Medical students’ and teachers’ perceptions of sexual misconduct in the student–teacher relationship

Development of professional behaviour has become a major part of education in competence-based medical curricula [1, 2]. Teachers play a key role in teaching professional behaviour, as they are important role models for trainee young doctors [3]. Unfortunately, teachers sometimes show unprofessional behaviour. Especially in the clinical workplace, where clinical teachers ought to be role models, misconduct in the student–teacher relationship (including sexual harassment) appears to occur [4, 5]. This is a serious problem, all the more because students are dependent on their clinical teachers for feedback and assessment [6]. To be able to outline a strategy to deal with (sexual) misconduct, it is important to determine which behaviours in the student–teacher encounters are perceived as (sexual) misconduct. In this study, we analyzed to what extent students and teachers consider incidents as misconduct and sexual harassment in the student–teacher relationship.

Unprofessional behaviours can be grouped into three different levels of severity: (1) atypical of the standard student–teacher relationship, (2) crossing boundaries and (3) violating boundaries [4]. In this study, we focus on unprofessional behaviours with sexual overtones. Examples of such behaviours range from inappropriate comments, unwelcome attention, flirtatious or sexual remarks to too personal questions and physical contact [6, 7]. The extreme forms of this type of misconduct are called sexual harassment. Sexual harassment—which is alarmingly often reported by students, with prevalence rates ranging from 18 to 60 % [6, 8‐10]—has been shown to have a negative impact on students’ well-being [11‐14]. Students who had been sexually harassed indicated that they functioned less well as a consequence and reported lower self-esteem and self-confidence [12]. Victims of sexual harassment also reported a diminished interest in or enthusiasm for their studies [10]. Furthermore, harassed students felt more stressed and depressed, drank more alcohol and tended to be more suicidal than non-harassed students [15]. There are also indications that sexual harassment affects students’ speciality choices [16]. For instance, female students confronted with incidents of harassment during their surgical clerkship did not specialize in general surgery, despite their initial intention and interest. The high prevalence rate of sexual misconduct in the student–teacher relationship and its negative impact on students denotes the importance of addressing sexual misconduct.

Medical schools have increasingly acknowledged the need to address sexual harassment. Several measures have been taken to address this issue. Hospitals and medical schools have, for instance, emphasized the fact that their students and teachers belong to a profession that has high ethical standards on maintaining appropriate professional boundaries in both the doctor–patient and the teacher–student relationship. In addition, hospitals and medical schools have formulated definite policies on sexual harassment and implemented procedures for reporting incidents of sexual harassment, and they have informed students and teachers about these policies and procedures [5]. Despite the fact that several measures have been taken to address (sexual) misconduct, students do not optimally make use of the established mechanisms for reporting abuse [12]. Reasons for not doing so are that students consider themselves as belonging to the lowest level of the hierarchy and they fear retaliation from abusive faculty, which could jeopardize their residency plans [15]. Another reason for not reporting sexual harassment is that female students feel that they, perhaps, may have been oversensitive [17]. Apparently, the measures taken are not enough to attain wholesome student–teacher relationships. Addressing sexual harassment actively in medical school curricula is needed to teach students how to deal with sexual misconduct and how to form and keep up professional relationships [18‐20].

Methods to address sexual misconduct actively in curricula may include interactive educational sessions, in which students can discuss harassing experiences together and with their teachers [18]. To make these educational activities effective, it is essential to examine whether students and teachers have similar views on what constitutes (sexual) misconduct or even sexual harassment. We noticed that our students and teachers easily agree on sexual harassment when it concerns extreme sexual misconduct like rape. However, during their small-group meetings, our students also mentioned incidents with a sexual overtone in the student–teacher relationship that did not concern extreme forms of sexual misconduct. While the students who brought these incidents up obviously considered them as sexual misconduct, remarkably, not all teachers and students did so. This observation puzzled us and we decided to investigate whether such differences in opinion only occur incidentally or whether students and their teachers differ structurally in their opinions about the severity of unprofessional behaviours. We wanted to gain more insight into the opinions of students and teachers in order to provide input for the educational sessions on this topic. The aim of this study was to explore to what extent students and teachers perceive certain inappropriate situations in the student–teacher encounters as sexual misconduct or—more severely—as sexual harassment.

We formulated the following research questions:

We were also interested in group and gender differences in views on incidents:

We also investigated whether female students who have already experienced harassment before/during medical school differed in their perception about incidents from those who have not experienced previous harassment. Therefore our last question was:

In this study, we explored medical students’ and teachers’ perceptions about written vignettes describing inappropriate student–teacher encounters. All vignettes were consistently considered more as misconduct than as actual sexual harassment. At the individual level, we found a large variation in perceptions of misconduct and sexual harassment. Both within and between respondents, opinions differed from incident to incident: some respondents perceived a particular incident as very harassing and the other incidents as not harassing at all, while other respondents, in contrast, perceived one of the other vignettes as particularly harassing. All incidents were considered by some as overt misconduct or as very sexually harassing and by others as not misconduct or sexual harassment at all. There was no consistency across respondents regarding which incidents they considered most serious or, in other words, a general sensitivity for sexual harassment does not seem to exist.

Upon comparison of the opinions of subgroups in our respondent sample, we found some differences between teacher and student perceptions, but there was no clear pattern. In some cases, teachers were more permissive, in other cases students were more lenient. This outcome differs from the results of a study conducted by Ogden et al. [23], who found that clinical teachers considered more behaviours to be abusive than did students. In addition, we found that male students were more lenient towards certain behaviours than female students. An explanation for the fact that females perceived vignettes more as sexual harassment and as misconduct than males did may be that female students themselves are more often victims of sexual harassment—in our study, for instance, 96 % of the harassed students were female—and that these experiences affect their perceptions of the vignettes [10, 15, 24, 25]. If this line of reasoning is true, we might expect different views between harassed and non-harassed students. However, we did not find any differences in the opinions of harassed and non-harassed female students.

A strength of our study is that we used real-life experiences of clerks to investigate their perceptions and those of their teachers. Considering each of these experiences was felt to be inappropriate by some and as acceptable by others stresses the need to address a range of examples of misconduct in education. In our study, the vignette in which the clerk was the harasser was perceived as most sexually harassing. Teachers indicated that they recognized the situation and that it made them feel uncomfortable and insecure because they doubted whether the clerk intentionally tried to harass or whether they had misunderstood the situation. Based on their study of sexual harassment of female doctors by patients, Schneider and Phillips [26] suggest that this phenomenon can be explained by the so-called contra power. Contra power harassers have a way of obstructing formal power in spite of an explicit power imbalance. They tend to use low-risk behaviour, because it can easily be explained as a misunderstanding. In our vignette, the student fulfilled the role of the harasser, although the teacher held the formal power. Considering our findings, we recommend not to limit the discussion of misconduct to stereotypical incidents in the student–teacher relationship in which the ‘harasser’ is an older male and the ‘victim’ is a young female, but also to discuss vignettes in which the clerk is the harasser.

We realize that our study, in particular the content of the vignettes, was limited to the Dutch context. Although our vignettes were based on real-life situations reported by our Dutch students, they may be culturally biased. The Netherlands is a country characterized by individualism and feminism and gender equity in social and sexual interaction is generally accepted in the Netherlands [27, 28]. Although the content of the vignettes may be specific to the Dutch culture—and maybe also to other countries high in individualism and femininity—the principle of incidents being differently valued by individuals, i.e. being considered as misconduct or not, may hold in different cultures. Future research is needed to find out whether our outcomes—that individuals differ strongly as to what they consider as acceptable or not acceptable—are also valid for other countries or cultures.

The most important finding of our study is the observation that students and their teachers differ structurally in their opinions about the severity of unprofessional behaviours. The differences in interpretations can be caused by many factors such as the respondent’s individual past experiences, personality, cultural background, religious background, family background or the way he/she was brought up. The thresholds for perceiving incidents as misconduct or even sexual harassment seem highly personal and which incidents are considered as most serious varies strongly across individuals. This outcome forms a plausible explanation for why it is so hard to define and address sexual harassment in medical schools. The lack of uniformity in answers hinders the formulation of strict guidelines on which conduct is permissible and which conduct is not.

The practical implications of these outcomes are that a different approach is required to address sexual misconduct. Interactive educational sessions in which students and teachers discuss vignettes together are recommended [18]. As study material for these educational sessions, we suggest—based on our outcomes—to present several (at least 4–5) different vignettes about the student–teacher relationship per session. Using vignettes with incidents of differing severity in a session helps to create awareness that there are individual differences in thresholds concerning what is acceptable and what is not. Such awareness may help participants of these educational sessions to realize and respect that other peoples’ boundaries may not be the same as their own. Second, we recommend taking gender differences into account in the educational sessions. Because male students were more permissive on some vignettes than female students, awareness of differences between males and females may be increased by composing mixed-gender small groups.

We would like to stress the importance of developing awareness among students and teachers, because it is not easy to find the right balance between closeness and distance. It is the teacher’s task to help students to acculturate or socialize in the ‘community of practice’ of the medical profession [18]. Therefore, the role of the clinical teacher requires a certain level of collegial and social closeness [18]. Since the student–teacher relationship is by definition one of unequal powers, however, finding the right balance between closeness and distance may be difficult [4]. Teachers may be unaware that they are deviating from professional standards of conduct. Because of power inequality, students may find it hard to negotiate boundaries or defend themselves against boundary crossings. The issue may be further complicated by the fact that what is acceptable is often not a clear-cut matter of right and wrong. Therefore, we encourage educators to explicitly pay attention to raising awareness of students and teachers that what is acceptable to some people may not be acceptable at all to others.

Students’ and teachers’ perceptions of sexual harassment and misconduct are not univocal. Our findings indicate that students and teachers recognize the concept of misconduct sooner than sexual harassment. We suggest teaching both students and teachers to be aware of different situations of misconduct within their mutual relationships, and to realize and respect that other people’s boundaries may not be the same as their own.