Medical students experience of different forms of discrimination at one Swedish medical school

doi:10.21203/rs.3.rs-1595914/v1

Introduction

The aim was to study discrimination in medical students at Uppsala University in Sweden.

Methods

All registered medical students in the spring semester of 2020 were sent a survey by e-mail. Data were compared with two previous studies. Questions about gender and sexual harassment were the same as in the study conducted in 2002 and 2013. In addition, the survey 2020 included a question about other grounds of discrimination.

Results

Forty percent, 453 of 1130 medical students, participated. The proportion of students reporting gender-based discrimination at the preclinical semesters was similar in women and men. During clinical semesters, significantly more women than men reported gender discrimination (41% vs 21.5%, p = 0.005) and sexual harassment (22% vs 5%, p = 0.001). Physicians were the most commonly reported perpetrator. Reports about not being respected had increased from 2.2–20.0% between 2013 and 2020 among female clinical students. The prevalence of experiencing several sexual harassing behaviors increased in female and male clinical students and female preclinical students. Receiving an unwelcomed touch increased from 1.3–6.8% in female clinical students. Discrimination due to ethnicity was reported by 36% of students with non-Swedish ethnicity compared to 3% of those with Swedish ethnicity.

Conclusion

Our findings confirm that experiences of different forms of discrimination exist in this medical school, and females and minorities are particularly affected.

Experiences of discrimination in medical students have been documented for three decades and remain common despite systematic work on equal rights and opportunities in academic education around the world [1, 2]. Most studies on discrimination at medical schools’ report gender mistreatment ranging from abusive behaviors, gender harassment to sexual harassment [3, 4]. In a recent meta-analysis (2011), 59.4% of 38 353 medical students, mainly female, had experienced gender discrimination at least once during their training [5]. Moreover, medical students may also be mistreated due to their ethnicity/race and sexual orientation [6]. Fear of negative impact on grades and career opportunities may discourage peers from reporting discrimination.

In two previous studies, 2002 and 2013, we investigated gender discrimination of medical students at Uppsala University in Sweden. We found that gender discrimination was experienced particularly during clinical clerkship training, and prevalence had decreased in men but increased in women. However, in the same studies, a decrease was seen in the prevalence of sexual harassment [7]. A study from another group found that medical students belonging to racial/ethnical minorities were more likely to encounter discriminatory treatment from supervisors, peers and patients [8].

Since our last follow-up study (2013) on gender-based mistreatment, a global movement against gender discrimination has occurred. In 2017 the #MeToo movement raised the importance of awareness of gender discrimination in the general society in many countries [9, 10]. Furthermore, a recent qualitative Swedish study on medical students and a report from the Swedish Association of Medical Students also highlighted an urgent need for increased awareness of other forms of mistreatment, especially related to ethnicity and race [8, 11].

Although there are several reports on mistreatment, few studies have monitored gender discrimination or other grounds of discrimination over time in medical schools. Aiming to reduce these gaps, in 2020, we repeated the survey of mistreatment due to gender of medical students performed at Uppsala University in 2002 and 2013. In addition, the recent study included questions on other grounds of discrimination, including age, ethnicity, religion, functional disability, sexual orientation and sexual identity.

The study design

A prospective observational study was designed at the Medical School of Uppsala University. All registered medical students at the university medical program in the spring semester of 2020 were invited to participate in a survey. There were no exclusion criteria. In May 2020, all students received an e-mail linked to the anonymous survey system, the Research Electronic Data Capture (REDCap) [12]. The students received three monthly reminders until the survey closed in August. The survey was a follow-up of previously conducted questionnaires on experiences of gender discrimination in 2002 and 2013 [7].

All participants were requested to fill in an online written informed consent before initiating the survey. No individuals' identifiers were recorded to ensure students' anonymity. The study was approved by the Ethical Review Board in Uppsala No. 2020/00311. The study was carried out in accordance to the Declaration of Helsinki.

Study population

The survey was sent to university e-mail accounts of 1130 registered medical students. As in the study 2002 and 2013, those who consented to participate in the survey were stratified into gender and preclinical and clinical semesters. The Swedish medical school comprises 330 high education credits (five and a half years of study) that leads to a medical degree. The education is divided into preclinical semesters (one to four) where peers have only limited contact with the clinical environment. In the clinical semesters (five to nine and eleven), the students participate in several clinical internship periods per semester in general hospitals and primary care centers. The 10th semester is devoted to a scientific project.

The survey

The same survey questions on specific examples of behaviors representing gender discrimination and sexual harassment were used as in the survey conducted in 2002 and 2013 [7]. The questions used a behavioristic approach to assess the personal experience of gender discrimination [13]. In accordance with the Swedish Discrimination ombudsman, gender discrimination includes gender harassment (an act that violates someone's gender dignity) and sexual harassment (an act of a sexual nature that range from the subtle offence of someone by words, comments through unwanted sexual attention or touch to sexual assault) [14]. Additionally, the survey 2020 included questions on other grounds of discrimination, transgender identity, ethnicity, religion, disability and sexual orientation. Age groups, gender, country of birth, semester of studies and sexual orientation were also collected as demographic characteristics. All survey questions used are presented in the Appendix, supplementary materials.

Statistics

The students were divided into study stage (preclinical and clinical) and sex (female and male). In those groups, categorical variables were reported as frequencies with proportions and continuous variables were reported as means with standard deviation. The difference between men and women at the preclinical and clinical semester and between underrepresented minorities and no minorities were assessed by Chi-2-test. Furthermore, we calculated the proportion of students who reported experiences of different discriminating behaviors and their frequency. In this analysis, as in the previous studies, 2002 and 2013 students from the 10th semester were excluded. The differences between 2002–2013, 2013–2020 and 2002–2020 were assessed by a ratio and 95% confidence intervals (95% CI). Mean slider scale scores were calculated to summarise the frequency of these behaviors; never (0), one (1) or several times (2). Moreover, the proportion of students reporting different perpetrators were shown. A p-value less than 0.05 was considered significant. R version 4.0.2 was used to perform all statistical analyses.

Basic characteristic

There were 453 students who completed the survey (response rate 40.1%) (Supplementary Table 1). Respondent's characteristics are shown in Table 1. We divided the student based on their legal gender. No students reported transgender identity. The ratio between female and male students was slightly skewed in the statistical sample (66%female/34% male in the study and 60% female /40% male among registered students). The majority of responding students were between 20–25 years old. There were no significant differences between females and males in the distribution of age groups, sexual orientation, ethnicity or function disability. However, significantly more females than males in the clinical semesters were born outside Sweden. The type of Function disability was reported by 25 students in the free text including: dyslexia (n = 8), attention deficit disorder/attention deficit hyperactivity disorder (n = 7), hearing problems (n = 3), social phobia (n = 1), bipolar disease (n = 1) and neuromuscular disease (n = 2). Some students shared their religious belief as Christian (n = 39), Islam (n = 15), Hinduism (n = 1) or other not specified (n = 17).

Table 1

The basic characteristic of the study population stratified into preclinical and clinical students and women and men. The differences between males and females were assessed by Chi-squared test. A P-value < 0.05 was considered significant.
	Preclinical		p-value	Clinical		p-value
	Female (n = 106)	Male (n = 53)	< 0.001	Female (n = 192)	Male (n = 102)	< 0.001
Age groups (years) < 20 20–25 26–30 > 30	6% 83% 4% 7%	9.5% 70% 9.5% 11%	0.107	0 66% 27% 7%	0 64% 28% 8%	0.782
Ethnicity Swedish Swedish and other Other than Swedish Do not want to answer	61% 24% 6% 9%	60% 15% 11% 14%	0.140	65% 17% 10% 8%	67% 10% 4% 19%	0.074
Born in Sweden Nordics Europe Outside Europe Do not want to answer	74% 3% 4% 9% 10%	72% 6% 6% 8% 8%	0.335	71% 14% 4% 2% 9%	77% 5% 1% 1% 16%	0.049
Function disability	7.5%	9%	0.92	4%	4%	1.00
Sexual orientation Hetero Homo Bi-sexual Did not answered	69% 3% 12% 6%	72% 4% 7.5% 6.5%	0.837	73% 3% 12% 12%	71% 4% 4% 12%	0.278

Discrimination due to gender

The proportion of students who reported experience of gender discrimination, gender harassment and sexual harassment was significantly higher in females than in males in the clinical semesters (Fig. 1). In the preclinical semesters, 15% of females and 19% of males reported that they had observed other students being discriminated. The corresponding prevalence from students in the clinical semesters were 30.5% of women and 22.5% of men. In addition, similar proportions of females and males reported hearing about other students being mistreated (46% and 41.5%, respectively). Significantly more women (75.5%) than men (59%) had heard of gender discrimination of other students (p = 0.021). Being favoured due to gender was reported by 4% of females and 6% of males in the preclinical and 21% females and 33% males at the clinical semesters (p = 0.011). Observing other students being favored due to gender was reported by 22% of women and 15% of men from the preclinical and 43% of women and 21% of men in the clinical stage (p = 0.002).

Perpetrators of sexual harassments

The most frequently indicated perpetrators of sexual harassment during the preclinical semester were nurses and/or other medical personnel, and the most common scene where the harassment occurred was at lectures. The clinical students reported physicians being the most common perpetrators (Table 2).

Table 2

The proportion of students reporting different perpetrators and the moment where the sexual harassments occurred in the medical school. The ration present differences between gender.
		Other students	Supervisor/ teacher	Medical doctor	Nurse and other healthcare personal	Patients
Pre-clinical	Female	6%	6%	8.5%	11%	9%
	Male	2%	2%	4%	9%	6%
	P-value	0.31	0.31	0.29	0.74	0.44
Clinical	Female	8%	10%	50%	12%	11.5%
	Male	1%	1%	19%	0	5%
	P-value	0.01	< 0.01	< 0.01	-	0.03

Gender discrimination and sexual harassment over time

Experience of gender harassing behaviors such as "experiencing stereotypic statements", 'being ignored", 'being not respected" had increased over time in preclinical and clinical female and preclinical males (Fig. 2 and Suppl table 2). The prevalence of experiencing being ignored and being not respected has increased from 1.3–26.7% and from 2.2–20.0%, respectively, between 2013 and 2020 among the female clinical students.

The prevalence of sexual harassing behaviors including "unpleasant comments on private life as well as clothes and appearance" and "receiving unwelcomed touch" had increased in female and male clinical students and in female preclinical students, whereas the prevalence of these behaviors had decreased over time in preclinical males. The prevalence of "receiving unwelcomed touch" had increased from 1.3–6.8% between 2013 and 2020 in female clinical students. Receiving requests for a sexual relationship at least twice has increased from 0 to 2.9% in male clinical students between 2013 and 2013. "Receiving sexually offensive jokes and comments" decreased in all the students over time.

Discrimination due to other grounds

Discrimination due to age, religion, function disability and sexual orientation was reported almost exclusively by minorities, whereas observation of those behaviors was reported by those not belonging to those minorities, Table 3. Being discriminated due to age, religion, function, disability or sexual orientation was similarly reported in women and men at the clinical and preclinical semesters, Table 3. The question on Swedish or non-Swedish origin was used when considering ethnicity in our study. Of the peers who reported non-Swedish ethnicity, 36% reported discrimination due to ethnicity. In the survey, 48% of those with functional disabilities reported mistreatment due to functional disability. In addition, we found that discrimination due to sexual orientation was significantly more often reported by homo- and bisexual than heterosexual students (Table 3).

Table 3: The proportion of students who reported discrimination due to other than gender grounds of discrimination. The table is stratified by gender and preclinical or clinical semester of studies. the difference between females and males was presented by Ch2.

URM =Underrepresented minority defined as age >30; homo- or bisexual; identified with religion; ethnicity Swedish and other and other than Swedish or having a function disability.

Preclinical

P-value

Clinical

P-value

URM

Not URM

P-value

Female (n=106)

Male

(n=53)

Female

(n=192)

Male

(n=102)

Experienced discrimination due to age

10%

7.5%

0.79

13.5%

11%

0.83

22%

12%

0.03

Observed discriminated due to age

14%

23%

0.24

21%

19%

1.0

34%

20%

0.42

Experienced discrimination due to sexual orientation

5%

3%

0.39

4%

3%

0.85

8%

2%

<0.01

Observed discrimination due to sexual orientation

6%

>0.99

7%

3%

0.34

8%

0.70

Experienced discrimination due to religion

7%

2%

0.37

6%

8%

0.64

22%

4%

<0.01

Observed discrimination due to religion

13%

7.5%

0.43

19%

10%

0.12

40%

11%

0.03

Experienced discrimination due to ethnicity

11%

>0.99

12.5%

8%

0.43

36%

3%

<0.01

Observed discrimination due to ethnicity

30%

13%

0.04

43

25.5

0.02

49%

32%

0.51

Experienced discrimination due to function disability

5%

2%

0.66

4%

3%

0.95

48%

1%

<0.01

Observed discrimination due to function disability

9%

4%

0.34

12%

4%

0.06

44%

8%

<0.01

Observed discrimination due sexual identity

7%

7.5%

>0.99

8%

4%

0.40

---

7%

----

The main result of this study was that at the clinical semesters, significantly more women than men experienced discrimination due to gender. The proportion of students reporting gender discrimination at preclinical semesters was lower, with no significant difference between women and men. Physicians were the most commonly reported perpetrators of sexual harassment and clinical training moments were the most common place where these behaviors were experienced. Our study also reported an increased prevalence of different gender discrimination and gender harassing behaviors over time in females and males during their preclinical semesters. Alarmingly, sexual harassment such as being "pointed out as of sexual interest" or "received intrusive touch" or "receive a request for sexual relationship" have increased in all clinical students over time. In addition, a substantial part of the medical students from minorities reported mistreatment due to "other grounds of discrimination". Discrimination of ethnic minorities and those with disabilities were particularly high.

Our findings that female medical students reported gender-based discrimination [6, 15], including sexual harassment [3, 16], more often than males corroborate with several international studies conducted before and after the #Metoo movement. Direct comparison of the proportion of affected medical students is, however, difficult because of the diversity in study design. In one study from the USA based on 27 504 surveys of graduating medical students, a significantly higher percentage of females than males reported discrimination due to gender [5]. A German study based on an online survey reported that 59% of medical students experienced sexual harassment [18], and in a French study, it was shown that 22.5% of female compared to 9.8% of male medical students reported to have been victims of gender discrimination and sexism. In this report, a comparable percent of women and men reported having witnessed discrimination due to gender [19]. Similarly, in our study, we found no significant differences in the proportion of females and males who reported having observed other students being discriminated. Interestingly, significantly more women than men in the clinical semesters reported that they heard about other students being discriminated. One explanation could be that women discuss gender issues with other female colleagues more often than men. Surprisingly, we found that more male students experienced being favoured compared to females, and this difference was significant during the clinical semesters. A higher proportion of female students than men observed other students being favoured.

Consistent with previous studies [16], we saw that significantly more female than male students experienced discrimination during clinical clerkships compared [17, 18] to other parts of training. The students in the clinical settings pointed out that physicians were the most common perpetrators. Similar results were shown in our previous studies conducted in 2002 and 2013 [7] and in reports in several other countries [19, 20]. The reason why physicians might be perceived to behave inappropriately while supervising students has been explained by complex organizational psychology as "see one, do one, teach one" [21]. As many medical doctors have experienced discrimination themselves, similar expressions might form their collegial expression and hidden curriculum [22]. This might lead to cynicism and also use of inappropriate teaching methods while supervising students. The reason why women are more affected by gender discrimination during their clerkship has been broadly addressed and claimed to be a combination of hierarchical and dependent relationships between students and supervisors in an, often male dominated and stressful environment [23].

Since the 1970s, there has been a continuous work in Sweden to provide equal rights and opportunities in the labor market and education system [24]. This has resulted in a universal act called the Discrimination Act (SFS 2008:567) set into legal effect in 2009 [24]. This act forbids unlawful mistreatment on the basis of all grounds of discrimination. Since 2015 Uppsala University has followed an action plan based on the Discrimination Act and the Action Plan of Equal Opportunity (UFV 2015/766) [25]. One of the aims was to monitor equal opportunities by the newly formed research groups [26] and another to recruit and appoint 48 percent female professors [25]. In the medical program, these aims are communicated and reflected through a mandatory course on gender medicine for all students during their final semester of medical studies. The course goals are to educate students on gender and other ground of mistreatments in the context of their forthcoming profession.

We found that experience of several forms of gender discrimination and harassment of women during their clinical semesters increased over time. In addition, sexual mistreatment have increased in clinical students. The explanation to why the reported prevalence of gender discrimination has increased between 2013 to 2020 might be due to higher awareness as a result of interventions from the university and the #Metoo movement. An increased reporting of these experiences after #Metoo was also found in the survey on working environment conducted in Sweden among randomly selected women employed in academic settings. In accordance with this report, there were 400% more reported cases of sexual harassment in a year after #Metoo (2018) compared to the year before (2017) [27].

There have been few longitudinal studies on mistreatment among medical students. Fried et al. examined discriminations among American medical students after third-year clerkships over 13 years between 1996 and 2008. This study used comparable definitions of sexual harassment as we did in our studies. They showed that these experiences remained on the same level throughout the study period and that females were significantly more affected compared to men [18].

More than one-third of the students with other than Swedish ethnicity reported experiencing discrimination. A recent national report of the Swedish Medical Association indicated that 5% of graduated students reported being mistreated due to ethnicity. However, that report did not report if those students belonged ethnic/race minority [28]. In our study, discrimination due to ethnicity was equally reported in females and males. Inversely a recent study from the USA found that discrimination due to race/ethnicity was significantly more commonly experienced among women than men [6]. Interestingly, another study highlighted that ethnic mistreatment, the forms of discrimination that medical students were least likely formally report [18].

Moreover, there was a small number of students (n = 25) who reported functional disability such as dyslexia. Half of them reported being discriminated against due to their disability. Only a few previous studies have addressed learning disabilities in medical students. Students with functional disabilities usually receive lower grades which may lead to lower self-esteem, stress and anxiety [29]. The previous studies have shown that most teachers in health care were not aware of the student's learning disabilities and did not know how to support these students, whose needs might not be understood, ignored or even unwelcomed [29].

Discrimination due to other grounds of discrimination was also assessed in our study. For example, we showed that discrimination due to sexual orientation was significantly more experienced by LGBT + students than heterosexual students (8% vs 2%, p < 0.001). In the study from the US, there was a much higher proportion of the students who reported mistreatment due to sexual orientation (43% in LGBT + and 23.6% in heterosexual, p < 0.001). Females reported significantly higher exposure to these behaviors than their male counterparts [6]. In our study, we also evaluated discrimination due to age and religion, which has not been previously addressed in studies on medical students.

Strength and limitations

The primary strength was that we evaluated discriminations due to gender including gender and sexual harassment, which was directly compared to data from 2002 and 2013 covering altogether a period of 18 years. We also addressed the frequency of discriminating behaviors and who was the main perpetrator. In addition, we assessed several other grounds of mistreatment.

The limitation of the study, in addition to the known constraints with a cross-sectional design, was the low response frequency that poses the same methodological challenges faced in several similar studies [3, 4, 16]. A potential selection bias is a concern and therefore, the generalizability of our results should be considered with caution. However, the study coincided with the start of the Covid-19 pandemic, and we were not able to distribute the survey during lectures as we did in the previous studies 2002 and 2013, where the response frequency was higher.

Importance and implication

Since discrimination seems to be common in medical school, those responsible for medical education must be aware of it. Discrimination has negative consequences on the students' academic motivation and can lead to poor self-esteem and also affect the physical, mental health negatively [30]. Encountering discrimination can lead to lower job satisfaction and productivity and a decline of empathy towards patients [31]. This, in turn, may lead to the inability to care for patients, avoidance of certain specialities or those in particular affected as females might quit their job which might lead to reduced workforce diversity in health care [32].

The substantial burden of mistreatment among medical students, in particular females and minorities, should motivate those responsible for academic education to evaluate the existing strategies. The mandatory course regarding gender medicine that medical students attend on their last semester should perhaps be moved to the beginning of the clinical part of medical students' training. This would improve students understanding of which behaviors are discrimination and how to recognize, prevent and respond to them before they enter their clinical clerkships.

A future direction might be to perfrom further follow-up studies among medical students at Uppsala University. We might also determine in which speciality students perceive the highest risk of mistreatment. In addition, a third part could be to invite health professionals to answer questions about their attitudes towards students and their experiences of discrimination. This might trigger reflection and understanding of inappropriate behaviors.

This might be the first study in the literature that has monitored gender discrimination over 18 years in the same medical school and additionally evaluated other grounds of discrimination. Our findings show that gender discrimination is common, especially among female students. A substantial proportion of students from underrepresented minorities, in particular ethnicity, also suffered mistreatment at the medical school. Improving awareness of discrimination and its eradication remains a challenge for the medical program.

Acknowledgements

We acknowledge the Uppsala University fond for equality 2020, UFV 2019/2180 that support this study.

Competing interest

The authors declare no conflict of interest.

Ethical approval and consent to participate

All participants were requested to fill in an online written informed consent before initiating the survey. No individuals' identifiers were recorded to ensure students' anonymity. The study was approved by the Ethical Review Board in Uppsala No. 2020/00311. The study was carried out in accordance to the Declaration of Helsinki.

Funding

MK received funding from the Uppsala University Equality Funds 2020 to perform this study.

Authors contribution

MK designed the study, sent the survey to participants, collected and analyzed data, write the manuscript. A R-A we co-designer of the study, write the manuscript. SK co-designed the study, sent the survey to participantsand write the manuscript. XZ analyzed data. MW designed the study and co-write the manuscript. SJ write the manuscript. CJ designed the study, analyzed data and write the manuscript.

Availability data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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No competing interests reported.

Supplementarymaterials.docx

Medical students experience of different forms of discrimination at one Swedish medical school

Status:

Version 1

Abstract

Introduction

Methods

Results

Conclusion

Figures

Introduction

Materials And Methods

The study design

Study population

The survey

Statistics

Results

Basic characteristic

Discrimination due to gender

Perpetrators of sexual harassments

Gender discrimination and sexual harassment over time

Discrimination due to other grounds

Discussion

Strength and limitations

Importance and implication

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1