性骚扰与预防培训

Cedeno Rommy, Bohlen Julie

Columbia University Irving Medical Center

StatPearls

Even though sexual harassment policies and procedures are required within the medical field, surveys reveal that unwanted sexual and gender harassment is prevalent in healthcare workplaces. In the healthcare community, sexual harassment remains an issue for worker wellness and productivity, as well as the optimal delivery of patient care. Sexual harassment is a risk factor for various mental health conditions and can result in qualified personnel leaving the workplace. Efficient training and preventive measures improve recognition of potential sexually offensive behaviors and help to establish an inclusive and respectful workplace. Acknowledging the problem is the first step, and prevention is the cornerstone of an effective anti-harassment strategy. Changes in institutional and organizational approaches can prevent sexual harassment and covert retaliation. Helpful initiatives include enhanced senior faculty member training and encouragement of bystander complaints when they witness prohibited behaviors. All medical fields can benefit from reflecting on workplace culture, focusing on prevention, reviewing policies and strategies, and committing to change. Sexual harassment continues to be prevalent in medical training, a pressing concern for leadership. The adverse effects detract from the professional workforce. According to the Equal Employment Opportunity Commission (EEOC), unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when submission to or rejection of this conduct explicitly or implicitly affects an individual’s employment; unreasonably interferes with an individual’s work performance; or creates an intimidating, hostile or offensive work environment. [See 29 CFR PART 1604] This unethical practice exploits inequalities in status and power, abuses the rights and trust of those affected, may influence or be perceived to influence professional advancement, harm working relationships, and is likely to jeopardize patient care. [See AMA Code of Medical Ethics Opinion 9.1.3] The United States EEOC enforces Title VII of the Civil Rights Act of 1964, which not only prohibits sexual discrimination, including pregnancy, sexual orientation, and gender identity, but also makes sexual harassment or retaliation illegal. Sexual harassment in the workplace is a form of sex discrimination that violates Title VII. Since Title VII, cultural and legal changes include decreased tolerance for harassment, increased legal responsibility assigned to institutions, and a significant increase in women choosing careers in medicine. Unwelcome sexual behavior occurs when the victim does not invite the behavior or when the victim regards the conduct as undesirable or offensive. If behavior starts as welcome behavior and then crosses over to unwelcome behavior, consent can be revoked at any time. The individual should announce that the behavior needs to stop. The harasser cannot use a defense that the other person started the behavior or initially gave consent after the alleged victim announces that welcome behavior is now unwelcome behavior. The work environment or the workplace is not limited to the assigned physical location of the employee. The work environment includes all locations where work is performed, and work-related business is conducted. Medical conferences and training sessions, satellite clinics, business travel, work-related social activities, and work-related communications are all considered part of the work environment or workplace. Ahostile work environment occurs when the harasser creates an uncomfortable or harsh atmosphere for the person subjected to unwelcome behavior. The harassment can be verbal, nonverbal, or physical and is sexual or based on someone's gender. Physical forms of sexual harassment may include intentionally touching, massaging, leaning over or cornering a person, caressing, pinching, kissing, and hugging, as well as sexual assault or rape. Verbal forms of sexual harassment include socially and culturally inappropriate and unwelcome comments or jokes with sexual overtones, persistent proposals, asking about sexual fantasies/preferences/history, spreading rumors or fabricating lies about one's personal sex life, inappropriate remarks about a woman's physical appearance, and unwelcome requests or persistent invitations to go out on a date. Referring to a woman by inappropriate names, such as doll, babe, honey, or similar, is unacceptable. Nonverbal forms of sexual harassment include unwelcome gestures, suggestive body language, indecent exposure, repeated winks, sexual gestures, whistling at someone, and unwelcome display of pornographic materials. Sending letters, phone calls, texts, emails, social media comments, blog posts, or other communications of a sexual nature may constitute harassment. In healthcare, verbal harassment is the most common form, primarily sexually suggestive statements or jokes, followed by meddling questions about one's intimate life or physical appearance. Occasional compliments that are socially and culturally appropriate and acceptable are not considered sexual harassment. Any consensual adult interaction of a sexual nature that is welcomed or reciprocated is also not harassment. The law does not prohibit simple teasing, offhand comments, or isolated incidents that are not serious. The behavior is illegal when it is more than a single incident and creates a hostile or offensive work environment, or when an individual’s employment is negatively affected. According to the EEOC, the two main types of sexual harassment claims are (1) quid pro quo and (2) hostile work environments. Quid pro quo, or “this for that,” sexual harassment implies that if “you do something for me, I’ll do something for you.” Quid pro quo sexual harassment involves demands for sexual favors in exchange for some benefit or to avoid some detriment in the workplace. This type of behavior occurs when an individual in an organization attempts to influence the process of recruitment, promotion, training, discipline, dismissal, pay increases, or other benefits of an employee or job applicant in exchange for sexual favors. Hostile work environment sexual harassment occurs when unwelcome sexual advances, requests for sexual favors, or any conduct of a sexual nature interfere with someone’s work performance or cause an intimidating, hostile, or demeaning work environment. Unlike quid pro quo harassment, the perpetrator could be anyone in the workplace, including a coworker, subordinate, contractor, consultant, patient, or supervisor. Examples of unwelcome conduct that could create a hostile work environment include sexual jokes or communications, offensive pictures, inappropriate touching, or repeated requests for dates. A 3-part classification system divides sexual harassment into these distinct categories: gender harassment, unwanted sexual attention, and sexual coercion. Sexual harassment is not necessarily about sexual activity or sexual desire. Sexual harassment is also discrimination based on gender, which includes one's biological sex and cultural gender-based stereotypes. Gender harassment includes verbal or physical behavior that denigrates or shows aversion to one's gender, gender identity, or sexual orientation. For example, calling out a man for being a "sissy" or telling a woman she isn't fit for a senior position in a male-dominated leadership environment may constitute gender harassment. Gender harassment can include hatred, objectification, exclusion, or giving second-class status to members of a particular gender. Sexist or heterosexist language, jokes, or comments also fall under this category. Given the circumstances, gender harassment can have the same unfavorable outcomes as one instance of sexual coercion. Unwanted sexual attention includes making suggestive statements about a person's body, spreading sexual rumors, and electronically sharing sexualized images. Sexual coercion, or quid pro quo, happens the least frequently of the 3 categories of sexual harassment but is the most reported. A large national medical center with more than 65,000 employees, including more than 4000 physicians and scientists, serves as a contemporary snapshot of the scope of the problem. A 2-year survey of more than 6200 healthcare workers, including physicians in all specialties, residents, nurses, nurse practitioners, and physician assistants, was conducted. Among physicians who reported sexual harassment, 12% were women, and 4% were men. About half of the harassers were physicians, with 37% in a superior hierarchical position. Only 40% of those who stated that they did experience harassing behaviors reported the behaviors. Of importance, 40% of the investigations could not be substantiated. In just over 3% of the claims, the patients were the alleged harassers. However, in another study, sexual harassment from patient to clinician was common, with 67% reporting inappropriate behavior. Approximately 84% of female providers reported some form of sexual harassment by patients, while 40% of male providers reported the same. Of those female providers, 42% experienced multiple episodes of sexual harassment by patients during their medical careers. The most common occurrences of patient-to-provider harassment were in outpatient clinics, with Veterans Affairs outpatient clinics reporting the highest frequency. Few providers in an inpatient setting reported sexual harassment by patients. According to a National Academies of Sciences, Engineering, and Medicine (NASEM) report, high rates of sexual harassment in medicine compromise the integrity of education and research. Of concern to leaders of academic medical institutions, medical students experience sexual harassment considerably more often than their peers in sciences and engineering. About 45-50% of female medical students reported that they experienced sexually harassing behavior from faculty or staff members. A systematic review revealed that 33.1% of medical students, 36.2% of residents, and 30.4% of younger faculty encounter sexual harassment. Surgery and emergency medicine female residents experience eminently high estimates of sexual harassment; the leading reason is that those fields value a hierarchical and authoritative workplace. Pediatric residents reported the lowest incidence of harassment. Recently, several investigations found that medical trainee harassment is not limited to specific nations or education programs. Sexual harassment charges filed with the EEOC have increased after the #MeToo movement received international attention beginning in the fall of 2017. Between 2018 and 2021, sexual harassment charges accounted for 27.7% of all harassment charges compared to 24.7% of all harassment charges between 2014 and 2017. Of the sexual harassment charges filed between 2018 and 2021, 78.2% were filed by women, while men filed 21.8%. [See EEOC Sexual Harassment in Our Nation's Workplaces] Roughly 3 out of 4 individuals who experience harassment never report the unwelcome behavior to a supervisor or manager, usually because they fear disbelief of their claim, no corrective action will occur, blame, or social or professional retaliation. According to the EEOC Select Task Force on the Study of Sexual Harassment in the Workplace, anywhere from 25% to 85% of women report having experienced sexual harassment in their work environments. The discrepancy in numbers was dependent on the vocabulary used in the surveys. For example, when employees were asked if they had experienced sexual harassment, 25% answered that they had. However, when employees were asked if they experienced a specific sexually-based behavior, such as unwanted sexual attention or coercion, the rate rose to 60% answering affirmatively. Recent cross-sectional studies revealed that women younger than 55 were at increased risk of sexual harassment or violence in their current workplace compared to women aged 55–69. Women who belong to a sexual minority (lesbian, bisexual, or not defined) more frequently encounter unwanted behavior than heterosexual women. Harassment was more common among women who worked shifts and irregular hours than women who worked during the day. This may be because women who work nights more often work alone due to factors such as understaffing, and they might be in contact with third-party individuals (eg, patients, clients, or vendors). Factors such as a hierarchical structure with faculty and trainees, a male-dominated environment, and a culture that tolerates harassing behavior from those in power make an organization particularly prone to sexual harassment. Healthcare organizations, including hospitals, nursing homes, and clinics, have all these elements.

尽管医疗领域要求制定性骚扰政策和程序，但调查显示，不受欢迎的性骚扰和性别骚扰在医疗工作场所普遍存在。在医疗界，性骚扰仍然是影响员工健康和工作效率以及患者护理最佳提供的一个问题。性骚扰是导致各种心理健康问题的一个风险因素，可能导致合格人员离开工作场所。有效的培训和预防措施有助于提高对潜在性侵犯行为的认识，并有助于建立一个包容和尊重的工作场所。认识到问题是第一步，预防是有效反骚扰策略的基石。机构和组织方法的改变可以防止性骚扰和隐蔽报复。有益的举措包括加强资深教员培训，并鼓励旁观者在目睹被禁止行为时提出投诉。所有医疗领域都可以从反思工作场所文化、注重预防、审查政策和策略以及致力于变革中受益。性骚扰在医学培训中仍然很普遍，这是领导层迫切关注的问题。其负面影响损害了专业劳动力队伍。根据平等就业机会委员会（EEOC）的规定，不受欢迎的性挑逗、性 favors 请求以及其他具有性性质的言语或身体行为，如果服从或拒绝这种行为明确或含蓄地影响个人就业、不合理地干扰个人工作表现或营造出一种令人生畏、敌对或冒犯性的工作环境，则构成性骚扰。[见《联邦法规汇编》第29编第1604部分] 这种不道德的行为利用了地位和权力的不平等，侵犯了受影响者的权利和信任，可能影响或被认为会影响职业发展，损害工作关系，并可能危及患者护理。[见美国医学协会《医学伦理准则意见》9.1.3] 美国平等就业机会委员会执行1964年《民权法案》第七章，该章不仅禁止包括怀孕、性取向和性别认同在内的性别歧视，还将性骚扰或报复定为非法行为。工作场所的性骚扰是一种违反第七章的性别歧视形式。自第七章通过以来，文化和法律方面的变化包括对骚扰的容忍度降低、机构承担的法律责任增加以及选择医学职业的女性人数大幅增加。当受害者没有主动邀请某种行为，或者受害者认为该行为不受欢迎或具有冒犯性时，就会发生不受欢迎的性行为。如果行为一开始是受欢迎的，但后来变成了不受欢迎的行为，同意可以随时撤销。个人应声明该行为需要停止。骚扰者不能以对方先开始行为或在所谓的受害者宣布欢迎行为现在不受欢迎后最初给予同意为由进行抗辩。工作环境或工作场所不限于员工指定的实际地点。工作环境包括进行工作和开展与工作相关业务的所有地点。医学会议和培训课程、卫星诊所、商务旅行、与工作相关的社交活动以及与工作相关的通信都被视为工作环境或工作场所的一部分。当骚扰者为遭受不受欢迎行为的人营造出一种不舒服或恶劣的氛围时，就会出现敌对的工作环境。骚扰可以是言语上的、非言语上的或身体上的，并且是性方面的或基于某人的性别。性骚扰的身体形式可能包括故意触摸、按摩、俯身或逼近某人、抚摸、捏、亲吻和拥抱，以及性侵犯或强奸。性骚扰的言语形式包括具有性暗示的、在社会和文化上不适当且不受欢迎的评论或笑话、持续的提议、询问性幻想/偏好/经历、传播关于某人个人性生活的谣言或编造谎言、对女性外貌的不当评论以及不受欢迎的约会请求或持续邀请。用不适当的称呼称呼女性，如洋娃娃、宝贝、亲爱的或类似的称呼，是不可接受的。性骚扰的非言语形式包括不受欢迎的手势、暗示性的肢体语言、暴露下体、反复眨眼、性手势、向某人吹口哨以及不受欢迎地展示色情材料。发送具有性性质的信件、电话、短信、电子邮件、社交媒体评论、博客文章或其他通信可能构成骚扰。在医疗领域，言语骚扰是最常见的形式，主要是具有性暗示的陈述或笑话，其次是对个人私密生活或外貌的多管闲事的询问。偶尔的、在社会和文化上适当且可接受的赞美不被视为性骚扰。任何双方自愿的、受欢迎或相互回应的具有性性质的成人互动也不是骚扰。法律不禁止简单的取笑、随意的评论或不严重的孤立事件。当行为不止是单一事件且营造出敌对或冒犯性的工作环境，或者个人的就业受到负面影响时，该行为就是非法的。根据平等就业机会委员会的说法，性骚扰指控的两种主要类型是：（1）交换条件型和（2）敌对工作环境型。交换条件型性骚扰，即“以这个换那个”，意味着“如果你为我做某事，我就为你做某事”。交换条件型性骚扰涉及要求性 favors 以换取某种利益或避免工作场所的某种不利情况。当组织中的个人试图影响员工或求职者的招聘、晋升、培训、纪律处分、解雇、加薪或其他福利过程，以换取性 favors 时，就会发生这种行为。当不受欢迎的性挑逗、性 favors 请求或任何具有性性质的行为干扰某人的工作表现或导致一种令人生畏、敌对或有辱人格的工作环境时，就会发生敌对工作环境型性骚扰。与交换条件型骚扰不同，骚扰者可能是工作场所的任何人，包括同事、下属、承包商、顾问、患者或主管。可能营造出敌对工作环境的不受欢迎行为的例子包括性笑话或通信、冒犯性图片、不当触摸或反复的约会请求。一种三分法分类系统将性骚扰分为这些不同类别：性别骚扰、不受欢迎的性关注和性胁迫。性骚扰不一定与性活动或性欲望有关。性骚扰也是基于性别的歧视，包括一个人的生理性别和基于文化性别的刻板印象。性别骚扰包括诋毁或表现出对某人的性别、性别认同或性取向厌恶的言语或身体行为。例如，称一个男人为“娘娘腔”，或者告诉一个女人她不适合在男性主导的领导环境中担任高级职位，可能构成性别骚扰。性别骚扰可以包括仇恨、物化、排斥或给予特定性别的成员二等地位。性别歧视或异性恋歧视的语言、笑话或评论也属于这一类别。在这种情况下，性别骚扰可能会产生与一次性胁迫相同的不利后果。不受欢迎的性关注包括对某人身体发表暗示性言论、传播性谣言以及通过电子方式分享性感图片。性胁迫，即交换条件型，在这三种性骚扰类别中发生频率最低，但报告率最高。一家拥有超过65000名员工，包括4000多名医生和科学家的大型国家级医疗中心，是该问题范围的一个当代缩影。对包括所有专科医生、住院医师、护士、执业护士和医师助理在内的6200多名医护人员进行了为期两年的调查。在报告遭受性骚扰的医生中，12%是女性，4%是男性。大约一半的骚扰者是医生，其中37%处于上级层级。在表示确实经历过骚扰行为的人中，只有40%报告了这些行为。重要的是，40%的调查无法得到证实。在略多于3%的指控中，患者是被指控的骚扰者。然而，在另一项研究中，患者对临床医生的性骚扰很常见，67%的人报告有不当行为。大约84%的女性医疗服务提供者报告曾受到患者某种形式的性骚扰，而40%的男性医疗服务提供者也报告了同样的情况。在那些女性医疗服务提供者中，42%在其医疗职业生涯中曾多次受到患者的性骚扰。患者对医疗服务提供者的骚扰最常发生在门诊诊所，退伍军人事务部门诊诊所报告的频率最高。很少有住院环境中的医疗服务提供者报告受到患者的性骚扰。根据美国国家科学院、工程院和医学院（NASEM）的一份报告，医学领域的高性骚扰率损害了教育和研究的诚信。学术医疗机构的领导层担心，医学生比他们在科学和工程领域的同龄人更容易遭受性骚扰。大约45 - 50%的女医学生报告说她们曾受到教职员工的性骚扰行为。一项系统评价显示，33.1%的医学生、36.2%的住院医师和30.4%的年轻教员遭遇过性骚扰。外科和急诊医学专业的女性住院医师遭受性骚扰的比例极高；主要原因是这些领域重视等级森严和权威的工作场所。儿科住院医师报告的骚扰发生率最低。最近，几项调查发现，医学实习生遭受的骚扰不限于特定国家或教育项目。自2017年秋季#MeToo运动受到国际关注以来，向平等就业机会委员会提出的性骚扰指控有所增加。2018年至2021年期间，性骚扰指控占所有骚扰指控的27.7%，而2014年至2017年期间为24.7%。在2018年至2021年期间提出的性骚扰指控中，78.2%是由女性提出的，而男性提出的占21.8%。[见平等就业机会委员会《美国工作场所的性骚扰》] 大约四分之三遭受骚扰的人从未向主管或经理报告这种不受欢迎的行为，通常是因为他们担心自己的指控不被相信、不会采取纠正措施、会受到指责或遭受社会或职业报复。根据平等就业机会委员会工作场所性骚扰研究特别工作组的数据，25%至85%的女性报告在工作环境中经历过性骚扰。数字上的差异取决于调查中使用的词汇。例如，当员工被问及是否经历过性骚扰时，25%的人回答经历过。然而，当员工被问及是否经历过特定的基于性的行为，如不受欢迎的性关注或胁迫时，肯定回答的比例上升到60%。最近的横断面研究表明，与55 - 69岁的女性相比，55岁以下的女性在当前工作场所遭受性骚扰或暴力的风险增加。属于性少数群体（女同性恋、双性恋或未定义）的女性比异性恋女性更频繁地遭遇不受欢迎的行为。与白天工作的女性相比，轮班和工作时间不规律的女性遭受骚扰更为常见。这可能是因为由于人员不足等因素，上夜班的女性更经常独自工作，并且她们可能会与第三方人员（如患者、客户或供应商）接触。诸如存在教员和学员的等级结构、男性主导的环境以及容忍有权势者骚扰行为的文化等因素，使得一个组织特别容易发生性骚扰。包括医院、疗养院和诊所在内的医疗保健组织都具备所有这些因素。