In Reply

We appreciate the thoughtful comments and questions raised by Dr Houtrow surrounding the reporting of sexual harassment in academic medicine by internal medicine residents.¹ We believe that any amount of sexual harassment is unacceptable and assert that our findings of 12.8% of residents (1 in 4 women residents) reporting sexual harassment is highly problematic. Continued efforts to reduce sexual harassment are warranted and needed.

We agree that the ambient harassment environment residents and others are exposed to may be associated with the normalization and acceptance of this behavior, thus driving underreporting of sexual harassment. We acknowledge that how residents recognize, internalize, or normalize sexual harassment may differ from the definition provided by the US National Academies of Science, Engineering, and Medicine report.² Moreover, the culture created within their program may further drive understanding and reporting of this phenomenon.

Dr Houtrow’s comparison to previous studies, however, warrants a larger discussion. Unlike the University of Michigan study that was a single-center study of faculty with a low response rate (25.9%),³ our study was conducted on a national level, focused on internal medicine residents and had a high response rate (72.5%). The study findings–12.8% of internal medicine residents self-reported experiencing sexual harassment¹–parallel the findings of other large multisite survey-based studies with similar response rates, including 1 centered on early career development awardees and another study of surgical residents where sexual harassment was reported by 16.3% and 10.3% of respondents, respectively.^1,4,5 It may be that high reporting of sexual harassment within a single site indicates a toxic environment. Alternatively, high rates of reported sexual harassment may indicate safe environments–created by efforts to combat the behavior and where sexual harassment is clearly defined, reporting structures are clearly outlined, and all are encouraged to and supported in reporting it.

The extent to which individuals recognize and perceive their experiences as sexual harassment is highly nuanced. To report sexual harassment, including the more insidious forms of gender harassment well described by Dr Houtrow, individuals must perceive the comment or behavior as inappropriate. Furthermore, these experiences are filtered through an intersectional lens that may also change how they are perceived, encountered, and classified. Using survey instruments such as the Sexual Experiences Questionnaire⁶ may allow researchers to further understand the influence of individuals who acknowledge and report being sexually harassed compared with those who report experiencing the behaviors but do not acknowledge being sexually harassed, and whether acknowledgment is associated with different outcomes (eg, burnout, depression, work satisfaction).

Our study was not intended to signal that the issue is resolved. On the contrary, at 12.8% sexual harassment is far from being resolved. Challenges remain and medical education must remain vigilant on this topic. Future work should focus on the drivers of nonreporting and identifying how to create safe and supportive environments for reporting. Lastly, our study highlights the residents’ lack of satisfaction with the reporting process; this must be addressed, otherwise we risk the perpetuation of a cycle of nonreporting owing to the belief that nothing will be done.