Kellie R. Brown, MD

PART I
Reports of sexual harassment and gender discrimination have dominated news headlines, and the #MeToo movement has brought the scope and severity of discriminatory behavior to the forefront of public consciousness. The #MeToo movement has raised national and global awareness of gender discrimination and sexual harassment in all industries and has given rise to Time’s Up initiative within health care.
Academic medicine has not been immune to workplace gender discrimination and sexual harassment as has been vastly reported in the literature and clearly documented in the 2018 National Academies of Sciences, Engineering, and Medicine report, which points out that … “the cumulative effect of sexual harassment is a significant and costly loss of talent in academic science, engineering, and medicine, which has consequences for advancing the nation’s economic and social well-being and its overall public health.”1 
With the increasing recognition that healthcare is an environment especially prone to inequality, gender discrimination and sexual discrimination, the Time’s Up national organization, supported by the Time’s Up Legal Defense Fund, launched the Time’s Up initiative for health care workers on March 1, 2019.2,3 The overarching goal of this initiative is to expose workplace inequalities; drive policy and legislative changes focused on equal pay, equal opportunity, and equal work environments; and support safe, fair, and dignified work for women in health care. 2,3
This article, presented over the next three issues of Vascular Specialist, will present data on the ongoing problem of sexual harassment in medicine, discuss why the problem is prevalent in academic medicine, and provide recommendations for mitigating the problem in our workplace.

Defining & Measuring Sexual Harassment
Although commonly referred to as “sex discrimination,” sexual harassment differs from sexual discrimination. Sex discrimination refers to an employees’ denial of civil rights, raises, job opportunities, employment or a demotion or other mistreatments based on sex. On the other hand, sexual harassment relates to behavior that is inappropriate or offensive. A 2018 report from the National Academies Press defined sexual harassment (a form of discrimination) as comprising three categories of behavior: gender harassment – verbal and nonverbal behaviors that convey hostility, objectification, exclusion, or second-class status about members of one sex; unwanted sexual attention – verbal or physical unwelcome sexual advances, which can include assault; and sexual coercion – when favorable professional or educational treatment is conditional based on sexual activity.1
During 1995-2016, more than 7,000 health care service employees filed claims of sexual harassment with the Equal Employment Opportunity Commission. While this number may seem large, the number of official reports severely undervalues the prevalence of sexual discrimination in U.S. health care.1 Prevalence is best determined using representative validated surveys that rely on firsthand experience or observation of the behavior(s) without requiring the respondent to label those behaviors.

Environments at Risk for Sexual Harassment 
Research reveals that academic settings in the fields of science exhibit characteristics that create high levels of risk for sexual harassment to occur. These environments historically are male dominated, tolerate sexually harassing behavior, and create a hierarchy in which men hold most of the positions of power and authority. Moreover, dependent relationships often exist between these gatekeepers and those subordinate to them, with gatekeepers directly influencing the career advancement of those subordinates.1
The greatest predictor of sexual harassment in the workplace is the organizational climate, which refers to the tolerance for sexual harassment and is measured on three elements: a lack of sanctions against offenders; a perceived risk to those who report sexually harassing behavior; and the perception that one’s report of sexually harassing behavior will not be taken seriously.1 Women are less likely to be directly harassed in environments that do not tolerate harassing behaviors or have a strong, clear, transparent consequence for these behaviors.  

Sexual Harassment in Academic Medicine
Academic medicine has the highest rate of gender and sexual harassment in the health care industry, with about 50% of female academic physicians reporting incidents of sexual harassment.1 A recent survey suggests that more than half (58%) of women surgeons experienced sexual harassment within just the previous year alone.4 The conditions that increase the risk of sexual harassment against women – male-dominated hierarchical environments and organizational tolerance of sexual harassment – still prevail in academic medicine. 
Higher-education environments are perceived as permissive environments in part because when targets report sexual harassment, they are retaliated against or there are few consequences for the perpetrator. Academic institutions are replete with cases in which the conduct of offenders is regarded as an open secret, but there are no sanctions for that bad behavior. These offenders often are perceived as superstars in their particular substantive area. Because they hold valued grants or national status within their specialty area, they often receive preferential treatment and are not held accountable for gender-biased and sexually harassing behavior. Interview data regarding sexual harassment in academic medicine reveals that interview respondents and other colleagues often know which individuals have a history of sexually harassing behavior. Both men and women warn colleagues of these perpetrators – knowing that calling out or reporting these behaviors is fruitless – and that the best manner for dealing with their behavior is to avoid or ignore it. This normalization of sexual harassment and gender bias was noted, unfortunately, to fuel similar behavior in new cohorts of medicine faculty.1 
Sexual harassment of women in academic medicine starts in medical school. Female medical students are significantly more likely to experience sexual harassment by faculty and staff than are graduate or undergraduate students. Sexual harassment continues into residency training with residency described as “breeding grounds for abusive behavior by superiors.”1 Interview studies report that both men and women trainees widely accept harassing behavior at this stage of their training. The expectation of abusive and grueling conditions during residency caused several respondents to view sexual harassment as part of a continuum that they were expected to endure. Female residents in surgery and emergency medicine are more likely to be harassed than those in other specialties because of the high value placed on a hierarchical and authoritative workplace. Once out of residency, the sexual harassment of women in the workplace continues. A recent meta-analysis reveals that 58% of women faculty experience sexual harassment at work. Academic medicine has the second-highest rate of sexual harassment, behind the military (69%), as compared with all other workplaces. Women physicians of color experience more harassment (as a combination of sexual and racial harassment) than do white women physicians.1 

Why Women Are Not Likely to Report Sexual Harassment
Only 25% of targets file formal reports with their employer, with even fewer taking claims to court. These numbers are even lower for women in the military and academic medicine, where formal reporting is the last resort for the victims. The reluctance to use formal reporting mechanisms is rooted in the “fear of blame, disbelief, inaction, retaliation, humiliation, ostracism, and the damage to one’s career and reputation.”1 Targets may perceive that there seem to be few benefits and high costs for reporting. Women and nonwhites often resist calling bad behavior “discrimination” because that increases their loss of control and victimhood.1 Women frequently perceive that grievance procedures favor the institution over the individual, and research has proven that women face retaliation, both professional and social, for speaking out. Furthermore, stark power differentials between the target and the perpetrator exacerbate the reluctance to report and the fear of retaliation. The overall effects can be long lasting. 

References:
1. National Academies of Sciences, Engineering, and Medicine. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. The National Academies Press, Washington, DC; 2018. doi. 10.17226/24994.
2. Choo EK et al. From #MeToo to #TimesUp in Health Care: Can a Culture of Accountability End Inequity and Harassment? Lancet. 2019 Feb 9;393(10171):499-502.
3. Choo EK et al. Time’s Up for Medicine? Only Time Will Tell. N Engl J Med. 2018 Oct 25;379(17):1592-3.
4. Medicine Has Its Own #MeToo Problems. Can Time’s Up Healthcare Fix It? 

Dr. Mitchell is a vascular surgeon at Salem (Ore.) Hospital; Dr. Drudi is as vascular surgery resident at McGill University, Montreal; Dr. Brown is a professor of surgery at the Medical College of Wisconsin. Milwaukee; Dr. Sachdev-Ost is an associate professor of surgery at the University of Pittsburgh Medical Center.

PART I
Reports of sexual harassment and gender discrimination have dominated news headlines, and the #MeToo movement has brought the scope and severity of discriminatory behavior to the forefront of public consciousness. The #MeToo movement has raised national and global awareness of gender discrimination and sexual harassment in all industries and has given rise to Time’s Up initiative within health care.
Academic medicine has not been immune to workplace gender discrimination and sexual harassment as has been vastly reported in the literature and clearly documented in the 2018 National Academies of Sciences, Engineering, and Medicine report, which points out that … “the cumulative effect of sexual harassment is a significant and costly loss of talent in academic science, engineering, and medicine, which has consequences for advancing the nation’s economic and social well-being and its overall public health.”1 
With the increasing recognition that healthcare is an environment especially prone to inequality, gender discrimination and sexual discrimination, the Time’s Up national organization, supported by the Time’s Up Legal Defense Fund, launched the Time’s Up initiative for health care workers on March 1, 2019.2,3 The overarching goal of this initiative is to expose workplace inequalities; drive policy and legislative changes focused on equal pay, equal opportunity, and equal work environments; and support safe, fair, and dignified work for women in health care. 2,3
This article, presented over the next three issues of Vascular Specialist, will present data on the ongoing problem of sexual harassment in medicine, discuss why the problem is prevalent in academic medicine, and provide recommendations for mitigating the problem in our workplace.

Defining & Measuring Sexual Harassment
Although commonly referred to as “sex discrimination,” sexual harassment differs from sexual discrimination. Sex discrimination refers to an employees’ denial of civil rights, raises, job opportunities, employment or a demotion or other mistreatments based on sex. On the other hand, sexual harassment relates to behavior that is inappropriate or offensive. A 2018 report from the National Academies Press defined sexual harassment (a form of discrimination) as comprising three categories of behavior: gender harassment – verbal and nonverbal behaviors that convey hostility, objectification, exclusion, or second-class status about members of one sex; unwanted sexual attention – verbal or physical unwelcome sexual advances, which can include assault; and sexual coercion – when favorable professional or educational treatment is conditional based on sexual activity.1
During 1995-2016, more than 7,000 health care service employees filed claims of sexual harassment with the Equal Employment Opportunity Commission. While this number may seem large, the number of official reports severely undervalues the prevalence of sexual discrimination in U.S. health care.1 Prevalence is best determined using representative validated surveys that rely on firsthand experience or observation of the behavior(s) without requiring the respondent to label those behaviors.

Environments at Risk for Sexual Harassment 
Research reveals that academic settings in the fields of science exhibit characteristics that create high levels of risk for sexual harassment to occur. These environments historically are male dominated, tolerate sexually harassing behavior, and create a hierarchy in which men hold most of the positions of power and authority. Moreover, dependent relationships often exist between these gatekeepers and those subordinate to them, with gatekeepers directly influencing the career advancement of those subordinates.1
The greatest predictor of sexual harassment in the workplace is the organizational climate, which refers to the tolerance for sexual harassment and is measured on three elements: a lack of sanctions against offenders; a perceived risk to those who report sexually harassing behavior; and the perception that one’s report of sexually harassing behavior will not be taken seriously.1 Women are less likely to be directly harassed in environments that do not tolerate harassing behaviors or have a strong, clear, transparent consequence for these behaviors.  

Sexual Harassment in Academic Medicine
Academic medicine has the highest rate of gender and sexual harassment in the health care industry, with about 50% of female academic physicians reporting incidents of sexual harassment.1 A recent survey suggests that more than half (58%) of women surgeons experienced sexual harassment within just the previous year alone.4 The conditions that increase the risk of sexual harassment against women – male-dominated hierarchical environments and organizational tolerance of sexual harassment – still prevail in academic medicine. 
Higher-education environments are perceived as permissive environments in part because when targets report sexual harassment, they are retaliated against or there are few consequences for the perpetrator. Academic institutions are replete with cases in which the conduct of offenders is regarded as an open secret, but there are no sanctions for that bad behavior. These offenders often are perceived as superstars in their particular substantive area. Because they hold valued grants or national status within their specialty area, they often receive preferential treatment and are not held accountable for gender-biased and sexually harassing behavior. Interview data regarding sexual harassment in academic medicine reveals that interview respondents and other colleagues often know which individuals have a history of sexually harassing behavior. Both men and women warn colleagues of these perpetrators – knowing that calling out or reporting these behaviors is fruitless – and that the best manner for dealing with their behavior is to avoid or ignore it. This normalization of sexual harassment and gender bias was noted, unfortunately, to fuel similar behavior in new cohorts of medicine faculty.1 
Sexual harassment of women in academic medicine starts in medical school. Female medical students are significantly more likely to experience sexual harassment by faculty and staff than are graduate or undergraduate students. Sexual harassment continues into residency training with residency described as “breeding grounds for abusive behavior by superiors.”1 Interview studies report that both men and women trainees widely accept harassing behavior at this stage of their training. The expectation of abusive and grueling conditions during residency caused several respondents to view sexual harassment as part of a continuum that they were expected to endure. Female residents in surgery and emergency medicine are more likely to be harassed than those in other specialties because of the high value placed on a hierarchical and authoritative workplace. Once out of residency, the sexual harassment of women in the workplace continues. A recent meta-analysis reveals that 58% of women faculty experience sexual harassment at work. Academic medicine has the second-highest rate of sexual harassment, behind the military (69%), as compared with all other workplaces. Women physicians of color experience more harassment (as a combination of sexual and racial harassment) than do white women physicians.1 

Why Women Are Not Likely to Report Sexual Harassment
Only 25% of targets file formal reports with their employer, with even fewer taking claims to court. These numbers are even lower for women in the military and academic medicine, where formal reporting is the last resort for the victims. The reluctance to use formal reporting mechanisms is rooted in the “fear of blame, disbelief, inaction, retaliation, humiliation, ostracism, and the damage to one’s career and reputation.”1 Targets may perceive that there seem to be few benefits and high costs for reporting. Women and nonwhites often resist calling bad behavior “discrimination” because that increases their loss of control and victimhood.1 Women frequently perceive that grievance procedures favor the institution over the individual, and research has proven that women face retaliation, both professional and social, for speaking out. Furthermore, stark power differentials between the target and the perpetrator exacerbate the reluctance to report and the fear of retaliation. The overall effects can be long lasting. 

References:
1. National Academies of Sciences, Engineering, and Medicine. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. The National Academies Press, Washington, DC; 2018. doi. 10.17226/24994.
2. Choo EK et al. From #MeToo to #TimesUp in Health Care: Can a Culture of Accountability End Inequity and Harassment? Lancet. 2019 Feb 9;393(10171):499-502.
3. Choo EK et al. Time’s Up for Medicine? Only Time Will Tell. N Engl J Med. 2018 Oct 25;379(17):1592-3.
4. Medicine Has Its Own #MeToo Problems. Can Time’s Up Healthcare Fix It? 

Dr. Mitchell is a vascular surgeon at Salem (Ore.) Hospital; Dr. Drudi is as vascular surgery resident at McGill University, Montreal; Dr. Brown is a professor of surgery at the Medical College of Wisconsin. Milwaukee; Dr. Sachdev-Ost is an associate professor of surgery at the University of Pittsburgh Medical Center.

PART I
Reports of sexual harassment and gender discrimination have dominated news headlines, and the #MeToo movement has brought the scope and severity of discriminatory behavior to the forefront of public consciousness. The #MeToo movement has raised national and global awareness of gender discrimination and sexual harassment in all industries and has given rise to Time’s Up initiative within health care.
Academic medicine has not been immune to workplace gender discrimination and sexual harassment as has been vastly reported in the literature and clearly documented in the 2018 National Academies of Sciences, Engineering, and Medicine report, which points out that … “the cumulative effect of sexual harassment is a significant and costly loss of talent in academic science, engineering, and medicine, which has consequences for advancing the nation’s economic and social well-being and its overall public health.”1 
With the increasing recognition that healthcare is an environment especially prone to inequality, gender discrimination and sexual discrimination, the Time’s Up national organization, supported by the Time’s Up Legal Defense Fund, launched the Time’s Up initiative for health care workers on March 1, 2019.2,3 The overarching goal of this initiative is to expose workplace inequalities; drive policy and legislative changes focused on equal pay, equal opportunity, and equal work environments; and support safe, fair, and dignified work for women in health care. 2,3
This article, presented over the next three issues of Vascular Specialist, will present data on the ongoing problem of sexual harassment in medicine, discuss why the problem is prevalent in academic medicine, and provide recommendations for mitigating the problem in our workplace.

Defining & Measuring Sexual Harassment
Although commonly referred to as “sex discrimination,” sexual harassment differs from sexual discrimination. Sex discrimination refers to an employees’ denial of civil rights, raises, job opportunities, employment or a demotion or other mistreatments based on sex. On the other hand, sexual harassment relates to behavior that is inappropriate or offensive. A 2018 report from the National Academies Press defined sexual harassment (a form of discrimination) as comprising three categories of behavior: gender harassment – verbal and nonverbal behaviors that convey hostility, objectification, exclusion, or second-class status about members of one sex; unwanted sexual attention – verbal or physical unwelcome sexual advances, which can include assault; and sexual coercion – when favorable professional or educational treatment is conditional based on sexual activity.1
During 1995-2016, more than 7,000 health care service employees filed claims of sexual harassment with the Equal Employment Opportunity Commission. While this number may seem large, the number of official reports severely undervalues the prevalence of sexual discrimination in U.S. health care.1 Prevalence is best determined using representative validated surveys that rely on firsthand experience or observation of the behavior(s) without requiring the respondent to label those behaviors.

Environments at Risk for Sexual Harassment 
Research reveals that academic settings in the fields of science exhibit characteristics that create high levels of risk for sexual harassment to occur. These environments historically are male dominated, tolerate sexually harassing behavior, and create a hierarchy in which men hold most of the positions of power and authority. Moreover, dependent relationships often exist between these gatekeepers and those subordinate to them, with gatekeepers directly influencing the career advancement of those subordinates.1
The greatest predictor of sexual harassment in the workplace is the organizational climate, which refers to the tolerance for sexual harassment and is measured on three elements: a lack of sanctions against offenders; a perceived risk to those who report sexually harassing behavior; and the perception that one’s report of sexually harassing behavior will not be taken seriously.1 Women are less likely to be directly harassed in environments that do not tolerate harassing behaviors or have a strong, clear, transparent consequence for these behaviors.  

Sexual Harassment in Academic Medicine
Academic medicine has the highest rate of gender and sexual harassment in the health care industry, with about 50% of female academic physicians reporting incidents of sexual harassment.1 A recent survey suggests that more than half (58%) of women surgeons experienced sexual harassment within just the previous year alone.4 The conditions that increase the risk of sexual harassment against women – male-dominated hierarchical environments and organizational tolerance of sexual harassment – still prevail in academic medicine. 
Higher-education environments are perceived as permissive environments in part because when targets report sexual harassment, they are retaliated against or there are few consequences for the perpetrator. Academic institutions are replete with cases in which the conduct of offenders is regarded as an open secret, but there are no sanctions for that bad behavior. These offenders often are perceived as superstars in their particular substantive area. Because they hold valued grants or national status within their specialty area, they often receive preferential treatment and are not held accountable for gender-biased and sexually harassing behavior. Interview data regarding sexual harassment in academic medicine reveals that interview respondents and other colleagues often know which individuals have a history of sexually harassing behavior. Both men and women warn colleagues of these perpetrators – knowing that calling out or reporting these behaviors is fruitless – and that the best manner for dealing with their behavior is to avoid or ignore it. This normalization of sexual harassment and gender bias was noted, unfortunately, to fuel similar behavior in new cohorts of medicine faculty.1 
Sexual harassment of women in academic medicine starts in medical school. Female medical students are significantly more likely to experience sexual harassment by faculty and staff than are graduate or undergraduate students. Sexual harassment continues into residency training with residency described as “breeding grounds for abusive behavior by superiors.”1 Interview studies report that both men and women trainees widely accept harassing behavior at this stage of their training. The expectation of abusive and grueling conditions during residency caused several respondents to view sexual harassment as part of a continuum that they were expected to endure. Female residents in surgery and emergency medicine are more likely to be harassed than those in other specialties because of the high value placed on a hierarchical and authoritative workplace. Once out of residency, the sexual harassment of women in the workplace continues. A recent meta-analysis reveals that 58% of women faculty experience sexual harassment at work. Academic medicine has the second-highest rate of sexual harassment, behind the military (69%), as compared with all other workplaces. Women physicians of color experience more harassment (as a combination of sexual and racial harassment) than do white women physicians.1 

Why Women Are Not Likely to Report Sexual Harassment
Only 25% of targets file formal reports with their employer, with even fewer taking claims to court. These numbers are even lower for women in the military and academic medicine, where formal reporting is the last resort for the victims. The reluctance to use formal reporting mechanisms is rooted in the “fear of blame, disbelief, inaction, retaliation, humiliation, ostracism, and the damage to one’s career and reputation.”1 Targets may perceive that there seem to be few benefits and high costs for reporting. Women and nonwhites often resist calling bad behavior “discrimination” because that increases their loss of control and victimhood.1 Women frequently perceive that grievance procedures favor the institution over the individual, and research has proven that women face retaliation, both professional and social, for speaking out. Furthermore, stark power differentials between the target and the perpetrator exacerbate the reluctance to report and the fear of retaliation. The overall effects can be long lasting. 

References:
1. National Academies of Sciences, Engineering, and Medicine. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. The National Academies Press, Washington, DC; 2018. doi. 10.17226/24994.
2. Choo EK et al. From #MeToo to #TimesUp in Health Care: Can a Culture of Accountability End Inequity and Harassment? Lancet. 2019 Feb 9;393(10171):499-502.
3. Choo EK et al. Time’s Up for Medicine? Only Time Will Tell. N Engl J Med. 2018 Oct 25;379(17):1592-3.
4. Medicine Has Its Own #MeToo Problems. Can Time’s Up Healthcare Fix It? 

Dr. Mitchell is a vascular surgeon at Salem (Ore.) Hospital; Dr. Drudi is as vascular surgery resident at McGill University, Montreal; Dr. Brown is a professor of surgery at the Medical College of Wisconsin. Milwaukee; Dr. Sachdev-Ost is an associate professor of surgery at the University of Pittsburgh Medical Center.