(2021) 19:59
Newman et al. Hum Resour Health
https://doi.org/10.1186/s12960-021-00569-0
Open Access
RESEARCH
Uganda’s response to sexual harassment
in the public health sector: from “Dying Silently”
to gender-transformational HRH policy
Constance Newman1* , Alice Nayebare2, Stella Neema3, Allan Agaba2 and Lilian Perry Akello4
Abstract
Introduction: Sexual harassment is a ubiquitous problem that prevents women’s integration and retention in
the workforce. Its prevalence had been documented in previous health sector studies in Uganda, indicating that it
affected staffing shortages and absenteeism but was largely unreported. To respond, the Ministry of Health needed
in-depth information on its employees’ experiences of sexual harassment and non-reporting.
Methods: Original descriptive research was conducted in 2017 to identify the nature, contributors, dynamics and
consequences of sexual harassment in public health sector workplaces and assess these in relation to available
theories. Multiple qualitative techniques were employed to describe experiences of workplace sexual harassment in
health employees’ own voices. Initial data collection involved document reviews to understand the policy environment, same-sex focus group discussions, key informant interviews and baseline documentation. A second phase
included mixed-sex focus group discussions, in-depth interviews and follow up key informant interviews to deepen
and confirm understandings.
Results: A pattern emerged of men in higher-status positions abusing power to coerce sex from female employees
throughout the employment cycle. Rewards and sanctions were levied through informal management/ supervision
practices requiring compliance with sexual demands or work-related reprisals for refusal. Abuse of organizational
power reinforced vertical segregation, impeded women’s productive work and abridged their professional opportunities. Unwanted sexual attention including non-consensual touching, bullying and objectification added to distress.
Gender harassment which included verbal abuse, insults and intimidation, with real or threatened retaliation, victimblaming and gaslighting in the absence of organizational regulatory mechanisms all suppressed reporting. Sexual
harassment and abuse of patients by employees emerged inadvertently.
Discussion/conclusions: Sex-based harassment was pervasive in Ugandan public health workplaces, corrupted
management practices, silenced reporting and undermined the achievement of human resources goals, possibilities overlooked in technical discussions of support supervision and performance management. Harassment of both
health system patients and employees appeared normative and similar to “sextortion.” The mutually reinforcing
intersections of sex-based harassment and vertical occupational segregation are related obstacles experienced by
women seeking leadership positions. Health systems leaders should seek organizational and sectoral solutions to end
sex-based harassment and make gender equality a human resource for health policy priority.
*Correspondence: cnewman@intrahealth.org
1
IntraHealth International, 6340 Quadrangle Drive, Suite 200, Chapel Hill,
NC 27510, USA
Full list of author information is available at the end of the article
Allan Agaba and Alice Nayebare: Formerly employees of IntraHealth.
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Newman et al. Hum Resour Health
(2021) 19:59
Page 2 of 19
Keywords: Sexual harassment, Gender-transformative workforce policy, Support supervision, Performance and
human resources management
Introduction
Background
Sexual harassment is a ubiquitous problem that prevents women’s integration and retention in the workforce [1–3]. The prevalence of sexual harassment in
Uganda’s public health sector had been documented
and linked to staffing shortages and absenteeism. In
a 2003 Uganda Ministry of Health (UMOH) study on
health worker retention, around 24% of workers the
majority of whom were female nurses reported that
they had been subjected to sexual “abuse” by a supervisor [4]. Approximately one in five reported sexual abuse by patients or their relatives (21%). Fewer
reported abuse by peers (16%) or while travelling to and
from work (18%). Health workers reported quitting in
response to such abuse.
A 2012 UMOH descriptive gender research study,
Gender Discrimination and Inequality Analysis [GDIA
[5] found that men were overwhelmingly concentrated
in senior levels of management. About 32% of GDIA
survey respondents reported that manager/supervisor
expectations of sexual favors in exchange for a good
evaluation, a promotion, or a salary raise (i.e., quid pro
quo sexual harassment) were either “somewhat common” or “very common.” Focus group (FGD) respondents perceived gendered power and subordination
(“When men are bosses, they think they can take anything they want from female subordinates, so they start
asking for sexual favors”) and retaliation (e.g., a woman
who “stands her ground” runs the risk of a bad evaluation or job loss). FGD participants affirmed that “Some
decide to ignore it while others suffer quietly” while others quit their jobs or found different ways of coping
rather than report it (“Sexual harassment is silent; no
one discloses).” District managers confirmed that rampant sexual harassment was a “serious form of corruption.” Other forms of sexual harassment included 1)
sexually suggestive gestures (30%); 2) being exposed
to sexually explicit discussions or conversations (25%);
3) unwanted attempts to establish sexual relationships
(22%); and 4) being the object of sexual jokes, comments, or leering (19%). There were also co-occurring
stereotypes of women’s leadership incompetence and
discrimination based on pregnancy and family responsibilities, which sidelined female health workers.
In summary, sexual harassment, especially by supervisors, was a silent and apparently unregulated problem in Uganda’s public health workplaces, mainly
affecting female employees, co-occurring with other
types of gender discrimination, in a context of vertical
segregation. Other Ugandan studies, while measuring
the prevalence of sexual harassment in different ways,
found it to be a problem in other public sectors, from
Parliament [6], the police force [7], the prison system
[8], education [9], to agriculture and at public markets,
where men’s non-consensual touching of women is so
common as to have a name– bayeye [10]. While Uganda
had launched national Sexual Harassment Regulations
in 2012, their implementation was uneven.
Methods
Prevalence had been previously measured, but information on how to prevent and respond to sexual harassment was lacking. Not everything that counts can
be counted [11], so additional UMOH research in 2017
involved a new descriptive approach employing multiple qualitative data collection techniques to address key
questions: What are UMOH employees’ experiences of
sexual harassment? Why is non-reporting of sexual harassment pervasive? What are the consequences? What
is the cross-cultural relevance of current theories, definitions and dynamics for UMOH human resources for
health policy and human resources management (HRM)?
The 2017 research not only aimed to describe the workings of sexual harassment and non-reporting in UMOH
workplaces but also assessed the relevance of current
sexual harassment theory and definitions, at a minimum,
to increase the consistency of measurement across settings. This approach required balancing discovery of participants’ lived experience with the explanatory potential
of pre-existing categories of understanding from the literature. The literature informed data collection tools and
interpretation.
Relevant literature
UMOH stakeholders stressed the importance of anchoring the research in the framework of Uganda’s Sexual
Harassment Regulations. The literature review (published
and “gray”) examined theories that account for sexual
harassment, how it is defined, and the problems and
dynamics of reporting.
Theories
There is no single explanation or theoretical framework
that fully accounts for sexual harassment. Some include
[12, 13]:
Newman et al. Hum Resour Health
(2021) 19:59
• Nature: Sexual harassment is a natural extension of
mate selection in evolutionary theory, behavior that
is motivated by mutual sexual desire and “natural”
and therefore not a social or workplace problem.
• Sex role/sociocultural spillover: Sexual harassment is
the outcome of norms that socialize men into sexual
assertion, social dominance and superiority, and persistence, and women into sexual submission and passivity. Harassers bring inappropriate expectations to
workplace interactions, thereby perceiving women in
their sex, rather than their work, roles. The result of
these inappropriate role expectations is behavior that
is perceived as sexually harassing.
• Economics: Sexual harassment is used to drive out
women (and cultural minorities) who compete for
valued jobs traditionally held by men, as if to communicate “women don’t belong here” [14]. Maintaining the most highly-rewarded forms of work as
domains of masculine competence results from “tormenting members of minority and other disadvantaged groups seeking upward mobility through work”
[15].
• Power: Organizations are “public patriarchies” in
which violence and violences are forms of power,
domination and oppression that structure organizations [16, p.20 and p.29]. Sexual harassment embodies sexist ideologies of male superiority and female
inferiority. The (patriarchal) gender order of the
larger society translates into organizational gender
regimes [17] which are maintained through a dominant form of [hegemonic] masculine behavior vis a
vis ideal feminine behavior to maintain an unequal
gender order. Power differentials increase the likelihood of sexual harassment, and since men typically
hold more power, they are more likely to be perpetrators [18]. Women are at most risk to be targets
of sexual harassment and more vulnerable to its
economic, psychological, social and physical consequences. Managers and supervisors (in the health
workforce, predominantly men [19]) are structurally situated in organizational hierarchies to exercise
power [18] over their subordinates and have control
over work-related outcomes such as positive performance evaluations, salary increases, or flexible work
[18].
There is a substantial vein of research and human
rights literature that puts unequal power at the center
of theory where asymmetries of power [20], threats
or acts of violence, gender stereotyping and economic control of work result in the subordination of
women. Cockburn’s early research led her to conclude
that women’s presence in the workplace was a highly
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political issue for men, and that women’s claim to economic independence and an equal place in organizational life called forth new measures of exclusion and
reassertion of male authority [21, p. 143]. Sexual harassment maintains an already existing gender stratification through “the unwanted imposition of sexual
requirements in a relationship of unequal power” [22].
While men may be vulnerable to harassment if they
are perceived as feminine, women are targeted when
they challenge their subordinate position in the gender
order. Konik and Cortina augmented sex-based harassment theory by studying sexualized harassment, gender
harassment, and heterosexist harassment, which yield
an integrated model of workplace oppression based on
gender-role enforcement, i.e., “policing gender” [23]. In
Schultz’s thinking, the problem with workplace harassment is sexism and not sex; it is more about upholding
gendered status and identity than it is about expressing
sexual desire [24].
The United Nations posited “that violence against
women (including sexual harassment) is a manifestation of historically unequal power relations between
men and women, which have led to domination over
and discrimination against women by men and to the
prevention of the full advancement of women, and that
violence against women is one of the crucial social
mechanisms by which women are forced into a subordinate position compared with men” [25].
The term "violence against women" means any act
of gender-based violence that results in, or is likely
to result in, physical, sexual or psychological harm
or suffering to women, including threats of such acts,
coercion or arbitrary deprivation of liberty, whether
occurring in public or in private life [25]. A COFEM
brief recently noted that “everyday sexism, sexual harassment and other forms of gender-based violence
share a root cause—gender inequality and the oppression of women and girls– and distinguishing different
forms of gender-based violence as more serious than
others ignores how patriarchy and gender inequality
create a culture in which [all] violence against women
and girls is accepted and normalized” [26].
Summarizing power theories, sexual harassment is an
assertion of power, a manifestation of historically unequal power relations between men and women, serves
to police appropriate ways of “doing gender,” penalizes
gender non-conformity [27] and protects or enhances
men’s gender-based social status [24]. The 2017 UMOH
research assessed the cross-cultural relevance of these
theories. It should be noted that patterns of workplace
sexual harassment of men may differ from the sexual harassment of women and sexual minorities. The reader is
therefore directed to relevant readings [28–31].
Newman et al. Hum Resour Health
(2021) 19:59
Definitions
Fitzgerald, Berdahl, Schultz and Leskinen et al. [24,
27, 32–36] are researcher-theorists whose definitions
reflect the gender inequality and power concerns of “sexbased harassment” which encompasses sexual coercion,
unwanted sexual attention and gender harassment, the
latter involving hostile behaviors that are believed to have
little to do with sexuality, and everything to do with gender [33]. Sexual coercion and unwanted sexual attention
include behaviors consistent with the well -known categories “quid pro quo” and hostile environment harassment; the third category, gender harassment, includes a
wide range of sexist, insulting, demeaning behaviors that
are motivated by hostility toward individuals who violate
gender ideals or norms, not by desire for those who meet
them [27]. Gender harassment does not typically aim at
sexual cooperation and is “more put down than come
on” [33]. This category is useful for understanding other
aspects of women’s experiences in hostile work environments. For example, Leskinen and Cortina augmented
the category to include sex-related insults featuring hostility against motherhood status [36]. Indeed, a broader
range of harassing, discriminatory behaviors that cooccur with “sexual harassment” (e.g., pregnancy discrimination and “hostile animus”) has been documented in
recent health workforce research [37–41].
Additional file 1, Illustrative Definitions, shows the
variety of definitions of sexual harassment in the literature. It is defined as violence, discrimination, an assault
on dignity or a human rights violation. Some focus on the
sexual nature of “quid pro quo” and hostile environments,
while others define three categories of “sex-based harassment.” Reflecting this variety, the 2019 ILO Convention
190 [42, 43] was inclusive and defined “violence and harassment” broadly, though it includes “gender-based violence and harassment”. A narrow focus on sex or conduct
of a sexual nature ignores the broader range of gender
harassing and policing behaviors that figure in genderpower theories and that occur in health workplaces [44].
A broadly inclusive definition involves challenges for
measurement across settings. The UMOH research was
framed by Uganda’s definition of “sexual harassment”
which describes conduct of a sexual nature in quid pro
quo and hostile environment harassment [see Additional file 2, Definition and Interpretation from Uganda’s
Employment (Sexual Harassment) Regulations, 2012].
Problems of reporting
There is substantial evidence of under- or non-reporting
of workplace violence (which includes sexual harassment). The ILO/ICN/WHO/PSI Framework Guidelines
for Addressing Workplace Violence in the Health Sector
identified sexual harassment as a form of both physical
Page 4 of 19
and psychological violence [45]. Di Martino noted that,
though reporting is essential for an effective response to
health sector violence, reporting procedures were often
lacking in his six study countries [46]. Employers did not
investigate violence adequately and effective investigation
did not follow, resulting in impunity. Unions, associations
and the community were slow to support targets of workplace violence, and in fact, played an insignificant role in
protecting their members. When targets did report incidents of violence to managers or colleagues, they were
less forthcoming about sexual and racial harassment. A
2006 study of sexual harassment in the health sector of
India found that 57% of doctors and nurses in the sample had been harassed, but only 29% made a formal complaint [47]. In a 2008 study of health workplace violence
in Rwanda, 40% of targets disclosed to no one [38].
That sexual harassment is under/un-reported is wellestablished [48, 49]. A 2015 European Union survey
found that out of all women who described the most
serious incident of sexual harassment that had happened
to them, 35% did not speak about it to anyone, only 4%
talked to an employer or boss, and less than 1% consulted
a lawyer, a victim support organization or a trade union
representative [50]. Reasons given for non-reporting
of sexual harassment appear consistent across studies:
Procedural and evidentiary (burden of proof ) hurdles;
a belief that nothing will come of a report; feelings of
shame and fear of being ostracized by co-workers and
retaliated against for reporting; considered as a normal
part of work [51]; repercussions such as being fired or
blacklisted or having to quit, damage to reputation and
loss of career prospects, and conflicting emotions about
the harasser [52]. Retaliation is a real risk, as victims
who file harassment complaints are much more likely to
lose their jobs than those who experience similar levels
of harassment and say nothing [53]. The targets of sexual
harassment experience a range of personal, professional
and organizational harms which are relevant to human
resources for health and management (HRH/M), such as
decreased job satisfaction and morale; increased absenteeism and job loss/leaving; deteriorating relationships
with coworkers; financial stress and incremental economic harms to the employee [54], higher rates anxiety,
depression and PTSD [55–57].
Dynamics of silencing and non‑reporting
It is possible that non-reporting is pervasive because
of the evidentiary hurdles, for example, in documenting its psychological harms. There are also psychological and social dynamics that may explain the tendency
for targets to remain silent and not report. The notion
of the rape myth has been extensively used in sexual violence research to understand the sociocultural context
Newman et al. Hum Resour Health
(2021) 19:59
of non-disclosure [58]. False cultural beliefs about the
culpability of the victim and the innocence of the sexual
offender, or the illegitimacy of rape as a serious offense
[59] serve to deny and justify sexual aggression against
women [60]. For example, “What was she wearing?”
deflects responsibility onto the victim’s dress. Rape myths
are driven by (1) gender inequality and society’s acceptance of patriarchy and male dominance, leading to tolerance of aggression against women; and (2) structural
violence within which societal tolerance normalizes,
justifies and legitimizes sexual violence against women,
so that we do not see the violent act, or at least not as
violence [58]. Baugh [61] found that the reason so few
instances of sexual harassment are formally reported,
and why so many targets who do make formal reports see
the situation as worsening, is the pervasive tendencies
to “blame the victim for her own plight” and to discount
the target’s definition of sexual harassment. “Blaming
the victim” facilitates the persistence of sexual harassment because institutionalized contributors or responses
remain unquestioned [61]. Power differentials in maledominated workplaces legitimize and institutionalize
male perspectives and definitions [61].
Attempts at holding perpetrators to account for harassing, violent behavior typically evoke defensiveness and
hostility [62]. In what has been described as a “DARVO”
dynamic (Deny, Attack, Reverse Victim and Offender)
[63], a perpetrator’s response to being held accountable
puts the target of violence under scrutiny, and casts the
target (or whistleblower) as the perpetrator. Examples
include accusing the target of seeking revenge for a poor
performance appraisal, or using terms like “male-bashing” [62] which suggests that it is the victim who is the
violent party for bringing a charge of harassment, or for
trying to affix perpetrator responsibility. Institutional
betrayal describes organizational actions/inaction that
are experienced as violations of trust that exacerbate
the original harm of sexual harassment [60]. Examples
include when the administration shows excessive concern for the future of the perpetrator, or when it participates in a target’s demotion, transfer or firing—effectively
silencing attempts to stop the harassment. “Gaslighting”
refers to a form of psychological manipulation in which
a person or a group sows seeds of doubt and undermines
self-confidence, making the target question their own
memory, perception, or judgment, again with an effect of
silencing [64]. Stark developed the notion of manipulative gaslighting, which denies, minimizes or challenges
testimony about harms done to the target [65], by sidestepping evidence that supports the target’s testimony,
or attributing cognitive or characterological defects
to the target, e.g., “Can’t you take a joke? “ or “Why are
you obsessing on this?” Ahern referred to whistleblowing
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gaslighting, which involves trauma resulting from the
emotional manipulation used by employers to discredit
and punish employees who report misconduct [66].
A reluctance to report or even label behaviors as sexual
harassment is documented in academic medicine, where
for example, female physicians-in-training developed
strategies such as “not sweating the small stuff ” (i.e., minimizing) and humor as tactics of resistance to deal with
hostile environments, and acceptance of mistreatment
which was normalized and passed from one generation to the next [67, p.5]. Wear and Altman also remark
that physicians-training learn institutional norms that
whistleblowing against one’s peers is considered unprofessional or unreliable behavior, and that gender socialization may encourage women to emphasize empathy for
harassers over confrontation and punishment. Hinze [68]
found that a target’s self-doubt and asking themselves if
they are being “too sensitive” were common reactions
in which attention was deflected back onto the target of
harassment. Hinze also suggested that denying or ignoring harassment, or “not taking it personally,” are tactics
used by female physicians to distance themselves from
the stigma of being publically devalued, and that these
tactics interrupt the naming of sexual harassment, and
ensure its continuance [68]. All the foregoing processes
serve to silence a target, inhibit reporting and maintain
impunity.
Hearn and Parkin suggested that the recognition of
violence is difficult not only because the relative isolation of survivors and feelings of shame or self-blame, but
because violence and violation contradict the dominant
ideological constructions of most organizations [16]. As
organizations become more aware, violence is more likely
to be identified, recognized, problematized, “spoken” and
contested, but then is followed by further organizational
“dynamics of violation.” Dynamics of violation are at
play in the institutional betrayal of whistleblowers, such
as official or unofficial reprisals, reprimands, punitive
transfer, referral to a psychiatrist, social ostracism—all
of which, the authors claim, should be anticipated. These
damaging processes make it hard to keep sexual harassment “spoken” in the face of organizational pressure to
silence targets [16].
Data collection tools and strategy
The qualitative data collection techniques employed by
the study elicited UMOH employees’ lived experience
with or observations of sexual harassment and factors
that constrained reporting. In Phase 1, data collection
involved policy document review, male/female same-sex
FGDs with health workers, national and district level key
informant interviews (KIIs), and baseline documentation
of health employees’ understanding of sexual harassment
Newman et al. Hum Resour Health
(2021) 19:59
and policy guidance available at UMOH worksites. Phase
2 involved mixed-sex FGDs to elicit gender, social class,
regional and ethnic dimensions and interaction and
reporting dynamics, and in-depth interviews (IDIs) with
employees or facility in-charges to deepen understandings of evidence that had emerged in Phase 1. See Additional file 3, for a detailed description of the methodology
and sample.
Data collection took place between August–November 2017 with assistance from the (now-ended) USAIDfunded, IntraHealth-led Strengthening Human Resources
for Health (SHRH) project. The study sites included those
of the UMOH and other central-level ministries, district
human resources management (HRM) structures, hospitals and health facilities. The two categories of study population were key informants at the national and district
levels and health workers and managers at health facilities. District-level data were collected in the ten districts
in which the sexual harassment prevention and response
system would be piloted. The districts were selected from
the 44 project priority districts where there were staff
shortages and where second year project efforts were
concentrated. A purposive sample included 294 health
workers (including managers) from Central (Mukono
and Mubende); East Central (Bugiri, Namayingo); East
(Tororo); Karamoja (Abim); North (Gulu); West Nile
(Adjumani); West (Hoima); and South West (Rukungiri).
Data collector training
Data collectors were trained to understand the protocol, tools and ethical requirements, and to address their
attitudes about and experiences of sexual harassment, so
that they would be at ease discussing issues that might
initially might be met with reticence or discomfort, or
might require probing. Female data collectors facilitated
and recorded FGDs. Data collectors were also provided
a five-day methodology training to reinforce their skills
in collecting data using particular qualitative techniques
(e.g., pile sorting), recording data and developing transcripts. Following training was a one-day pre-test and
revision of the data collection tools.
Data analysis
The transcripts were coded by research assistants who
had participated in data collector training, and who had
had previous experience with Nvivo. They were supervised by a research consultant with a background in
anthropology and sociology. The research assistants
read through the transcripts and became immersed in
the data. The code structure evolved inductively. The
researchers adapted the Gioia et al. “First-order/second
order’’ analysis approach [69], and later created a data
structure visual to graphically represent how analysis
Page 6 of 19
progressed from raw data to higher-level understandings
and inter-relationships, and connections between the
data and theory (see Fig. 1):
1. “First order concepts” expressed informants’ understandings (For example, “They are dressing indecently’);
2. “Second order themes” expressed researchers understandings, i.e., abstract-level concepts and themes
and a larger narrative describing “What is going on
here?” in theoretical terms (For example, “Indecent
dressing’ suggests victim-blaming”);
3. Aggregate dimensions that might help explain various concepts and themes suggested by the data; and
4. Revisiting the relevant literature to see whether the
research findings had precedents and if they had
revealed new concepts.
Results
Findings for this paper were synthesized from the transcripts and unpublished report text, and presented both
in this section and in Additional files 4, 5, 6, 7. Additional
file 4 illustrates the forms and examples of sexual harassment emerging from FGDs, IDIs and KIIs, including the
physical, verbal, written/visual, and gestural behaviors
and dynamics featured in health employees’ descriptions
of sexual harassment. Additional file 5 contains excerpts
from two key informant transcripts describing secondary
injury, to illustrate the additional risks and harms faced
by targets who had reported sexual harassment. The
extensive use of quotes in the text below aims to convey
health workers’ lived experiences or informants’ observations, and how they made sense of sexual harassment, in
their own voices. Quotes were selected to illustrate categories and types of sexual harassment, its power dynamics, contributors and consequences. Findings in this
section answer the two key questions: What are UMOH
employees’ experiences of sexual harassment? Why is nonreporting of sexual harassment pervasive?
Employees’ experiences of sexual harassment
There appear to be patterns of male-on-female aggression
featuring sexual coercion and quid pro quo, unwanted
sexual attention and gender harassment. Abuse of organizational power to coerce sex by managers and supervisors occurred throughout the employment cycle (see
Table 1).
Sexual coercion started during recruitment of health
workers and continued after hiring, perpetrated by
men in hierarchically superior decision-making positions– supervisors, senior managers (including human
resources) or medical superintendents. Female applicants
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(2021) 19:59
Page 7 of 19
Second order themes: Expressing
researcher’s understandings, progressing to
abstract themes and larger narrative: “What
is going on here?”
First order concepts: Expressing informants’ terms and understandings
“Culture of sexualizing women’s bodies and not respecting women as human
beings”…They have grown up thinking they may be flattering the women, that
when they touch them, they are doing them a favor“…”He will … squeeze you,
when you try to resist he will use force.”…”Bad touches. Someone can touch your
bums, breasts that are unwanted and unpleasant”..”Keeps touching without
permission...” “It is a sexual kiss, not merely kiss, a sexual peck, not merely peck.”
Unwanted sexual attention: Entitlement,
objectification and scrutiny of women’s bodies and
behavior. Physical, verbal, gestural violation of
space in interactions between male and female
employees
Sexual coercion, abuse of power and quid pro
quo exchanges throughout employment cycle:
Normative use of superior organizational power,
blackmail and threats. Work rewards or
punishment subject to compliance with, or
rejection of, sexual demands.
“Forced sex, male colleagues force the females against their consent.”…“They are
demanded for sex before being given jobs.” ….”If you refuse, I will put other things
in your report.”...”If you don’t give in, you are not promoted”…” “When she refuses,
then she will be sacked”...”They can deny you salary”…“If you refuse to give in, they
can transfer you to far-off health centers like close to Sudan.”…” Some start hitting on
you through abuses and criticism that you are lazy at work, yet it is not true”.. “When I
resisted, he tortured me. He made sure that I didn’t attend any workshops.”
Psychologically
distressing work
environment: Conflict,
disrupted teamwork, fear
of harasser
Corruption of formal
HR/performance management
system
Masculine identity and work
status maintained
“Calling you unqualified”…”.. You have glue between your legs”…”Negative
comments about her body to belittle her”…”He became hostile to such an extent
they could not go to his ward” …”You are ugly…”It can be abusive or praising
but you are uncomfortable…You wonder: Am I stupid? Am I less of a woman?
So, it is physical, sexual and psychological.”
Gender harassment: Taunting, insulting,
demeaning verbal abuse. Assault on
competence and confidence. Reminder of
sexual not professional role. Intimidation
and gaslighting.
“”Putting on these blouses which just cover only breasts, the rest of the body part
is naked.” ”Our sisters from Busoga are perceived to give in easily…
“At first it was sexual harassment, in the end, she enjoyed.. ““Are you sure, has it
happened? What did he do—only touched you? Is that a matter worth reporting to
me?” Why are you so obsessed with this?” “You brought me a girl who is telling
lies—a non-performer.” ..“Most die silently” “At the end you will find you become
a victim yourself.”
“Poor induction” “The HR take advantage of their office to make direct or
indirect sexual advances to the jobseekers.” “So we have women overrepresented in the bottom of any organization and for the men, it is … inverted
pyramid whereby as you go up the power ladder, men become more and
more”....So a man has power if a woman’s recruitment or promotion depends on
this powerful man. There is a tendency to abuse that power.”..”.. “Lack of
grievance/reporting process”. Poverty and unemployment.
Aggregate dimensions describing
the phenomena suggested in the data
Dynamics of “dying silently”: Rape myths,
deflection, rationalization. Victim-blaming and
compounded stereotyping. Fear of/secondary
injury (Scrutiny, gossip; minimization,
manipulative gaslighting, institutional betrayal).
Stigma; Retaliation.
Organizational structures and norms:
Unclear definitions and expectations of
professional behavior; vertically segregated
supervision; unregulated management/
supervisory power; women’s economic and
organizational vulnerability; non-action and
impunity or use of transfers
Female employees silenced and
subordinated. Opportunities to earn a
living and progress in a career abridged
Absenteeism, turnover,
and attrition
.
Fig. 1 Employees’ experiences of sexual harassment, dying silently and consequences (Drawn from FGDs, IDIs, KIIs)
Table 1 Abuse of organizational power by managers and supervisors throughout the employment cycle
At recruitment, women are asked for sex and men are asked for money
During orientation, the old staff may start to frequent your office and in the end,
they may start to sexually harass you
Delays in confirmation of your service—some people have taken long without being
confirmed
Delayed promotion even if you work for many years
During appraisals—need a good report
Disciplinary action can be taken selectively—if it is a lady, she may not be called for
disciplinary action, but if it is a man, he will be called immediately for disciplinary action
Misuse of funds, e.g., those who are heading certain facilities are given a basic fund for the
staff, but you will find that they will be sharing it between the boss and the sex mate
Sexual harassment comes as orders. So whether you are harassed or not, it comes as an ‘order.’
Use of authority to schedule a duty which is not necessary—from there, sexual harassment can occur
Some others have power to dismiss because if you don’t give in, you are at a risk of losing your job
were promised or given jobs in exchange for sex. Such
transactional behavior continued into the job where incharges/supervisors offered bribes and rewards, such as
gifts, exemption from night duty, working fewer hours,
and opportunities for training or promotion, in exchange
for sex. Refusal was followed by further coercion, reprisals or psychological or administrative retaliation.
The following quotes express experiences and observations of sexual harassment in UMOH workplaces.
The abuse of superior organizational power
“I have always received reports about sexual harassment and it has taken different forms. Usually
it takes the form of power relations when people
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are looking for jobs in the public service. The HR
feels they have more power and they take advantage of their office to make direct or indirect sexual
advances to the jobseekers. For example, they could
tell the jobseeker that there is no job available and
that the jobseeker should keep coming back to the
office or that there is no free work, or they could ask
the jobseeker to come to the office at awkward hours.”
(Female National-level Key Informant).
“So we have women over-represented in the bottom of any organization and for the men, it is an
upward or inverted pyramid whereby as you go up
the power ladder, men become more and more and
are fewer at the bottom….so a man has power if a
woman’s recruitment or promotion depends on this
powerful man. There is a tendency to abuse that
power and they don’t even think that they are abusing it because they have grown up thinking they may
be flattering the women, that when they touch them,
they are doing them a favor. So, it is the whole culture of sexualizing women’s bodies and not respecting women as human beings. Their dignity, not
looking at them as individuals who have bodily
integrity and a choice. When you combine all those,
it is really what causes sexual harassment.” (Female
National-level Key Informant).
Sexual coercion and quid pro quo (Female health worker
FGDs).
“Demands for sexual favors are common for ladies.
They are demanded for sex before being given jobs.”
“Supervisors demand for sex from females in offices
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with threats of sacking upon refusal.”
“They wait for you at the time of appraisal and
harass
you.”
“Most of the sexual harassment occurs to the trainees
in the health sector who are coming for their practice. Most trainees will try to look for a place where
they can do their practice. But there is no place and
the only place they find, someone tells them that if
you do not sleep with me, you do not get the opportunity. So somehow you have to weigh between the
two, which one is better: Should I sleep with him and
get the opportunity or I leave?”
“Forced sex, male colleagues force the females
against their consent… The boss can call you in his
office and force you to have sex with him.”
“But sometimes it is economical because you have
refused to give in to the sexual favors, you are denied
some economic benefits- it could be allowances, field
trip, salary reduction, transfer so that your economic chances are reduced depending on how you
give in to the sexual favors or not. …There are people
who rotate in workshops or trips. If it is field, she is
the one, workshops- she is the one in charge of the
money/accounts, she/he is on every list…so you are
denied of some economic benefits as a way of harassing you to go into a sexual demand.”
“Some start hitting on you through abuses and criticism that you are lazy at work, yet it is not true…
when you give in the abuses stop”. Also, see Table 2.
Table 2 A Health Worker’s Experience of Non-Consensual Touching, Coercion and Psychological Distress [In-Depth Interview]
I: Can you please describe sexually harassing behaviors you are acquainted with?
HW: In my former workplace, I had a male in-charge. I was pregnant at the time. This guy wanted to go in a deep relationship with me. I had heard
that he would try to create a relationship with whoever was pregnant in that department. And if the person accepted, he would be in a deep relationship with her. I underwent serious struggles during that time because I had just joined the system. This guy tortured me. In my third trimester, he
said to me, “you are here and pregnant- you have come to work for a few months and you will go for your maternity leave, now what do you want?
It was better for you to first deliver your baby before starting work.” I was clueless on what action to take because I was a contract worker under the
MOH. But what hurt me most was that this guy wanted me in the TB ward despite my low immunity as a pregnant woman. He wanted me to get
exposed to so many things. Yes, I had to work, but there are some occupational hazards you are exposed to in the workplace. Another challenge
was that after delivering my baby, this guy wanted me back at work before the end of my maternity leave because I had combined maternity leave
with annual leave. He wanted me to work and did not want to give me time off to care for my baby. I was very weak. I couldn’t stand for so long and
I couldn’t sit for so long
I: Had he ever proposed to you?
HW: Yes, he did. Actually, the way he could harass me like he would come and touch me
I: Touch where?
HW: He would touch my bum. When I resisted, he tortured me. He made sure that I didn’t attend any workshops. Yet colleagues, who started the job
at the same time as me, went for workshops and outreaches. Whenever I requested to attend an outreach in order to gain some knowledge, he
would say, “No, you cannot go.” But my pregnant coworkers and coworkers with new-born babies attended the workshops
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Unwanted sexual attention
Findings in Additional file 4 illustrate the objectification
and sexualization of female health workers, non-consensual touching and gestural and verbal behaviors that
violate the space of the target through unwanted, unwelcome attention.
Non-consensual touching (Female health worker FGDs)
“Bad touches. Someone can touch your bums,
breasts, and some other parts that are unwanted
and unpleasant. Someone can come and touch on
your nose and chin.“
“Touching the person between colleagues, for example the male touching the breasts of the female when
she doesn’t want it-they are just working togetherbut this person keeps touching without permission.”
“When greeting some men, they can tickle/scratch
inside the female’s hand.”
“It is a sexual kiss, not merely kiss, a sexual peck, not
merely peck.”
Gender harassment
Evidence of “gender harassment” emerged from FGDs.
This category of harassment consisted of bullying, taunting, derogatory, sexually gross, insulting verbal abuse by
co-workers and supervisors, including the use of threats
or acts of retaliation. Targets apparently did not take the
behaviors in Table 3 as sexual invitation.
Together, the female health worker FGDs provide a
narrative in which the experience of harassment involved
psychological manipulation (gaslighting) which resulted
in confusion, loss of confidence and psychological
distress:
“The approach can be different- can be abusive or
praising but you are uncomfortable with the com-
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ment... It is psychological… In your mind you wonder- Am I stupid? Am I less of a woman? So, it is
physical, sexual, and psychological.”
“You are ugly--‘Whom do you think is interested in
you?’ when he was actually interested in her.”
“Somebody will be psychologically tortured like what
happened to the other student nurse. This is PTSDPost Traumatic Stress Disorder.”
Patients as targets of sexual harassment
Evidence of the sexual harassment of patients by clinicians emerged unexpectedly from the Phase 1 health
worker FGDs. This was followed-up by interviews with
16 facility In-Charges in the facilities where this behavior was reported. Irrelevant or unnecessary vaginal and
breast exams and “bad touching” were reported to be
the most common forms of sexual harassment by clinicians, though forms also included displaying a patient’s
nude body or body parts during clinical exams, and
sexual assault such as rape. Facility In-Charges observed
that victims rarely reported the health worker to police,
hospital administrators or others, likely for fear of negative consequences. For example, a Facility In-Charge
recounted a story in which a young woman who had
been sexually assaulted by a clinician complained to her
family and the village chief, and the latter asked her not
to report it further lest the village lose the one health
provider they had or possibly receive less preferential
treatment in the future [see Additional file 7, Patient Harassment by Health Workers].
When asked about contributed to sexual harassment
in general, male FGD participants mentioned the following examples which are relevant to the harassment of
patients: Medical examinations and clinical procedures
make clinicians vulnerable to harassing, such as palpation
of a female client, collection of vaginal swabs, making an
injection on the thigh of a female patient or observing a
Table 3 Examples of Gender Harassment with Unwanted Sexual Advances and Reprisals [From Female Health Worker FGDs]
“Provoking you. Calling you unqualified when you refuse sexual advances… So, words spoken- telling you how you are sexual, how you are not using your
endowment, how you are not exploiting yourself for higher offices, abusing you, you are ugly that’s why you have nobody loving you.”
“You are told how beautiful you are. Like that name calling- sweetheart, honey, Virgin Mary- an older woman wonders why someone calls her a Virgin Mary,
because we have not seen you sleep around! You are told how you are “magulu gaamu” (meaning have glue between your legs, can’t give in for sex)—we
wonder who sleeps with you, you refuse giving us.”
“And also making comments about the lady—he makes a pass at the lady, but she responds in a negative way, so he starts making negative comments about
her body to belittle her, to annoy her.”
And intimidating words, someone comes and tells you …you think your husband is faithful to you?”
“Using vulgar words which are not good for our mouth to pronounce.”
“He became hostile to such an extent that they could not go to his ward.”
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female worker insert a catheter in a male patient. This
finding suggests that responsibility for harassing behavior is deflected onto a medical task or onto a female body
which during examination has aroused the perpetrator.
Contributors/causes of employee harassment
Study respondents identified contributors to sexual harassment at several levels.
Individual and relationship‑level contributors
A recurrent theme in focus groups was a belief that
women’s “indecent dressing” caused sexual harassment,
deflecting attention onto the target who was said to be
responsible for calling forth harassing behavior. Stereotypical notions seemed to portray men as victims of
seductresses whose manner of dress or walking enticed
perpetrators:
“Dressing still on ladies, like putting on these blouses
which just cover only breasts, the rest of the body
part is naked. There is this term they use to call this
type of dressing, pimp dressing. You see they put on
this thing up to here; they call it cleavage dressing
(the navel just remains outside (The kundi shows).”
(Male Health Worker FGD)
“One of the other causes, I think is dress code.
Because if a lady dresses up and the dress is reveal-
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ing most of her body parts, that entices the opposite,
to initiate and at the end of the day, call it sexual
harassment.” (Male District-level Key Informant)
“…One thing I would really point out is that somebody may be doing something subconsciously and it
can be construed as sexual harassment. For example, if a lady was walking with her high-heeled shoes
and she is wriggling in the corridor while there are
other onlookers, that can’t be harassment...” (Male
District-Level Key Informant) (Table 4)
In the following job-seeking scenario, persistent, coercive
sexual demands in an imbalanced power relationship are
described as normal courtship behavior, in the face of the
target’s attempts at resistance:
“At first it can be harassment but later, it becomes
enjoyable. Let us take this scenario of these ladies
who are used when they want jobs…There is a lady I
know who wanted a job and the boss demanded for
sex and the lady gave in. After giving in four times,
the boss ended up marrying the lady…so it started
as sexual harassment, later on it was not. This lady
initially refused saying she is born again but after
giving in, she accepted and enjoyed the marriage.”
(Male Health Worker FGD).
Table 4 Perceived Contributors to Sexual Harassment (Health worker and managers FGDs and KIIs)
Perceived individual- or relationship-level contributors (from FGDs and KIIs)
“Indecent dressing”—women’s clothing provokes it
Provocative walking– women’s behavior provokes it
Medical examinations—women’s state of undress provokes it
Living away from spouse
Proximity to co-worker
Alcoholism
Libido
Morals/poor upbringing
Perceived organizational contributors (from FGDs and KIIs)
Abuse of power
Manager/supervisor power
Unclear expectations of professional behavior
Poor induction of new hires
Unclear definitions
Lack of grievance/reporting process
Lack of privacy in sleeping quarters
Belief women can be touched
Impunity for touching, sexual harassment
Only sexual assault or rape is taken seriously
Perceived cultural/societal contributors (from FGDs and KIIs)
Poverty and unemployment
Regional, ethnic and gender traits
Non-consensual touching of women
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Organizational factors, including inaction and impunity, emerged as major contributors to sexual harassment:
“I think the most common cause is that in Uganda,
there are no punitive actions against sexual harassment. You know you can touch a woman and get
away with it. You cannot report to police that soand- so touched me since even the police are some of
the main perpetrators…When you report to the local
council they will not help you because they think it is
normal for women to be touched. The only thing they
can listen to is rape.” (Female Health Worker FGD).
Key Informant).
Beliefs about regional, ethnic and gender attributes
Additional file 6 presents FGD and IDI data on perceptions of regional and ethnic attributes that intersect
gender beliefs and that explain sexual harassment. For
example, women or men from urban regions were stereotyped as “easy” (e.g., “Dot.com Girls”). Traits attributed
to Banyakole, Busoga or Batooro women and men were
also implicated in perceptions of sexual harassment.
(Why) is non‑reporting of sexual harassment pervasive?
“There was one case scenario—this was not an
employee but then it was someone seeking for a service in one of the public places, and it happened to
be a nun. She went to this person and this person
without shame turned to this person and started
demanding for sexual favors from the nun. Of
course, nun made an alarm that attracted attention
and probably the church should have started from
there but…no decision was taken.” (National-level
This section presents data on reactions to and consequences of sexual harassment as well as silencing
dynamics in UMOH workplaces that shed light on
non-reporting.
Reactions to sexual harassment
FGD participants were about asked common reactions to sexual harassment. Table 5 shows that transfer/
Table 5 Reactions of Health Workers (From FGDs and IDIs)
Reactions
No. of times mentioned (More than one time in 26 FGDs)
Leave the job (Transfer/abscond)
15 (58%)
No. of times
mentioned (10
IDIs)
Ignore, resist, avoid harasser
15 (58%)
8 (80%)
Comply, give in
12 (46%)
5 (50%)
Talk to friends, colleagues
7 (27%)
Quarrel with harasser
12 (46%)
Report the incident
13 (50.0%)
Keep quiet
3 (30%)
2 (20%)
Table 6 Personal and professional consequences of sexual harassment (Female health worker FGDs)
1. Loss of self-esteem/dignity
2. Loss of interest in the work
3. Lower productivity
4. Psychologically affected: Feeling stigmatized, depressed, guilty, self-blame, trauma
5. Conflict with spouse/divorce
6. Drop in work performance due to stress
7. Decreased job satisfaction
8. Absenting oneself from work/absconding
9. Health consequences: HIV/STI, unwanted pregnancy, abortions
10. Relationship between perpetrator and target undermined
11. Poor work conditions
12. Bad comment on your performance appraisal (Retaliation)
13. Delay in your confirmation (Retaliation)
14. Deleting your name from the payroll and you miss your salary (Retaliation)
15. Demotion when you refuse to give in (e.g. supervisor can demote you from being an in-charge of a ward to a mere nurse (Retaliation)
16. Loss of job, promotion or economic benefit (Retaliation)
17. Unwanted, punitive transfers (Retaliation)
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absconding (leaving the job) tied with avoiding/resisting/
ignoring the harasser as the most common reactions.
These common reactions and compliance with sexual
demands suggest silence or non-reporting. However,
quarreling and reporting (46%, 50%) indicate that reactions other than silence exist, i.e., that sexual harassment
is resisted and reported to someone. It should be noted,
however, that no formal UMOH reporting system existed
at the time.
Perceived consequences
Fear of the consequences of sexual harassment which
involve retaliation suppresses reporting. See Table 6,
items 12–17.
Actual loss of employment was a consequence, as
“Sometimes you can even lose your job. The man may
make advances at you and you always say no and at
times may decide to leave the job. I have a friend who
left her job and went to sit home because the boss was
always demanding her for sex which she could not accept.”
(Female Heath Worker FGD). Punitive transfer can occur
“If you refuse to give in to sexual harassment… they can
transfer you to far-off health centers like close to Sudan.”
(Female Health Worker FGD). In addition to personal
and professional consequences, study respondents mentioned the effects of sexual harassment on work climate,
including: Conflict and disrupted teamwork; fear of or
loss of respect for the harasser; undermining the relationship between harasser and target; and undermining of
supervisory authority.
Dynamics of silencing
The two cases described by national-level stakeholders in Additional file 5 illustrate the secondary injury or
revictimization that may result from reporting and that
silences reporting. In Case 1, retaliation, excusing the
harasser and attempts at normalizing sexual harassment
as an expected part of life, are described. Case 2 illustrates
the disbelief and minimization involved in manipulative
gaslighting, where the hierarchical superior appeared to
challenge the target who attempted to report: “Are you
sure, has it happened? What did he do—only touched
you…? Is that a matter worth reporting to me?” “Why are
you so obsessed with this? Also, there is damage to reputation and a countercharge of false allegation: “You brought
me a girl who is telling lies—a non-performer.” In the second case, the target is described as losing her educational
program, her job and her marriage.
A national-level key informant described institutional
betrayal in this way: “In Uganda, reporting is quite low…
most people fear to report because of the consequences—
you don’t know what will end. At the end you will find
you become a victim yourself. You think you are trying
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to salvage yourself from the challenges you are facing by
using the channels available to talk about your boss – who
is harassing you sexually, but instead, it will turn against
you.”
Feelings of shame, embarrassment, and fear of exposure, gossip and stigma hindered reporting. A target who
considers reporting fears heightened scrutiny or publicity, gossip, disbelief, intimidation or cover up:
“Some victims do not want the issue to be said out.
They feel ashamed when the community gets to know
they were sexually harassed. So, when the witness
tries to bring it out, denial is also there. When the
victim denies, it makes it difficult for the witness to
proceed with the case. Sometimes the harasser may
be on side of you both, so they will just sit on your
issue…” (Female Health Worker FGD)
“When you are a victim and you report, you become
the talk of the city. It is not that whenever you report
all people will believe you. You may report and people think you are deceiving. So, it is better you keep
quiet.” (Female Health Worker FGD)
“You may talk to a friend of yours seeking advice,
that so- and- so wants to give you a job but you first
have to give him sex. That friend will ask you, do you
remember the number of years you have spent without a job? Just give in, the secret will be between you
and the boss. And you will remain with ‘your thing’
and life continues. People no longer take it seriously.”
(Female health worker FGD)
“I was at the pediatric ward and so I used to take
blood sample to the lab. I think that is where he
saw me from and he started picking interest in. He
started talking to me and finally, he told me what
he wanted. I personally told him that I cannot be
involved in such relationships because I am married. The whole time I worked at the hospital, I never
told anyone until when I was leaving for more studies. He was ever on my neck and yet he is even an old
man.” (Female IDI)
“Intimidation from the boss and the boss tells you
even if you report no one will support you. ‘We are
known’ and you end up keeping quiet.” (Female
Health Worker FGD)
The findings demonstrate the feared and real risks
of secondary harm and institutional betrayal related to
reporting. As a national HRH key informant observed: “It
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is a complex thing that most people die silently. Like for
the common cadres, they will ask for a transfer to other
facilities away. Most of the people suspected to be harassing their subordinates, especially sexual harassment—at
best what they do is also transfer them to other places and
there are quite a number of scenarios, so what they do is
to transfer the person to other facilities or another department. So, because of that, most people don’t see the reason
to go and report and say [they] would rather die with the
problem.”
How the UMOH took the study results into account
“Dying silently” renders sex-based harassment formally
invisible. The research results were disseminated within
the UMOH and among stakeholders, were used in 2018
to develop gender-transformative Guidelines to Implement the Policy on Prevention and Response to Sexual
Harassment, and posted on the UMOH website later in
2018 [70]. The UMOH Guidelines used research evidence
to create several entry points for speaking about harassment, and to shift understandings of sexual harassment.
For example, The Guidelines used the study participants’
own experiences of sexual harassment to illustrate its
forms, thus shifting the power to define sexual harassment to the target of harassment, and allowing the target
to “reclaim the narrative” [71]. The UMOH Guidelines
also provided policy directives to health sector employees related to two particular abuses documented by the
study: Supervisor/supervisee relationships and sexual
harassment by clinicians of patients. These policy “guardrails” aimed to transform aspects of gender power relations. In 2021, a workplace climate improvement survey
will be conducted in 30 health districts of Uganda’s Eastern region to improve health facility workforce governance capacity. See Additional file 8 for details.
Discussion
In this section, we discuss the cross-cultural relevance
of current theories; how sex-based harassment corrupts management/supervision systems (something
overlooked in technical discussions of support supervision and performance management); power and gender
inequality; the mutually reinforcing intersections of sexbased harassment and vertical occupational segregation;
the harassment and abuse of health system patients and
employees; and implications for HRH/M policy.
Figure 1 brings together the research results in a visualized data structure [68] to answer the questions,
What are UMOH employees’ experiences of sexual harassment? Why is non-reporting of sexual harassment
pervasive? First-order concepts expressed informants’
experience of sexual harassment in their own words.
Second-order themes suggested three categories of
Page 13 of 19
sex-based harassment, the dynamics of non-reporting
(“dying silently”) and aspects of organizational structures and norms that perpetuate sexual harassment. Figure 1 also depicts aggregate dimensions, i.e., the broader
HRH effects such as a psychologically distressing work
environment, the corruption of the formal performance
and HR management/supervisory systems, female health
employees’ subordination and abridgement of employment opportunity, and organizational consequences
such as absenteeism, attrition and turnover (through
requested or punitive transfers). The inter-relationships
depicted between second-order themes and aggregate
dimensions are not exhaustive.
The cross-cultural portability of organizational
silencing dynamics, such as victim-blaming, retaliation,
minimizing, deflection, gaslighting and institutional
betrayal, is borne out in the study results [16, 61, 62,
64, 66]. Some of the theories of sexual harassment mentioned earlier also appear portable to UMOH workplaces. For example, sexual harassment as a natural
extension of mate selection emerged in describing the
targeting of a resistant job seeker with persistent sexual
harassment as courtship and that the target eventually
enjoyed it. Sex role/sociocultural “spillover” appears
in the intrusion of pervasive, non-consensual touching in UMOH workplaces (“bayeye”). One could argue
that economic motives underlay the punitive transfers
to “far-off health centers like close to Sudan,” effectively
kept female health workers from competing for valued
and influential jobs traditionally held by men [14, 15]
The cross-cultural portability of power-based theories and the three categories of “sex-based harassment”
were also demonstrated in study results. For example,
unwanted sexual attention was embodied in persistent
demands and non-consensual touching in frequent violations of women’s personal and professional spaces
[16]. Sexualizing talk served to remind female health
workers of their sexual, rather than professional, role
(“Words spoken telling you that you are not using your
endowment”). Superior and apparently unregulated
organizational (management and supervisory) power
was widely (ab)used to coerce sexual quid pro quos. As
Hearn and Parker suggest, “nor is sexual harassment
only a process of subordination and re-subordination
of women as workers in a hierarchy. It has to be seen
an individual appropriation of women, a male sex right”
[16, p.13–14]. Sexual harassment functions as an agent
of social control [7], with the practice of using women’s
sexuality to keep women in subordinate positions as
key to the way women are treated [6], at least in maledominated workplaces. That gender inequality drives
sexual harassment [26] is evident in the study data.
Newman et al. Hum Resour Health
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Gender harassment involved “gendered opprobrium”
[34] such as “abusive or praising but you are uncomfortable with the comment… In your mind you wonder- Am
I stupid? Am I less of a woman?” Female employees
also described the denigration of being labeled “ugly”
in response to refusal of unwanted sexual attention and
coercion. Gender harassment has been described as
not aimed at sexual cooperation, “more put down than
come on” [33], though this research revealed Ugandaspecific instances of gender harassment that seemed
both “come on” and “put down” [20] in the service of
unwanted sexual attention and coercion. However,
consistent with prior descriptions, gender harassment
did appear used to police appropriate ways of “doing
gender” [23, 27], i.e., to enforce a feminine gender
ideal of compliance that, when advances were resisted
or rebuffed, ended in punishment. As a jurist once
observed, it is “demeaning and disconcerting” for a
worker to “run a gauntlet of sexual abuse in return for
the privilege of being allowed to work and make a living” [72].
Cockburn’s [21] description of sexual harassment as
an expression of power, not of unbridled desire, is an
apt recapitulation of and prelude to understanding
manager/supervisor harassment in the Uganda context:
“Hierarchies are expressions of differential power,
maps of the distribution of authority and subordination in an organization. Men’s treatment of
junior women (being touched, women-objectifying
talk) is a clear instance of the exercise of sexual
power … We see sexual harassment as being a
male intervention for the assertion of power, as a
warning to a woman for stepping out of her proper
place. It is a controlling gesture to diminish any
sense of power she may be acquiring and to remind
her “you’re only a woman, that’s the way I see you.
And at that level, you’re vulnerable to me or any
man” [p.142].
In UMOH workplaces, managers and supervisors
were structurally situated to exercise power and to
control work-related outcomes [18] such as positive
performance evaluations, promotions and opportunity
for in-service training. Sexual coercion and blackmail
emerged as a workplace pattern where men in higher
status positions abused unregulated organizational
power to intimidate and subordinate female UMOH
employees, and extort sex, throughout the employment cycle (NB: There was only one mention of seniorlevel female-on-male sexual coercion, which was an
“outlier”). Rewards and sanctions were levied in these
seemingly informal “management” systems where compliance with sexual demands or suffering the penalties
Page 14 of 19
were “rules of the game” and where female health
employees could expect little professional advancement without being expected to pay for it in sexual
“currency” [73]. This suggests that the relationships,
rewards and sanctions of formal HR management and
supervision systems were corrupted by the abuse of
unregulated organizational power. Kabatt-Farr and
Crumley remind us that it is the hierarchy of health
care that normalizes the power differentials between
men and women that enables the harassment that protects superior status and excludes people from full participation in the workforce [74].
Transferring the perpetrator (“pass the harasser”
[48]) or the target of harassment are both administrative dysfunctions in this informal performance management system. Supervisor-supervisee relationships
and functions likely lost credibility through routine
attempts to coerce sex. It seems reasonable to suppose
that these processes directly or indirectly contributed
to absenteeism, turnover and attrition—the very workforce shortages that dogged the health sector and that
should have been addressed by HRM systems. Technical discussions of performance management and
supervision appear to overlook these possible systems’
corruptions.
It has been argued that sexual harassment is not
meant to appeal to women—it is meant to coerce them
[75]. When the target has no choice in the encounter,
or has reason to fear the repercussions of refusal, the
interaction has moved out of the realm of invitation,
courtship or flirtation, and into the realm of intimidation and aggression [75]. Schultz suggests that, once
sex-based harassment is understood as a means of protecting hegemonic masculine work status and identity,
“even unwanted sexualized attention becomes visible as
a means of putting women down” [34], i.e., of maintaining subordination. The UMOH results also evoke the
ongoing difficulties for female employees to progress
beyond sexual objectification and subordination and
to establish professional credibility under conditions
of poorly regulated sexual aggression. These harassing processes not only undermined the HRM goal of
retention, but also abridged opportunities for female
employees to engage in economically productive work
and progress in a career. The mutually reinforcing
intersections of sexual harassment and vertical occupational segregation appear to be related discriminations
and not independent obstacles experienced by women
seeking leadership positions.
Psychological and physical violence and organizational violations [16] in the forms of sexual coercion and
blackmail, gender harassment, the dynamics of silencing,
retaliation and secondary injury appeared so pervasive in
Newman et al. Hum Resour Health
(2021) 19:59
UMOH workplaces as to suggest organizational norms
and systems. For example, an abuse of power and the
corruption of management/supervisory appear normative. The abuse of superior power is also apparent in the
“sextortionary” [73] harassment of female clients by clinicians and also suggests normative organizational processes. Such breaches of trust by persons who abuse the
social power derived from their positions, and the silence
surrounding these processes appear systemic and have
relevance for the conceptualizations health system governance, HRM and the quality of services.
Implications for HRH/M Policy
The study results have implications for definitions and
measurement, prevention and response. First, sexual/
sex-based harassment presents as a systems corruption,
not a localized problem. Second, that sex-based harassment is a manifestation of gender inequality. The term
“sexual harassment” fails to address the unequal genderrelational and “put-down” behaviors captured by the category of gender harassment in “sex-based harassment.”
Three categories may better account for the range of violence and discrimination that female health workers may
face at work.
Given the foregoing, what interventions and mechanisms are most likely to be effective in prevention and
response? The first answer is this: Policies and interventions should target gender inequality and link efforts to
end workplace violence and harassment with efforts to
end other forms of inequality and violence in the health
sector [26]. Moreover, since sexual harassment involves
individuals, groups, communities (including organizational “communities") institutions and structures, policies
and interventions should be multi-level and follow an
ecological model [26] similar to other gender-based violence prevention and response efforts.
The second answer is aimed at HRH/M leaders: Interventions should target organizational change. Research
has demonstrated that the most powerful determinant
of sexual harassment is organizational climate and its
tolerance of harassment [74, 76]. Changing an organization’s climate may involve leadership dissemination of
a zero-tolerance policy, management visibly taking all
complaints seriously, reporting on the results of investigations and following through on sanctions [74] to end
impunity. The problem of sex-based harassment should
be “spoken” [16] through reporting systems that are safe
and not punishing to targets. However, there is not much
evidence that internal complaint processes, alone or as
they are currently designed, prevent sex-based harassment, because typically leave in place the broader organizational drivers that perpetuate harassment [24], rely or
focus on individuals and expose the individual target to
Page 15 of 19
professional, economic and psychological risks. Certainly, formal and non-formal grievance mechanisms
should be available to employees, but take note of a 2002
study that concluded that it is unreasonable to report sexual harassment, and that sometimes the most reasonable
course of action is to avoid reporting, when the organizational response is likely to minimize the experience,
where there are procedural difficulties, or when a lack
of leadership commitment contributes to greater negative and psychologically distressing effects [76]. KabattFarr and Crumley point out that targets of harassment
develop multiple coping strategies that may or may not
include reporting and that it is unfair and uninformed to
disregard the experience of harassment simply because it
is not reported [74]. Wear and Altman recommend that
the focus of inquiry should be on the institutional environment and not on the target’s report [67]. Efforts to
eradicate an ongoing culture of workplace of sex-based
harassment must avoid policies or practices that suppress
reporting: Standards that make sexual harassment actionable only if cases are “severe” and “pervasive,” nondisclosure agreements or forced mediation/arbitration [77], as
well as anti-retaliation policies that fail to anticipate the
“dynamics of violation” and the pressure to silence complaints once they are “spoken” [16]. Testing additions or
alternatives to individual, face-to-face reporting include
workplace climate surveys or an information escrow system that would allow a target to place a private complaint
into the custody of a third party, to take effect only when
a specified condition has been fulfilled, e.g., a complaint
is lodged with authorities if an “escrow agent” receives
at least one additional allegation of sexual harassment
against the same individual [78].
Training employees by itself, and as it is typically designed, has likewise proven ineffective [79]. A
bystander program, which takes the onus of ending sexual harassment off the shoulders of the individual and
places responses on the organizational community, targets changes in behavioral/ organizational norms and
may be effective if bystander training integrates contextspecific research evidence on victim-blaming and other
silencing dynamics, and links sex-based harassment to
sexism, gender inequality and other forms of gendered
violence[26], in addition to training witnesses to disrupt
harassing behaviors in safe ways [80, 81]. It is likely that
the prevention of violence and harassment would be
more effective if bystander programs were established
upstream during heath professional training [82].
Researcher-practitioners have already identified a
key (gender-transformational) structural intervention:
“We already know how to reduce sexual harassment at
work, and the answer is pretty simple: Hire and promote more women” [24, 79]. This may be difficult in the
Newman et al. Hum Resour Health
(2021) 19:59
physician-dominated healthcare setting [74], yet real
gender parity will likely provide the authority, strength
and safety to counter stereotypes, resist harassment and
contribute to reshaping non-sexist organizational norms
and cultures [24]. Flattening the hierarchy [74] may ultimately be necessary to regulate unchecked, subjective
and arbitrary HRM/supervisory authority [24], though
preventive action can be taken during hiring, induction
and ongoing employment and management processes,
such as outlining the parameters of management/supervisory authority, communicating examples of abuses of
management power and conflicts of interest backed up
by a written professional code of conduct, clearly defined
consequences for infractions and due diligence follow-up.
The practice of transferring a serial harasser (“pass the
harasser” [48]) must be named as an HRM and health
system dysfunction that contributes to impunity. “Sextortion” by supervisor or clinician brings into sharp relief
the need for sectoral as well as organizational intervention to disrupt systemic abuses of power and authority.
Effectively ending sex-based harassment may require
anti-corruption measures that have been effective in
other sectors [73, 83, 89–91] including: The use of an
independent external reporting and investigation mechanism; linking to other anti-corruption or good governance efforts; collective action with gender justice groups;
guidelines, sanctions and disciplinary measures against
institutions and individuals found to have perpetrated
corrupt/sextortionary practices; and professional codes
of conduct. In Uganda, in the UMOH worked with health
professional councils to integrate zero tolerance in professional codes of conduct [see Additional file 8].
Good workforce governance and management require
a gender-aware, human rights-based approach that holds
employers accountable through HRM policies and practices which reflect international human rights and labor
standards that protect health workers from gender-based
harassment, violence and discrimination in the workplace [40, 42, 84, 85]. It has been observed that Human
Resource departments function to protect the organization, not the employee [86]. In contrast, human rightsbased HR would facilitate access to justice, through
administrative measures to end impunity as well as
access to legal remedies where administrative measures
prove ineffective [85, 87].
Research on health system dysfunction should survey and make visible incidents of sex-based harassment
in efforts to create health workplaces that offer “decent
work” [88] to employees and high-quality services to clients. Future research should assess often-hidden patterns
of sexual/sex-based harassment, including organizational context- and culture-specific patterns of coercion,
gender harassment and unwanted sexual attention and
Page 16 of 19
leadership tolerance of these; the dynamics of sex-based
and racial/ethnic and other culturally-relevant bases
of harassment, the prevalence of “sextortion” of both
patients and employees, including their (similar or different) dynamics, effects and consequences, and test administrative and legal measures that effectively disrupt them.
Health system strengthening in the time of COVID-19
suggests that research should track how this social disruption may exacerbate or disrupt, or create new, patterns of sex-based abuse and vulnerability in health
systems.
Conclusions
Sex-based harassment created distressing work environments in UMOH workplaces, abridged female health
workers’ rights and opportunities and patients’ safety,
corrupted HRM and performance management systems
and undermined the achievement of human resource systems’ goals. Health systems leaders should seek organizational and sectoral solutions to end sex-based harassment
and make gender equality and the protection of employees’ rights HRH policy priorities.
Abbreviations
GBV: Gender-Based Violence; GDIA: Gender Discrimination and Inequality
Analysis; HR: Human Resources; HRH/M: Human Resources for Health/Management; HSS: Health Systems Strengthening; KII: Key Informant Interview; IDI:
In-Depth Interview; FGD: Focus Group Discussion; UMOH: Uganda Ministry of
Health.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12960-021-00569-0.
Additional file 1: Illustrative Definitions.
Additional file 2: Definition and Interpretation from Uganda’s 2012
Employment (Sexual Harassment) Regulations.
Additional file 3: Data Collection Methods and Sample.
Additional file 4: Forms and Examples of Sexual Harassment Experienced
by Health Employees.
Additional file 5: Two Cases of Secondary Injury after Reporting Sexual
Harassment.
Additional file 6: Regional, Ethnic and Gender Stereotypes.
Additional file 7: Patient Harassment by Health Workers.
Additional file 8: How the MOH Took the Study Results into Account.
Acknowledgements
The authors wish to acknowledge the visionary leadership of Uganda’s
Minister of Health the Hon. Dr. Jane Ruth Acheng and Permanent Secretary Dr.
Diana Atwine. We gratefully acknowledge the support of Dr. Vincent Oketcho,
former Chef of Party of the Strengthening Human Resources for Health project
and its senior management team, for their advocacy and instrumental support; Kaitlyn Moloney for coordination of the data collection; and Cassie Rice
for assistance with the literature review.
Newman et al. Hum Resour Health
(2021) 19:59
Authors’ contributions
CN conceived, designed, and interpreted study results, oversaw the design
and implementation of the initiative and drafted the article. SN and AA implemented the research, analyzed the results and made major contributions to
the research report. AN lead health sector dissemination and coordinated
the design and implementation of pilot interventions. LA reviewed the final
manuscript. All authors read and approved the final manuscript.
Funding
The US Agency for International Development funded the research and implementation through contract No. AID-617-LA-14-00001, Strengthening Human
Resources for Health with IntraHealth International.
Page 17 of 19
9.
10.
11.
12.
13.
Availability of data and materials
Datasets and transcripts were destroyed after the study was completed as
per the protocol. Data necessary to interpret, replicate and build upon the
findings are in unpublished text files available from the corresponding author
on reasonable request.
14.
15.
Declarations
Ethics approval and consent to participate
Ethical approval for the assessment was obtained from Makerere University
School of Public Health Research and Ethics committee and Uganda National
Council for Science and Technology (Number SS4137).
Consent for publication
Not applicable.
Competing interests
There are no financial and non-financial competing interests.
16.
17.
18.
19.
20.
Author details
1
IntraHealth International, 6340 Quadrangle Drive, Suite 200, Chapel Hill, NC
27510, USA. 2 Formerly an employee of Intrahealth International, Kampala,
Uganda. 3 Department of Sociology and Anthropology. School of Social Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda. 4 Uganda Ministry
of Health, Plot 6, Lourdel Road, Wandegeya, P.O Box 7272, Kampala, Uganda.
21.
Received: 30 April 2020 Accepted: 18 February 2021
23.
22.
24.
References
1. UN Women. Towards an end to sexual harassment: the urgency and
nature of change in the era of #MeToo. 2018. p. 11
2. European Union Agency for fundamental rights. Violence against
women: an EU survey. Main results. 2014.p. 95–96. https://fra.europa.eu/
en/publication/2014/violence-against-women-eu-wide-survey-mainresults-report
3. #MeToo Impact Report. 2019. https://metoomvmt.org/wp-content/uploa
ds/2020/01/2019-12-09_MeToo_ImpactReport_VIEW_4.pdf2020/01/
2019-12-09_MeToo_ImpactReport_VIEW_4.pdf. Accessed Oct 20, 2018
4. Uganda Ministry of Health Workforce Study. Satisfaction and intent to stay
among current health workers. Chapel Hill: USAID Capacity Project; 2003.
5. Newman C, Mugisha M, Matsiko C. Uganda Ministry of Health gender
discrimination and inequality analysis report. IntraHealth International,
Chapel Hill. 2012. https://www.intrahealth.org/sites/ihweb/files/files/
media/uganda-ministry-of-health-gender-discrimination-and-inequalityanalysis-report/GDIA-Report.pdf
6. Tamale S. When hens begin to crow: Gender and parliamentary politics in
Uganda. Boulder: Westview Press; 1999. p. 135.
7. Kyomukama S. Sexual harassment at the workplace: A case study of the
Uganda police force. 2004.
8. Aloka J. Prevalence and management of sexual harassment at the workplace: The case of Uganda prison service (2002–2006). A thesis submitted
in partial fulfilment of the requirements for the award of the degree of
Masters of Arts in public administration and management of Makerere
University. 2009
25.
26.
27.
28.
29.
30.
31.
32.
33.
Research Triangle Institute and World Vision. School-related genderbased violence formative assessment. USAID/Uganda Literacy Achievement and Retention Activity. 2018
The Guardian. ’Men fear us’: Kampala’s market women unite against harassment.” Nd. https://www.theguardian.com/global-development/2019/
aug/19/men-fear-us-kampalas-market-women-unite-against-harassment
Attributed to Albert Einstein. Not everything that counts can be counted,
and not everything that can be counted counts. http://www.braintrainingto
ols.org/skills/not-everything-that-counts-can-be-counted-by-albert-einstein/
Pina, A, Gannon TA & Saunders, B. An overview of the literature on sexual
harassment: Perpetrator, theory, and treatment issues. Aggression and
Violent Behavior (14). 2009. 126–138. P. 130.
Advocates for Human Rights. Causes, theories and effects of sexual
harassment. http://www.stopvaw.org/Theories_of_Sexual_Harassment.
Accessed February 2020.
Yount KR. Ladies, flirts and tomboys: strategies for managing sexual
harassment in an underground coal mine. J Contemp Ethnogr.
1991;19:396–422.
Friedman GS, Whitman JQ. The European transformation of harassment
law: Discrimination versus dignity. SSRN Journal. 2003.
Hearn, J, Parkin. Gender, sexuality and violence in organizations: the
unspoken forces of organizational violations. 2001. Sage Publications.
Connell R. Gender, health and theory: Conceptualizing the issue, in local
and world perspective. Social Science and Medicine. (2011) pp. 1675–1683.
O’Connell CE, Korabik K. Sexual harassment: The relationship of personal
vulnerability, work context, perpetrator status, and type of harassment to
outcomes. J Vocat Behav. 2000;56(3):299–329.
World Health Organization. Delivered by women, led by men: A gender
and equity analysis of the global health and social workforce. Human
Resources for Health Observer Series No. 24. 2019. https://www.who.int/
hrh/resources/health-observer24/en/
Advocates for Human Rights. http://www.stopvaw.org/Violence_and_
Power; http://www.stopvaw.org/Perpetuation_of_Gender_Stereotypes;
http://www.stopvaw.org/Economic_Power_over_Women. Accessed Feb
2020.
Cockburn C. In the way of women. Men’s resistance to sex equality in
organizations. Cornell International Industrial and Labor Relations Project.
ILR Press: Ithaca, NY. 1993. Number18. 141–142
McKinnon C. Sexual harassment of working women: a case of sex discrimination. New Haven: Yale University; 1979.
Konik J, Cortina L. Policing gender at work: intersections of harassment
based on sex and sexuality. Social Justice Res. 2008;21(3):313–37.
Schultz V. Open statement on sexual harassment from employment
discrimination law scholars. 71 Stanford Law Review Online. 2018
United Nations. Declaration on the elimination of violence against
women. 1993. https://www.un.org/en/genocideprevention/documents/
atrocity-crimes/Doc.21_declaration%20elimination%20vaw.pdf
Coalition of Feminists for Social Change (COFEM). Connecting genderbased violence, sexual harassment and everyday sexism. Feminist Pocket
Book. TIP SHEET #3. 2018. https://cofemsocialchange.org/wp-content/
uploads/2018/11/TS3-Connecting-gender-based-violence-sexual-haras
sment-and-everyday-sexism.pdf
Berdahl JL. Harassment based on sex: Protecting social status in the
context of gender hierarchy. The Academy of Management Review.
2007a;32(2):641–58.
Advocates for Human Rights. Sexual harassment and the subordination
of women. http://www.stopvaw.org/Sexual_Harassment_and_the_Subor
dination_of_Women. Accessed Feb 2020.
Stockdale MS, Berry CG, Schneider RW, Cai F. Perceptions of the sexual
harassment of men. Psychol Men Masculinity. 2004;5(2):158–67.
Berdahl J, Magley VR, Waldo C. The sexual harassment of men?:
Exploring the concept with theory and data. Psychol Women Quar.
1996;1(20):527–47.
Knapp DE, Kustis GA. Same-sex sexual harassment: A legal review with
implications for organizational policy. Employee Responsibilities and
Rights Journal. 2000;12:105–19.
Fitzgerald LF, Gelfand MJ, Drasgow F. Measuring sexual harassment:
Theoretical and psychometric advances. Basic Appl Soc Psychol.
1995;17(4):425–45.
Schultz V. Reconceptualizing sexual harassment. The Yale Law Journal.
1998;107:125.
Newman et al. Hum Resour Health
(2021) 19:59
34. Schultz V. Reconceptualizing sexual harassment, again. SSRN Journal.
2018.
35. National Academies of Sciences, Engineering, and Medicine; Policy
and Global Affairs; Committee on Women in Science, Engineering, and
Medicine; Committee on the Impacts of Sexual Harassment in Academia;
Benya FF, Widnall SE, Johnson PA, editors. Washington (DC): National
Academies Press (US); 2018
36. Leskinen EA, Cortina LM, Kabat DB. Gender harassment: Broadening our
understanding of sex-based harassment at work. Law and Human Behavior. 2010.
37. Newman C, Ng C, Pacqué-Margolis S, Frymus D. Integration of gendertransformative interventions in health professional education reform for
the 21st century. Human Resourc Health. 2016;14:14.
38. Newman C, De Vries D, Kanakuze J, and Ngendahimana G. Workplace Violence and Gender Discrimination in Rwanda’s Health Workforce: Increasing Safety and Gender Equality. Human Resources for Health. 2011. Vol. 9.
39. Newman C, Chama PK, Mugisha M, Matsiko CW, Oketcho V. Reasons
behind the current gender imbalance in senior global health roles and
the practice and policy changes that can catalyze organizational change
in gendered organizations. Global Health, Epidemiology and Genomics.
Global Health, Epidemiology and Genomics. 2017. Volume 2, e19.
40. Newman C. Time to address gender discrimination and inequality in the
health workforce. Human Resourc Health. 2014;12:25.
41. Newman C, Kimeu A, Penders C, Shamblin L, Bwonya J, McQuide P.
Making nondiscrimination and equal opportunity for education a reality
in Kenya’s pre-service health training institutions: results of a gender
analysis. World Health and Population. 2011;13(2):11.
42. International Labour Organization. Violence and Harassment Convention
190. Article 1. 2019.https://www.ilo.org/dyn/normlex/en/f?p=NORML
EXPUB:12100:0::NO::P12100_ILO_CODE:C190
43. Olney S. ILO Convention on Violence and Harassment: Five key questions.
International Labour Organization. https://www.ilo.org/global/abouttheilo/newsroom/news/WCMS_711891/lang--en/index.htm. Accessed
May 2020
44. Berdahl JL. The Sexual harassment of uppity women. J Appl Psychol.
2007b;92(2):425–37.
45. International Labour Organization, International Council of Nurses,
World Health Organization and Public Services International. Framework
guidelines for addressing workplace violence in the health sector. Geneva,
International Labour Office, 2002. https://apps.who.int/iris/handle/10665/
42617
46. di Martino V. Workplace violence in the health sector: Country case studies
Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and an additional
Australian study: Synthesis report. Geneva, Switzerland: ILO/ICN/WHO/PSI
Joint Programme on Workplace Violence in the Health Sector, 2002. http://
www.who.int/violence_injury_prevention/violence/activities/workplace/
WVsynthesisreport.pdf
47. Chaudhuri, P. Sexual harassment in the workplace: Experiences of women in
the health sector. Health and Population Innovation Fellowship Programme
Working Paper No. 1. New Delhi: Population Council 2006.
48. Cantalupo, NC, Kidder, WC. Sexual harassment of students by university
faculty: A systematic look at a serial problem. Utah Law Review. Volume
2018. Number 3. Article 4.
49. Sen P, Borges E, Guallar E, Cohran J. Towards an end to sexual harassment:
The urgency and nature of change in the era of #MeToo. Office of the
Executive Coordinator and Spokesperson on Addressing Sexual Harassment
and Discrimination at UN Women. 2018.
50. European Union Agency for fundamental rights. Violence against women:
an EU survey. Main results. 2014.p. 95-96. https://fra.europa.eu/en/publi
cation/2014/violence-against-women-eu-wide-survey-main-results-report
51. Hlavka HR. Normalizing sexual violence: Young women account for harassment and abuse. Gender Soc. 2014;28(3):337–58. https://doi.org/10.1177/
0891243214526468.
52. Mateo A, Menza K. The results of a 1976 survey of women about sexual
harassment at work remain virtually unchanged in 2017. Redbook. 2017.
https://www.Redbookmag.Com/Life/Money-Career/A49220/Sexual-Haras
sment-In-The-Workplace/. Accessed Febr 2020.
53. Dobbin F, Kalev A. Why diversity programs fail. Harvard Business Review.
2016.
54. McLaughlin H, Uggen C, Blackstone A. The economic and career effects of
sexual harassment on working women. Gend Soc. 2017;31(3):333–58.
Page 18 of 19
55. Schneider KT, Swan S, Fitzgerald LF. Job-related and psychological effects of
sexual harassment in the workplace: empirical evidence from two organizations. J Appl Psychol. 1997;82(3):401–15. https://doi.org/10.1037/0021-9010.
82.3.401.
56. Willness CR, Steel P, Lee K. A Meta-Analysis of the Antecedents and
Consequences of Workplace Sexual Harassment. Personnel Psychology.
2007;60(1):127–62. /https://doi.org/10.1111/j.1744-6570.2007.00067.x
57. Feldblum CR, Lipnic VA. Select Task Force on the Study of Harassment in the
Workplace: Report of Co-Chairs. 2016. https://www.eeoc.gov/eeoc/task_
force/harassment/report.cfm
58. Suarez E, Gadalla TM. Stop blaming the victim: a meta-analysis on rape
myths. J Interpers Viol. 2010;25(11):2010–35.
59. Chapleau KM, Oswald DL, Russell, BL. Male rape myths: The role of gender,
violence and sexism. Journal of Interpersonal Violence. 2008.
60. Fitzgerald L. Still the last great open secret: Sexual harassment as systemic
trauma. J Trauma Dissoc. 2017;18(4):483–9.
61. Baugh SG. On the persistence of sexual harassment in the workplace. J Bus
Ethics. 1997;16(9):899–908.
62. Katz J. The macho paradox: Why some men hurt women and how all men
can help. Sourcebooks: Inc; 2006. p. 73.
63. Freyd JJ. What is DARVO? https://dynamic.uoregon.edu/jjf/defineDARVO.
html. Accessed Sept 2019.
64. Abramson K. Turning up the lights on gaslighting. Philos Persp. 2014;28:1.
65. Gaslighting SC. Misogyny and psychological oppression. Monist.
2019;102:221–35.
66. Ahern K. Institutional betrayal and gaslighting: Why whistle-blowers are so
traumatized. Continuing education Perinat Neonat Nurs. 2018;32(1):59–65.
67. Wear D & Altman J. Sexual harassment in academic medicine: Persistence,
non-reporting, and institutional response. Med Educ Online. 2005:10:10.
http://www.med-ed-online.org.
68. Hinze SW. “Am I being oversensitive?” Women’s experience of sexual
harassment during medical training. health: an Interdisciplinary. J Soc Study
Health Illn Med. 2004;8:1.
69. Gioia DA, Corley KG, Hamilton AL. Seeking qualitative rigor in inductive
research: Notes on the Gioia methodology. Org Res Meth. 2013;16:15.
70. Uganda Ministry of Health. Guidelines to implement the policy on prevention and response to sexual harassment. 2018. http://library.health.go.ug/
publications/gender-based-violence/guidelines-implement-policy-preve
ntion-and-response-sexual
71. Manne K. Down Girl: The logic of misogyny. Oxford: Oxford University Press;
2017.
72. Boland, ML. Sexual harassment: Your guide to legal action. What you should
know and what you can do. Sphinx Publishing: Napierville: 2002 (Quoting
the decision on Meritor v. Vinson]
73. International Association of Women Judges. Stopping the abuse of power
through sexual exploitation: Naming, shaming, and ending sextortion. 2012.
Washington, D.C.: Frank Vohl. http://www.iawj.org/wp-content/uploads/
2017/04/Corruption-and-Sextortion-Resource-1.pdf
74. Kabat-Farr D, Crumley ET. Sexual harassment in healthcare: a psychological
perspective. Online J Issues Nurs. 2019;24:4.
75. Advocates for Human Rights. Violence and power. http://stopvaw.org/Viole
nce_and_Power. 2018. Accessed Feb 2020.
76. Bergman ME, Langhout RD, Palmieri PA, Cortina LM, Fitzgerald LM. The (un)
reasonableness of reporting: Antecedents and consequences of reporting
sexual harassment. J Appl Psychol Copyright 2002 by the American Psychological Association, Inc. 2002, Vol. 87, No. 2, 230–242.
77. Precious T. New workplace sexual harassment protections become law.
buffalonews.com. Accessed Dec 2020
78. Ayres I & Unkovic C. Information Escrows. 111 Mich. L. Rev.145 (2012).
https://repository.law.umich.edu/mlr/vol111/iss2/1.
79. Dobbin F, Kalev A. Training programs and reporting systems won’t end
sexual harassment. Promoting women will. Harvard Business Review. 2017.
80. Schulte, Brigid. To combat harassment, more companies should try
bystander training. Harvard Business Review. 2018.
81. Swann, SL. Bystander interventions. Wisconsin Law Review. 2015:975–1047
82. Kahsay WG, Negarandeh R, Dehghan N, Hasanpour M. Sexual harassment
against female nurses: a systematic review. BMC Nurs. 2020;19:58. https://
doi.org/10.1186/s12912-020-00450-w.
83. Rimmer A. BMA sexism: Doctors at annual meeting hear fresh allegations of
harassment. BMJ. 2019.
Newman et al. Hum Resour Health
(2021) 19:59
84. United Nations Human Rights Office of the High Commissioner. CEDAW
General Recommendation 35 on gender-based violence against women.
July 2017. Treaty bodies Download (ohchr.org). Accessed December 2020.
85. United Nations General Assembly: Report of the Working Group on the
Issue of Discrimination Against Women in Law and Practice. Human Rights
Council; 2012. A/HRC/20/28. [http://www.ohchr.org/Documents/Issues/
Women/AHRC-20-28_en.pdf ].
86. Kasperkevic, J. HR is not there to be your friend. It’s there to protect the
company. Marketplace. 2017. Accessed Dec 2020.
87. United Nations Human Rights Office of the High Commissioner. Optional
Protocol to the Convention on the Elimination of All Forms of Discrimination against Women. OHCHR | Optional Protocol CEDAW. Accessed December 2020.
88. International Labor Organization. Decent work. Decent work (ilo.org)
accessed January 2021.
Page 19 of 19
89. International Peace Institute.Combatting sexual harassment at the United
Nations. March 29, 2018. Combating Sexual Harassment at the United
Nations | International Peace Institute (ipinst.org). Accessed Feb 2021.
90. Hossain N, Musembi CN and Hughes, J. Corruption, accountability and
gender: Understanding the connections. Primers in gender and democratic
governance. UNDP and UNIFEM. 2010. Corruption-accountability-andgender(9).pdf. Accessed Feb 2021.
91. United Nations Development Program. Fighting corruption in the education sector: Methods, tools and good practices. UNDP. 2011. Anticorruption
Methods and Tools in Education Lo Res (1).pdf. Accessed Feb 2021.
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Madhusudan Subedi
Patan academy of health sciences
Werner Soors
Institute of Tropical Medicine, Antwerp
Alberto N Ramos Jr
Universidade Federal do Ceará
Garumma T Feyissa
Drexel University
