Sexual Harassment in Medical Education: How We Can Do Better

“This is just another thing you’re going to have to learn how to deal with,” the female resident said matter-of-factly. We had just seen a patient who had made lewd comments about our appearance, questioned our qualifications, and called us little girls. It was not the first time one of the authors had encountered sexual harassment. But it was the first time experiencing it in a patient care setting.

Sexual harassment is distressingly pervasive in medical education. Encounters of harassment are not isolated; rather, they follow a pattern of incidents that repeatedly occur throughout medical training due to deeply ingrained unconscious and conscious sex-based biases. In a meta-analysis of 51 studies from a 24-year period, female trainees were significantly more likely to be subject to sexual harassment compared to their male peers.¹ A report from the National Academies of Science, Engineering, and Medicine revealed that female medical students are 220 percent more likely than peers in non-STEM disciplines to encounter sexual harassment.²

Despite their ubiquity, moments of sexual harassment are difficult to address. As students, we are placed in the uncomfortable position of confronting an inherently vulnerable person because of their status as a patient. At the same time, with our response, we risk being labeled by our superiors as too hard-headed, not tough enough, or unable to take a joke. The way in which our actions, not just as students, but as women, are perceived can dictate whether we experience retaliation in the form of poor clinical evaluations and fewer learning opportunities.

Here, we share 5 archetypes of leaders who inadequately respond to sexual harassment in clinical settings, accompanying examples, and a five-step framework for improvement.

Archetype 1: The Avoider

Avoiders behave as if instances of sexual harassment have not happened.

A female medical student and male attending physician see a male patient in the emergency department presenting with a possible incarcerated inguinal hernia. During the exam, the patient winks at the student and says, “It’s been a while since I’ve had a young girl playing around down there. She wasn’t nearly as pretty as you.” The student briefly makes eye contact with the attending who looks uncomfortable but says nothing.

The attending’s silence, regardless of its intent, condones the patient’s behavior and sends a message to the student that harassment from patients is acceptable.

Archetype 2: The Authoritarian

Authoritarians may not acknowledge that sexual harassment is a true problem and believe that students should not be offended by patients’ statements.

A female medical student sees a patient with lower abdominal pain in a surgery clinic. During her exam alongside the male attending physician, the patient looks up with a wink and asks, “What else can you do for me?” The attending laughs and completes the exam for the student. When the student later tries discussing the incident, the attending tells her that the patient was obviously joking and that she needs to grow thicker skin if she wants to make it in surgery.

The attending thinks that the only problematic aspect of sexual harassment is the woman’s response to it. The student bears both the responsibility and burden of learning how to manage harassment in an unsupportive environment.

Archetype 3: The Dismisser

Dismissers believe that physical assault, such as unwanted touching or groping, is the most pressing obstacle women face, and only those actions warrant a response.

As she visits her patients with a resident, a female medical student is asked by a male patient, “Are you a virgin? Because you sure look like one.” The resident ignores the question and proceeds with taking the history. When the student tries to discuss the incident with the female attending physician, the attending responds, “That’s just part of the job.”

The attending fails to support the student and cites a history of inappropriate behavior as a reason for accepting current inappropriate behavior. Additionally, the resident, who is a bystander, fails to confront the patient in the moment. As a result, the student learns that speaking out against harassment will not be taken seriously.

Archetype 4: The Ineffective Supporter

Ineffective supporters have a genuine desire to support their team members and condemn sexual harassment, but they could benefit from a more effective approach.

“You’ve got a model in your presence,” the patient tells the female attending physician during morning rounds, nodding to the female medical student. The attending awkwardly chuckles and leaves the room. One week later in a feedback session, she tells the student, “I spoke to the patient privately to tell him that he should stop making those inappropriate statements.” The patient never changed his behavior.

The attending appreciates the vulnerability of both the student and patient and tries to support them both by addressing the sexual harassment in private. However, she misses the opportunity to address the incident immediately after it occurs, which would have allowed her to demonstrate her support of the student and more effectively change behavior.

Archetype 5: The Enabler

Enablers do not recognize incidents of sexual harassment and they may even contribute to the harassment.

While a female student and resident interview a male patient, he tells the medical student that she should wear a dress because scrubs don’t flatter her body type. When the student later mentions this comment to the male attending physician, he chuckles and says, “Well, he’s got a point.”

The attending makes no attempt to correct inappropriate behavior or support the student. Instead, he becomes an active offender, disrespecting the student and not fulfilling his role as a teacher or role model. The resident, a bystander, also does not intervene. The student realizes she is in an unsafe learning environment and is unsure of how to handle the harassment.

Suggested Solutions

We are hopeful that leaders and bystanders will successfully transform into the archetype we all want and need: the ally. While we strive to emulate this ideal advocate who is able to tactfully confront instances of sexual harassment without straining patient or student relationships, attaining this response can be overwhelming without concrete guidance. We offer a five-step framework (Table 1).

Table 1 Framework for Response Strategies to Sexual Harassment

The burden of sexual harassment cannot be addressed solely by individuals. Rather, the solution requires extensive changes within the cultures of institutions. Although these changes often start at the top, they require individuals to not only accept changes, but also embrace and adopt them to be sustainable. As systems and institutions are composed of individuals, individual behaviors therefore merit scrutiny.³ When one person stands silent in the face of harassment, they grant their permission for these actions to continue.

As students, we are often the silent observers, witnessing the spillage of these failures into other interactions within hospitals. We see them when medical teams do not listen to female leaders during a code, or when health care providers question a female physician’s qualifications. We observe these events time after time and wonder just how many more barriers we will need to overcome to simply do our jobs.

We are hopeful for a different outcome. We look forward to a future in which medical students develop into thriving physicians, unhindered by encounters of sexual harassment, thanks to the prepared allies in medicine who have fought for change.