Witte, Florence M. MA; Stratton, Terry D. PhD; Nora, Lois Margaret MD, JD
A number of studies have found that both female and male medical students experience abuse and mistreatment of various kinds, including gender discrimination and sexual harassment, during medical school.1–7 Our own research4–7 has shown that incidents of gender discrimination and sexual harassment are relatively common during medical school, particularly during core clerkships,7 and that such incidents can influence students’ choice of specialty and ranking of residency programs.8 However, although the prevalence of gender discrimination and sexual harassment during medical training has been well documented, far less is known about the actual behaviors deemed by students to be discriminatory or harassing.
One notable exception is a study by Hinze,9 who used telephone interviews supplemented with personal interviews of residents to determine the effects of gender on specialty selection for medical residency programs. Five interview questions presented to female subjects asked specifically about experiences during medical school with “hostile environment” characteristics such as sexual advances, sexual comments, displays of pornographic material, and jokes about women. Qualitative analysis of these narratives resulted in two emergent themes: the sensitivity of women to incidents of sexual harassment, and the tactics used by women to resist such incidents.10
In the present study, we inductively examined graduating medical students’ written descriptions of their personal experiences with gender discrimination and sexual harassment during medical school. To descriptively summarize these incidents, we placed the written descriptions of students’ experiences into a classification scheme developed from an initial review of the data. This review of the narratives reinforces the importance of such personal descriptions in better understanding medical student abuse and leads us to suggest that useful interventions may be informed by the categories we describe below.
In 1997, we administered a two-page, self-report questionnaire regarding experiences with gender discrimination and sexual harassment to 1,911 graduating medical students at 14 U.S. medical schools; the results of that study have been previously reported.6 That survey instrument provided an open-ended opportunity for students to elaborate on or provide additional information about any of their responses.
During the 2001–02 academic year, we administered a revised three-page questionnaire to 1,643 graduating seniors at 13 U.S. medical schools, some of which had participated in our previous studies.5,7,8 Our goal was to examine specific aspects of students’ exposure to gender discrimination and sexual harassment during undergraduate medical education. An attached cover letter contained detailed operational definitions of each of the two constructs6 and further stated that participation in the study was voluntary and that both women and men could be subject to gender discrimination and sexual harassment. So that students’ privacy could be safeguarded, all responses were anonymous; no attempt was made to match responses with individual students. The research protocol and the questionnaire were approved by the local institutional review boards.
The revised questionnaire consisted of several sections containing quantitative measures of students’ exposure to gender discrimination and sexual harassment during undergraduate medical education. The last section, however, asked each student to think about and then describe in writing “the single most noteworthy example of gender discrimination or sexual harassment” that he or she had experienced, observed, or heard about during medical school and to discuss the personal effect of the experience. The student was then asked to identify the setting in which the experience occurred (e.g., classroom, clerkship, clinic) and the person(s) who had perpetrated the behavior (e.g., faculty member, resident, fellow student, patient). The current report focuses on our analysis of this section of the questionnaire.
We inductively analyzed these written responses in an attempt to determine whether recurring themes might allow categorization of the reported events. After independently reviewing students’ written accounts, we formulated a classification scheme composed of seven basic types of gender discrimination and sexual harassment:
▪ Educational inequalities (differences in the training environment for men and women)
▪ Stereotypical comments (for example, statements that women should be nurses rather than doctors or remarks indicating that a student’s sex would prevent the student from doing well on a certain task)
▪ Sexual overtures (ranging from requests for dates to explicit requests for sexual contact)
▪ Offensive, embarrassing, or sexually explicit comments (including sexually oriented jokes and comments about genitalia)
▪ Inappropriate touching (unwanted physical contact, often to a student’s breasts or buttocks)
▪ Sexist remarks (such as references to female students as “honey,” “babe,” or “girl”)
▪ Events that were not classifiable (e.g., because not enough information about the event was provided, because the event did not occur in the training environment, or because the event described related to a subject other than gender discrimination or sexual harassment)
The process of validly classifying students’ reports about gender discrimination and sexual harassment was iterative and consisted of a series of reviews by the three of us. Cases for which at least two of us agreed on the classification were assigned this consensus rating. If this initial agreement was lacking, we recompiled the cases and reviewed them again. If consensus was still lacking, we reviewed the cases individually and discussed them together.
Because the response rate from graduating students at one of the 13 schools was unusually low (18 responses from 165 graduating students; 10.8%), we omitted this school from the analysis. Of the 1,478 questionnaires sent to students graduating from the 12 remaining schools, 793 were returned with usable responses (response rate, 53.7%). Although the return rates varied among the 12 schools, the gender composition of the entire sample used in the present study was nearly identical to that of the samples used in two previous studies of gender discrimination and sexual harassment in medical education.7,8 This similarity suggests that there was no discernible response bias.
Of the returned questionnaires, 290 (36.6%), from students at all 12 schools, contained written responses to the question asking students to describe “the single most noteworthy example of gender discrimination or sexual harassment” that they had experienced, observed, or heard about. Similar numbers of male and female students submitted written descriptions of such incidents (147 men, 50.7%; 141 women, 48.6%; two students [0.7%] did not indicate their sex). However, female students were more likely to report having personally experienced gender discrimination or sexual harassment (85 of 141 women; 60.3%), whereas male students were more likely to report having observed or heard about the experiences of others (97 of 147 men; 66.0%).
Table 1 presents the frequency with which students’ reported experiences fit into the categories we developed. Although we asked students to describe their single most noteworthy experience of gender discrimination or sexual harassment, some responses contained descriptions of multiple incidents that could be placed into more than one category. As a result, the number of reported incidents (313) is not equal to the number of respondents (290). Of the 313 reported incidents, 153 (48.9%) were reported by men; 160 (51.1%), by women. To avoid hearsay or rumors and to counterbalance some of the limitations of survey research, we eliminated the reports of incidents that the students had observed or heard about and focused only on the 166 reports of personal experiences with incidents of gender discrimination or sexual harassment and only on those that occurred in the training environment. Of these, 20 comments were categorized as not classifiable (for example, one comment reported “Just some poor taste”); after we removed these reports, we were left with written reports of 146 personal incidents for analysis.
Interrater agreement was generally good. In the initial review, at least two of us agreed on the classification of entries for 95 (65.1%) of the 146 reported personal incidents that were included in this study. We then extracted the remaining 51 incidents and rated them again; this process resulted in majority ratings for another 26 incidents (an additional 17.8% of the total). The residual cases were categorized on the basis of detailed review and group discussion.
Interrater agreement was further examined by using Cohen’s kappa, a nonparametric measure of concordance between multiple raters on a nominal scale.11 Because students’ incidents could be classified into more than one category, kappa estimates were derived separately for each category. When the guidelines formulated by Landis and Koch12 were used, interrater agreement ranged from “moderate” (kappa = .55, p < .001) to “almost perfect” (kappa = .83, p <.001), with an overall average of .67 among the three of us.
The type of personally experienced discriminatory or harassing behavior reported most commonly by the graduating medical students involved differences in the training environments of male and female medical students; interestingly, more reports of personal experiences with this type of behavior came from men (34) than from women (20; see Table 1). Of the 34 reports from men, 13 described inadequate participation by male medical students on the obstetrics–gynecology (ob–gyn) service. Some of these men wrote that some women patients refused to allow them to assist with labor and delivery or to perform pelvic examinations. Five others wrote that the ob–gyn attending physicians, residents, and nursing staff (many of whom were women) often refused to allow them to see certain patients or to perform pelvic examinations.
One male student described prejudicial treatment by a female surgery resident: “In surgery while on walk rounds, the female resident pulled my fellow classmates aside (two female students) to make a teaching point. When I inquired about the teaching point, she looked toward me and exclaimed, ‘No, not for you!’ ”
Some of the female medical students believed that their educational experience had been diminished because male faculty physicians or residents refused to work with them, ignored them during teaching situations, or questioned them excessively to the point of embarrassment. One female student wrote that “male attending physicians speak to female medical students as if they are inferior and treat you as [if] you are a little child. They treat male medical students with utmost respect and ask them all the questions since they feel females can’t answer them.” In contrast, one male student wrote that female ob–gyn residents questioned male medical students excessively in front of attending physicians.
The comments of 12 of the male students indicated that female residents and attending physicians, particularly those on obstetrics services, favored female students, gave more and harder work to male students, or simply did not like male students. Seven male students believed that male residents and attending physicians showed favoritism toward female students. According to these students, the male residents and physicians were more likely to provide one-on-one instruction to attractive female students than to male students, to treat female students more kindly than male students and criticize them less, and to give female students better evaluations. One male student wrote, “Too many of the male surgery residents date medical students on their rotation for anything fair to be going on.”
Four of the female students wrote that male attending physicians and residents were biased toward male students and ignored or were rude to female students. Another female student wrote that a male faculty physician asked a male student more challenging questions and gave him more meaningful responsibilities, whereas the female student was given more secretarial duties and was asked very basic questions. One female student wrote that a female resident was more attentive to male students than to female students on her service: she taught them more and was more affable with them.
One female student wrote, “I feel that some female students used their bodies and sexual awareness to get ahead or [to get] preferential treatment.” Interestingly, some students reported using the situation to their advantage. One student wrote, “I got out of a large patient load and longer call hours because I was favored by my resident for being a girl!”
Several students reported that their grades in certain rotations were negatively affected because of their sex. One male student reported that a female attending physician openly stated that women in medicine had to “stick up for themselves against men in medicine.” This student believed that he received an unfairly low grade in the rotation. Another male student reported to a male attending physician his mistreatment by a female resident; the student believed that his grade had been lowered because he reported the incident. Three male students reported that a male attending physician gave disproportionately better grades to female students; two said that the females involved were “attractive” or “flirty.” In contrast, one female student reported that a female faculty physician consistently gave lower grades to female students.
The second most commonly reported type of gender discrimination or sexual harassment was stereotyping. Both male and female respondents (15 women, 11 men) reported being stereotyped by patients, residents, attending physicians, or administrators. Several women described incidents in which male patients assumed that the female students were nurses, expected the students to perform nursing duties, or refused to discuss their medical conditions with the students. Another woman wrote, “Whenever my husband and I attend [medical school] functions together, he is always approached and assumed to be the medical student. I cannot recall any circumstance in which a physician or administrator I did not know introduced himself or herself to me first.”
Some female students reported being told that they were not as intelligent as male students or were incapable of doing the jobs usually performed by men. Examples of such comments follow: “You females and your pea-sized brains!” “Females have fluff in their heads.” “Oh, you’re just a girl, so you can’t know how to do this surgical technique.” A report from one female student described the way in which she was made to feel less than equal:
I was repeatedly called “little girl” and was not considered adequate as second assistant because I was a female (the attending surgeon told the resident he could not operate “alone” and asked a male medical student to scrub in as second assistant as I was standing there already scrubbed in).
Some female students were told that women did not belong in surgery and should choose “mommy” careers. In contrast, some male students were told that women were better physicians. Other students reported incidents related to specialty selection: female students were often assumed to want to specialize in pediatrics or obstetrics because of their sex, and male students were often assumed to want to specialize in surgery and to be less capable in pediatrics and obstetrics than female students.
Students also provided reports (17 from women, four from men) of undesired sexual overtures or suggestive comments. One male student reported that a female resident had inappropriately flirted with him. Female students reported comments made by male attending physicians, residents, nurses, or patients about the students’ physical appearance. One student reported that a male professor made inappropriate comments during a laboratory exercise in a room filled with more than 30 students. She wrote:
When I answered his question correctly, he replied, “Beautiful!!! You are absolutely delicious, delicious, I say!” Getting very close to me and smiling. He has, at other times, kissed my hand in greeting while making comments on how I was “charming.”
Other comments were more blatantly suggestive, and the perpetrators were sometimes relentless. One female student reported that a male resident “asked to come home with me several times and constantly inquired about my sexual relationship with my husband (who is away in school in another state).” Another wrote, “He complimented my appearance daily. He would call me at home and want me to come to his home.” Still another wrote, “He made remarks on a daily basis about my clothing, hairstyle, etc., in front of other students.” Yet another wrote that the “chief resident asked explicit questions about my sexuality/experiences/practices. He could not be discouraged and continued doing so throughout the entire rotation.” Many comments of this nature were accompanied by violations of personal space, requests for a sexual encounter, suggestions about starting a relationship, or comments about “what he would like to do” or about “the two of us having sexual relations.” Two male students reported experiencing same-sex advances. In one instance, a male attending physician requested special meetings with the student and asked whether he had seen the student in the city’s gay district.
Offensive, embarrassing, or sexually explicit comments
Another reported type of gender discrimination or sexual harassment (14 reports by women, six by men) consisted of sexually oriented language, often couched as jokes, which the students viewed as embarrassing or humiliating. These comments were described as “sexual,” “sexually oriented,” or “lewd and inappropriate.”
Other reported incidents involved much more explicit comments and were personally embarrassing to the respondents, particularly when the comments were made in the presence of others (other students, residents, attending physicians, or patients). One female respondent reported the following incident:
I was in mid- to late pregnancy. On rounds one day I became a little short of breath after climbing a few flights of stairs. I was next to present a patient and commented that I needed a moment to catch my breath. [The female] attending physician rudely commented, “I rode my mare the entire time she was pregnant and she never had a problem.” This was in the middle of surgical rounds—80% men.
Another female student wrote that the male attending physician with whom she worked “told a patient I was about to examine that most men would want to take off their shirt in front of me or undress in front of me.” Still another woman reported that she was translating a conversation between a resident and a patient when the resident asked “whether I had asked the patient if I could perform oral sex on him. The incident… was dismissed as ‘funny’ by the rest of the team. In retrospect, I wish that I had said something about it.”
Many of the reported incidents of offensive or sexually explicit remarks occurred on surgery rotations or in the operating room. One female student wrote, “There are always jokes being made on the various surgery services referring to men’s genitalia and also degrading women.” Another wrote, “On a surgical subspecialty service there was sexually explicit talk to a degree that made me uncomfortable (porn descriptions, etc.), by both residents and attending.” One woman wrote about a male urologist who commented on the genitalia of his patient: “Doesn’t this penis look great? How many penises have you seen? No one is allowed to have a penis bigger than mine.” Three male students and one female student reported homophobic jokes or comments. Two of these comments reportedly occurred on surgery services; two were made in reference to openly homosexual patients.
Thirteen graduating medical students (11 women, two men) reported incidents of inappropriate touching by others of the opposite sex during their medical school experience. The incidents reported by female students involved touching the shoulders, back, or legs; patting the posterior; pinching the waist; stroking hands; rubbing or massaging; or grabbing the breasts. One male student reported that a female resident made physical advances to him. The other male student reported inappropriate touching by a male faculty physician.
Another type of inappropriate comments reported by 12 female respondents consisted of sexist remarks made by attending or faculty physicians, residents, or patients. These women reported frequently being called “honey,” “girl,” or “babe”; one wrote that a male administrator told her to be a “good little girl” and commented that she was “just like my wife, and it drives me crazy.” Two women wrote that men (one faculty physician, one patient) commented about how “lucky” the doctors were to be working with such attractive women. Another student wrote about a faculty physician who stated that women’s place in society was “in the home or on their backs.”
One woman wrote that a resident “referred to my team as ‘his angels’ [reference to Charlie’s Angels] and told us to wear makeup so that he could take a picture of our team, who were all women. I felt that this was degrading and that no male students would ever have been referred to in this way.” Another described an incident in which an attending physician made a derogatory comment about female doctors in the presence of a patient and her husband. She wrote, “Normally in any other situation if a sexist comment like that was made to me, I would have spoken back. However, in the hierarchy of medicine when your career is at stake—I just stayed quiet.” One woman reported sexist comments couched in homophobic language that “was degrading to lesbians.”
In this study, we examined medical students’ written accounts of incidents of gender discrimination or sexual harassment that they had personally experienced during medical school. Using broad, inductively developed categories, we established a framework into which these reported personal experiences could be classified. This approach allowed us to evaluate the students’ experiences as reported in their own words and brought to life what would otherwise be mere numbers. Given the range of schools included in this study, our results suggest that incidents of gender discrimination or sexual harassment during undergraduate medical education are widespread. Additionally, we can infer that students generally recognize such incidents when they occur and that they have not yet become immune to such treatment.
Consistent with those of previous research,7,8 these results portray gender discrimination and sexual harassment as largely but not exclusively directed toward female students. Whereas female students encountered such behaviors across varied contexts and with varied effects, male students most often reported being denied equal educational opportunities (gender discrimination) in certain clinical settings, most often ob–gyn. Whether this finding is the result of attending physicians’ personal biases or a perceived reflection of patients’ preferences is unclear. Nonetheless, this finding illustrates the broad and pervasive nature of discrimination and shows how such experiences may result in differences in educational opportunities.
Female students, too, reported suffering the effects of gender discrimination on their educational experiences. However, for female students, gender discrimination and, to a lesser extent, sexual harassment appeared to be less rooted in a particular context. Instead, the more widespread notion that female students were somehow less capable or, at best, qualitatively unique in their medical training may have resulted in more widespread exposure to these behaviors, including those that involved outright sexual harassment.
Experiences of gender discrimination or sexual harassment by all students during medical school are important not only because they create a hostile learning environment but also because they set a tone implying that such behavior is normal. One female respondent wrote:
In preclinical coursework, a professor repeatedly belittled women in a joking fashion. I felt angered but as I observed the other students around me who accepted this behavior as part of the person’s personality—I accepted it too! In this clinical clerkship—core surgery clerkship—repeatedly the male residents would make lewd sexual remarks about women in general and everyone around us (medical students) would laugh and consider it funny—which sent a message to us (medical students) that this type of behavior is not only accepted from surgeons but it is also expected!
Many of the students who provided these written accounts reported feelings of disgust at the behaviors to which they were subjected. They also reported feelings of frustration when no action was taken after they reported incidents of gender discrimination or sexual harassment to medical school administrators. One female respondent wrote, “I complained to the course director. She said there were other complaints about this attending. However, nothing was done and he is still the head of the residency program. Frustrating!” Another wrote, “The administration was fully aware and did little to prevent it.”
Perhaps understandably, given the stressful and highly competitive environment of medical education, students were particularly disturbed when they believed that their grades might be negatively affected by their responses to events that they perceived as gender discrimination or sexual harassment. One female student wrote, “An attending on my surgery rotation asked me out in the OR. He was the primary grader of students on the rotation. I did not report it, despite the fact he made other female students uncomfortable as well, because I did not want to get a reputation as a complainer.” Another wrote, “The resident made me feel as if I had to endure his sexual behavior/advances in order to get a good evaluation.” A male student reported that a female faculty physician used sexual innuendo in talking with or about her male students: “If the student, such as myself, rebuffed her comments, she became verbally aggressive and it was reflected in the student evaluation she completed.”
In response to such experiences, some students reported that they had changed services, changed curricular tracks, or stopped attending classes. Other students reported that their tolerance level for such behaviors had increased during their medical school years. One female student wrote, “My sensitivity for [gender discrimination] and [sexual harassment] has become much lower since I entered medicine. I learned what things to just let roll off my back; otherwise I would be upset too often.”
The fact that female physicians and residents seem to be perpetuating the same abuse on their male students that they themselves may have experienced during medical school suggests that the “hidden curriculum” described by Hafferty and Franks13 may indicate to medical students that these experiences are a normal or even necessary part of their medical training.10 Weston and Brown14 write:
Becoming a physician is more than simply learning a set of knowledge, skills, and attitudes; medical training… also changes the person. In this sense, medical education is as much about the acquisition of values and character development as it is about learning a discipline. Unfortunately,… medical education is often inimical to healthy personal development.
Is it possible that the perpetrators of gender discrimination and sexual harassment do not know that their actions and comments may be perceived as harassing or discriminatory? If so, perhaps formal antiharassment policies need to be more specific in providing examples based on the categories revealed by inductive analyses such as this one. Perhaps, too, medical school administrators may wish to conduct environmental assessments to determine the prevalence of gender discrimination and sexual harassment in their own schools. Finally, perhaps comments such as those quoted above from graduating medical students could be used to develop educational interventions for physicians in supervisory positions (e.g., residents, attending physicians, faculty physicians), particularly those in the specialties in which gender discrimination or sexual harassment has been documented as more likely to exist. One reported intervention prepared medical students for the potential of gender discrimination and sexual harassment during the residency selection process15; with appropriate modifications, such an intervention could be used to inform supervisors about the behaviors that medical students consider harassing or discriminatory.
This study is limited by several factors. First, as with all retrospective survey research, the respondents’ recall of past events, behaviors, or situational specifics may be unreliable. However, because we surveyed graduating medical students rather than residents, the events described should have been somewhat more proximal than those reported by Hinze.10 Second, the incidents were reported by only one of the parties involved; the other party might have provided a different interpretation of the events. Nevertheless, these stories paint an unpleasant picture of medical education as experienced by many students. Finally, the number of responses analyzed probably underestimates the number of incidents that actually occur during medical school, because some students who did not respond probably also had stories to tell. Indeed, some of the students who returned questionnaires did not describe a particular incident because of discomfort or fear of recognition. One female student wrote:
The biggest incident for me is so specific that I am not comfortable writing it even here. I suppose many people imagine that this is true for things that have happened to them as well…. Even on an anonymous form, these feelings silence many of us.
On the other hand, neither can it be assumed that every incident of gender discrimination or sexual harassment was reported by the students who did respond. Although students were asked to list only their single most noteworthy experience with gender discrimination or sexual harassment, several reported more than one incident; one student wrote, “These events are so prevalent it does not do the subject justice to ask for description of a single event.” Additionally, the fact that students were asked to describe their most noteworthy experience suggests that only the most egregious experiences may have been reported and that these experiences may not be representative of all experiences of gender discrimination or sexual harassment in the medical school environment.
Despite these limitations, these descriptions of students’ personal experiences with gender discrimination and sexual harassment offer insight into the medical school environment. This study demonstrates the value of carefully attending to these diverse, poignant personal experiences as described in the students’ own words. Further studies of this type should be added to the medical literature to provide a “human” dimension to these incidents and to give a voice to the students who are affected by them.
The authors acknowledge and thank Ms. Candy Norman for data entry and evaluation. This work was partially supported by Research Scholar funding from the American Association of University Women to Lois Margaret Nora, MD, JD.