The inherent strict hierarchy in medical training programs can make it particularly difficult for students to report sexual harassment. Along with the fear of retaliation, harassment may also have damaging psychological effects.  

In an episode of the “AMA Moving Medicine” podcast, Tiffani Bell, MD, a child and adolescent psychiatry resident in Winston-Salem, North Carolina, and a former AMA Resident and Fellows Section representative, is joined by David Gabor, a partner at the Wagner Law Group in Boston. Together they discuss the psychological effects and legal ramifications of sexual harassment and discrimination.

Below is a lightly edited full transcript of their conversation. You can tune in on Apple Podcasts, Google Play or Spotify.

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Dr. Bell: I'm going to briefly go through three definitions that I found quite interesting.

Sexual harassment is defined as unwelcome sexual advances, request for sexual favors and other verbal or physical conduct of a sexual nature when the conduct is made as a term or condition of an individual's employment, education or living environment. They are unwelcome verbal, visual or physical conduct of a sexual nature that is severe and pervasive and affects working conditions.

Now this one had a clause that some behaviors are considered minor and thus can be brushed off, except if they are recurring, which is frequent comments about a person's body. So, that would make it to seem that if the behavior was an occasional comment about, "Oh, you look really nice today," or, "I like your body," or something along those lines, or a very inappropriate joke or a comment, maybe that wouldn't be considered sexual harassment, which I don't necessarily agree with.

And then the third definition was, another definition of sexual harassment is a myriad of behaviors ranging from daily microaggressions, subtle derogatory messages and negative jokes to direct acts of physical sexual assault.

Microaggressions are defined as actions, statements and incidents which, in general, are indirect, subtle or sometimes unintentional discrimination against a marginalized group. And in this case, it would be the women are marginalized in medicine. So what people normally assume is that if it happened to me, I would report it right away. I would tell. I would let someone know.

And we'll talk about this a little later in scenarios, but this is referencing the Australian case where a senior surgeon pretty much warned trainees who complained about sexual harassment that these incidents were not well-supported by their superiors. The trainees were sort of advised to comply with the unwanted request due to fear of jeopardizing one's career.

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So, you have to imagine that, as a trainee, you often feel your career is in jeopardy at any point and you're trying your best to get through training. If your superior is telling you to kind of go along with it, you would feel, probably, a lot more pressure to go along with it, even if you weren't OK with it. And it's important to remember that women do have legal rights to gender equality and freedom from sexual harassment in the workplace.

My question to you is, do the legal rights equal reality? So, because you have a right to gender equality, does that mean you're actually going to be treated equally and not be exposed to sexual harassment? I would guess the answer to that is no. It is important to note, as mentioned earlier, that sexual harassment can happen in any field. It can happen to any gender, so I won't be binary and say either gender.

It is especially difficult in medicine, as we mentioned, because there is a known hierarchy and you really are expected to stay in place and stay in line or else your career, again, may be ruined. And so, a lot of these events are just not reported due to fear of retaliation and not making it through training. So, I think this is a really vulnerable population of women.

Experiencing sexual discrimination and harassment can lead to—all of these symptoms I'm going to list are pretty much avoidance.

So, you start avoiding the stressor that you're experiencing. Desire to leave work early, using PTO—which, in training, you don't necessarily have PTO, so you have some sick days … skipping group meetings if they're not mandatory, or making excuses if your attacker or whomever is harassing you is there. Difficulty staying focused at work. And then ultimately, some people quit their jobs or change their career fields, so maybe you go from one field to another.

The problem with all of these symptoms is that, if you're avoiding work, if you're not there, people who don't know you're being sexually harassed will then see you as a slacker or someone who's just not very invested in their education. And that can lead to problems with your career success in the long run.

Some of the very important physical and psychological effects are listed here. We'll go through them. But it's important to realize that a lot of people feel like this is something you can brush off … and there are no lasting effects.

But people have symptoms of anxiety. They have depression, symptoms of depression, adjustment disorders, which basically mean that if you weren't in that situation, possibly you would not have those symptoms, headaches, PTSD. So avoidance, hypervigilance, nightmares, re-experiencing the event—and all of these, obviously, will negatively impact your ability to function as a physician.

Weight loss or gain due to changes in appetite, poor sleep, poor self-esteem or self-worth, self-doubt—which, if you're full of self-doubt, you're probably going to use your coping skills improperly, you won't be able to learn effectively, and again, that will lead to issues with your career—and hypertension. There were many other ones, but we just wanted to list some of the symptoms that are more than just your feelings are hurt or you’re embarrassed.

And I just put this here briefly, and then I'm wrapping up. But if you're a victim of sexual harassment or discrimination, regardless of if you report it to someone, you still can get help.

So, what we would recommend is that if someone were having the symptoms of depression, anxiety, suicidal thoughts, you still want to get treatment for that. At least get those symptoms evaluated. And even if you don't report the abuse for the many reasons that we’ve already discussed, it's still important to take care of yourself, because the suicide risk can increase if you are living with untreated depression.

That's it. Thank you for your attention, and we'll go back to this during the question section.

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Gabor: Good morning. I'm David Gabor. I'm the attorney in the room. Don’t hate me for that. …

So, basically, studies show that 25–54% of women claim they experienced sexual harassment. And the numbers vary depending on the question, because if a person thinks the question is, “Were you physically touched,” the percentage is lower. But sexual harassment is not just physical touching. It also can be verbal. It can be other physical acts without actually touching the person.

Three-quarters of the people who complain feel like they've been the victim of retaliation. And as a result, a lot of the harassment doesn't get reported.

In 2015 alone, there was $140 million paid out at the EEOC and cost the companies probably closer to a billion dollars. People talk about a revolution, and there are a lot of reasons why it may have started, but we are in a revolution.

We had the case involving the U.S. Olympic team. We've got the entertainment industry. Harvey Weinstein and 35 or 40 other celebrities. It's in politics, both parties. This isn't a Democrat or Republican issue. It's across the board. Executives of companies, like Steve Wynn.

The impact is more people are going to start talking about it. And because of that, as an employer, people need to be much more proactive. And as an individual, and from a human standpoint, this is a problem that's existed for a long time and it has not been resolved.

So, let's talk a bit about some of the definitions.

I'm going to refer to what my colleagues said, but harassment can be physical, or it could be verbal. It could be severe. It can be pervasive. Severe would be touching somebody inappropriately. Pervasive would be constantly commenting about a person, her appearance, asking her to go to dinner, asking for dates, again and again and again, and that can become harassment. Quid pro quo. “If you do X, I'll get you a promotion, you can keep your job, you can make a lot of money.”

Very important: Intent does not matter. It is not necessary for me to intend to sexually harass somebody. If I intend to commit the act, the act alone is enough without it actually intending to hurt somebody.

Also, we talk about gender neutral. Just briefly, it could be male-on-female, female-on-male. The issue of male-on-male, female-on-female or harassment of people because of their gender identity, transgender or sexual orientation hasn't been fully resolved with the court.

My recommendation to all of you is: Any harassment should not be tolerated. …Harassers can be an employee, it could be your supervisor, it could be your subordinate, it could be the FedEx guy, the UPS guy, it could be a vendor, the computer person. It doesn't have to be a person who you work with.

And retaliation … so important. Retaliation basically is a person opposes what they believe to be illegal conduct committed towards them or they witness with somebody else. They oppose it, and within a relatively short amount of time, [what] we call close temporal proximity, something bad happens to that person.

In 1998, the Supreme Court decided Farragher and Ellerth. Basically, what those cases said was if you have a good complaint mechanism in place, and people can report in that mechanism—you've got an employee manual, you've got some level of training—then employers have protection. And at first, people started to do really good things. But then, unfortunately, we switched over to canned programs. So, you can watch a 30-minute webinar as part of your job. And if you watch that webinar, you're going to learn how bad sexual harassment is.

Unfortunately, this shift was away from really good, proactive training to canned programs.

Now, by a show of hands, how many of you have watched the webinar and multitasked? Tweeting, texting, emailing. That's a problem. If you look around the room, almost everybody. And that's the problem. The message from the employer to the employees got lost.

Live programs. And I get up on my soapbox pretty much every day of the week and plead with people: Have live programs. Make them interactive. Get people talking. Set forth your expectations. Shift the focus to make the employees in the room responsible to help get rid of sexual harassment in your workplace.

And we talk about culture. When you watch a webinar, and it's a canned webinar, and you're telling people, "Don't harass somebody," that's the same as telling people, "Don't run red lights. Don't burn down your house for the insurance money." Because those people don't benefit from the program … you lose that opportunity in a canned program. So, we do talk a lot about live programs being so important

This is an important slide. On the left side are comments taken from real cases about what should not be done:

  • "Oh, boys will be boys."
  • Promising things that can't be delivered.

Look on the right side:

  • "Thank you for bringing this complaint to my attention.”
  • “We take these matters seriously.”
  • “I'll be reaching out to HR immediately.”
  • “You can reach out yourself to HR.”
  • “We do not tolerate retaliation.”

And then let them know that they can come to you if they've got questions.

And basically the idea, and this is talking about solutions, is switching the power dynamic in your organization, getting people to understand that this is a company that wants to hear from you if there's a problem. This is a company that wants to resolve problems. And that's why we're training with top down buy-in.

So, we've got a top 10 list of things that are takeaways.

Audiences must relate to a training. How many of you have seen that video of the pretty woman walking down the road and the construction worker whistling at her? People have seen that, a few people have. The problem is if you train, make it relevant. Talk about things that are real in your workplace and then, in a few minutes, Henry's going to lead us is some scenarios and we're all going to chime in and talk about that.

If you can't get live training, try to have something like a town hall or a forum where people can talk it through with a facilitator.

Look for people skills when you hire. … People skills are as important as technical skills.

Get top down support. Get your C-suite, the top people in your hospital, in your medical group, wherever you're working, to buy in and tell people, “This is what we want as a great place to work.”

When decisions are made, don't look at the financial. Look at what's right. I showed you the slide about what managers should say if somebody comes to them, but make sure they're ready in advance. 

Follow up with people. If someone complains, follow up to make sure they're not being retaliated against, that they still feel like they are a valued member of your team. Defining relationships. People date. What happens in your organization if people go out on one date? Do you have a policy in place? Think about that. Too many organizations don't have a policy.

Also, early resolution. Sometimes disputes aren't really malicious, and they could be resolved by getting people to talk in a mediation.

And, last but not least, let's talk about really assessing your culture. What is your culture right now and how can we make it even better?

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