Creating Work and Learning Environments Free of Gender-Based Harassment in Pediatric Health Care

Sexual harassment is described by the United States Equal Employment Opportunity Commission (EEOC) in the following way: “It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include “sexual harassment” or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex or gender. For example, it is illegal to harass a woman by making offensive comments about women in general.”¹  Although sexual harassment has been illegal for more than 50 years, there has been increased social awareness of the scope of the problem since the MeToo movement, including an increased awareness of the role of more subtle gender-based harassment.²  Gender-based harassment includes not only behaviors that are meant to objectify or sexually exploit an individual but also behaviors or comments that are meant to reinforce harmful gender norms, perpetuate gender-based stereotypes, and degrade or disrespect a person on the basis of their sex (male, female, or intersex, assigned at birth), gender identity (how they perceive themselves), or sexual orientation (to whom they are attracted). A significant proportion of the burden of sexual harassment experienced by physicians originates from patients and families. Although sex-based harassment of women (and men, although with less frequency) is well-recognized, harassment of people of sexual and gender minorities remains an underrecognized and related problem. Much of the research on harassment has focused on cisgender women and men, and thus, the experiences of transgender and nonbinary people are not as well understood or described. Newer concepts have emerged that deepen our understanding of sexual harassment. Microaggressions are the everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target people based solely on their marginalized group membership.^3,4  These microaggressions may stem from conscious or unconscious bias. Examples of common microaggressions that relate to sexual harassment include the following⁵ :

• Don’t worry your pretty little head about it.”

• That’s women’s work.”

• Let a man take care of that for you.”

• We understand you have pregnancy brain and can’t keep up.”

• Persistently (whether intentionally or unintentionally) using the wrong pronouns for a person who is nonbinary or transgender.

• Calling a woman doctor by her first name, but introducing a male colleague as “Dr.”

• Referring to a woman colleague as “young and lovely.”

Microaggressions are frequently accompanied by racial or ethnic overtones and typically are demeaning in their nature. “Intersectionality” refers to the unique patterns of compounding discrimination that reaches beyond a single minority status, noting the increased burden experienced by people who are members of 2 or more marginalized and/or minoritized groups. Harassment is more common where power differentials coexist, such as the traditional hierarchy observed in the medical profession. Thus, students and resident physicians are often much more likely than attending physicians to be victims. Nurses, medical assistants, and nonmedical administrative or support staff can face increased susceptibility to harassment as well.

Harassment regarding issues related to gender are not perpetrated only by men or limited to only women victims. It is well recognized that transgender individuals experience harassment at high rates with severe consequences.⁶  As pediatric health care becomes a more women-dominated field, disparaging gender-based remarks directed at men warrant acknowledgment and recognition as potential harassment cases.

Sexual harassment remains a prevalent problem for people of all genders, especially women, in many fields of work, including medicine. Our understanding of what constitutes harassment and who is victimized has expanded significantly since the 2006 American Academy of Pediatrics policy statement “Prevention of Sexual Harassment in the Workplace and Educational Settings.”⁷ 

The EEOC defines sexual harassment as unwelcomed sexual advances, requests for sexual favors, and other verbal or physical behavior of a sexual nature. However, the EEOC also highlights that sexual harassment is not always sexual. It can also include offensive remarks or behavior regarding a person’s sex.¹  Sex and gender discrimination are recognized as forms of sexual harassment that violate Title VII of the Civil Rights Act of 1964.⁸ 

Harassment is known to produce negative consequences. A recent study on the extent of sexual harassment among pediatric, internal medicine, and general surgery resident physicians (n = 1700) found that sexual harassment was associated with lower levels of vitality (being energized by work) and higher rates of ethical and moral distress.⁹  Resident physicians who experience mistreatment, including sexual harassment, are more likely than those who do not to report symptoms of burnout and also report higher stress levels and lower quality of life. In addition, resident physicians who experience harassment are less likely to believe that their program prioritizes collaboration, education, and mentoring.^10,11 

Despite decades of increased awareness, sexual harassment remains a common problem faced by health care professionals. Women resident physicians who identify as lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) reported significantly higher rates of sexual harassment than those who did not identify as LGBTQ (19% vs 6.2%).⁹  Using data from the spring 2019 Pediatric Resident Burnout and Resilience Consortium’s online survey, a study of 1290 pediatric residents in 46 programs found that 5% of pediatric resident physicians reported sexual harassment.¹²  In response to the Association of American Medical Colleges’ 2017 Medical School Graduation Questionnaire, which surveyed graduating medical students at 140 medical schools, 14.8% of students reported that they had been subjected to offensive sexist remarks or names at least once, 4.3% reported unwanted sexual advances, and 0.3% reported they were asked to exchange sexual favors for grades or other awards.¹³  According to the same questionnaire, only 21% of students who experienced harassment or other offensive behaviors reported these incidents to faculty members or medical school administrators. Among those who said that they experienced offensive behaviors, 28% said they did not report the incident because of a fear of reprisal.¹⁴  A 2018 Medscape survey of 3700 physicians and medical residents reported that 27% of physicians have been sexually harassed by a patient, compared with 7% who reported being harassed by other medical personal or administrators in their workplace.¹⁵  A systematic review and meta-analysis of 51 studies published in Academic Medicine revealed that 59% of medical trainees had experienced 1 form of harassment or discrimination during their training. The most reported source of harassment or discrimination was other physician consultants at 34%, followed by patients or patients’ families at 22%.¹⁶  Harassment has been long described as occurring with perpetrators such as teachers or supervising employers. More recently, the phenomenon of patients or their family members as perpetrators of mistreatment has been discussed in the literature.¹⁷ 

Since the initial publication of the AAP’s policy statement on sexual harassment in 2006, several concepts have emerged that have broadened and deepened our understanding of the nature of sexual harassment and its consequences. One such concept is that of microaggressions, which are subtle behaviors or hurtful or invalidating statements that may arise from unconscious biases or prejudice. Microaggressions were first described in relation to historically disadvantaged racial and ethnic groups³  but have since been studied in women, people of gender and sexual minorities, and other marginalized groups.¹⁸  Unlike more overt sexual or sexist aggressions, which may be intentional, openly hostile, and obvious, microaggressions are often unintentional and may appear innocuous or even invisible to a bystander. For members of marginalized groups, experiencing the cumulative effect of months or years of microaggressions can profoundly harm psychological well-being and contribute to adverse health outcomes.¹⁹  This evidence supports antiracist activist and professor Ibram Kendi’s supposition that the very term “microaggressions” understates the accumulation of these incidents as profoundly abusive and discriminatory.²⁰  Gender-based microaggressions in medical workplaces have been described as falling into 6 themes that women in medicine commonly experience: (1) encountering sexism; (2) encountering pregnancy- and child care-related bias; (3) having one’s abilities underestimated; (4) encountering sexually inappropriate comments; (5) being relegated to mundane tasks; and (6) feeling excluded or marginalized.²¹ 

Since the initial publication of the AAP’s policy on sexual harassment, we have become increasingly aware of the concept of intersectionality.²²  This framework was first introduced by professor and civil rights advocate Kimberle Crenshaw in 1989 to describe the dual burdens of sexism and racism experienced by Black women. It is now applied to individuals with more than 1 marginalized identity.²³  Specifically, the term “intersectionality” describes how a person possessing 2 or more marginalized identities can experience a distinct form of discrimination that reaches beyond the individual bounds of sexism, racism, or homophobia as they are commonly understood.²⁴  For example, Crenshaw described how African American women lived at the intersection of racism and sexism, rendering them nearly invisible in matters of equality, access to opportunities, and vulnerability to violence.²⁵  In science and medicine, minoritized women with marginalized racial and ethnic identities feel the effects of intersectional discrimination and report higher rates of feeling unsafe at work than White women, minoritized men with marginalized racial and ethnic identities, or White men.²⁶  Minoritized people with marginalized racial and ethnic identities who identify as LGBTQ and/or disabled may also experience uniquely complicated intersectional effects of racism, ableism, homophobia, or transphobia.

Men can be victims of gender-based harassment. Although attention to gender-based harassment typically focuses on men as perpetrators and women as victims, it is important to take a holistic approach to the issue, especially as a recognition for the workforce within the field of pediatrics. In 2017, nearly three quarters of pediatric resident physicians were women; nearly two thirds of practicing pediatricians were women, and just over half of pediatric academicians were women.²⁷  Many departments may comprise mostly women, and smaller divisions or private practices may have 1 or few men as trainees or faculty members. Even in environments with men in the majority, men may also experience gender-based harassment in the form of overt sexist comments, microaggressions, or sexualizing language. With the traditional gender power dynamics of leadership continuing to favor men, the skew of women as well as gender and sexual minorities as victims of harassment remains in place, even as the number of women physicians grows in pediatrics.

Although patient expectations are often stated about timeliness to the visit, payments for services rendered, and other activities involved in the clinical interaction, it is less common to see statements of patient expectations regarding respectful treatment of clinical staff. In many settings, this culture is changing in recognition that stating expectations for patient behavior helps to establish a healing-oriented culture. Furthermore, naming respectful treatment and nondiscrimination as expectations for patient and family behaviors supports clinicians’ wellness and sustainability.

A key feature affecting patient safety is culture. The lag in leadership roles and positions of authority for people from marginalized and minoritized groups (race and ethnicity, gender, sexual orientation, etc.) demonstrates the pervasiveness of inequity in a patriarchal racialized culture.²⁸  Respect is an essential component of a culture that supports patient safety, and working in a culture that demonstrates respect is key to well-being.²⁹  A culture that protects clinician well-being has a positive effect on patient safety, clinician sustainability, and clinical productivity. A lack of psychological safety compromises learning and clinical care. Several tools exist to maintain respect, inclusion, and belonging, including bystander training and reporting mechanisms.

Bystander training prepares people for how to respond when microaggressions and other forms of mistreatment and harassment occur to protect and promote a positive climate. Based on the idea that people of any gender can interrupt behavior that threatens safety, bystander training includes anticipating that these events will occur and preparing individuals for how to respond when they do. Optimal bystander training programs teach individuals that microaggressions or other mistreatment will occur and encourage people to intervene when they recognize such infractions. Individuals learn to address incidents in real time with comments and actions that support the victim and concurrently encourage a positive culture. When a bystander takes action to improve the situation, mitigate bias, and boost the culture toward equity, they may be referred to as an “upstander.” Strategies for upstander interventions may include redirecting attention from the negative behavior (distraction), interrupting through the appropriate use of wit, or directly confronting the behavior.³⁰ 

Additionally, bystander training promotes shared accountability for the culture in a particular setting. Shared training experiences create a knowledge base and common language to address these repeated situations that occur. Such training can also re-establish social norms. In addition to bystander training regarding responding to microaggressions, there are culture-boosting programs that recruit allies and advocates for gender equity.^31,32 

The responsibility of clinicians to maintain a culture free from gender-based harassment encompasses considerations for the subtle, gender-based messages conveyed during our patient interactions. These behaviors can potentially foster an environment that normalizes gender-based maltreatment and allows it to flourish. Examples include rigid and excessive attention paid to binary gender classification of newborn infants, ascribing certain colors to delineate genders, and gender stereotypes reinforced through toy choices. These examples are in addition to the wider range of comments and behaviors that imply gender-based expectations. To create an equitable culture based on gender, we must consider the implications of our actions.^33,34 

Victims of gender-based harassment are encouraged to report their experiences to the human resource or other authority bodies in their workplace. Similarly, bystanders can report observed harassment to bolster accountability within the professional environment. Those in certain leadership positions are mandated to report incidents of gender-based harassment that are brought to their attention. Irrespective of the broadened definition for recognized gender harassment, egregious incidents of sexual harassment continue to occur. In addition to causing trauma, these incidents increase the risk of career sabotage that can result from the effects on performance, adverse impact on mental health, or as a consequence of retaliation against the reporter. Practical strategies for eliminating sexual and gender-based harassment provide supportive services for reporters, establish systematic management of complaints, and assure zero tolerance for retaliation against reporters.³⁵  Accountability, prevention from continued harm, and consequences for perpetrators of harassment are vital to successful elimination of harassment and mistreatment.³⁶ 

Sexual and gender-based harassment is an ongoing problem in society, and medicine is not immune. Creating pediatric work and learning environments free of harassment supports wellness and sustainability for the workforce and the learners within it. Addressing sexual harassment and gender-based maltreatment is important to creating an environment where all can thrive.

Beyond a zero tolerance toward overt forms of sexual harassment, we must remain vigilant against subtle comments and actions that make people feel diminished, sexualized, or excluded. We can teach victims and bystanders what to do in such moments and empower them to respond. Prioritizing these actions and the following recommendations help us create an environment that genuinely welcomes people of all genders.

1. Work and learning environments should not tolerate gender-based harassment by employees or educators. Employers and institutions should investigate reports of harassment by employees and act against the perpetrator when verified.

2. Perpetrators should be held accountable for their actions. Clear policies and practices in each place of employment and education should ensure no tolerance of harassment based on gender, gender identity, or sexual orientation as part of a broader antidiscrimination and harassment policy.

3. Gender-based harassment that occurs with patients or family members as perpetrators, although more complicated given the nature of the caregiving relationship, should also be acknowledged as a potential source of harassment and not tolerated.

4. Practices should establish a list of expected patient behaviors to protect from harassment of all care providers, including attending physicians, resident physicians, medical students, and all staff.

5. Practices should develop a protocol for managing harassment by patients.

6. Victims who report gender-based harassment deserve support and protection from retaliation.

7. Data regarding the incidence of harassment in a workplace should be transparently shared among staff to ensure accountability. This information must be shared in a way that maintains confidentiality, especially to avoid retaliation.

8. Workplaces and educational institutions need to prioritize positive work environments where people feel respected as professionals and never sexually objectified.

9. To enhance the workplace culture, institutions should offer training to increase awareness of gender-based harassment and its consequences.

10. Bystander training should be provided to prepare those witnessing discrimination and/or harassment to respond and report appropriately.

11. Professionals should consider the gender-based messages conveyed through their personal interactions and the actions of their places of work.

12. Professional specialty groups within organized medicine, accreditation bodies, and leaders within health care organizations should accept their responsibilities to play active roles in creating safe, respectful environments and moving organizations toward equity.

Julie Story Byerley, MD, MPH, FAAP

Nancy A. Dodson, MD, MPH, FAAP

Tiffany St. Clair, MD, FAAP

Valencia P. Walker, MD, MPH, FAAP

Harold K. Simon, MD, MBA, FAAP, Chairperson

Julie Story Byerley, MD, MPH, FAAP

Nancy A. Dodson, MD, FAAP

Eric N. Horowitz, MD, FAAP

Thomas W. Pendergrass, MD, MSPH, FAAP

Edward A. Pont, MD, FAAP

Kristin N. Ray, MD, FAAP

William B. Moskowitz, MD, FAAP, Immediate Past Chairperson

Laurel K. Leslie, MD, MPH, FAAP – American Board of Pediatrics

Lauren F. Barone, MPH

EEOC

US Equal Employment Opportunity Commission

LGBTQ

lesbian, gay, bisexual, transgender, queer, or questioning