What Proportion of Women Orthopaedic Surgeons Report Having Been Sexually Harassed During Residency Training? A Survey Study

Abstract

Background 

The field of orthopaedic surgery is not free from sexual harassment, with one recent study revealing that 47% of surveyed American Academy of Orthopaedic Surgeons (AAOS) members reported experiencing sexual harassment during their careers. Further characterization of the reported sexual harassment experienced by orthopaedic surgeons is warranted, especially as it relates to women trainees.

Questions/purposes 

(1) What is the overall proportion of women orthopaedic surgeons who reported having experienced sexual harassment during their orthopaedic residency? (2) Is the proportion of current orthopaedic trainees who report having experienced sexual harassment at work lower than the proportion of women attending orthopaedic surgeons who recall having been sexually harassed during their residency years? (3) Does this finding differ based on location of residency training?

Methods 

An anonymous 12-question online survey was distributed between October 2019 and December 2019 to the 682 active and resident members of the Ruth Jackson Orthopaedic Society, a professional society for women orthopaedic surgeons. The survey was created by Speak Up, an organization that is dedicated to identifying and correcting sources of workplace sexual harassment. Though not validated, the authors felt that this survey was the most easily adaptable to reflect orthopaedic training, and the authors felt it had good face validity for the purpose in a study of this kind. A total of 37% (250 of 682) of those contacted returned completed surveys. Twenty percent (51 of 250) were current residents, and 80% (199 of 250) were currently in fellowship or in practice. All survey respondents self-identified as women. Survey data were analyzed using descriptive and comparative statistics to determine the differences in proportions of sexual harassment among current residents and attendings, as well as differences in geographic locations.

Results 

Sixty-eight percent (171 of 250) of women reported having experienced sexual harassment during their orthopaedic training. We found no differences between current and past trainees in terms of the proportion who reported having experienced sexual harassment during residency training (59% [30 of 51] versus 71% [141 of 199], odds ratio 0.59 [95% CI 0.31 to 1.11]; p = 0.10). Compared with the northeast region of the United States, we found no differences in the proportion of women who reported having experienced sexual harassment during residency training in the South region (65% [55 of 84] versus 67% [36 of 54], OR 1.06 [95% CI 0.51 to 1.17]; p = 0.89), the Midwest region (75% [53 of 71], OR 1.55 [95% CI 0.77 to 3.12); p = 0.22), or the West region 66% [27 of 41], OR 1.02 [95% CI 0.46 to 2.23); p = 0.97).

Conclusions 

We found that a high proportion of women orthopaedic trainees report having experienced sexual harassment during orthopaedic residency. Residency programs should take steps to further identify and combat the sources of sexual harassment by increasing the number of women in leadership roles within the department and by ensuring that women trainees have adequate mentorship from both women and men attendings. After such measures are implemented, future studies should aim to evaluate their efficacy.

Level of Evidence 

Level II, prognostic study.

Introduction

Sexual harassment and gender discrimination have been identified as problems in medical training [^{2, 3}]. Numerous studies have described factors that contribute to the low percentage of women pursuing a career in orthopaedics, including the lack of women role models and the perception of a difficult work-life balance [^{2, 3, 6, 12}]. Tosi and Mankin [¹⁴] sought to identify barriers to success among academic orthopaedic surgeons who are women. The authors requested a panel of 21 women and 24 men orthopaedic surgeons review a 200-item survey that was distributed to 128 orthopaedic academic attendings who were women. Gender bias, including anecdotal evidence of sexual harassment, was cited as the second most important barrier to success, with the most important being the lack of mentorship [¹⁴].

Additionally, in 2020, Balch Samora et al. [¹] published a study characterizing the presence of “discrimination, bullying, sexual harassment, and harassment (DBSH)” that women and underrepresented minorities who were members of the American Academy of Orthopaedic Surgeons (AAOS) reported experiencing. The authors found that 81% of women, compared with 35% of men, reported having experienced DBSH behaviors, with 54% of women specifically having been subject to sexual harassment during their career (compared with 10% of men). Although this study highlighted the high frequency with which women report sexual harassment, we hoped to delve further into reported sexual harassment. As orthopaedic training is a unique time in a surgeon’s career, and is one with an established hierarchy, we wished to examine this particular time of a woman orthopaedic surgeon’s career.

We therefore asked: (1) What is the overall proportion of women orthopaedic surgeons who report having experienced sexual harassment during their orthopaedic residency? (2) Is the proportion of current orthopaedic trainees who report having experienced sexual harassment at work lower than the proportion of women attending orthopaedic surgeons who recall having been sexually harassed during their residency years? (3) Does this finding differ based on location of residency training?

Materials and Methods

Overview

An anonymous 12-question, voluntary online survey was distributed using the Survey Monkey platform (San Mateo, CA, USA) to resident and active members of the Ruth Jackson Orthopaedic Society (RJOS), a professional society for women orthopaedic surgeons. We elected to distribute the survey to RJOS members because this group constitutes a high percentage of women orthopaedic surgeons and thus serves as a representative cohort. Follow-up emails were sent 2 and 4 weeks later (between October 2019 and December 2019) to encourage participation.

Survey Instrument

The survey was adapted from Speak Up’s Survey on Sexual Harassment in the Workplace (see Appendix 1; Supplemental Digital Content, https://links.lww.com/CORR/A408) [¹³]. Speak Up is an international organization that aims to help workplaces identify and eliminate sources of workplace sexual harassment. Although not validated, the authors felt this survey was to be most appropriately adapted to be reflective of the experience of orthopaedic residency training. There is a precedent for using a modification of a pre-existing survey for the orthopaedic experience [¹].

Study Population

We distributed surveys to 682 active and resident members of the Ruth Jackson Orthopaedic Society, 37% (250) of whom returned a completed survey. All respondents self-identified as women.

Eighty percent (199 of 250) of the respondents were attendings, while 20% (51 of 250) were current residents (Table 1). With regard to the geographic location of residency training, the largest proportion of respondents had completed their residency or were current residents in programs in the Mid-Atlantic region of the Northeastern United States (24%; 59 of 250 respondents) (Table 1). Respondents were from each geographic region within the United States (Table 2).

Table 1. - Timing and location of residency training

Questions on timing and location of residency training	Total, % (n = 250)	Harassed, % (n)
How many years ago were you in residency?
Current junior resident	11 (27)	41 (11 of 27)
Current senior resident	10 (24)	79 (19 of 24)
Current fellow	5 (12)	67 (8 of 12)
0-5 years	24 (60)	77 (46 of 60)
6-10 years	17 (43)	67 (29 of 43)
11-15 years	10 (25)	68 (17 of 25)
16-20 years	7 (17)	76 (13 of 17)
21-30 years	12 (29)	69 (20 of 29)
> 30 years	5 (13)	62 (8 of 13)
In which region did you complete residency?
Northeast – New England	10 (25)	56 (14 of 25)
Northeast – Mid-Atlantic	24 (59)	69 (41 of 59)
South – South Atlantic	12 (30)	70 (21 of 30)
South – East South Central	2 (5)	40 (2 of 5)
South – West South Central	6 (15)	67 (10 of 15)
Midwest – East North Central	18 (44)	77 (34 of 44)
Midwest – West North Central	11 (27)	70 (19 of 27)
West – Mountain	4 (11)	64 (7 of 11)
West – Pacific	12 (30)	67 (20 of 30)

Cumulative values may not equal 250 due to missing data.

Table 2. - Residency location as a factor of residency completion

Residency location	Current resident, % (n = 51)	Past resident, % (n = 155)	p value
Region
Northeast – New England	8 (4)	14 (22)	0.24
Northeast – Mid-Atlantic	24 (12)	30 (46)	0.72
South – South Atlantic	10 (5)	15 (23)	0.36
South – East South Central	2 (1)	4 (6)	0.51
South – West South Central	6 (3)	8 (12)	0.66
Midwest – East North Central	16 (8)	23 (36)	0.25
Midwest – West North Central	10 (5)	14 (22)	0.42
West – Mountain	4 (2)	6 (9)	0.60
West – Pacific	18 (9)	14 (21)	0.52

Primary and Secondary Study Endpoints

Our primary study endpoint was to determine the overall proportion of women who reported having experienced sexual harassment during their orthopaedic training. Our secondary study endpoints were to compare the proportion of current and past trainees who reported having experienced sexual harassment, and identify differences in the proportions according to geographical locations within the United States.

Statistical Analysis

Survey data were analyzed using descriptive and comparative statistics. Comparisons were performed using the chi square test, with significance defined as a two-tailed p value < 0.05. All analyses were performed using SPSS Statistics for Macintosh, Version 25.0 (IBM Corp, Armonk, NY, USA). Nonqualitative data that were not amenable to statistical analysis were also collected.

Results

Overall Proportion of Women Reporting Sexual Harassment During Residency Training

Sixty-eight percent (171 of 250) of respondents reported experiencing sexual harassment during their orthopaedic residency training.

Proportion of Current Versus Past Trainees Reporting Sexual Harassment

We found no differences between current and past trainees in terms of the proportion who reported having experienced sexual harassment during residency training (59% [30 of 51] versus 72% [141 of 199], odds ratio 0.59 [95% CI 0.31 to 1.11]; p = 0.10).

Differences by Geographic Location of Residency Training

Compared with the northeast region of the United States, we found no differences in the proportion of women who reported having experienced sexual harassment during residency training in the Southern region (65% [55 of 84] versus 67% [36 of 54], OR 1.06 [95% CI 0.51 to 1.17]; p = 0.89), the Midwest region (75% [53 of 71], OR 1.55 [95% CI 0.77 to 3.12); p = 0.22), or the West region 66% [27 of 41], OR 1.02 [95% CI 0.46 to 2.23); p = 0.97).

Other Relevant Findings

The most common forms of reported sexual harassment were obscene images in the workplace (29%; 72 of 250 respondents), unwanted touching (21%; 53 of 250), and persistent and unwanted invitations of a sexual nature (14%; 34 of 250) (Fig. 1). Among those who indicated experiencing sexual harassment, 71% (122 of 171) noted harassment by residents who were men, 71% (122 of 171) by attending surgeons who were men, and 43% (73 of 171) by patients (Fig. 2). Fifteen percent (26 of 171) of respondents who reported having experienced sexual harassment during residency reported the incident. Current residents were more likely to report sexual harassment than respondents who already completed residency (26% [9 of 35] versus 11% [17 of 155], OR 2.81 [95% CI 1.13 to 6.98]; p = 0.026).

Fig. 1: This graph shows the types of sexual harassment experienced by residents who have reported harassment.

Fig. 2: This graph shows the professional status and gender of those reported to have committed sexual harassment.

Among respondents who reported having experienced sexual harassment, 42% (72 of 171) indicated that they discussed the harassment with someone outside the medical profession, such as a friend or family member, while 12% (20 of 171) of respondents reported the sexual harassment event to co-residents, 7% (12 of 171) reported it to the orthopaedic residency program director, and 5% (8 of 171) reported it to an attending surgeon in their residency program (Fig. 3).

Fig. 3: This graph shows the proportion of sexual harassment reporting by professional status among residents who have reported harassment.

Of the 85% (145 of 171) of respondents who did not report harassment, the most commonly cited reasons included concerns that reporting would result in a negative impact on their career (50%; 73 of 145), reporting was pointless because the department of orthopaedic surgery would not act anyway (43%; 62 of 145), and not wanting to report because the harasser was a superior (39%; 56 of 145) (Fig. 4). Thirty-four percent (49 of 145) of the respondents who did not report the harassment selected the option of “other,” in which 33% (16 of 49) noted that the incident “wasn’t that big a deal” or that they “brushed it off.”

Fig. 4: This graph shows the proportion of reasons cited by residents for why they did not report sexual harassment.

Qualitative Data of Sexual Harassment Experiences

Fifty percent (85 of 171) of the respondents who report having experienced sexual harassment during their training chose to elaborate on their specific experiences (Table 3).

Table 3. - Specific allegations of sexual harassment provided by respondents (Warning: Please note that Table 3 contains sexually explicit language.)

Residency status	Allegation
Current resident	“Had co-workers grab and/or slap my buttocks more than once. Was asked as an intern about how many men I’ve had sex with, what kind of birth control I use, how heavy my menstrual flow is, and if I’ve ever tasted cum. Was told I’m not allowed to get pregnant during residency. Have had co-workers and clinic staff discuss and vote on my best physical attributes.”
Current fellow	“Attending made comments about having sex with me and told a male resident to take me into a clinic room and ‘do me right’ when I said I was cold in clinic. Blood on floor once was referenced as me getting my period. Going through joint capsule with rush of joint capsule attending would repeatedly say to me ‘you gave him a happy ending.’”
0-5 years ago	“Many comments about how I shouldn’t get pregnant in residency and people were going to put birth control in my food.”
0-5 years ago	“My buttock was grabbed by a patient as I held counterforce during a reduction maneuver.”
0-5 years ago	“Event occurred during a rank meeting when applicants were being ranked based on appearance and when I tried to speak up I was told to know my place.”
6-10 years ago	“While fixing a lateral epicondyle fracture, a male attending normally says ‘get on your knees to better see the fracture.’ After he said that to me, he followed up with ‘I know that you’re used to that position.’”
6-10 years ago	“Attending used me as a human lead shield during a fluoro case and stated in my ear ‘I’m close enough to kiss your neck right now but I won’t.’ I was introduced by a co-resident to a group of med students as the fluffer for the other residents. I had to look that one up.”
11-15 years ago	“An attending talked about his sexual escapades during surgery. These were relations with someone other than his wife. An attending made comments about an asleep patient’s breasts.”
16-20 years ago	“Talk of other women's bodies, of the guys’ sexual exploits with nurses and medical students.”
21-30 years ago	“Male attending playing footsies under the OR table and talking in a sexual banter way. My not playing along started his campaign of why I was a bad resident.”
> 30 years ago	“An unscrubbed attending grabbed my butt while I was nailing a femur fracture.”

These allegations were taken verbatim from the free-text field of the survey.

Discussion

Sexual harassment and gender discrimination in the workplace have become prominent topics in medicine, especially in surgical fields, with a recent study revealing that 54% of women orthopaedic surgeons who responded to an AAOS survey reported having experienced sexual harassment during their career [¹]. In our study, we aimed to explore this reported sexual harassment with further characterization, especially focusing on the formative residency years. To do so, we aimed to identify the number of women who reported having experienced sexual harassment during residency training period. We then asked questions to further delineate the types of sexual harassment and any barriers to reporting the reported sexual harassment. We found that a high number of women orthopaedic surgeons report experiencing sexual harassment during residency, regardless of when or where within the United States they completed their training.

Limitations

There are several limitations to this study. First, this study had a low response percentage of 37%. However, this response proportion is higher than that of the published related survey study by Balch Samora et al. [¹], which yielded a 27% response proportion. Additionally, even if all non-responders had not experienced sexual harassment during residency, the proportion of positive responders would still have been 25%, which itself would be alarming. Second, we elected to survey the active and resident women members of RJOS instead of the larger AAOS membership. This choice limited the authors to a subset of women orthopaedic surgeons, and thus may had a lower overall response number as a result. The previous Balch Samora et al. [¹] study surveyed the women of the AAOS, with a 27% (621 of 2322) response percentage among women. The authors hoped that by targeting a subset of women they would ultimately achieve a higher response percentage.

Next, given that the survey asked women orthopaedic surgeons about events during their training, the responses were subject to recall bias as well as the individual’s own definition of sexual harassment. Although certain actions constitute clear sexual harassment or assault as defined by the law, other actions and words may be perceived as sexual harassment while not necessarily fitting that exact definition. For example, although one woman may perceive a certain joke said in her presence to be sexual harassment, another may not. However, with 68% of women reporting an experience of sexual harassment during residency, many with very clear allegations (Table 3), our results seem important regardless.

Third, neither the distributed survey nor the Speak Up survey has been validated. Although validated surveys on sexual harassment in the workplace exist, they do not adequately reflect the situations unique to women orthopaedic trainees and must therefore also be modified.

Overall Proportion of Women Reporting Sexual Harassment During Residency Training

Sixty-eight percent (171 of 250) of respondents reported experiencing sexual harassment during residency, which is slightly higher than the proportion reported in several studies that investigated sexual harassment in various surgical training programs [^{7, 11}]. It is also higher than the previously reported proportion of women orthopaedic surgeons who reported having experienced sexual harassment during their career as a whole [¹]. However, this proportion is lower than some other fields that are practiced mostly by men, such as cardiothoracic surgery. In one study, 81% of attending cardiothoracic surgeons who were women reported having been subjected to sexual harassment at all levels of training, including medical school, residency, fellowship, and as an attending [⁵]. The authors found the incidence of reported sexual harassment among women trainees alone was as high as 90%. Thus, sexual harassment during training is not unique to orthopaedics, and the medical field as whole must work to increase the women in these men-dominated specialties.

Proportion of Current versus Past Trainees Reporting Sexual Harassment

We found no differences in the proportion of women who reported sexual harassment who are currently training in our specialty and those who have graduated. With the recent media interest in sexual harassment and the development of the #metoo movement, as well as the recent interest within the orthopaedics [^{1, 10}], the authors had theorized that the proportion of current women residents who report having experienced sexual harassment would be lower than those who had already graduated. However, this was not the case, and our results suggest that increased awareness has not yet translated to a decrease in proportion. Compared with other specialties, orthopaedics has failed to increase the number of women entering the specialty from medical school [³]. We believe that programs must start looking to recruit more women in orthopaedics, and it has been suggested that increased the exposure to the specialty through good mentorship is imperative [¹⁰]. Increasing the number of women in orthopaedics, as well as placing women in leadership roles, may lead to an overall culture shift to decrease the number of women who report harassment during their training.

Differences by Geographic Location

We did not find any geographic differences in the proportion of women orthopaedic surgeons who reported sexual harassment. Balch Samora et al. [¹] evaluated sexual harassment across the United States, they did not analyze the finding by geographic locations across the country. Given the cultural differences in orthopaedic residency programs throughout the United States and inherent stereotypes (such as the idea of “the old boys club”) that surround some programs, we thought that geographic location might play a role in the experiences of the women within those programs. However, based on the findings from our study, that does not appear to be the case and, thus, even those programs who do not find themselves with a “old boys club” label should take accountability and develop ways to protect their trainees.

Other Relevant Findings

In our study, women who report having experienced sexual harassment most commonly described being exposed to inappropriate verbal remarks, followed by obscene images in the workplace, unwanted touching or staring, and persistent and unwanted sexual invitations. A recent study surveyed women physicians across all medical disciplines and found that 50% of respondents were harassed while practicing in an academic environment [⁴]. The most common types of harassment in that study were sexist remarks, unwanted sexual advances, bribery or threats to engage in sexual activity, or coercive advances.

We also found that women mostly commonly reported residents who were men, attendings who were men, and patients as those who committed the sexual harassment. Prior studies have suggested that the perpetrators of sexual harassment and gender discrimination have varied, but often include attending physicians who are men, co-residents who are men, other hospital staff, and patients or patients’ families [^{8, 9, 10}]. Freedman-Weiss et al. [⁸] found that women residents most commonly identified attending physicians as the harassers. Additionally, most respondents in our study who reported having experienced sexual harassment or gender discrimination did not report the incident, a finding that has been reported by others [^{8, 11}]. However, it is encouraging that current residents were more likely to report the incident, and this may represent the beginning of a culture shift and possibly the implementation of better reporting systems, in which those who report the sexual harassment do not fear repercussions.

Conclusions

In this study, we found that sexual harassment as reported by women orthopaedic trainees remains pervasive across training programs throughout the United States. In light of these findings, training programs should consider implementing specific training and awareness programs that target not only the trainees but also attending surgeons. These programs should include how to mentor women who are deciding whether they would like to pursue orthopaedic surgery, as good mentorship is seen as key to increasing women in the orthopaedic specialty [¹⁰]. Concerns within medicine have arisen in the #metoo era over how to appropriately mentor those of the opposite gender, and such programs can help to make both the mentor and protégé(e) more comfortable in their roles. Reported sexual harassment remains pervasive in the orthopaedic profession, however with an emphasis on the increase of the recruitment of women to our field through mentorship, coupled with the increase of women in leadership positions, the orthopaedic community can work towards making the specialty more inclusive.