Sexual harassment and abuse: when the patient is the perpetrator

A young female physician receiving unwelcomed sexual attention from a patient and feeling unsafe is not a new problem. However, these encounters destabilise patient–physician relationships and can have negative consequences for the physician’s future. The patient–physician relationship is founded on trust and entered into by mutual consent.¹ Now that more than 50% of medical students in the UK and the USA are women, systematic approaches are needed to ensure that female clinicians can safely treat patients in populations where sexism is common.^2,3

The UK General Medical Council (GMC) and the American Medical Association define sexual harassment as unwelcomed attention or behaviour that a person finds offensive and that makes them feel unsafe and uncomfortable.^4,5 The US National Academies of Sciences, Engineering, and Medicine divides sexual harassment into gender discrimination, unwanted sexual attention, and sexual coercion.⁶ They note that female medical trainees report vastly higher rates of sexual harassment than trainees in the sciences or engineering.^6–8 Yet the governing bodies for medical trainees—eg, the Liaison Committee on Medical Education and Graduate Medical Education (USA), GMC (UK), Committee on Accreditation of Canadian Medical Schools, Medical Board of Australia, and the German Medical Association—limit their guidance to peer and supervisor-initiated sexual harassment. There is no clear guidance on how to respond to patient-initiated sexual harassment and abuse when the physician is tasked with caring for the health of the patient, while at the same time potentially diminishing her own health or safety.⁹

Traditional perspectives on patient-initiated sexual harassment have generally dismissed the effects on physicians as simply a hazard of the job that should be handled by physician resilience. However, sexual harassment needs to be addressed directly and proactively. There should be clear, written expectations and responsibilities about how patients and providers should behave in clinical settings (universal codes of conducts). Additionally, clear guidelines and policies on patient-initiated sexual harassment must be developed. Policies must support the physician and ensure that the patient continues to receive appropriate medical care.

Extrapolating from work on racist patients,¹⁰ we provide an algorithm to guide physicians and medical trainees in balancing their obligation to provide effective and appropriate care with their need to work in a safe and respectful environment (figure). The pivotal question in the algorithm for a physician or trainee is “do you feel safe?” If a physician feels safe, the patient’s behaviour needs to be clearly and firmly addressed. If a physician feels unsafe, it is the physician’s right to excuse herself from the patient encounter as safely and quickly as possible while seeking help from a colleague or supervisor. All instances of patient-initiated sexual harassment should be reported to the appropriate leadership (their division, department, programme, or hospital leadership). At the physician’s discretion, the patient’s care can be transferred to a different provider. Institutions have an obligation to support the decision of the physician while caring for the patient.

Figure:

Decision-guiding algorithm for physicians who experience patient-initiated sexual harassment and abuse

Ensuring the safety and wellbeing of physicians is an ethical imperative. Doing so fosters a diverse workforce, reduces contributors to work dissatisfaction and burnout, and can help retain female physicians in academic medicine—all of which contribute to improved care for patients.^6,11,12 Institutions have a responsibility to provide a road map for navigating these encounters, and accrediting and governing agencies should offer guidance to member organisations.

For too long, patient-initiated sexual harassment and abuse have been dismissed and neglected. Governing bodies that oversee medical education and care must provide guidance and policy recommendations for addressing this problem, and teaching institutions and other health-care organisations must implement them.¹³ The time is up for allowing trainees, clinicians, and the future pipeline of physicians to continue to operate in a world that once viewed sexual harassment at the hands of patients as just part of the job.