PURPOSE

INTRODUCTION

Broad cultural movements focused on sexual harassment (SH) such as #metoo and #TIMESUP have reached medicine, where harassment and its impact on physician well-being and professional outcomes are increasingly recognized.^1-3 This motivates efforts to characterize the scope, nature, and impact of experiences with SH in oncology with the same rigor as in other fields.^4,5 Clinical oncology encompasses diverse clinicians from various practice settings, cultural backgrounds, and subspecialties.^6,7 Understanding exactly what happens, where, when, and to whom is essential to inform efforts to transform culture and eradicate problematic behaviors.

To standardize the study of SH, organizational psychologists developed the Sexual Experiences Questionnaire (SEQ), an extensively validated, behaviorally based survey instrument.^8,9 The SEQ captures all three dimensions of SH identified by social scientists: gender harassment, unwanted sexual attention, and sexual coercion (Fig ​(Fig11).¹⁰ Gender harassment includes verbal and nonverbal behaviors conveying hostility to, objectification of, exclusion of, or second-class status about one gender.³ Unwanted sexual attention describes unwanted sexual advances, including unwanted touches or attempts to establish a sexual relationship despite discouragement. Finally, sexual coercion involves making job-related threats or promising job-related benefits to coerce compliance with sexual demands.¹¹ To evaluate behaviors perpetrated by members of health care organizations and by patients and families, investigators developed an SEQ version appropriate for physicians.¹²

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FIG 1.

Defining the three subtypes of sexual harassment. This figure provides definitions of the three forms of sexual harassment that have been described by social scientists³ and are measured by the Sexual Experiences Questionnaire instrument used in the present study.

Although previous studies have explored SH in cancer medicine, few to our awareness in oncology use comprehensive validated measures to investigate the experiences of oncologists.^13-15 To that end, we sought to rigorously evaluate oncologists' lived experiences and consequences of SH perpetrated by both institutional insiders (peers and/or superiors) and patients and/or families in a cross-sectional survey.

METHODS

RESULTS

Participant Demographics

In total, 304 practicing oncologists including 238 of the 1,000 targeted through the ASCO RSP and 66 through social media outreach, all authenticated their identity with confirmation of their eligibility to participate and subsequently accessed the survey link. Of these, 273 provided responses (215 [79%] via RSP and 58 [21%] via social media). Appendix Table A​A11 (online only) compares the characteristics of the RSP vs social media respondents; of note, there were no differences in rates of reporting SH between RSP respondents and social media participants.

Among the 1,000 RSP invitees, comparing demographics of the responders versus nonresponders shows that response rates were similar by gender, race and ethnicity, and geographic practice location. Response rates were significantly different for practice setting (with respondents more likely to be in academic settings and less likely in training programs) and age (with respondents less likely to be in the youngest age group and more likely to be in the middle age groups).

The respondents included 153 cisgender women and 118 cisgender men. One person was gender nonconforming, and one responded that none of the gender descriptors describe them. Overall, the 271 respondents who self-identified as cisgender formed the analytic data set (Table ​(Table1),1), of whom 153 (56%) were women and 118 (44%) were men. One hundred forty-four (53%) were White, and 95 (35%) were Asian or Pacific Islander, whereas 30 (11%) self-identified as African American or Hispanic. Two hundred fifty-six (94%) identified as heterosexual; 15 (6%) identified as a sexual or gender minority. Most respondents (n = 172, 63%) were born in the United States, and 237 (87%) held US citizenship. Of 271 respondents, 250 were physicians in practice and 21 were resident or fellow physicians; 168 (62%) practiced in academic settings, and 236 (87%) practiced medical oncology.

TABLE 1.

Characteristics of Oncology Physicians in the Analytic Data Set

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Incidence of SH

Figure ​Figure22 and Appendix Table A​A22 (online only) detail the incidence of past-year SH and its three subtypes by both perpetrator types (institutional insiders and patients and/or families). Overall, 189 respondents (70%), including 80% of women and 56% of men (P < .0001), endorsed past-year SH by institutional insiders. Gender harassment was indicated by 79% of women and 55% of men (P < .0001), unwanted sexual attention by 22% of women and 9% of men (P = .005), and sexual coercion by 3% of women and 2% of men (P = .42). Similarly, past-year SH by patients and/or families was endorsed by 143 (53%) oncologists overall, including 67% of women and 35% of men oncologists (P < .0001). Specifically, patient- and/or family-perpetrated gender harassment was indicated by 66% of women and 34% of men (P < .0001), unwanted sexual attention by 5% of women and 6% of men (P = .84), and sexual coercion by 1% of women and 1% of men (P = .70).

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FIG 2.

Incidence of SH in previous year alone by type and by respondent characteristics. (A) Proportion of respondents reporting at least one experience perpetrated by institutional insiders (peers and/or superiors) of any SH and then each SH subtype separately, by respondent gender, career stage, race and ethnicity, and specialty. (B) Proportion of respondents reporting at least one experience in the previous year alone perpetrated by patients and/or families of any SH and then each SH subtype separately, again by respondent gender, career stage, race and ethnicity, and specialty. NOTE. Six respondents did not answer the Patient-Family SEQ, one Insider SEQ, two did not answer their race and ethnicity. SH, sexual harassment.

Downstream Impact of SH on Workplace Wellness

Table ​Table22 details eight separate multivariable regression models examining the associations between past-year SH by institutional insiders and by patients and/or families, separately, and the four outcomes of interest (mental health, job satisfaction, turnover intentions, and sense of workplace safety), after controlling for respondent demographics. In the multivariable analyses, past-year SH by institutional insiders was significantly associated with decreased mental health (β = –0.45, P = .004), sense of workplace safety (β = –0.98, P < .001), and increased turnover intentions (β = 0.93, P < .0001). Similarly, past-year SH by patients and/or their families was significantly associated with decreased mental health (β = –0.41, P = .002), decreased sense of workplace safety (β = –0.42, P = .014), and increased turnover intentions (β = 0.58, P = .0004). Past-year SH by institutional insiders (β = –0.69, P = .001) but not patients (P = .21) was significantly associated with the respondents' job satisfaction. No significant interaction between gender and SEQ score for each outcome was found, suggesting that the SEQ-measured impact on the outcomes is similar by gender. The models that included SH by patients and/or families suggest lower job satisfaction (β = –0.24, P = .026) and sense of workplace safety (β = –0.24, P = .034) among women oncologists although gender was not significant in the models including SH by institutional insiders. None of the outcomes were otherwise significantly associated with physician gender, career stage, race and ethnicity, and/or oncologic subspecialty.

TABLE 2.

Regression Results Predicting Mental Health, Job Satisfaction, Sense of Workplace Safety, and Turnover Intentions Among Physician Respondents

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DISCUSSION

To our knowledge, this is the first study in oncology to use validated measures of SH to systematically characterize the incidence and nature of past-year SH experienced by a diverse sample of oncologists, using best practices as recommended by the National Academies of Sciences, Engineering, and Medicine (NASEM).³ The SEQ scoring–based finding of past-year SH by peers and/or superiors was significantly associated with decreased mental health, lower job satisfaction, less workplace safety, and higher turnover intention, with a similar significant impact on all outcomes but job satisfaction for SEQ scoring–based finding of SH by patients and/or families. Although the incidence of any SH between men and women physicians was significantly different, the downstream impact was not. No significant interactions existed between the respondents' gender and the impact of SH for any outcome. These findings demonstrate the impact of SH on men and women oncologists in multiple domains of workplace experience. This study provides critical data to inform the need for and design of effective protective and preventive workplace policies in oncology.

NASEM's landmark 2018 report on SH showed that female medical students were 220% more likely than students in non-science, technology, engineering, and mathematics disciplines to experience SH. By far, the most common form of harassment is the sexist remarks and crude behaviors that constitute gender harassment. Indeed, NASEM disseminated the metaphor of SH as an iceberg, whereby much attention focuses on the rare egregious cases of unwanted sexual attention and sexual coercion, but the bulk of behaviors lurk beneath the surface in the form of gender harassment. The few studies that have used sensitive validated measures to evaluate physicians' experiences of workplace SH have shown strikingly high rates of past-year harassment, with the overwhelmingly most common form being gender harassment.^4,12,14,23 Disappointingly, the present study provides compelling evidence that the rates of gender harassment in oncology are substantial, experienced by the majority of not only women but also men studied here. Thus, although attention is often focused on shocking individual cases of sexual coercion, the data suggest that the problem of SH is both more widespread and nuanced in its manifestations than commonly recognized.^24,25

Experiences with gender harassment are not without impact, as further illustrated by our findings. Behavior need not be sexually predatory to derogate, demean, or humiliate individuals on the basis of sex in a way that has consequences for their well-being.²⁶ Indeed, consistent with decades of research in organizational psychology that has demonstrated clear associations between experiences of workplace SH and the physical, mental, and professional well-being of workers, we found significant associations between past-year experiences of SH and the four outcomes that we measured: mental health, job satisfaction, turnover intentions, and sense of workplace safety.^27,28

To address workplace SH, studies to demonstrate what behaviors are currently occurring, to whom, by whom, and with what effect, within a specific field, can provide a powerful call to action. Our findings that women are more likely to experience harassment than men, but that men are also frequently experiencing unwanted behaviors, are important to both motivate and guide changes to policy and practice.

To date, although documents exist to guide entities in developing policies and procedures for misconduct in the workplace, no nationally standardized, widely adopted strategies to counter SH across the United States exist.²⁹ Instead, individual institutions, health systems, and other entities develop their own approaches and policies with limited reporting on impact and outcomes. Common unifying themes of such programs center on creating a safe workplace culture with accountability, robust institutional policies specifically covering SH, continuous education efforts of local stakeholders to ensure broad awareness of these policies, robust reporting processes, and supportive services for those affected by SH with an emphasis on ensuring continuous enforcement of policies and standard governing behaviors in the workplace as it pertains to employees as well as patients and families.³⁰

Through our findings, we recognize not only the implications of these behaviors on the workplace experience of oncologists but also the broader impact of these behaviors on other members of the oncologic workforce, whose experience was outside of the scope of this study. We hope that our study findings will lead to evidence-based intervention, including innovative approaches to foster cultural transformation through the cultivation of civility and respect, allyship, and empowerment of bystanders.^2,31,32 Findings that highlight the role of patients and families as perpetrators can further guide efforts to include strategies such as development of patient rights and responsibilities statements to address this common challenge.^33-36

Limitations in interpretation of our data include a modest response rate among those who were invited to participate. We took care not to advertise the specific subject of the investigation in our request for participation, to avoid demand effects and selection bias, and we are reassured that the rates of response to our survey were similar to other studies conducted using the ASCO RSP (and were among the highest response rates for surveys fielded by the RSP during the disruptions that occurred in 2020). Nevertheless, there is a risk that the incidence estimates might not be generalizable; this is less of a concern for the associations observed. It is challenging to quantify whether our respondents are representative of the national pool of clinical oncologists, given limited contemporaneous data characterizing the cross-disciplinary US oncologic workforce during the survey period and that our study is limited to physicians in an oncology subspecialty in full-time practice at their current institution for at least a year. Compared with published data characterizing the general oncology workforce at large, there may be higher representation of certain demographic groups among our study's RSP invitees, who were randomly selected members of the voluntary RSP pool meeting our study eligibility criteria.^37,38 This includes a higher proportion of academic practitioners and those identifying as Asian in the RSP sample who received our study invitations (50% in academia and 25% self-identified as Asian in their ASCO membership profile per the organization's definition) and, in turn, in our respondents (62% academia and 35% Asian or Pacific Islander per our methodology). Given that a portion of our outreach was through social media that included women physicians' sites, we characterized the demographics of our participants by the recruitment approach; we reassuringly found that, among those who were targeted by the ASCO RSP, the respondents were similar to nonrespondents by gender, and those who responded after social media outreach were not more likely to report harassment than those who responded via the RSP. Therefore, given the extremely high incidence rates, this study provides compelling evidence of a problem of sufficient magnitude to warrant action. Even if very few nonrespondents experienced harassment in the past year, the fact that such a large majority of respondents did would mean that the underlying population rate of harassment is unacceptably high. Furthermore, the limited participation from each oncologic subspecialty other than medical oncology, oncologic physicians in training, and noncisgender respondents precluded any separate analyses into these groups' unique experiences. Our findings call for further study of the experiences of oncologists facing the challenges of intersectional membership in multiple historically marginalized groups. Future research would also be valuable to integrate the understanding of how SH experiences may relate to the strikingly high levels of burnout documented in oncology.

Given the limited data characterizing the nature and scope of SH in oncology, this study presents critical data to inform effective policies to protect the oncology workforce that provides care and produces research that serves patients and society.

ACKNOWLEDGMENT

APPENDIX

TABLE A1.

Sample Demographics by Survey Type Completed

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TABLE A2.

Incidence of Any Sexual Harassment in the Previous Year, by Type and by Perpetrator

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Notes

Ishwaria M. Subbiah

Consulting or Advisory Role: MedImmune (I)

Research Funding: Bayer (I), Novartis (I), GlaxoSmithKline (I), NanoCarrier (I), Celgene (I), Northwest Biotherapeutics (I), Incyte (I), Fujifilm (I), Pfizer (I), Amgen (I), AbbVie (I), Multivir (I), Exelixis (I), Loxo (I), Blueprint Medicines (I), Takeda (I)

Travel, Accommodations, Expenses: Bayer (I), PharmaMar (I), Novartis (I), MedImmune (I)

Merry Jennifer Markham

Stock and Other Ownership Interests: Pfizer (I)

Consulting or Advisory Role: GlaxoSmithKline

Research Funding: Aduro Biotech (Inst), Lilly (Inst), Tesaro (Inst), Novartis (Inst), VBL Therapeutics (Inst), AstraZeneca (Inst), Merck (Inst)

Open Payments Link: https://openpaymentsdata.cms.gov/physician/890992/summary

Stephanie L. Graff

Stock and Other Ownership Interests: HCA Healthcare

Honoraria: Publicis Health

Consulting or Advisory Role: Seattle Genetics (Inst), Novartis (Inst), Pfizer, Novartis, Daiichi Sankyo/Lilly, AstraZeneca, Genentech

Speakers' Bureau: OncLive

Research Funding: Boehringer Ingelheim (Inst), Lilly (Inst), Genentech (Inst), Immunomedics (Inst), Novartis (Inst), Celldex (Inst), Dana-Farber Cancer Hospital (Inst), TapImmune Inc (Inst), Merus NV (Inst), Odonate Therapeutics (Inst), Innocrin Pharma (Inst), GRAIL (Inst), AstraZeneca (Inst), Bristol Myers Squibb (Inst), Daiichi Sankyo (Inst), Eisai (Inst), Roche (Inst), H3 Biomedicine (Inst), Merck (Inst), Foundation Medicine (Inst), Seattle Genetics (Inst), Taiho Pharmaceutical (Inst), Sermonix Pharmaceuticals (Inst), Polyphor (Inst)

Laurie B. Matt-Amaral

Speakers' Bureau: Bristol Myers Squibb, Research to Practice

Travel, Accommodations, Expenses: Bristol Myers Squibb

Reshma Jagsi

Employment: University of Michigan

Stock and Other Ownership Interests: Equity Quotient

Research Funding: Genentech (Inst)

Expert Testimony: Baptist Health/Dressman Benzinger LaVelle Law, Kleinbard, LLC, Sherinian and Hasso

Travel, Accommodations, Expenses: Amgen

Other Relationship: JAMA Oncology

Open Payments Link: https://openpaymentsdata.cms.gov/physician/373670/summary

No other potential conflicts of interest were reported.

PRIOR PRESENTATION

SUPPORT

REFERENCES