A survey was carried out of psychiatric trainees' work-related experiences of unwanted sexual contact. A structured postal questionnaire was administered to 100 psychiatric trainees from senior house officer to specialist registrar level in a large psychiatric rotation. There was an 85% response rate; 86% (73) of the sample had experienced unwanted sexual contact, with 47% (40) experiencing deliberate touching, leaning over or cornering, and 18% (15) receiving letters, telephone calls or material of a sexual nature. Three-quarters (64) of respondents had experienced unwanted sexual contact from patients and 64% (54) from staff. Experiences and attitudes did not generally differ by gender, grade or training experience. Four out of 48 female respondents described stalking by patients. Of the 39 respondents who had reported harassment by patients, 31 felt supported by colleagues, while of the 13 who had reported harassment by colleagues, eight felt supported. Two-thirds of the respondents considered sexual harassment ‘sometimes’ or ‘frequently’ a problem for the profession. Diagnoses of confusional states, mania or schizophrenia made subjects less likely to consider unwanted sexual behaviour to be ‘sexual harassment’ (86%, 80%, and 67%, respectively), but not for other diagnoses. Levels of threatening and intrusive sexual harassment are unacceptably high in this study group. Health trusts should adopt policies of ‘zero tolerance’ and all incidents should be reported. Psychological impact on victims should be acknowledged even when the behaviour of the perpetrator can be explained by diagnosis.
psychiatric trainees commonly experience intrusive sexual harassment from patients and sometimes colleagues
levels are unacceptably high and Health Trusts should adopt ‘zero tolerance’ policies
psychological impact of harassment should not be underestimated, even when a patient's behaviour is explicable by diagnoses of psychosis or confusional states
levels of sexual harassment need to be established among other medical specialties, particularly those involving community-based treatments
- sexual harassment
- postgraduate training
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The Equal Employment Opportunity Commission has defined sexual harassment as “unwelcome sexual advances, requests for sexual favours, and other verbal or physical conduct of a sexual nature”.1 Its consequences include major psychological trauma and its impact may have been underestimated.2 To our knowledge, there are no published studies of sexual harassment of doctors in the UK, but Canadian reports suggests that over 75% of female physicians have been harassed, and 4% experienced ‘grossly inappropriate touching’.3 Some of these cases demonstrated features unique to the profession, such as exploitation of genital exposure and close physical contact during clinical examination.4
Psychiatrists may have a higher risk of sexual victimisation, given a high incidence of violence in psychiatric hospitals5 6and of sexual victimisation of psychiatric in-patients.7However, similar issues are likely to pertain to all branches of medicine, including primary care. The added vulnerability resulting from community-based treatments generates a pressing need for data which, to our knowledge, have been lacking so far.
Postal details of all the psychiatric trainees from senior house officer to senior/specialist registrar level in a large psychiatric rotation involving several different NHS trusts were obtained from the rotational tutors' departments. They were sent an anonymous, confidential postal questionnaire concerning experiences and attitudes toward ‘unwanted sexual contacts’ at work. Questions categorised levels of sexual harassment, and distinguished perpetrators in terms of status (staff or patient) and gender. Attitudinal questions explored the impact of the perpetrators' diagnoses and extent to which harassment was regarded as a problem for the profession, with comments invited. Information concerning respondents included gender, age, grade and training experience. (Copies of the full questionnaire are available from the corresponding author on request.) The study was approved by the local ethics committee, with permission of area tutors. The results were stored and analysed using SPSS software, generating descriptive statistics and ‘between group’ comparisons (χ2 test) to observe differences between genders and in terms of training experience.
One hundred questionnaires were sent out, and 85 trainees responded, of whom 44% (37) were male. Sixty-one per cent (52) were senior house officers or pre-Calman registrars, and 39% (33) were senior or specialist registrars. The mean age of respondents was 32.6 years (range 24–54 years, SD 4.91). Training experience of respondents was reflected in a mean of 4.5 years in psychiatric training (1–14, SD 2.84) and a mean of 8.0 years qualified as a doctor (1–33, SD 4.68). Comparison of groups by indices of training experience (length of time in the profession, grade) did not reveal any significant differences at the 5% significance level.
EXPERIENCES OF SEXUAL HARASSMENT
Most (86%) of the sample had experienced some form of unwanted sexual behaviour during their psychiatric training, with 75% (64) experiencing it from patients and 64% (54) from colleagues. Frequencies of specific forms of unwanted sexual behaviour are shown in table 1.
COMPARISON OF GENDERS
Similar proportions of men and women had experienced some form of unwanted sexual behaviour (86% vs 85%, respectively). The majority had received this from patients (73% (35/48) of women and 78% (29/37) of men), with 64% (31/48) of the females and 62% (23/37) of the males receiving this from colleagues. For female trainees, 91% (32/35) of patient perpetrators and 97% (30/31) of staff perpetrators were male. For male trainees, 97% (28/29) of patient perpetrators and 91% (21/23) of staff perpetrators were female. There were no significant differences between genders at the 5% significance level for any of these ‘between group’ comparisons.
Experience of specific behaviours and attitudes to these behaviours are shown in table 2 for each gender. Figures in brackets indicate the same distribution for ‘same-sex’ perpetrators only.
Comparing specific behaviours between genders, no differences reached statistical significance at the 5% significance level, for either staff or patient perpetrators. Likewise there were no significant attitudinal differences between genders in classifying such behaviours as ‘sexual harassment’, except for ‘uninvited sexual teasing, jokes, remarks, questions, looks or gestures’ by staff, with female trainees classifying this as sexual harassment more than males (χ2 (1) = 4.30, p=0.038).
ATTITUDES TO SEXUAL HARASSMENT
Asked “to what extent do you consider sexual harassment to be a problem for the psychiatric profession?”, three respondents replied ‘never’, 27 ‘rarely’, 53 ‘sometimes’, and two ‘frequently’. These responses did not differ by gender, grade or experience.
Subjects were asked to consider a list of psychiatric diagnoses and to decide if they would make the subject less likely to consider unwanted sexual behaviour on the part of a patient to be ‘sexual harassment’. In order of magnitude, subjects replied ‘yes’ to acute confusional state (86%), dementia (86%), mania (80%), schizophrenia (67%), depression (46%), substance abuse (20%), neurosis (18%), and personality disorder (4%). Responses did not significantly differ at the 5% significance level between gender, grade or experience.
Subjects were asked to consider which of four categories of unwanted sexual behaviour they would regard as ‘sexual harassment’ if experienced from other members of staff or from patients. The results are shown in table 3.
There were no differences at the 5% significance level in attitudes to hypothetical behaviours from staff or from patients. Attitudes did not differ in terms of training experience or grade. Only one attitudinal question distinguished genders, with 73% of females and 49% of males regarding “uninvited sexual teasing, jokes, remarks, questions, looks or gestures” as sexual harassment (χ2 (1) = 5.24, p=0.022)
DESCRIPTION OF BEHAVIOURS
Twenty-one respondents appended descriptions. Concerning harassment by colleagues, women more often described physical threats, for example “I was physically cornered by a member of staff and threatened with violence if I didn't comply,” while men described more consensual acts, for example “A female registrar offered me sex for doing her ‘on-call’ (repeatedly).” Concerning harassment by patients, both men and women described threatening and violent behaviour, for example (female victim) “I was followed around corridors” or (male victim) “A middle aged woman grabbed my backside.” Four female respondents described repeated and persistent stalking, for example “I was stalked and (my stalker) suggested I was sexually harassing him.”
REPORTING OF EVENTS TO COLLEAGUES AND PERCEIVED LEVEL OF SUPPORT
Thirty-nine of the 63 positive respondents had informed colleagues about harassment from patients, and 79% of these felt they had received adequate support. Only 25% (13/52) of positive respondents had informed colleagues about harassment by other colleagues, of whom 62% felt they had received adequate support. There were no significant differences between genders or grades for the reporting of unwanted sexual experiences or perceived support.
Twenty-five respondents added comments on support; 11 indicated general satisfaction, for example, “I received empathy and understanding”, while 14 indicated dissatisfaction, for example, “Totally unsupported by consultant. Advised to contact MDU”, “Laughed off generally, especially by nursing staff”, or “Staff viewed this as a joke.”
In the context of a high response rate, this study suggests that sexual harassment is an extremely common experience for psychiatric trainees. Prevalence figures appear higher than previous studies involving family doctors or physicians abroad, though direct comparison would be inappropriate. Almost half of the sample (47%) had experienced “uninvited and deliberate touching, leaning over or cornering”, while 18% had received “uninvited letters, telephone calls or material of a sexual nature”. These intrusive and potentially violent behaviours were evenly experienced from both colleagues and patients. Less intrusive behaviours such as “sexual teasing” affected 80% of respondents, but less than half the sample regarded this as “sexual harassment”, and this was more commonly experienced from patients than colleagues.
No significant differences emerged between genders regarding actual experience of sexual harassment as a whole, nor were there gender differences if specific forms of harassment were examined. The absence of gender differences may be genuine or may be attributed to a type II statistical error. At a descriptive level, a small number of female respondents described severe forms of harassment including stalking by patients and sexual coercion involving threats of violence by colleagues. Most subjects had informed colleagues of harassment from patients, and most of these felt adequately supported by their peer group. Fewer subjects felt willing to report harassment by their colleagues, and fewer of these felt supported in doing so. Where support was forthcoming, it appeared to operate at a high level. However, there appeared to be many specific incidences where reported sexual harassment was not taken seriously and simply dismissed as part of the job. Unwanted sexual experiences in which the perpetrator was of the same sex were rare. Where this occurred, male victims were more likely to construe their experience as harassment than females, who seemed more tolerant.
Two thirds of the sample saw sexual harassment as ‘sometimes’ a problem, though few saw it as a frequent issue. There were few gender differences in attitudes to specific behaviours except for “uninvited teasing, jokes, remarks, questions, looks or gestures”, of which males were more tolerant. This seems to accord with societal norms. Unsurprisingly, where perpetrators were patients, their diagnoses altered perceptions of behaviour. Confusional states and psychoses appeared likely to protect the perpetrator from accusations of sexual harassment, but not other diagnoses.
Although the study had a high response rate, no information is available regarding the 15% of trainees who did not reply. There are also possible limitations as to the validity of information obtained by a postal questionnaire in such a sensitive area, particularly given the complexity of the questionnaire. All attitudinal studies run the risk of being skewed by the order and framing of questions. This study attempted to avoid such bias by placing questions concerning actual experiences before questions concerning hypothetical attitudes. The disparity between actual experiences and hypothetical attitudes is suggested by comparison of tables 1 and 3, from which it appears that many more respondents said they would consider specific behaviours as harassment than actually did form such judgements.
This study did not examine the frequency of these unwanted sexual experiences, their psychological impact or the relationship between the two. Future studies could address these issues with reference to context, for example, comparing traumatic response where sexually inappropriate behaviour is a manifestation of a patient's mental state and where it is independent. Nonetheless, in our opinion the levels of intrusive and threatening sexual harassment revealed in this study are unacceptable. We suggest that all Health Trusts should have explicit policies of ‘zero tolerance’ for dealing with harassment by colleagues or patients, and trainees' attention should be drawn to these on entry into the training scheme. Victims should be encouraged to report incidents, and particularly not to dismiss them as ‘part of the job’ or an inevitable feature of a patient's diagnosis. Even when unwanted sexual behaviours are explicable or excusable on account of the mental state of the perpetrator, it remains important that the victim does not thereby dismiss the psychological impact on themselves, which is a particular risk in the stoical medical profession. It is not clear if this level of sexual harassment applies in other branches of the profession in the UK, and further studies are needed as a matter of priority.