553430
research-article2014
CPJXXX10.1177/0009922814553430Clinical PediatricsEom et al
Article
Sexual Harassment in Middle and High School Children and Effects on Physical and Mental Health
Clinical Pediatrics 2015, Vol. 54(5) 430–438 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814553430 cpj.sagepub.com
Elizabeth Eom, MS1,2, Stephen Restaino, DO1,2, Amy M. Perkins, MS1,2, Nicole Neveln, MS1,2, and John W. Harrington, MD1,2
Abstract Sexual harassment can be physical interaction and touching, as well as, psychological, environmental, or via Internet and text messaging. An online survey in an urban clinic asked children, aged 12 to 18 years the following: demographic data, height and weight, chronic medical conditions, healthcare use, questions concerning sexual harassment— witnessed and exposure, and finally questions from the Pediatric Symptom Checklist (PSC-35). Overall, 124 of 210 (59%) of the 12- to 18-year-olds surveyed had experienced sexual harassment, with the predominance being female 69% (80/116) versus 48% (49/92) male. Participants who had experienced sexual harassment were significantly more likely to score positive for psychological impairment than those who had not experienced sexual harassment (chi-square test P < .001; odds ratio: 4.7 (95% confidence interval, 1.9-11.8). There was a borderline significant association between elevated body mass index and having experienced sexual harassment (2-sample t test P = .08). Sexual harassment has a direct correlation to psychological impairment in adolescents, especially females. Keywords sexual harassment, adolescent, mental health Defining sexual harassment can be challenging, since it is not only considered physical face-to-face interaction and touching, it can be psychological, environmental, and via Internet and text messaging.1 Since there is no universal definition and sexual harassment has commonly been paired with bullying, widely variable rates of sexual harassment have occurred across studies. In a recent national survey done by telephone in the United States in 2011, the respondents of youths aged (10-13 years) and (14-17 years) had experienced sexual harassment in the past year at rates of 2.8% and 9.3% respectively.2 However, in studies directly surveying children and adolescents from fifth grade throughout high school, who were asked if they experienced some form of sexual harassment within the past 2 weeks or ever, the reported rates of sexual harassment varied anywhere from 15% to 81%.3-5 Some studies have shown females to be much more likely to experience sexual harassment, and other studies have shown males and females to have an equal likelihood of experiencing sexual harassment.2,5 Gender differences in how a student might experience sexual harassment have been noted. Females are likely to experience belittlement and objectification because of their sex, whereas males experience vulgar and homophobic
comments.6,7 Youth with more advanced pubertal status are also more likely than their less advanced peers to be victims of harassment.7,8 Despite the frequency and awareness of sexual harassment, there is little research found in the pediatric literature concerning the longitudinal mental and physical health effects on both male and females as they progress through school. Goldstein et al8 reported that sexual harassment in eighth grade predicted increased problems with substance use, lower self-esteem, and symptoms of depression 3 years later. It has also been reported that sexual harassment can increase school absences, worsen academic performance, and create mental stress leading to mental health problems.9 In addition, sexual harassment can increase an adolescent’s preoccupation with appearance and thus increase the risk of developing eating disorders.10 Chiodo et al11 reported on multiple 1
Eastern Virginia Medical School, Norfolk, VA, USA Children’s Hospital of The King’s Daughters, Norfolk, VA, USA
2
Corresponding Author: John W. Harrington, Department of Pediatrics, Children’s Hospital of The King’s Daughters, 601 Children’s Lane, Norfolk, VA 23507, USA. Email: [email protected]
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Eom et al psychosomatic parameters in their longitudinal study utilizing 12 items from the depression and anxiety subscales of the Brief Symptom Inventory.12 Their study showed strong correlations with sexual harassment and emotional distress, self-harming behaviors, and suicidal ideation. Although studies have focused on psychosomatic complaints related to sexual harassment, few have looked directly at physical complaints or ailments. It has been shown that students who are bullied, perhaps a proxy for sexual harassment, can be affected by poor physical health. This can be manifested by a variety of symptoms including headache, backache, abdominal pain, skin problems, sleeping problems, bed-wetting, and dizziness.13-17 Some schools consider sexual harassment as a form of bullying.18,19 Distinguishing between the 2 terms is important because they have different definitions and therefore may not have similar longitudinal outcomes. Sexual harassment, for our purposes, will be defined as unwelcome conduct of a sexual nature which can include unwelcome sexual advances, requests for sexual favors, or other verbal, nonverbal, or physical conduct of a sexual nature.20,21 This study seeks to specifically look at sexual harassment in the teenager age population by (1) assessing the prevalence of sexual harassment amongst adolescents, who present for well and sick care at a General Academic Pediatric practice, in a predominantly urban African American population and (2) determining whether exposure to sexual harassment correlates with psychological impairment on the Pediatric Symptom Checklist-35–Youth Report (Y-PSC-35), and (3) if exposure to sexual harassment has any effect on overall body mass index (BMI), increased listing of chronic illnesses, or increased health care utilization.
Methods This study applied a questionnaire to adolescents in the clinic setting to investigate their experiences with sexual harassment at school and outside of school.
Survey Population Participants were patients between the ages of 12 and 18 years, scheduled for a well or sick visit in the General Academic Pediatrics practice located on the main floor of the Children’s Hospital of The King’s Daughters, in Norfolk, Virginia. The patient population is predominantly African American (85%) with Medicaid or Medicaid managed care as their primary insurance. Participation required both—consent from parent or legal guardian and assent from the adolescent.
Development of the Survey The online survey tool SurveyMonkey was used to create the questionnaire used in this study. We included questions on demographic data (age, sex, grade, and ethnicity); height and weight; questions on chronic medical conditions and on the use of health care; questions about the frequency of sexual harassment witnessed; questions concerning exposure to sexual harassment from American Association of University Women,20 and 35 questions from the Y-PSC-35.22 A copy of the full survey is available on request. Psychological impairment was defined as any score ≥ 30 on the Y-PSC-35. Participants were defined as having experienced sexual harassment if they reported “rare”, “occasional”, “often”, or “very often” occurrences of at least 1 of the following: (1) I have been the target of sexual comments, jokes, teasing, gestures, or looks; (2) I have had my clothing pulled in a sexual way; (3) I have had sexual rumors spread about me; (4) I have had my way blocked in a sexual way; (5) I have been touched, grabbed, or pinched in a sexual way; or (6) I have been shown or given sexual pictures, photographs, illustrations, messages, or notes.
Survey Administration We collected data over 2 time periods—from June 2012 through August 2012 and from April 2013 through June 2013. An additional question concerning how the participant handles exposure to sexual harassment via electronic and social media was included in the second time period. Participants completed the survey in the clinic at the time of their medical appointment using an iPad provided by the researcher. The research assistant reviewed all the patients scheduled for the day in the General Academic Pediatric outpatient area and identified adolescents that met the study inclusion criteria as they were being triaged. Once the patient was placed in a room, the research assistant entered and explained to the patient and parent/guardian that they are recruiting the adolescent for an anonymous survey that will ask questions concerning their experiences with sexual harassment at school and outside of school. Once the parent/ guardian consented and the adolescent assented to the study, the survey software was explained and the survey was completed by the adolescent. A research team member was present to ensure software functionality and ensure that there was no parental input in answering the survey questions. After the final question was completed, the participant alerted the assistant and the connection to SurveyMonkey was discontinued (generally this occurred automatically, but was confirmed by the assistant).
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Clinical Pediatrics 54(5)
Table 1. Demographics (N = 210).
Age (years), mean ±SD Gender Male Female School level Middle school High school Graduated high school Dropped out Race/ethnicity African American Caucasian Latino/Hispanic Native American Asian Multiracial Other Height (in.), mean ± SDa Weight (lb), mean ± SDb BMI (kg/m2) mean ± SDc
n
%
14.6
1.8
92 118
43.8 56.2
81 109 18 2
38.5 51.9 8.6 1.0
169 12 5 3 1 18 2 64.2 145.1 24.76
80.4 5.7 2.4 1.4 0.5 8.6 1.0 3.6 38.0 6.10
Abbreviations: SD, standard deviation; BMI, body mass index. a Seventeen participants did not respond. b Ten participants did not respond. c Data missing for 20 participants.
Statistical Analysis The data were analyzed using SAS 9.3 (SAS Institute, Cary, NC) and SPSS 19 (IBM, Armonk, NY) software. Descriptive statistics were reported for the survey responses, and unknown or missing values were excluded from the analysis. P values less than .05 were considered statistically significant. Comparisons of means between groups were performed using 2-sample t tests. Proportions were compared using chi-square or Fisher’s exact tests, where appropriate. A logistic regression model for having experienced sexual harassment assessed the significance of the relationship with psychological impairment after adjusting for school level, gender, ethnicity, BMI, chronic illness, and health care utilization.
Results
Table 2. Chronic Medical Conditions and Doctor Visits (N = 210).
Long-term medical conditions Asthma Eczema Constipation Attention deficit hyperactivity disorder Allergies Diabetes Obesity Headaches/migraines Seizures Acne Abdominal pain Sickle cell disease Heart problems Other Frequency of seeing doctora Today is the first time I remember seeing a doctor About once every 2 years About once a year About once every 6 months About once every 3 months About once a month About twice a month Weekly Not sure
n
%
74 25 3 19
35.2 11.9 1.4 9.1
69 0 6 21 0 21 4 0 5 9
32.9 0.0 2.9 10.0 0.0 10.0 1.9 0.0 2.4 4.3
3
1.4
7 54 59 25 18 7 4 31
3.4 26.0 28.4 12.0 8.7 3.4 1.9 14.9
a
Two participants did not respond.
medical conditions indicated by participants and the most common interval to visit a doctor was every 6 months (Table 2).
Psychological Impairment Overall, 39 participants (18.6%) had psychological impairment as measured by the Y-PSC-35. After excluding participants with ADHD (attention deficit hyperactivity disorder), 33 of the 191 participants without ADHD (17.3%) had psychological impairment (Table 3).
Demographics and Medical Conditions
Sexual Harassment
Of the 238 patients approached, 210 (88%) agreed to participate in this study. Data was not collected on the 27 patients who did not participate. Approximately 89% of the patients surveyed were African American or multiracial and most were currently in high school (Table 1). Asthma and allergies were the most common
In response to the question “How much do you think sexual harassment happens in your school?”, 57 (27.5%) said “It doesn’t happen,” 73 (35.3%) said “It happens to only a few people,” 38 (18.4%) said “It happens to a fair number of people,” and 39 (18.8%) said “It goes on all the time” (Table 4). One hundred five (50.5%) had
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Eom et al Table 3. Pediatric Symptom Checklist—Youth Report (N = 210). Question Number
n
%
Total Y-PSC-35 score, mean ± SD — 20.3 10.5 Total Y-PSC-35 score (excluding — 19.8 10.4 ADHD) (N = 191), mean ± SD Y-PSC-35 score ≥30 — 39 18.6 Y-PSC-35 score ≥30 (excluding — 33 17.3 ADHD) (N = 191) Ranked Y-PSC-35 questions for participants with score ≥30 (N = 39) Distract easilya 9 38 100.0 Are irritable, angry 12 38 97.4 Worry a lota 22 36 94.7 Feel sad, unhappy 11 36 92.3 School grades dropping 18 36 92.3 Have trouble concentrating 14 35 89.7 Have trouble sleeping 21 35 89.7 Complain of aches or painsa 1 34 89.5 Tire easily, little energy 3 34 87.2 Feel that you are bad 24 34 87.2 Take unnecessary risks 25 34 87.2 Do not listen to rules 29 34 87.2 Seem to be having less funb 27 32 86.5 Spend more time alone 2 33 84.6 Daydream too much 8 33 84.6 Do no show feelings 30 33 84.6 Fidgety, unable to sit still 4 32 82.1 Have trouble with teacher 5 31 79.5 Less interested in school 6 31 79.5 Visit doctor with doctor finding 20 30 78.9 nothing wronga Are afraid of new situations 10 30 76.9 Down on yourself 19 30 76.9 Absent from schoola 17 29 76.3 Get hurt frequently 26 29 74.4 Feel hopeless 13 26 66.7 Want to be with parent more 23 26 66.7 than before Do not understand other 31 25 65.8 people’s feelingsa Fight with other children 16 25 64.1 Less interested in friends 15 24 61.5 Refuse to share 35 24 61.5 Blame others for your troublesa 33 23 60.5 Act as if driven by motor 7 23 59.0 Tease othersb 32 20 54.1 Act younger than children your 28 20 51.3 age Take things that do not belong 34 18 47.4 to youa Abbreviations: Y-PSC-35, Pediatric Symptom Checklist–Youth Report; SD, standard deviation; ADHD, attention deficit hyper-activity disorder. a One participant did not respond. b Two participants did not respond.
witnessed or seen sexual harassment at their school; 68 (32.7%) said they had not, and 35 (16.8%) were not
sure. Overall, 19 (9.2%) had seen or heard of 1 instance of sexual harassment, 36 (17.5%) said 2 to 5 instances, 44 (21.4%) said 6 or more instances in the past year, and 107 (51.9%) said none/not applicable. One hundred twenty-four (59.6%) reported that they had experienced sexual harassment. More specifically, 44 of 92 males (47.8%) and 80 of 116 females (69.0%) had experienced sexual harassment. Females were statistically significantly more likely to have experienced sexual harassment than males (chi-square test P = .002; odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.4-4.3; Figure 1). There were no significant differences in having witnessed or experienced sexual harassment between African American and Caucasian participants (Fisher’s exact test, both P > .05).
Psychological Impairment and Sexual Harassment Thirty-three of the 124 participants (26.6%) who had experienced sexual harassment scored positive for psychological impairment on the Y-PSC-35. Six of the 84 participants (7.1%) who had not experienced sexual harassment scored positive for psychological impairment. Participants who had experienced sexual harassment were statistically significantly more likely to score positive for psychological impairment than comparable participants who had not experienced sexual harassment (chi-square test P < .001; OR = 4.7; 95% CI = 1.9-11.8; Figure 2). A logistic regression model was used to determine that this relationship remained significant after adjusting for school level, gender, ethnicity, BMI, chronic illness, and health care utilization (P = .048; OR = 2.9; 95% CI = 1.0-8.5; Table 5). After excluding participants with ADHD, 30 of the 113 participants (26.6%) who had experienced sexual harassment scored positive for psychological impairment. Three of the 76 participants (4.0%) who had not experienced sexual harassment scored positive for psychological impairment. After excluding participants with ADHD, those who had experienced sexual harassment remained statistically significantly more likely to score positive for psychological impairment than were comparable participants who had not experienced sexual harassment (N = 189; chi-square test P < .001; OR = 8.8; 95% CI = 2.6-30.0). Conversely, the Y-PSC-35 symptoms were not made worse by the combination of ADHD with sexual harassment (Fisher’s exact test, all P > .05), but this negative finding is most likely because of a lack of power given the small number of subjects with ADHD (n = 19). This analysis compared the Y-PSC-35 responses (“never” vs “sometimes” or “often”) for participants with ADHD who had experienced sexual
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Clinical Pediatrics 54(5)
Table 4. Responses to Sexual Harassment Questions (N = 210). n
%
How much do you think sexual harassment happens in your school?a It doesn’t happen 57 27.5 It happens to only a 73 35.3 few people It happens to a fair 38 18.4 number of people It goes on all the time 39 18.8 Have you witnessed or seen sexual harassment at your school?b No 68 32.7 Yes 105 50.5 Not sure 35 16.8 How many instances have your seen or heard of in the past year?c 1 19 9.2 2-5 36 17.5 6+ 44 21.4 Not applicable 107 51.9 124 59.6 Experienced sexual harassmentd I have been the target of sexual comments, jokes, teasing, gestures, or looksb Very often 4 1.9 Often 13 6.3 Occasionally 19 9.1 Rarely 58 27.9 Never 114 54.8 I have had my clothing pulled in a sexual wayb Very often 3 1.4 Often 2 1.0 Occasionally 14 6.7 Rarely 15 7.2 Never 174 83.7 I have had sexual rumors spread about mec Very often 4 1.9 Often 3 1.5 Occasionally 9 4.4 Rarely 24 11.7 Never 166 80.6 I have had my way blocked in a sexual wayb Very often 2 1.0 Often 5 2.4 Occasionally 7 3.4 Rarely 17 8.2 Never 177 85.1 I have been touched, grabbed, or pinched in a sexual waya Very often 7 3.4 Often 7 3.4 Occasionally 21 10.1 (continued)
Table 4. (continued) n
%
Rarely 37 17.9 Never 135 65.2 I have been shown or given sexual pictures, photographs, illustrations, messages, or notesc Very often 10 4.9 Often 6 2.9 Occasionally 17 8.3 Rarely 22 10.7 Never 151 73.3 I have been physically intimidated by another student or personb Very often 6 2.9 Often 3 1.4 Occasionally 17 8.2 19 9.1 Rarely 163 78.4 Never I have stayed home, cut class, or missed work because I felt intimidatedb Very often 1 0.5 3 1.4 Often 6 2.9 Occasionally 8 3.9 Rarely 190 91.4 Never I have felt unsafe in school or outside homec Very often 5 2.4 6 2.9 Often 4 1.9 Occasionally 22 10.7 Rarely 169 82.0 Never I have been punished, threatened, or harassed more as a result of complaining about or reporting sexual harassmente Very often 2 1.0 8 3.9 Often 6 2.9 Occasionally 7 3.4 Rarely Never 182 88.8 a
Three participants did not respond. Two participants did not respond. c Four participants did not respond. d Data missing for 2 participants. e Five participants did not respond. b
harassment (n = 11) versus those with ADHD who had not experienced sexual harassment (n = 8).
Health Status The mean BMI and standard deviation (± SD) was 25.22 ± 6.46 kg/m2 for participants who had experienced sexual harassment and 23.74 ± 4.99 kg/m2 for participants
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Eom et al
who had not experienced sexual harassment. There was a borderline statistically significant association between BMI and having experienced sexual harassment (2-sample t test P = .08). Ninety of 143 participants (62.9%) with a chronic disease had experienced sexual harassment, and 34 of 65 participants (52.3%) without a chronic disease had experienced sexual harassment. There was, however, no association between having a chronic illness (or each individual illness) and having experienced sexual harassment (chi-square or Fisher’s exact test, all P >.05). In addition, there was no association between health care utilization and having experienced sexual harassment (chi-square test P =.37).
Discussion
Figure 1. Student responses to whether they had experienced sexual harassment stratified by gender (N = 208).
Figure 2. Student psychological impairment on the Y-PSC-35 stratified by whether they had experienced sexual harassment (N = 208). The result remained significant after excluding students with attention deficit hyper activity disorder (P < .001, N = 189). Abbreviation: Y-PSC-35, Pediatric Symptom Checklist—Youth Report.
Our study demonstrates that females in middle and high school are more likely to be sexually harassed than males. Although recent studies have shown equal sexual harassment in males and females,11our study mirrors many of the findings in Goldstein et al8 and Nadeem et al,23 where African American females were more likely to be harassed and more likely to have negative psychological outcomes from exposure. This current study also suggests that there may be differences in the pattern of sexual harassment based on a child’s ethnicity and socioeconomic class. Our study reinforces the fact that exposure to sexual harassment can affect the emotional well-being of a child. The data clearly show a correlation for adolescents who experienced sexual harassment to be more likely to have a positive score on the Y-PSC-35. Although the Y-PSC-35 is not a screen that can provide an avenue to a specific diagnosis, data from previous studies show that 67% of children or adolescents with a positive score will have a moderate to severe impairment in psychosocial functioning with the other 33% with a positive score having at least a mild impairment, and all would likely benefit from more specific mental health testing.24,25 Although the mean BMI had SD that overlapped for those who had experienced sexual harassment (25.22 ± 6.46) and those who had not experienced sexual harassment (23.74 ± 4.99), there was a borderline statistically significant association with the 2-sample t test yielding a P value of .08. This may be related to the possibility that females who are heavier may have started their pubertal growth spurts earlier and this may have made them targets for harassment, or perhaps after being harassed they may have been more likely to eat for comfort from being emotionally distraught. There does not appear to be any correlation with sexual harassment and any chronic underlying
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Clinical Pediatrics 54(5)
Table 5. Multiple Logistic Regression Model for Psychological Impairment Using SAS PROC LOGISTIC.a Variable
Coefficient (β)
SE
Wald χ2
P Value
OR
95% CI
−7.3
1.8
15.6
research-article2014
CPJXXX10.1177/0009922814553430Clinical PediatricsEom et al
Article
Sexual Harassment in Middle and High School Children and Effects on Physical and Mental Health
Clinical Pediatrics 2015, Vol. 54(5) 430–438 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814553430 cpj.sagepub.com
Elizabeth Eom, MS1,2, Stephen Restaino, DO1,2, Amy M. Perkins, MS1,2, Nicole Neveln, MS1,2, and John W. Harrington, MD1,2
Abstract Sexual harassment can be physical interaction and touching, as well as, psychological, environmental, or via Internet and text messaging. An online survey in an urban clinic asked children, aged 12 to 18 years the following: demographic data, height and weight, chronic medical conditions, healthcare use, questions concerning sexual harassment— witnessed and exposure, and finally questions from the Pediatric Symptom Checklist (PSC-35). Overall, 124 of 210 (59%) of the 12- to 18-year-olds surveyed had experienced sexual harassment, with the predominance being female 69% (80/116) versus 48% (49/92) male. Participants who had experienced sexual harassment were significantly more likely to score positive for psychological impairment than those who had not experienced sexual harassment (chi-square test P < .001; odds ratio: 4.7 (95% confidence interval, 1.9-11.8). There was a borderline significant association between elevated body mass index and having experienced sexual harassment (2-sample t test P = .08). Sexual harassment has a direct correlation to psychological impairment in adolescents, especially females. Keywords sexual harassment, adolescent, mental health Defining sexual harassment can be challenging, since it is not only considered physical face-to-face interaction and touching, it can be psychological, environmental, and via Internet and text messaging.1 Since there is no universal definition and sexual harassment has commonly been paired with bullying, widely variable rates of sexual harassment have occurred across studies. In a recent national survey done by telephone in the United States in 2011, the respondents of youths aged (10-13 years) and (14-17 years) had experienced sexual harassment in the past year at rates of 2.8% and 9.3% respectively.2 However, in studies directly surveying children and adolescents from fifth grade throughout high school, who were asked if they experienced some form of sexual harassment within the past 2 weeks or ever, the reported rates of sexual harassment varied anywhere from 15% to 81%.3-5 Some studies have shown females to be much more likely to experience sexual harassment, and other studies have shown males and females to have an equal likelihood of experiencing sexual harassment.2,5 Gender differences in how a student might experience sexual harassment have been noted. Females are likely to experience belittlement and objectification because of their sex, whereas males experience vulgar and homophobic
comments.6,7 Youth with more advanced pubertal status are also more likely than their less advanced peers to be victims of harassment.7,8 Despite the frequency and awareness of sexual harassment, there is little research found in the pediatric literature concerning the longitudinal mental and physical health effects on both male and females as they progress through school. Goldstein et al8 reported that sexual harassment in eighth grade predicted increased problems with substance use, lower self-esteem, and symptoms of depression 3 years later. It has also been reported that sexual harassment can increase school absences, worsen academic performance, and create mental stress leading to mental health problems.9 In addition, sexual harassment can increase an adolescent’s preoccupation with appearance and thus increase the risk of developing eating disorders.10 Chiodo et al11 reported on multiple 1
Eastern Virginia Medical School, Norfolk, VA, USA Children’s Hospital of The King’s Daughters, Norfolk, VA, USA
2
Corresponding Author: John W. Harrington, Department of Pediatrics, Children’s Hospital of The King’s Daughters, 601 Children’s Lane, Norfolk, VA 23507, USA. Email: [email protected]
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Eom et al psychosomatic parameters in their longitudinal study utilizing 12 items from the depression and anxiety subscales of the Brief Symptom Inventory.12 Their study showed strong correlations with sexual harassment and emotional distress, self-harming behaviors, and suicidal ideation. Although studies have focused on psychosomatic complaints related to sexual harassment, few have looked directly at physical complaints or ailments. It has been shown that students who are bullied, perhaps a proxy for sexual harassment, can be affected by poor physical health. This can be manifested by a variety of symptoms including headache, backache, abdominal pain, skin problems, sleeping problems, bed-wetting, and dizziness.13-17 Some schools consider sexual harassment as a form of bullying.18,19 Distinguishing between the 2 terms is important because they have different definitions and therefore may not have similar longitudinal outcomes. Sexual harassment, for our purposes, will be defined as unwelcome conduct of a sexual nature which can include unwelcome sexual advances, requests for sexual favors, or other verbal, nonverbal, or physical conduct of a sexual nature.20,21 This study seeks to specifically look at sexual harassment in the teenager age population by (1) assessing the prevalence of sexual harassment amongst adolescents, who present for well and sick care at a General Academic Pediatric practice, in a predominantly urban African American population and (2) determining whether exposure to sexual harassment correlates with psychological impairment on the Pediatric Symptom Checklist-35–Youth Report (Y-PSC-35), and (3) if exposure to sexual harassment has any effect on overall body mass index (BMI), increased listing of chronic illnesses, or increased health care utilization.
Methods This study applied a questionnaire to adolescents in the clinic setting to investigate their experiences with sexual harassment at school and outside of school.
Survey Population Participants were patients between the ages of 12 and 18 years, scheduled for a well or sick visit in the General Academic Pediatrics practice located on the main floor of the Children’s Hospital of The King’s Daughters, in Norfolk, Virginia. The patient population is predominantly African American (85%) with Medicaid or Medicaid managed care as their primary insurance. Participation required both—consent from parent or legal guardian and assent from the adolescent.
Development of the Survey The online survey tool SurveyMonkey was used to create the questionnaire used in this study. We included questions on demographic data (age, sex, grade, and ethnicity); height and weight; questions on chronic medical conditions and on the use of health care; questions about the frequency of sexual harassment witnessed; questions concerning exposure to sexual harassment from American Association of University Women,20 and 35 questions from the Y-PSC-35.22 A copy of the full survey is available on request. Psychological impairment was defined as any score ≥ 30 on the Y-PSC-35. Participants were defined as having experienced sexual harassment if they reported “rare”, “occasional”, “often”, or “very often” occurrences of at least 1 of the following: (1) I have been the target of sexual comments, jokes, teasing, gestures, or looks; (2) I have had my clothing pulled in a sexual way; (3) I have had sexual rumors spread about me; (4) I have had my way blocked in a sexual way; (5) I have been touched, grabbed, or pinched in a sexual way; or (6) I have been shown or given sexual pictures, photographs, illustrations, messages, or notes.
Survey Administration We collected data over 2 time periods—from June 2012 through August 2012 and from April 2013 through June 2013. An additional question concerning how the participant handles exposure to sexual harassment via electronic and social media was included in the second time period. Participants completed the survey in the clinic at the time of their medical appointment using an iPad provided by the researcher. The research assistant reviewed all the patients scheduled for the day in the General Academic Pediatric outpatient area and identified adolescents that met the study inclusion criteria as they were being triaged. Once the patient was placed in a room, the research assistant entered and explained to the patient and parent/guardian that they are recruiting the adolescent for an anonymous survey that will ask questions concerning their experiences with sexual harassment at school and outside of school. Once the parent/ guardian consented and the adolescent assented to the study, the survey software was explained and the survey was completed by the adolescent. A research team member was present to ensure software functionality and ensure that there was no parental input in answering the survey questions. After the final question was completed, the participant alerted the assistant and the connection to SurveyMonkey was discontinued (generally this occurred automatically, but was confirmed by the assistant).
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Clinical Pediatrics 54(5)
Table 1. Demographics (N = 210).
Age (years), mean ±SD Gender Male Female School level Middle school High school Graduated high school Dropped out Race/ethnicity African American Caucasian Latino/Hispanic Native American Asian Multiracial Other Height (in.), mean ± SDa Weight (lb), mean ± SDb BMI (kg/m2) mean ± SDc
n
%
14.6
1.8
92 118
43.8 56.2
81 109 18 2
38.5 51.9 8.6 1.0
169 12 5 3 1 18 2 64.2 145.1 24.76
80.4 5.7 2.4 1.4 0.5 8.6 1.0 3.6 38.0 6.10
Abbreviations: SD, standard deviation; BMI, body mass index. a Seventeen participants did not respond. b Ten participants did not respond. c Data missing for 20 participants.
Statistical Analysis The data were analyzed using SAS 9.3 (SAS Institute, Cary, NC) and SPSS 19 (IBM, Armonk, NY) software. Descriptive statistics were reported for the survey responses, and unknown or missing values were excluded from the analysis. P values less than .05 were considered statistically significant. Comparisons of means between groups were performed using 2-sample t tests. Proportions were compared using chi-square or Fisher’s exact tests, where appropriate. A logistic regression model for having experienced sexual harassment assessed the significance of the relationship with psychological impairment after adjusting for school level, gender, ethnicity, BMI, chronic illness, and health care utilization.
Results
Table 2. Chronic Medical Conditions and Doctor Visits (N = 210).
Long-term medical conditions Asthma Eczema Constipation Attention deficit hyperactivity disorder Allergies Diabetes Obesity Headaches/migraines Seizures Acne Abdominal pain Sickle cell disease Heart problems Other Frequency of seeing doctora Today is the first time I remember seeing a doctor About once every 2 years About once a year About once every 6 months About once every 3 months About once a month About twice a month Weekly Not sure
n
%
74 25 3 19
35.2 11.9 1.4 9.1
69 0 6 21 0 21 4 0 5 9
32.9 0.0 2.9 10.0 0.0 10.0 1.9 0.0 2.4 4.3
3
1.4
7 54 59 25 18 7 4 31
3.4 26.0 28.4 12.0 8.7 3.4 1.9 14.9
a
Two participants did not respond.
medical conditions indicated by participants and the most common interval to visit a doctor was every 6 months (Table 2).
Psychological Impairment Overall, 39 participants (18.6%) had psychological impairment as measured by the Y-PSC-35. After excluding participants with ADHD (attention deficit hyperactivity disorder), 33 of the 191 participants without ADHD (17.3%) had psychological impairment (Table 3).
Demographics and Medical Conditions
Sexual Harassment
Of the 238 patients approached, 210 (88%) agreed to participate in this study. Data was not collected on the 27 patients who did not participate. Approximately 89% of the patients surveyed were African American or multiracial and most were currently in high school (Table 1). Asthma and allergies were the most common
In response to the question “How much do you think sexual harassment happens in your school?”, 57 (27.5%) said “It doesn’t happen,” 73 (35.3%) said “It happens to only a few people,” 38 (18.4%) said “It happens to a fair number of people,” and 39 (18.8%) said “It goes on all the time” (Table 4). One hundred five (50.5%) had
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Eom et al Table 3. Pediatric Symptom Checklist—Youth Report (N = 210). Question Number
n
%
Total Y-PSC-35 score, mean ± SD — 20.3 10.5 Total Y-PSC-35 score (excluding — 19.8 10.4 ADHD) (N = 191), mean ± SD Y-PSC-35 score ≥30 — 39 18.6 Y-PSC-35 score ≥30 (excluding — 33 17.3 ADHD) (N = 191) Ranked Y-PSC-35 questions for participants with score ≥30 (N = 39) Distract easilya 9 38 100.0 Are irritable, angry 12 38 97.4 Worry a lota 22 36 94.7 Feel sad, unhappy 11 36 92.3 School grades dropping 18 36 92.3 Have trouble concentrating 14 35 89.7 Have trouble sleeping 21 35 89.7 Complain of aches or painsa 1 34 89.5 Tire easily, little energy 3 34 87.2 Feel that you are bad 24 34 87.2 Take unnecessary risks 25 34 87.2 Do not listen to rules 29 34 87.2 Seem to be having less funb 27 32 86.5 Spend more time alone 2 33 84.6 Daydream too much 8 33 84.6 Do no show feelings 30 33 84.6 Fidgety, unable to sit still 4 32 82.1 Have trouble with teacher 5 31 79.5 Less interested in school 6 31 79.5 Visit doctor with doctor finding 20 30 78.9 nothing wronga Are afraid of new situations 10 30 76.9 Down on yourself 19 30 76.9 Absent from schoola 17 29 76.3 Get hurt frequently 26 29 74.4 Feel hopeless 13 26 66.7 Want to be with parent more 23 26 66.7 than before Do not understand other 31 25 65.8 people’s feelingsa Fight with other children 16 25 64.1 Less interested in friends 15 24 61.5 Refuse to share 35 24 61.5 Blame others for your troublesa 33 23 60.5 Act as if driven by motor 7 23 59.0 Tease othersb 32 20 54.1 Act younger than children your 28 20 51.3 age Take things that do not belong 34 18 47.4 to youa Abbreviations: Y-PSC-35, Pediatric Symptom Checklist–Youth Report; SD, standard deviation; ADHD, attention deficit hyper-activity disorder. a One participant did not respond. b Two participants did not respond.
witnessed or seen sexual harassment at their school; 68 (32.7%) said they had not, and 35 (16.8%) were not
sure. Overall, 19 (9.2%) had seen or heard of 1 instance of sexual harassment, 36 (17.5%) said 2 to 5 instances, 44 (21.4%) said 6 or more instances in the past year, and 107 (51.9%) said none/not applicable. One hundred twenty-four (59.6%) reported that they had experienced sexual harassment. More specifically, 44 of 92 males (47.8%) and 80 of 116 females (69.0%) had experienced sexual harassment. Females were statistically significantly more likely to have experienced sexual harassment than males (chi-square test P = .002; odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.4-4.3; Figure 1). There were no significant differences in having witnessed or experienced sexual harassment between African American and Caucasian participants (Fisher’s exact test, both P > .05).
Psychological Impairment and Sexual Harassment Thirty-three of the 124 participants (26.6%) who had experienced sexual harassment scored positive for psychological impairment on the Y-PSC-35. Six of the 84 participants (7.1%) who had not experienced sexual harassment scored positive for psychological impairment. Participants who had experienced sexual harassment were statistically significantly more likely to score positive for psychological impairment than comparable participants who had not experienced sexual harassment (chi-square test P < .001; OR = 4.7; 95% CI = 1.9-11.8; Figure 2). A logistic regression model was used to determine that this relationship remained significant after adjusting for school level, gender, ethnicity, BMI, chronic illness, and health care utilization (P = .048; OR = 2.9; 95% CI = 1.0-8.5; Table 5). After excluding participants with ADHD, 30 of the 113 participants (26.6%) who had experienced sexual harassment scored positive for psychological impairment. Three of the 76 participants (4.0%) who had not experienced sexual harassment scored positive for psychological impairment. After excluding participants with ADHD, those who had experienced sexual harassment remained statistically significantly more likely to score positive for psychological impairment than were comparable participants who had not experienced sexual harassment (N = 189; chi-square test P < .001; OR = 8.8; 95% CI = 2.6-30.0). Conversely, the Y-PSC-35 symptoms were not made worse by the combination of ADHD with sexual harassment (Fisher’s exact test, all P > .05), but this negative finding is most likely because of a lack of power given the small number of subjects with ADHD (n = 19). This analysis compared the Y-PSC-35 responses (“never” vs “sometimes” or “often”) for participants with ADHD who had experienced sexual
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Table 4. Responses to Sexual Harassment Questions (N = 210). n
%
How much do you think sexual harassment happens in your school?a It doesn’t happen 57 27.5 It happens to only a 73 35.3 few people It happens to a fair 38 18.4 number of people It goes on all the time 39 18.8 Have you witnessed or seen sexual harassment at your school?b No 68 32.7 Yes 105 50.5 Not sure 35 16.8 How many instances have your seen or heard of in the past year?c 1 19 9.2 2-5 36 17.5 6+ 44 21.4 Not applicable 107 51.9 124 59.6 Experienced sexual harassmentd I have been the target of sexual comments, jokes, teasing, gestures, or looksb Very often 4 1.9 Often 13 6.3 Occasionally 19 9.1 Rarely 58 27.9 Never 114 54.8 I have had my clothing pulled in a sexual wayb Very often 3 1.4 Often 2 1.0 Occasionally 14 6.7 Rarely 15 7.2 Never 174 83.7 I have had sexual rumors spread about mec Very often 4 1.9 Often 3 1.5 Occasionally 9 4.4 Rarely 24 11.7 Never 166 80.6 I have had my way blocked in a sexual wayb Very often 2 1.0 Often 5 2.4 Occasionally 7 3.4 Rarely 17 8.2 Never 177 85.1 I have been touched, grabbed, or pinched in a sexual waya Very often 7 3.4 Often 7 3.4 Occasionally 21 10.1 (continued)
Table 4. (continued) n
%
Rarely 37 17.9 Never 135 65.2 I have been shown or given sexual pictures, photographs, illustrations, messages, or notesc Very often 10 4.9 Often 6 2.9 Occasionally 17 8.3 Rarely 22 10.7 Never 151 73.3 I have been physically intimidated by another student or personb Very often 6 2.9 Often 3 1.4 Occasionally 17 8.2 19 9.1 Rarely 163 78.4 Never I have stayed home, cut class, or missed work because I felt intimidatedb Very often 1 0.5 3 1.4 Often 6 2.9 Occasionally 8 3.9 Rarely 190 91.4 Never I have felt unsafe in school or outside homec Very often 5 2.4 6 2.9 Often 4 1.9 Occasionally 22 10.7 Rarely 169 82.0 Never I have been punished, threatened, or harassed more as a result of complaining about or reporting sexual harassmente Very often 2 1.0 8 3.9 Often 6 2.9 Occasionally 7 3.4 Rarely Never 182 88.8 a
Three participants did not respond. Two participants did not respond. c Four participants did not respond. d Data missing for 2 participants. e Five participants did not respond. b
harassment (n = 11) versus those with ADHD who had not experienced sexual harassment (n = 8).
Health Status The mean BMI and standard deviation (± SD) was 25.22 ± 6.46 kg/m2 for participants who had experienced sexual harassment and 23.74 ± 4.99 kg/m2 for participants
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who had not experienced sexual harassment. There was a borderline statistically significant association between BMI and having experienced sexual harassment (2-sample t test P = .08). Ninety of 143 participants (62.9%) with a chronic disease had experienced sexual harassment, and 34 of 65 participants (52.3%) without a chronic disease had experienced sexual harassment. There was, however, no association between having a chronic illness (or each individual illness) and having experienced sexual harassment (chi-square or Fisher’s exact test, all P >.05). In addition, there was no association between health care utilization and having experienced sexual harassment (chi-square test P =.37).
Discussion
Figure 1. Student responses to whether they had experienced sexual harassment stratified by gender (N = 208).
Figure 2. Student psychological impairment on the Y-PSC-35 stratified by whether they had experienced sexual harassment (N = 208). The result remained significant after excluding students with attention deficit hyper activity disorder (P < .001, N = 189). Abbreviation: Y-PSC-35, Pediatric Symptom Checklist—Youth Report.
Our study demonstrates that females in middle and high school are more likely to be sexually harassed than males. Although recent studies have shown equal sexual harassment in males and females,11our study mirrors many of the findings in Goldstein et al8 and Nadeem et al,23 where African American females were more likely to be harassed and more likely to have negative psychological outcomes from exposure. This current study also suggests that there may be differences in the pattern of sexual harassment based on a child’s ethnicity and socioeconomic class. Our study reinforces the fact that exposure to sexual harassment can affect the emotional well-being of a child. The data clearly show a correlation for adolescents who experienced sexual harassment to be more likely to have a positive score on the Y-PSC-35. Although the Y-PSC-35 is not a screen that can provide an avenue to a specific diagnosis, data from previous studies show that 67% of children or adolescents with a positive score will have a moderate to severe impairment in psychosocial functioning with the other 33% with a positive score having at least a mild impairment, and all would likely benefit from more specific mental health testing.24,25 Although the mean BMI had SD that overlapped for those who had experienced sexual harassment (25.22 ± 6.46) and those who had not experienced sexual harassment (23.74 ± 4.99), there was a borderline statistically significant association with the 2-sample t test yielding a P value of .08. This may be related to the possibility that females who are heavier may have started their pubertal growth spurts earlier and this may have made them targets for harassment, or perhaps after being harassed they may have been more likely to eat for comfort from being emotionally distraught. There does not appear to be any correlation with sexual harassment and any chronic underlying
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Table 5. Multiple Logistic Regression Model for Psychological Impairment Using SAS PROC LOGISTIC.a Variable
Coefficient (β)
SE
Wald χ2
P Value
OR
95% CI
−7.3
1.8
15.6
