Sexual Harassment, Abuse, and Discrimination in Obstetrics and Gynecology

This systematic review investigates the prevalence of harassment, including sexual harassment, bullying, and abuse, among obstetrics and gynecology medical students and clinicians.


Introduction
Bullying, sexual harassment, and discrimination are pervasive across society, and mistreatment is often based on personal characteristics or demographics, such as sex, gender, and race and ethnicity.
A 2021 systematic review 1 found that within academic medicine, bullying commonly involved overwork and was associated with negative outcomes for well-being and psychological distress.
Academic bulling was associated with 44% of women reporting loss of career opportunities and 32% of men experiencing decreased confidence. 1 Unlike bullying, which can be more amorphous, sexual harassment in the workplace comprises 3 major forms: sexual coercion, consisting of using professional rewards or threats for sexual favors; unwanted sexual attention, such as unwelcome advances, touching, assault, or rape; and gender harassment, referring to offensive verbal slurs, gestures, or sexist remarks like "Women don't belong in surgery." 2,3In 2018, the National Academies of Sciences (NAS) found that sexual harassment was highly prevalent, with more than 45% of women in medicine experiencing sexist hostility and 18% experiencing crude behavior.Findings confirmed that sexual harassment is associated with impeded professional and educational goal attainment for women, undermined research integrity, a reduced talent pool, and negative physical and mental health outcomes among targets and bystanders. 3ilding on the NAS report, several authors reported even higher rates of harassment in women 4 and extended findings to include men, transgender and gender nonbinary individuals, and those with intersectional identities across various medical subspecialties. 5In 2023, harassment in various forms was reported via traditional media outlets and digital and social media.This led to multiple society statements condemning harassment and violence in medicine and a commitment by the American College of Obstetricians and Gynecologists 6 and other professional societies, including the Society of Gynecologic Surgeons (SGS) and Society of Gynecologic Oncology (SGO), to address needs of professional members. 7The joint SGS/SGO statement, endorsed by 11 other societies and foundations, outlines the expectation that members uphold principles of ethical conduct; categorically opposes and condemns sexual or verbal harassment of any kind; reiterates that all people should be treated with dignity, respect, and compassion; and provides resources to individuals experiencing harassment. 7The purpose of this systematic review was to investigate the prevalence of sexual harassment, bullying, abuse, workplace discrimination, and other forms of harassment in the obstetrics and gynecology (OB-GYN) field and evaluate interventions to reduce harassment across surgical specialties.

Methods
This systematic review was conducted as a joint venture between the SGS Systematic Review Group and SGO using standard systematic review methodology, including an a priori protocol (PROSPERO registration, CRD42023439415).The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.The University of Louisville Institutional Review Board determined that this systematic review did not require institutional review board approval because the project did not meet the Common Rule definition of human participant research.
We evaluated workplace harassment among and by health care workers.We excluded harassment by patients or family members.Eligibility criteria for prevalence and intervention studies, along with further details about methods, are described in eAppendix 2 in Supplement 1. Abstracts were screened in duplicate using Abstrackr software (Brown University Center for Evidence Synthesis in Health). 8Potentially relevant full-text articles were rescreened in duplicate.We extracted data in duplicate into SRDRplus. 9

Statistical Analysis
Prevalence studies were assessed for clarity, completeness of reporting, representativeness of surveyed participants, response rate, and reliability and validity of the survey instrument.
Intervention studies were assessed with the Cochrane risk of bias tool, and selected questions from the Risk of Bias in Nonrandomized Studies of Interventions tool were used as applicable per study. 10,11ch study was assigned as good, fair, or poor quality based on likelihood of biases, scientific merit, and completeness of reporting.

Results
The literature search identified 13 886 citations, of which 162 were retrieved for full-text screening.

Prevalence
A total of 10 studies met inclusion criteria for reporting on prevalence of harassment, bullying, and mistreatment in OB-GYN in the US and Canada, including 6 studies 2,4,12,13,15,19 among 2214 practicing OB-GYN clinicians or OB-GYN clinicians in training and 4 studies 14,[16][17][18] among 3638 medical students surveyed about mistreatment, harassment, belittlement, and verbal and physical abuse while on their OB-GYN clerkship.Studies were predominantly survey based and cross-sectional.Overall, the quality of studies was moderate, with concerns about low response rates (range, 907 of 7026 individuals [12.9%] 13 to 505 of 513 individuals [98.4%] 16 ) (Table 1).

Prevalence of Sexual Harassment
A total of 3 studies queried the prevalence of sexual harassment among OB-GYN clinicians (Figure 2). 2,4,13Definitions and reporting of sexual harassment differed by study.A survey of 402 gynecologic oncologists found that 256 respondents (63.6%) had experienced some form of sexual harassment, including unwanted sexual advances, sexist remarks, or the exchanging of sexual favors for an academic position.Sexual harassment was more common among females (181 of 255 respondents [70.9%]) but also commonly occurred among male respondents (75 of 147 respondents [51.0%]). 4ong 907 physician members of the AAGL (formerly the American Association of Gynecologic Laparoscopy), 250 respondents (27.6%) reported sexual harassment, including suggestive or offensive stories, attempts to establish a sexual relationship, bribes to engage in sexual behavior, and sexual assault. 13 Reporting of sexual harassment to colleagues, supervisors, or other responsible parties varied widely.A total of 32 of 256 gynecologic oncologists (12.5%) and 21 of 250 AAGL members (8.4%) reported their sexual harassment.In the survey of 366 OB-GYN trainees, 32.6% of respondents who experienced harassment reported their harassment, predominantly (71.8%) to another trainee. 2,4,13ong respondents who reported their harassment, 8% said that they did not feel that it was taken seriously. 2From 63 of 188 individuals (33.5%) 4 to 80 of 199 individuals (40.2%) 13 experiencing harassment did not report due to fear of retaliation.
Across all clerkship rotations, including general surgery, OB-GYN was noted to have the lowest professionalism scores. 16In a small study from 1992, 17 4 of 16 medical students (25.0%) reported that they had experienced physical abuse while on OB-GYN.

Institutionwide Interventions
There were 2 studies that described institutionwide initiatives to decrease medical student mistreatment. 22,26The Gender and Power Abuse Committee 22   Brown et al, 13  We assessed 4 studies that evaluated video-based discussions, 21,25,28,30 1 study that evaluated videos in a multipronged intervention, 26 2 studies that evaluated clinical scenarios and case-based workshops to prompt discussion, 24,31 and 2 studies (by the same author evaluating different medical specialties) that evaluated a forum theater intervention. 20,27Forum theater is a learning modality in which learners become participants who watch, respond to, and step in to the play to act out potential solutions while a facilitator debriefs and reinforces key messages. 20Target audiences were residents, 20,21,24,27 medical students, 25,28,30,31 or faculty 26 in the specialties of general surgery, 21,24,25,27,28,30 OB-GYN and urology, 20 or the entire medical school or class. 26,31Overall, programs helped trainees to recognize mistreatment and were associated with improved confidence in intervening on their own behalf or on the behalf of others (Table 2).

Addition of Reporting Modules and Other Interventions
There were 3 studies that described programs to improve trainee education regarding mistreatment reporting, 22,25,26 and 1 study evaluated a real-time, web-based reporting module for medical students on the surgical clerkship. 29While students perceived less intimidation and greater satisfaction with systems designed to improve reporting, the decrease in perceived abuse was not statistically significant.The implementation of a video-and discussion-based mistreatment program during a surgery clerkship was associated with a decrease in medical student mistreatment reports from 14 reports the year prior to the mistreatment program to 9 reports in the first year and 4 in the second year after implementation. 25Using a real time, web-based reporting module, students with access to modules were less intimidated than students in a control group based on a 1 to 10 intimidation score (4.02 vs 5.31) and faculty (5.26 vs 6.28). 29ere was 1 study that evaluated a 9-week, departmentwide cultural competency curriculum on bias based on race, ethnicity, sexual orientation, or gender in the surgery department. 23The curriculum included formal presentations, role play-based simulation, and small group interactions and engaged faculty, residents, and staff.Among 148 participants, 73.7% reported that these interventions helped to analyze their own bias, 65.5% reported improvement in responding to their own bias, and 68.1% reported an improved ability to respond when they see bias in the workplace. 23

Discussion
This systematic review found high rates of sexual harassment, gender bias, bullying, and discrimination within OB-GYN.However, interventions to limit these behaviors have not been adequately studied, were limited to medical students, or did not specifically address sexual or other forms of harassment.
The current literature reports a high prevalence of harassment behaviors directed toward surgical trainees.This was consistent with a systematic review addressing academic bullying that found that 32% of general surgery, 25% of OB-GYN, and 21% of medicine interns and medical students reported bullying. 1Another systematic review found that 27% of surgical trainees (including OB-GYN) reported sexual harassment 32 and a study reviewing harassment rates across multiple medical specialties found that OB-GYN was second only to general surgery as the specialty associated with the highest rates of sexual harassment. 33Undermining and bullying behaviors are commonplace in surgical specialties, with several physicians condoning tantrums, swearing, humiliation, and undermining of trainees as a "rite of passage." 34This can create a cycle of mistreatment, as seen when medical students experience high rates of belittlement and harassment from OB-GYN residents, who may be modeling behavior seen in senior physicians. 14,34Surgical specialties, including OB-GYN, are also high-pressure environments; combined with perfectionist characteristics seen in surgeons, this can create an environment of bullying and harassment. 34uipping OB-GYN clinicians to be better surgical educators, providing clinical support, and modeling positive behavior may help disrupt the culture of harassment. 34,35e power differential between medical trainees and other health care professionals, including physicians and nursing staff, can also lead to underreported abuses of professional power.The role of gender is critical to understanding sexual harassment.Although sexual harassment and gender bias were more commonly reported by female OB-GYN respondents, male OB-GYN respondents also reported high rates of sexual harassment and gender discrimination, often by female perpetrators.
This suggests that focus should be on perpetrators and leadership demographics to identify harassment behaviors.Unlike many other surgical specialties, OB-GYN has had an increase in the number of women clinicians, from 47% in 2010 to the majority (61%) in 2021. 36 of chairs in 2013 and 34% of chairs in 2021. 36,37However, the continued high rates of harassment in OB-GYN suggest that simply increasing the number of women in medicine is inadequate to address gender bias and discrimination.Rather, the role of power dynamics should be better studied and addressed to reduce harassment.
The high prevalence of sexual harassment in this review may be due in part to varied definitions of sexual harassment across studies.Sexual harassment can include a broad range of behaviors that humiliate, diminish, and demean a person on the basis of sex or gender, including gender harassment, unwanted sexual attention, and sexual coercion.While providing tools to educate health care staff about harassment may be associated with improved trainee and bystander confidence in standing up for individuals experiencing harassment, the need to maintain confidentiality in reporting presents an additional challenge. 1,20This is especially true in cases of sexual harassment where details may be known only to the perpetrator and the individual experiencing harassment.When physicians are required to report their grievances to immediate supervisors, they may perceive senior physicians as untouchable. 1,38,39One viable approach appears to be establishing an office of gender equity, as reported by the Medical University of South Carolina, 38 comprising university faculty with experience in responding to sexual harassment and interpersonal violence.All complaints are evaluated by an intermediary third party who interviews the accuser and accused separately before coming to a determination, thus protecting the individual reporting harassment and alleged perpetrator. 38Additional approaches include the Office of Professionalism developed by the University of Colorado School of Medicine, which provides nonpunitive feedback and makes professionalism a component of promotion. 26

Strengths and Limitations
This study has several limitations, with the major limitations related to the heterogenous evidence base, including wide variability of assessed forms of harassment and inconsistent or incompletely defined terminology.Additionally, variations in study participant specialties and subspecialties and level of training precluded meta-analyses across studies.Studies were predominantly survey based and retrospective, with moderate to low quality of evidence.Nonresponse and recall bias may have played a large role given that individuals who have been sexually harassed are less inclined to respond to this type of survey. 2 Therefore, the prevalence of sexual harassment may be different than that reported here.With 1 exception, 20,27 each intervention was evaluated by 1 study.
This study also has several strengths.It was a joint collaboration among experienced gynecologists, urogynecologists, and gynecologic oncologists and was conducted using a robust methodology.While other systematic reviews have addressed these topics in general surgery, this study specifically identified studies that included or were limited to OB-GYN to provide data within a surgical specialty that currently is majority female.

JAMA Network Open | Obstetrics and Gynecology
Sexual Harassment, Abuse, and Discrimination in Obstetrics and Gynecology

Figure 2 .
Figure 2. Sexual Harassment in Obstetrics and Gynecology 100

JAMA Network Open | Obstetrics and Gynecology
2n the Sexual Experiences Questionnaire.2This included gender harassment, unwanted sexual attention, and sexual coercion.The largest group of perpetrators consisted of senior OB-GYN attending physicians (30.1%), while 13.1% were residents or fellows, 8.2% were patients, and 7.7% were operating room staff.2While10.6% of perpetrators were women, they were the perpetrators in 57.7% of cases in which the individual experiencing harassment was a man trainee.2 45plicate publicationbeing told to smile more, dress in certain ways, or to "act more female" or "motherly."15Inanotherstudy of gynecologic oncologists,471 of 215 women (33.0%) reported being denied opportunities for training or rewards based on gender compared with 25 of 131 men (19.1%).Although men experienced significantly less workplace discrimination than women (138 of 358 men [38.5%]) vs 354 of 527 women [67.2%]), gender discrimination was the most common form of discrimination for men (99 of 137 men [72.3%]) and women (318 of 353 women [90.1%]) in gynecologic surgery.
4,13,15ed bias, microaggressions, or workplace discrimination related to gender, sexual orientation, and race among OB-GYN clinicians.One study12considered OB-GYN to be a female-dominant surgical specialty and compared it with other surgical specialties considered to be male dominant (eg, general surgery, orthopedics, neurosurgery, and ear, nose, and throat surgery).Another study19queried multiple surgical specialists, including OB-GYN clinicians, about microaggressions against surgeons based on gender, race, and ethnicity.The other 3 studies4,13,15focused on OB-GYN clinicians.A survey of 250 female gynecologic oncologists found that 131 of 248 respondents with data (52.8%) reported bullying and 142 of 249 respondents with data (57.0%) reported gender discrimination.Most respondents (208 individuals [83.2%]) reported microaggressions, including Figure 1.Study Flowchart13 886 Records identified from PubMed and Embase 2169 Records screened 162 Studies retrieved and assessed for eligibility 22 Studies included in review 10 Prevalence 2, 4, 12-19 12 Intervention 20-31 11 717 Records removed before screening 10 316 Records marked as ineligible

Table 1 .
Studies Reporting on Prevalence Abbreviations: AAGL, American Association of Gynecologic Laparoscopy; ENT, ear, nose, and throat; OB-GYN, obstetrics and gynecology; SGO, Society of Gynecologic Oncology.aStudy quality was assigned as good (A), fair (B), or poor (C) based on likelihood of biases, scientific merit, and completeness of reporting.

Table 2 .
Studies Reporting on Interventions Abbreviations: NR, not reported; OB-GYN: obstetrics and gynecology.a Study quality was assigned as good (A), fair (B), or poor (C) based on likelihood of biases, scientific merit, and completeness of reporting.

Despite high JAMA Network Open | Obstetrics and Gynecology
numbers of women OB-GYN residents and overrepresentation of women in residency program director roles, women continue to be underrepresented in departmental leadership, making up 24% JAMA Network Open.2024;7(5):e2410706.doi:10.1001/jamanetworkopen.2024.10706(Reprinted) May 8, 2024 8/13 Downloaded from jamanetwork.comby guest on 05/24/2024 263Most women do not consider or report gender harassment as sexual harassment, 2 explaining the wide range of reported prevalence depending on terminology used in surveys.Additionally, many women underreport incidents of harassment and sexual assault,3and unclear definitions make it difficult for individuals who have experienced harassment to definitively come forward.All trainees should be better versed in all aspects of harassment to improve recognition and reporting in a confidential way free of fear of retaliation.Interventions to address these pervasive behaviors would seem to be the obvious next step, but unfortunately, interventions to decrease harassment and specifically sexual harassment have been poorly studied.Successful interventions involved change at an institutional level and required support from multiple levels, including hospital administration, management, and leadership.26