According to the National Academies of Sciences, Engineering, and Medicine report on the culture of sexual harassment in academic institutions (1), sexual harassment is extremely common across scientific fields, with the highest prevalence in medicine (2). These high rates are pervasive across sites and disciplines, including psychiatry (2–6).
Sexual harassment and gender discrimination are intimately linked (7). Gender disparities in salary and career advancement exist across health care fields (8–10) and serve to devalue women in the workplace. These disparities also create an environment with detrimental power dynamics that limit women’s ability to report or defend themselves against harassment (11). These dynamics are even worse for women from diverse backgrounds (e.g., racial-ethnic minorities; the lesbian, gay, bisexual, transgender, queer community) (12).
Given this current landscape, TIME’S UP Healthcare was launched on March 1, 2019, with the mission to ensure a safe, equitable, and dignified health care workplace. With the support of TIME’S UP, its parent affiliate, TIME’S UP Healthcare is a 501(c)(3) organization that combats gender inequity and sexual harassment through advocacy, education, and action. The value of diversity has been imbued throughout the TIME’S UP Healthcare organization. Founding members represent women in leadership throughout medicine, nursing, physician assistants, pharmacy, research, and administration. Our diversity extends beyond job titles and includes representation across race, sexual orientation, gender identity, and women at the intersections of multiple identity groups. Five psychiatrists are among the 50 volunteer founding members, including two past APA presidents.
Using its national platform to raise awareness, TIME’S UP Healthcare will attempt to provide health care workers with the knowledge, resources, and support to speak up (Table 1). In addition, TIME’S UP Healthcare has partnered with health care organizations to promote an equitable work environment and protect targets of harassment and discrimination. Partners committed to date include the American College of Physicians, the American Nurses Association, Brigham Health, the Mayo Clinic, and the Yale School of Medicine.
TABLE 1. Actions for mental health care providers to advance the goals of TIME’S UP Healthcare
|TIME’S UP Healthcare Goal||Potential Steps for Mental Health Care Providers|
|Unite health care workers across fields|
• Sign up for TIME’S UP Healthcare listserv to receive updates on the organization’s initiatives.
• Encourage interdisciplinary team members to join.
• Develop cross-disciplinary women’s peer-mentorship groups at your institution.
|Improve care for targets of harassment and inequity|
• Provide affected individuals with access to resources through the TIME’S UP web site.
• Understand the steps for reporting in your own institution and share with colleagues.
• Understand what kind of trauma-informed care is available at your institution for referrals.
• Support patients, trainees, and colleagues who turn to you with these issues using a nonjudgmental, trauma-informed stance.
• Understand that trainees may be afraid of being alone with a patient, and consider accompanying them, specifically in high-risk situations.
|Raise awareness and knowledge|
• Talk about gender inequity and harassment with colleagues.
• Wear TIME’S UP pins or scrubs or place stickers on laptops to facilitate discussion with colleagues.
• Present about gender harassment and discrimination in grand rounds and workshops in national and international meetings.
• Identify and name instances of sexual harassment and inequity when they occur in the workplace.
• Provide routine education about harassment for the entire health care workforce in your own health care delivery setting.
• Help individuals understand what defines sexual harassment, including the range of verbal and nonverbal behaviors that convey coercion, hostility, intimidation, objectification, exclusion, and behaviors or practices that convey or enforce the second-class status of women.
|Support health care organizations in making this issue central and visible|
• Encourage your health care organization to sign on as a signatory institution to TIME’S UP Healthcare (https://www.timesuphealthcare.org/signatories).
• Make your sexual harassment policies accessible and visible, including posting signs about having zero tolerance of harassment in your institution.
• Consider encouraging your institution to adopt online reporting systems like Callisto (www.projectcallisto.org), which has been shown to reduce time and increase reporting of sexual assault.
• Promote gender equity by inviting women to speak at grand rounds at your organization and/or to be on panels at national and international conferences.
• Begin to address underlying gender inequities at your home institution by developing structural processes to promote sponsorship and nomination of women and other intersectional minority groups for awards and promotion.
|Provide a link to the TIME’S UP Legal Defense Fund|
• Refer health care workers to the TIME’S UP Legal Defense Fund, which connects those who experience sexual misconduct with legal and public relations assistance. This includes people who experience assault, harassment, abuse, and related retaliation in the workplace or when trying to advance their careers.
|Advocate for meaningful standards|
• Advocate for a zero-tolerance policy at your home institution.
• Advocate for bystander training and improved sexual harassment training at your home institution.
• Advocate at the state and national level for clear rules about sexual harassment and response to the perpetrator.
• Advocate for funding organizations (federal, state, and philanthropic) to consider the role of sexual harassment allegations in grant funding opportunities.
• Identify metrics to ensure existing policies and procedures are implemented effectively and to measure critical outcomes like attrition of women and underrepresented minorities; resource allocation equity; and occupational, mental, and general medical health outcomes of targets after harassment.
• Perform root cause analysis of harassment cases to shed light on organization factors fostering harassment and inequities.
|Advance research on harassment and inequity|
• Study the prevalence of sexual harassment in mental health care settings and training programs.
• Study the influence of workplace gender inequity on mental health and burnout.
• Develop and study novel interventions to eliminate gender inequities in health care.
TABLE 1. Actions for mental health care providers to advance the goals of TIME’S UP HealthcareEnlarge table
We believe that mental health care providers should be leading the fight for change. We are trained to understand the emotional toll that stressors like harassment, discrimination, and abuse have on individuals from all backgrounds. We also know that these stressors often require clinically complex interventions, including targets at the individual, interpersonal, community, and policy levels. The combination of our clinical and research skills positions us to better help develop system-level solutions, as described below.
First, our expertise in mental health can help design a person-centered and trauma-informed approach to individuals and systems affected by discrimination and harassment. We can educate leaders to recognize and respond to the psychological burden of these experiences without retraumatizing victims. We can also highlight the importance of supporting those helping the victims, who are at risk for both primary and secondary trauma themselves.
Second, we understand how structural factors influence well-being (13). It is well recognized that institutional discrimination, caused by systemic practices, regulations, and policies (e.g., lack of paid maternity leave) (14), requires intervention above the level of an individual worker. Because our patients disproportionately face discrimination, mental health clinicians routinely navigate the complex interrelationship between systemic and individual challenges. We hope to use this knowledge to inform our work with Title IX offices in medical schools to develop pragmatic solutions to address underreporting and ensure that trauma-informed care is easily accessible.
Third, behavioral health scientists are uniquely prepared to study the impact of workplace gender inequity upon mental well-being and burnout. Research suggests that gender inequity and sexual harassment can contribute to the development or exacerbation of mental health disorders such as depression, substance use, and anxiety (15). Burnout, depression, and suicide are also highly prevalent in health-related professions (16) and affect patient care (17). Understanding the association between gender inequity and burnout—and their associated human and economic costs—can help galvanize organizations that are already committed to fighting burnout to enact change.
The launch of TIME’S UP Healthcare is a unique opportunity to raise awareness about the challenges that women face working in health care. However, awareness is not enough. It is time to develop systemic solutions to confront gender disparities in the health care workplace and the mental health sequelae that may result. We can all help foster equitable work environments, and some potential options described in Table 1.
TIME’S UP Healthcare believes that a safe, equitable, and dignified workforce will promote high-quality patient care. As mental health professionals, we must take a leadership role in addressing the corrosive impact of gender discrimination and harassment in health care. This is critical for the well-being of both our colleagues and our patients. The time for change is now.
1 : Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. Washington, DC, National Academies Press, 2018Google Scholar
2 : Prevalence of sexual harassment in academic medicine. JAMA Intern Med 2019; 179:108–111Crossref, Medline, Google Scholar
3 : Sexual harassment in medicine: #MeToo. N Engl J Med 2018; 378:209–211Crossref, Medline, Google Scholar
4 : Sexual harassment in nursing: a long-standing, but rarely studied problem. Am J Nurs 2018; 118:19–20Crossref, Medline, Google Scholar
5 : Sexual harassment of psychiatric trainees: experiences and attitudes. Postgrad Med J 1999; 75:410–413Crossref, Medline, Google Scholar
6 : Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey. JAMA Intern Med 2017; 177:1033–1036Crossref, Medline, Google Scholar
7 : From #MeToo to #TimesUp in health care: can a culture of accountability end inequity and harassment? Lancet 2019; 393:499–502Crossref, Medline, Google Scholar
8 : Gender differences in the salaries of physician researchers. JAMA 2012; 307:2410–2417Crossref, Medline, Google Scholar
9 : Sex differences in physician salary in US public medical schools. JAMA Intern Med 2016; 176:1294–1304Crossref, Medline, Google Scholar
10 : Salary differences between male and female registered nurses in the United States. JAMA 2015; 313:1265–1267Crossref, Medline, Google Scholar
11 : Time’s up for medicine? Only time will tell. N Engl J Med 2018; 379:1592–1593Crossref, Medline, Google Scholar
12 : Gender, race/ethnicity, and National Institutes of Health R01 research awards: is there evidence of a double bind for women of color? Acad Med 2016; 91:1098–1107Crossref, Medline, Google Scholar
13 : Alleviating the mental health burden of structural discrimination and hate crimes: the role of psychiatrists. Am J Psychiatry 2018; 175:929–933Link, Google Scholar
14 : Paid family and childbearing leave policies at top US medical schools. JAMA 2018; 319:611–614Crossref, Medline, Google Scholar
15 : Patterns of gender equality at workplaces and psychological distress. PLoS One 2013; 8:e53246Crossref, Medline, Google Scholar
16 : Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA 2016; 316:2214–2236Crossref, Medline, Google Scholar
17 : Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002; 136:358–367Crossref, Medline, Google Scholar