Context:

Sexual harassment is a growing concern in higher education. Athletic training students should feel safe in their programs, whether in the didactic or clinical setting. Though the Commission on Accreditation of Athletic Training Education creates standards to keep the students safe, there are none regarding sexual harassment training for athletic training students.

Objective:

To determine the rate of sexual harassment training in athletic training students, with a secondary purpose of determining, if indeed sexual harassment training occurs, whether it is associated with the college or university or is offered through an outside entity.

Design:

Survey.

Setting:

Online.

Patients or Other Participants:

Eight hundred eighty-five athletic training students (613 females, 272 males).

Main Outcome Measure(s):

Data were analyzed through SurveyMonkey, and the statistical software R. Frequency counts and percentages were determined. A Fisher exact test was run to determine if there was a relationship between the athletic training student's current knowledge and whether the athletic training student had received harassment training.

Results:

The study found that more than 50% of male and female athletic training students had not recieved sexual harassment training, whereas 75% of all respondents stated that they knew what resources were available to report issues of sexual harrassment. The odds of a person not knowing what resources were available to report harassment and not having training were 6 times the odds of those who had training and did not know what resources were available.

Conclusions:

Our study emphasizes the need for sexual harassment training in athletic training programs. Athletic training students need to know what sexual harassment is and who to report it to. Additionally, they should not feel threatened by reporting any instances of harassment.

INTRODUCTION

Sexual harassment is a growing concern in both didactic and clinical educational settings.13  Recognizing that sexual harassment can interfere with a student's education, the US Supreme Court and the Office of Civil Rights of the US Department of Education have prohibited this discrimination based on Title IX of the Educational Amendments of 1972.2,3  The Equal Employment Opportunity Commission defines sexual harassment 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.”4  According to the Office of Civil Rights, sexual harassment prohibited by Title IX can include touching of a sexual nature; making sexual comments, jokes, or gestures; writing graffiti or displaying or distributing sexually explicit drawings, pictures, or written materials; calling students sexually charged names; spreading sexual rumors; rating students on sexual activity or performance; or circulating, showing, or creating e-mails or Web sites of a sexual nature.3  Though Title IX states that students can sue when the school is “deliberately indifferent” to harassment claims, it is at the institution's discretion to determine how to handle complaints and accusations.3  Most universities implement Title IX as a way to protect student-teacher and peer-to-peer interactions. Any incident involving a person affiliated with the university or taking place on campus is considered to be a reportable event to the Title IX compliance officer. Students placed in an internship setting through their program or major are included in this category. Alarmingly, 49% of student interns have reported5  some form of sexual harassment.

Within the field of athletic training, 64% of female certified athletic trainers perceived they had been sexually harassed as a student and/or professional during clinical rotations or in the professional workplace.4  In 1997, the Atlanta Journal6  reported that an athletic trainer was awarded $672 000 in damages and back pay when a jury found she was victimized by male supervisors and center officials in her position at the Federal Law Enforcement Training Center. The Belleville Times7  (2015) reported a $515 000 award to an athletic trainer who was subjected to harassment and retaliation by requiring her to work after verbal threats were made by her supervisors. Failure to correct a blatantly offensive act may create a hostile environment, which can lead to disciplinary actions, civil lawsuits, and termination of employment. The types of sexual harassment that may occur are also important to consider8 :

  • Peer: Athletic training student to athletic training student (eg, other similar-age individuals)

  • Group: Members of an elite group of students or team

  • Adult to student: Athletic trainer to athletic training student

  • Student to adult: Athletic training student to athletic trainer (contrapower harassment)

  • Adult peer or colleague

  • Administrator to subordinate

  • Subordinate to administrator (contrapower harassment)

In the case of the athletic training students, there can be more than one type of sexual harassment they may face, including peer, group, adult to student, and administrator to subordinate.

In 2000, a questionnaire was developed by researchers9  to assess an athletic training student's perception of various physical and nonphysical sexually harassing behaviors. The questionnaire was sent to students of National Athletic Trainers' Association (NATA) Districts 1 and 2. The results demonstrated that athletic training students reported experiencing at least one behavior of a sexually harassing nature with a student-athlete (88%), coach (49%), and a certified athletic trainer (47%). However, only 21% of those respondents classified the encounters as sexual harassment. Furthermore, the athletic training students reported that the sexually harassing behaviors were more frequently with male (91%) than with female (9%) coaches and were more frequent (69%) in a field experience involving male sports. Though 54% indicated their institution has a formal sexual harassment policy, just over 50% knew what steps to take in the event of sexual harassment. Only 16% reported having received sexual harassment training, though 68% believed that formal training should be required in their athletic training education.9 

As a result of the nature of healthcare professions, internships and clinical rotations are essential components of the learning process. Female (63%) and male (15%) medical school residents reported10  at least one incidence of sexual harassment during the internship experience. Furthermore, 53% of senior medical students reported1  sexual harassment at some point over the course of their medical school program. Interestingly, a multifaceted program aimed at educating professors and students about sexual harassment and gender sensitivity awareness was effective in reducing faculty perceptions of sexual harassment, gender discrimination, and gender insensitivity in the medical school program.11  Specifically, faculty in leadership positions (eg, program directors) attended diversity retreats that provided insight into race and gender sensitivity issues.11 

The Commission on Accreditation of Athletic Training Education (CAATE) requires all students in athletic training programs to complete clinical experiences in a variety of settings under the guidance of preceptors. The CAATE has created standards to keep athletic training students safe, requiring technical standards, immunizations, Occupational Safety and Health Administration training, and cardiopulmonary resuscitation training.12  Sexual harassment training, while not a required component of accreditation, has been recommended by the CAATE.13  All administrators, instructors, and clinical preceptors associated with an athletic training program should be practicing ethically and legally, as outlined by the NATA Code of Ethics, Board of Certification standards of practice, state practice act, and institutional policy.13  These supervisors are expected to provide a safe environment in which athletic training students can work without the threat of harassment, whether or not it is sexual in nature.8 

While limited research on the prevalence of sexual harassment in athletic training exists,4  there are even less data from the student's perspective. In 1998, Velasquez8(p175) stated “athletic trainers ought to understand that the issue of sexual harassment is not excluded from the athletic training setting, will not likely go away, and, therefore, must be dealt with through education and policy enforcement.” Nearly 20 years later, there remains a paucity of evidence that suggests programs are incorporating sexual harassment training into athletic training curricula, although it can be found in medical school training.11  The primary purpose of this study was to determine the rate of sexual harassment training in athletic training students, as well as the differences between the sexes in terms of the training. A secondary purpose was to determine if training is associated with the college or university or, rather, is offered through an outside entity.

METHODOLOGY

Data Collection

Contact information for program directors from all professional and postprofessional CAATE-accredited programs was collected from the CAATE Web site. Researchers contacted each program director over the phone to explain the purpose of the study and to inform him or her that the survey link would be e-mailed to them for dissemination to the students currently enrolled in the athletic training program. Survey links were sent to 460 CAATE-accredited program directors within 1 week of initial contact. Two follow-up e-mails were sent over the course of 6 weeks to remind the program directors to send the link to students. By completing and returning the survey, students agreed to voluntarily participate in the research study. A total of 885 athletic training students completed the survey. Demographic information, including a breakdown by NATA district, is included in Table 1.

Instrumentation

The survey was adapted from a previous questionnaire14  developed to assess the perceptions and experiences of female student-athletes. The format and wording of questions were changed to simplify the responses and to include males. The researchers wanted to include males to examine what gender differences may exist in the identification of harassment.

The adaptation of the survey was reviewed by a panel of experts, including the researchers, the Associate Director of the Student Success Center, the Director of Equal Opportunity/Affirmative Action and Diversity, and a university statistician. Once the survey was accepted by all individuals, it was piloted by 5 students via SurveyMonkey (Palo Alto, CA). The pilot resulted in the identification of survey items that were modified to improve clarity and understanding.

The survey used was part of a larger study examining athletic training students' attitudes toward actions that constitute sexual harassment. The questions included in this article address student answers to general questions about sexual harassment training at their institution and reporting procedures. Those students who indicated they received training outside of their institution were given the opportunity to indicate where training occurred via an open-ended question. Once the survey was completed, they all received information as to whom they could contact if they felt they had been harassed or had witnessed harassment.

SurveyMonkey was used to create and distribute the survey, in addition to storing participant responses. Questions and question type used for analysis are included in Table 2.

Data Analysis

Data were analyzed through SurveyMonkey and the statistical software R (R Foundation, Vienna, Austria). Frequency counts and percentages were determined. The Fisher exact test was run to determine if there was a relationship between the athletic training student's knowledge of what resources are available and whether the athletic training student had received harassment training, based on an α of .05. The Fisher exact test is testing the hypothesis that the knowledge of resources available is independent of sexual harassment training.

RESULTS

A total of 885 athletic training students responded to the survey, consisting of 613 self-identified females and 272 self-identified males. Of the 613 females who responded to the survey, 377 (61.5%) responded that they had not received sexual harassment training; of the 273 males who responded, 145 (53.3%) responded that they had not received training. Figure 1 shows a bar chart of sexual harassment training by gender, suggesting that there is a significant difference between genders and training received, based on Fisher exact test (P = .026, odds ratio [OR] = 1.4, 95% confidence interval on OR = 1.037, 1.886).

Of the 613 females who responded to the question about knowing which resources were available, 454 (74.0%) reported knowing which resources were available. Of the 273 males who responded to this question, 210 (77.2%) responded that they knew which resources were available. The Fisher exact test suggests that the gender of the athletic trainer and the knowledge of available resources are independent of each other, suggesting that a person's gender does not influence the knowledge of what resources are available (P = .354). Table 3 illustrates to which authority figure athletic training students would report potential harassment situations.

Relationship Between Training and Knowledge of Reporting

Table 4 illustrates the comparisons of those who had received training and those who knew which resources were available at the institution. Of the 885 respondents, only 363 (41%) reported that they had received training from their institution. Despite having sexual harassment training, 25% (N = 222) of respondents did not have knowledge of what resources were available.

The data suggest that the knowledge of resources available is dependent on the training athletic training students received (P < .001). The OR of 6.118 (95% confidence interval on OR = 4.030, 9.539) suggests that for athletic training students who have not received training, the odds of not knowing what resources are available were about 6 times the odds of a person having had training not knowing what resources are available.

Athletic Training Student Sexual Harassment Training

There were 592 participants who reported receiving training at various points during their college career (Figure 2). A majority of the students who responded that they had training as a part of the college experience received it during their freshman year. Overall, 29% stated that they received training during a freshman orientation, while 23% stated they had training during their freshman year. Students were also asked if they had received training in places other than the university setting. There were 333 who responded that they had received training elsewhere. Respondents were asked to list where they received training as an open-ended question. Responses that occurred 2 or more times are demonstrated in Figure 3. The larger the word is, the more common the response.

DISCUSSION

The NATA 2014 year-end statistics15  revealed student membership to be 39% male and 61% female. It was the intention of the researchers to match these numbers, but only 30.7% of respondents were male. Regardless of sex, the percentage of respondents who had receieved training was less than that of those who had not. These results demonstrated that a significantly higher percentage of males reported receiving the training. Given the student demographics, it may be expected that a larger percentage of females reported the training.

There were various authority figures to whom students would report sexual harassment, including an assortment of university administrators and athletic training program personnel. Unfortunately, a small percentage (3.13%) chose not to report. Fortunately, 75% of the respondents who went through training retained the knowledge regarding to whom to report sexual harassment.

While 41% of students who received sexual harassment training did so at some point through a college experience, 59% reported receiving it outside of college. These reported trainings may have been formal (eg, training for a job) or informal (eg, parents, Boy Scouts). This becomes problematic in the healthcare setting, where patient and professional interactions are extremely different because of the nature of the athletic training profession. A standardized sexual harassment training protocol would alleviate the burden placed on program directors and university administrators.

According to the Office of Civil Rights, schools must take proactive steps to prevent sexual harassment within their educational programs.2  There are numerous ways schools can do this, including conducting seminars, workshops, and lectures about sexual harassment for both students and faculty; creating mandatory annual surveys of all clinical preceptors and faculty to assess understanding of appropriate behaviors; and having training for those who work with students in recognizing and dealing with sexual harassment issues.2 

In 2008, Shingles and Smith4  demonstrated that there was a lack of understanding about sexual harassment and assault within female certified athletic trainers. The female athletic trainers believed they had to adapt their attitude to the situation rather than recognize that they were victims of a harassing environment. According to Shingles and Smith,4  this lack of understanding suggested that athletic training education, as well as continuing education, needed to be reviewed to determine whether these concerns are being addressed. In the current study, athletic training students who never received any training were 6 times less likely to know what to do in harassing situations. With over 64% of female athletic trainers admittng that they had been sexually harassed, there is a clear need for athletic training students to receive appropriate training that incorporates strategies for creating a safe environment.4 

There are several limitations to this study. The total number of athletic training students in CAATE-accredited programs is unknown, which makes it difficult to calculate a response rate. It is unknown what percetange of students responded to this study, although an attempt was made to reach all students. With the variablity of timing and method of sexual harassment training, students may have displayed recall bias when answering the questions. Additionally, if programs offer training once per year during the spring semester, students who responded to the survey may not have had the opportunity to receive planned programmatic training before participation. While the percentage of male responses (31%) was lower than that of females, it is was close to the reported percentage of male NATA student members (39%).

CONCLUSIONS

Clinical preceptors are expected to provide a safe environment in which athletic training students, patients, and other staff athletic trainers can work without the threat of harassment, sexual or not.8  Unless sexual harassment training is expected at all levels, inappropriate behaviors may be perpetuated. Too often there are comments, jokes, conversations, and physical contacts that are offensive or unwelcome, yet individuals are uncomfortable or embarrassed to speak out.8  All clinical preceptors should be practicing ethically and legally as outlined by the NATA Code of Ethics, their state standards of practice, their state practice act, and institutional policy.13  Athletic training students need to know what sexual harassment is, who to report it to, and that they should not feel threatened by reporting it.

FUTURE DIRECTIONS

The current study results emphasize the need for sound harassment training within athletic training education programs. Future research should focus on the creation of a training program and on determining the effectiveness of training on athletic training student knowledge, perception of sexual harassment, and standard reporting procedures. In addition, because of the imbalance of males and females, we would recommend further study of males and sexual harassment in more detail.

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Author notes

Dr Mansell is currently Assistant Professor and Director of Athletic Training Education at Temple University.