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40 Sexual harassment, discrimination, and faculty–student intimate relationships in anesthesia practice
The author wishes to thank Rosemary Maddi MD for her contributions to the author’s understanding of discrimination and harassment in the anesthesia workplace. Regretfully, due to illness Dr. Maddi was unable to participate personally in the writing of this chapter, which is nevertheless a direct result of her previous writings, teaching, and discussions with the author.
The Case
Dr. Frances K. Conley held a tenured professorship in Neurosurgery at Stanford University. She was the first woman to complete a surgical internship at Stanford in 1966, and the first woman appointed to a tenured professorship at any US medical school in 1986. In 1991 she abruptly resigned when a male colleague with a widely publicized pattern of misogyny, harassment and disrespect of female physicians and staff members was appointed Acting Chair of her department. In a letter to the Los Angeles Times, Dr. Conley described a workplace that was relentlessly hostile and demeaning. She related stories from her own illustrious career: a male colleague who repeatedly suggested in front of colleagues that she “go to bed” with him, professional presentations she had attended in which images of Playboy centerfolds “spiced up” the lectures, and male physicians who groped female colleagues and staff members at will in the operating room. She described finding that “any deviation on my part from the majority view often was prominently announced as being a manifestation of either PMS syndrome or being ‘on the rag.’ She ultimately rescinded her resignation, but not before her office had been rifled, her name had been summarily removed from the university stationery (even before her resignation had taken effect), and her research lab had been dismantled. Only 12 years ago Dr. Conley wrote, “I have acquired a curious inner peace … realizing, in my lifetime, I will not see women obtain the equality that should be theirs.”1
Frances Conley’s story is a sadly familiar one to the more than 80% of female academic physicians who report sexual harassment or discrimination on the job.2 Sexual harassment and discrimination represent only the tip of an iceberg of similar issues in the medical workplace that include discrimination based on race and sexual orientations, and bullying.
Sexual harassment
In the US, sexual harassment is considered sexual discrimination and violates the Civil Rights Act of 1964 – Title VII. Sexual harassment is anti-social and unacceptable behavior defined as unsolicited sexual advances or requests for sexual favors, or any verbal or physical conduct of a sexual nature. Sexual harassment is independent of the gender of the offender or the recipient. It can occur between members of the same or opposite sex, and between workers of any rank. The victim is defined as anyone who is offended by the behavior, not just the person toward whom the behavior is directed. It can take the form of inappropriate jokes or stories, touching, or subtle or overt pressure for sexual activity. Sexual harassment is deemed to exist if the victim’s job performance is adversely affected by the behavior, or if an offensive, hostile, or intimidating work environment results from it.
In the US, federal law recognizes two forms of sexual harassment. The first is “quid pro quo” harassment, in which the offender demands verbal or physical sexual behavior from an employee in return for job benefits or advancement. The second is the creation of “a hostile work environment” in which no quid pro quo exists.3 The law also recognizes retaliation against an employee for resisting or complaining about offensive conduct as unlawful.
In 2005, Great Britain amended the Sex Discrimination Act of 1975 to include sexual harassment, defined as verbal, nonverbal, or physical conduct based on sex that has the effect of violating [her] dignity or creating a hostile, degrading, humiliating, or offensive environment. British courts further recognize that women suing for sexual harassment need not show that a man would have been treated differently in order to prevail. The European Union defines sexual harassment as unwanted conduct of a sexual nature affecting the dignity of women and men at work.4
Sexual discrimination is more commonly directed against women, but male students are not immune from mistreatment. In pediatrics, obstetrics, and gynecology, for example, men report frequent discrimination with regard to mentoring, educational opportunities, and even general support for entering these specialties.5
How is this behavior harmful?
Many ethical principles and values are breached, whether intentionally or not, when sexually charged and discriminatory behavior is tolerated in the workplace. Discrimination flies in the face of social principles that hold that all persons have intrinsic value, and that equals should be treated equally. It also violates principles of justice, beneficence, nonmaleficence, and respect for individual autonomy.
Discrimination creates exclusionary classes of persons – unfairly bestowing benefits on some while harming others – and thus violates the ethical principle of justice. Unfair benefits to a “privileged” group include a greater sense of power and control, lower stress, greater access to educational and promotional opportunities, and by extension, professional and financial advancement, job security, and greater social acceptability. By excluding some individuals, members of the privileged class also proportionally increase the remaining benefits to themselves.
Exclusion from the privileged class assures lower quality education, personal and professional insecurity, higher stress secondary to bullying and harassment, lower rates of promotion and lower rates of pay. In the case of Frances Conley, the “privileged” class was male physicians, and the “excluded” class was women on the healthcare team. But unfair discrimination can just as well be described for any racial, ethnic, financial, or social divisions in which professionally and intellectually comparable persons are treated unequally due to qualities that are unrelated to their ability to perform the job required of them.
Discrimination restricts the individual autonomy of members of the “excluded” class. They do not have the same freedom that the members of the “privileged” class have to choose their associates or their profession – discrimination reduces even their ability to acquire mentors who could advocate for them. The oppressive environment increases stress and limits the individual’s emotional ability to cope with bullying. In extreme cases, some individuals may feel compelled to engage in unwanted sexual acts to secure a benefit or promotion they desperately want or need.
Tolerance of discrimination is harmful to patients as well as to the medical profession as a whole, while conferring few if any benefits. When talented future physicians are excluded from training or practice due to discrimination, advancements for the profession that these individuals might have contributed are never achieved. Physicians as a whole are less able to understand and advocate for their patients when the profession is restricted to a sexually and ethnically narrow group of individuals that is not reflective of the population of patients they serve. Restriction of access to the profession gives everyone in the “privileged” group the short-term gain of a larger share of “benefits,” but at the expense of long-term degradation of physician resources for patient care – the very reason for which the medical profession exists.
It has been shown that trainees who experience or witness sexual harassment or discrimination in the workplace become accepting of it, and more likely to commit abuses themselves in the future.6 Thus the harasser of today not only harms today’s trainee, but the trainees of tomorrow as well. Physicians often justify the presence of hostile work elements as “routine” and even a “rite of passage,” implying that mistreatment and abuse of staff and trainees is not merely acceptable, but somehow necessary because it toughens the trainee to a demanding occupation. This further entrenches discriminatory behavior, even while being antithetical to the training of empathetic, compassionate physicians. Furthermore, demeaning any victim who objects to such treatment as “too sensitive” or “not able to play with the boys” violates the values of respect and preservation of dignity of individuals – values that are integral to the ethical practice of medicine.
These harms are not merely theoretical, and certainly are not trivial. In one study,7 more than 80% of women medical students had heard jokes in the workplace demeaning to women, 71% had experienced subtle sexual comments, 62% had heard overtly sexual comments, 22% had received unwanted sexual advances, and 36% had seen printed sexual material such as magazines or “pin-up” images of women in sexual situations in the workplace. Such behaviors were more common on surgical rotations (74%) and rare on anesthesia rotations (2%). However, the specialty of anesthesia was not exempt: one student described an attending anesthesiologist who asked her about “the sexy things” she was wearing under her scrubs and then told her to “lighten up” when she was offended. Another study found that anesthesiology residency was fourth among specialties (following only surgery, internal medicine, and emergency medicine) in frequency of sexual harassment of residents.8
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Animal subjects research Part I: Do animals have rights?
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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