Abstract

Background: Sexual harassment (SH) and Gender discrimination (GD) faced by medical students have been neglected areas of study in India. Only a few recent studies could be found, despite frequent media reports on SH and GD. This study aimed to assess the attitudes and perceptions of sexual harassment and gender discrimination and evaluate the forms of SH and GD experienced by them.

Methods: A Google form based mixed method survey tool was distributed amongst students of 28 medical colleges in Maharashtra. Participants were assured of confidentiality and anonymity.

Results: Of the 308 students who were eligible for the present study, 14.3% (44) and 26.6% (82) reported incidence of sexual harassment and gender discrimination, respectively, while 133 (43.2%) of them reported having experienced some or the other form of SH/GD. A wide range of instances of SH and GD were described by the students.

Conclusions: The study highlights the need to create awareness about sexual harassment and gender discrimination amongst medical students, and to create an atmosphere where such abuses do not occur.

Keywords: sexual harassment, gender discrimination, medical students.

Introduction

Sexual harassment (SH) constitutes “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when 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.”[1] SH can range from subtle forms to criminal acts. Schneider and Philips divide SH into four categories: “a) Gender harassment which encompasses insulting or degrading sexist remarks; b) unwanted sexual attention, including touching or requests for dates after a person has refused; c) sexual bribery/ coercion; and d) attempted sexual assault.” [2]

Gender discrimination (GD) refers to “gender-based behaviour, policies and actions that adversely affect work by leading to disparate treatment or creation of an intimidating environment” [3]. It also includes “systematic unfavorable treatment of the individual on the basis of their gender, which denies those rights, opportunities or resources” [4].

A US study highlighted that SH against males is usually neglected because of low incidence. However, it is seen that men in lower socioeconomic groups are not protected from it [5]. Another study conducted in Ohio, USA, reported that sexual harassment occurs regularly during medical training, most commonly in clinical settings, primarily in surgical specialties, and remains largely unreported [6]. According to an American study in 2018, nearly, 47% of female medical students have experienced sexual harassment, as compared to their peers in science (20%) and engineering (27%) [7]. Another study conducted in Australia observed that patient-initiated sexual behaviour, such as compliments about physical appearance, subtle sexual comments concerning the doctor-patient relationship, requests to see the student socially, sexist slurs and touching or grabbing, are of increasing concern. Behaviours like these are detrimental to the doctor-patient relationship and may lead to less than effective healthcare. The socio-prevalence data range from 12-29% (male students) and 52-71% (female students) [8].

SH can lead to both physical and psychological problems such as anxiety, depression and social isolation. Disruptive workplace behaviour has been shown to have a dire impact on team collaboration and communication efficiency, leading to diminished staff performance and morale [9, 10]. Exposure to gender discrimination and sexual harassment during undergraduate education may influence some medical students’ choice of specialty [11]. Medical students are particularly vulnerable to abusive behaviour, because of their lack of power. They are often expected to perform clerical work or run errands for their superiors, which is typically seen as getting acquainted to the field of medicine. Some medical school teachers view intimidation and embarrassment as an “effective method” for teaching. This approach can possibly have harmful effect on development of professional and personal identity of the student doctor which has been described as “traumatic de-idealisation”. This can have negative effects on doctors, their care for patients and on the institution of medicine itself. Medical students interviewed in a study reported that verbal abuse is common, especially from residents and attending physicians, which led them to lose faith in the profession [12].

“Denial of equality, rights, and opportunities and suppression in any form on the basis of gender amounts to GD.” [13] While women constitute around 50% of the world population and perform around 2/3rds of the total volume of work in the world, they receive only 1/10th of the world’s total income [13]. India’s patriarchal culture has made GD an ingrained habit [13]. Gender differences observed in adulthood often stem from childhood upbringing [14]. GD, like all other aspects, is seen in medical schools as well, contributing to reduced academic performance and increased risk of psychiatric complications in students. According to a study from Germany, though the percentage of female medical students graduating with a medical degree has increased to 60%, women doctors are underrepresented in leadership positions and are seldomly appointed to top academic posts. Nineteen percent of women doctors reported having abandoned their preferred medical specialty, most commonly surgery, due to gender discrimination. They also reported unequal treatment in surgery wards [2].

The topic certainly demands attention in order to have a more just medical education and health system. However, there is paucity of data regarding the prevalence of SH and GD in medical profession in India, especially among doctors and even after a thorough literature search, not many recent studies conducted on this topic were found, while those found were conducted in a non-medical setting. Hence, this survey was devised to assess the attitudes and perceptions of sexual harassment and gender discrimination among undergraduate medical students in the state of Maharashtra. The survey was aimed to understand the views of undergraduate medical students regarding these issues and to identify the types of sexual harassment and gender discrimination they face. It also aimed to compare these experiences amongst medical students studying in second, third and final year and those undergoing internship.

Methods

This multicentric study was conducted using a semi-structured questionnaire designed to cover various aspects of SH and GD as would have been experienced by medical students, as well as general questions to ascertain their knowledge and attitudes towards SH and GD. The study involved 28 medical colleges across the state of Maharashtra. The survey forms were circulated maintaining anonymity using Google forms. The questionnaire had some binary “yes/no” options, and some open-ended qualitative descriptive questions which allowed the respondent to describe their personal experiences with SH and GD.

The questionnaire was validated by five senior professors with more than 20 years teaching experience in medical colleges and the questionnaire was developed only in English. Incomplete questionnaires were rejected from the final assessment. The data were compiled in an excel sheet and analysed using descriptive statistics with frequency and percentages, and quantitative statistics using mean and standard deviation (SD). Data analysis was conducted using SPSS software version 24.

The study was approved and passed by the Institutional Ethics Committee of Lokmanya Tilak Municipal Medical College, Mumbai.

Results

This was a multi-centric study with 28 medical colleges participating from across the state of Maharashtra. The mean age of the students participating was 21.31 years (SD: ± 1.82 years, range = 18-25 years). In total, 317 responses were received out of which nine surveys were excluded for being from outside of Maharashtra. At the end, a total of 308 students participated in the present study.

Out of the 308 students who participated in the present study, 167(54.2%) were 2nd year MBBS students, 83(26.9%) were 3rd year Part I MBBS students, 34(11%) were 3rd year Part II MBBS students, and 24 (7.7%) were interns. Of these 308, 164 (53.2%) students believed that the incidents of SH and GD were higher at undergraduate level while 144 (46.8%) believed that these were higher at postgraduate level. Of the 308 students, 179 (58.12%) were females and 129 (41.88%) were males. The female-to-male ratio was 1.38.

The study reported an incidence of 14.3% (44) and 26.6% (82) for SH and GD, respectively, among medical students in Maharashtra [Table 1], while 43.2% (133) of the participants reported having experienced some or the other form of SH/GD when asked specifically [Table 2].

Table 1. Perception of sexual harassment and gender discrimination among medical students

Table 2. Forms of sexual harassment and/or gender discrimination faced (N = 308)

For the open-ended questions, students provided descriptions of GD and physical SH, which included lewd comments, unwanted touch, bias in practical examinations, discrimination based on their appearance, and gender-based discrimination in hostel regulations and facilities. Incidents of gender discrimination were reported more frequently than those of sexual harassment, though the number of cases of sexual harassment was still significant. Lack of awareness, leading to these incidents being considered “part and parcel” of the MBBS curriculum, was seen. Many of the students faced discrimination based on their region, especially those from outside Maharashtra. Many of them reported that this affected their mental health. Most of the complaints reported from different institutions involved the same type of harassment, implying that these issues were common to almost every institution, and were not limited to any one college. A few of the comments received, demonstrating the same, have been given below:

• “I was sexually harassed by a post-graduate in anesthesia. Though it did happen off campus, it still qualifies as an assault. His senior urged him and a female co-intern enabled it to happen.”

• “I was in first year when a guy from my class groped my chest and my rear, on separate occasions. He even used a book to spank me on my rear, but I could never quite catch him red handed.”

• “Touched inappropriately by seniors under the tag of ragging. It left me mentally disturbed for my self-respect was challenged. Gender discrimination is done on daily basis for women are ill-treated, given names, harassed from a distance especially when walking alone to their hostels. It might not seem infuriating but the constant taunting affects them mentally.”

• “A professor in our college while taking viva asks inappropriate questions to female students.”

• “Girls in my class (during lecture) were derogatorily asked to leave because they had not tied their hair up while boys who had not brought even books and pens were allowed to sit”

• “I’m a female and I’ve been made to feel “down” or lower than males, be it by brain, strength, power, or rules. I’m from All India quota and been discriminated on that basis also”

• “I have been told to take up non-clinical fields or stereotyped clinical fields like dermatology or obgyn because I am female. I was also once told that women waste MBBS and post-graduation seats because they don’t end up practicing medicine in the end.”

• “Sexist jokes have been cracked by multiple professors during lectures and postings. Male colleagues have touched me in ways that made me uncomfortable.”

• “In our college the girls mess doesn’t allow eggs while boys enjoy protein diet every breakfast. Moreover, the gym instruments in girl’s hostel are the 2nd hand instruments from boys’ hostel who get new gym equipment.”

• “I see Gender discrimination when it comes to elections in the college. Anything related to being in power is always considered a male’s work or ‘right’.”

• “We have been told by many professors that women are not suited for being a doctor.”

• “The amount of gender discrimination faced by me in a day is like equal to the no. of times people check their phone …It seriously affects my mental health. with already having to go through stress of MBBS and family.”

• “Gender discrimination is widely prevalent in my college. Many of the senior teachers are biased towards the boys. Girls’ opinion and ideas are not taken into consideration. Some teachers do the opposite. They purposely give girls more marks in viva and give lesser marks to the boys. We should be treated as students and not separately as boys and girls. The dean himself doesn’t listen to girls and their complaints. The worst part about my college is that there is “IN-TIME” for the girls’ hostel and girls have to get a leave form signed from the rector and the dean before going home, whereas there are no such rules for boys’ hostels….the boys can roam around anywhere and at any time. This gender discrimination should end.”

• “There is senior who is homosexual, most of his batch mates don’t talk with him, like he comes to mess alone and watches his mobile only, does not interact with anyone (seems like he is afraid), some people also make laugh about it or think its unnatural. I think insecure old patriarchic male ego is still more prevalent.”

• “In my city and overall in my family circle I have seen that men and women start their medical career at same rate, but they do not advance in same rate.”

• “The complaint was taken to the woman grievance committee and they acted immediately on it to inform the higher authorities, however, the higher authorities left the case with just an ‘assurance’ that it won’t happen again. I was the one who was interrogated and the accused party left on a warning in spite of it being the second complaint lodged for the same man.”

However, there were a few participants who reported that they had not encountered any such incidents of SH or GD. The results of the questionnaire used in the survey have been given in Table 1 and 2.

In the survey conducted, the reported perpetrators included professors, including heads of departments, senior students, batch-mates, resident doctors and non-teaching staff, including hospital workers and hostel wardens. Victims reported that the harassment was commonly by individuals with “higher authority” and “higher seniority”.

Personal fears reported by participants included fear of failing exams on reporting any such incident, losing marks in case of non-compliance, being shamed or boycotted by batch-mates and seniors, receiving no support from college, the complaint being ignored or mishandled due to authorities being incompetent, and concerns over breach of confidentiality if reported. Deleterious effects on mental health including suicidal tendencies and the fear of “losing their career” were also reported. One participant stated that those in authority actively discouraged any such complaints to protect the reputation of the institution.

• “Reporting such events will affect my scores and academics”

• “Reporting against those with strong political support might backfire and have negative repercussions”

• “The fact that women are more often than not blamed for the incident themselves and questioned multiple times and even if proof is provided the matter is brushed off as an overreaction. There’s no safe space to complain about such incidents without the matter ruining one’s own reputation and possibly their career too.”

• “When the accused is left on a warning and no action had been taken, the person might try to cause bodily harm for reporting his misdeeds.”

• “It can very easily get out of hand where someone kills themselves. It’s probably better to nip these problems in the bud.”

• “Lack of support from the authorities and Victim blaming”

• “People having grudges and hampering future career options of students involved”

• “In the Medical Colleges faculty holds the power to your scores in exam. They can decide whether you can pass a subject or not. So, there is a fear among the students that if they complain their results would have to suffer”

• “It obviously affects the studies and also some cases lead to suicide. (I knew a person who was boycotted to such a degree that he attempted suicide and I don’t want that to happen to anyone)”

• “Since the committees set up to address such complaints are made up of professors lacking gender sensitivity training, the issues aren’t resolved even when they’re reported. The members of such committees instead themselves discourage such complaints to maintain the image of the college.”

However, there were also responses reporting “no fear at all” and “no comments” besides those mentioned above.

An increasing trend in incidents of GD and SH was observed in the higher years of the undergraduate course, with 2nd year students reporting the lowest and interns reporting the highest number of incidents. This was true for both, SH and GD events, as given in Table 3.

Table 3. Incidents of SH and GD in different study groups

Discussion

This study was conducted to address a gap in research in India on this important subject. Sexual harassment can be difficult to define, as it often blurs the line between behaviours like flirting, playful courtship and harassment. Our findings reflect this challenge. When participants were asked if they had experienced sexual harassment and/or gender discrimination, only 99 of them responded affirmatively. However, when given specific examples of the forms of sexual harassment/gender discrimination, 133 responses were received, indicating a lack of knowledge and difficulty in differentiating harassment/discrimination from healthy interactions [Table 2]. In India, discussions on sex are deemed taboo and problems like sexual harassment are not discussed openly, which may have contributed to the difficulty in identifying and understanding such experiences. However, even without coherent descriptions of the events, the discomfort and sense of violation reported by students clearly indicate experiences of harassment and/or discrimination. Our study highlights the prevalence of sexual harassment and gender discrimination in medical institutions in Maharashtra, and most participants believed that there is a significant lack of awareness regarding SH and GD among medical students.

The results indicated that both men and women were exposed to some form of sexual harassment during their academic life. Many victims tend to avoid situations where such incidents might occur and normalise such experiences as part of the journey at the institution. When probed, 42.5% of students reported that they were afraid to report such events, 13.6% of them felt such experiences were normal and part of medical training, and 62.7% felt that reporting such events could negatively affect their grades and future career prospects [see Table 1]. This suggests that such events are under-reported and that there is a need for greater focus in this area. The perception of such incidents varies among individuals. Accordingly, this can affect the victim differently, resulting in both short term and long-term mental health problems. Digitalisation of communication also increases the risk of sexual harassment by the sending of obscene pictures or messages to the victim.

The student-teacher relationship involves a level of collegial closeness, which also reflects an unequal power dynamic. Therefore, it is important to maintain a balance in this system of power to prevent the exploitation of those with less power by those higher up in the hierarchy. Precedence of gender harassment was seen especially during examinations and practicals, as this puts the perpetrator and victim in a one-on-one position. The groups with senior students reported higher number of cases of SH and GD because of increased interaction during clinical postings. The power imbalance often results in misconduct and paves the way to sexual harassment. Victims reported feeling helpless as the perpetrators held authority over their grades or promotion to the next class. Confrontation is considered difficult in such scenarios.

A similar scenario was observed in harassment faced by juniors from their seniors. The feeling of powerlessness was common, as seniors often had the influence to manipulate the victims’ college experience. Ragging remains prevalent in many places across the country, further exacerbating this issue [15].

We tried to explore the perception and awareness among the students regarding sexual harassment and gender discrimination. While many of the students seemed to be aware of these terms, the less serious events were generally normalised by most of them. Our report may also underestimate the problem, as only the severe cases of harassment or discrimination are typically reported. The effect that this had on the participants, as reported, was mental health deterioration including suicidal tendencies, increased distrust among peers, reduced quality of education, lowering of self-esteem, perpetuation of abuses in society, fear and anxiety among students, marginalisation in severe cases, and a feeling of helplessness among many others.

The highest number of SH incidents were reported among Interns followed by 3rd (II), 3rd(I) and 2nd year students, while those of GD were again highest among Interns followed by 3rd(I), 3rd (II) and 2nd year students, as shown in Table 3. This suggests that the incidents of abuse are more prevalent among senior students. Coupled with increasing academic stress, this may have a serious impact on their mental health. The higher incidence may be attributed to greater clinical exposure and increased interactions with senior professionals in the advanced study years.

The major limitation of this study was the small number of participants. Under-reporting was seen, as many participants refused to fill the form due to fear of being held accountable for their statements. This happened in spite of promising them complete anonymity. Another limitation was the unequal number of forms received from participants in the different classes, making it difficult to draw conclusions through a comparison. Despite these limitations, a significant number of survey participants reported experiencing sexual harassment and gender discrimination.

Conclusion

In our study, we found that even though not everyone had faced SH/GD, almost everyone wanted a change in the system. As these incidents were reported from different institutes, it is evident that this is not an isolated issue but a systemic one. Therefore, safety measures need to be implemented across institutions. Although more than half of the respondents reported that their college had a reporting mechanism in place, a large number expressed fear of reporting such incidents. A standardised system of surveillance should be implemented. The heads of institutions/deans have a responsibility to maintain a strict environment with zero tolerance for such incidents and should actively undertake efforts to develop fair reporting procedures. Most of the participants believed that their professors should receive training in recognising and dealing with sexual harassment and in gender sensitisation.

Acknowledgment: The authors would like to express their gratitude to the Department of Psychiatry at Lokmanya Tilak Municipal Medical College, Mumbai, for their invaluable assistance in designing the survey.

Conflict of Interest: The authors declare no conflict of interest.

Funding: There was no source of funding or support for this study.

Statement of similar work: There have been no other studies published using this data.

Data sharing: The data supporting the findings of this study are included in the tables within the manuscript. Due to concerns about participant confidentiality and maintaining anonymity, additional raw data cannot be made publicly available. For inquiries regarding data access, please contact the corresponding author.