Policy Document Sexual Harassment Background Definition The Australian Bureau of Statistics defines sexual harassment as “experiences or behaviours that an individual is subjected to which made them feel uncomfortable and were offensive due to their sexual nature” (1). It can encompass both physical contact, and verbal harassment, which may be written, and may be received through telecommunications or social media (2). Certain behaviours may constitute harassment even in situations where the individual did not intend for them to be offensive, but were nonetheless perceived as inappropriate by the victim (2). These behaviours can be used to assert power over an individual and degrade and humiliate them (1). Sexual harassment occurs as part of a continuum of sexual violence and gender-based discrimination which have similar social and cultural underpinnings (3). Prevalence There is limited research about the prevalence of sexual harassment in Australian medical schools. The majority of studies that have been published in this field are cross-sectional and reported prevalence relies on a subjective interpretation of the term “sexual harassment”, often in the absence of clear definitions. Furthermore, few studies report solely on sexual harassment and many do not provide primary data. (4) Medical students are at risk of experiencing sexual harassment at all stages of their training, including in the pre-clinical academic setting. The Australian Human Rights Commission (AHRC) have reported that 51% of Australian university students were sexually harassed on at least one occasion in 2016 and have identified that young people, especially young women between the ages of 18 and 24, are at an increased risk of experiencing sexual harassment. Worryingly, 47% of students knew nothing or little about where to seek assistance and support. (5) Postgraduate students were identified as being almost twice as likely as undergraduate students to be sexually harassed by a lecturer or tutor at their university. (6) As medical students transition to the clinical setting, they are also at risk of experiencing sexual harassment in the workplace. The AHRC reports that 25% of women and 16% of men have experienced sexual harassment in the workplace in the past five years (7). A survey of 293 medical students from an Australian university conducted in 2000 reported that 37.9% had experienced some form of sexual harassment. (8) Female students were twice as likely as their male counterparts to have experienced sexual harassment and fellow students were the most common perpetrators. (8) Recent media reports suggest that there are many instances of unwitnessed sexual harassment in the Australian medical workplace and that this behaviour is part of a broader cultural issue. (9) The Royal Australasian College of Surgeons (RACS) (9) and the College of Intensive Care Medicine of Australia and New Zealand (CICM) (10) have recently reported the prevalence of sexual harassment amongst their members as 7% and 3% respectively. The RACS Expert Advisory Group on discrimination, bullying and sexual harassment acknowledged the propensity for incidents of sexual harassment to be underreported (9). Studies from countries such as Canada (11), the Netherlands (12), Japan (13) and the USA (8,14) that sexual harassment is experienced widely by medical students from across the globe. A systematic review (4) about harassment and discrimination in medical training found 35 studies that reported on sexual harassment. 33.1% of trainees and 33.3% of medical students had experienced sexual harassment. The perpetrators of sexual harassment identified by Fnais et al. are overwhelmingly, though not exclusively, male (4). Consultants are the most commonly cited source. While patients also may be perpetrators of sexual harassment, it appears that colleague-related harassment may have a more significant impact on victims, as these colleagues often hold positions of power. Given the lack of data, it may be appropriate to extrapolate the experience of medical students in the clinical workplace from the experiences of junior doctors. A recent study of PGY1 and PGY2 junior doctors in New South Wales and the Australian Capital Territory reported that 16-19% of junior doctors had been sexually harassed, including 29% of female participants. (15) Participants discussed the workplace normalisation of these behaviours, fear of reprisal and lack of knowledge of confidence in the reporting process. The authors suggest that interventions targeted at the level of junior doctors to improve the culture are unlikely to be helpful due to the systemic nature of the problem. Further research is required to develop a clearer understanding of the nature and scope of the problem, the adverse effects and the potential targets for change. In particular, further research should examine the specific impact of sexual harassment on medical students in order to inform the development of effective prevention and management strategies. Contributing factors and risk factors An ecological framework is useful to explore why some people are at a higher risk of sexual harassment than others. Medical students bring their own personal history and behaviours into their day-to-day interactions at university and in the clinical setting. In studies of sexual harassment, several factors are found to increase the vulnerability of an individual, including gender and sexual orientation. (4,16) Women are more likely to experience sexual harassment than males in the medical workplace (17) and the literature suggests that an entrenched culture of sexism pervades medicine (15). In the systematic review by Fnais et al., 12 studies reported a statistically significant higher prevalence of sexual harassment amongst female trainees. (4) Often these women stay silent for fear of being viewed as overly sensitive or “complainer[s]” (18) and are at risk of experiencing post-traumatic stress disorder, anxiety and depression as a result (19). LGBTIQ students represent a marginalized group in medical school and LGBTIQ physicians have reported verbal harassment, derogatory statements, inferior treatment, and refusal of privileges based on their sexual orientation (16). LGBTIQ students not only feared disclosing the harassment they may have experienced, but also reported feeling uncomfortable regarding their sexual orientation (16). Additionally, non-white racial groups are at greater risk of sexual harassment in predominantly Caucasian countries. (20) Discrimination towards Indigenous medical students is prevalent, showing in various forms such as “blatant racism”, negative expectations from non-Indigenous peers and faculty members, as well as derogatory comments. (21) Such forms of harassment have prevented these Indigenous medical students from seeking out support or even reporting harassment (21). Understanding these broader patterns of discrimination, power and privilege provide a context for the occurrence of sexual harassment at university and in the clinical environment. The competitive medical environment contains established hierarchies, power imbalances and gender stereotypes that have enabled the institutionalisation of bullying and harassment (22). Medical students readily accept this culture in order to begin their professional careers. (23) It is important to acknowledge the powerful influence of supervisors on learning outcomes for medical students under the existing system of “patronage”; (23) Medical students, whose professional advancement may be threatened by reporting unwanted sexual advances, especially by consultants (22,24), often let unprofessional actions go unreported in order to retain access to educational and professional opportunities (15). This notion is further supported by evidence from an Australian study (25) which highlighted that whistleblowers of inappropriate actions are identified, vilified, and often denied further professional advancement. Furthermore, logistical barriers, such as receiving limited support from the Director of Medical Services and other senior staff made reporting difficult (26). Thus, the framework that underpins medical culture enables sexual harassment to occur at a wide scale, and are unfortunately underreported. Consequences Victims of sexual harassment report losing autonomy and control, along with feeling guilty, humiliated and alienated (27). This has broader implications on an individual’s psychological state of mind resulting in reported higher rates of depression, anxiety and alcohol abuse (28,29). This highlights that for many individuals, the impact of the harassment lasted longer than the incident itself and that it shaped their future behaviours. (30) Following an incident of sexual harassment, most students said they avoided the perpetrator or department where the incident occurred, and one-sixth considered leaving medical school altogether (30). By feeling the need to avoid certain locations, students potentially miss out on educational opportunities, including clinical experiences, which can significantly impact their learning (8). To minimise the impact of sexual harassment, students reported that they would like training in how to respond to unwanted sexual behaviours and maintaining professional boundaries, along with clearer guidelines and information on who and where to report issues should they arise (8). Students who experienced gender and sexual based discrimination and harassment during their training noted that these experiences influenced not only their