BRIEF OBSERVATION

Us, Too. Sexual Harassment Within Academic

Medicine in the United States
Linda H. Pololi, MBBS, FRCP,a Robert T. Brennan, EdD,b Janet T. Civian, EdD,c Sandra Shea, BA,d
Emma Brennan-Wydra, MSI,e Arthur T. Evans, MD, MPHf
a
Director, National Initiative on Gender, Culture and Leadership in Medicine: C-Change, Brandeis University, Waltham, Mass; bResearch
Associate, Boston College, School of Social Work, Chestnut Hill, Mass; cSenior Analyst, Brandeis University, Women’s Studies Research
Center, Waltham, Mass; dConsultant, CIR Policy and Education Initiative, New York, NY; eAssessment Program Manager, Yale School of
Medicine Teaching and Learning Center, New Haven, CT; fProfessor of Medicine, Weill Cornell Medical College, New York, NY.

ABSTRACT

PURPOSE: We report on the extent of sexual harassment among residents and examine its relationship to
specialty and program year and effects.
METHODS: Using the C−Change Resident Survey, we surveyed residents in 34 internal medicine, pediat-
rics, and general surgery programs in 14 academic medical centers (AMCs). A total of 1708 residents com-
pleted the survey (70% response-rate); 51% (n = 879) were women. Respondents reported unwanted
sexual comments, attention, or advances by a superior or colleagues within the last 2 years. Measures of
vitality and ethical or moral distress were included in the surveys.
RESULTS: Rates of sexual harassment reported by women differed across the 34 programs, with an inter-
quartile range of 0%-11%. Residents in pediatrics had the lowest frequencies of sexual harassment (mean
2%, 95% confidence interval [CI] 0%, 4%). Residents in internal medicine had higher rates of sexual
harassment (mean 7%, 95% CI 1%, 25%). Residents in surgery had the highest rates (mean 12%, 95% CI
2%, 33%). Sexual harassment was associated with lower levels of vitality and higher ethical or moral dis-
tress (both, P < 0.05).
CONCLUSIONS: Sexual harassment is more common for women residents in Internal Medicine and Surgery
programs. The adverse effects of sexual harassment on female residents detracts from an institution’s pro-
fessional workforce.
Ó 2019 Elsevier Inc. All rights reserved.  The American Journal of Medicine (2020) 133:245−248

KEYWORDS: Culture of medicine; Residents; Sexual harassment

We have studied perceptions of the culture of academic
medicine for residents, medical students, and faculty in aca-
demic medical centers (AMCs) for more than a decade.1−3
Funding: This study was funded by the National Initiative on Gender,
Culture and Leadership in Medicine: C-Change at Brandeis University.
This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors. The Arnold P. Gold Foun-
dation supported initial studies with the C-Change Resident Survey.
Conflicts of Interest: None.
Authorship: All authors had access to the data and a role in writing
this manuscript.
Reqeusts for reprints should be addressed to Linda Pololi, MBBS,
FRCP, Distinguished Research Scientist, Director, National Initiative on
Gender, Culture and Leadership in Medicine: C Change, Brandeis Univer-
sity, Mailstop 079, 415 South St, Waltham, MA 02454-9110.
E-mail address: lpololi@brandeis.edu
We report on sexual harassment in AMCs nationally among
residents.
Aligned with national trends, there is also increased
recent attention in the health sciences to gender discrimina-
tion and sexual harassment,4,5 but few quantitative studies
specifically address sexual harassment. Studies conducted
nearly 30 years ago found that 73% of female residents in
internal medicine (IM) had been sexually harassed at least
once during their training, primarily by attending physi-
cians and colleagues.6 More recently, a meta-analysis
reported on “the surprisingly high prevalence of harassment
and discrimination.”7 In a recent survey of US medical
faculty receiving National Institutes of Health (NIH)
career-development awards, 30% of the women reported
experiencing sexual harassment,8 and female leaders have

0002-9343/© 2019 Elsevier Inc. All rights reserved.

https://doi.org/10.1016/j.amjmed.2019.06.031
246 The American Journal of Medicine, Vol 133, No 2, February 2020

called for attention to sexual harassment in AMCs.9 The lit- residency programs and AMCs. Where the outcome was
erature includes studies of sexual harassment in medical dichotomous, a Bernoulli (ie, logistic) model was
students; this report contributes quantitative data on the cur- employed. Descriptive statistics were estimated using
rent prevalence of sexual harassment in a nationally repre- Systat v. 13 (Systat Software, San Jose, CA).
sentative sample of residents.
RESULTS
METHODS Table presents a demographic over-
CLINICAL SIGNIFICANCE view of residents; Figure presents
Measures  Female residents reported prevalent rates of sexual harassment by spe-
Using the validated C−Change cialty and program year. Fourteen
Resident Survey (CRS),2,3 we asked
sexual harassment in US academic programs had none of the women
residents to report on their personal medicine centers. residents reporting sexual harass-
experiences of sexual harassment  Reported rates of sexual harassment ment within the past 2 years, but
during residency training. The CRS were significantly higher among resi- 9 programs had more than 10%
also assesses dimensions of the cul- dents who are lesbian, gay, bisexual, of women reporting recent sexual
ture from the perspective of resi- transgender, or queer or questioning harassment. Specialties differ in
dents, including dimensions of (LGBTQ). the amount of sexual harassment
vitality; relationships, inclusion,  Experiencing sexual harassment was reported. When we restrict our
and trust; values alignment; ethical related to lower vitality and increased analysis to the first 3 postgraduate
or moral distress; self-efficacy in ethical and moral distress among resi- years of training, GS had the highest
career advancement; institutional dents. (12%, 95% confidence interval [CI]:
support; mentoring; respect; gender  Academic medical centers are not 2%, 33%), followed by IM (7%,
equity; equity for underrepresented 95% CI: 1%, 25%), and least in
in medicine minority members;
immune to the sexual harassment that pediatrics (2%, 95% CI:0%, 4%).
work-life integration; and leader- is being reported in numerous sectors Only the differences between pedi-
ship aspirations. of our society. atrics and GS, and between pediat-
rics and IM were statistically
Sample significant.
GS residency programs require 5 years of training. Two
In 2014-2015 we surveyed electronically all residents in a of 13 women in their fourth year of GS (15%; 95% CI:
purposive representative sample of 14 AMCs. The AMCs -1%, 38%) reported sexual harassment, as did 9 of 24
represented different attributes of residency programs, women in their fifth year of GS training (37%; 95% CI:
including study-site diversity by region of the United States, 17%, 50%).
patient population served, institutional funding (public or
private), and size of programs. Within these 14 academic
health centers, we invited all 35 residency programs in gen-
eral surgery (GS; 12), IM (12), and pediatrics (11) to partic- Table Demographic Characteristics of Female Medical Residents
ipate. These three specialties were selected because they Female Residents All Internal Pediatrics General
are represented in almost all AMCs and are usually the larg- Specialties Medicine Surgery
est residency programs. Thirty-four of the 35 residency-pro-
Total, no. 792 399 287 106
gram directors agreed to include their programs in the URMM, no. (%) 133 (17) 56 (14) 62 (22) 15 (14)
study. All residents (1333 IM, 643 pediatrics, and 476 GS) LGBTQ, no. (%) 21 (2.7) 13 (3.3) 5 (1.7) 3 (2.8)
were invited to participate. A total of 1708 completed the Children, < 18 years 76 (9.6) 34 (8.5) 29 (10) 13 (12)
survey—overall response rate 70%; 51% (n = 879) were old at home, no. (%)
women and 16% (n = 286) were from underrepresented in IMG, no. (%) 136 (17) 69 (17) 59 (21) 8 (7.6)
medicine minority (URMM) groups. The proportion of Age, mean (SD) 30 (2.7) 30 (2.7) 30 (2.7) 31 (3.0)
female residents varied by specialty: pediatrics, 71%, IM, Postgraduate Year, no. (%)
46%, and GS, 42%. PGY1 295 (37) 153 (39) 104 (36) 38 (36)
The following item was included in the surveys: “I have PGY2 219 (28) 108 (27) 96 (34) 15 (14)
PGY3 234 (30) 132 (34) 87 (30) 15 (14)
personally experienced unwanted sexual comments, atten-
PGY4 13 (2) — — 13 (12)
tion or advances by a superior or colleagues at my
PGY5 24 (3) — — 24 (23)
institution.” Possible responses were: “Yes, within the last
IMG = international medical graduate; LGBTQ = lesbian, gay, bisexual,
two years;” “Yes, over two years ago;” or “No.”
transgender, or queer or questioning; PGY, postgraduate year; sd = stan-
For the analyses reported here, the sample was limited to dard deviation; URMM = underrepresented in medicine minority. Num-
women. Data analysis was undertaken with HLM v. 7 (Sci- bers in the table reflect the demographics of women respondents before
entific Software International, Skokie, IL) applying a multi- multiple imputation was conducted to replace missing values (i.e., com-
level model to accommodate the clustering of reports in plete case analysis).
Pololi et al Sexual Harassment in Residents
Figure Rate of Sexual Harassment in Residents by Specialty and Program Year.
Reported rates of sexual harassment among female resi-
dents self-identifying as lesbian, gay, transgender, bisexual,
or queer or questioning (LGBTQ) were significantly higher
than those not expressing that identity (odds ratio [OR]
3.59, CI: 1.09-11.79. P = 0.03), with 19% (n = 4) of resi-
dents identifying as LGBTQ vs 6.2% (n = 46) of residents
not identifying as LGBTQ reporting sexual harassment.10
In assessing correlations between sexual harassment and
dimensions of the culture assessed by the CRS, sexual
harassment was associated with lower levels of vitality
(being energized by work) with a small-to-medium stan-
dardized effect (b = 0.31, se = 0.12, P = 0.01, Cohen’s d =
0.35). Sexual harassment was associated with higher lev-
els of ethical or moral distress, with a large standardized
effect size (b = 0.60, se = 0.11, P < 0.001, Cohen’s d =
0.96).
DISCUSSION
For residents in our study, sexual harassment by colleagues
and supervisors was less prevalent in pediatrics, where
women residents and faculty outnumber men, than in IM or
GS. Nationally, 36% of faculty in IM are female, but only
19% of surgical faculty are female.
For residents, sexual harassment is associated with
reduced vitality and higher levels of ethical or moral dis-
tress. This relationship between sexual harassment and
vitality and ethical or moral distress is also true for a
national sample of women faculty at AMCs; additionally,
female faculty reporting recent sexual harassment were
2.60 times more likely to intend to leave their institution
(unpublished data).
Although using abbreviated measures to inquire about
sexual harassment may lead to underestimation of
harassment prevalence,4 we hypothesize that our survey
item captured particularly egregious experiences above
some threshold of "bad enough" to be recalled and
reported.
247
It is chilling to realize the widespread extent of this
unprofessional behavior among physicians in medical train-
ing programs. In our institutions of healing, learning, and
discovery, gender bias and harassment must be eliminated.
Our institutional leadership can help to create a culture in
which individuals can speak out without fear when observ-
ing or experiencing sexual harassment. Sexual harassment
is illegal and unprofessional and must be treated as the dep-
rivation of equal rights that it is. In this era of cultural reck-
oning for women, academic medicine needs to look to its
own house and ensure accountability and transparent
responses to unprofessional behaviors, including sexual
harassment.
ACKNOWLEDGMENTS
We thank the many residents who completed the C-Change
Resident Survey.
References
1. Pololi LH, Evans AT, Civian JT, et al. Faculty vitality—surviving the
challenges facing academic health centers: A national survey of medi-
cal faculty. Acad Med 2015;90:930–6.
2. Pololi LH, Evans AT, Civian JT, Shea S, Brennan RT. Assessing the
culture of residency using the C-Change Resident Survey: validity evi-
dence in 34 U.S. residency programs. J Gen Intern Med 2017;32
(7):783–9.
3. Pololi LH, Evans AT, Civian JT, Shea S, Brennan RT. Resident vital-
ity in 34 programs at 14 academic health systems: insights for educat-
ing physicians for the future. J Surg Educ 2018;75:1441–51.
4. National Academies of Sciences. Engineering, and Medicine. Sexual
Harassment of Women: Climate, Culture, and Consequences in Aca-
demic Sciences, Engineering, and Medicine. Washington, DC:
National Academies Press; 2018.
5. Collins FS, Tabak LA, Wolinetz CD, et al. Update on NIH’s efforts to
address sexual harassment in science. NIH Website. February 28,
2019. Available at” https://www.nih.gov/about-nih/who-we-are/nih-
director/statements/update-nihs-efforts-address-sexual-harassment-
science. Accessed April 30, 2019.
6. Komaromy M, Bindman AB, Haber RJ, Sande MA. Sexual harass-
ment in medical training. N Engl J Med 1993;328(5):322–6.
248
7. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in
medical training: a systematic review and meta-analysis. Acad Med
2014;89(5):817–27.
8. Jagsi R, Griffith KA, Jones R, et al. Sexual harassment and discrimination
experiences of academic medical faculty. JAMA 2016;315(19):2120–1.
The American Journal of Medicine, Vol 133, No 2, February 2020
9. Freischlag JA, Faria P. It is time for women (and men) to be brave: a
consequence of the #MeToo movement. JAMA 2018;319:1761–2.
https://doi.org/10.1001/jama.2018.4059.
10. Brogan DJ, Frank E, Elon L, et al. Harassment of lesbians as medical
students and physicians. JAMA 1999;282(13):1290.