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Gender Discrimination and Reporting Experiences among Academic Pediatric Faculty: A Qualitative, Single-institution Study

  • Abby R. Rosenberg
    Correspondence
    Address correspondence to Abby R. Rosenberg, MD, MS, MA, Palliative Care and Resilience Program, Seattle Children's Research Institute, 1920 Terry Ave, CURE-4, Seattle, WA 98101
    Affiliations
    Department of Pediatrics, Division of Hematology/Oncology (AR Rosenberg), University of Washington School of Medicine, Seattle, Wash

    Palliative Care and Resilience Program (AR Rosenberg, KS Barton, C Bradford), Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Wash
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  • Krysta S. Barton
    Affiliations
    Palliative Care and Resilience Program (AR Rosenberg, KS Barton, C Bradford), Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Wash

    Core for Biostatistics, Epidemiology, and Analytics in Research (KS Barton, C Bradford), Seattle Children's Research Institute, Seattle, Wash
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  • Miranda C. Bradford
    Affiliations
    Palliative Care and Resilience Program (AR Rosenberg, KS Barton, C Bradford), Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Wash

    Core for Biostatistics, Epidemiology, and Analytics in Research (KS Barton, C Bradford), Seattle Children's Research Institute, Seattle, Wash
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  • Shaquita Bell
    Affiliations
    Department of Pediatrics, Division of General Academic Pediatrics (S Bell), University of Washington School of Medicine, Seattle, Wash

    Odessa Brown Children's Clinic (S Bell), Seattle, Wash
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  • Linda Quan
    Affiliations
    Department of Pediatrics, Division of Emergency Medicine (L Quan, A Thomas), University of Washington School of Medicine, Seattle, Wash
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  • Anita Thomas
    Affiliations
    Department of Pediatrics, Division of Emergency Medicine (L Quan, A Thomas), University of Washington School of Medicine, Seattle, Wash
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  • Leslie Walker-Harding
    Affiliations
    Department of Pediatrics (L Walker-Harding), University of Washington School of Medicine, Seattle, Wash

    Center for Child Health, Behavior, and Development (L Walker-Harding), Seattle Children's Research Institute, Seattle, Wash
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  • Anne C. Slater
    Affiliations
    Department of Pediatrics, Division of Emergency Medicine (L Quan, A Thomas), University of Washington School of Medicine, Seattle, Wash
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Open AccessPublished:September 23, 2022DOI:https://doi.org/10.1016/j.acap.2022.09.014

      Abstract

      Objective

      Gender-harassment is well-described in academic medicine, including pediatrics. We explored academic pediatricians’ qualitative descriptions of: 1) workplace gender-harassment; 2) its professional and emotional tolls; 3) barriers to and outcomes of reporting gender-harassment; and 4) tools to intervene.

      Methods

      We conducted a cross-sectional, anonymous, survey-based study within a single, large pediatrics department. Surveys included demographic items, validated measures to assess prevalence of gender-harassment, and optional, free-text boxes to elaborate. Here, we present the directed content analyses of free-text responses. Two trained qualitative researchers coded participant comments to identify types of gender-harassment, its impact, and participants’ experiences reporting it. Final agreement between coders was outstanding (Kappa>0.9). A secondary, inductive analysis illustrated the emotional burdens of and opportunities to interrupt gender-harassment.

      Results

      Of 524 total faculty, 290 (55%) completed the survey and 144 (27% of total, 50% of survey-respondents) provided text-responses. This sub-cohort was predominantly white women >5 years on-faculty. Compared to the full cohort, sub-cohort participants had more commonly witnessed/experienced workplace-harassment; 92% of sub-cohort women and 52% of men endorsed fear of reporting it. Respondents described harassment by institutional staff (24% of respondents), patients/families (35%), colleagues (50%), supervisors/leadership (50%), and the system (63%). Women used stronger emotional descriptors than men (ie, “humiliated” vs “uncomfortable”). Only 19% of women (and no men) had reported witnessed/experienced harassment; 24% of those described a negative consequence and 95% noted that no changes were made thereafter.

      Conclusions

      This single-center study suggests gender-harassment in academic pediatrics is common. Faculty feel fear and futility reporting it.

      Keywords

      What's New
      Over a quarter of academic pediatricians experience workplace gender-harassment. Nearly all women and most men endorse fear of reporting their experiences; most women and few men also believe reporting is futile. We provide tools to recognize and respond to harassment.
      Gender-based discrimination in academic medicine is well-described, including in pediatrics.

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      • Spector ND
      • Asante PA
      • Marcelin JR
      • et al.
      Women in pediatrics: progress, barriers, and opportunities for equity, diversity, and inclusion.
      • Byerley JS
      • Dodson NA
      • St Clair T
      • et al.
      Creating work and learning environments free of gender-based harassment in pediatric health care.
      It is also persistent. People who identify as women continue to be paid less than men for similar jobs, receive less grant funding for similar science, be promoted less often despite equal credentials, and be under-represented in positions of influence despite a parity of women and men in the academic workforce.
      • Frintner MP
      • Sisk B
      • Byrne BJ
      • et al.
      Gender differences in earnings of early- and midcareer pediatricians.
      • Witteman HO
      • Hendricks M
      • Straus S
      • et al.
      Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency.
      • Richter KP
      • Clark L
      • Wick JA
      • et al.
      Women physicians and promotion in academic medicine.
      • Carr PL
      • Raj A
      • Kaplan SE
      • et al.
      Gender differences in academic medicine: retention, rank, and leadership comparisons from the national faculty survey.
      Women also continue to report broad experiences of gender-harassment, including macro-aggressions like unwanted sexual attention, and micro-aggressions like disrespectful comments, brief indignities, and an overall feeling of “less” compared to their male counterparts.

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      ,
      • Byerley JS
      • Dodson NA
      • St Clair T
      • et al.
      Creating work and learning environments free of gender-based harassment in pediatric health care.
      These experiences take a toll; both the targets of gender-harassment and those who witness it are more likely to suffer from burnout and psychological distress, and to leave the workforce entirely.
      • Periyakoil VS
      • Chaudron L
      • Hill EV
      • et al.
      Common types of gender-based microaggressions in medicine.
      • Mathews E
      • Hammarlund R
      • Kullar R
      • et al.
      Sexual harassment in the house of medicine and correlations to burnout: a cross-sectional survey.
      • Fnais N
      • Soobiah C
      • Chen MH
      • et al.
      Harassment and discrimination in medical training: a systematic review and meta-analysis.
      Recent evidence suggests that continued quantitative description gender-harassment is not enough to fix it.
      • Spector ND
      • Asante PA
      • Marcelin JR
      • et al.
      Women in pediatrics: progress, barriers, and opportunities for equity, diversity, and inclusion.
      ,
      • Shannon G
      • Jansen M
      • Williams K
      • et al.
      Gender equality in science, medicine, and global health: where are we at and why does it matter?.
      • Kang SK
      • Kaplan S.
      Working toward gender diversity and inclusion in medicine: myths and solutions.
      • Dzau VJ
      • Johnson PA.
      Ending sexual harassment in academic medicine.
      • Choo EK
      • Byington CL
      • Johnson NL
      • et al.
      From #MeToo to #TimesUp in health care: can a culture of accountability end inequity and harassment?.
      Establishing gender-equity in academic medicine requires addressing at least 3 persistent barriers. First, the majority of men, including those in positions of influence, do not recognize gender-harassment when it occurs.
      • Periyakoil VS
      • Chaudron L
      • Hill EV
      • et al.
      Common types of gender-based microaggressions in medicine.
      ,
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      ,
      • Ruzycki SM
      • Freeman G
      • Bharwani A
      • et al.
      Association of physician characteristics with perceptions and experiences of gender equity in an academic internal medicine department.
      Similarly, the historical, hierarchical culture of medicine tends to normalize and tolerate abusive behavior; offenders are rarely held accountable, particularly when they are leaders or well-funded researchers.
      • Choo EK
      • Byington CL
      • Johnson NL
      • et al.
      From #MeToo to #TimesUp in health care: can a culture of accountability end inequity and harassment?.
      ,
      • Rosenberg AR
      • Jagsi R
      • Marron JM.
      Picture a professional: rethinking expectations of medical professionalism through the lens of diversity, equity, and inclusion.
      Gender-equity efforts must include real-time bystander training, new standards of “professionalism,” and accountability for those who perpetuate gender-harassment, regardless of stature.

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      • Spector ND
      • Asante PA
      • Marcelin JR
      • et al.
      Women in pediatrics: progress, barriers, and opportunities for equity, diversity, and inclusion.
      • Byerley JS
      • Dodson NA
      • St Clair T
      • et al.
      Creating work and learning environments free of gender-based harassment in pediatric health care.
      ,
      • Dzau VJ
      • Johnson PA.
      Ending sexual harassment in academic medicine.
      ,
      • Choo EK
      • Byington CL
      • Johnson NL
      • et al.
      From #MeToo to #TimesUp in health care: can a culture of accountability end inequity and harassment?.
      ,
      • Rosenberg AR
      • Jagsi R
      • Marron JM.
      Picture a professional: rethinking expectations of medical professionalism through the lens of diversity, equity, and inclusion.
      Second, few faculty who experience or witness gender-harassment report it; the most cited reasons are fear of retaliation and a sense of futility.
      • Dzau VJ
      • Johnson PA.
      Ending sexual harassment in academic medicine.
      ,
      • Binder R
      • Garcia P
      • Johnson B
      • et al.
      Sexual harassment in medical schools: the challenge of covert retaliation as a barrier to reporting.
      ,
      • Vargas EA
      • Cortina LM
      • Settles IH
      • et al.
      Formal reporting of identity-based harassment at an academic medical center: incidence, barriers, and institutional responses.
      Even if overt retaliation is publicly disallowed, “covert retaliation” (ie, vindictive comments, subtle criticisms in promotion-, grant-, or peer-review, alienation of the accuser, and minimizations of professional opportunities), is common and insufficiently scrutinized.
      • Binder R
      • Garcia P
      • Johnson B
      • et al.
      Sexual harassment in medical schools: the challenge of covert retaliation as a barrier to reporting.
      Gender-equity efforts must include accessible, anonymous, and normalized reporting venues and monitoring of covert retaliatory efforts.
      • Byerley JS
      • Dodson NA
      • St Clair T
      • et al.
      Creating work and learning environments free of gender-based harassment in pediatric health care.
      ,
      • Binder R
      • Garcia P
      • Johnson B
      • et al.
      Sexual harassment in medical schools: the challenge of covert retaliation as a barrier to reporting.
      Third, there are too few qualitative descriptions of academicians’ experiences of gender-harassment. To recognize, intervene, and ultimately correct gender-inequity, we need richer and more nuanced descriptions of the breadth of gender-harassment experiences and ways to interrupt them.
      To begin addressing these barriers in academic pediatrics, we first conducted a cross-sectional, survey-based study to assess the prevalence of gender-harassment at our single, large, institution.
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      We previously reported the quantitative findings from that study: gender-harassment was common, and a disproportionately low number of male faculty recognized the harassment female faculty experienced.
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      In this report, we present qualitative analyses of participants’ optional, free-text stories of experienced or witnessed gender-harassment. The objectives of this exploratory mixed-methods analysis were to describe: 1) nuanced examples of the breadth of workplace gender-harassment; 2) the professional and emotional impacts of gender-harassment; 3) barriers to and outcomes of reporting gender-harassment; and 4) tools for bystanders and victims to intervene.

      Methods

      Study Description

      All faculty within the Department of Pediatrics at the University of Washington School of Medicine were eligible for this single-institution, cross-sectional, survey-based study.
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      In September, 2020, Department leadership emailed faculty members with a request to complete an anonymous survey about their experiences and perspectives of gender equity in the workplace. Two reminder emails were sent approximately 2- and 4-weeks later. All participants provided electronic informed consent prior to accessing the Research Electronic Data Capture (REDCap) survey. The Seattle Children's Hospital Institutional Review Board approved the study.

      Survey Items

      The survey was pre-tested for face- and content-validity with diverse faculty.
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      ,

      Creswell JW, Klassen AC, Plano Clark VL, Smith KC for the Office of Behavioral and Social Sciences Research. Best practices for mixed methods research in the health sciences. 2011. National Institutes of Health. Available at: https://obssr.od.nih.gov/training/online-training-resources/mixed-methods-research/. Accessed April 24, 2020.

      It first requested demographic information, including participant-reported gender (“male,” “female,” “transgender male,” “transgender female,” “another gender,” “prefer not to answer”), age, race/ethnicity (“Asian,” “Black/African American,” “Hispanic/Latino,” “Mixed/Other,” “white,” and “prefer not to answer”), and number of years in practice on-faculty. The rest of the survey consisted of 26 items adapted from validated instruments used in previous studies assessing gender discrimination and sexual harassment in academic settings.
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      ,
      • Cabrera MT
      • Enyedi LB
      • Ding L
      • et al.
      Sexual harassment in ophthalmology: a survey study.
      ,
      • Lu DW
      • Lall MD
      • Mitzman J
      • et al.
      #MeToo in EM: a multicenter survey of academic emergency medicine faculty on their experiences with gender discrimination and sexual harassment.
      Five items were drawn from the Overt Gender Discrimination at Work (OGDW) scale, which directly queries perceptions and experiences of unfair treatment on the basis of sex/gender (ie, “I have been treated unfairly at work because of my gender”).
      • Lu DW
      • Lall MD
      • Mitzman J
      • et al.
      #MeToo in EM: a multicenter survey of academic emergency medicine faculty on their experiences with gender discrimination and sexual harassment.
      Additional items queried perceptions/experiences of 1) gender-equity with respect to salary, promotion, and opportunity (ie, “Promotion is equitable within my division, regardless of gender”); 2) the impact of gender-inequity on professional confidence and career development(ie, “These experiences have negatively impacted my confidence in myself as a professional”); 3) the risk and repercussion of reporting these experiences/observations and if the participant reported them (ie, “There are repercussions if I discuss discriminatory behavior based on gender”). The 5-point Likert scale response options for these items ranged from Strongly Disagree to Strongly Agree. Two items queried the frequency of discriminatory experiences/observations (ie, “I've experienced discriminatory treatment based on my gender,” 5-point Likert scale options Weekly to Never).
      Finally, the survey included optional, open-ended text boxes for participants to provide details (“Please describe an incident where you felt you experienced discriminatory treatment,” “[If you reported your experience/observation] what was the outcome? [If you did not report your experience/observation] why not?” or, “If you answered ‘agree’ or ‘strongly agree’ to the question [about repercussions], from whom do you think you would you feel repercussions?”)

      Quantitative Analysis

      We limited this analysis to the subset of faculty who completed the survey and provided optional free-text comments. We summarized demographic variables descriptively. Because we were interested in the experiences of faculty based on self-identified gender and had few participants who identified as transgender or “preferred not to answer” the gender-identity item, we limited the analysis to those who identified as male or female. We recognize this does not represent the spectrum of gender identities and corresponding experiences. This decision was made, in part, to protect the anonymity of our participants. Survey responses were dichotomized based on evidence of agreement (Strongly Disagree/Disagree/Neutral vs Agree/Strongly Agree) to enable ease of interpretation. OGDW scores were additionally dichotomized based on evidence that respondents had experienced/witnessed none (0) vs any (1–5) of the exemplary types of gender discrimination. Although we tallied responses by participant-reported gender, we did not conduct formal hypothesis tests to detect differences by gender in this exploratory analysis.

      Creswell JW, Klassen AC, Plano Clark VL, Smith KC for the Office of Behavioral and Social Sciences Research. Best practices for mixed methods research in the health sciences. 2011. National Institutes of Health. Available at: https://obssr.od.nih.gov/training/online-training-resources/mixed-methods-research/. Accessed April 24, 2020.

      Qualitative Analysis

      Two authors with formal training in qualitative methods conducted qualitative analyses (A.R.R. and K.S.B.). For context, A.R.R. completed her pediatrics residency and fellowship training at Seattle Children's Hospital and has been a member of the University of Washington Department of Pediatrics faculty for over a decade, and K.S.B. is the senior qualitative methodologist within the Seattle Children's Research Institute Biostatistics, Epidemiology, and Analytics for Research Core, where she has worked for nearly a decade.
      First, to minimize bias of interpretation, all free-text responses were catalogued separately from the rest of survey data, including demographics. Coders were blinded to participant gender, race, and experience. Second, we reviewed all free-text responses and used both deductive and inductive directed content analysis
      • Hsieh HF
      • Shannon SE.
      Three approaches to qualitative content analysis.
      to develop a codebook identifying: 1) types of discriminatory experience (based on definitions from the National Academies of Science, Engineering, and Medicine

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      and the Equal Employment Opportunity Commission,

      U.S. Equal Opportunity Commision. Policy guidance on current issues of sexual harassment. 3/19/90. Available at: http://www.eeoc.gov/policy/docs/currentissues.html. Accessed June 30, 2022.

      including unwanted sexual advances and belittling language or treatment); 2) from whom those experiences came (based on prior published evidence that sexual harassment in academic medicine may come from patients/families, institution staff, colleagues, supervisors/leadership, and the system)

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      ,
      • Spector ND
      • Asante PA
      • Marcelin JR
      • et al.
      Women in pediatrics: progress, barriers, and opportunities for equity, diversity, and inclusion.
      ; 3) the sense of emotional burden respondents experienced from such discrimination (based on descriptive words used in free-text answers); and 4) indications that the respondents felt fearful of reporting, that reporting might be futile, and if/how they experienced retaliation from reporting (based on descriptions of incidents provided in free-text answers). Third, we shared the preliminarily coded data with all co-authors to confirm face-validity and relevance.
      Fourth, we re-reviewed and coded all free-text responses using the validated codebook, categorizing responses in the (1–4) domains above. Fifth, we assessed inter-rated concordance using kappa statistics and noted initial agreement ranged from good (Kappa 0.79 for discrimination from colleagues) to nearly perfect (Kappa 0.97 for evidence that a respondent was fearful of reporting). Sixth, we discussed discrepancies and independently re-coded all responses. Seventh, we re-conducted the kappa statistics; in this final assessment, agreement was outstanding (Kappa >0.9, corresponding to agreement in >95% of all text comments).
      To explore the experiences of faculty with intersectional identities (ie, those who identify as both women and of a historically marginalized race or ethnicity), we then conducted sensitivity analyses to determine if the distribution of codes was different for faculty who identified as “white,” “Asian, Black/African American, Hispanic/Latinx, Mixed Race,” or who stated they “Prefer not to answer” the race/ethnicity survey-question. We recognize that collapsing all non-white race and ethnicity categories inappropriately conflates the unique experiences of these individuals and groups. This decision was made because demographic variables may have made individual faculty more identifiable.
      Finally, we conducted 2 additional analyses to enrich the presentation of results. First, using formal qualitative methods software,
      Dedoose Version 7.0.23, Web Application for Managing, Analyzing, and Presenting Qualitative and Mixed Method Research Data.
      we inductively coded and catalogued “emotion” words used by participants to describe the burden of their experiences. New words were added to the list if they had not been previously used, and versions of the same word were coded under the original code (ie, “unfair,” “wasn't treated fairly,” and “no consistency in fairness,” were all coded as “unfair.”). Words were coded when describing personal experiences as well as experiences participants had observed. We 1) generated a word cloud to illustrate code frequencies, and 2) unblinded the gender-identities of all participants to compare the emotions evoked by male vs female faculty. Second, recognizing that many respondents described ubiquitous micro-aggressions and expressed a sense of futility with responding such experiences, 4 authors (ARR, KSB, MCB, and ACS) selected diverse examples of participant-reported micro-aggressions. Then, all authors reviewed the quotes and applied their training and perspectives (i.e, from Bias-Reporting in Medicine trainings and/or personal experiences) to 1) explain to those perpetuating discrimination why/how their actions may be received; and 2) provide language for participants and allies to respond in real time.

      Results

      Of 524 total faculty, 290 (55%) participated in the study's full survey-based cohort
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      and 144 (27% of total faculty and 50% of study participants) provided optional free-text comments. Participants in both the full cohort and the present sub-cohort of qualitative responders (hereafter referred to as “sub-cohort”) were predominantly white women in various stages of their careers (Table 1). Sub-cohort participants were more likely to be women (full cohort 61% women, sub-cohort 76% women), and seemed more likely to have experienced or witnessed some sort of harassment regardless of sex/gender. In the full cohort, 61% of females and 21% of males agreed with at least 1 OGDW statement, whereas in the sub-cohort 82% of females and 45% of males endorsed the same. Similarly, in the full cohort, 75% of females and 45% of males reported a fear of repercussions from reporting gender discrimination compared to 92% and 52%, respectively.
      Table 1Demographics of Full- and Sub-Cohort of Respondents Who Also Provided Qualitative Comments
      Participant-Reported Demographic CharacteristicsFull Cohort

      (N = 290)

      n (%)
      Qualitative Responders

      (Present Sub-Cohort, N = 144)

      n (%)
      Gender
       Male101 (35)29 (20)
       Female177 (61)110 (76)
       Prefer not to answer12 (4)5 (3)
      Age (years)
       ≤ 303 (1)3 (2)
       31-4085 (29)48 (33)
       41-50109 (38)51 (35)
       51-6054 (18)23 (16)
       > 6032 (11)13 (9)
       Prefer not to answer7 (2)6 (4)
      Race and Ethnicity
       Asian39 (13)22 (15)
       Black/African American5 (2)4 (3)
       Hispanic/Latinx4 (1)1 (<1)
       Mixed/Other16 (6)9 (6)
       White201 (69)96 (67)
       Prefer not to answer25 (9)12 (8)
      Years on-faculty
       0-540 (14)20 (14)
       6-1062 (21)36 (25)
       11-1553 (18)32 (22)
       16-2048 (17)21 (15)
       > 2076 (26)30 (21)
       Missing/Prefer not to answer11 (4)5 (3)
      Survey-Responses Regarding Experiences With Harassment and ReportingFull Cohort, Females (N=177)Full Cohort, Males (N=101)Sub-Cohort, Females (N=110)Sub-Cohort, Males (N=29)
      OGDW scores
       0 endorsements of harassment69 (39)73 (72)20 (19)16 (55)
       1-5 endorsements of harassment108 (61)28 (28)90 (82)13 (45)
      Fear of repercussions from reporting
       No44 (25)56 (55)9 (8)14 (48)
       Yes133 (75)45 (45)101 (92)15 (52)
      OGDW indicates Over Gender Discrimination at Work scale (Queries 5 perceptions of unfair treatment and/or gender discrimination in the work-place: “I have been treated unfairly at work because of my gender,” “The people I work with make sexist statements and/or decisions,” “The policies and practices of my workplace are sexist,” “At work, I feel that my gender is a limitation.” Any affirmative answer was coded as an endorsement of harassment for this analysis.
      Female sub-cohort participants reported multiple types of gender-discrimination and harassment, and more than males (Fig. 1). The breadth of types and perpetrators of discrimination/harassment was broad; at least a quarter of female faculty reported each type of gender-harassment. The most reported types were from the system (ie, inequitable representation and opportunity for leadership, promotion, and salary-equity) and from supervisors or leaders who female faculty felt made career advancement more challenging due to gender. The distribution of harassment types was similar for faculty who identified as “white,” “Asian, Black/African American, Asian, or Mixed Race/Other” and for those who preferred not to answer the race/ethnicity question (Supplementary Table); thus, we report data for the whole sub-cohort, by gender, here. In total, female respondents shared 263 unique instances of harassment (2.4 per person), compared to 46 instances (1.6 per person) among males.
      Figure 1
      Figure 1Percentage of sub-cohort female and male faculty endorsing various types of sexual- and gender-harassment with exemplary quotes.
      These experiences were burdensome (Fig. 2). Sixty (42% of sub-cohort) quotes suggested an emotional toll from gender-harassment experiences. We identified 45 descriptive emotional words that were used 469 times. Females tended to use words that conveyed strong negative emotions like, “humiliated,” “traumatic,” and “abandoned,” whereas males tended to use words like “uncomfortable” and “unfair.” Words used commonly by females and never endorsed by males were “devalued” (n=24 unique instances), “futile” (n = 24), “fear” (n = 16), “ignored” (n = 11), “excluded” (n = 9), “belittled” (n = 6) and “unsafe” (n = 5).
      Figure 2
      Figure 2The emotional burdens of systemic gender discrimination. Word Cloud of extracted words used by male and female faculty to describe the emotional burden and/or impact of gender bias in the workplace. Larger words suggest more frequent endorsement.
      Both female and male respondents qualitatively described a fear of negative consequences if they reported gender discrimination, including 50% of females and 24% of males (Fig. 3). Similarly, 53% of females (and only 7% of males) believed reporting discrimination was futile. Again, the distribution of responses was similar by race/ethnicity (Supplementary Table). Only 19% of females (and no males) had reported their witnessed/experienced harassment. Of the N = 21 females who did report their discriminatory observations/experiences, n = 5 (24%) described a negative consequence and 20 (95%) reported that no changes or improvements were made after their report (Fig. 3).
      Figure 3
      Figure 3Percentage of sub-cohort faculty-endorsed barriers and outcomes of reporting discrimination and harassment with exemplary quotes. Panel A: Full sub-cohort faculty (N = 110 females and N = 29 males); Panel B: Sub-cohort of faculty who reported experienced/witnessed harassment to institution or leadership (n = 21 females, n = 0 males).
      Finally, we identified multiple examples of micro-aggressive statements that perpetuated gender bias in the academic workplace (Table 2). These included complaints by male participants who felt “overlooked” by diversity efforts; lack of appropriate recognition of female physicians’ titles; comments on female faculty's looks; assessments of female faculty competency based on motherhood; comments that made female faculty feel “dismissed” or “invisible;” as well as overt sexual assault. In each instance, we identified subtle and/or overt ways to intervene.
      Table 2Examples of Participant Experiences With Micro-Aggressions and Potential Allied Responses to Better Promote Equity
      Sample Micro-Aggression (Identifying Information Removed to Protect Participant Anonymity)Reason Interrupting This Type of Micro-Aggression is ImportantPotential Ways to Interrupt This Type of Micro-Aggression
      “The culture currently strongly favors putting women in leadership positions. I know I have been overlooked because I am a male.”It is frustrating to feel overlooked. Evidence suggests women have been overlooked for leadership positions for decades; for example, although 72% of pediatrics residents and 63% of active pediatricians are women, only 26% of pediatric department chairs are women.
      • Spector ND
      • Asante PA
      • Marcelin JR
      • et al.
      Women in pediatrics: progress, barriers, and opportunities for equity, diversity, and inclusion.
      Promoting equity necessarily involves correcting this imbalance and advancing women and those who have been historically marginalized.
      “It must feel frustrating to feel overlooked. Thank you for giving capable women the opportunity they have lacked for so long!”

      “Eighty percent of the faculty here are women. I am excited that our leadership is finally reflecting our workforce!”
      “I see men called ‘Doctor’ and women called by their first name ALL OF THE TIME.”When asked to “picture a scientist,” children routinely describe men.
      • Chen J
      • Sau Leung WS
      • Wong W
      • et al.
      Research: When Women Are on Boards: Male CEOs Are Less Overconfident.
      This has not changed in 50 years. Indeed, professionalism standards academic medicine are based on historical archetypes that tend to be White and Male.
      • Ruzycki SM
      • Freeman G
      • Bharwani A
      • et al.
      Association of physician characteristics with perceptions and experiences of gender equity in an academic internal medicine department.
      Calling women by their “doctor” honorific both respects their credentials and reminds those around them that women can be doctors, too.
      To patients/families: “Please call me/her Dr. [Name]” or, “Dr. [Name] is a terrific doctor! Did you know that she [insert accomplishments]? I'm so glad she is taking care of your child!”

      To colleagues/staff: “Could you please call me Dr. [Name] when we are working with patients and families?”
      “'Wow, you are too pretty to be a doctor you should do something else.’”



      “’You're so young’ before asking the younger male resident about the child's care plan.”
      Comments about women's looks and age are ubiquitous micro-aggressions in medicine.

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      Women tend to be judged for their looks, and flirtatious statements like this one meet criteria for sexual harassment at most institutions. Women tend also to be discounted when they appear “too” pretty, “not pretty enough,” “too” young or “too” old. Together, these comments undermine a woman's identity and accomplishments.
      As a bystander: “I'm sorry, what did you just say?” or, “Dr. [Name] is a highly trained and skilled physician,” or, “I'm curious how her age is relevant to her ability to do her job?”

      To the recipient of the micro-aggression: “I'm sorry he said that to you. That is not right. How can I support you to feel seen and heard for who you are (not how you look) in the future?”
      “The most common events are basically being invisible, where my opinion doesn't register and if the same information is presented by another male person, it is noted to be a great idea."Women commonly report that they are talked over, need to repeat ideas, and/or that their ideas are only recognized after being amplified by men. When this happens, women's ideas and contributions are marginalized and under-recognized.As an ally in a meeting: “I want to go back to [Woman Doctor's Name]’s really good idea. Dr [Name], can you say more about [subject]?”

      Consider also repeating and amplifying the comments of women and those who have been historically marginalized: “Thanks, Dr. [Woman Doctor's Name]. I like your idea to [subject].”
      “A female colleague was given negative feedback about how well she was doing (publishing many articles in one year) and told she should not publish as much because it makes her (male) colleagues feel badly.”Female professionals should not need to hold themselves back to cater to the (perhaps fragile) egos of male colleagues.Mark published as much as I did last year. Did people feel badly about this accomplishments, too?”

      “You know, I am really proud of my contributions and particularly happy to be a role model to other women.”
      “Recently, I spoke up. While I got a half-apology, I also got an ‘explanation’ for why this person decided to use pejorative language towards me.”It is not uncommon for those who have made micro-aggressive statements to try to explain their intention, especially if they feel a threat to their self-identity as an ally. Well-intentioned allies need to learn the unintended consequences of their words. Non-allies must have their words reflected back in order to make change.“Thanks for the explanation. I know you didn't intend it this way, but when I hear you say [phrase], the impact of that statement is that I feel slighted. I hope that by sharing my experience with you, you might avoid unintentionally hurting someone else in the future.”
      “I was told by [leader] that I would have to choose between my job and motherhood.”These types of comments suggest women are less capable (or less committed) because they have children. There is no evidence that women (or men) cannot work and be good parents at the same time. Both women (and men) should be allowed to choose the right work-life balance for their own families.“John has 2 young kids, too. Would you say the same thing to him?”
      “There is a female physician who is referred to as ‘the bitch’ by older male colleagues because she called one out in a meeting for saying something sexually inappropriate.”Slanderous and derogatory language cannot be tolerated. Perpetuating these slurs not only undermines this woman's efforts to interrupt bias, it creates a culture of fear and silences others who may wish to do the same.“That type of language is offensive and unprofessional. It is also a form of sexual harassment that can be reported to HR.”

      (Consider also reporting this type of harassment to HR and other institutional leadership immediately and often.)
      “Research mentor placed his hand on my knee without permission. I have no idea what we were talking about because all I recall is feeling violated.”Unwanted sexual advances are never appropriate and always considered harassment. This type of behavior also creates a power imbalance and physical threat that undermines the woman's success.Consider leaving the room as soon as possible and reporting the behavior to the appropriate leadership, anonymous reporting, or HR representative. In the future, suggest joint meetings with an additional co-mentor.

      Discussion

      We endeavored to explore academic pediatricians’ voluntarily shared descriptions of workplace gender-harassment. We found that harassment is common in every aspect of academia; it comes from institution staff, patients and families, colleagues, supervisors and leaders, and the academic “system” as a whole. These experiences take a toll, particularly for women faculty. The words used by women to describe their experience invoke a sense of exhaustion, hopelessness, and belittlement, whereas the words from men suggest inconvenience. Most women and men in our sample believe that reporting their experiences and observations risks retaliation, and almost all women (and no men) also believe that reporting is futile. Indeed, of the few women who reported their experiences or observations, 1-in-4 experienced direct retaliation and only 1-in-20 believed their efforts resulted in positive change.
      Some of these findings were expected; gender-based discrimination and harassment in academic medicine are well-described and endorsed by over 70% of women physicians.

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      Indeed, our objectives with this analysis were to enrich such quantitative descriptions of the problem with more nuanced, qualitative data. Doing so allowed us to identify concrete examples of the various types of gender-harassment that women (and men) experience, as well as the helpful (and perhaps harmful) ways that their colleagues and institutions may respond.
      Some of these findings were less expected; sensitivity analyses suggested that faculty with intersectional identities (ie, those who identified as women from historically marginalized racial or ethnic groups), reported similar numbers and types of harassment to faculty who identified as white. This is different from our own previously published data as well as the wealth of literature suggesting that harassment is more common, traumatic, and career-limiting for women faculty who are not white.

      National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequneces in Academic Sciences, Engineering, and Medicine. Washington, D.C.2018.

      ,
      • Slater AC
      • Thomas A.A.
      • Quan L.
      • et al.
      Gender discrimination and sexual harassment in a department of pediatrics.
      ,

      Williams J, Phillips KW, Hall EV. Double Jeopardy? Gender bias against women of color in science. 2014.

      We think this difference is important. We do not know if women with intersectional identities truly shared fewer stories than expected, or if white women shared comparatively more. Regardless, these findings suggest that continued efforts to understand the nuances of gender-harassment in academia will be critical.
      We also identified previously described sources of gender-harassment, such as that from patients and families. Examples from our participants included some that could seem benign (ie, persistently turning to more junior male trainees instead of recognizing the senior female attending physician) as well as some that are more obviously problematic (unwanted sexual advances from patients’ caregivers). It is important to note that both examples are consistent with gender-harassment and both are harmful to the targets and the workplace. These everyday occurrences (especially in combination with myriad other marginalizing experiences) have a powerfully detrimental effect on psychological well-being.
      • Periyakoil VS
      • Chaudron L
      • Hill EV
      • et al.
      Common types of gender-based microaggressions in medicine.
      In a recent analysis of ∼6500 U.S. Physicians, 50% of females compared to 15% of males reported verbally dismissive, abusive, sexist language from their patients/families, and 30% and 15%, respectively, reported physical assaults.
      • Dyrbye LN
      • West CP
      • Sinsky CA
      • et al.
      Physicians' experiences with mistreatment and discrimination by patients, families, and visitors and association with burnout.
      Each experience substantially increased the risk of burnout and contributed to a workplace that felt hostile-to-women. In a female-predominant specialty like academic pediatrics, these experiences exacerbate an already too-wide gender equity gap.
      Our findings also emphasize the substantial challenges with current harassment-reporting systems. Most of our sample endorsed fear and futility with reporting their observations and experiences. These impressions are not unfounded. Three-quarters of American organizations have sexual-harassment reporting procedures and 100% of academic medical centers with NIH funding have them.

      US Department of Health and Human Services Health Resources and Services Administration. Shortage designation: health professional shortage areas and medically underserved areas/populations. Available at: http://www.hrsa.gov/shortage/. Accessed October 17, 2016.

      Nevertheless, the number of claims has not changed since the 1980s. The systems do not work. Worse, retaliation, especially the covert retaliation our participants described, is common.
      • Binder R
      • Garcia P
      • Johnson B
      • et al.
      Sexual harassment in medical schools: the challenge of covert retaliation as a barrier to reporting.
      Two-thirds of sexual harassment claimants are subsequently assaulted, taunted, demoted, fired, marginalized, or deliberately excluded by the harassers or the harasser's friends.

      Dobbin F, Kalev A. Why Sexual Harassment Programs Backfire. Harvard Business Review 2020. Available at: https://hbr.org/2020/05/confronting-sexual-harassment. Accessed June 3, 2020.

      This has long-term effects; women who file complaints end up with worse professional mobility, and inferior physical and mental health than those who do not. Moreover, this experience teaches other women (and men) not to come forward. Indeed, only 10% of those who experience harassment ever bring it to institutional attention.
      • Dzau VJ
      • Johnson PA.
      Ending sexual harassment in academic medicine.
      Together, it is no wonder that the emotional resonance of female physicians in our sample bordered on defeat. The cumulative sense of powerlessness, fear, and lack of recognition that result from uncorrected gender-harassment is a key reason that up to 40% of female physicians consider leaving the workforce.
      • Dyrbye LN
      • West CP
      • Sinsky CA
      • et al.
      Physicians' experiences with mistreatment and discrimination by patients, families, and visitors and association with burnout.
      ,

      Why women leave medicine. AAMC news, October 1, 2019. Available at: https://www.aamc.org/news-insights/why-women-leave-medicine. Accessed June 30, 2022.

      ,
      • Dyrbye LN
      • Massie Jr, FS
      • Eacker A
      • et al.
      Relationship between burnout and professional conduct and attitudes among US medical students.
      The implications of these findings are critical as the health care industry moves beyond the COVID-19 pandemic. Physician attrition is at an all-time high and projected to worsen.
      • Bhardwaj A.
      COVID-19 pandemic and physician burnout: ramifications for healthcare workforce in the United States.
      If female and other historically marginalized faculty are disproportionately more likely to leave academia due to ongoing discrimination and harassment, pediatric patients and systems will suffer. Not only do women physicians have superior medical and surgical outcomes,
      • Tsugawa Y
      • Jena AB
      • Figueroa JF
      • et al.
      Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians.
      ,
      • Wallis CJ
      • Ravi B
      • Coburn N
      • et al.
      Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study.
      a racially- and gender-diverse faculty is better able to recruit and support representative patients and trainees. The benefits of having women in leadership positions is also well-established; businesses with women leaders have improved organizational performance, fewer errors, and better function.
      • Chen J
      • Sau Leung WS
      • Wong W
      • et al.
      Research: When Women Are on Boards: Male CEOs Are Less Overconfident.
      ,

      Do Companies with Female Executives Perform Better? The balance. 2021. Available at: https://www.thebalance.com/do-companies-with-female-executives-perform-better-4586443. Accessed June 30, 2022.

      Together, this means that academic pediatrics organizations must endeavor not only to protect and retain women faculty, they must also endeavor to promote them and put them in positions of influence. Gender-, racial-, and other equities benefit everyone.
      This analysis has several limitations. First, our sample is from a single center and has limited racial diversity; responses may be biased by local institutional culture and/or recent institutional experiences. To protect the anonymity of faculty from historically marginalized groups, we chose not to evaluate stories based on race or transgender-identity. Also, participants who chose to share their stories may not be representative of the larger whole of our department or academic pediatrics, in general. While it is possible those who experienced gender-harassment were more likely to tell us about it, it is equally possible that many participants chose not to share their stories out of fear, shame, or hopelessness. We do not know how many stayed silent. We also do not know how many normalized their everyday marginalization; many may not recognize that this is qualifies as harassment because it is, by definition, discriminatory. Our findings may thus be less generalizable to other individuals, other departments, or other centers. They also may fail to address more egregious types of racial- and gender-harassment.
      An additional limitation is in the implication of our findings. Qualitative approaches enable researchers to richly capture experiences that may not be fully reflected by quantitative data, including the perspectives of those “on the margins.”

      Creswell JW, Klassen AC, Plano Clark VL, Smith KC for the Office of Behavioral and Social Sciences Research. Best practices for mixed methods research in the health sciences. 2011. National Institutes of Health. Available at: https://obssr.od.nih.gov/training/online-training-resources/mixed-methods-research/. Accessed April 24, 2020.

      They are, by definition, exploratory and designed to suggest hypotheses for future studies. Hence, we did not conduct formal quantitative tests to demonstrate “statistically significant” differences between male and female faculty experiences. Qualitative findings are also inherently subject to interpretation; all authors identify as women, and our impressions of qualitative data are biased by our own experiences. Finally, we did not explicitly ask participants for suggestions to interrupt gender-harassment; our compiled recommendations are our own. Readers must consider if and how to implement these suggestions within the larger context of what they and their institutions believe will work.
      We believe these findings represent a call to action. Our and others’ data suggest we have made little progress towards gender-equity in academic pediatrics. Female pediatricians continue to report gender-harassment that is ubiquitous in every area of their workplace, that is emotionally burdensome, and that is unlikely to improve if they report it. It is time for change. Perpetrators must be held accountable, bystander intervention must be common and championed, and both individuals and groups must be able to report their harassment without overt or covert retaliation.
      • Byerley JS
      • Dodson NA
      • St Clair T
      • et al.
      Creating work and learning environments free of gender-based harassment in pediatric health care.
      ,
      • Kang SK
      • Kaplan S.
      Working toward gender diversity and inclusion in medicine: myths and solutions.
      ,
      • Choo EK
      • Byington CL
      • Johnson NL
      • et al.
      From #MeToo to #TimesUp in health care: can a culture of accountability end inequity and harassment?.
      ,
      • Binder R
      • Garcia P
      • Johnson B
      • et al.
      Sexual harassment in medical schools: the challenge of covert retaliation as a barrier to reporting.
      Processes for improvement must be data-driven, transparent, and constantly adjusted to ensure success; faculty need to see the evolving gender-equity actions of their institutional leadership, from the idea to the implementation to the outcome.
      • Spector ND
      • Asante PA
      • Marcelin JR
      • et al.
      Women in pediatrics: progress, barriers, and opportunities for equity, diversity, and inclusion.
      ,
      • Byerley JS
      • Dodson NA
      • St Clair T
      • et al.
      Creating work and learning environments free of gender-based harassment in pediatric health care.
      Finally, we need to create psychologically safe ways to interrupt bias, normalize such interruptions, and celebrate the importance of influential allies who help to overcome existing barriers to change. This includes recognizing and shifting the entrenched status quo that seems to tolerate opposition to equity. With these efforts, academic pediatrics can not only model a climate of accountability and transparency, it can also improve the experiences of faculty and pediatric patients alike.

      Acknowledgments

      We want to thank the Pediatrics Faculty participants in this study, especially the people who shared their own, difficult stories of workplace harassment and discrimination. This project was supported by the University of Washington Department of Pediatrics, including with endorsements from leadership and funding for biostatistical analyses. ARR has received grants for unrelated work from the National Institutes of Health, the American Cancer Society, Arthur Vining Davis Foundations, Cambia Health Solutions, Conquer Cancer Foundation of ASCO, CureSearch for Children's Cancer, the National Palliative Care Research Center, and the Seattle Children's Research Institute. The opinions herein represent those of the authors and not necessarily those of their institutions or funders.

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