The prevalence of mistreatment students experience during medical training is well-documented in both the United States1–3 and abroad.4–6 It runs the gamut from the inappropriate use of students by attendings and housestaff to verbal and even physical attacks by patients.7 Among the most pervasive and potentially troubling forms of mistreatment—especially given the increasing numbers of women in medicine8—are “gender discrimination” and “sexual harassment.” In fact, highlighting the magnitude of the problem, the Council on Graduate Medical Education (COGME)9 concluded in a 1995 report that: “Gender bias, a reflection of society's value system, remains the single greatest deterrent to women achieving their full potential in every aspect of the medical profession and is a barrier throughout the professional life cycle.”9
Although most research strongly concurs that women students are more likely than are men students to be victims of discriminatory or harassing behaviors based on their sex and gender,1,3,10 men students are not exempt from such mistreatment. Indeed, in the fields of pediatrics3,11,12 and obstetrics and gynecology,3,11–14 perceptions of discriminatory behavior towards men exist in terms of mentoring, educational opportunities, and general encouragement to enter these fields. Conversely, for women students, surgery is often identified as the least hospitable field of practice.15,16
Despite their widespread prevalence, identifying such behaviors is complicated by the fact that definitions of gender discrimination and sexual harassment are subject to a host of contextual circumstances17—all of which are perceptually filtered through “the eyes of the beholder.” For example, in general, women typically define a broader range of social–sexual behaviors as harassing than do men.18 Moreover, in the workplace, the same behavior is more likely to be seen by subordinates as constituting sexual harassment when coming from a supervisor or someone holding evaluative power.19
Nonetheless, research has shown perceived mistreatment to be associated with increased cynicism,20 a lessened commitment to the profession,21 and even various negative psychological (e.g., poor self-esteem, depression)22 and psychopathological sequelae.23 Research has similarly suggested that the effects may be lingering and recurrent, as evidenced by the observed correlation in women between the severity of sexual harassment experienced and posttraumatic stress disorder symptoms.24
Although sex and gender represent legitimate and often critical dimensions in medical training,25 unsanctioned biases predicated on these attributes permeate the “hidden curriculum,” where societal sex and gender roles and stereotypes are latently (and often unknowingly) reinforced.11 Indeed, beginning in the admissions process26,27 and continuing into the basic science years,28 considerations of gender have been implicated in clinical experiences,29,30 patient care,31 clinical judgment32 and, perhaps most apparently, in medical career choice.33,34
It is widely established that women are more likely than men to choose primary care specialties such as pediatrics, family medicine, and internal medicine,33,34 although whether this choice is due to a specialty's or applicant's characteristics is unclear. For example, women students tend to have lower income expectations than do men, an effect shown to be stable over time and across specialties.35 Another relevant factor in specialty selection is the presence of an influential mentor or an excellent instructor during medical training,36,37 although this may vary somewhat by specialty. That is, although men are more likely than women to be influenced by early role models in selecting primary care specialties,38 the presence of surgical role models for women appears crucial in attracting women into surgical careers.39 Lastly, personality factors may be implicated in the relationship of gender and specialty choice.40
Still, the importance of clinical experiences during undergraduate medical training is a dominant force in shaping students' specialty choices.41 Consequently, if students are attracted to specialties by positive experiences during medical training, it is plausible that negative experiences may dissuade students from specialties. As noted, mistreatment, specifically in the form of gender discrimination and sexual harassment, is one such negative experience often reported by medical students.1–3 This study examines the relationship of students' exposure to gender discrimination and sexual harassment with their selections of a medical specialty and a residency program.
We developed a questionnaire that allowed students to describe their exposure to gender discrimination and sexual harassment during medical school by type and frequency of event, their perceptions of gender discrimination and sexual harassment in various specialties and environments during and after training, and the degree to which their concerns about gender discrimination and sexual harassment had influenced their choices of specialty and residency program. Using a four-point Likert-type scale (0 = “never,” 1 = “rarely” [one or two times], 2 = “sometimes” [three or four times], and 3 = “often” [five or more times]), the students rated their direct experience with, their observations of, and what they had heard about gender discrimination and sexual harassment during preclinical coursework, core (required) clerkships, elective clerkships, residency selection, or outside the medical training environment. Students were then asked to rate on a five-point scale (0 = none, 1 = a little bit, 2 = some, 3 = quite a bit, and 4 = the deciding factor) the degree to which their considerations of gender discrimination and sexual harassment affected their specialty career choice and ranking of residency program choices.
To ensure that students understood the concepts of gender discrimination and sexual harassment, a cover letter presented carefully worded definitions. We based the definition of sexual harassment on one formulated by the National Advisory Council on Women's Educational Programs, “the use of authority to emphasize the sexuality or sexual identity of a person in a manner that prevents or impairs that person's full enjoyment of education benefits, climate or opportunities.”42 We used a common definition for gender discrimination (modified to include men), “those behaviors, policies, and other activities, which adversely affect either women or men because of disparate treatment, disparate impact, or the creation of a hostile environment.”43 The cover letter emphasized that gender discrimination and sexual harassment could be encountered by members of both sexes. Respondents were not asked to distinguish between gender discrimination and sexual harassment, but rather to treat the two events in a combined fashion.
The University of Kentucky Institutional Review Board approved the study design and the instrumentation. No extramural funding was garnered in support of this study.
The questionnaire was initially pilot tested in 1995 with students not included in the current study, and it was then administered a year later to 190 fourth-year students in two medical schools (also nonparticipants).12 Based on these limited data, a subsequent article published in 1996 contained a comparable examination of correlations, in addition to students' perceptions of gender discrimination and sexual harassment across medical specialties. More recently, a 2002 article reporting on perspectives gained by a 14-school study examined students' perceptions of gender discrimination and sexual harassment across medical specialties, in addition to the prevalence, nature, and contexts of these behaviors.3 The present analyses, although based on these 14-school data, excludes gender discrimination and sexual harassment behaviors encountered “outside the medical training environment,” and presents exposure data solely within academic contexts. Lastly, effect sizes and confidence intervals are presented for each statistically significant correlation.
Descriptive univariate analyses of students' exposures to gender discrimination and sexual harassment (experienced, observed, heard about) in specific settings (preclinical coursework, core clerkships, elective clerkships, residency selection) were performed with these factors presented as dichotomous variables (0 = no exposure, 1 = any exposure) and also in their original scaled forms. Pearson product moment correlation coefficients with accompanying confidence intervals were used to examine the linear association between students' exposure to gender discrimination and sexual harassment and their self-reported effects on specialty and residency program choices; these coefficients were also presented as effect sizes.44 A dichotomous (0 = no effect, 1 = any effect) measure of perceived effects of exposure to gender discrimination and sexual harassment on choice of specialty and residency program was cross-tabulated with men and women students' chosen areas of medical specialization. Finally, the prevalence of gender discrimination and sexual harassment that students personally experienced during residency selection (0 = no exposure, 1 = any exposure) was analyzed by students' chosen areas of medical specialization.
Of the 1,911 questionnaires administered, 1,314 (69%) were returned. The data were aggregated after analyses revealed no statistically significant differences between responses from students in public or private medical schools. Differences between men and women students were calculated from the 1,184 questionnaires on which respondents indicated their sex (90% of students returning questionnaires and 62% of those surveyed). Analyses of self-reported gender discrimination and sexual harassment exposure were based on the 1,175 students who provided valid responses to all related items (type of exposure within academic context). Given the large sample size and number of variables, a critical alpha of ≤ .01 was specified. A more detailed description of the sample characteristics has been reported elsewhere.3
Figure 1 outlines the degree of exposure to gender discrimination and sexual harassment (experienced, observed, heard about) in various educational contexts by men and women medical students. Substantial percentages of women (92.8%) and men (83.2%) reported encountering (i.e., experiencing, observing, hearing about) gender discrimination and sexual harassment in some medical training context (i.e., preclinical coursework, core clerkships, elective clerkships, residency selection). Across all types of exposure and contexts, women reported encountering higher levels of gender discrimination and sexual harassment, although the differences were greatest among behaviors directly experienced. More students reported hearing about gender discrimination and sexual harassment than observing it, and more students reported observing it than experiencing it. For both men and women, reported encounters of gender discrimination and sexual harassment in a medical training context were greatest within core (required) clerkships.
Of the 1,027 students (478 women, 549 men) who indicated some exposure to gender discrimination and sexual harassment during their undergraduate education, all provided responses to questions asking the degree to which considerations of gender discrimination and sexual harassment affected their choices of medical specialty and rankings of residency programs. As shown in Figure 2, most students reported that considerations about gender discrimination and sexual harassment did not influence their choice of medical specialty (men, 83.6%; women, 54.8%) or residency program rankings (men, 89.2%; women, 74.6%). However, significantly greater proportions of women believed that their specialty choice (χ2 = 100.9, df = 1, p ≤ .0001) and residency program rankings (χ2 = 36.7, df = 1, p ≤ .0001) were influenced by gender discrimination and sexual harassment considerations. Overall, women were 2.2 times more likely than were men to report basing some part of their specialty choice decisions on gender discrimination and sexual harassment concerns, and they were 1.8 times more likely to report that gender discrimination and sexual harassment concerns affected their rankings of residency programs.
Among the 1,027 students reporting any exposure (experienced, observed, heard about) to gender discrimination and sexual harassment during medical school, 358 students (34.9%) reported being influenced by gender discrimination and sexual harassment in their choice of medical specialty or residency program rankings (109 men, 249 women). Of students reporting any exposure (experienced, observed, heard about) to gender discrimination and sexual harassment and any impact (a little, some, quite a bit, the deciding factor) on specialty choice or residency rankings, the degree of perceived effect did not vary significantly between men and women. Interestingly, five of the six most extreme assessments of the consideration of gender discrimination and sexual harassment on these choices (i.e., the students indicated that the concern was the deciding factor) were rendered by men students.
The relationship of self-reported exposure to gender discrimination and sexual harassment to students' career decisions is presented in Table 1. Exposure to such behaviors appears to be implicated in students' choice of specialty. Among women, all types of gender discrimination and sexual harassment exposure (experienced, observed, heard about) in core clerkships were significantly associated with specialty choice. For men, the relationships between exposure to gender discrimination and sexual harassment and reported impact on career choices tended to be stronger and involve a broader impact of medical training contexts (e.g., preclinical and elective clerkships) on both specialty and residency program rankings. In fact, compared with exposure to gender discrimination and sexual harassment in other medical training contexts, exposure during elective (rather than core) clerkships had the strongest association with the specialty decisions of men.
Finally, Figure 3 identifies those medical disciplines in which students were most prone to exposure to gender discrimination and sexual harassment during residency selection. As shown, students specializing in obstetrics and gynecology (42.6%), general surgery (20.5%), emergency medicine (19.5%), and pediatrics (19.3%) were most likely to be exposed to situations that they interpreted as gender discrimination and sexual harassment. Of course, as with previously reported exposure rates, these overall compilations are based largely on reports of gender discrimination and sexual harassment made by women students. Indeed, upon closer examination, comparatively larger percentages of women reporting exposure to gender discrimination and sexual harassment during the residency selection are found in all but one medical specialty: among students choosing to practice obstetrics and gynecology, a larger percentage of men (56.6% versus 38.0%) reported encountering gender discrimination and sexual harassment in the residency selection process.
Historically, the overt discrimination against women entering the medical profession45—particularly prior to World War II26—reflected then-prominent societal values regarding sex roles, work, and occupations. Although the admissions process to medical school is still not entirely free of gender bias,27 a general shift in these social morays has seen medical school enrollments become increasingly gender-balanced. Yet, informal remnants of a system with gender preferences appear to exist intraprofessionally within certain disciplines, and these remnants have an impact on the educational experiences and career paths of men and women alike.
Pertinent to this hypothesis, related research has empirically demonstrated that both women and men medical students experience gender discrimination and sexual harassment in the learning environment.3 In addition to examining the relationship of exposure to gender discrimination and sexual harassment and students' specialty choices, we sought to better understand students' experiences with gender discrimination and sexual harassment during residency selection. Although we did not explicitly define the residency selection process, we believe it incorporates multiple aspects, such as career counseling, reviewing residency program materials, speaking to residents and others about various programs, making residency program visits, and completing interviews.
Thirty-one percent of respondents indicated that considerations of gender discrimination and sexual harassment played some role in their specialty choices, although the magnitude of self-assessed impact was generally small. This is similar to the findings of Field and Lennox,46 who concluded that although women medical students in the United Kingdom were more likely than were men to experience discrimination and be dissuaded from pursing certain specialties (e.g., surgery), the direct effect of gender on personal career choice was negligible. Instead, women were distanced from certain specialties more by incompatible lifestyle considerations regarding family.
Nonetheless, our findings do suggest that, for some students, exposure to gender discrimination and sexual harassment during the undergraduate years may play some role in future career decisions. For example, encountering gender discrimination and sexual harassment during core and elective clerkships may have the greatest impact on specialty choice, whereas encountering it during the residency selection process appears to exert some influence on program rankings. Our findings also suggest that students need not personally experience gender discrimination and sexual harassment for it to affect their career choices; what students observe and hear about may also affect their selections.
Both men and women students believed that gender discrimination and sexual harassment considerations had a greater impact on specialty choice than on residency program rankings, although the difference was slight for men. This is perhaps understandable, given the ample opportunities for students to encounter gender discrimination and sexual harassment during undergraduate medical training—when impressions of medical specialties are being actively formed. In general, more women than men reported that consideration of gender discrimination and sexual harassment had some impact on their career choices. However, although fewer men felt affected by exposure to gender discrimination and sexual harassment, the exposures they reported were more strongly associated with specialty and residency program decisions.
The reasons for this finding are not entirely clear, but perhaps the greater, more wide-spread exposure that women encounter, both within and outside the medical field, mitigates or dilutes the impact of specific incidents on their career decisions and, conceivably, on their future job performance.47 In her examination of medical students' narratives, Hinze48 offers another possibility—namely that women feel compelled to “write off” sexual harassment as a minor nuisance in hopes of countering the prevailing “sensitive female” stereotype.
Our study found that 10.2% of men (67) and 27.5% of women (139) reported personally experiencing gender discrimination and sexual harassment during their selection of a residency program, and additional students observed or heard about such incidents. When the data were analyzed by students' chosen specialties, the largest percentage of men who personally experienced gender discrimination and sexual harassment during residency selection chose obstetrics and gynecology (56.5%), although more than one-third (38.0%) of women in that specialty also reported experiencing gender discrimination and sexual harassment. Reports of personal experience of gender discrimination and sexual harassment in residency selection were most prevalent in obstetrics and gynecology (men and women), general surgery (women), and neurology (women), findings that tend to mirror those from other studies.49 However, because of the small numbers of men and/or women students in some disciplines, prevalence figures should be interpreted cautiously, particularly in the case of neurology.
Identifying obstetrics and gynecology as the sole area in which men perceived more gender discrimination and sexual harassment than did women warrants further commentary. Kerssens and colleagues50 found that gender preferences played a greater role in those disciplines “engaged in intimate and psychosocial health problems,” which they attributed to perceived differences in communication styles (rather than perceived sex or gender stereotypes) between men and women physicians. In this vein, Lyon13 suggests that men wishing to practice obstetrics and gynecology adapt to this “female-advantaged environment” by acquiring “traditionally female skills” (e.g., good communication and empathy)—just as women have been forced to acclimate to surgical careers.10,13
Yet, other research suggests that patients' preferences for same-sex physicians hinge more on the intimacy of the associated examination,51 making the practice of obstetrics and gynecology especially prone to considerations of gender. Various reasons exist for these preferences, but Watson and Mahowald25 recommend that requests for a male or female obstetrician be honored only when they are “based on patient characteristics rather than provider generalizations.” Still, the effects of gender bias within obstetrics and gynecology training are real, as research has shown that gynecology attendings who are men are more likely than are their women colleagues to allow residents (men or women) to participate as primary surgeon in cases involving abdominal or vaginal hysterectomies.14
Thus, exposure to gender discrimination and sexual harassment during the residency selection process, particularly by men students, tends to be most closely associated with effects on program choice. For women, this specific effect is not as pronounced as is the effect of exposure to gender discrimination and sexual harassment encountered in other medical training contexts. Indeed, overall, these relationships tended to be slightly weaker for women students, as evidenced by the comparatively smaller correlations. Nevertheless, it appears that what women and men students see, hear, and experience related to gender discrimination and sexual harassment does factor into their rankings of residency programs.
This study has several limitations. First, the cross-sectional design limits any discussion of causal relationships, and recent research52 advocating the separation of sexual harassment from gender discrimination could not be accommodated in this study. Also, because specialty choice is largely determined before students choose a specific residency program, we assumed that any gender discrimination and sexual harassment they had personally experienced during the residency selection process occurred within the student's chosen area of medical specialization. If students interviewed across specialties, this assumption may not be valid. We believe, however, that multiple-specialty interviews are fairly infrequent.
Second, the potential instability of the coefficients because of skewed data may also limit the rigor of some conclusions, especially for men. However, supplemental analyses (not shown) using nonparametric measures of association and dichotomous (e.g., “no effect” versus “any effect”) variables resulted in a slightly attenuated but not substantively different pattern of statistically significant correlations.
Third, we deemed the “impact” of gender discrimination and sexual harassment exposure on career choices to be negative, an interpretation we believe is overwhelmingly the case. However, a recent qualitative study suggests that, within surgical training, certain intimidating and harassing behaviors may be perceived by faculty and housestaff as functional educational tools.53 Conversely, seemingly unwelcome environments may also attract students who, in response to gender discrimination and sexual harassment behaviors encountered on some clerkships, actually strengthen their resolve to impart a distinctly male or female perspective within that discipline.11 In either case, we cannot rule out the possibility that a small number of students may, in fact, be attracted to specialties or programs that they associate with gender discrimination and sexual harassment.
Lastly, although the topic remains timely, the age of the study's data (1997) poses some potential limitations. For example, in similar data from a 2002 sample * (including some, but not all, of the schools in our study), prevalence estimates of reported gender discrimination and sexual harassment to which students were exposed were generally lower for both men and women across most training contexts. However, most general trends and relationships remained largely unchanged (e.g., the percentages of men and women students reporting that gender discrimination and sexual harassment affected their selection of medical specialty or residency program; the perceptions of gender discrimination and sexual harassment prevalence across medical specialties), suggesting that the underlying phenomenon likely persists in medical education today. Moreover, it is unclear whether the observed attenuations in prevalence are due to changes in students' perceptions, a real reduction in gender discrimination and sexual harassment, or merely sample variability.
This study demonstrates that sizeable percentages of students, most notably women, report some influence of gender discrimination and sexual harassment on their choice of medical specialty and, to a lesser extent, on their decisions regarding residency program rankings. Within the residency selection process, personal experience with gender discrimination and sexual harassment was most frequently reported by men and women students intending to specialize in obstetrics and gynecology and by women intending to specialize in general surgery.
A decade ago, the changing mix of men and women medical students and faculty prompted some to urge that a formal reassessment of the teacher–learner relationship be undertaken—a change that included discussions of human sexuality as well as the requisite communication skills.8 Since then, numerous attempts have been made to highlight the problem and educate individuals to the nature, extent, and impacts of gender discrimination and sexual harassment.
For example, in preparation for the residency selection process, Cheever and associates54 devised a voluntary, interactive workshop in which students review, discuss, and respond to commonly encountered questions related to gender. In a more comprehensive approach, Jacobs and colleagues55 detailed a multifaceted program featuring students' workshops on sexual harassment, mandatory sexual harassment education for medical faculty, and the establishment of an administratively sanctioned diversity council to formally address related grievances. Lastly, Heru,56 striving to disrupt the “transgenerational legacy”57 of unprofessional behaviors from learners to students, used role-playing exercises to sensitize residents to the problem of medical student mistreatment.
Truly meaningful efforts to address gender discrimination and sexual harassment in medical training cannot be undertaken in isolation from other social and professional forces. For example, women remain grossly underrepresented in leadership positions within academic medicine,58 and women role models continue to be in short supply in various disciplines (e.g., surgery, most subspecialties).59 Increasing the gender parity in both arenas might help legitimize gender discrimination and sexual harassment behaviors as bona fide professionalism issues. Moreover, Women in Medicine initiatives—along with other faculty development opportunities involving gender issues—can help delineate and address those societal and structural barriers that impact the educational experiences and career potential of both men and women.58
In light of fluctuating applicant pools and expanding class sizes, the potential effects of gender discrimination and sexual harassment become magnified. Although the number of men applying to U.S. medical schools is projected to remain relatively constant, a modest increase is anticipated in the number of women seeking to enter the profession.60 This, combined with projected shortages of general surgeons61 and obstetrics and gynecology subspecialists62—each highly “gendered” fields of practice—may greatly intensify competition for the most qualified students regardless of gender.
Given the documented discrepancies in defining and identifying gender discrimination and sexual harassment during medical training, it is plausible that some perpetrators may not recognize their own behaviors as discriminatory or harassing. Unless these issues are explicitly addressed, it should not be assumed that students or faculty share an understanding of acceptable and unacceptable behaviors—even those as seemingly “obvious” as maintaining appropriate sexual boundaries with patients.63
Most notably for women physicians, gender discrimination and sexual harassment behaviors have been shown to persist into medical practice,64,65 suggesting that any truly comprehensive response to the problem not be restricted to any one segment of medical training. Still, to the extent that such behaviors are learned during undergraduate education—especially core clerkships—students should be educated to recognize and encouraged to report incidents of gender discrimination and sexual harassment, and a satisfactory organizational response should be assured.66
Educating students, trainees, and faculty about gender discrimination and sexual harassment is a logical first step—provided the ultimate goal is real behavior change and not simply a public acknowledgment of the problem geared toward bolstering individuals' coping skills. Moreover, because some discrepancies undoubtedly exist in how medical specialties define gender discrimination and sexual harassment, an interdisciplinary approach to the problem seems warranted. After all, legal definitions notwithstanding, individuals are affected by actions they deem to be discriminatory or harassing, regardless of whether the perpetrator or a third party might agree. As a result, not all behaviors in all training contexts may be easily addressed, and it may be necessary to reach some common ground in defining instances that are most frequent and, hence, most generalizable.
Various studies have aptly documented the prevalence of gender discrimination and sexual harassment in certain disciplines and within certain curricular areas, pinpointing the problem areas in which initial attempts could be focused. However, the topic is perhaps best broached in a more comprehensive manner—ideally, on an institutional level and in the larger context of medical professionalism. That is, presented in a framework that is highly pertinent and readily applicable to all physicians, housestaff, and students—regardless of specialty, residency program, or level of training. Only then will the overarching normative culture of medical education be challenged to change.
Dr. Nora is the recipient of a 2002–2004 American Association of University Women Research Scholar-in-Residence Award, and acknowledges the contribution of that award to this research program. The authors gratefully acknowledge the contributions of Amy E. Murphy-Spencer, EdS, and Donald B. Witzke, PhD, in the research design and data collection of this study. They also thank Timothy Hansen, PhD, Richard L. Holloway, MD, Gwen Naguwa, MD, Carolyn Nicolosi, Emilie Osborn, MD, and Michael Rainey, PhD. Lastly, the authors wish to thank all participating medical students, without whom this study would not have been possible.
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*Data gathered in Spring 2002 from fourth-year students (n = 811) enrolled in 13 public and private U.S. allopathic medical programs (response rate 49.4%), and validated against prevalence data ranked for each participating school on two items contained in the AAMC's annual 2002 Graduation Questionnaire (rs = .86, df = 12, p = ≤ .05 and rs = .84, df = 12, p = ≤ .05, respectively).