Erin Jackson, a health care compliance attorney with Jackson LLP Healthcare Attorneys in Chicago, works with physical therapists (PTs) who want to start new practices. Female PTs often confide to Jackson that one reason for leaving previous employers is that they experienced sexual harassment or gender discrimination from male colleagues or supervisors.

The sexual harassment about which the PTs most complain, Jackson says, tends to be sexual banter and unwanted physical contact. The discrimination involves being passed over for promotions and being excluded from practice decision-making, professional development, and other opportunities in favor of male colleagues. "They felt less valued as part of the skilled workforce compared with their male counterparts," Jackson says. "They realized they would not achieve the professional success they wanted."

Gender harassment—which includes sexual banter—is just one form of sexual harassment (itself a subset of "discriminatory behavior"). In fact, there are at least 3 categories of sexually harassing behavior. A recent report by the National Academy of Sciences (NAS)¹ identified them as:

• Gender harassment: Verbal and nonverbal behaviors that convey hostility, objectification, exclusion, or second-class status toward members of 1 gender. Researchers have identified 2 primary types of gender harassment: (1) sexist hostility and (2) crude harassment. According to the NAS report, gender harassment "is, by far, the most common type of sexual harassment."
• Unwanted sexual attention: Verbal or physical unwelcome sexual advances, which can include assault. Examples include unwanted touching, hugging, stroking, and persistent requests for dates or sexual behavior despite discouragement.
• Sexual coercion: Instances in which favorable professional or education treatment is conditioned on sexual activity.

Further, the NAS report describes, harassing behavior can be either direct (targeted at an individual) or ambient (a general level of sexual harassment in an environment). While the recipient of sexual harassment may be either male or female, most are female. The US Equal Employment Opportunity Commission (EEOC), for example, received 7,609 complaints of sexual harassment in fiscal year 2018. Of those, 15.9% were filed by males. Those numbers are similar to annual totals stretching back to well before 2010, when the EEOC received 7,944 charges, of which 16.2% were filed by men.²  

Sexual harassment and discrimination also are applicable in situations based on a person's gender identity or sexual orientation. According to the commission, "EEOC interprets and enforces Title VII's prohibition of sex discrimination as forbidding any employment discrimination based on gender identity or sexual orientation. These protections apply regardless of any contrary state or local laws."³ Employment discrimination, per the EEOC, includes hiring, firing, pay, job assignments, promotions, layoff, training, fringe benefits, and any other term or condition of employment.⁴  

Still, this aspect of sexual harassment is only part of the story when it comes to health care workers. Another significant element found in health care is inappropriate patient sexual behavior (IPSB), which may include leering, sexual remarks, deliberate touching, indecent exposure, and sexual assault. IPSB may be directed at clinicians, staff, or other patients. One recent study of PTs, physical therapist assistants (PTAs), and students found that the career prevalence of IPSB was 84%, and the 12-month prevalence was 47%.⁵  

Sexual Harassment of Employees or Students

The #MeToo movement has illuminated the longstanding and pervasive nature of sexual harassment of employees in many professions and industries. It has highlighted the problem of underreporting incidents involving unwanted verbal or physical conduct of a sexual nature for many reasons, including fear of retaliation from people in authority, a workplace culture of avoidance, and inadequate procedures, policies, and staff training.

The #MeToo movement also has focused attention on sexual harassment in the medical and health care professions—which includes the dimension of patient care.

Although there does not appear to be an extensive body of research on sexual harassment—outside of IPSB—in the profession of physical therapy, substantial research has been conducted on sexual harassment in medicine and in health care in general at the student, academician, and clinician levels.

For example, a survey conducted by the University of Texas System found that more than 40% of medical students said they had experienced sexual harassment from faculty or staff.⁶ The Pennsylvania State University System conducted a similar survey and found that 50% of medical students reported experiencing sexual harassment from faculty or staff.

The effect of sexual harassment on students include declines in motivation to attend class, greater truancy, dropping classes, paying less attention in class, receiving lower grades, changing majors, transferring to another educational institution, and dropping out.¹

The effect on employees includes declines in job satisfaction, withdrawal from their organization, declines in organizational commitment, increases in job stress, and declines in productivity or performance.¹

Research has shown that sexual harassment can lead to mental health problems for the victims and that employers may face decreased productivity, increased absenteeism, resignations, and lawsuits.

According to the NAS report, sexual harassment remains a persistent workplace problem. Across workplaces, the report says, 5 common characteristics emerge:

• Women experience sexual harassment more often than do men.
• Gender harassment (eg, behaviors that communicate that women do not belong or do not merit respect) is by far the most common type of sexual harassment.
• Men are more likely than women to commit sexual harassment.
• Coworkers and peers more often commit sexual harassment than do superiors.
• Sexually harassing behaviors are not typically isolated incidents. Rather, they are a series or pattern of sometimes escalating incidents and behaviors.

One aspect of sexual harassment may appear in consensual relationships. As the NAS report explains, "A sexual relationship welcomed by both parties by definition cannot be categorized as harassment to them. That is, to those in the relationship, the behavior does not meet the definitions of harassment as established by social science and law."

But it's not that simple. The NAS report elaborates, "There are circumstances in which the two parties' agreement to a relationship is not consensual, even while appearing to be consensual from the outside. In these situations, powerful individuals might lure subordinates, or even a succession of subordinates, into relationships that are not truly consensual because they are the result of pressure from one party that leads the other party to reluctantly consent to the relationship. Such relationships are exploitative and, in fact, constitute sexual harassment because they are unwanted and are the result of coercion."

Even when none of these conditions exists, the NAS report continues, sexual harassment still can occur: "Even if parties to a relationship feel in no way coerced, consensual relationships with formal power differentials can become sexually harassing when they create a hostile environment for others in the context (eg, within the campus department, or within the campus organization). That is, the law considers a consensual relationship as sexual harassment when it (1) results in favoritism based on sexual favors given and (2) becomes so widespread that women as a group are demeaned."

To help prevent sexual harassment, Jackson works with practices to create written policies and procedures. "Frequently, practice liability insurance doesn't cover this type of damage inflicted by gender discrimination or harassment. When practice owners learn they could be held legally responsible for an individual employee's sexual harassment, they become interested in ferreting it out. The cost of legal fees to establish policies around this conduct pales in comparison to the financial devastation of a lawsuit," Jackson says.

In addition, practice owners need to have "crystal-clear compliance and penalty procedures—including potential termination—that must be applied to all staff, regardless of gender, age, or rank. The best way to tamp down on sexual harassment," Jackson says, "is for everyone to understand that the practice is serious about implementing its written policies, and that violations might result in termination or reports to the appropriate ethical boards."

Jackson adds that some court cases suggest an employer's liability for an employee's harassing behavior might be limited if it can demonstrate its quick response to the employee's harassment complaints, legally sufficient policies, and clear termination procedures for violators.

She clarifies that a direct victim of sexual harassment is not the only employee who has legal claims. "Even if the harasser's primary victim refrains from filing a complaint or lawsuit, other ‘bystander' employees might have claims," Jackson notes. "For example, if a mid-level supervisor promotes a less-experienced employee to reward her for accepting his sexual advances, the employee who was passed over for promotion is now aggrieved, if she was not promoted because she refused an employer's advances.

"This sort of workplace culture can be the end of a practice, if they end up in court and are held responsible for large amount of damages," Jackson cautions.

Women and men have options besides leaving their jobs when they experience sexual harassment or discrimination. They can file a complaint with the EEOC or a similar state agency, and hire employment attorneys to pursue a sexual harassment or discrimination case.

Jackson encourages victims of harassment to jot down notes during or shortly after mistreatment occurs, including the names of witnesses. Keep those notes in pocket planners or phones, she suggests, and save related emails. But, she advises, "Remember that communications exchanged on workplace computers and email accounts are the practice's property, so they shouldn't be removed from the workplace unless your attorney tells you otherwise. If you're at this stage, it's advisable to consult with an attorney who can guide you through your state's specific procedures for addressing harassment."

Inappropriate Patient Sexual Behavior

Last year, Jennifer "Jenn" Davia, PT, DPT, had an encounter with a male patient. She describes him as in his late 60s, 6-foot-3, muscular, and with a large frame. "He was sitting down, waiting for the evaluation," she recounts. "When I walked toward him to introduce myself and shake his hand, he pulled me into his lap. I was startled and shocked. But because I was the only pelvic health specialist in my town and at this hospital, I felt obligated to evaluate him for stress incontinence," says Davia, a board-certified clinical specialist in women's health physical therapy and director of education of APTA's Section on Women's Health. She has concentrated on women's health and pelvic health since 2007. She worked as a PT in an outpatient hospital setting for 22 years before recently moving into private practice.

Davia began asking the patient questions about his condition and then about his sexual activity, at which point he said, "Oh, I get to talk to you about that—this is going to be fun."

Davia says, "The longer we talked, the more inappropriate his comments became. I felt he was leering at me and assessing me. I decided not to treat him, but I completed the evaluation."

As Davia recounted to her boss what happened, she burst into tears. "It was then I realized how threatened, vulnerable, and scared I had been. I talked with a social worker and cancelled the rest of my patients for the day."

Her boss discharged the patient and notified the hospital's attorney about what happened. Her boss also said that she could have stopped the evaluation when the patient tried to pull her onto his lap. Davia contacted the referring physician to explain what happened and their decision to terminate treatment. He apologized on behalf of his patient. "I felt very validated and supported by my boss," she says.

However, she realized that her institution only had policies and procedures for handling staff-related sexual harassment. "We had to follow our gut instincts in my case. We do need these IPSB policies in place, because boundaries can be hard to define."

Davia's encounter was perhaps predictable. PTs, PTAs, and PT and PTA students in clinical settings are likely to experience IPSB at least once in their careers, according to a study published in PTJ (Physical Therapy) in 2017.⁵ IPSB behaviors reported in the study ranged from sexual assault, indecent exposure, and deliberate touch, to sexual remarks and leering.

The study's respondents were predominantly women, aged 30 and older, possessing advanced degrees (master's or doctorate in physical therapy), treating patients with cognitive impairments, and treating equal numbers of men and women. The majority worked in outpatient settings.

This was the first study to assess prevalence of IPSB among US physical therapy professionals in 20 years. It also was the first to include PTAs and PTA students, as well as being the largest study of its kind. However, the career prevalence rates of PTs were similar to those found in previous studies.

"This shows that nothing has been done in the past 20 years to significantly mitigate the situation," says lead author Jill Boissonnault, PT, PhD. "There hasn't been a groundswell of interest in trying to figure out how best to address the issue, how to prepare students for this in the workplace, how to help therapists and PTAs who experienced it, and, overall, how to prevent it," she continues. Boissonnault is an associate professor within and associate director of the Division of Physical Therapy at Shenandoah University in Leesburg, Virginia.

The study solicited open-ended comments and analyzed the 187 comments it received. Eighteen respondents indicated that there were "employers who clearly don't know how to help employees when this happens, or refused to help them when IPSB happens," says Boissonnault. For example, one participant reported, "I was told that when patients were inappropriate with me, it was ‘part of the job.' I did not have support from management to address the situation or take further steps."

In addition, some of the students' comments indicated that their clinical instructors (CIs) were not trained to handle IPSB. "Although my CI was generally supportive, he said nothing when a patient's husband commented on my physical appearance. He also joined in when a patient started discussing my personal life and tried to give me dating advice," wrote one student.

The study found that IPSB was more likely to occur when female practitioners were treating male patients, were in training, and were routinely working with patients with cognitive impairments. The risk of IPSB for female PTs increased 400% when they worked with male patients, according to the study.

However, the study's primary findings came as a surprise to the researchers. According to the study, "It was hypothesized that physical therapist sex would be the strongest risk factor, based on data from the reliability pilot survey." Although women did report significantly higher rates of IPSB than did men, "Clinical inexperience is the most predictive factor determined by the risk models, explaining the most variability in risk of IPSB."

The second most predictive risk factor for IPSB is working with patients with cognitive impairments (PWCI)—defined as dementia, delirium, or acquired or traumatic brain injury. Forty-six percent of the 187 comments were related to patients with cognitive impairments, and this was the only significant risk factor found for severe IPSB. These findings suggest a need for clear workplace policies and procedures for managing IPSB in this population, according to the authors.

The third most predictive risk factor was the practitioner's sex. Females were found to be at greater risk for IPSB, which the study reports is consistent with previous studies. Only indecent exposure and stalking resulted in equal risk for men and women.

The final risk factor predictive of IPSB was the patient's sex. Treating male patients, regardless of the practitioner's sex, was associated with increased risk of IPSB.

"As a clinician with 22 years of experience working in a residential facility with people with brain injuries, I expect a certain amount of inappropriate patient behavior and comments in this population due to their impairment," says Mary Beth Osborne, PT, DPT, chair of the APTA Academy of Neurologic Physical Therapy's Brain Injury Special Interest Group and a senior physical therapist at Duke University Health System.

Osborne received training in the Mandt System^® from her institution. The program's goals are to prevent, deescalate, and, if necessary, intervene when the behavior of individuals poses a threat of harm to themselves and/or others. "The basic premise is that you build relationships with patients based on mutual trust and understanding, you identify the crisis cycle as behaviors escalate, and you know how to act based on what's happening with the patient," Osborne says.

This includes knowing what words to choose, what body language to model, and whether to continue or cut off interaction. "Although you can't prevent every negative reaction from a patient, most reactions can be managed," she says. "When you know the person and what the triggers are, you can employ techniques that calm that person down."

Osborne has found that certain strategies work well with this population, such as redirecting and changing her tone of voice and body language. For example, "If a male patient says I look nice today and starts to flirt, I will say, ‘Thank you. What time is your therapy appointment today and what are you working on?'"

Another paper by Boissonnault and coauthors looked at PT survey responses related to IPSB and treating sensitive body areas. The results, which are to be published in the Journal of Women's Health Physical Therapy, found that pelvic health PT practitioners had significantly more IPSB events than did general respondents treating sensitive body areas.

The pelvic health PT respondents mostly were experienced female practitioners, primarily treating women. They terminated and transferred care to others more often in the face of IPSB than did general respondents, according to the authors.

Davia described an incident of IPSB that occurred in a previous job. A female middle-aged patient began asking her increasingly personal sexual questions and proposing certain activities. "I was really shocked and said ‘No thank you. At this point, I can't help you, and I recommend that you see a psychologist or psychiatrist for your condition.'"

She reported this incident to her boss, who "shrugged it off as simply an unpleasant encounter, because I hadn't felt physically threatened by the patient."

Patients With Dementia

Cathy Ciolek, PT, DPT, FAPTA, worked in skilled nursing facilities for more than a decade. She now has her own consulting firm—Living Well with Dementia LLC. "Unfortunately, the side-effects of dementia can include a loss of inhibition, seen in such manifestations as exposing oneself, hypersexual behavior, and obsessive-compulsive sexual behavior," she notes. "These sexual behaviors are displayed in inappropriate ways because people with dementia lack the normal filters and no longer have normal outlets to express their sexuality."

Ciolek is a board-certified clinical specialist in geriatric physical therapy and is vice president of APTA's Academy of Geriatric Physical Therapy.

Historically, she says, the attitude of long-term care staff—including PTs—toward IPSB among people with dementia has been that this behavior goes with the territory. "Now, perhaps with the #MeToo Movement, there's greater awareness among PTs that IPSB is wrong," Ciolek says, "and that we need to draw the line as soon as this behavior is exhibited—using systems, policies, and procedures to prevent and mitigate it."

A good reporting system also is important, she adds, to document instances of IPSB so that staff can deploy consistent approaches—minimizing triggers and providing support.

Christine Lehmann is a freelance writer.