As a medicai student in 1960, one of 10 women in a class of approximately 200 men. it was clear that sexual harassment was prevalent. The harassment took many forms. Tt began upon entrance into medical school when each of us was told that we were "taking a man's place" and we "ought tu bo in the1 kitchen as we would never practice medicine." It continued as we found penises stuffed in the female organs of our cadavers. On the pretext of being taught, many of our instructors hovered around us. touching us inappropriately and making lewd comments. However, female medical students in 1960 were a passive lot. We rarely complained except to one another. The worst offender taught a course on the embryology of the pig. Each of us had been subjected to comments, touching, jokes, and other forms of harassment by him. Christmas Day, 1960. our medical sorority had a traditional brunch at which vodka and orange juice were served. This passive group of women students found their courage fortified and purchased a pig's bead at the farmers' market. One of the janitors at the medical school understood our plight and allowed us to sneak into the building; we placed the pig's head on a tray in this professor's office, knowing full well that it would decay, deteriorate, and leave an unbearable stench by the time the Christmas holidays were over. This was our passive reaction. I doubt whether the professor ever got the point; that is, that he was a malo chauvinist pig, but we felt better.
Fortunately, the world is changing. Medical students, women professionals, and women in general are not a passive lot and more are starting to speak up and claim their rights. In the last edition of the Research and Resources Guide to Sexual Harassment, a report prepared by the National Council for Research on Women, the authors reported that between the years of 1985 and 1990. the number of sexual harassment, complaints filed with the Equal Employment Opportunity Commission (EEOC) went from 4953 to 5557. Since 1989, the number of sexual harassment charges has increased \V2r/r. As a result of changes resolved by the EEOC in 1993. 1546 complainants won '$252 million in benefits from their employers, including back pay, remedial relief, damages, promotions, and reinstatements.
Sexual harassment, of course, exists in institutes of higher education. A 1985 American Psychological Association report presented the results of a mail survey of graduate student members of APA's Division of Clinical Psychology and Division of Counseling Psychology. Of the 246 women responding (the N of the survey is not known), 12.7% reported being sexually harassed, 21.(Ki did not enroll in a course to avoid sexual harassment. 11.0% tried to report an incident of sexual harassment. 3.0% dropped a course because of sexual harassment, and 15.99% reported being assaulted.
Sexual harassment is widespread in the medical profession. The American Medical Women's Association, in a study entitled Gender Bias Against, and Sexual Harassment of AMWA Members in Massachusetts, documented the profound effect of gender bias on rights of sexual harassment. In a survey conducted in 1993. the researchers reported that three fourths of female doctors had been sexually harassed by their patients. Most of the offenses involved suggestive looks and sexual remarks, although some told of touching and being prcssured for dates (New York rimes, December 23, 1993).
As a forensic psychiatrist, I have had an increase in referrals for both evaluation and treatment of women alleging sexual harassment. Even those women patients who are not involved in litigation or who do not present with depression and anxiety following harassment complain freely and openly about degrading and humiliating experiences on the part of their employers.
One of the first women I evaluated was a line worker for a power company. She was one of the first female employees placed in a nontraditional job. Her fellow workers presented her with a pink hard hat, littered her desk with cartoons, and posted jokes and obscene comments in the women's restroom. She reported that although her colleagues had been to!d in no uncertain terms to train her, on training exercises, she discovered that they regularly took the wrong equipment, were late, or managed to avoid her needed instruction.
In our experience, more women than not who have been exposed to sexual harassment do present with clinical symptoms of depression and anxiety at the time of evaluation. Ms. D., as a professional in a dental clinic in an all-male prison, was tearful as she described her employer's comments about her "big boobs" as she attempted to perform her duties as a hygienist and assistant. This was particularly upsetting as the comments were made in front of male prisoners who then used her employer as a role model and also commented about her anatomy. She admitted to being very frightened when her employer chased her out of the dental clinic into an unused ward where there were many empty beds. Needless to say, the anxiety and depression that she complained about seemed quite obvious in her clinical examination.
Blaming the Victim
Feminist scholars have identified several similarities and attitudes toward rape and sexual harassment. The practice of blaming the victim is perpetuated by the following myths: (a) women ask for it, or the. harassment is a form of seduction; (b) women say no but mean yes; and Cc) women lie, as illustrated by the sequential case examples.
Ms. A., an attractive, well-spoken. 26-yearold personal secretary, told a story of being regularly demeaned by discussion of the size of her breasts and other parts of her anatomy. She also reported that she bitterly complained to her employer and positioned herself so that he had to go through extraordinary gyrations to peer down her blouse. On interview, her employer insisted that her clothing was provocative, seductive, and that she liked this despite her repeated protests for him to stop. He "knew" that she, liked his repeated compliments because of the way she dressed.
Mrs. B. was asked repeatedly by her employer to accompany him on business trips. She refused, recognizing that his intentions were less than honorable. She was offended and angered when her employer made both airline and hotel reservations for her and presented her with them saying that this was a gift and there would be no "quid pro quo" (this for that).
Ms. C. accused her employer, a prominent attorney, of coercing her into sexual intercourse in order to keep her job as a legal assistant despite the fact that she could describe intimate details of her employer's most private anatomy because he exhibited it to her in one of his more amorous moods. Her employer stated that she was lying.
Overt and Covert Harassment
I have seen a number of women physicians who have reported both overt and covert harassment. Covert harassment generally consists of unequal opportunities, lack of mentorship, different standards for promotion, and excessive expectations with regard to work performance for promotion, as exemplified by Dr. E.. a patient currently in treatment suffering from anxiety, depression, and posttraumatic stress disorder. She is in the midst oflitigation in regard to discriminatory practices by her academic department, resulting in a lack of promotion. She has found her life in turmoil and the litigation has affected her relationship with her husband, her children, and her colleagues. She feels that she has been blacklisted in opportunities in her super-specialized Held of medicai practice. She stated, "Aiiy decision I make is the wrong one." She has lost her ability to objectively evaluate situations and experiences. The sense of control over her life and destiny is rapidly waning. She has feft her profession temporarily to regain a sense of self while she pursues litigation.
According to Catherine MacKinnon. research data suggests that working -class women may encounter physical as well as verbal harassment more often than professional women, who experience more verbal than physical forms of harassment.' as illustrated by the following examples.
In 1979, a third-year iemale medicai student requested a fourth-year elective from the chief resident of orthopedic surgery. He responded, in the presence of his all-male entourage, "The only way I like my female medical students is flat, on their back and spread eagle."
In 1992. a fourth-year female resident experienced a 20-minute delay in morning work rounds while her male supervisor and fellow resident discussed whether a female model on the cover of a fashion magazine ( based on the contour of her breasts] had undergone "a boob job."
A female colleague related to me that she had not responded to the flirtatious remarks of the father of one of her young male patients. The father began bringing his son to his pediatrie appointments without being accompanied by the child's mother. During a physical examination at 18 months, while the child was being examined for the presence of undescended testes, the father took the liberty nf standing uncomfortably close to the physician. When asked to step back, the father refused and continued to focus his attention on the physician instead of his son.
THE PSYCHIATRIST'S ROLE
Psychiatrists are asked to see women who allege harassment as both treaters and expert witnesses. Diane Shrier and Jean Hamilton have developed protocols for therapists treating patients who have alleged harassment. They suggest that the treating psychiatrist (D assess the severity of the iininediate crisis and validate the seriousness of the experience; (2) evaluate the degree of depressive, psychosomatic, anxiety, and posttraumatic stress symptoms; (3) allow exploration and expression of feelings; (4) support existing coping strategies, facilitate the development of additional coping skills, and formulate a plan of action to reestablish a senso of control; (5) assess and protect against potential losses and adverse consequences; and (61 assess prior victimization experiences compounding the present.
The role of the treating therapist is obviously quite different from that of the forensic expert. The ground rules of forensic consultation are offered here. Before taking the case, the forensic clinician consults with the referring attorney and forms ground rules under which he or she will participate in a forensic consultation. The ground rules should address at least the following:
1. The forensic expert must be allowed to be objective and evaluate each case on its merits, whether appointed by the court or asked to participate by attorneys for the defendant or plaintiff. The psychiatrist is an advocate for his or her professional opinion, not for either side of the case.
2. The expert must be able to review all available documents. Even the most competent attorney, selecting materials from a file, sometimes selects materials that are most favorable to the client's position and omits others.
3. The clinician must, let the attorney know that it is impossible to assess mental status and psychiatric damages adequately without personal contact with the patient/client unless the psychiatrist is only going to be an expert, on a particular psychiatric disorder or aspects of sexual harassment independent of a client's particular case.
4. The clinician should reach an agreement with the attorney about fees and make clear that they are not contingent on the case's successful outcome. Discussing payment and the attorney's contractual responsibility for payment does not mean the report will be biased or prejudicial in favor of the attorney's client. Attorneys are quite comfortable with discussions of retainers and frequently offer them.
5. The clinician may offer to provide relevant materials to the attorney. Such materials might include scientific studies, case examples, literature, and so on.
It is not unusual to have a forensic client call the expert after testimony has been given and request psychiatric treatment. Rapport has been developed, as has a relationship. Such a request puts the expert in a difficult position. The expert has conducted an evaluation and rendered an opinion: there are transferentiaJ elements already in play. It is clearly best to refer the patient to another mental health clinician tor treatment and to contact the referring attorney. This is essential if the examination revealed that the client/patient is in need of treatment and has not. been so advised.
MISUSE OF POWER
Sexual harassment is one of the most recently identified of a spectrum of sexually exploited behaviors in which power is misused to victimize others. Included in this spectrum is child sexual molestation; acquaintance, stranger, and spouse rape; sexual exploitation by patients, therapists, and other health professionals; and other types of workplace discrimination based on gender, race, sexual orientation, and handicap. Exposure to sexual harassment is likely to be part of the life experience of most women and a small number of men. Sexual harassment behaviors range from sexual innuendo, touching, and flirtatious remarks, to clear-cut sexual assault and rape accompanied by retaliation for reporting.2 The severity and type of emotional, physical, interpersonal, and economic sequelae of the harassment varies depending on the nature of the harassment, how it is perceived and experienced, its severity, chronicity, and the past history of the person who is being harassed. It is also influenced by the pervasiveness within a particular workplace setting, the response of the workplace supervisory structure to reported abuse, and the potential for retaliation and ostracism of the target.
A rise in formal sexual harassment court cases has triggered a vicious legal trend within the court system as employers seek to minimize their liability through aggressive tactics that undermine and attack the victim's credibility, alleging that she is the victimize]-, the seductress, the willing participant. The abuse that Navy Lieutenant. Paula Coughlin faced for blowing the whistle at the 1991 Tailhook Convention is clear evidence that retaliation is alive and well.
There is no doubt that since the Clarence Thomas confirmation hearings the issue of sexual harassment has moved center stage into public consciousness and the consciousness of the psychiatric profession. Sexual harassment is no longer a taboo subject. It is discussed openly and professionally in meetings and seminars. Despite the fact that it is discussed openly and represents growing problems, the steps that are taken to change the climate of our community goals by our professional organizations are "baby steps." Scholars argue the fact that there are difficulties in conducting research with an. organization about harassment due to problems of privacy and liability. Organizational researchers and clinicians, who study harassment as they would other sensitive issues within the community and workplace, need to develop theoretical models, protocols, and a variety of individualized treatment plans. As teachers. clinicians, and researchers, we are part of that process and need to address issues of harass - merit in our multiple roles.
1. MacKinnon C. Sexual Haraasmenl of Working Women. New Haven, CT: Yale University Press; 1979.
2. TerpsLra D, Baker DD. Outcomes of federal court densions on seicua| harassnwnl. Academy of Management Journal, 1992;35(1):181-190.