Sexual harassment of female chiropractors by their patients: a pilot survey of faculty at the Canadian Memorial Chiropractic College

Abstract

Background:

The purpose of this study was to survey a group of female chiropractors and inquire as to whether or not they had been sexually harassed by their patients.

Methods:

An online questionnaire was emailed via Survey Monkey to 47 female faculty members at the Canadian Memorial Chiropractic College (CMCC). Respondents were asked if they had been sexual harassed and, if so, the characteristics of the incident(s), their response to it, how serious they perceived the problem to be and whether or not they felt prepared to deal with it.

Results:

Nineteen of 47 questionnaires were completed and returned. Of these 19, eight respondents reported being sexually harassed by a patient (all male), most commonly within the first 5 years of practice and most commonly involving a ‘new’ patient. It was rarely anticipated. The nature of the harassment varied and respondents often ignored the incident. Most respondents perceive this to be a problem facing female chiropractors.

Discussion:

Although this is the first survey of its kind, this is a significant problem facing other healthcare professionals.

Conclusions:

Among this group of respondents, sexual harassment by patients was a common occurrence. More training on how to handle it, during either a student’s chiropractic education or offered as a continuing education program, may be warranted.

Introduction

Chiropractic licensing bodies across Canada and the United States have enacted very stringent standards of practice with respect to boundary violations between chiropractors and their patients, and the penalties for this type of professional misconduct are among the most severe in the regulatory world.^1,2 Boundary violations are referred to as sexual harassment, sexual misconduct, sexual impropriety, sexual violation or sexual abuse- depending on the jurisdiction and the nature of the transgression.² Actions deemed to be boundary violations run the gamut from idle chatter of a sexual nature, offensive jokes, suggestive or insulting sounds (whistling, ‘wolf’ or ‘cat-calls’), improper gowning procedures, inappropriate comments about a patient’s appearance or sexual orientation, inquiries into their sex life, sexual fantasies or preferences all the way to overtly sexual acts.² Inappropriate sexual acts can include kissing and hugging to penetrative sexual activities or masturbation of the doctor by the patient or of the patient by the doctor. If proven, penalties typically involve reprimands, suspension of a doctor’s certificate of registration or, in the case of Ontario, Canada a mandatory revocation of licensure for five years. Repeat offenders face permanent revocation. Estimates vary, but a recent jurisdictional review by the Health Professions Regulatory Advisory Council² in Ontario reported a prevalence of between 4% and 10%, a rate of recidivism of up to 80% and the typical profile of an offender to be a Caucasian male between the ages of 45 and 55 years old.

But what if the patient initiates the boundary violation toward the doctor? Given that chiropractic care is, by its very nature, among the most intimate forms of healthcare since it involves direct physical contact between the doctor and patient, there is certainly the possibility that a patient may misconstrue the motivation of the doctor’s actions. Although this area of health care is under-investigated (see discussion below) the data that does exist point to a common and often serious problem.

If a patient initiates a boundary violation of the doctor-patient relationship, this would constitute a form of sexual harassment. The Canadian Public Health Association (CPHA) defines sexual harassment as “any unwanted or unwelcome behavior about sex or gender that interferes with a person’s life and makes him/her uncomfortable, even if the harasser says he/she was only joking”.³ Table 1 lists the kinds of behaviors that would constitute sexual harassment according to the CPHA.

Table 1.

Examples of behaviors considered to be sexual harassment by the CPHA³

Rude jokes, sexual remarks, spreading rumors

Sexual put downs

Cat calls, rating appearance, whistling

Insults about sexual orientation

Bragging about sexual relations

Any forced sexual conduct (touching, patting, grabbing, kissing)

Twenty years ago a California federal appeals court ruled that a hostile work environment should be assessed not from the perspective of a ‘reasonable person’ but from the standpoint of a ‘reasonable woman’.⁵ While both men and women are the targets of sexual harassment, the majority of complaints come from women⁴ and the majority of studies investigating the incidence of characteristics of patient-initiated sexual harassment involve female practitioners (see Discussion below).

The purpose of this study was to survey a group of female chiropractors employed by the Canadian Memorial Chiropractic College (CMCC) and ascertain whether or not they had been sexually harassed by their patients and, if they had been, what were the circumstances and characteristics surrounding the incident.

Methods

Study Approval

This study was approved by the Ethics Review Board of CMCC.

Inclusion Criteria

An online questionnaire was emailed via Survey Monkey to all female chiropractic faculty members (n=47) at CMCC, since this was a convenient and readily accessible survey sample. Inclusion criteria were being a woman, being employed at CMCC, being a chiropractor and being involved with, or having been involved in, direct patient care. Participants were selected from the faculty database at CMCC and were contacted via faculty email.

Study Design

A cover letter explaining the purpose of the survey as well as the definition of sexual harassment as defined by the CPHA was sent to all female chiropractic faculty. The questionnaire included both multiple choice and short answer questions with the option of a confidential interview following the survey. The survey was modeled after the survey administered to female medical physicians practicing in Ontario, Canada in the early 1990s.⁶

In addition to general demographic information (e.g. respondent’s age, years in practice, type of practice) the survey inquired whether or not the clinician had experienced any form of sexual harassment while in a clinical setting (i.e. not during their private every-day lives) and, if so, to provide details of the nature of the incident(s). Respondents were also asked to list the age of the doctor at the time of the incident(s), how many years the doctor had been in practice at the time, what length of time the ‘harasser’ had been a patient at the time of the incident, the patient’s gender, what action (if any) was undertaken by the doctor, if the event was anticipated, and if the doctor felt adequately prepared to handle these types of situations Respondents were also asked to rate how severe they believed this problem is among female chiropractors on a 4-point rating scale (with ‘0’ being ‘not a problem’ and‘4’ being a severe problem). An ‘additional comments’ section was made available for each question. Respondents were asked if they would be willing to be interviewed by the investigators at a later day. If they opted to be interviewed, respondents were asked to self-identity themselves, thus permitting the investigators to contact them separately.

Beta testing of the Survey

The survey was not beta tested. Since it was virtually identical to the survey used by Schneider and Philips⁶ published in the New England Journal of Medicine we felt it was unnecessary to beta test our survey.

Confidentiality

The respondents were not asked to identify themselves in the questionnaire. A statement of consent and confidentiality agreement was included in the cover letter. The data was collected electronically, was password-protected and was only accessible by the researchers. No incentives were made to potential respondents to participate in the survey.

Study Distribution

The questionnaire was distributed electronically via CMCC’s internal email. A reminder to complete the survey was issued via email to those who did not respond within the first 10 days. The survey was kept open for 30 days.

Results

Response rate

Of the 47 female chiropractors surveyed, 19 (40.4%) completed the questionnaire. None of the respondents added any ‘additional comments’ and none of the respondents chose to be interviewed.

Demographic Characteristics:

The respondents ranged in age from 27 to 63, with 11 (57.9%) of respondents under the age of 40. Sixteen respondents (84.2%) had been in practice for less than 20 years. Seventeen respondents (89.5%) were currently involved in clinical practice and direct patient care. [Authors’ note: unlike some chiropractic colleges and universities, CMCC does not allow faculty members to have a private clinic on campus. This means faculty who are in clinical practice maintain it off-campus). The two respondents who were no longer in practice reported they have withdrawn from practice within the past 10 years. All 17 respondents who were in clinical practice reported they practiced in Toronto, Ontario. Only two respondents (10.5%) stated they were in solo practices; the other 15 respondents were in multi-doctor and often multi-discipline practices.

Harassment:

Eleven respondents (57.9%) reported being sexually harassed while in a clinical setting, and eight of these 11 respondents reported the sexually harassment was from a patient. The other three respondents stated they were sexually harassed by other chiropractors or by office staff. Table 2 describes the types of sexual harassment encountered.

Table 2:

Types of sexual harassment encountered by female chiropractors from patients (n=8)

Behavior	Number (%) of respondents
Suggestive looks	7 (36.8)
Sexual remarks	8 (47.1)
Suggestive physical gestures	4 (21.1)
Receiving inappropriate gifts	2 (10.1)
Pressure for romantic dates	5 (26,3)
Exposure of body part in a sexually suggestive way	2 (10.1)
Inappropriate brushing, touching, or grabbing	2 (10.1)
Unwanted contact	3 (15.8)
Unwanted communication	3 (15.8)
Other: compliments on make-up/hair	1 (5.3)

Age and Number of Years in Practice of Respondent when incident of Sexual Harassment took place

At the time of the incident, five respondents reported they were between the ages of 25 and 30 years old. Five respondents stated they were in clinical practice for less than five years when the sexual harassment occurred. One respondent commented that she has encountered sexual harassment at different times though out her entire career, which spanned over 30 years.

Length of time of Doctor-Patient Relationship

With respect to how long the doctor-patient relationship had been established, seven of the eight respondents who had experienced an incident of sexual harassment stated they had been treating the patient for less than six months at the time of the incident.

Response to Harassment

Three respondents stated they ignored the behavior and continued to provide care for the patient. Three other respondents stated they gave the patient a verbal warning to stop their actions and then proceeded to continue care. One respondent referred the patient to a male doctor. None of the doctors reported the incident to law enforcement (Table 3).

Table 3:

Practitioner response to harassment

Response	Number of respondents
Ignored and continued care	3
Verbal warning and continued care	3
Immediate dismissal	0
Delayed dismissal after attempted continued care	1
Legal action	0
Contacted malpractice carrier	0

Level of preparedness

When asked if the chiropractor anticipated the incident of harassment seven respondents reported they had not anticipated it. When asked, four of the respondents stated they felt adequately prepared to handle the incident. That said, 13 of the 19 respondents said that additional training via continuing education or during their undergraduate education at CMCC could have helped them anticipate or handle such an event better.

Perception of the Seriousness of Sexual Harassment of Chiropractor by their Patients

When asked to rate how serious a problem they believe sexual harassment by patients toward doctors is, using a 4-point rating scale with “4” being a serious problem and “0” being not a problem at all, all but one of the 19 respondents stated they perceived it to be a problem. Of the 18 respondents who thought this is a problem, 7 respondents rated the seriousness of the problem as 1/4, 7 as 2/4, 1 rated the problem 3/4 and 3 rated the seriousness of the problem as a 4/4.

Discussion

To the best of our knowledge, this is the first study that surveyed female chiropractors and inquired as to their experience with respect to being sexually harassed by their patients. A literature search did not uncover any studies such as ours; however, it did find a number of studies that investigated this issue among other healthcare providers.

In a national survey of American physical therapists, 86% reported unwelcome sexual behavior during the course of treatment, while 63% reported at least one incident of harassment towards them by the patient.⁷ A study by Pennington et al⁸ examining dental hygienists and the incidence of sexual harassment in a clinical setting found 54% of respondents reported experiencing sexual harassment. In that study, 99% of respondents who reported being sexually harassed were woman, and in 45% of cases the offender was a male patient. Another survey of 650 dental hygienists in Washington State revealed over 26% of them had personally experienced one or more forms of sexual harassment.⁹ In that study, the most frequent types of sexual harassment was ‘aesthetic appreciation’, ‘active mental groping’, ‘social touching’ and actual ‘sexual threats’. Fifty-four of respondents (all women) indicated the harasser was a male dentist/employer, and 37.1% stated the harasser was a male patient.⁹ Garbin et al⁴ reported 15% of students enrolled in a dental program in Brazil stated they had been sexually harassed by either patients or, far less frequently, by a professor (5.4% of all incidents). The study by Garbin et al⁴ was the only study to report that men were three times more likely to be sexually harassed than women.

A survey of 188 critical care nurses reported that 46% of respondents had been harassed in various ways, the most common being the recipient of offensive sexual remarks (56%), unwanted physical contact (53%), unwanted nonverbal attention (27%), requests for dates (16%) and sexual propositions (9%).¹⁰

Phillips and Schneider⁶ surveyed 1064 female family physicians in Ontario, Canada. Over 75% of respondents reported some type of sexual harassment by patients at some time during their career, usually in their own office by their own patients. A qualitative study by Schneider and Phillips¹¹ examining sexual harassment of female doctors by their patients found that in some instances “the gender of the patient takes precedence over her occupational status and, this combined with the unique characteristics of the doctor/patient relationship, can make the practice of family medicine more conducive to sexual harassment than other professions”.

McNamara et al¹² examined the extent of harassment toward emergency medical residents and found that 98% reported at least one occurrence of abuse or harassment, with patients being the most frequent source of these action. Women were more likely than men to report unwanted sexual advances. Another study by Vukovich¹³ surveyed 1,802 female family physician residents in the United States. The response rate was just over 50% (n=916) and 32% of respondents reported being the recipient of unwanted sexual advances, 48% reported use of sexist teaching material, 66% reported favoritism based on gender, 36% reported poor evaluation based on gender, 37% reported malicious gossip, 5.3% reported punitive measures based on gender and 2.2% reported being sexually assaulted during their residency.¹³

Brogan and Schiffman¹⁴ reported that, among a group of American female physicians (n=4,501), 47.7% respondents reported experiencing gender-based harassment, and 36.9% experienced sexual harassment. Characteristics associated with an increase likelihood of being sexually harassed included: Being younger; born in the United States; being divorced or separated and; having a history of depression or suicide attempts. Woman who were Asian or who were currently working in a group or government setting were less like to report being sexually harassed.¹⁴ Respondents in this study stated harassment was more common while they were in medical school. This finding was similar to a much early study by Komaromy et al.¹⁵

This problem is not unique to Canada or the United States. A 2013 study by Bratuskins et al¹⁶ investigated the nature and extent of sexual harassment among female Australian general medical practitioners. A random sample of 600 female medical physicians was surveyed, using a questionnaire based on an early study by Philips and Schneider⁶; 178 completed surveys were returned. Fifty four percent of respondents reported being sexually harassed by their patients. The most common behaviors reported were request for inappropriate examination (64.9%), inappropriate exposure of body parts (55.7%), gender-based remarks (43.3%), inappropriate gifts (42.3), sexual remarks (36.1%) and touching or grabbing (30.9%). Of those respondents who reported being sexually harassed by their patients, two-thirds (66%) reporting making personal changes or changes to their consultation style. Examples of these changes include adoption of a more formal demeanor, alter or avoid performing certain examinations, keeping the personal details of their own lives more private, changing their style of dress and no longer working after hours or alone. Only 6.7% of respondents reported that they have received any form of training related to strategies to deal with sexual harassment by patients.¹⁶

Two recent commentaries^17,18 discussed the perils to healthcare providers caused by the stalking behavior of some of their patients, and provided strategies to proactively prevent it. Preventive strategies include: being clear about the professional nature of the doctor-patient relationship; establishing clear boundaries; taking care to protect one’s privacy; minimizing any personal self-disclosure; considering transferring patients whose inappropriate behavior persists; informing colleagues of any event and; considering legal action.^17,18

Although our pilot study had a very small number of respondents, the data collected was very consistent with the findings of previous studies reviewed above. In general, it is not uncommon for a healthcare provider to be the target of a variety of different forms of sexual harassment. Most incidents of sexual harassment involved inappropriate remarks or comments; relatively few involved overt sexual contact and the target of this conduct was typically female practitioners.

In our study, the characteristics most commonly associated with being the target of sexual harassment were: being a more recent graduate; working with a male patient and; the likelihood of some kind of sexual harassments increased if the doctor-patient relationship was relatively new (i.e. less than 6 months). Most respondents did not anticipate the incident happening. Similar to other studies, no legal or police action was taken by any of the respondents. Unfortunately, when not penalized in any meaningful way, an abuser may feel emboldened to repeat the behavior with another healthcare provider. Almost all respondents consider the issue of sexual harassment in clinical practice to be a problem for female chiropractors.

Our study was accepted as a poster presentation at the 2014 Association of Chiropractic College and Research Agenda Conference (ACC-RAC) held in Orlando, Florida.¹⁹ Two of the reviews of our manuscript submission, along with several chiropractors (predominately women) who viewed our poster during the conference all commented that our study did not address the issue of the doctor’s attire or appearance. Specifically, comments were raised that perhaps the doctor was dressed provocatively or inappropriately, or that the doctor in some way invited the harassing behavior upon herself. The law does not recognize this as a mitigating factor and instead focuses only on the behavior of the ‘harasser’. One reviewer suggested that there ought to be a difference between a patient complimenting a doctor’s appearance versus an overtly sexual remark; perhaps there should be, but the law does not make this distinction. More importantly, any inquiries into this topic area would undoubtedly itself be considered inappropriate and possibly misogynistic; it is for that reason we purposefully avoided making inquiries into the doctor’s appearance or conduct.

Limitations

There were several limitations to our study. The small sample size as well as inclusion criteria restricted to female chiropractic faculty only within a single institution makes it unlikely our results are generalizable to the profession at large. There may also have been some confusion with respect to our question structure. For example, a respondent may have experienced more than one incident of sexual harassment: When asked to describe the characteristics of any these incidents, the respondent may have been confused as to whether they should describe the most recent event or the most serious one. In any event, we erred in not providing more clear instructions or a better survey structure to enable respondents to describe more than one incident of sexual harassment.

In surveys such as these, respondents may suffer from recall bias or, as Wells⁵ suggests respondents may have interpreted an innocuous comment from a patient as a form of sexual harassment, depending on the respondent’s cultural background. It is possible the data was skewed in that only respondents who were the target of sexual harassment were most likely to complete the survey. It is possible that a person chose not to respond to our survey since they were concerned (not without justification) that, given the small sample size, by describing their personal demographics they could be identified. Lastly no inference can be made toward male chiropractors, since they were not surveyed and, according to Brogan et al¹⁴ women may perceive certain actions as a sexual harassment whereas men would not.

Future Studies

Based on the results obtained from this study, we would redesign any future study to allow a respondent the ability to describe the characteristics of as many incidents of sexual harassment as they may have experienced. We would expand the study to include male chiropractic faculty and, ultimately, expand the study to a sample of chiropractors outside the college faculty.

Conclusions

In one chiropractic college, eight of 19 female practitioners who responded to our survey stated they had been sexually harassed by their patients while in clinical practice. All of the incidents were by male patients, most commonly occurred during the doctor’s first five years in practice and if the patient was a relatively ‘new’ patient (less than six months). The doctors most often chose to either ignore the incident or provide a verbal warning; in only one instance was the patient referred to another (in this case male) chiropractor. In no cases was the patient dismissed from care outright. In all instances, the doctor had no suspicion the incident was forthcoming. Respondents tended to report they perceived sexual harassment toward female chiropractors to be a problem This may speak to a need for more training on this topic during either student undergraduate education or provided by continuing education programs. Future studies will involve both male and female chiropractors and will be better structured to allow a fulsome description of all incidents of sexual harassment experienced by respondents.

Age:

Gender:

Marital Status:

Years in practice:

Location of practice:

Total number of employees in clinic setting:

Please answer the following questions:

1a)	Are you currently involved in active patient care as a significant part of your practice activities?
	❑ Y     ❑ N
1b)	If NO, when was the last time you were involved in providing active patient care as a significant part of your practice activities? within the past 5 years 10 years 15 years 20 years more than 20 years

2)	Have you ever experienced any form of sexual harassment, in a clinical setting or otherwise?
	❑ Y     ❑ N

3a)	In accordance to the aforementioned definition of “sexual harassment”, have you ever experienced sexual harassment in the clinic setting from a patient?
	❑ Y     ❑ N
3b)	If YES, what was the nature of the harassment? Choose all that apply. Suggestive looks Sexual remarks Suggestive physical gestures Receiving inappropriate gifts Pressure for romantic dates Exposure of part of the body in a sexually suggestive manner Inappropriate brushing, touching or grabbing Unwanted contact Unwanted communication (ex: phone calls, email, twitter, facebook, etc) Other
	Additional comments: _____________________________________________________________

4.	At the time of the incident, approximately how many years had you been in practice?
	Less than 1 year 1–5 years 5–10 years Over 10 years
Additional comments: ________________________________________________________________

5.	At the time of the incident, what was your approximate age?
	25–30 years old 31–40 years old 41–50 years old 51–60 years old Over 60 years old

5.	What was the gender of the patient?
	Male Female

6.	What was the approximate age of the patient?
	Less than or equal to 25 years old. 26 – 35 years old 36 – 45 years old 46 – 55 years old 56 – 65 years old 65 years and above
Comments:________________________________________________________________

7.	What was the duration of care of the patient prior to incident?
	Less than 3 months 3–6 months Over 6 months
Comments: _______________________________________________________________

8.	Following the incident, what was your plan of action?
	Continued care Ignored and continued care Verbal warning and continued care Immediate dismissal Delayed dismissal after attempted care Legal action Contacted governing body (CPPA)
Comments: ______________________________________________________________

9.	Did you anticipate the incident of harassment?
	❑ Y     ❑ N
	Comments: __________________________________________________________

10.	Did you feel adequately prepared to handle the incident?
	❑ Y     ❑ N
	Comments: __________________________________________________________________________

11.	Do you feel that additional training or preparation for such events provided through continuing education or time in college could have helped you anticipate or handle such an event?
	❑ Y     ❑ N
	Comments: __________________________________________________________________________

12.	How would you rate the severity of the problem of harassment of practitioners by their patients?
	0 (not a problem). 1 2 3 4 (a serious problem).
Comments: ______________________________________________________________________________

13.	Would you be willing to participate in a confidential interview following this survey?
	❑ Y     ❑ N

Thank you for your participation.