In this study, we analyzed the changes in prevalence and the pattern of self-reported experience of gender discrimination (GD), including gender harassment, and sexual harassment (SH) of medical students between 2002 and 2013 at Uppsala University (UU) in Sweden.
In this study we separated SH from other GD as those types of behaviors are the most alarming and must be highlighted [35]. In the presentation of the results, we focus on increased ratios as it is the most important to define what interventions are needed for the future. The main result of our study is that although the prevalence of several examples of GD showed a tendency to decrease between 2002 and 2013, these results are complicated by an increased difference between the sexes, widening the gender gap for prevalence of GD and SH. Alarmingly, the prevalence of SH increased for both women and men, but particularly in pre-clinical settings, where the prevalence of some behaviors doubled. The most severe form of SH, the demand for sexual acts, was uncommon in 2002 but more common in 2013. Based on the fact that SH-experiences increased but not the observations of others being subjected to these behaviors, we can suspect that these interactions occur behind the scenes, making it harder for others to notice.
Our previous studies concluded that the total prevalence of self-reported GD/SH was higher in students during clinical rather than pre-clinical training and affects women more than men [21, 22]. In this study, the graphics in Figure 1 support these conclusions. It is worrying but not surprising as several other studies and the recent meta-analysis presented similar outcomes [2, 36].
Several studies showed that discriminating behaviors lead to negative consequences for medical students and their professional future [10, 37, 38]. In addition, even observations of other students being mistreated have a negative impact [39]. Therefore, we also analyzed if medical students observed other students being discriminated against, which was common. Pre-clinical male students who between the years became less subjected to GD themselves noticed a higher prevalence of mistreatment of other students, which supports the self-reported increase in experiences among pre-clinical female students.
The reason of increasing reporting of GD/SH in 2013 compared to 2002 is most probably due to raised awareness of those behaviors among students. This can be a result of universities’ attempt to address discriminations, such as curricular changes done at UU in 2006 [18] but also conventional media and culture. Also, social media had increasingly offered information on the topic, even long before #MeToo.
In our opinion rising awareness of gender equality and understanding gender discrimination might contribute to higher response rate in 2013 than in 2002. Also, the distribution during lectures as done in 2013 was probably more effective than using postal service in 2002.
Between 2002 and 2013, the context of mistreatment changed and was less common during the theoretical moments but increased in the clinical context, most noted in the pre-clinical group and especially in the female pre-clinical group. In this group, the occurrence of mistreatment during clinical training increased five times by female supervisors and seven times by male supervisors between 2002 and 2013. This is probably partly explained by changes in the educational program at UU, where pre-clinical students in the 2013 cohort have had regular clinical rotations in primary care since the first semester. Out of all the clinical supervisors, medical doctors were most often identified as the perpetrator in 2013.
Although male students’ experiences of GD in general changed for the better, reports on medical doctors as perpetrators increased also in this group. Evidently, these curricular interventions fail to reach the clinical environment. When mistreatment is not addressed properly, studies suggest that students may incorporate the bad norms and attitudes of the teaching physicians as part of the hidden curriculum [40, 41]. When the teaching physician is being discriminatory, it may cause a negative spiral of these behaviors. The acceptance of mistreatment may increase and even worse, people who suffered from mistreatment often become perpetrators themselves [42].
Strengths and limitations
Our research benefited from two independent cohorts of medical students. Because of the large number of participants and high response rate, our results may be generalizable to other medical schools with similar educational structure. Another advantage is the use of previously validated behavioristic questions, which helped to decrease the risk of bias.
There are however limitations to this study. It is cross-sectional with no control group. The questionnaires use closed-ended questions, where respondents are not able to clarify their choice or verify if the interpretation was the one intended. With self-reports, there is always a perception bias and participants offer their subjective experiences. The examples of GD/SH may be differently interpreted between individuals and groups, and there may be a risk for result bias. The study evaluated only the experience of medical students (victim’s perspective). Some aspects that may impact the answers were not considered in the study such as other minority identities reflecting other grounds of discrimination and social status of the participant. Another limitation may be that the authors analyzed data from their own institution.
Study implications
With this study, we want to show that medical students experience GD/SH during their medical education. Moreover, the context of those experiences is often the clinical environment, which can be hard for universities to monitor and change. Efforts by universities to detect gender discrimination with the currently used instruments such as course evaluations might not be adequate as underreporting is a known problem [43-45], and response rates are usually low. Recurrent mistreatment of medical students by faculty staff was showed to be of the driving forces of burnout, and psychiatric disorders [46, 47]. Evidence-based strategies to decrease GD/SH involved education of staff and students including knowledge of student’s rights, proactive encouragement of reporting, and regular monitoring of discriminatory behaviors [2, 7, 8, 39]. Also, teaching on gender equality may play a pivotal role in bridging the gap from gender bias to gender awareness [48]. Change might depend on educating and promoting reflexive abilities and well-being among clinical supervisors [49]. All this to align the formal curriculum including confident engaging in learning activates supported by teaching stuff with the informal or hidden one, thus creating a good learning environment for students.