Psychological Harm

Sexual harassment causes psychological harm, ranging from poor psychological wellbeing to specific mental disorders like depression, anxiety and PTSD. (Reference Cortina and Areguin1; Reference Stockdale, Logan and Weston15; Reference Mushtaq, Sultana and Imtiaz16) One in five health care workers who experience sexual harassment report feelings of helplessness and despair, (Reference Talas, Kocaöz and Akgüç17; 18) with one in three victims feeling disgust and anger. (Reference Talas, Kocaöz and Akgüç17; 18)

Feelings of powerlessness can be particularly challenging for doctors, who are used to being able to manage their lives and work. (Reference Mushtaq, Sultana and Imtiaz16) Doctors have a reasonable expectation of being safe and respected at work. Violation of this trust can result in profound feelings of betrayal, and impaired trust in colleagues and the organisation they work within. Survivors may present with psychosomatic features such as headaches, nausea, exhaustion, gastrointestinal problems, and respiratory complaints. (Reference Cortina and Areguin1) The psychological harm caused by harassment may give rise to adverse coping mechanisms, such as disordered eating, self-harm, and substance misuse. (Reference Cortina and Areguin1) The higher the frequency of sexual harassment, the stronger the association is between sexual harassment and poorer mental health. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7) Health care workers placed in environments of repeated and unreported sexual harassment are at increased risk of psychological harm.

Burnout

Sexual harassment causes burnout, (Reference Linos, Lasky-Fink, Halley, Sarkar, Mangurian and Sabry5; Reference Mathews, Hammarlund, Kullar, Mulligan, Le and Lauve19) a syndrome associated with chronic unresolved workplace stress. (20) Burnout has three dimensions. The first is feelings of exhaustion and energy depletion. The second is depersonalization, whereby the employee places increasing mental distance between themselves and their employment. The third is feelings of reduced personal accomplishment. (20; Reference Koutsimani, Montgomery and Georganta21) All of these features impact the therapeutic relationship. A doctor who is exhausted, interpersonally unstable and insecure has less to offer in the therapeutic relationship. The workplace also becomes associated with stress, anxiety, and depression, reducing the doctor’s professional performance. (Reference Templeton, Bernstein, Sukhera, Nora, Newman and Burstin13; Reference Koutsimani, Montgomery and Georganta21–Reference Maske, Riedel-Heller, Seiffert, Jacobi and Hapke23).

Employment

One in four sexual harassment victims report that sexual harassment had a negative impact on their career or employment. (Reference Commission6) Victims may try to avoid the workplace area where the harassment occurred due to the psychological trauma, or to keep themselves safe from further harm. This is difficult in the medical profession as treatment rooms and theatres can become associated with trauma. In addition to avoiding physical locations, victims may seek to avoid the perpetrator. This extends to missing educational and networking events, which hampers career progression. (Reference Commission6)

Workplace withdrawal occurs as the individual becomes less attached to their workplace and less motivated to attend work. (Reference Cortina and Areguin1; Reference Willness, Steel and Lee24) As job satisfaction decreases, doctors are more likely to leave their employment. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7; Reference Chan, Chow, Lam and Cheung25) Consequently, individuals may be dissuaded from working in particular hospitals or from pursuing training in a particular specialty. One of the authors of this chapter was deterred from working on surgical wards after being repeatedly harassed by a senior male surgeon, with comments such as, ‘It’s good to see a woman on her knees. It always makes me hopeful’, while she was filing notes on a ward round trolley. Survivors of this sort of behaviour may well exit the profession as their early experiences in one hospital can affect how they perceive the profession as a whole. (Reference Commission6; Reference Komaromy, Bindman, Haber and Sande26)

While there is legal recourse for survivors of sexual harassment, many do not report. In one study, 79% of workplace harassment was not reported. (27) Worryingly, 42% of doctors who had experienced sexual harassment felt that they could not report it. (28) The most common reason for not reporting sexual harassment is the belief that no action would be taken, while more than half of victims feared that reporting the issue would negatively affect their collegiate relationships. (28)

Despite women making up half of medical graduates for over a decade, disparities persist in the number of women entering certain surgical training programmes, such as orthopaedics, or progressing to medical leadership roles. While the factors behind these situations are undoubtedly complex, sexual harassment is one impediment to women doctors’ career progression.

Gender

Gender moderates how sexual harassment is perceived and reported. Men and women interpret workplace sociosexual behaviours differently (Reference Willness, Steel and Lee24; Reference Welsh29). A large majority of perpetrators of sexual harassment are men, (Reference Perumalswami and Jagsi30) while women are more likely than men to observe that harassment has occurred. (Reference Willness, Steel and Lee24; Reference Rotundo, Nguyen and Sackett31) Men may wrongly assume a behaviour to be harmless or ‘just a joke’, while woman may perceive the same action as a threat. (Reference Rotundo, Nguyen and Sackett31; Reference Kara and Toygar32) When presented with different scenarios, women are more likely than men to find the behaviour in question to be offensive, inappropriate, and severe. (Reference Willness, Steel and Lee24; Reference Rotundo, Nguyen and Sackett31) Interestingly, an act is more likely to be perceived as sexual harassment if it takes place in a male-dominant or mixed working environment than if it occurred in a female-dominant environment. (Reference Kara and Toygar32; Reference Sheffey and Tindale33) Women are significantly more likely to report sexual harassment than their male counterparts. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7) Some male physicians may not report being victims of sexual harassment out of fear of not being believed or being accused of the harassment due to their gender. (Reference Farkas, Scholcoff, Machen, Kay, Nickoloff, Fletcher and Jackson34) These findings reinforce the importance of programmes such as ‘Operating with Respect’, which reinforce that legal definitions of sexual harassment focus on the victim’s experience rather than the perpetrator’s intent. (Reference Williams, Mayes and Lipworth35)

How gender influences the impact of sexual harassment on the victim remains unclear. Earlier research found that, following an incident of sexual harassment, women were more likely than men to develop symptoms of anxiety, depression, disordered eating, or PTSD. (Reference DeSouza and Fansler36–Reference Harned and Fitzgerald38) Similarly A more recent study found that male physicians are less likely to experience emotional distress than female physicians following sexual harassment. (Reference Farkas, Scholcoff, Machen, Kay, Nickoloff, Fletcher and Jackson34) Women surgeons who experience sexual harassment are more likely than men to report burnout. (Reference Ceppa, Dolejs, Boden, Phelan, Yost and Donington39) Despite several studies indicating women’s higher prevalence of worsened mental health due to sexual harassment, other studies have concluded the opposite. One study found that at high levels of sexual harassment, male victims are more likely to experience poor mental health. (Reference Street, Gradus, Stafford and Kelly40) That study posited that the effects of harassment might be stronger for males as it is less common and less normative. (Reference Street, Gradus, Stafford and Kelly40) Their gender role could be under threat, causing further feelings of powerlessness. (Reference Street, Gradus, Stafford and Kelly40; Reference Singer41) Despite the gender differences observed in some primary studies, a meta-analysis of forty-nine studies found no difference regarding how men and women are impacted by sexual harassment. (Reference Chan, Chow, Lam and Cheung25) In particular, there was no difference between the groups concerning either job-related satisfaction, commitment, withdrawal or stress. (Reference Chan, Chow, Lam and Cheung25)

While being the victim of sexual harassment may affect both genders equally, the financial and employment outcomes are worse for women than men. (Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7; Reference Ceppa, Dolejs, Boden, Phelan, Yost and Donington39) Women are more likely to take a pay-cut or leave their career in order to avoid the perpetrator. (Reference Commission6; Reference Vargas, Brassel, Cortina, Settles, Johnson and Jagsi7) And, of course, a large majority of the victims of harassment are women, meaning that the burden of harm falls heavily on women. This has significant implicants for gender equity in medicine, which has traditionally been a male-dominated workforce. (42; Reference Burgess, Shaw, Ellenberger, Segan, Castles, Biswas, Thomas and Zaman43)

Age

Age further moderates how a person perceives sexual harassment and how it impacts them. There is a positive relationship between a person’s perception of sexual harassment and their age. (Reference Ohse and Stockdale44) This means that older individuals are more likely than younger individuals to notice sexual harassment. (Reference Ohse and Stockdale44) This may indicate that younger employees are less able to recognise a hostile work environment than older colleagues due to their limited workplace experience. (Reference Ohse and Stockdale44) Interestingly, however, the repercussions of sexual harassment appear worse for younger individuals than older individuals. There is a stronger correlation between sexual harassment and employee wellbeing in those under forty years old than in their older colleagues. (Reference Chan, Chow, Lam and Cheung25) Similarly, that younger age group is more likely to have decreased work satisfaction and commitment following sexual harassment. (Reference Chan, Chow, Lam and Cheung25) The consequences of sexual harassment may be heightened among younger people as those who are middle-aged may have higher levels of emotional regulation and greater career security. (Reference Chan, Chow, Lam and Cheung25) The sharpened impact of harassment on younger individuals is exacerbated as more than half of health care workers who are sexually harassed are below the age of thirty. (Reference Celik and Çelik45) This may have adverse consequences for the levels of anxiety, stress and depression among doctors who have recently entered the health care workforce. (Reference Mushtaq, Sultana and Imtiaz16)

Doctors in Training

Sexual harassment leaves lasting effects on victims early in their medical career, or even before they complete their medical education. Sexual harassment is more common in medical school than in any other university faculty. (Reference Stone, Phillips and Douglas46) Sexual harassment can interfere with a student’s academic performance, increase emotional distress, and escalate burnout. (Reference Templeton, Bernstein, Sukhera, Nora, Newman and Burstin13; Reference Sheehan, Sheehan, White, Leibowitz and Baldwin47) Among medical students who are sexually harassed, 9% no longer seek out that area of medicine while 7% take time off medical school. (Reference Wilkinson, Gill, Fitzjohn, Palmer and Mulder48) A further 5% are likely to consider exiting the medical field completely. (Reference Wilkinson, Gill, Fitzjohn, Palmer and Mulder48) Like medical students, trainee specialists may also have their careers curtailed by sexual harassment. Some surgical cohorts, such as those in US obstetrics and gynaecology training programmes, have reported that 69% of their trainees have been victims of sexual harassment. (Reference Menhaji, Pan and Hardart49) Trainees who have been sexually harassed have lower emotional wellbeing and stress tolerance than those who have not been harassed. (Reference Menhaji, Pan and Hardart49) They are also less likely to feel that their hospital workload is reasonable or safe. (Reference Menhaji, Pan and Hardart49) Junior doctors and medical students, who are victims of sexual harassment, often do not report their experiences out of fear of retaliation. (Reference Sheehan, Sheehan, White, Leibowitz and Baldwin47) This fear is not unfounded, as perpetrators can act as gatekeepers to their professional development. (Reference Stone, Phillips and Douglas46) Senior surgeon Gabrielle McMullin notoriously told surgical trainees, ‘if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request’. While not condoning sexual harassment in any form, Dr McMullin said the sad truth is that female doctors who complain will be ‘hung out to dry; … [and] seen as a liability’. (Reference Matthews50)

Unfortunately, as abuse remains underreported, sexual harassment can become normalized within the medical faculty and workforce. (Reference Phillips, Webber, Imbeau, Quaife, Hagan, Maar and Abourbih51) This can perpetuate transgenerational abuse (Reference White52) with the survivor becoming the abuser to the next generation of students.

Culture

The personal damage caused by sexual harassment seeps into the workplace, harming workplace culture and degrading organisational health. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2; Reference Commission6) In addition to harming the victim, sexual harassment affects those who witness it. (8; Reference Raver and Gelfand53) The vicarious trauma caused by sexual harassment can cause bystanders to experience symptoms similar to PTSD. (Reference Commission6) Bystanders may also feel decreased job satisfaction and describe poorer job performance. (Reference Commission6) High ambient levels of sexual harassment, measured as the frequency of indirect exposure to sexual harassment, correlates with higher levels of workplace withdrawal and intention to quit. (8) Sexual harassment can divide teams, with co-workers ‘choosing sides’ regarding the harassment. This fracture in employee dynamics can result in communication errors, trust breakdowns, and failures in teamwork. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2)

Interestingly, it is organisational rather than individual traits that are the biggest predictor of workplace sexual harassment. (Reference Cortina and Areguin1) Factors that correlate with harassment are the percentage of men in the team, whether the employment is stereotypically male, and whether most leaders are men. Sexual harassment is linked to workplaces that foster a climate of disrespect and where the organisation has no guidelines against the practice. (Reference Cortina and Areguin1) Consequently, workplace culture can be affected by sexual harassment, but it may also be a driver of it. Cultural change is required to prevent the persistence of sexual harassment of doctors by doctors.

Productivity

Productivity is decreased by sexual harassment due to heightened presenteeism, absenteeism and eventual employee turnover. Absenteeism and presenteeism are both significantly more likely to occur in sexual harassment victims than in those who have not been harassed. (Reference Merkin and Shah54) Absenteeism is defined as short-term absences from work, which is commonly in the form of sick leave, annual leave or unpaid leave. (Reference Commission6) Presenteeism is when the individual attends work, but where they are less productive than what they would have normally been. (Reference Commission6) Both result in a loss of health care output as the functional staffing shortfall leads to less patients being seen over a given period.

The loss of productivity associated with presenteeism differs depending on the type of sexual harassment. (9) Non-physical sexual harassment causes a 3% decrease in productivity for just over two weeks. Comparatively, physical sexual harassment results in a 13% loss of productivity that lasts close to thirteen weeks. (9) Sexual harassment not only reduces the victim’s productivity, but also that of the entire department. (Reference Willness, Steel and Lee24) Similarly, witnessing workplace sexual harassment is associated with heightened levels of absenteeism. (8) Sexual harassment lessens the survivor’s quality of work. This may be due to their impaired concentration or their avoidance of particular colleagues and areas of work. (Reference Valente and Bullough55) Consequently, sexual harassment is both an individual and organisational concern. It is detrimental not only to the victim, but also to the provision of health care services. Sexual harassment leads to a less effective health care workforce.

Financial

Sexual harassment is costly, and the financial implications are broad. They include loss of productivity, deterioration of the workplace environment, and legal fees. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2) Decreases in productivity, resulting from sexual harassment, impose high economic costs on workplaces. (9) These costs arise from lost managerial time, presenteeism, absenteeism, and eventual increases in turnover. (9) Managerial costs include the opportunity loss of time spent investigating and addressing harassment claims. (9) Presenteeism may occur when victims continue to attend work, but with a reduced level of functioning due to the consequences of sexual harassment. (9; Reference Homrich, Dantas-Filho, Martins and Marcon56; Reference Foote and Goodman-Delahunty57) Absenteeism costs arise when doctors who have been sexually harassed need to take time off work, requiring health care organisations to fill their roles. Longer term, increased staff turnover associated with sexual harassment imposes a substantial cost, accounting for around a quarter of the total organisational cost of sexual harassment. Replacing doctors is expensive, with high costs associated with recruitment, training, on-boarding and retention. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2; Reference Rimmer58) Organisations may also face substantial legal bills and reputational harm, which can affect their ability to recruit staff in the future.

In addition to the workplace expenditure, sexual harassment can cause the victim economic harm. One in ten survivors will be in a worse financial position following sexual harassment. (Reference Commission6) This is most commonly due to pursuing legal remedies, taking unpaid leave, or transferring to a lesser paid job. (Reference Commission6) Sexual harassment is an unnecessary health care expense. Uprooting it from the medical workforce could untangle much needed health care funds.

Professional Impacts on Patient Safety

The detrimental effects of sexual harassment on individual doctors can lead to worsened patient care. Poor mental health is a key risk factor for medical errors and worsened patient safety. (Reference Aghighi, Aryankhesal and Raeissi10; Reference Honno, Kubo, Toyokuni, Ishimaru, Matsuda and Fujino59) Depression reduces a person’s concentration and attention, (Reference Honno, Kubo, Toyokuni, Ishimaru, Matsuda and Fujino59) and can lead to slower thinking and action. (Reference Honno, Kubo, Toyokuni, Ishimaru, Matsuda and Fujino59) This can be particularly harmful for individuals working in the acute care setting, whereby fast paced work is required for better patient outcomes.

Doctors in training who are depressed are six times more likely to make a medication error than those who are not depressed. (Reference Kaneko, Koinuma and Ito60) They are significantly more likely to self-report their health as poor, work in an impaired condition and have difficulties focusing. (Reference Kaneko, Koinuma and Ito60) Absenteeism, which is associated with sexual harassment, is linked with reduced patient satisfaction and safety. (Reference Duclay, Hardouin, Sébille, Anthoine and Moret61) When doctors feel unsafe to attend work, their absence can also interfere with a patient’s continuity of care. Sexual harassment is harmful to patient care as it hampers the decision-making ability of the individual, while interfering with workplace flow. Protecting doctors from sexual harassment is a patient safety issue.

Burnout and Patient Safety

Burnout is associated with an increase in medical errors and a reduction in professional behaviours (Reference Rodrigues, Santos and Sousa3; Reference Al-Ghunaim, Johnson, Biyani, Alshahrani, Dunning and O’Connor12) leading to patient harm (Reference Ceppa, Dolejs, Boden, Phelan, Yost and Donington39). Burnout is linked with a 2.5-fold increase in medical errors, with higher levels of burnout associated with an increased risk of error. (Reference Al-Ghunaim, Johnson, Biyani, Alshahrani, Dunning and O’Connor12) The relationship is likely to be global, as a meta-analysis of nine primary studies found similar associations across different jurisdictions. (Reference Al-Ghunaim, Johnson, Biyani, Alshahrani, Dunning and O’Connor12) Whether burnout in fact causes medical errors remains unclear. However, the relationship is thought to be cyclical. This means that while burnout may lead to decreased patient safety, a decline in patient safety may exacerbate burnout. (Reference Hall, Johnson, Heyhoe, Watt, Anderson and O’Connor62)

Burnout decreases professionalism, which is linked to a reduction in practitioner empathy and an increase in loss of temper. (Reference Zheng, Shao and Zhou63) As a consequence of loss of professionalism, burned-out doctors are more likely to be the subject of lawsuits or complaints. (Reference Al-Ghunaim, Johnson, Biyani, Alshahrani, Dunning and O’Connor12) Combined with the expense of medical errors, burnout can be costly for the professional and health care system. (Reference West, Dyrbye and Shanafelt64)

Burnout may be linked to a decrease in patient satisfaction. Physicians who have burnout are more likely to receive lower patient satisfaction scores than their non-burnt-out peers. (Reference West, Dyrbye and Shanafelt64) High physician depersonalization and high emotional exhaustion significantly correlate with lower patient satisfaction scores. (Reference Anagnostopoulos, Liolios, Persefonis, Slater, Kafetsios and Niakas65) It is thought that doctors who have burnout reduce their emotional investment with patients, causing a worsened communication style. (Reference Anagnostopoulos, Liolios, Persefonis, Slater, Kafetsios and Niakas65; Reference Hobfoll and Freedy66) Doctors who have burnout may pivot from a biopsychosocial communication style, which focuses on the needs of the patient, to a more instructional biomedical interaction. (Reference Anagnostopoulos, Liolios, Persefonis, Slater, Kafetsios and Niakas65) In addressing the disease rather than the patient, the patient–doctor interaction and health outcome may be worsened. As sexual harassment is a key correlate of burnout, (Reference Ceppa, Dolejs, Boden, Phelan, Yost and Donington39) patient satisfaction may be worse for doctors who are victims of harassment.

Organisational Effects on Patient Safety

Sexual harassment can also affect patient safety by eroding effective team dynamics. (Reference Aghighi, Aryankhesal and Raeissi10; Reference Ceppa, Dolejs, Boden, Phelan, Yost and Donington39) Teamwork is one of the most important factors in avoiding medical errors and harm to patients. (Reference Aghighi, Aryankhesal and Raeissi10) Effective teamwork requires communication, trust, and shared situational awareness. (Reference Leonard, Graham and Bonacum67) Sexual harassment damages teamwork as it breaks down professional relationships and hampers trust between individuals. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2) Furthermore, it re-enforces workplace hierarchies, which can stop health care professionals from questioning unsafe medical decisions. (Reference Rihal, Baker, Bunkers, Buskirk, Caviness and Collins2; Reference Houck and Colbert4; Reference Aghighi, Aryankhesal and Raeissi10)

Tellingly, in a survey to health care workers, 53% of individuals found that disruptive behaviour, which includes sexual harassment, contributed to hospital near misses. (Reference Veltman14) Similarly, 42% of surveyed health care workers reported that a specific adverse outcome had occurred due to disruptive behaviour. (Reference Veltman14) The survey highlights how supportive, rather than intimidating, work environments are necessary for patient safety. (Reference Longo and Hain68; Reference Brubakk, Svendsen, Deilkås, Hofoss, Barach and Tjomsland69) As patient safety is dependent upon open communication, teamwork and trust, (Reference Veltman14) undermining either of them can be harmful to the patient. Sexual harassment is detrimental to the patient in its creation of a hostile workplace environment. Health care systems that foster positive workplace conditions, free from sexual harassment, could lead to better patient outcomes.