Qualitative description of sexual harassment and discrimination of women in emergency medicine: Giving the numbers a voice

Abstract

Introduction

Gender disparities in medicine are well documented; however, little qualitative data exist. This study sought to provide a qualitative assessment of harassment and discrimination experienced by female physicians in emergency medicine (EM) specifically by colleagues or supervisors.

Methods

An electronic survey was distributed to female EM physicians on October 18, 2018, asking if they have felt harassed, diminished, uncomfortable, or discriminated against by a male colleague or supervisor at work based on a sexual comment or unwanted advance. Space for descriptive experiences was provided. A data abstraction tool was developed, and experiences were placed into thematic categories. The survey was closed on December 18, 2018, and data were analyzed.

Results

There were 1280 responses. Responses that were incomplete, not attributable to women, and outside of EM were excluded leaving 1144 to be analyzed. Respondents were primarily White (81%) and working in nonacademic environments (53.5%). The majority (57.3%) felt harassed, diminished, uncomfortable, or discriminated against by a male colleague or superior at work based on sexual comment or innuendo; 22.3% experienced an unwanted sexual act or advance. There were 482 descriptive experiences reported, most frequently focusing on patronizing behavior (16.5%), pregnancy/maternity leave (15.9%), and physical appearance (12.5%).

Conclusions

Women in EM experience sexual harassment and discrimination at work by their peers and supervisors. Exploring the themes of their shared experiences can guide and focus efforts on both prevention and intervention. Further studies are needed to determine if these experiences contribute to disparities in earnings, promotion, and leadership roles of women in medicine.

INTRODUCTION

Studies have shown that gender disparities exist in medicine regarding salary, career advancement, and resource allocation. ¹ A 2009–2010 survey of academic emergency departments found that female emergency medicine (EM) faculty earned 10% to 13% less than male faculty. ² In 2014, an updated survey of academic EM faculty found that female gender was negatively associated with having a major leadership role and with attaining associate or full professor rank, even after adjusting for years in practice. ³ In addition to career advancement barriers, women in medicine disproportionately experience sexual harassment by patients and colleagues primarily in the form of verbal abuse. ⁴ Further complicating the experiences of women in medicine is the focus of harassment publicized in the context of negative actions perpetrated by patients. ⁵ While this is an important area to examine in health care and specifically EM, it can detract from the separate and perhaps equally detrimental harassment and discrimination committed by colleagues or supervisors. ⁵

Harassment starts early in women’s careers. A recent review found that almost 60% of medical students have experienced discrimination or harassment in some form by the end of medical school. Consultants were the most commonly cited source of harassment and discrimination. ⁶ Only 21% of students who experienced harassment or other offensive behaviors reported the incidents to faculty members or administrators. The reasons cited for not reporting: “The incident did not seem important enough to report” (57%), “I did not think anything would be done about it” (37%), “fear of reprisal” (28%), and “I did not know what to do” (9%).” ⁷

Although these numbers are alarming, putting them into the context of real female physician experiences is important to help delineate their potential impact. Narrative description has long been used as a learning tool to help provide cultural context, improve concept retention, and inform cultural outcomes. Specifically, medical students who participated in story telling had improved attitudes toward persons with dementia. ⁸ Patients with hypertension who participated in a storytelling program had significant decreases in blood pressure compared to those who did not. ⁹ As Bietti et al. ¹⁰ eloquently states “storytelling is part of an adaptive functional toolkit for the transmission of cultural information, the specific benefit of which is enabling collective sensemaking.” The objective of this study was to transmit the cultural information included in the experiences of women emergency physicians by collecting and telling their stories. To achieve this, a mixed‐methods analysis of the experience of harassment and discrimination of women EM physicians by colleagues and supervisors was performed.

METHODS

Study design and setting

A descriptive, qualitative method, rooted in phenomenology was applied to understand the experience of women in EM as they perceive them. Phenomenology is a qualitive research approach that concentrates on the commonality of individuals lived experiences within a specific group. It is centered on the premise that reality is based on an individual’s perception and understanding of events.

Selection of participants

A cross‐sectional survey of women in EM was completed. The survey was distributed electronically beginning October 17, 2018. A link to the electronic survey was distributed on Twitter three times from October 17 through November 6, 2018. Groups representing emergency physicians and women in EM such as Academy for Women in Academic Emergency Medicine, FeminEM, American Associated of Women Emergency Physicians Section, and attendees of the FIX 2018 conference were targeted to complete the survey on Twitter. Groups targeted on Facebook included EM Docs, Progressive EM Docs, EM Physician Moms, and FeminEM. The link to the survey was posted six times on Facebook through the course of the survey. To reach women who were not utilizers of Facebook or Twitter, email distribution occurred by accessing alumni databases of the author’s training and current practice locations and asking those recipients to forward the survey on to other women EM colleagues. One initial email was sent followed by a reminder email that the survey was going to close.

Interventions/measurements

The survey asked for basic demographic information and information regarding clinical training. Although respondents could remain anonymous, they could also provide their name and email address if they chose to. Women were asked if they had ever felt harassed, diminished, uncomfortable, or discriminated against by a male colleague or supervisor at work based on a sexual comment or an unwanted sexual advance. Space was provided for description of up to two experiences and the state and year in which those experiences occurred. The survey was pilot tested by the authors and two of their colleagues. Those responses were not included in the final analysis.

Data analysis

Data were collected for 8 weeks and the survey was closed on December 18, 2018. Respondents were excluded if they did not agree to have their responses used for research, their survey was incomplete, or they self‐identified as male or non‐EM physicians. IP addresses of responses were evaluated for uniqueness and, if found, duplicate responses were removed. The remaining responses were then analyzed as long as 55% of the survey was complete. The 55% completion threshold was based on our survey design; it allowed for minimal demographic information to be entered while still permitting submission of up to two experiences, because the experiential reports were deemed the most important aspects of the survey. Demographic data including age, race, total years of practice, fellowship training, other advanced degrees, and current type of EM practice were also recorded. Data were abstracted from the survey and experiences were initially categorized by the two authors (K.M., J.T.) into primary theme in the following predetermined categories: inappropriate physical contact, discrimination regarding expressing breastmilk or “pumping,” lack of advancement based on gender, pregnancy/maternity leave discrimination, inappropriate behavior at work‐related events, sexual advances, and only positive experiences to report. These themes were chosen based on the personal experience of the authors and what has been reported previously about women in medicine. Experiences that did not fit into the initial thematic categories were reevaluated and additional themes became clearly apparent. These were overt sexual behavior or comments, comments on physical appearance, being mistaken for a nurse, being asked to perform pelvic exams, and patronizing behavior. If the theme was not clear or the authors were in disagreement, the experience was categorized as “other.” The number of responses was then tabulated by theme. A chi‐square analysis of the proportion of subjects who reported unwanted comments and unwanted actions between White and non‐White respondents was also conducted. Non‐White was not further delineated due to the small number of non‐White respondents. Data were analyzed using Microsoft Excel for Office 365 MSO.

The shared experiences were also separated into having occurred in training or as an attending. If there was no indication of whether or not an experience occurred in training it was marked unknown. Prior to publication all effort was made to contact those who shared their experiences to ensure that they were still comfortable with dissemination via print. This study was approved by the institutional review board at the Medical College of Wisconsin.

RESULTS

Of the 1280 responses, 1144 were available for final analysis. Responses were removed from respondents who indicated that they did not want to be included in research (5), who were not women (7), and who did not complete at least 55% of the survey (124). As of 2017 there were 11,658 actively practicing EM physicians identified as female ¹¹ ; we were able to obtain responses from slightly less than 10% of practicing emergency physicians. The mean age of respondents was 38.4 years with a minimum of 25 years and a maximum of 69 years and most were White (81%). More than half had been in practice for less than 10 years (61.5%) and work in nonacademic environments (53.5%). Almost a quarter (23.4%) had fellowship training and 19.4% had a secondary degree.

When asked if women in EM felt harassed, diminished, uncomfortable, or discriminated against by a male colleague or supervisor at work based on a sexual comment or innuendo, 57.3% indicated that they had felt this way. A smaller percentage, 22.3%, reported that they had experienced an unwanted sexual act or advance. In a separate subgroup the proportion of subjects who reported unwanted comments did not differ between White and non‐White respondents (χ² (1, N = 1099) = 0.42, p > 0.05). The proportion of subjects who reported unwanted actions also did not differ between White and non‐White respondents (χ² (1, N = 1099) = 0.19, p > 0.05).

There were 473 descriptive experiences shared by 312 women. The most frequent themes were patronizing behavior (n = 78, 16.5%), discrimination regarding pregnancy/maternity leave (n = 75, 15.9%), and comments on physical appearance (n = 59, 12.5%; Table 1). Inappropriate physical contact and unwanted sexual advances combined represented 17.1% (n = 81) of all experiences (9.7% and 7.4%). We were unable to determine if the experience occurred in training or after training in 140 (29%) of the experiences shared. Of the experiences where we could determine when in practice they occurred (n = 333), about 51% (n = 172) occurred while in training. Experiences where the EM physician agreed to have their experience shared publicly are displayed in Table 2. Additionally, there were nine comments that highlighted positive experiences, were critical of the survey, or suggested that the questions were “missing the point” (stating most harassment comes from patients and our focus should be on that).

TABLE 1.

Number of experiences shared and distribution by themes

Theme	N	%
Patronizing comments or behavior	78	16.5
Pregnancy/maternity leave	75	15.9
Other	60	12.7
Comments on physical appearance	59	12.5
Inappropriate physical contact	46	9.7
Unwanted sexual advance	35	7.4
Overtly sexual comments	35	7.4
Pumping	24	5.1
Lack of advancement based on gender	22	4.7
Conference/social event	10	2.1
Mistaken for a nurse	10	2.1
Asked to do pelvic exams	10	2.1
Positive	9	1.9
Total	473

Of the 482 experiences shared, a total of 312 women provided descriptions of their experiences as women in EM and 170 women provided more than one experiences.

TABLE 2.

Experiences of women in EM

Category	Theme	Examples	Year
Sexual harassment	Comments on physical appearance	While pregnant male colleague said, “I see the breast fairy visited you.”	2013
	Comments on physical appearance	One of my attendings yelled out at me “holy shit your tits are huge!” I was one week postpartum, and my program director made me come up to discuss my maternity leave. I was with my one‐week‐old infant and not cleared to drive after my C‐section. My program director was standing beside him and I was talking to two of the secretaries. That attending continued to harass me the rest of my residency.	Not given
	Overtly sexual comments	An attending when I was in residency implied that the reason I was having a bad day was that I must “not be getting any.” Those were his exact words.	Not given
	Overtly sexual comments	A male colleague and I were signing out and he said, “I bet I could find a nice mammary vein on you.” We had been talking about IV access on a patient. He then went on to talk about how he would be able to find some veins on a penis. I was shocked at the time. This doctor was much older than me and it came out of the blue. I told my director and he talked with the doctor and he eventually quit.	2017
	Unwanted sexual advance	A male surgical resident asked me out and when I refused, he made it unbearable to work with him. He was rude, condescending, and unprofessional. Even after I declined his advances, he sent me a text message saying that watching me save a life gave him a “boner.”	2017
	Unwanted sexual advance	A male attending tried to lean in to kiss me while in medical school	2014
Sexual assault	Inappropriate physical contact	I had an attending unhook my bra when I was intubating a patient, and from the way the staff reacted, I wasn’t the first.	2009
	Inappropriate physical contact	In residency, I was cornered in a hospital elevator by an off‐service attending physician. We were the only two people in the elevator. He was a tall man and physically forced me into the corner, leaned over me, and said, “if only I were a little bit younger and you a little more single.” Thankfully, the door opened and he backed up. This was an unwanted, unprovoked advance from a superior. Needless to say, the rest of the month was uncomfortable and I dreaded consulting cardiology for the rest of residency.	2003
Gender discrimination	Pumping	When I was a third‐year resident, on one of my first shifts back from maternity leave after having my first baby, I had returned to my work area after stepping away for 15 minutes to pump. My male attending said to me, “Man, I wish I could take a 15‐minute break at work to go jerk off.”	2014
	Pumping	Trying to pump during residency (I was the only female in my year) and male residents and attendings would call the call room where I was to make “moo” sounds and place pictures of cows on my door.	2004
	Lack of advancement	Chair discouraged me from being residency director. Said, “How are you going to be a mom and a residency director at the same time?”	2012
	Lack of advancement	Although fully capable of being chief resident, I had to consistently tell people that my having two children at home should not exclude me from being considered. I had to constantly reassure others that I would not have put my hat in the ring if I did not actually want it and carefully considered the responsibility. My male colleagues didn’t have that misconception to deal with even though at least one other had kids as well. I lost and it is still unclear how much this bias played a role.	2015
	Mistaken for a nurse	Had a colleague roll his eyes when I asked a hospital employee (to whom I had just introduced myself as doctor) to call me "doctor" and not "miss" after repeatedly referring to me as the nurse.	2018
Asked to do pelvic exams	Doctors saving alleged rape cases for me citing better to have a woman doctor. This has happened many times over my career—some patients waiting 6 hours for me to come to work. Not a single one of these patients asked for a female doctor. These patients were dumped.	“Multiple times over the years”
	Patronizing	My husband has a prestigious job. When I was a resident, it came up in a group conversation with the chair of the emergency department. He said, “well if that's the case, why are you still working?” We didn't have any kids at the time and my husband and I both went to an Ivy League medical school. Why wouldn't I work?	2013
	Patronizing	When interaction regarding Press Ganey told, “smile more,” “wear glasses,” “put your hair in a bun.”	2017
Pregnancy/maternity leave	Was told that I shouldn’t pursue fellowship by my mentor because I was pregnant at the time, because (as he said) “you’re just going to leave medicine anyways to be with your baby.”	2014
	Pregnancy/maternity leave	I asked my director for some specific shifts as I was undergoing IVF (infertility) treatments; his response was “no but can you cover (for a co‐worker) who’s wife is having a baby in the next couple days.”	2017
	Other	After presenting a case of a patient with suspected appendicitis, the attending asked how I was sure that the rebound symptoms they described on their car ride were related to this possible cause. In addition to medical literature and training, I personally recalled my own bout of appendicitis as a 16‐year‐old and described that very feeling. He then went on to ask, “how sure were you that it wasn't PID?” I then reconfirmed that I myself had appendicitis and he went on to say, “or that's what the doctors told your parents since they didn't want to them to know the truth about you.” It was an incredibly disgusting conversation and also was incredibly demeaning that he was basically insisting that I had a PID secondary to an STD when I was 16 instead of appendicitis. I hated working with him before that and every time after was even worse.	2009
	Positive	I feel lucky that I haven't had any major experiences	Not given
	Positive	If anything happened, I don't remember. I truly don't remember anything from colleagues—patients for sure, but not from colleagues.	Not given

Abbreviations: PA, physician assistant; PID, pelvic inflammatory disease; STD, sexually transmitted disease.

DISCUSSION

The percentages of women experiencing an instance of sexual harassment in our survey (57.3%) are similar to the percentage of medical students reporting harassment (59.4%). ⁶ In 1995 the prevalence of sexual harassment in academic medicine was found to be 52%, which is slightly less than our data suggest. ¹² This discrepancy is likely because our survey included residents, fellows, and attendings. In a more recent study 52.9% of female academic emergency physicians reported unwanted sexual behaviors; however, unlike our survey, this included experiences involving patients. ⁵

Over half of the shared experiences, when able to be determined, happened during training. Although many of these physicians had been out practicing for years, when given a platform, they related experiences from medical school or residency. It is possible that the power differential that is well established in medical training made women more vulnerable during these years to harassment. These are also very foundational years in a physician’s career and harassment during this time may have had a greater and longer lasting impact. We suspect that both a power differential and training being a formative time in a physician’s life likely increased the reporting of training‐related experiences.

The majority of the responses occurred within the past 10 years, highlighting the misconception by some that this behavior is somehow a thing of the past. Although there is a delay from the collection of data to publication, the notion that sexism, discrimination, and harassment toward women in the workplace is a thing of years ago is invalid. Furthermore, the fact that this behavior occurs to highly educated physicians in a higher paying profession emphasizes that education and financial resources do not eliminate harassment or discrimination.

LIMITATIONS

There are many limitations to this study. First, definitions of harassment and discrimination were not provided, and respondents were allowed to self‐interpret these terms. This survey data represent a convenience sample of 9.8% of practicing female emergency physicians, which may not be truly representative of female emergency physicians. We assumed that if a respondent answered that they were female that they in fact were; however, we were not able to confirm that. It is possible that the data were skewed by nonfemale respondents. We find this to be unlikely because many of the experiences shared were similar to each other and the percentage of reported discrimination and harassment is similar to what has been published previously. The shared experiences were self‐reported and without corroboration. It is probable that there was selection bias in that people who had troubling experiences to share were more likely to respond to the survey than those who did not. However, some who had experiences that were too embarrassing or painful or thought to be not important enough to share also may not have responded, creating a selection bias in favor of not reporting. Also, respondents were asked about discrimination or harassment from a male colleague or supervisor, limiting the responses concerning female precipitated experiences. Nevertheless, the focus of the survey was to explore women’s experiences surrounding harassment and discrimination in EM, not necessarily to quantify the number of women experiencing discrimination or harassment.

CONCLUSION

A number of female physicians in emergency medicine have experienced sexual harassment or discrimination during their career. A lesser percentage, however still remarkably high, have experienced an unwanted sexual advance by a colleague or supervisor at work or a work‐related event. The descriptive nature of the respondents’ shared experiences allows us to begin to develop focused prevention efforts to combat these sexist practices. Within the medical community, efforts to change our behavior will need to be begin in medical school and focus on a “don’t do” and “don’t tolerate” mentality. The recurrent themes reported in these experiences provide us with areas to focus future interventions and ensure that we are encompassing these aspects of discrimination in our efforts. It is possible that some of these themes have not fully been appreciated as forms of discrimination and harassment in the past; however, the voiced experiences of these women no longer make that possible to ignore. The majority of experiences shared occurred within the hospital walls and in the presence of other people, which may include other physicians, nurses, trainees, or supervisors. Emergency medicine must adopt a zero‐tolerance policy proposed by Bates et al. ¹³ where monitoring, sanctions, and dismissals occur for those committing sexual harassment and due diligence of employers ensuring that prior offenders are not hired at another institution. As an emergency medicine community, we need to provide a place where victims can safely come forward and bystanders feel emboldened to speak up.

CONFLICT OF INTEREST

The authors have no potential conflicts to disclose.

AUTHOR CONTRIBUTION

Both authors conceived the study, designed the survey, obtained institutional review board approval, collected data, performed data analysis, drafted the manuscript, and revised it. Kristi Maso takes responsibility for the paper as a whole

Maso K, Theobald JL. Qualitative description of sexual harassment and discrimination of women in emergency medicine: Giving the numbers a voice. AEM Educ Train. 2022;6:e10727. doi: 10.1002/aet2.10727