JRLDEC2006 Inside SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 4 9 SEXUAL HARASSMENT OF THE PHYSIOTHERAPIST IN SOUTH AFRICA S C H O L A R LY A R T I C L E ABSTRACT: No study has been conducted on sexual harassment of physio- therapists in South Africa and it is therefore not known whether harassment occurs and if it does, to what extent. To this purpose, a questionnaire on sexual harassment and other sexual-related issues in the physiotherapy work environment in South Africa, was sent to a random selection of 982 physio- therapists registered with the Health Professions Council of South Africa. The response rate was 32%. This paper presents the results of the first half of the questionnaire, which was devoted to sexual harassment of the physio- therapist. Approximately 60% had experienced sexual harassment, of which 83.98% had been perpetrated by patients. Only 5.82% of the respondents had received some form of information in this regard. The most common form of harassment was requests for a hug or kiss. KEY WORDS: SEXUAL HARASSMENT, INAPPROPRIATE SEXUAL BEHAVIOUR, SEXUAL MISCONDUCT, SEXUAL MISBEHAVIOUR, PHYSIOTHERAPIST, PHYSICAL THERAPIST Bütow-Dûtoit L [PhD]1 Eksteen CA [PhD]1 De Waal M [D Litt et Phil]2 Owen JH [BSc (Hons)]3 1 Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria. 2 Former Director, Centre for Gender Studies, Department of Sociology, University of Pretoria. 3 Senior Research Consultant, Department of Statistics, University of Pretoria. INTRODUCTION Sexual harassment of physiotherapists is not openly discussed and it is therefore difficult to know the extent to which it occurs and how to eliminate it. According to the Labour Relations Act (1995), the Employment Equity Act (1998) and the Promotion of Equality and Prevention of Discrimination Act (‘Equality Act’) (2000) sexual harass- ment is considered as a form of discri- mination since it is based on gender discrimination. Both the South African Constitution (The Constitution 1996) and the ‘Equality Act’ (2000) prohibit discrimination, amongst others, on the grounds of gender. Sexual harassment may be recog- nized by the forms of behaviours associ- ated with it: verbal harassment, such as innuendos, sexist and sexual remarks or jokes, unwelcome graphic comments on the person’s body or person, inappropri- ate enquiries about a person’s sex-life; physical harassment, such as unwanted physical contact (including inappro- priate touching, sexual assault and rape); non-verbal and non-physical harassment, such as leers, wolf-whistles, unwelcome gestures, indecent exposure (Grieco 1987, Ovid Scope Note 1993). It is obvious that written remarks, offensive drawings or pictures and sexual videos shown in the workplace, would all be considered as behaviour which is detri- mental to the work environment. In South Africa, the Guidelines and Codes of Practice (1998) also includes the exploitation of sexually explicit objects, although these are not further described. The perception of sexual harassment involves interpersonal behaviour and subjective appraisal of these events (deMayo 1997). What one person may perceive as harassment, another might find only mildly irritating, or not at all offensive. Healthcare professionals, including physiotherapists, may be vulnerable to sexual harassment by both patients and co-workers in their work environment. Sexual harassment of physiothera- pists has been studied internationally (McComas et al 1993, deMayo 1997, Weerakoon and O’Sullivan 1998), but not in South Africa. The aim of this article is to discuss the prevalence of sexual harassment of physiotherapists in South Africa. RESEARCH METHODOLOGY A descriptive survey by means of a questionnaire was conducted to deter- mine the prevalence of sexual harassment of the physiotherapist in the physiothe- rapy work environment in South Africa. The questionnaire was compiled and tested during a pilot study in which six physiotherapists anonymously partici- pated. They reported no discomfort with any of the questions and the ques- tions that were unclear were adjusted accordingly. Since there were 4,133 physiotherapists registered with the Health Professions Council of South Africa (HPCSA) at the time of the study, the realised sample size would have had to be approximately 300 physiothe- rapists for the statistical test to have sufficient power. Survey questionnaires conducted by mail may have a response rate of only 30%, and it was therefore decided that about 1,000 questionnaires should be posted. The final sample consisted of a random selection of 1,007 physiotherapists. Twenty-one of the pos- sible respondents had mailing addresses CORRESPONDENCE TO: L Bütow-Dûtoit P O Box 345 Wapadrand 0050 Tel: (012) 807-0814 Fax: (012) 807-3064 This article is based on research which was approved by the Research Ethics Committee (Protocol number 141 / 2002), Faculty of Health Sciences, University of Pretoria 10 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 4 for overseas countries, and a further four had been chosen to participate in another section of the broader research study. Their names were therefore removed from the list. Thereafter the question- naire was sent to 982 physiotherapists. A self-addressed envelope, as well as an explanatory letter, was included and a second follow-up letter was sent as a reminder two weeks later. Respondents’ identities could not be traced from the questionnaires. Because of the sensitivity of the subject, respon- dents were also not under the obligation to answer all the questions. Sixty-one questionnaires could not be accounted for for various reasons, such as incorrect addresses and physiotherapists working abroad. The possible recoverable num- ber was 921. The response rate on the survey questionnaire was 32% (n = 295). Only the principal researcher had access to the answered questionnaires. By responding, it was accepted that the participants had given their free consent to participate in the study. A descriptive statistical analysis, based on frequency, was done on the collected data. RESULTS Biographical data of respondents The respondents’ ages ranged from 22 to 75 years (n = 290) (mean = 38.08, SD = 11.89). The cultural distribution was White 84%, Black 8%, Indian 5% and Coloured 2% (n = 295). In addition, there was one respondent who indi- cated an ‘other’ cultural group. Female respondents represented 93.56% of the gender distribution, and the male respondents, 6.44%. The respondents’ work experience ranged from 1 to 47 years (mean = 14.02, SD = 10.76). Results Ninety percent (90%) of the respondents agreed that training in the handling of sexual harassment in the work place was necessary, but only 5.82% had received some form of education in managing sexual harassment, mostly in the form of advice during their ethical and professional education during their undergraduate years. Ten of the 11 for- eign-trained physiotherapists had also not received any training in this regard. The respondents were not directly asked whether they had ever been sexually harassed, but if relevant, were requested to indicate who the perpetra- tor had been, and the specific behaviour associated with, their worst incident of sexual harassment. The majority, namely 61.35% (n = 295), indicated who the perpetrator had been. Patients were the main perpetrators (Table 1).The most common form of sexual harassment had been requests for a hug or a kiss (15.74%) (n = 108) (Table 2). They were also asked to supply the actual dates (years only) that the incidents had occurred. Dates were supplied for 141 incidents and the mean age of the respondents at the time that they were harassed, was calculated to have been 28.2 years (SD = 8.28). Fifty-seven per- cent of these incidents occurred within the first five treatment sessions. Only 7% (n = 149) of these patient-perpetrators had been under the influence of medi- cation, psychiatric disease or other con- ditions which might have influenced their behaviour. Perpetrator Frequency Percent Patient 152 83.98 % Other health care professional 23 12.71 % Physiotherapy lecturer 2 1.10 % Other lecturer 0 0 Student or physiotherapy colleague 4 2.21 % Total number of incidents = 181 Table 1: Perpetrator category of ‘worst incidents’ of sexual harassment expe- rienced by respondents. Type of sexual harassment Frequency Percent Requests for physical contact (hug/kiss) 17 15.74 % ‘Accidental’ touching 14 12.96 % Innuendo / sexual comments 13 12.04 % Suggestive gestures 12 11.11 % Requests for a ‘date’ 10 9.26 % Requests for intimate relationships 10 9.26 % Severe harassment: Deliberate sexual exposure 9 8.33% Gross sexual comments 5 4.63 % Severe harassment: Forceful sexual touching 5 4.63% Suggestive stares/whistles 4 3.70 % Stalking 4 3.70 % Unwanted contact made after-hours 2 1.85 % Severe harassment: Sexual assault - rape / attempted rape 2 1.85% Suggestive gifts 1 0.93 % Promises of a reward for sexual contact 0 0 Descriptions supplied for 108 incidents (Total number of incidents = 181) Table 2: Respondents’ descriptions of worst incidents of sexual harassment directed towards them. SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 4 11 In the nine worst incidents experi- enced by the 19 male respondents, the most common form of sexual harass- ment was requests for an intimate relationship by a patient [in three of the nine incidents]. In the 99 worst inci- dents described in a similar way by the 276 female respondents, the most common incidents (patients only) were requests for physical contact, innuendo and sexual comments, ‘accidental’ touch- ing and suggestive gestures. The respondents were also asked about their cognizance or awareness of sexual harassment being directed towards physiotherapists in the work environment. The most common form of sexual harassment of which the respondents had heard or witnessed, was innuendos or sexual comments (21.13%), followed by ‘accidental’ touching (12.53%), inappropriate requests for a date (12.35%), suggestive stares or whistles (10.65%) and suggestive gestures (10.29%). By far the most common perpetrator of which they knew, was also the patient (58.23%), followed by other healthcare profession- als (24.52%) (n = 1652). DISCUSSION This study, which investigated the prevalence of sexual harassment of physiotherapists, revealed that sexual harassment by patients, other healthcare professionals, physiotherapy lecturers and physiotherapy or student colleagues does take place within the South African context. There have been three relevant stu- dies, conducted by means of survey questionnaires, on sexual harassment by patients directed towards physiothe- rapists (or physiotherapy students) [McComas et al 1993 and 1999, deMayo 1997, Weerakoon and O’Sullivan 1998, O’Sullivan and Weerakoon 1999]. McComas et al (1993) considered the term sexual harassment to be alienating and consequently used the term ‘inap- propriate patient sexual behaviour’. DeMayo (1997) did not use the terms inappropriate sexual behaviour or sexual harassment, but only referred to such behaviour as ‘sexually related patient behaviours’. The respondents to this sur- vey questionnaire were supplied with the following definition of sexual harassment in the covering letter: (1) Where the employee has to submit to sexual advances in exchange for job benefits, and / or be penalized for refusing; (2) Where the work environment becomes hostile in the sense that offensive sexual conduct occurs and the employee’s well-being is threatened (Ovid Scope Note 1993). Furthermore, the questionnaire specifically listed behaviours that were considered as sexual harassment and then requested the respondents whether any of these behaviours had been directed towards them. Sexual harassment by patients was reported by 52% of the respondents in the current study. In comparison, sexual harassment by patients was reported by 86% of the respondents in deMayo’s (1997) study, by 80.9% in McComas’s et al (1993) survey and by 85% in Weerakoon and O’Sullivan’s research. However, since this study investigated sexual harassment by perpetrators other than patients, the total prevalence of worst incidents described, was 61.35%. Rape, as well as incest and promiscuity, have been associated with low self- esteem and the desire to control others in the transgressor (Steffenhagen and Burns 1987). Since rape may also be included in the wide spectrum of beha- viours associated with sexual harass- ment, controlling behaviour may also be an element of sexual harassment. The scenario is set for this form of offensive behaviour when the need for dominance, is combined with hostility towards a specific gender and an unequal distribu- tion of power (Vetten n d). However, sexual harassment may also be perpe- trated by those who are not in positions of power. ‘Non-superior’ harassment occurs when patients harass healthcare professionals (Robbins, Bender and Finnis 1997). There are other unique reasons for sexual harassment in the healthcare environment: - physical contact with parts of the body considered as private and inti- mate - low self-esteem resulting from the stress of being ill or having a disease - close physical contact between the physical therapist and the patient (deMayo 1997) - close interpersonal relationship between the physical therapist and the patient (McComas et al 1993) - breaching of professional boundaries (social contact) beforehand (Assey and Herbert 1983) - transference (Assey and Herbert 1983), which happens when the patient transfers emotions that he / she is experiencing to the healthcare professional Survey questionnaires generally have a low response rate. DeMayo (1997) had a response rate of 48.6%, McComas et al (1993) of 74.1%, Weerakoon and O’Sullivan (1998) of 37.5% and the response rate to this study was 32%. The high response rate in McComas et al’s (1993) study, might be explained by the fact that unlike the other two international studies, their questionnaire was personally distributed to various work places and student classes, and then anonymously returned. The lower response rate to this survey questionnaire, may be explained by the following: - The topic might have been too broad, since it entailed questions on both sexual harassment as well as on other sexual-related issues (not discussed in this paper). This fact could have contributed to the possibility that the questionnaire might have taken longer than 15-45 minutes (a really wide time range) that was indicated in the covering letter. - Although only 295 questionnaires were returned to the sender, it is pos- sible that the problems in the postal services at the time might have been a cause of non-delivery of post (Louis 2003). - Sexual harassment is a sensitive topic and although the questions were formulated as carefully as possible, and the fact that the respondents could choose not to answer certain questions, sensitive or personally-affected physiotherapists might have felt either offended or vulnerable and chose not to respond. The topic might not have appealed to 12 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 4 those physiotherapists who believe that only studies related to clinical work or education should be supported. - In spite of offering anonymity, phy- siotherapists who have been sexually harassed might still fear exposure and might therefore not have responded. - Since the questions were related to events that had occurred in the past, it is possible that some physiothera- pists felt that they could no longer accurately reflect the incidents and therefore did not respond. - The questionnaire listed specific behaviours pertaining to sexual harassment. However, some physio- therapists might not have recognised behaviour directed towards them as having been sexual harassment in the context of the definition supplied in the covering letter. Since some survey questionnaires have reported a response rate of 29% (Robbins, Bender and Finnis 1997), the response rate of 32% on this survey questionnaire is within an acceptable response rate. DeMayo (1997) found that a slightly higher percentage of women, (81.5%), answered their ques- tionnaire, in comparison to the gender distribution of physical therapists regis- tered with the American Physical Therapy Association, where female physiotherapists accounted for 74.0% of the registrations. This study had a female response rate of 93.56%, although the registrations (from 1974 - 2002) of physiotherapists at the HPCSA reflect that 87.2% of these persons are female (HPCSA 2003). DeMayo’s (1997) rea- soning that perhaps more women are inclined to respond to any questionnaire, or perhaps to a questionnaire on this topic, may be relevant to this study too. The studies by McComas et al (1993), deMayo (1997) and Weerakoon and O’Sullivan (1998), revealed that sexual harassment of physiotherapists occurs in Canada, the United States of America, as well as in Australia, respec- tively. This study indicates that this is an universal problem and that physio- therapists in South Africa are also exposed to sexual harassment in their work environment. CONCLUSION This survey reveals that the prevalence of sexual harassment of physiotherapists in their work environment in South Africa is 61.35%. Although the majority of the perpetrators are patients, other healthcare professionals, physiotherapy lecturers and student or physiotherapy colleagues have also directed sexual harassment towards physiotherapists. This is the first time that sexual harass- ment of the physiotherapist has been studied in South Africa, and now that the extent of the problem is known, recom- mendations for managing sexual harass- ment of the physiotherapist in the work place may be compiled. Since only 5.82% of the respondents had received any information on this issue, one of the cornerstones of management would be education in sexual harassment at undergraduate level. Statistical infor- mation gained from this study, such as the prevalence of sexual harassment, the mean age of the respondents when they experienced their worst incidents of harassment and the most common forms of sexual harassment directed towards physiotherapists, may, amongst other information pertaining to sexual harass- ment, be included in an educational program. ACKNOWLEDGEMENTS The South African Society of Physio- therapy partially funded the research. REFERENCES Assey JL, Herbert JM 1983 Who is the seductive patient? 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