored by our survey. This 18 percentage was the highest in GP trainees (53%), followed by specialist trainees (50%) and master 19 students (39%). Perpetrators of sexual violence varied, most often they were medical staff members, 20 students or patients. In most types of sexual violence, nobody reacted to this behaviour. Women 21 (57.3%) talked about what happened afterwards more often than men (39.7%). When asked about 22 their knowledge of possible bystander reactions and support services for sexual violence, 60% of the 23 respondents did not know about their existence. 24 Conclusions: Sexual violence is still a relatively frequent issue in medical students and trainees. 25 Patients form an important part of the assailants. In a third of reported sexual violence cases, nobody reacted. In addition, male victims seem to underreport. There is still much need for sensibilisation on 27 support mechanisms and centres for victims and witnesses of sexual violence.

reacted. In addition, male victims seem to underreport. There is still much need for sensibilisation on 27 support mechanisms and centres for victims and witnesses of sexual violence. 28 Keywords 29 Sexual violence, sexual harassment, medical students, bystander actions, support resources, Flanders, 30 Belgium, medical school, trainee, graduate, postgraduate, undergraduate 31 Background 32 The World Health Organization (WHO) defines sexual violence as 'any sexual act that is carried out 33 against someone's will. It can be carried out by any person, regardless of his or her relationship to the 34 victim, in any setting'. [1] Sexual violence is divided in different types according to the degree of 35 physical contact. Generally, a distinction is made between 'hands-off' behaviour such as sexual 36 remarks, so called jokes and sexting and 'hands-on' behaviour such as kissing, touching or forced 37 intercourse.
[2] 38 Reports of sexual violence in medical training date back to the early nineties in the United States. [3] 39 Sexual violence has increasingly been recognized around the world as an issue in medical training and 40 healthcare ever since. Renewed attention was drawn to this issue by the 'Me Too' movement, with 41 broad media coverage of recent revelations of sexual violence, inducing concern about its frequency 42 and impact. Recent studies have shown that between 30% and 50% of medical trainees self-report an 43 experience of sexual violence during their medical training. [4-7] 44 In Belgium, medical education is divided into three phases. As a bachelor (undergraduate) student, 45 medical students spend most of their time in university halls for theoretical courses. In general, 46 bachelor students are exposed to the hospital environment only during a 1-or 2-week introductory clerkship. After three years, students enter their masters (graduate). During the masters (3 years), 48 students participate in at least 12 months of hospital internships in both university hospitals as well as 49 general hospitals and GP offices. Finally, after graduating, students enrol in postgraduate training to 4 become a specialist as specialist trainee (called "arts-specialist in opleiding" or "ASO" in Flanders) for 51 4-6 years or general practitioner as GP trainee (as "huisarts in opleiding" or "HAIO") for 3 years. For 52 each internship there is a supervisor who is responsible for the evaluation and education of the intern 53 or trainee. 54 Several characteristics of medical training programs might predispose medical students and trainees 55 to encounter sexual violence. The very nature of a physicians' work can be considered sexually charged 56 and emotionally taxing. Working long hours in small groups in a new, unfamiliar environment can 57 contribute to a breakdown of social barriers. [3] Reports of female victims are much more frequent 58 than reports by their male colleagues. Many young trainees nowadays are women, while most 59 supervising physicians are still male. Furthermore, sexual violence is often underreported out of 60 shame, guilt or fearing retaliation from the harassers.
[8] In male students, this risk is even bigger 61 because of the taboo on the subject as well as the long-time neglect of inclusion of male participants 62 in research into sexual violence.
[9] 63 The fear of a negative impact on grades, the quality of the education or even career opportunities 64 discourage many medical students and trainees to report sexual violence, especially in the highly 65 competitive environment of medical training. In short, medical trainees have a high risk of becoming a 66 victim of sexual violence and research is needed to examine the context wherein this happens and the 67 actions that can be taken to prevent sexual violence from happening. 68 Our goal is to advocate for an effective policy to prevent sexual violence during medical training in 69 Flanders as well as to improve the knowledge of and access to support resources for victims. 70 In this paper, we aim to assess the prevalence of various hands-off and hands-on types of sexual 71 violence during medical education in Flanders (Belgium) and to identify the main obstacles for 72 reporting this behaviour.

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This study was initiated and coordinated by the Vlaams Geneeskundig StudentenOverleg (VGSO), the 76 medical student representation organ regrouping the five medical schools in Belgium. 77 We designed a survey using demographic and behaviour-specific questions inquiring whether 78 participants had been exposed to specific types of behaviour. Thereby we avoided predefining sexual 79 violence. First, we asked the respondent's sex, university, current education level and cumulative 80 duration of internships up to the enquiry. The behavioural questions were based on the UN-81 MENAMAIS questionnaire of Keygnaert et al. [10] as well as the SAV-S questionnaire by Krahé et al. 82 [11]We focused on those types of behaviour most applicable to medical education and added context 83 where applicable. The behaviour types defined as sexual violence and sexual violence investigated 84 both hands-on and hands-off behaviour. Within hands-off behaviour we looked at (attempts of) 85 inappropriate jokes or remarks, sexting and unwanted undressing (of the victim and/or perpetrator or 86 taking a recording thereof). Within hands-on behaviour we looked at (attempts of) unwanted acts of 87 kissing, touching, oral sex and penetration. Participants were asked to limit their responses to 88 workplace-related events. 89 When a respondent acknowledged having experienced a type of behaviour, we asked to specify the 90 type of perpetrator (student, trainee, medical staff, supervisor, paramedical staff, patient or others), 91 the frequency of this behaviour, circumstances facilitating the behaviour (hierarchical position, 92 inability to flee, threats regarding performance results, alcohol or drugs, physical violence, others) and 93 if somebody reacted to this behaviour. When somebody reacted to this behaviour, we further explored 94 who reacted (the victim him/herself, a student, trainee, medical staff, supervisor, paramedical staff, 95 patient or others) as well as the type of reaction according to the 4 D's of bystander intervention: direct 96 action (confronting the perpetrator with his behaviour), distraction (distracting the perpetrator from 97 the situation), delay (asking the victim how he/she feels afterwards) and delegate (reporting to higher 98 instance).
[12] For each D we explored the most applicable example of this behaviour within the context 99 of medical education. 100 After looking into these specific types of behaviour, we asked if respondents who were a victim of one was sent to all potential participants by the administration of each medical school using a premade 119 template text identical for all schools. Only students who participated in at least one medical internship 120 were asked to participate. Two reminders were sent to all potential participants with a 2-week interval. 121 The survey was open from the 1st of April 2019 until mid-May 2019 (6 weeks in total).

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The incomplete (defined as not having answered at least 1 behavioural question) and disqualified 124 (didn't participate in an internship yet) responses were removed, as we only wanted to examine 125 workplace-related behaviour. The data from SurveyMonkey was exported into SPSS. We conducted 126 all statistical analyses using SPSS statistical software, version 25.0 (SPSS Inc., Chicago, IL., USA). A chi-127 square test of goodness-of-fit was performed to determine whether the human sex ratio was equally 128 obtained for the study population in comparison with the initial target population. Statistical 129 significance was set at a p-value ≤ 0.05. Furthermore, we used descriptive statistics to quantitatively 130 describe the differences in frequency of all variables. 131

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In total, we received 3299 responses to our survey. After excluding 220 participants because they did 134 not participate in any internship yet and 64 participants because they did not answer at least one 135 behaviour-specific question, 3015 valid responses were analysed (table 1). We obtained a total 136 response rate of 29,6% of which 35% of participants were male and 65% were female. 137 The potential target population consists of 42.1% men and 57.9% women, whereas the study 140 population consists of 35% men and 65% women. The sex ratio in the study population was not equal 141 to the initial target population according to a chi-square test of goodness-of-fit (p < 0.001). 142

Incidence of sexual violence in medical students and trainees
143 Within the total study population, 1168 of 3015 participants (38,73%) reported having been victim of 144 at least one type of sexual violence as explored by our survey. This percentage was the highest in GP 145 trainees (53%), followed by specialist trainees (50%) and master students (39%) (table 2). A difference 146 is observed between the relative frequency of incidents reported in male (21%) and female (48%) 147 respondents. 148 Five percent (n = 48 men, n = 95 women) of the respondents reported having received unwanted 159 sexually tinted texts or images. Moreover, being asked to undress (with or without images being taken) 160 or (being witness to) unwarranted undressing was reported by 1.5% (n = 9 men, n = 32 women) of the 161 respondents. Patients were cited as perpetrator in 55% of these cases. In 28.6% of cases this happened 162 more than once. 163

Hands-on sexual violence
165 Of the respondents, 3.7% (n = 30 men, n = 73 women) had experienced an unwanted attempt to kiss. 166 In 21% of the cases this happened more than once. Moreover, 8.7% (n = 44 men, n = 203 women) were 167 touched or somebody tried to touch him/her without consent. In 39% of cases this happened more 168 than once and in 4% this happened regularly. 169 There were ten reports (n = 4 men, n = 5 women, n = 1 unknown) of (an attempt at) unsolicited oral 170 sex (passive or active). The inability to escape from the situation (n = 1), use of alcohol or drugs (n = 2) There were nine reports (n = 3 men, n = 5 women, n = 1 unknown) of (an attempt at) unwanted sexual 173 penetration. The (hierarchical) position of the person exhibiting the behavior (n = 1), the inability to 174 flee from the situation (n = 3), use of alcohol or drugs (n = 2) and physical violence (n = 1) were cited 175 by these victims. Of the participants, two male respondents reported both unwanted oral sex and 176 penetration. 177 The percentage of type of perpetrator of this behaviour can be found in table 4. 178  In most types of sexual violence, no immediate reaction followed the unwanted behaviour. Except for 187 kissing (53%), the amount of cases in which somebody reacted was inferior to 40%, ranging from 188 around 37% in case of unwanted touching or undressing to barely 22% in the case of unwanted 189 penetration. 190 In most cases (>80%) this reaction was by the victim him/herself. Other persons were more likely to paramedic staff). In cases of unwanted oral sex or penetration, there never was a reaction of somebody 194 else than the victim. 195 The type of reaction, categorised according to the 4 D's of bystander reactions, differed from behaviour 196 to behaviour (figure 1). Direct reaction and distraction were the strategies used most often. Not many 197 incidents were reported to higher instances. There were no statistically significant differences 198 observed in the amount or type of reactions to sexual violence according to the perpetrator categories. 199  More than one tenth (12.8%, n = 386) of the study population witnessed potential sexual violence 208 towards another medical student or trainee colleague. In 56% of cases this behaviour was by a medical 209 staff member (n=215) and in 22% of cases this behaviour was by a supervisor (n=83  Because this study did not question the study level of the respondents at the time of the reported 248 behaviour, we cannot compare the incidence of sexual violence between undergraduate, graduate and 249 postgraduate students. It is possible that the respondents reported events that happened earlier in 250 their training. This is also reflected by an increase in reports as students advance in their careers and 251 are more exposed to the workplace. 252 GP trainees reported the highest percentage of sexual violence. This might be explained because of 253 the isolated and intimate relationship they have with their supervisor working at a GP office. 254 Considering that specialist postgraduate training is double the length of GP postgraduate training, this 255 difference is even more remarkable. 256 Women reported significantly more incidents of sexist remarks or jokes and unwanted physical 257 contact. The approximate 2:1 ratio in female:male reports was seen by Krahé et al. as

well in another 14
In only 20-30 % of cases of sexual violence, someone reacted immediately to the event. This reaction 261 was mostly from the victim him/herself. Most often this reaction was a direct action or distraction. 262 This might be because most people do not know how to react, which is confirmed in this study. It is 263 also possible that bystanders are scared to respond to the behaviour, because of the position of the 264 perpetrator or because of peer pressure. When somebody other than the victim responded, it was 265 mostly indirect action, by asking how the victim felt after the event. In the cases of unwanted oral sex 266 or penetration, no immediate reaction was reported by somebody else. This could be explained by the 267 fact that the victim was alone with the perpetrator at that moment. It should be noted as well that 268 most types of behaviour did not receive any reaction at all. After experiencing sexual violence, about 269 half of the victims talked about the event with someone else, mostly friends or family. This can be of 270 importance because these persons might encourage the victim to report the incident, whilst the victim 271 might not have done this if he/she did not disclose. 272 More than one tenth of the respondents witnessed sexual violence of another medical student or 273 colleague. Two third of these persons reacted to this behaviour, mostly by asking about the feelings of 274 the person who underwent the situation, but one third undertook no action. It is possible that there is 275 a retention bias, where respondents have forgotten or don't want to remember those occurrences of 276 sexual violence where they did not react. 277 More than two third of respondents acknowledges not to know what to do when personally 278 experiencing sexual violence, and 60% of respondents does not know how to react as a direct or 279 indirect bystander nor where to get help with or report sexual violence when they are a witness. 280 As this study shows sexual violence is a frequent problem in medical trainees, it is worrisome that a lot 281 of them (more than 50%) do not know where they can report or get support. In Belgium, there are 282 contact points at each medical school as well as governmentally sanctioned contact points and care 283 centres not related to medical school where victims can find help in any form after sexual violence. 284 Unfortunately, these contact points are poorly known by students and postgraduates. A first step to Secondly, their functioning must be screened for weak points and possible issues such as lack of 287 accessibility for medical students and trainees. 288 In addition, most respondents indicate not to know how to react when witnessing sexual violence. 289 Bystander roles have proven to be an effective source of primary, secondary and tertiary prevention. 290 [18][19][20] This is also reflected by the fact that in one third of the cases of sexual violence, nobody 291 reacted. Therefore, this subject should be addressed in the training and all university and hospital 292 personnel should also receive a training in bystander roles. More reaction to possible sexual violence 293 shows that such behaviour is not accepted, thereby possibly lowering its incidence. 294 Notwithstanding the results, our study has several limitations that should be mentioned. The total 295 response rate of our survey within the target population is 29,8%. This target population consists of all 296 undergraduate, graduate and postgraduate medical students. However, our goal was to focus on 297 internship-related sexual violence. Therefore, those (undergraduate) students indicating that they had 298 not participated in any internship yet were disqualified. This means that the target population consists 299 of both potential respondents as well as disqualifying respondents. It is impossible to calculate the 300 exact target population, although we can presume this comes down to about one third of the bachelor 301 students (first year students have no internship experience). Therefore, the real response rate is 302 slightly higher. There is an inherent possibility of selection bias as well: possibly the respondents are 303 the ones that have been the victim of sexual violence and have a need to talk about it. However, there 304 is also the possibility of the opposite case where participants that have been victim of sexual violence 305 will not respond to the survey because they feel ashamed or don't want to relive their trauma. Some 306 of the missing answers might be explained by respondents who experienced sexual violence and 307 stopped completing the questionnaire because of the emotions that were raised whilst responding. 308 Another weakness of our study is that the questionnaire was distributed by the faculty administration, 309 which might have a deterring effect on possible respondents. 310 dementia or patients under the influence of alcohol -is not researched in this result. We wanted to 313 focus our study on sexual violence related to the status of being a medical student, but this can be 314 interpreted broadly. A lot of sexual violence is not workplace-related however, and this will not be 315 detected by our study. However, we did observe 25% of undergraduate students reporting workplace 316 related sexual violence which is remarkably high with regards to their limited internship experience 317 (<1 month). 318 For future research, it is important to keep monitoring the prevalence of sexual violence in this 319 population, to keep track of the evolution and to further investigate in which context sexual violence 320 occurs. Doing this, better tools can be developed to prevent such behaviour. It would be interesting to 321 investigate the prevalence of sexual violence in other healthcare workers and students, such as nursing 322 students, to see if sexual violence is a problem in these groups as well. 323 Conclusion 324 Sexual violence is a frequent issue in young people and medical students around the world with a big 325 impact on performance and personal wellbeing. With this study, we firstly wanted to investigate 326 whether sexual violence was frequently reported in the workplace context of medical undergraduate, 327 graduate and postgraduate students. We also wanted to know more about the context in which this 328 behaviour happened and who the perpetrator was. Secondly, we wanted to inquire whether a reaction 329 took place against this behaviour and what this reaction consisted of. We investigated indirect 330 exposure to sexual violence as well. Finally, we also wanted to investigate if students have knowledge 331 of possible bystander reactions and support resources after sexual violence. 332 We saw that sexual violence is indeed an important issue in medical students and trainees. In about 333 one third of occurrences of sexual violence, nobody reacted. When looking into the knowledge of 334 possible bystander reactions and supporting instances for victims and witnesses of sexual violence, Declarations article writing. LD and MH were involved from the beginning and responsible for the data analysis and 360 statistical processing. MG was involved in the conception of the study and responsible for the 361 discussion by doing a literature review as well as interpreting the results and placing them into context. 362 NP helped writing the initial study protocol and subsequent amendments for approval by the ethics 363 board as well as critically overseeing the article development and data interpretation. IK was 364 responsible for giving the scientific background to the project by using her extensive knowledge on the 365 subject to design the survey and help us process and interpret the results next to critically overseeing 366 the article development. 367