Sexual Harassment and Prevention Training

Issues of Concern

Barriers to Reporting Sexual Harassment in Medicine

Barriers to reporting sexual harassment include worry of not being believed, shame if peers know, lack of trust in authority, and a belief that these behaviors are necessary to advance.[1] Other barriers to reporting include fear of retaliation, lack of clarity about what counts, and confusion with the reporting process.[14] In a survey of surgery residents, nearly 50% experienced at least one form of sexual harassment during training, and most did not report the behavior, believing that the action was harmless (62.1%) or believing reporting to be a waste of time (47.7%).[1] A survey of family medicine residents revealed the most significant barriers to reporting are a lack of trust that the system will respond appropriately or at all and the concern of embarrassment or damage to the reporter's reputation.[15] A recent report explained that sexually harassed female physicians stayed silent because of decreased self-worth, the fear they brought unwelcome actions on themselves, and the concern they would be labeled as troublemakers.[15] The most commonly cited reason clinicians failed to report harassment from a patient was the fear of jeopardizing the doctor-patient relationship.[14] Clinicians also mentioned the challenge of mental health comorbidities in patients with sexually harassing behavior; they conveyed a tendency to tolerate SH from patients with a psychiatric disorder.[14]

Despite juridical and organizational reassurances, fear of reprisal and career harm are obstacles exacerbated by the hierarchy in medicine and medical education. Trainees and junior faculty are less likely to report and fear reprisal.[1][14] Many trainees fear covert retaliation, which includes vindictive comments about accusers in confidential settings, such as grant reviews, award selection, promotion discussions, and search committee meetings.

Employer Liability

Someone can be the victim or perpetrator of sexual harassment regardless of sexual orientation or gender identity. Victims can include employees, nonemployees, and patients, as well as witnesses or bystanders to the harassment. Nonemployees directly perform services for the employer, such as contractors, consultants, sales representatives, vendors, and delivery people. The victim does not have to be the person harassed but could be anyone affected by the offensive behavior. Unlawful sexual harassment may occur without economic injury to or discharge of the victim.

Employers have the responsibility regarding sexual harassment to (1) prevent the incident, (2) investigate incidents, and (3) correct the incidence in their workplaces. Employers are responsible for sexual harassment when perpetrated by their employees or nonemployees and when patients harass employees or nonemployees. Employers are strictly liable for sexual harassment when managers or supervisors are the perpetrators, regardless of whether the employer was aware of the behavior. On the other hand, employers are liable for sexual harassment when employees or nonemployees are the perpetrators only if the employer knew or reasonably should have known of the harassment and did not take immediate corrective action.

The Role of Bystanders and Changing Bystanders to Upstanders

Bystanders witness discrimination or harassment and have the opportunity to condone, intervene, or ignore the behavior.[16] An upstander is a bystander who takes a stand and interrupts inappropriate behavior to support the targeted person.[17]

When bystanders ignore harassing behavior, they appear to be condoning the behavior. By encouraging bystanders to speak up when they witness discriminatory or harassing statements or behavior, an organization can change bystanders into upstanders who help make harassment-free workplaces safe and more inclusive. Individuals need to be motivated and educated to provide them with confidence and practical ways to confront and intervene when harassing behavior occurs.

Bystander intervention is when a bystander becomes an upstander when discriminatory or harassing behavior occurs. The bystander effect is the psychological theory that people are less likely to help a victim or intervene when other people are present because there is a diffusion of responsibility and a social influence of other individuals’ choice not to intervene. Therefore, bystander intervention is not the same as the bystander effect.[16]

When bystanders decide to become upstanders, they intervene to mitigate the effects of unwelcome behavior or words. One proactive option for bystander intervention is to use the Right to Be 5 Ds (previously known as Hollabacks! 5 Ds) – Distract, Delegate, Document, Delay, and Direct. [See the Right to Be 5 Ds on righttobe.org] These methods are designed to de-escalate situations and provide a safe environment; 4 are indirect intervention methods and do not require confrontation.

The Right to Be 5 Ds

1. Distract: Indirectly diffuse the situation by interrupting the harasser and the victim. Distraction is an excellent option for those who are somewhat uncomfortable with confrontation or when the upstander thinks the harasser may escalate behavior if confronted. Examples of distraction include the following:

• Ask the harasser for information such as the time, directions, upcoming meeting details, or any random information intended to redirect the harasser from continuing to target the victim.
• Move between the harasser and the victim while continuing to do what you were doing. Use your presence to separate them.
• Cause a commotion to shift attention, such as spilling coffee, dropping files, or pretending to have lost your phone and need help locating it.

2. Delegate: Ask someone for help with intervening in harassment. Look for someone close in proximity and willing to help. Supervisors or leaders are ideal delegates. Communicate what is happening and how you’d like their assistance. Examples of what the upstander could do:

• Ask the delegate to stand between the two individuals and distract the harasser so the upstander can ask if the one potentially being harassed is okay.
• Work with another bystander to team up and intervene.

3. Document: Record or take notes of the harassment if someone is already helping the targeted person and if your safety is ensured. Always ask the person who was harassed if they want your recording or notes, and don’t use them without their permission, especially posting online.

4. Delay: Check in with the person targeted with discriminatory or harassing behavior after the incident. Often, harassment happens quickly, and there isn’t time to intervene, but the upstander can speak to the person targeted after the incident and offer support and assistance. Examples of practical assistance include the following:

• Tell them you saw what happened, reinforce that the behavior was wrong, and ask how they feel about the incident.
• Ask them what they think is the best way to support them and offer to be present with them for a while.
• Offer to help them report the behavior and ask if they want the documentation you have of the incident.

5. Direct: If everyone is physically safe and you don’t think the situation will escalate, respond directly and speak against the harassment or discrimination in short, succinct language. Avoid debating or arguing with the harasser. If the harasser responds and tries to debate, focus on the one harmed and do not engage with the harasser. Prioritize safety and do not put yourself or others in harm’s way.

If you choose direct intervention, some examples of what you could say are as follows:

• “Please stop now” or “leave her alone.”
• “She’s asked you to leave her alone, and I’m going to support her.”
• “That’s inappropriate,” or substitute “inappropriate with “disrespectful,” “gender discrimination,” “harassment,” “homophobic,” or other appropriate terminology.

Studies within institutions have shed light on key elements to encourage bystanders to become upstanders. Leaders need to be prepared to be upstanders, as individuals first look to leadership to intervene or address the behavior. Creating a work culture based on respect, listening with checks for understanding, and modeling appropriate behavior encourages bystander-to-upstander action.[18] Seeing leadership model upstander behavior is significantly associated with direct intervention, peer response, and self-efficacy.

Clinicians play a crucial role because they interact with staff and patients and may be present when sexual harassment occurs. Bystanders must know that they can become upstanders and have the power to interrupt harassment and provide support to targets of sexual harassment, even if they feel unable to confront a harasser directly.[19] However, bystanders may fear retaliation, especially if the bystander is in a position of subordination to the harasser. For example, a fellow or medical student witnessing a clinician leader in the training program speak or behave in a harmful way to others. Inaction may also be detrimental to the bystander, who could suffer the consequences of indirect harassment in isolation.[20]

The behavioral options for bystanders in a low-immediacy situation are to provide support and advise the target to report the behavior. The bystander could directly confront the harasser afterward and later serve as a proxy reporter. In high-immediacy situations, the bystander can interrupt the behavior, remove the target from the immediate situation, and encourage the target to report the behavior.[19]

Organizational Culture - Most Potent Predictor

Research suggests that organizational culture is the most potent predictor of sexual harassment, and leaders can change corporate culture. The degree to which those in the organization perceive the behavior to be tolerated or not tolerated impacts the prevalence of the behavior. Concrete steps to reduce sexual harassment within the entire organization to ensure that workers interact safely in a harmonious work environment are necessary to change the behavior.[8]

The highest management level must lead the charge to create a workplace culture where harassment is not tolerated, and practical prevention efforts are in place. Beyond a commitment to an inclusive and respectful workplace, accountability systems must ensure that harassers are held responsible in appropriate ways. Those who prevent or respond to harassment should be rewarded, and those who fail to respond should be held accountable for the failure. Effective leadership ensures that the appropriate time and resources are spent on harassment prevention. 

Men overwhelmingly occupy leadership positions such as department chairs, search committee leads, deans, and chief executive officers of hospitals and physician-hospital organizations, even though women outnumber men in those workplaces.

Although individual behavioral changes can yield meaningful results, wholesale cultural transformation is key to preventing sexual harassment. The employer should design a culture based on mutual respect, inclusion, and dignity. Improving transparency and accountability, clearly communicating a code of conduct that forbids unacceptable behavior, outlining punitive repercussions, and promoting a zero-tolerance attitude help define an anti-harassment culture.[19] Senior faculty should be encouraged to intervene when they become aware of harassing conduct because they can be role models and positively impact those involved. 

Archetypes of Leaders Who Inadequately Respond to Sexual Harassment in Medical Education

There are five types of leaders who do not respond adequately to sexual harassment in medical education: avoiders, authoritarians, dismissers, ineffective supporters, and enablers.[21] Avoiders act as if sexual harassment has not occurred; they generally remain quiet and permit a patient's inappropriate behavior while sending a message to the trainee that patient harassment goes with the territory. Authoritarians may not acknowledge the seriousness of sexual harassment; often, they assume clinicians and trainees should disregard patients' inappropriate statements and consider the real problem is the response to conduct.[21] Dismissers presume only the more severe actions, such as the unwanted touching or groping of physical assault, are the most pressing, and only those actions warrant a response. Ineffective supporters genuinely want to defend their team members and condemn inappropriate behaviors; however, they usually lack a practical strategy to address the issues. Enablers may not see unwanted behaviors of a sexual nature as wrong, and they may even contribute to the harassment. In this case, the attending or bystander does not strive to rectify unacceptable conduct or support the trainee or clinician exposed to the harassment.[21]

Business Case for Prevention

A compelling business case for preventing harassment exists. Between 2018 and 2021, the EEOC recovered nearly $300 million for individuals who filed harassment claims. Victims of sexual harassment in the workplace experience mental, physical, and economic harm. All workers are affected when productivity decreases, turnover increases, and the organization's reputation is harmed.[See EEOC Sexual Harassment in our Nation's Workplaces] Several investigations identified job-related outcomes, such as decreased job satisfaction, absenteeism, organizational commitment, requests for transfers, decreased productivity, and increased work withdrawal. Sexual harassment can influence career trajectories and result in judiciary and economic expenses that negatively impact the finances and reputation of the organization and the industry in general.[22][23]

Clinical Significance

Effects, Consequences, and Reactions of Sexual Harassment in Medicine

Workplace sexual harassment, categorized as gender harassment, unwanted sexual attention, and sexual coercion, is considered a risk factor for women's mental health problems. Women who have encountered sexual harassment in their workplace report depression, anxiety, increased use of alcohol and drugs, and eating disorders. In addition, negative mood, self-blame, reduced self-esteem, emotional exhaustion, anger, disgust, envy, fear, and reduced satisfaction with life have also been demonstrated. Sexual harassment increases the risk of suicidal behavior and severe psychiatric illness.[24]

Over the longer term, it is typical for women to become less trusting and more careful in developing professional connections and dealing with potential academic collaborators. Some women evade male mentors or permanently modify their interpersonal interactions with colleagues, which often harms professional relationships.[25] Several women investigate gender or inclusion issues within their fields. In contrast, other victims can become heavily implicated in awareness-raising activities or measures to change policies within their institutions or professional associations.[25] Some reject job opportunities to evade their perpetrators or circumstances.[25] Retaliation has negative consequences for the victims. In one study, the most commonly described situations for the victim included being fired for disclosing harassment, not receiving tenure or not becoming a full professor, feeling pressure to step down from an assistant dean position, accepting a position at a lower-ranked university, or dropping out of a significant research project.[25]

Other Issues

Strategies to Decrease Sexual Harassment and Retaliation

Prevention is the best tool for the elimination of sexual harassment. Prevention requires the construction of inclusive and comforting workplaces where inappropriate behavior, such as sexual harassment, is not tolerated. An employer should take all steps necessary to prevent sexual harassment from occurring. Measures should include raising the subject, expressing strong disapproval, developing appropriate sanctions, informing employees how to report, and developing methods to empower all to be a part of the solution.[26]

According to the EEOC's best practices for use in the workplace, the following five core principles have generally proven effective in preventing and addressing harassment:

• Committed and engaged leadership;
• Consistent and demonstrated accountability;
• Solid and comprehensive harassment policies;[21]
• Trusted and accessible complaint procedures; and
• Regular, interactive training tailored to the audience and the organization.

Leadership, Accountability, and Workplace Culture

Leadership should develop an overall strategy that promotes diversity, inclusion, and the belief that all employees deserve respect. Leaders should also ensure that the entire management team leads by example and models appropriate behavior. 

The cornerstone of a successful harassment prevention strategy is the commitment to create and maintain a harassment-free culture. Workplace culture is heavily influenced by what are perceived to be rewarded or punished behaviors. Employers should demonstrate that they take workplace harassment seriously through proper prevention and appropriate response to harassment and alleged inappropriate behavior. For example, employees should be encouraged to report harassment claims and know their efforts are appreciated because the entire team plays a role in maintaining a harassment-free work environment. Claims should be investigated promptly, and those who engage in harassment should receive consistent discipline appropriate for the harassment's severity. 

Best practices dictate that leadership should allocate sufficient resources and staff time for effective harassment prevention and engage all organizational leaders in prevention and correction efforts. Harassment risk factors should be identified, and steps should be taken to eliminate those risks. To maintain a harassment-free workplace, leadership should continually monitor the work environment and conduct a sexual harassment climate check throughout the year. For example, staff could discuss the topic at meetings, in-services, and through newsletters or other staff communications.

Dismantling a culture that exempts punishment or freedom from consequences may be necessary.[2] Leaders and bystanders hopefully will transform into allies that advocate for those subjected to harassment without straining patient or student relationships. A 5-step framework as a response strategy to sexual harassment is fair to the victim.[21] This framework includes (1) confronting the offender, (2) naming the behavior, (3) setting the expectation that the institution does not tolerate the behavior, (4) supporting the victim, and (5) being proactive.[21] This type of demeanor cannot be addressed solely by the individual harassed. However, the solution demands extensive modifications within the cultures of institutions. Although these changes often commence at the top, they require individuals to accept and adopt changes to be sustainable. The actions may continue when one bystander stands silent when faced with sexual harassment.

Written Harassment Policy

Employers should establish a clearly written comprehensive harassment policy and regularly communicate it to all parties. The policy should be available in the languages commonly used. The policy applies to all employees regardless of their position in the hierarchical structure and applicants and non-employees who play a role in the work environment. Examples of non-employees who interact with employees are security guards, food service staff, contractors, the board of directors, repair workers, oversight committees, delivery personnel, sales representatives, and hospital volunteers. Within the policy, employees should be encouraged to report inappropriate conduct, even if they are unsure it constitutes harassment. In addition, employers should ensure that they do the following with their written policies:

• Provide all policies to employees upon hire and during trainings;
• Post policies centrally in locations such as the employee handbook, the company’s website, near time clocks, break rooms, and other commonly used areas; and
• Review policies periodically and update them as needed.

Additionally, a comprehensive harassment policy includes the following:

• Description of prohibited conduct, including specific examples;
• Processes for employees to informally share or obtain information about harassment without filing a complaint, eg, phone line, employee assistance team, or chat on an internal website;
• Details of the organization's harassment complaint system, including, if possible, several easily accessible reporting avenues;
• Assurance that leadership will provide prompt and thorough investigation as well as prompt appropriate corrective action if the harassment did occur;
• Confidentiality assurance of parties involved, such as the reporter, alleged victims, alleged harassers, and witnesses, as possible and permitted by the law;
• A clear, unequivocal statement prohibiting retaliation, assuring that those who report and participate in investigations will not be subjected to retaliation and are protected under federal law. [See EEO Retaliation Law)

Harassment Complaint Systems

Effective reporting systems for harassment allegations are critical. The system should include ways for those who have experienced alleged harassment and those who have observed prohibited conduct to report the behaviors. When employees know that questions and complaints are welcome and early reporting is preferred, all are empowered to work as a team to achieve the goal of a harassment-free workplace. Leadership should ensure that all employees who receive, investigate, and resolve complaints are well-trained, objective, and neutral. They also need the authority to act accordingly and have the resources to resolve complaints appropriately. All concerns and complaints should be taken seriously and responded to swiftly.

A multifaceted reporting system is best. Besides the traditional method of reporting to the employee's supervisor or a designated human resource person, other reporting avenues, such as a hotline, an online process, and multiple individuals within management and human resources designated to receive the complaints. Senior leadership needs a clear avenue to report inappropriate behavior within the reporting process. Designated personnel should maintain an environment where all parties feel comfortable reporting prohibited behavior.

Effective designated reporting personnel treat all parties involved with respect and are impartial. They must document every complaint from initial reporting through resolution. Documentation of the detailed steps taken during the investigation, their findings and recommendations, and corrective actions are crucial to the process and future harassment prevention. 

An effective complaint system includes alternative ways to resolve disputes regarding behaviors that are not necessarily prohibited but could eventually escalate to that level. Designated personnel could facilitate communication among the parties and assist in preventive measures, so hopefully, there is a win-win for all involved. All parties involved should know that their involvement is confidential and within relevant legal responsibilities. Critical to the process is the assumption that all alleged harassers are presumed innocent and not prematurely disciplined until the investigative findings are conclusive for harassment. 

When harassment is inconclusive, the resolution of the complaint is communicated to the complainant and the alleged harasser. When harassment is conclusive, preventative and corrective action is taken, disciplinary measures can be implemented, and education regarding zero tolerance for retaliation should occur. If retaliation takes place, sanctions are imposed, at a minimum. 

Appropriate corrective disciplinary action may include counseling, further training, or closer supervision of the employee if the behavior is concerning but does not violate policy or the law. At times, restructuring the work environment or reporting relationships is necessary. Corrective disciplinary action may also result in termination of employment. After corrective action is taken, the complainant should not be forgotten. Regular follow-up with the complainant to ensure their environment remains harassment-free is advised. 

Harassment Training Programs

Regular comprehensive training ensures that employees understand the policies, expectations, prohibited conduct, consequences of misconduct, and ways to prevent inappropriate behavior. Respect in the workplace training is beneficial to help team members recognize a respectful and inclusive work environment.

Additional training for supervisors is recommended because they have greater responsibilities than other employees when maintaining a harassment-free environment and responding appropriately to prohibited behavior and complaints. [See EEOC Olguin Task Force Testimony, supra note 9] Non-managerial personnel, such as team leaders, may also benefit from additional training.

Training is most effective if senior leaders champion it. From the CEO to the human resources personnel, all employees should see a unified front with all leadership engaged in the process. Training should be reinforced regularly, easy to understand, and easily accessible to employees at every level within the hierarchy. The training is most effective when tailored to the specific workplace, the individual's role, and the workforce's daily experiences. Interactive training with active engagement is preferable. 

Successful training includes employees' rights and responsibilities when they are aware of potential prohibited conduct, regardless of whether or not they were subjected to inappropriate behavior. Successful training also includes the following:

• Encouragement of early reporting before conduct rises to prohibited harassment;
• Specific steps of the complaint process and voluntary alternative dispute resolution;
• Confidentiality assurance, when applicable by law;
• Possible consequences for those who engage in prohibitive behavior;
• Ways to openly discuss topics and ask questions; and
• Contact information for designated personnel who can assist and handle the complaint and resolution processes.

Practical training for supervisors and managers includes details on identifying, preventing, stopping, and correcting prohibited behaviors. Instruction on identifying risk factors, minimizing the risks, addressing harassment when they see it, and reporting behaviors appropriately are essential to prepare supervisors and managers for their role within the organization to ensure a harassment-free environment. Leadership should know precisely what conduct is protected from retaliation under federal law. These conducts include expressing intent to complain about harassment, filing a complaint, resisting sexual advances or intervening to protect others, and participating in a harassment investigation. 

Senior faculty members are critical components of institutional and organizational approaches to decrease sexual harassment and covert retaliation. Initiatives encouraging senior faculty members to intervene and file bystander complaints are beneficial. When experienced faculty witness inappropriate comments or behaviors and participate in group reporting when the same person harasses multiple individuals, a culture that expects a safe and harassment-free workplace is strengthened.[1]

What Should You Do When Harassment Occurs

If you experience, witness, or become aware of unwelcome sexual conduct, know that:

You have the right to tell the person to stop. The behavior should stop upon request. The conduct may be illegal if the behavior does not stop or retaliation occurs.

You have the right to report sexual harassment. The reporting option chosen may depend on the nature or severity of the unwelcome behavior. Individuals who report sexual harassment or participate in investigations are protected from retaliation. The behavior may be reported to a supervisor, management, or human resources member who knows the internal complaint and resolution process.

The EEOC enforces Title VII of the Civil Rights Act of 1964, the federal law that makes sexual harassment or retaliation illegal. Victims may file a charge any time within 300 days of the incident. The EEOC has the authority to investigate employers who have 15 or more employees.

Legal Remedies Available

After the EEOC completes an investigation, the employee who filed the charge (complainant) may file a lawsuit in federal court. The EEOC may help all involved settle through an informal process referred to as a conciliation if they determine there is reasonable cause to believe the violation occurred. Complainants who prevail in federal court may be awarded remedies allowed under Title VII to make the employee “whole.” Remedies may include compensation for back pay or lost benefits, clearing a personnel file, damages, hiring, promotion, reinstatement, punitive damages, and attorney’s costs. 

Individual Precautionary Measures for Sexual Harassment in Medicine

An individual team member's ability to work effectively depends on a favorable work environment. When harassment occurs, team dynamics break down, and ultimately, patient care is adversely affected. Clinical care and medical training require highly functional teams for optimal performance. Individual action plans should be developed to safeguard team members in threatening situations from patients, peers, and superiors.[6] Personal protection from patient harassment usually involves nonverbal communication, behavioral cues, and simple and direct requests to stop unwanted behavior. If the behavior continues, the worker could ask a colleague for assistance.[27] For personal protection from harassment by peers and superiors, a practical approach is to form alliances among coworkers who can trust each other to assist with personal safety. When peers are involved, if direct requests to stop are disregarded, confronting the person perpetrating the unwanted conduct can be a practical next step. In the case of superiors, a leadership figure could mediate on behalf of those affected.[27]

Enhancing Healthcare Team Outcomes

Sexual harassment in the healthcare workplace is a significant issue that can have profound effects on both individuals and the broader organization. Clinicians must understand the various forms of sexual harassment, from unwanted advances to gender-based discrimination, and recognize their responsibilities in creating safe and respectful environments. Legislation exists to combat this unacceptable practice, but surveys reveal its prevalence, highlighting the need for proactive prevention strategies.

In healthcare, threatening situations can come from patients, peers, and superiors. Teamwork is the best policy. Creating alliances among female coworkers and encouraging superiors to intervene and mediate for those affected are beneficial practices.[27] Commitment to a harassment-free workplace should be part of an overall diversity and inclusion strategy.

Effective sexual harassment strategies start with top leadership and involve every team member. Maintaining an environment of inclusion and respect requires commitment from all staff, regardless of their hierarchical levels. Coordinated interprofessional management and an integrated strategic approach are necessary to avoid these unprofessional and unwanted behaviors.[6] A code of conduct with information about rights, obligations, policies, and counseling services is essential for prevention. Every team member should know how to recognize and promote an institutional culture of zero tolerance. Harassing behavior should be reported.[27] Leadership at every level needs to be engaged to execute the interventions detailed in the best practices and protect victims from retaliation.[27] Effective trained designated personnel are crucial to the investigative process.[6]

Through training, clinicians learn to recognize potential sexually offensive behaviors, understand the impact on worker wellness and patient care, and acquire strategies for promoting inclusivity and preventing harassment. By actively engaging in sexual harassment prevention efforts, clinicians contribute to a safer, more supportive healthcare environment for both staff and patients. Ultimately, prioritizing prevention and fostering a culture of respect and inclusivity are essential steps in addressing sexual harassment in the healthcare workplace.