recommendation in research about discrimination

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Perceived Racial/Ethnic Discrimination and Mental Health: a Review and Future Directions for Social Epidemiology

Anissa i. vines.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 266 Rosenau Hall, CB #7435, 135 Dauer Drive, Chapel Hill, NC 27599-7435

Julia B. Ward

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435

Evette Cordoba

Kristin z. black.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7440, Chapel Hill, NC 27599-7440

Purpose of review

Recent literature on racial or ethnic discrimination and mental health was reviewed to assess the current science and identify key areas of emphasis for social epidemiology. Objectives of this review were to: 1) Determine whether there have been advancements in the measurement and analysis of perceived discrimination; 2) Identify the use of theories and/or frameworks in perceived discrimination and mental health research; and 3) Assess the extent to which stress buffers are being considered and evaluated in the existing literature.

Recent findings

Metrics and analytic approaches used to assess discrimination remain largely unchanged. Theory and/or frameworks such as the stress and coping framework continue to be underused in majority of the studies. Adolescents and young adults experiencing racial/ethnic discrimination were at greater risk of adverse mental health outcomes, and the accumulation of stressors over the life course may have an aggregate impact on mental health. Some growth seems evident in studies examining the mediation and moderation of stress buffers and other key factors with the findings suggesting a reduction in the effects of discrimination on mental health.

Discrimination scales should consider the multiple social identities of a person, the context where the exposure occurs, how the stressor manifests specifically in adolescents, the historical traumas, and cumulative exposure. Life course theory and intersectionality may help guide future work. Despite existing research, gaps remain in in elucidating the effects of racial and ethnic discrimination on mental health, signaling an opportunity and a call to social epidemiologists to engage in interdisciplinary research to speed research progress.

Introduction

Over two decades of research have shown that subjective or perceived exposure to racial or ethnic discrimination has deleterious effects on both physical and mental health for African Americans, and recent studies report similar findings for Asian Americans, Latinos, and other ethnic groups [ 1 ]. Whether racial discrimination, racism, ethnic discrimination, or cultural racism, often used interchangeably, the shared meaning of these terms is the unfair treatment that members of marginalized racial and ethnic groups experience because of their phenotypical or linguistic characteristics and cultural practices. Perceived exposure to discrimination (broadly stated here to imply unfair treatment due to one’s race or ethnicity) has been conceptualized as a unique chronic stressor [ 1 – 3 ]. Consistent with other stressors, perceived discrimination can elicit variable emotional and behavioral responses that have been hypothesized to adversely affect mental health [ 3 ].

Several reviews have been published characterizing the state of the science on discrimination and mental health with a preponderance of the evidence showing that discrimination has a negative impact on mental health status and as a result contributes to declines in physical health [ 1 , 3 – 5 ]. Pascoe and Smart-Richman conducted a meta-analysis that included 107 papers on discrimination and mental health examining a total of 500 statistical associations, with 69% (345 of the 500 studies) showing a statistically significant association between high perceived discrimination and poor mental health [ 6 ]. Of 26 articles included in a 2009 review of discrimination and mental health among children, a positive association between discrimination and poor mental health was found in most studies [ 7 ]. The socio-environment and developmental stage of adolescents may greatly influence how they perceive the discriminatory encounter(s) [ 2 , 5 ]. In addition, children may experience discrimination vicariously through their parents, and the parents’ response to stressors may influence their children [ 2 , 5 ].

The current paper uses a conceptual stress and coping framework that depicts the chronic stress nature of perceived discrimination to provide an update of the United States (U.S.) literature within areas of relevance to social epidemiology. We frame this review to achieve the following objectives: 1) Determine whether there have been advancements in the measurement and analysis of perceived discrimination; 2) Identify the theories and/or frameworks used to guide research on perceived discrimination and mental health; and 3) Assess the extent to which stress buffers are being considered and evaluated in the existing literature.

We identified peer-reviewed U.S.-based journal articles published on perceived race or ethnicity discrimination and mental health within the past five years, 2011–2016. Electronic databases used for the search included PubMed, PsycInfo, CINAHL, and Scopus. The literature search strategy consisted of the following key words: (“unfair treatment” or “discrimination” or “racism” or “prejudice”) and (“race” or “ethnicity” or “African American” or “African American” or “Latino” or “Latina” or “Asian American” or “Muslim” or “Islamic” or “Native American” or “Hispanic” or “Puerto Rican” or (“Cuban and “American”) or (“Mexican and “American”) or (“Dominican” and “American”) or “culture”) and (“mental health” or “depression” or “anxiety” or “post-traumatic stress disorder” or “PTSD”) or (“race-based traumatic stress injury” or “historical trauma” or “historical trauma response” or “emotional distress” or “intrusion” or “vigilance” or “anger” or “avoidance”) and (“psychology*” or “stress” or “stressor”). There were 712 articles identified upon removing duplicates.

To identify articles that measured discrimination as a primary variable in relation to mental health, the authors reviewed the titles and abstracts of each study using Covidence (Melbourne, Victoria, Australia; www.covidence.org ). Specifically, we selected studies that included race, ethnic, or cultural-based discrimination as the main exposure or on the pathway and reported a mental health symptom or outcome (clinical diagnosis or assessed mental status/state) among adolescents and adults. Studies related to discrimination based on gender, health status (e.g., body size), or sexual orientation without a racial or ethnic discrimination component and those that did not examine any mental health outcomes or that evaluated mental health delivery services were excluded from the review. Inclusion criteria were met by 171 articles, which were further evaluated for data extraction.

Data Extraction

The following themes emerged upon review of the articles meeting inclusion criteria: methods, stress buffers, intersectionality, life course, and historical trauma. These themes were used to inform the data extraction tool. To assess the studies’ findings, the authors extracted the following data: research questions, study population and location, sample size, study design and methods, exposure, outcome, covariates, type of discrimination and metric, type of mental health disorder and metric, key findings, strengths, limitations, and identified theme(s). During full article review, we identified an additional 25 studies that did not meet the inclusion criteria described above, and the remaining studies (N=171) were categorized into the following themes (numbers are not mutually exclusive) and used in the review summary: 47 methods (out of 80), 30 buffers (out of 48), 13 intersectionality (out of 30), 20 life course (out of 27), 11 historical trauma (out of 42), and 10 without an assigned theme ( Table 1 ).

Empirical studies of the association between discrimination and mental health outcome in the U.S. by racial and ethnic groups

Guiding Conceptual Framework of Discrimination and Mental Health

Perceived discrimination has been described as a chronic stressor within various stress and coping frameworks. Drawing from several existing frameworks for the study of discrimination and health, we present a framework to guide this review of the literature ( Figure 1 ). In general, everyone experiences daily stress throughout life. However, it is the persistent and unpredictable nature of exposure to discrimination that can diminish one’s protective psychological resources (e.g., personality) over time; create changes behaviors (e.g., smoking, drug use); and weaken emotional control to increase vulnerability and susceptibility to poor mental health [ 6 ]. Mental health also has the potential to impact health behaviors, creating the potential for an adverse cyclical pattern. The family context (e.g., parenting practices) and other demographic variables (e.g., socioeconomic status (SES)) may influence the degree to which the individual perceives the stressor and ultimately how it manifests in affecting mental health.

Conceptual Framework of Discrimination Stress, Coping and Mental Health

Measurement of Discrimination and Analytic Methods

Discrimination measures.

The 9-item subjective Everyday Discrimination Scale that asks participants to indicate the frequency (0=never, 1=rarely, 2=sometimes, 3=often) with which they experience various forms of mistreatment in their daily lives remains the most commonly used measure in the literature [ 8 ]. However, the studies we examined employed this scale in various ways. Some utilized a continuous score based on the sum of all nine responses [ 9 – 13 ], others dichotomized the variable into never and ever discrimination [ 14 ], and others averaged the scores of all the items [ 15 – 18 ]. Further, some studies asked participants to specify what they felt was the primary reason for the unfair treatment [ 11 , 13 , 14 , 18 – 20 ], while others did not appear to ask for such specification and examined perceived discrimination in general [ 9 , 10 , 12 ].

While the Everyday Discrimination Scale was developed for use in African Americans and later adapted for other groups, there are some scales designed for specific groups including: (1) Perceived Discrimination subscale of the Acculturative Stress Scale for International Students [ 21 ]; (2) Bicultural Stress Scale among recently immigrated adolescents [ 22 ]; (3) the Social, Attitudinal, Familial, and Environmental Acculturation Stress Scale and Intragroup Marginalization Inventory-Family Scale [ 23 ]; and (4) the Asian American Racism-Related Stress Inventory [ 24 , 25 ]. Some studies utilized scales to address specific types of harassment in addition to race-based, such as weight-based, SES-based, and sexuality-based [ 26 , 27 ]. A few studies assessed historical trauma as an important factor in elucidating the detrimental impact that long-term and historical exposure to discrimination can have on the mental health status of marginalized racial and ethnic groups. However, the measures of historical trauma used, such as the Historical Loss Scale and Historical Loss Associated Symptoms Scale [ 28 ], were developed for Native American populations and may not incorporate concepts that are pertinent to other racial or ethnic groups’ experiences. Additionally, bullying, a form of violence characterized by repeated unprovoked aggressive behavior that intends to cause harm [ 27 , 29 , 30 ], has been examined among marginalized racial/ethnic adolescents. With the scarcity of racial/ethnic discrimination measures designed specifically for use with adolescents, some studies have examined independently or in addition to questions related to discrimination in the form of “bullying” with metrics such as the Bully Survey [ 26 , 27 , 29 – 31 ].

Analytic Methods

Several longitudinal studies were referenced in the articles, but only a few analyzed data using longitudinal methods [ 18 , 22 , 30 , 32 – 43 ]. Overwhelmingly, the findings are based on cross-sectional data. Regression analysis was primarily used, but some employed more sophisticated methods, such as latent class analysis and latent profile analysis to create categories of various exposure variables, including discriminatory experience, cultural stressors, and coping styles [ 22 , 28 , 30 , 31 , 44 , 45 ]. Techniques were employed by some studies to examine potential intermediary pathways between discrimination and mental health, such as through depressive symptoms or anxiety [ 19 , 24 , 43 , 46 ], avoidant coping strategies [ 33 , 47 ], trans diagnostic factors [ 48 ], general stress [ 40 ], stronger belief in an unjust world [ 49 ], acculturation-related and social support variables [ 13 , 50 , 51 ], anger [ 46 ], prosocial behavior [ 33 ], and perfectionism [ 52 ]. Other studies employed mediation techniques to examine if discrimination was on the pathway between a more upstream exposure, such as childhood adversity [ 53 ], historical trauma [ 28 ], a perpetual foreigner stereotype [ 37 ], white composition of one’s environment [ 29 ], critical ethnic awareness [ 50 ], and nativity [ 54 ], and a mental health outcome. Moderation by stress buffers was also considered in several studies described below.

Buffers: Coping and Personality

Coping strategies or personality traits of individuals and social support networks may mediate or moderate the relationship between discrimination and mental health outcomes (e.g., depression) [ 55 ]. Figure 1 depicts these as externalizing behavioral patterns used to cope with discrimination and the internalizing psychological responses to discrimination based on personality traits [ 56 ].

Externalizing behavioral patterns

One study found that adolescents exposed to discrimination and who have high levels of depressive symptoms use an avoidance coping response more frequently [ 31 ]. Other studies demonstrate that minority youth exposed to discrimination were more likely to engage in nonphysical aggression, aggressive or retaliatory behavior, and drug use [ 57 , 58 ]. Among ethnic minority adults (e.g., Latinos), discrimination has been associated with being a current smoker, substance abuse (e.g., marijuana), and risky sexual behavior [ 10 , 11 , 59 – 61 ]. Specifically, Filipino Americans were found to have a two-fold increased probability of alcohol dependence for every one-unit increase in reported unfair treatment due to their ethnicity, speaking a different language, or having an accent [ 60 ]. Among African American heterosexual men, risky sexual behaviors have been associated with everyday racial discrimination and post-traumatic stress disorder [ 59 ].

Internalizing psychological responses

The effects of discrimination on predicting greater risky behaviors have been shown to vary by individual personal traits, such as tendency for angry rumination [ 62 ]. Other personality traits, such as self-esteem, ethnic or racial identity, and spirituality can also influence the response to discrimination [ 63 ]. Young adults who reach a high level of ethnic identity maintain high self-esteem and have lower depressive symptoms, even at high levels of discrimination stress [ 64 ]. Ethnic identification also moderates the effects of discrimination on alcohol use disorder, indicating that high ethnic identity may mitigate the negative implications of discrimination on mental health and adverse coping behaviors for some ethnic groups [ 60 , 65 ]. However, results are conflicting for Jewish Americans and Latinos. Although ethnic identity predicted higher self-esteem, the moderating effect of ethnic identity on perceived discrimination and depressive symptoms among Jewish Americans indicated that greater ethnic identity was associated greater depression scores in the face of discrimination [ 66 ]. Additionally, among Latino men, being a current smoker was more likely for those who had high levels of racial or ethnic identity and experienced everyday discrimination [ 11 ].

External supportive buffers

Ethnic socialization has also been found to have a protective role against the adverse effects of discrimination on mental health status through pathways, such as increasing self-esteem, ethnic identity, or bicultural self-efficacy [ 25 , 64 , 67 ]. Such ethnic socialization and social networks may provide the necessary social and emotional support needed to combat negative internalization of discrimination and poor mental health outcomes [ 68 ]. High ethnic social connectedness has been associated with a weakening effect of racial discrimination on post-traumatic stress symptoms in Asian Americans [ 21 ]. Moreover, among African Americans adolescents, high emotional support buffered the impact of racial discrimination on biological stress markers (e.g., allostatic load) related to mental health [ 69 ].

For Asian Americans, family and spousal support weakened the effects of discrimination/unfair treatment on stress, major depressive disorders, and psychological distress [ 12 , 16 , 17 ]; whereas, discrimination and low social support have been associated with mental health problems and substance use [ 70 ]. Among Latino men, a reduction in the effect of discrimination on suicidal ideation was observed with improved interactions and family relationships [ 71 ]. Religious affiliations may also provide support to ethnic minorities facing discrimination. For African Americans, church-based social support moderates the impact of racial discrimination on generalized anxiety disorder [ 72 ]. Among Asian Americans and Latinos exposed to discrimination, frequent religious attendance is associated with lower likelihood of major depression [ 15 ] and better self-rated mental health [ 73 ]. Moreover, Muslim Americans reporting higher levels of spirituality and increased practice of daily prayer show less likelihood of depression despite discrimination [ 74 , 75 ].

Life Course

A life course perspective may be an important lens to examine associations between discrimination and mental health. While much work remains to be done in this arena, studies among youth and young adults may shed light on the importance of discrimination at critical developmental points along the life course. Several studies have shown that adolescents and young adults experiencing racial or ethnic discrimination were at greater risk of depression, anxiety, alcohol and cigarette use, victimization, aggression, violent behaviors, and suicidal ideation [ 30 , 36 , 43 , 47 , 52 , 67 , 76 – 83 ]. Certain groups of adolescents, such as African American boys, appeared to be more frequent targets for racial discrimination as they aged [ 81 ]. While these studies indicate that direct experiences of discrimination during adolescence may impact long-term mental health status, parental experiences of discrimination may also be related to child emotional problems via parental depression and parenting practices [ 84 ]. These studies of youth and young adults suggest that a complex interplay of childhood adversity, trauma, and experiences of discrimination may influence adult mental health [ 45 , 53 ].

The accumulation of stressors throughout life may have an aggregate impact on mental health. Longitudinal studies during adolescence found an association between increasing frequencies of racism and worse mental health [ 85 ]; these studies also found that perceiving being stereotyped as a perpetual foreigner led to increasing perceived discrimination, which in turn led to increased risk of depression over time [ 37 ]. Studies of adolescents over time also found that not only may discrimination influence depression, but there may be a feedback loop whereby depression also influences future perceptions of discrimination [ 35 ].

Historical Trauma

Research tends to focus on interpersonal level discrimination. Yet, it is the histories of marginalized racial and ethnic in the U.S. that have shaped their experiences of mistreatment over generations. This intergenerational experience of overt and institutionalized oppression (e.g., land loss, enslavement, segregation, genocide, colonization, war, and other forms of social, political, and cultural subjugation) affecting generations of indigenous, African, Asian, Latino, and other marginalized racial and ethnic descendants living in the U.S., is called “historical trauma.” Historical trauma reflects not only the influence this trauma has on those who experience it first-hand, but also its persistent effects on future generations [ 28 , 86 ].

Historical trauma has been conceptualized as a form of unfair treatment with evidence of its contribution to higher prevalence of poor mental health status in marginalized racial and ethnic groups. In a study of reservation-based Native American adolescents and young adults, Brockie et al. [ 87 ] found that the odds of depression (aOR=3.74, 95% CI: 1.49–9.41) and PTSD symptoms (aOR=5.60, CI: 2.19–14.30) were significantly higher in those with high versus low levels of historical loss associated symptoms (HLAS; measure of emotional responses related to historical loss, including loss of self-respect, language, culture, and land). Additionally, those who had greater experiences of perceived discrimination had higher odds of PTSD symptoms (aOR=3.01, CI: 1.31–6.88) compared to those with low discrimination. These findings attest to how the history of land loss and culture among Native American populations continues to have a negative impact on the mental health of Native American youth. Further, Mendez et al. [ 88 ] found that residential segregation and redlining were associated with reported stress among African American and Latina pregnant women. This highlights how institutionalized policies of segregation may contribute to experiences of stress.

The negative mental health impact of long-term historical trauma in the U.S. is even more evident in examples of the “immigrant paradox.” The “immigrant paradox” describes the phenomenon of poorer health among U.S.-born marginalized racial or ethnic groups than among their foreign-born counterparts, despite the higher SES of U.S.-born groups. Studies show that U.S.-born Asian, African Caribbean, and Latino populations have higher odds of depressive and anxiety symptoms [ 19 , 89 – 91 ], as well as diagnosed mental disorders and anxiety [ 9 ] than their foreign-born counterparts. The Perreira et al. [ 91 ] study of adult foreign-born Latinos suggests that immigrants experience increased exposure to stressful conditions, such as discrimination, and may simultaneously lose some of their protective social and culture resources the longer they reside in the U.S., which leads to increased psychological distress. These findings allude to the profound effect that increased residency in the U.S. and perceived discrimination have on mental health. In contrast, studies of Asian American adults have shown that racism-related stress is a significant predictor of mental health status for foreign-born and first-generation U.S. immigrants, but not their U.S.-born counterparts [ 24 , 25 ]. The immediate shock of being treated as a racial or ethnic minority, especially for those who have migrated to the U.S. from more racially or ethnically homogenous populations may result in higher levels of discrimination-based stress. Whereas U.S.-born marginalized racial or ethnic groups may have become immune to the effects of discrimination over time and as a result developed buffers to shield them from the everyday stress of discrimination.

Intersectionality

Marginalized racial or ethnic groups may face discrimination on several fronts beyond their perceived racial or ethnic classification. Discrimination based on gender, SES, age, sexuality, religion, and other identifying factors may lead to racial and ethnic groups experiencing discrimination that is linked to more than one of their identities. This interaction of exposure to multiple forms of discrimination may lead to some groups experiencing a synergistic effect of discrimination that is stronger than the effect of experiencing discrimination based on one identity [ 92 , 93 ]. The concept of intersectionality provides a lens for examining how race, class, gender, and other forms of social identity interact and are perceived to shape people’s health experiences [ 94 , 95 ].

Several studies have examined the intersection of race or ethnicity and gender, specifically, with regards to discrimination. Behnke et al. [ 96 ] found that among Latino/a ninth graders, but especially among adolescent girls, there was a significant association between perceived societal discrimination and depressive symptoms. Similarly, results from Piña-Watson et al.’s [ 97 ] study of Mexican high school students suggest that gender moderates the relationship between discrimination stress and well-being, with female adolescents experiencing higher levels of somatic symptoms, depressive affect, suicidal ideation, and discrimination stress than their male counterparts. Studies of Asian American, Latina, and African American women have explored how they are exposed to discrimination based on at least two of their social identities (i.e., race and gender), which may negatively influence their mental health outcomes, such as stress [ 98 ] and PTSD [ 99 ]. Stevens-Watkins et al. [ 98 ] insist that it is problematic to exclude the constructs of racism and sexism from the measurement of stressful life events, since they are correlated with one another and with stressful life events. This highlights the importance of examining the intersectionality of social identities in mental health research, and there is a growing body of literature on this topic. Studies have examined SES [ 100 ], sexual orientation [ 101 – 103 ], and religious [ 73 ] differences in the discrimination-mental health association with findings indicating that marginalized groups have higher odds of poor mental health.

Conclusions

In this review, we sought to address using recent U.S. literature: 1) any methodologic advancements in measuring perceived discrimination; 2) the extent to which theories and/or frameworks have been used in perceived discrimination and mental health research; and 3) the inclusion and analysis of stress buffers. Little improvement in the definition, conceptualization, and measurement of racial and ethnic discrimination as a chronic stressor has occurred. Although only a handful of measures have been used by a majority of studies, there is substantial variation in the use of each measure with an unclear rationale cited for scale selection. Future measurement work should consider the multiple social identities of a person, the social context/domain in which the exposure occurs, how the stressor manifests in adolescents since many of the current measures were developed for adults, and exposure assessment over time. As part of future efforts to improve exposure assessment, the need exists for discrimination scales to reflect the historical traumas experienced by many marginalized racial and ethnic groups.

We positioned this review within a stress and coping framework. However, there are other relevant frameworks, concepts, and theories that were highlighted in this review as important in the study of discrimination and mental health status; these include life course theory, intergenerational effects, intersectionality, and historical trauma. This growing body of literature highlights the destructive consequences of discrimination perceived at different time points throughout the life course, the linkage between parents and child perceptions, and the accumulative stressor and traumatic effect on mental health. Historical trauma is one concept that explains the detrimental impact that long-term and historical exposure to discrimination can have on mental health. Ultimately, it may be important to explore both historical trauma and perceived interpersonal discrimination in order to disentangle the true effect of these constructs on mental health.

Studies of youth and young adults suggest that a complex interplay of childhood adversity, trauma, and experiences of discrimination may influence adult mental health; however further research into the impact of discrimination at different critical periods in the life course and the accumulation of stress due to discrimination throughout life represent an important gap in the current literature. Another important, yet related, gap in the discrimination literature is the need for intergenerational studies. Discrimination experienced across multiple generations may affect health outcomes of future generations as a consequence of accumulated and persistent exposure to stressors and the resulting disruption of physiological systems [ 104 – 108 ]. Consequently, to understand more comprehensively the impact of discrimination on mental health, the intergenerational effect of stress should be taken into account.

Lastly, identifying the buffers that reduce the effects of discrimination on mental health status will help researchers understand why individuals respond differently to discrimination and signal possible areas for intervention. While some individuals display resilience to discrimination, others may turn to adverse health behaviors to cope with the stressor which over time may adversely impact mental health. More studies that investigate the longitudinal effects of buffers on the relationship between discrimination and mental health status are needed. A better understanding on how buffers change throughout the life course will help inform which buffers are most important for adolescent and adult populations. Given the direction of how a person is socialized with regards to their race, ethnicity, and SES, these factors may buffer or enhance the effects of discrimination on mental health status.

Implications for Social Epidemiologic Research

Despite volumes of research spanning decades, gaps remain in our understanding of the factors and mechanisms associated with perceived discrimination and mental health status. This signals an opportunity and a call to social epidemiologists to engage in interdisciplinary research to speed progress in elucidating the effects of racial and ethnic discrimination on mental health. Epidemiology is the science of disease discovery. Hence, there is a need for more emphasis on the development and use of statistical methods to elucidate the various mechanisms that underlie the relationship between discrimination and mental health. With the bulk of the findings based on cross-sectional data, there is a need for more longitudinal studies designed explicitly for the study of discrimination and health. However, longitudinal data of this sort will require more advanced statistical methods such as mediation analysis that has long been used by social scientists. As the call continues for improved measures and defining of the discrimination stress construct, insight can be gleaned from community-based racial equity activists who recognize that while discrimination addresses the unfair nature of the action, many of the current measures do not address the power dynamics inherent in racism or its pervasiveness in institutions. Further, engaging these activists and other stakeholders can inform the critical dimensions of discrimination stress with regards to frequency, appraisal, context/domain, etc. and how this stressor intersects with other identities and personal traits. While this review uncovered little movement in the field, some key future research directions were identified.

Compliance with Ethical Standards

Conflict of Interest

Anissa I. Vines, Julia B. Ward, Evette Cordoba, and Kristin Z. Black each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Contributor Information

Anissa I. Vines, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 266 Rosenau Hall, CB #7435, 135 Dauer Drive, Chapel Hill, NC 27599-7435.

Julia B. Ward, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435.

Evette Cordoba, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435.

Kristin Z. Black, Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7440, Chapel Hill, NC 27599-7440.

Papers of particular interest, published recently, have been highlighted as: * Of importance

Diversity and Discrimination in Research Organizations: Theoretical Starting Points

Diversity and Discrimination in Research Organizations

ISBN : 978-1-80117-959-1 , eISBN : 978-1-80117-956-0

Publication date: 1 December 2022

This article outlines the theoretical foundations of the research contributions of this edited collection about “Diversity and Discrimination in Research Organizations.” First, the sociological understanding of the basic concepts of diversity and discrimination is described and the current state of research is introduced. Second, national and organizational contextual conditions and risk factors that shape discrimination experiences and the management of diversity in research teams and organizations are presented. Third, the questions and research approaches of the individual contributions to this edited collection are presented.

• Comparative research
• Implicit bias

Müller, J. , Striebing, C. and Schraudner, M. (2022), "Diversity and Discrimination in Research Organizations: Theoretical Starting Points", Striebing, C. , Müller, J. and Schraudner, M. (Ed.) Diversity and Discrimination in Research Organizations , Emerald Publishing Limited, Leeds, pp. 3-30. https://doi.org/10.1108/978-1-80117-956-020221001

Emerald Publishing Limited

Copyright © 2023 Jörg Müller, Clemens Striebing, and Martina Schraudner

Published by Emerald Publishing Limited. This work is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this work (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Purpose of this Edited Collection

The era of team science has long since dawned ( Wang and Barabási, 2021 ; Pavlidis et al., 2014 ). Diverse teams are considered to have the potential to work particularly efficiently. Creative thinking, diversity of perspectives and the ability to solve complex problems might be pronounced in diverse teams, which has not only been shown for multidisciplinary but also gender-diverse teams (Abdalla et al., 1999; Bear and Woolley, 2011 ; Østergaard et al., 2011 ). Such skills are key competencies for research organizations that want to be influential and internationally-recognized sites for cutting-edge research.

However, in order for the individual members of a team to work well, research organizations need to provide a productive and naturally non-discriminatory working environment. The fact that bringing together and integrating researchers and their diverse backgrounds in effective teams is precarious due to the structural conditions of the research system – that is, it does not happen on its own – will be further discussed here. To harness the positive effects of diversity, it must be managed proactively ( Nielsen et al., 2018 ). In this context, the edited collection has the following purposes:

to contribute rare quantitative analyses of the extent of discrimination according to diverse socio-demographic characteristics of individuals in research-performing organizations;

to contribute analyses of the contextual organizational factors that affect the perception of discrimination within research-performing organizations, and

to seek the connection to practice by highlighting options for action.

The publication explores discrimination in research organizations, by which we mean all forms of organizations whose main purpose is to conduct research. The focus is on public research organizations such as universities or non-university research institutions (represented in the edited collection primarily by the German Max Planck Society). Research departments of companies – which in our view operate more according to the rules of the private sector than academia – are not included.

In principle, discrimination can be discussed for all areas of society and is regularly relevant simply due to its strong significance for the working climate and the well-being of individuals and teams. The relevance of research-performing organizations as a research topic seems to be additionally given by the political efforts of advanced (trans-)national innovation systems to combat systemic discrimination and the major role that effective diversity management plays for successful cooperative creative processes. At a political level, as editors and researchers active in national and international projects we experience the European Commission as a particularly proactive actor. With its “Horizon Europe” funding programme for research and innovation, the EC also promotes research projects and practical measures to reduce discrimination and create an inclusive research culture in the research systems of its member states. In doing so, it strives to strengthen international mobility and the competitiveness of a common European research area as part of its mandate laid down in Article 179 of the EU Treaty. 1

Diversity and Discrimination: A Sociological Definition

Conceptual understanding of discrimination.

Research on discrimination in the labor market and work organizations has lost none of its relevance. This continued interest by researchers and practitioners is partly due to the fact that discrimination has become more subtle while still producing adverse effects for disadvantaged social groups. Over the decades, theory as well as empirical research has moved away from understanding discrimination as deliberate and intentional acts of exclusion perpetuated by individuals toward more complex and elusive mechanisms including cognitive “implicit bias” ( Quillian, 2006 ), “microaggressions” ( Sue, 2010 ), unfair and biased organizational processes ( Nelson et al., 2008 ), or the systemic nature of what Barbara Reskin (2012) has called “ über discrimination.”

Nonetheless, while discriminatory practices have become less overt ( Sturm, 2001 ), their effects continue to be felt in a very direct and real way by individuals as well as organizations. Findings presented by Jones et al. (2016) in their meta-analysis show that subtle forms of discrimination are “at least as substantial, if not more substantial” (italics original) than overt forms regarding diminishing the physical and mental health of individuals, job satisfaction, or organizational commitment, to name just three of its effects. The resulting reduced well-being and self-esteem of staff has organizational-level consequences as employees’ work attitudes decline, turnover intentions increase or job performance dwindles, affecting the overall effectiveness of firms (for a review, see Colella et al., 2012 ). Thus, while it has become more difficult to detect discrimination, its negative consequences are as direct and powerful as ever, calling for equally strategic and systemic counter-measures.

Discrimination has a long and substantive research pedigree in the social and behavioral sciences, with contributions spanning several disciplines including economics, sociology, psychology, management and law. Although the explanatory models for discrimination differ across these fields of knowledge, there is a certain agreement on its basic definition: discrimination involves the differential treatment of individuals based on functionally irrelevant status cues such as race or gender ( Merton, 1972 ; Altonji and Blank, 1999 ).

Unpacking this definition first implies recognizing that discrimination is based on group membership and as such it never targets a person due to individual reasons. Discrimination happens because individuals are perceived as belonging to a social group delineated by gender, race or national origin, age, health conditions or disability, religion, and/or sexual orientation ( Colella et al., 2012 ; Baumann et al., 2018 ). These categories often do not function as unified, mutually-exclusive entities, but rather they “intersect” and can thereby aggravate experiences of oppression and power ( Collins, 2015 ).

Second, discrimination implies an “unjustified” differential treatment that occurs due to social group membership rather than actual differences in terms of task-relevant qualifications, contributions, or performance. Thus, job opportunities, promotions or rewards (e.g., wages) differ between women and men, even when comparing equally qualified and experienced persons. Consequently, discrimination is considered not only unfair but also illegal in many contexts.

Third, discrimination refers to behavior rather than solely beliefs and attitudes. Although the psychological literature predominately explains discrimination with references to prejudice and stereotypes, this is insufficient to constitute an act of discrimination ( Fiske et al., 2009 ). For discrimination to occur, actions need to be carried out that exclude, disadvantage, harm, harass or deprive the members of a less favored group compared to the members of a more favor group. Although most research conceives discrimination as negative behavior against disadvantaged groups, it can also involve positive behavior, that is, giving advantages to already-privileged groups. In fact, as Nancy DiTomaso (2020, 2013) argues, for the perpetuation of social inequality, the

positive actions taken on behalf of those who are already advantaged may be as consequential or more so than the negative actions that deny opportunity to those who are disadvantaged.

Conceptual Understanding of Diversity

Similar to research on discrimination, research on workplace diversity continues to be a burgeoning academic field. As Faria (2015) suggests, diversity research came into being in the US during the 1980s as a specific reaction against the previous social justice-based Equal Employment Opportunity (EEO) and Affirmative Action (AA) policies dealing with discrimination. Driven by an increasingly heterogeneous workforce and economic globalization, these justice-based policies were considered to be inefficient and costly, and replaced in favor of an emerging business case for diversity. Whereas discrimination involves a moral component in terms of the “unjustified” differential treatment ( Altman, 2011 ), diversity relinquishes these moral and legal burdens, concentrating instead on a pragmatic strategy to increase the corporate bottom line ( Litvin, 2006 ). Diversity research therefore attenuates regulatory approaches for ameliorating the negative effects of discrimination and instead emphasizes proactive measures to capitalize on heterogeneous resources available in different work settings. For diversity research, the focus on measurable profits implied the establishment of a matrix of quantification where certain clear-cut, easily observable demographic differences could be set in relation to equally quantifiable, dependent outcomes. Backed up by the predominant positivist research tradition in the US, demographic differences according to gender, age, race as well as functional differences such as educational background were thus operationalized and enshrined as measurable, stable markers of identity to be harnessed by Human Resource Departments and Management for improved profitability.

As a result, a major difference between discrimination and diversity approaches in workplace settings concerns the role reserved for markers of social identity such as age, gender, or race. While diversity scholars conceived these differences in terms of a-historical, personal attributes, discrimination scholars are mostly attentive to the ways in which these individual attributes delineate group-based membership, which in turn is tied to historically-grown positions of privilege and power ( Prasad, Pringle, and Konrad, 2006 ).

Today, diversity research has increasingly overcome its initial and overly simplistic conceptions of fixed identity attributes, partly driven by the largely inconsistent findings of its initial research program, which failed to establish any clear-cut linear relationship between diversity attributes and economic benefits ( Haas, 2010 ). While subsequent work has become more aware of the contextual nuances that moderate and mediate the effects of diversity ( van Knippenberg and Schippers, 2007 ; Joshi and Roh, 2007 , 2009 ), other approaches appear to have come full circle in terms of recognizing the importance of power and status processes for working groups ( van Dijk and Van Engen 2013 ; Ravlin and Thomas 2005 ; DiTomaso et al., 2007 ). As van Dijk et al. (2017) rightly emphasize, diversity research needs to take into account that

members of different social groups are likely to be perceived and approached differently because of their membership in a given social category […] and, in part as a consequence, may behave differently (p. 518).

Diversity and Discrimination — Common Ground

Thus, as these recent developments suggest, discrimination and diversity research are becoming more closely aligned. This is especially apparent from the combination of the underlying psychological models in work groups and their organizational context factors. As we argue, social categorization models need to be combined with status-/power-based approaches (e.g., AA and equal opportunities) to work group diversity, prevent discriminating behaviors and enable organizations to take full advantage of their diverse human resources. Studies of discrimination and diversity appear in this sense as two sides of the same coin, suggesting that measures leading to a reduction of discrimination not only reduce adverse effects at the individual level but also hold the potential to create more productive and effective work environments.

Approaches to Studying Discrimination and Diversity

Levels of analysis.

While research on diversity primarily operates at the level of teams and small- to medium-sized work groups ( Roberson, 2019 ; van Knippenberg and Schippers, 2007 ), research on discrimination can target the micro-, meso- and macro-level of society or a combination of these levels of analysis. At the macro-level, the magnitude and persistence of discrimination has been well documented in relation to race and gender in employment, housing, credit markets, schooling and consumer markets ( Pager and Shepherd, 2008 ). For example, concerning housing and credit markets, Pager and Shepherd (2008) summarize that “blacks and Hispanics face higher rejection rates and less favorable terms in securing mortgages than do whites” (p. 189). Although differential treatment varies across countries and even cities, discrimination remains pervasive and an important barrier to residential opportunities. Gender-based discrimination in the labor market – to use a second macro-level example – is just as widespread and structural as race-based inequalities. The wage gap between women and men remains at an estimated 16 percent globally ( International Labour Office, 2018 ). In the EU-28, women in Research & Development earn on average 17 percent less than their male colleagues (European Commission, 2019). Together with the horizontal segregation of women and men in certain labor market segments and vertical segregation restricting women from access to decision-making positions, these macro-level forms of discrimination constitute defining structural fault lines of contemporary labor markets.

While macro-level accounts usually produce evidence regarding the extent of structural disadvantages between social groups, meso- and micro-level accounts have advanced explanatory models of why discrimination occurs at all. The crucial influence of the organizational climate on discrimination constitutes a well-known example at the meso level. Thus, it has been shown that the organizational climate is the single-most important driving factor for sexual harassment to occur (National Academies of Sciences, Engineering, and Medicine, 2018; Willness, Steel, and Lee, 2007 ). On the other hand, micro-level accounts build upon psychology and social psychology to expose the individual-level dimensions of discrimination. Different psychological models exist concerning how prejudice and stereotypes are linked to discriminating actions, such as when implicit attitudes shape the behavior toward others defined by their social group identity ( Greenwald and Krieger, 2006 ). The contributions of this edited collection in their entirety cover the macro-, meso- and micro-level.

Discrimination and Diversity through a National and Organizational Lens

While considerable advances have been achieved to untangle the hidden dynamics of discrimination in organizations, the collection of research articles presented here makes two specific contributions to the existing literature. First, they contribute research on aggregated and individual identity-related experiences of workplace misconduct at the research workplace. The contributions focus on different socio-demographic groups of people and consider research organizations that operate in different national contexts. The contributions reflect the influence of the systemic framework of academia.

Second, the relationship between diversity and discrimination in the context of the academic workplace is especially interesting in relation to one of the most decisive transformations of the academic environment over recent decades, namely the simultaneous intensification of work and diminishing resources/funding. The introduction of a new managerialism and regimes of accountability has obliged academics to do more with fewer resources and less time. As incipient research shows, the effects in terms of discrimination are particularly felt by minorities and those collectives that are already in more precarious and disadvantaged situations. Although research on the “neoliberal university” is abundant, there is a clear lack of more focused approaches to understand its implications for discrimination as well as diversity in work teams.

The contributions gathered in this edited collection are all situated in different national and organizational contexts, from the USA, France, Germany and Nigeria to Vietnam, and the conditions of academic workplaces in non-university and university contexts as well as public or private research organizations at different hierarchical levels and in different disciplines are examined. These national and organizational contextual conditions must be taken into account when considering the transferability of the results to other contexts, as explained below.

The Relevance of National Context

Discrimination is a persistent phenomenon throughout time, but levels of discrimination considerably differ across countries. As Quillian et al. (2019) show in their meta-analysis of job application field experiments, the strength of racial discrimination can considerably vary across the nine countries included in their study. White job applicants receive up to 65–100 percent more callbacks in France and Sweden than non-white minorities. Discrimination of job applications is weaker in Germany, the United States and Norway, where they receive on average 20–40 percent fewer callbacks. Similar findings are available from the large GEMM study carried out in several EU countries, particularly focusing on hiring discrimination based on ethnic background. Discrimination ratios were the highest in Britain – where ethnic minorities need to send out 54 percent more applications to achieve the same callback rate as the majority group – and the lowest in Germany, where minority applicants need to send out 15 percent more applications ( Lancee, 2021 ; Di Stasio and Lancee, 2020 ). Examining religion, the study also finds that in the Netherlands, Norway and the UK, Muslims are “more than 10 percentage points less likely than majority members to receive a callback” ( Di Stasio et al., 2021 , p. 1316).

Comparative studies examining the effects of perceived discrimination equally attest to country-level differences concerning both gender and race. As Triana et al. (2019) show, differences in outcomes in terms of the psychological and physical health of gender discrimination at work can be linked back to differences in national labor policies and gender-egalitarian cultural practices between countries. To the degree that institutional frameworks such as labor market policies, legal regulations or cultural norms differ between countries, levels of discrimination will vary accordingly. Along the same lines, Quillian et al. (2019) see the comparatively high levels of hiring discrimination in France and Sweden as resulting from unconstrained employers’ discretion that is neither monitored nor held in check by discrimination lawsuits such as in the US.

The role of national context factors for diversity are equally not fully understood. Although Joshi and Roh (2007) highlight national culture as one “distal omnibus” element affecting diversity outcomes, results are not particularly abundant. Early insights suggest that important dimensions of teamwork such as hierarchical versus more horizontal peer-based control structures vary across cultures and can invert the outcomes of diversity. Thus, van der Vegt, Van de Vliert, and Huang (2005) show that in cultures where power is more centralized, tenure and functional diversity are negatively associated with innovative climates, whereas in low power distance cultures diversity is positively associated with innovative climates.

As the GLOBE study across 62 societies has amply documented, cultural differences not only exist in terms of “power distance” but also regarding other important features affecting diversity climate in work groups such as risk avoidance, performance orientation, gender egalitarianism, or levels of collectivist versus more individualized values ( House et al., 2004 ). For certain areas of diversity research such as the under-representation of women on corporate boards, cultural differences in terms of gender egalitarianism and/or traditional gender roles have been shown to play a decisive role ( Lewellyn and Muller-Kahle, 2020 ). However, since the primary interest of diversity research lies at the work group level, explorations of macro-scale patterns that are so common for discrimination research are rare. Instead, national differences are frequently operationalized in terms of the diversity of cultural values that individual team members bring to the work group ( Bodla et al., 2018 ).

An important additional perspective for understanding the national context of discrimination concerns a situational perspective. Apart from institutional differences in terms of labor market legislation between countries, discrimination has also been linked to historical legacies of oppression such as slavery. Apart from historical legacies, situational accounts frequently also explain discrimination with reference to current economic and demographic conditions or political events ( Quillian and Midtbøen, 2021 ). Right-wing politics stigmatizing certain ethnic or religious groups – for example in relation to terrorist attacks – can fuel discrimination. In situations of crisis such as the recent Covid-19 outbreak, discrimination can be aggravated. As reported by Pew Research Center (2020) , 40 percent of black and Asian Americans indicate an increase in discriminating behavior toward them by others since the start of the pandemic. The Covid-19 pandemic has also clearly shown that under conditions of stress or crisis, minorities and marginalized groups will be even further disadvantaged compared to majority social groups ( Kantamneni, 2020 ). However, while the effects of a public health crisis on discrimination have been extensively explored, this is not necessarily true for the effects of economic crises or recessions. Among the few studies directly examining the link between worsening economic conditions and discrimination, Kingston, McGinnity, and O’Connell (2015) show that non-Irish nationals experienced higher rates of work-based discrimination during the recession in 2010 compared to time of economic growth in 2004. Implicitly, there seems to be an understanding that “under conditions of threat (e.g., recessions, downsizing)” or insecurity, organizations and individuals fall back into “a limited set of well-learned and habituated behavioral scripts” ( Gelfand et al., 2005 , p. 93) to the disadvantage of already-marginalized and excluded social groups.

Overall, it remains unclear how these wider economic situational factors play out in terms of discrimination experiences and possibilities of fostering diverse teams. This holds especially in relation to the transformation of academic life in general. Driven by wider transformations and restructuring of the post-war European welfare states, academic work has experienced dramatic shifts over recent decades. Scientific autonomy has increasingly been replaced with an orientation toward performance measures, a focus on excellence and competition, entrepreneurship, or the emphasis on cost efficiency ( Herschberg and Benschop, 2019 ). How these recent developments play out in terms of discrimination experiences within academic organizations remains to be more fully understood. The work conducted here at the meso and micro level provides promising avenues for discrimination research. As we will argue in the next section, organizational culture and climate are not only influenced by wider national settings but they also modulate and refract some of these broader national trends with important implications for reducing discrimination and fostering team effectiveness. As the organizational level is the primary work environment in which people interact, it is one of the most important arenas to control and diminish discrimination.

The Relevance of the Organization

Organizational factors play an important role for discrimination rates and experiences in work settings. Organizational policies have also been identified as a crucial element for taking advantage of diversity. Formal and informal structures, organizational culture and climate, leadership or human resources, or workplace composition may all contribute to or attenuate discrimination ( Gelfand et al., 2005 ). For example, transparent and formal evaluation criteria at the organizational level – for promotion or recruitment – can reduce discrimination as decision-making is accountable to objective criteria. Similar, holding managers socially accountable for performance ratings is one of three promising and effective strategies in terms of increasing workforce diversity and diminishing discrimination in companies ( Dobbin and Kalev, 2016 ). In addition to encouraging social accountability, two further factors mentioned by Dobbin and Kalev (2016) to reduce discrimination effectively concern the engagement of managers in solving problems and the increase of contact among people from different groups. Both factors can be decisively steered through organizational policies.

Organizational climate – to mention another important organization-level factor – is a key driver of harassment ( Pryor, Giedd, and Williams, 1995 ). Incidents of sexual and other harassment are more likely to occur in working environments where harassment is “tolerated” by a leadership that fails to act on complaints, does not sanction perpetrators or protect complainants from retaliation (National Academies of Sciences, Engineering, and Medicine 2018). This is especially true in settings where men are overrepresented among staff and at the leadership level. For example, a recent study on sexual harassment of undergraduate female physicists in the US – with women being under-represented in physics – revealed that three-quarters of respondents had experienced at least one type of sexual harassment ( Aycock et al., 2019 ). Organizational-level factors such as the overall gender ratios or the wider work climate are therefore considered key elements that can inhibit or encourage discrimination.

Examining organizational context factors of discrimination more broadly, most evidence from the US is largely based upon plaintiff accounts of discrimination lawsuits. Thus, Hirsh and colleagues ( Hirsh, 2014 ; Hirsh and Kornrich, 2008 ) show – for example – how several factors such as the previous vulnerable economic or social status, the workplace culture and the workplace composition affect the perception of discrimination by employees. Similar, Bobbitt-Zeher (2011) exposes how organizational practices and policies combine with workplace composition and gender stereotyping to produce workplace gender discrimination in quite predictable ways. As mentioned, gendered norms of behavior, dress code, or sexualized talk in often male-dominated management and leadership positions create an organizational culture in which discrimination can flourish.

Among the few studies to explore the organizational context via an extensive survey is Stainback, Ratliff, and Roscigno (2011) whose study is based upon a sample of 2,555 respondents to the US National Study of the Changing Workforce in 2002. Corroborating the insights of Hirsh (2014) , and Bobbitt-Zeher (2011) , the results show that the experience of discrimination is reduced for both genders when they are part of the numerical majority in their organization and where a supportive workplace culture is in place. In their survey among 176 employees in the United States, Kartolo and Kwantes (2019) show that behavioral norms related to organizational culture modulates perceived discrimination.

While the majority of research on discrimination operates with a concept of behavior that disadvantages or harms people, diversity research foregrounds measures that foster a climate for inclusion to take full advantage of diverse assets within work groups. Indeed, promoting an organizational climate for inclusion is not only beneficial at the individual level (e.g., higher job satisfaction, better physical and psychological health) but also improves group-level outcomes such as overall team or organizational performance. As Brooke and Tyler (2011) succinctly state,

[…] by creating an environment in which all employees know they are valued and feel safe from discrimination, every employee can feel comfortable as a valued member of the organization (pp. 745–746).

Along these lines, research from Google regarding the perfect team has underlined previous insights from small group research on the importance of psychological safety for diverse teams ( Duhigg, 2016 ; Edmondson and Lei, 2014 ). Risk-taking and making errors – elements that are crucial for innovation – are only possible to the degree that employees feel safe in their team and the wider work environment. Thus, Reinwald, Huettermann, and Bruch (2019) argue – based on a sample of 82 German companies – that diversity climate has positive effects for firm performance, especially where there is a relatively high convergence among employees in their climate perceptions. Similar findings are available from research on military working groups, showing that diversity climate is consistently and positively related to work group performance and that this relationship is mediated by discrimination ( Boehm et al., 2014 ). Already in earlier work, Nishii (2012) has argued for the benefits of a “climate for inclusion” that reduces interpersonal bias and diversity conflict (see also Richard, 2000 ).

While research has established the importance of organizational climate and culture for discrimination and diversity, it is somewhat surprising that one of the major transformations over the recent decades within academic organizations has received relatively scant attention. None of the aforementioned studies thus far takes into account how academic organizations at large are affected by or confronted with decreasing public funding while having to grope with a heightened sense of accountability. The introduction of New Public Management principles aiming to reduce and streamline a supposedly oversized and inefficient public sector has certainly affected public universities and research institutions over recent decades ( Hood, 1991 ; Newman, 2005 ). A new managerialism tied to the introduction of Total Quality Management principles ( Aspinwall and Owlia, 1997 ) – for example – as well as a marketization of the public sector have undermined the autonomy and independence of the academy and provoked considerable resistance among scholars. However, although the discriminatory effects of the so-called neoliberal working conditions in academic contexts is a burgeoning field of research ( Pereira, 2016 ; Berg, Huijbens, and Larsen, 2016 ; Heath and Burdon, 2013 ; Craig, Amernic, and Tourish, 2014 ), there is clearly a dearth of studies addressing how the wider organizational culture associated with competitiveness, performance demands, or audit culture affects the perception of discrimination. As some studies suggest, especially vulnerable minorities are likely to be disproportionately affected by these more demanding, neoliberal work environments ( Anderson, Gatwiri, and Townsend-Cross, 2019 ; Cech and Rothwell, 2020 ).

Risk Factors of Discrimination in Research Organizations

From the perspective of a researcher in the European Union, it should be noted that there is hardly any other sector in which such highly-qualified personnel work under comparably insecure working conditions as in academia. As editors of this collection, we do not believe that scientific and non-scientific employees in research organizations experience discrimination or workplace misconduct more frequently than in other sectors (for a discussion for sector differences in bullying, see Keashly, 2021 ). However, depending on the contextual conditions of the academic sector, very specific patterns of structural discrimination emerge.

From a governance perspective, discrimination can take place especially in situations where effective structures are lacking that may constrain decision-makers to minimize the influence of bias on their decisions ( Williams, 2017 ). This refers to accountability structures as well as checks and balances in decision-making processes and procedures that aim to reduce or dissolve one-sided dependencies between the individual actors in the research system (e.g., staff councils, PhD schools, supervisory committees, equal opportunities officers, representatives for the severely disabled, transparent and binding promotion criteria, etc.). Where such structures are lacking, a high degree of variance in working cultures and leadership styles in the individual teams is possible, with both positive and negative consequences.

The Equal Employment Opportunity Commission (EEOC) – a US federal agency tasked with ensuring the implementation of the applicable anti-discrimination legislation in the labor market – has formulated concrete organizational risk factors for workplace harassment, which can also be applied to research organizations and academia ( Feldblum and Lipnic, 2016 ). With their understanding of the term harassment, the authors focus on intentional forms of discrimination, as opposed to unreflective discrimination due to cognitive bias or institutionalized structures (such as not counting care periods in the evaluation of performance). In our view, the risk factors named in Table 1 and explained by indicators and anecdotal examples from academia can also be largely applied to systemic discrimination. Table 1 can thus be understood as the summary of the above elaborations on the importance of national and organizational contextual factors.

Chart of Risk Factors for Harassment and Responsive Strategies (for an extended version, see US Equal Employment Opportunity Commission, 2021).

The anecdotal examples in Table 1 convey the notion that it seems inappropriate to place academia under the general suspicion that experiences of discrimination and discriminatory behavior as well as the negation of diversity are more widespread here than in other workplaces. The heterogeneity of the workforce and the prevailing workforce norms vary between different national, regional, and disciplinary contexts. Furthermore, a vertical and horizontal gender segregation as well as a status- and organization-politically elevated position of leadership personnel are not peculiarities of research organizations. However, discrimination processes in academia can be framed in particular by the following distinct characteristics of the research and higher education system:

the “customer service” provided by scientific staff – that is, teaching students – can certainly be considered an important additional stress factor, which is only present in comparable form in other teaching professions;

the important role of international mobility for scientific career development, which is explicitly promoted by national and supranational organizations such as the EU and structurally reflected in cultural and linguistic differences in the workforce;

the shared governance principle of academia (Keashly, 2021), within which the faculty makes the crucial decisions on research strategy and personnel policy. Other staff have a subordinate role. Within shared governance, other university groups are often represented alongside the faculty, and decision-making power is distributed pyramid-like according to seniority: while all of the voices of the few chair holders as “high-value employees” are often heard, early career researchers, non-tenured researchers, administrative staff and the many students are often not represented or they are only represented by a few representatives.

The principle of senior shared governance or “peer principle” is based on a collegial appreciation of the peer’s respective sphere of influence on constructiveness and cooperativeness. For academic leadership staff, shared governance is essentially a peer evaluation system in which each participant is just as powerful as any other. In cases of conflict, this system of mutual tolerance can reach its limits ( Keashly, 2021 ); for example, when the prevailing structures in the academic workplace are questioned, or when a colleague should be confronted due to a biased decision or their misconduct toward groups of people who are not involved in senior shared governance.

In order to make HR processes more professional and rational, the professionalized and clearly more sovereign university administrations in relation to the faculty ( Gerber, 2014 ) today have a variety of different tools at their disposal. As van den Brink and Benschop (2012) argue, these tools like promotion guidelines, gender equality plans, trainings, or participatory decision-making too rarely aim at structural change and take little account of disciplinary specificities (e.g., the pool of female talent strongly differs between computer science and medicine). In particular, the authors highlight that practices aimed at reducing discrimination are closely intertwined with the contextual conditions that gave rise to the discrimination to be combated in the first place. For example, the gender equality officer’s say and the rules set for the appointment of a new chair are sometimes undermined by the preferences and informal power resources of the academic management, whereby ultimately the candidate who had been preferred by the institute’s management from the beginning prevails in most cases. Accountability structures for strengthening diversity usually lack the binding force and sanctioning power to have an immediate effect (ibidem).

At the European level, we observe a growing awareness of the lack of effectiveness of the current gender equality policies and measures in academia, accompanied by the will to strengthen its effectiveness. A particular expression of this attitude is that since 2021 gender equality plans have been declared a mandatory requirement to apply for project funding within the framework of the most important European research framework program, “Horizon European” (European Commission, 2020). Furthermore, within the framework of its Gender Equality Strategy 2020–2025, the European Commission attaches importance to an intersectional approach in which discrimination is not restricted to gender but is thought of comprehensively.

Overview of Chapters

The peer principle as an element of research governance essentially ensures the scientific quality of research. Who else should evaluate the excellence of a research project, research design and researcher, if not their peers? However, as explained above, the peer principle does not guarantee modern and bias-free personnel management as required by a number of state equal opportunity acts.

It is research policy and administrative as well as scientific research managers who are decisively entrusted with the standardization and quality assurance of personnel management in the research system and who thus make an essential contribution to ensuring optimal working conditions for academic mid-level and non-scientific staff as well as equal opportunities when filling professorships. With the studies collected in this anthology, we hope to contribute to the informed action of these central actors in research policy to enable researchers and research teams to operate in optimal conditions. The articles can be roughly divided into two categories according to the guiding questions of this edited collection: macro studies surveying the extent of discrimination and harassment in research organizations and micro studies exploring the influence of the specific cultural contextual conditions of the academic workplace on experiences of discrimination and harassment related to the diversity of the workforce.

About the Extent of Discrimination in Research Organizations

Striebing’s “Max Planck studies” belong to the first category of macro analyses. These are three contributions that resulted from a research project commissioned and funded by the Max Planck Society in Germany on the work culture in its institutes and facilities and in particular on the experiences of bullying and sexual discrimination. The project was carried out in 2018 and 2019 and included a series of qualitative interviews and a full survey of the more than 23,600 scientific and non-scientific employees of the Max Planck Society, which is one of the world’s largest and most comprehensive institutions for basic research.

In his first contribution, Striebing explains how the evaluation of the group climate and the leader varies according to the socio-demographic characteristics gender, nationality and responsibility for childcare of the Max Planck researchers. He examines the intersectionality, in terms of interaction effects, of these characteristics, and also considers the context of the respondents’ hierarchical position. Striebing proceeds in a similar way in his second contribution. In addition to the researchers, the non-scientific employees of the Max Planck Society are also examined. The question is pursued concerning how the socio-demographic characteristics of the employees as well as the contextual conditions of hierarchical position, scientific discipline and administrative area affect the extent of bullying experiences. In the third contribution, Striebing examines whether men and women in the academic workplace have a different understanding of bullying and sexual harassment and discrimination. The contribution explores patterns of gender-related differences in the self-reporting of acts of workplace misconduct and self-labeling as having been bullied or experienced sexual discrimination and/or harassment.

Pantelmann and Wälty offer a comprehensive insight into the prevalence of sexual harassment among students. They present data from a survey conducted at a German university and critically reflect the role of the university and the work culture in academia in preventing and managing experiences of sexual harassment on campus. The results presented by the authors come from the “Perspectives and Discourses on Sexual Harassment in International Higher Education Contexts” project in which eight research teams from very different international higher education contexts cooperated.

Sheridan, Dimond, Klumpyan, Daniels, Bernard-Donals, Kutz, and Wendt also conducted a so-called campus study, examining the prevalence of hostile and intimidating behavior at the University of Wisconsin-Madison in the US and its variance by gender among persons of color, LGBTQ persons and persons with disability at two different measurement points. More importantly, in their article the authors describe the policy package enacted by the university for prevention and conflict resolution and discuss its effectiveness using their longitudinal data as well as survey data from training interventions. The authors thus present a very rare evaluation study in the context of discrimination, which is highly relevant for theory and practice alike.

Nguyen, Tran, and Tran contribute a systemic macro analysis of a lower-investment research and innovation system and a different culture. They analyze data from 756 researchers in the Vietnam Academy of Social Sciences, examining differences in the scientific achievements of male and female researchers and investigating the factors influencing them.

Cultural Context Conditions of Academia for Diversity and Discrimination

The discourse in research organizations has a particular influence on how diverse teams and cases of discrimination are dealt with, that is, what is said, how it is said and what can be said. This discourse is the result of the respective organizational and team culture and it decisively determines which experiences are perceived and recognized as discrimination in the organization.

In an experimental survey study, Kmec, O’Connor, and Hoffman presented a representative sample of the US population with a vignette describing an incident of sexual harassment between a department director and one of his team members, asking respondents to rate whether it was inappropriate behavior, sexual harassment, or neither. The authors are interested in the question of whether the respondents’ value orientations – in terms of gender essentialism, gender egalitarianism and their belief in meritocracy – significantly influence sensitivity to the perception of sexual harassment.

Of the papers in this edited collection, Vandevelde-Rougale and Guerrero Morales most directly address the implications of the extension of managerialism and New Public Management to discrimination in research organizations. The authors examine managerial discourse, by which they mean a utilitarian, cost-benefit-oriented way of interpreting and organizing the affairs and processes of research teams. Through multiple case studies from Ireland and Chile, they explore what the focus on the pragmatic exploitation of diversity brings to bear on individuals who experience workplace bullying and discrimination, as well as what the managerial approach to conflict solutions can contribute to ensuring a safe and discrimination-free work culture.

The third discourse-related study in this edited collection is provided by Steuer-Dankert, who deals with diversity belief in a complex research organization. Diversity belief is understood as a working group’s belief in its own diversity and the positive benefits of diversity. Steuer-Dankert not only contributes the most comprehensive reflection on diversity management in research organizations among the contributions of this collection, but she also provides answers to another interesting aspect. Previous studies often examine diversity and discrimination in teams under the assumption of a relative constancy of team structures and members, but in a modern innovation system research often takes place in project-wise institutionalized and theme-oriented network structures such as the German Cluster of Excellence examined by Steuer-Dankert. The temporary network forms a further governance level horizontal to the classic university organization and features independent team interactions and ultimately also a specific organizational culture.

While the aforementioned studies describe individual specific aspects of the organizational culture of research organizations, Gewinner reconstructs the experiences of discrimination of a specific group of people based on biographical interviews. Using Russian-speaking female scholars in Germany, she develops a comprehensive and intersectional theory on the vulnerability of foreign researchers to experiences of discrimination and workplace misconduct.

Since a major aim of this edited collection is not only to understand and describe discrimination in research organizations but also to make a small contribution to reducing discrimination, we conclude by formulating a number of implications for practice. In the concluding chapter, we set out several basic features and requirements for an effective system for preventing and managing discrimination in research organizations and summarize what we consider to be the main lessons learned from this edited collection in a simple catalogue of options for action.

About Our Intersectional Approach

The intersectionality approach assumes that an individual belongs to “multiple categories of difference” defined by socially-constructed categories such as gender, age, or ethnicity that result in a specific set of opportunities and oppressions for each individual stemming from their “blended social identity” (Dennissen et al., 2020; Silva, 2020; Ghavami et al., 2016 ; Crenshaw, 1991). These intersections of identity and discrimination result in individual experiences of discrimination based on different group memberships. Accordingly, the concrete discrimination experiences of black women – for example – differ from those of black men and white women. An intersectional approach considers the addition of experiences of discrimination, but furthermore also considers interaction effects (Bowleg, 2008). As a result of the intersectional analysis, it may emerge – for example – that black women experience discrimination less frequently than black men or white women, although they experience discrimination due to their status as women and black people. The task of intersectional research is to identify the structural and situational dynamics of discrimination processes and their specific contextual conditions.

The contributions of the edited collection and their framing explicitly follow an intersectional approach. This means that the single contributions not only discuss differences between persons of different genders but also pursue taking into account intersections between identity categories (and the different systems of oppressions represented by them) in the analysis. We apply a broad understanding of intersectionality. Which categorizations are ultimately taken up in the contributions to the edited collection was open and depended on the authors’ research foci and available data. In principle, it is possible to analyze the manifold interactions of gender with racial or ethnic origin, religion or belief, disability, sexual orientation and other categorizations, which can form the starting point for systemic discrimination.

Nevertheless, an intersectional analysis in the strict sense was not always possible. Especially in quantitative studies, large numbers of cases are necessary to make statements with high statistical power and thus not only identify very strong statistical effects. In cases with low statistical power, it was not the interactions of, for example, gender and age that were analyzed, but rather the simple effects of gender and age. In addition, several authors of the edited collection adopt an intersectional perspective when discussing the generalizability of their results. For example, Kmec et al. (in this collection) discuss whether a connection between merit thinking and sexual discrimination could also be proven if the discrimination was not positioned in a heterosexual setting between an old white supervisor and a young white female researcher.

Funding Note

The present contribution is not related to externally funded research.

The text of Article 179 of the Treaty on the Functioning of the European Union (2012) paraphrased here is: “The Union shall have the objective of strengthening its scientific and technological bases by achieving a European research area in which researchers, scientific knowledge and technology circulate freely, […].”

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Discrimination: What it is and how to cope

For many people, discrimination is an everyday reality. Discrimination is the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age, or sexual orientation.

• Racism, Bias, and Discrimination
• Race and Ethnicity
• Socioeconomic Status

What is discrimination?

Discrimination is the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age, or sexual orientation. That’s the simple answer. But explaining why it happens is more complicated.

The human brain naturally puts things in categories to make sense of the world. Very young children quickly learn the difference between boys and girls, for instance. But the values we place on different categories are learned—from our parents, our peers, and the observations we make about how the world works. Often, discrimination stems from fear and misunderstanding.

Stress and health

Discrimination is a public health issue. Research has found that the experience of discrimination—when perceived as such—can lead to a cascade of stress-related emotional, physical, and behavioral changes . Stress evokes negative emotional responses, such as distress, sadness, and anger, and can often lead to an increase in behaviors that harm health, such as alcohol, tobacco, and other substance use, and a decrease in healthy activities, such as sleep and physical activity.

Discrimination can be damaging even if you haven’t been the target of overt acts of bias. Regardless of your personal experiences, it can be stressful just being a member of a group that is often discriminated against, such as racial minorities or individuals who identify as lesbian, gay, bisexual, or transgender.

The anticipation of discrimination creates its own chronic stress. People might even avoid situations where they expect they could be treated poorly, possibly missing out on educational and job opportunities.

Discrimination, big and small

Laws are in place to protect people from discrimination in housing and employment.

• The Fair Housing Act prohibits discrimination in the sale, rental, and financing of dwellings on the basis of race, color, national origin, religion, sex, familial status, and disability.
• The Civil Rights Act, the Age Discrimination in Employment Act, and the Americans with Disabilities Act prohibit discrimination in employment on the basis of race, color, sex, ethnic origin, age, and disabilities.

Unfortunately, discrimination still occurs.

Yet experts say that smaller, less obvious examples of day-to-day discrimination—receiving poorer service at stores or restaurants, being treated with less courtesy and respect, or being treated as less intelligent or less trustworthy—may be more common than major discrimination. Such day-to-day discrimination frequently comes in the form of “microaggressions” such as snubs, slights, and misguided comments that suggest a person doesn’t belong or invalidates his or her experiences.

Though microaggressions are often subtle, they can be just as harmful to health and well-being as more overt episodes of major bias. People on the receiving end of day-to-day discrimination often feel they’re in a state of constant vigilance, on the lookout for being a target of discrimination. That heightened watchfulness is a recipe for chronic stress.

Dealing with discrimination

Finding healthy ways to deal with discrimination is important, for your physical health and your mental well-being.

Focus on your strengths. Focusing on your core values, beliefs, and perceived strengths can motivate people to succeed, and may even buffer the negative effects of bias. Overcoming hardship can also make people more resilient and better able to face future challenges.

Seek support systems. One problem with discrimination is that people can internalize others’ negative beliefs, even when they’re false. You may start to believe you’re not good enough. But family and friends can remind you of your worth and help you reframe those faulty beliefs.

Family and friends can also help counteract the toll that microaggressions and other examples of daily discrimination can take. In a world that regularly invalidates your experiences and feelings, members of your support network can reassure you that you’re not imagining those experiences of discrimination. Still, it’s sometimes painful to talk about discrimination. It can be helpful to ask friends and family how they handle such events.

Your family and friends can also be helpful if you feel you’ve been the victim of discrimination in areas such as housing, employment, or education. Often, people don’t report such experiences to agencies or supervisors. One reason for that lack of reporting is that people often doubt themselves: Was I actually discriminated against, or am I being oversensitive? Will I be judged negatively if I push the issue? Your support network can provide a reality check and a sounding board to help you decide if your claims are valid and worth pursuing.

Get involved. Support doesn’t have to come from people in your family or circle of friends. You can get involved with like-minded groups and organizations, whether locally or online. It can help to know there are other people who have had similar experiences to yours. And connecting with those people might help you figure out how to address situations and respond to experiences of discrimination in ways you haven’t thought of.

Help yourself think clearly. Being the target of discrimination can stir up a lot of strong emotions including anger, sadness, and embarrassment. Such experiences often trigger a physiological response, too; they can increase your blood pressure, heart rate, and body temperature.

Try to check in with your body before reacting. Slow your breathing or use other relaxation exercises to calm your body’s stress response. Then you’ll be able to think more clearly about how you want to respond.

Don’t dwell. When you’ve experienced discrimination, it can be really hard to just shake it off. People often get stuck on episodes of discrimination, in part because they’re not sure how to handle those experiences. You might want to speak out or complain, but you’re not sure how to go about it, or are afraid of the backlash. So instead, you end up ruminating, or thinking over and over about what you should have done.

In a calmer moment, it might be helpful to talk over the ways you can cope with similar experiences in the future. Try to come up with a plan for how you might respond or what you could do differently next time. Once you’ve determined how to respond, try to leave the incident behind you as you go on with your day.

Seek professional help. Discrimination is difficult to deal with, and is often associated with symptoms of depression. Psychologists are experts in helping people manage symptoms of stress and depression, and can help you find healthy ways to cope. You can find a psychologist in your area by using APA’s Psychologist Locator Service.

Discrimination resources

If you have questions about policies or concerns about discrimination in your workplace, the human resource department is often a good place to start. To learn more about discrimination in housing and employment, or to file a complaint, visit:

• Equal Opportunity Employment Commission
• U.S. Department of Housing and Urban Development

Recommended Reading

Related reading.

• Psychology topics: Racism, bias, and discrimination
• Stress in America
• Talking to your kids about discrimination

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Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine (2018)

Chapter: 7 findings, conclusions, and recommendations, 7 findings, conclusions, and recommendations.

Preventing and effectively addressing sexual harassment of women in colleges and universities is a significant challenge, but we are optimistic that academic institutions can meet that challenge—if they demonstrate the will to do so. This is because the research shows what will work to prevent sexual harassment and why it will work. A systemwide change to the culture and climate in our nation’s colleges and universities can stop the pattern of harassing behavior from impacting the next generation of women entering science, engineering, and medicine.

Changing the current culture and climate requires addressing all forms of sexual harassment, not just the most egregious cases; moving beyond legal compliance; supporting targets when they come forward; improving transparency and accountability; diffusing the power structure between faculty and trainees; and revising organizational systems and structures to value diversity, inclusion, and respect. Leaders at every level within academia will be needed to initiate these changes and to establish and maintain the culture and norms. However, to succeed in making these changes, all members of our nation’s college campuses—students, faculty, staff, and administrators—will need to assume responsibility for promoting a civil and respectful environment. It is everyone’s responsibility to stop sexual harassment.

In this spirit of optimism, we offer the following compilation of the report’s findings, conclusions, and recommendations.

FINDINGS AND CONCLUSIONS

Chapter 2: sexual harassment research.

• Sexual harassment is a form of discrimination that consists of three types of harassing behavior: (1) gender harassment (verbal and nonverbal behaviors that convey hostility, objectification, exclusion, or second-class status about members of one gender); (2) unwanted sexual attention (unwelcome verbal or physical sexual advances, which can include assault); and (3) sexual coercion (when favorable professional or educational treatment is conditioned on sexual activity). The distinctions between the types of harassment are important, particularly because many people do not realize that gender harassment is a form of sexual harassment.
• Sexually harassing behavior can be either direct (targeted at an individual) or ambient (a general level of sexual harassment in an environment) and is harmful in both cases. It is considered illegal when it creates a hostile environment (gender harassment or unwanted sexual attention that is “severe or pervasive” enough to alter the conditions of employment, interfere with one’s work performance, or impede one’s ability to get an education) or when it is quid pro quo sexual harassment (when favorable professional or educational treatment is conditioned on sexual activity).
• There are reliable scientific methods for determining the prevalence of sexual harassment. To measure the incidence of sexual harassment, surveys should follow the best practices that have emerged from the science of sexual harassment. This includes use of the Sexual Experiences Questionnaire, the most widely used and well-validated instrument available for measuring sexual harassment; assessment of specific behaviors without requiring the respondent to label the behaviors “sexual harassment”; focus on first-hand experience or observation of behavior (rather than rumor or hearsay); and focus on the recent past (1–2 years, to avoid problems of memory decay). Relying on the number of official reports of sexual harassment made to an organization is not an accurate method for determining the prevalence.
• Some surveys underreport the incidence of sexual harassment because they have not followed standard and valid practices for survey research and sexual harassment research.
• While properly conducted surveys are the best methods for estimating the prevalence of sexual harassment, other salient aspects of sexual harassment and its consequences can be examined using other research methods , such as behavioral laboratory experiments, interviews, case studies, ethnographies, and legal research. Such studies can provide information about the presence and nature of sexually harassing behavior in an organization, how it develops and continues (and influences the organizational climate), and how it attenuates or amplifies outcomes from sexual harassment.
• Women experience sexual harassment more often than men do.
• Gender harassment (e.g., behaviors that communicate that women do not belong or do not merit respect) is by far the most common type of sexual harassment. When an environment is pervaded by gender harassment, unwanted sexual attention and sexual coercion become more likely to occur—in part because unwanted sexual attention and sexual coercion are almost never experienced by women without simultaneously experiencing gender harassment.
• Men are more likely than women to commit sexual harassment.
• Coworkers and peers more often commit sexual harassment than do superiors.
• Sexually harassing behaviors are not typically isolated incidents; rather, they are a series or pattern of sometimes escalating incidents and behaviors.
• Women of color experience more harassment (sexual, racial/ethnic, or combination of the two) than white women, white men, and men of color do. Women of color often experience sexual harassment that includes racial harassment.
• Sexual- and gender-minority people experience more sexual harassment than heterosexual women do.
• The two characteristics of environments most associated with higher rates of sexual harassment are (a) male-dominated gender ratios and leadership and (b) an organizational climate that communicates tolerance of sexual harassment (e.g., leadership that fails to take complaints seriously, fails to sanction perpetrators, or fails to protect complainants from retaliation).
• Organizational climate is, by far, the greatest predictor of the occurrence of sexual harassment, and ameliorating it can prevent people from sexually harassing others. A person more likely to engage in harassing behaviors is significantly less likely to do so in an environment that does not support harassing behaviors and/or has strong, clear, transparent consequences for these behaviors.

Chapter 3: Sexual Harassment in Academic Science, Engineering, and Medicine

• Male-dominated environment , with men in positions of power and authority.
• Organizational tolerance for sexually harassing behavior (e.g., failing to take complaints seriously, failing to sanction perpetrators, or failing to protect complainants from retaliation).
• Hierarchical and dependent relationships between faculty and their trainees (e.g., students, postdoctoral fellows, residents).
• Isolating environments (e.g., labs, field sites, and hospitals) in which faculty and trainees spend considerable time.
• Greater than 50 percent of women faculty and staff and 20–50 percent of women students encounter or experience sexually harassing conduct in academia.
• Women students in academic medicine experience more frequent gender harassment perpetrated by faculty/staff than women students in science and engineering.
• Women students/trainees encounter or experience sexual harassment perpetrated by faculty/staff and also by other students/trainees.
• Women faculty encounter or experience sexual harassment perpetrated by other faculty/staff and also by students/trainees.
• Women students, trainees, and faculty in academic medical centers experience sexual harassment by patients and patients’ families in addition to the harassment they experience from colleagues and those in leadership positions.

Chapter 4: Outcomes of Sexual Harassment

• When women experience sexual harassment in the workplace, the professional outcomes include declines in job satisfaction; withdrawal from their organization (i.e., distancing themselves from the work either physically or mentally without actually quitting, having thoughts or

intentions of leaving their job, and actually leaving their job); declines in organizational commitment (i.e., feeling disillusioned or angry with the organization); increases in job stress; and declines in productivity or performance.

• When students experience sexual harassment, the educational outcomes include declines in motivation to attend class, greater truancy, dropping classes, paying less attention in class, receiving lower grades, changing advisors, changing majors, and transferring to another educational institution, or dropping out.
• Gender harassment has adverse effects. Gender harassment that is severe or occurs frequently over a period of time can result in the same level of negative professional and psychological outcomes as isolated instances of sexual coercion. Gender harassment, often considered a “lesser,” more inconsequential form of sexual harassment, cannot be dismissed when present in an organization.
• The greater the frequency, intensity, and duration of sexually harassing behaviors, the more women report symptoms of depression, stress, and anxiety, and generally negative effects on psychological well-being.
• The more women are sexually harassed in an environment, the more they think about leaving, and end up leaving as a result of the sexual harassment.
• The more power a perpetrator has over the target, the greater the impacts and negative consequences experienced by the target.
• For women of color, preliminary research shows that when the sexual harassment occurs simultaneously with other types of harassment (i.e., racial harassment), the experiences can have more severe consequences for them.
• Sexual harassment has adverse effects that affect not only the targets of harassment but also bystanders, coworkers, workgroups, and entire organizations.
• Women cope with sexual harassment in a variety of ways, most often by ignoring or appeasing the harasser and seeking social support.
• The least common response for women is to formally report the sexually harassing experience. For many, this is due to an accurate perception that they may experience retaliation or other negative outcomes associated with their personal and professional lives.
• The dependence on advisors and mentors for career advancement.
• The system of meritocracy that does not account for the declines in productivity and morale as a result of sexual harassment.
• The “macho” culture in some fields.
• The informal communication network , in which rumors and accusations are spread within and across specialized programs and fields.
• The cumulative effect of sexual harassment is significant damage to research integrity and a costly loss of talent in academic science, engineering, and medicine. Women faculty in science, engineering, and medicine who experience sexual harassment report three common professional outcomes: stepping down from leadership opportunities to avoid the perpetrator, leaving their institution, and leaving their field altogether.

Chapter 5: Existing Legal and Policy Mechanisms for Addressing Sexual Harassment

• An overly legalistic approach to the problem of sexual harassment is likely to misjudge the true nature and scope of the problem. Sexual harassment law and policy development has focused narrowly on the sexualized and coercive forms of sexual harassment, not on the gender harassment type that research has identified as much more prevalent and at times equally harmful.
• Much of the sexual harassment that women experience and that damages women and their careers in science, engineering, and medicine does not meet the legal criteria of illegal discrimination under current law.
• Private entities, such as companies and private universities, are legally allowed to keep their internal policies and procedures—and their research on those policies and procedures—confidential, thereby limiting the research that can be done on effective policies for preventing and handling sexual harassment.
• Various legal policies, and the interpretation of such policies, enable academic institutions to maintain secrecy and/or confidentiality regarding outcomes of sexual harassment investigations, arbitration, and settlement agreements. Colleagues may also hesitate to warn one another about sexual harassment concerns in the hiring or promotion context out of fear of legal repercussions (i.e., being sued for defamation and/or discrimination). This lack of transparency in the adjudication process within organizations can cover up sexual harassment perpetrated by repeat or serial harassers. This creates additional barriers to researchers

and others studying harassment claims and outcomes, and is also a barrier to determining the effectiveness of policies and procedures.

• Title IX, Title VII, and case law reflect the inaccurate assumption that a target of sexual harassment will promptly report the harassment without worrying about retaliation. Effectively addressing sexual harassment through the law, institutional policies or procedures, or cultural change requires taking into account that targets of sexual harassment are unlikely to report harassment and often face retaliation for reporting (despite this being illegal).
• Fears of legal liability may prevent institutions from being willing to effectively evaluate training for its measurable impact on reducing harassment. Educating employees via sexual harassment training is commonly implemented as a central component of demonstrating to courts that institutions have “exercised reasonable care to prevent and correct promptly any sexually harassing behavior.” However, research has not demonstrated that such training prevents sexual harassment. Thus, if institutions evaluated their training programs, they would likely find them to be ineffective, which, in turn, could raise fears within institutions of their risk for liability because they would then knowingly not be exercising reasonable care.
• Holding individuals and institutions responsible for sexual harassment and demonstrating that sexual harassment is a serious issue requires U.S. federal funding agencies to be aware when principal investigators, co-principal investigators, and grant personnel have violated sexual harassment policies. It is unclear whether and how federal agencies will take action beyond the requirements of Title IX and Title VII to ensure that federal grants, composed of taxpayers’ dollars, are not supporting research, academic institutions, or programs in which sexual harassment is ongoing and not being addressed. Federal science agencies usually indicate (e.g., in requests for proposals or other announcements) that they have a “no-tolerance” policy for sexual harassment. In general, federal agencies rely on the grantee institutions to investigate and follow through on Title IX violations. By not assessing and addressing the role of institutions and professional organizations in enabling individual sexual harassers, federal agencies may be perpetuating the problem of sexual harassment.
• To address the effect sexual harassment has on the integrity of research, parts of the federal government and several professional societies are beginning to focus more broadly on policies about research integrity and on codes of ethics rather than on the narrow definition of research misconduct. A powerful incentive for change may be missed if sexual harassment is not considered equally important as research misconduct, in terms of its effect on the integrity of research.

Chapter 6: Changing the Culture and Climate in Higher Education

• A systemwide change to the culture and climate in higher education is required to prevent and effectively address all three forms of sexual harassment. Despite significant attention in recent years, there is no evidence to suggest that current policies, procedures, and approaches have resulted in a significant reduction in sexual harassment. It is time to consider approaches that address the systems, cultures, and climates that enable sexual harassment to perpetuate.
• Strong and effective leaders at all levels in the organization are required to make the systemwide changes to climate and culture in higher education. The leadership of the organization—at every level—plays a significant role in establishing and maintaining an organization’s culture and norms. However, leaders in academic institutions rarely have leadership training to thoughtfully address culture and climate issues, and the leadership training that exists is often of poor quality.
• Evidence-based, effective intervention strategies are available for enhancing gender diversity in hiring practices.
• Focusing evaluation and reward structures on cooperation and collegiality rather than solely on individual-level teaching and research performance metrics could have a significant impact on improving the environment in academia.
• Evidence-based, effective intervention strategies are available for raising levels of interpersonal civility and respect in workgroups and teams.
• An organization that is committed to improving organizational climate must address issues of bias in academia. Training to reduce personal bias can cause larger-scale changes in departmental behaviors in an academic setting.
• Skills-based training that centers on bystander intervention promotes a culture of support, not one of silence. By calling out negative behaviors on the spot, all members of an academic community are helping to create a culture where abusive behavior is seen as an aberration, not as the norm.
• Reducing hierarchical power structures and diffusing power more broadly among faculty and trainees can reduce the risk of sexual ha

rassment. Departments and institutions could take the following approaches for diffusing power:

• Make use of egalitarian leadership styles that recognize that people at all levels of experience and expertise have important insights to offer.
• Adopt mentoring networks or committee-based advising that allows for a diversity of potential pathways for advice, funding, support, and informal reporting of harassment.
• Develop ways the research funding can be provided to the trainee rather than just the principal investigator.
• Take on the responsibility for preserving the potential work of the research team and trainees by redistributing the funding if a principal investigator cannot continue the work because he/she has created a climate that fosters sexual harassment and guaranteeing funding to trainees if the institution or a funder pulls funding from the principal investigator because of sexual harassment.
• Orienting students, trainees, faculty, and staff, at all levels, to the academic institution’s culture and its policies and procedures for handling sexual harassment can be an important piece of establishing a climate that demonstrates sexual harassment is not tolerated and targets will be supported.
• Institutions could build systems of response that empower targets by providing alternative and less formal means of accessing support services, recording information, and reporting incidents without fear of retaliation.
• Supporting student targets also includes helping them to manage their education and training over the long term.
• Confidentiality and nondisclosure agreements isolate sexual harassment targets by limiting their ability to speak with others about their experiences and can serve to shield perpetrators who have harassed people repeatedly.
• Key components of clear anti-harassment policies are that they are quickly and easily digested (i.e., using one-page flyers or infographics and not in legally dense language) and that they clearly state that people will be held accountable for violating the policy.
• A range of progressive/escalating disciplinary consequences (such as counseling, changes in work responsibilities, reductions in pay/benefits, and suspension or dismissal) that corresponds to the severity and frequency of the misconduct has the potential of correcting behavior before it escalates and without significantly disrupting an academic program.
• In an effort to change behavior and improve the climate, it may also be appropriate for institutions to undertake some rehabilitation-focused measures, even though these may not be sanctions per se.
• For the people in an institution to understand that the institution does not tolerate sexual harassment, it must show that it does investigate and then hold perpetrators accountable in a reasonable timeframe. Institutions can anonymize the basic information and provide regular reports that convey how many reports are being investigated and what the outcomes are from the investigation.
• An approach for improving transparency and demonstrating that the institution takes sexual harassment seriously is to encourage internal review of its policies, procedures, and interventions for addressing sexual harassment, and to have interactive dialogues with members of their campus community (especially expert researchers on these topics) around ways to improve the culture and climate and change behavior.
• Cater training to specific populations; in academia this would include students, postdoctoral fellows, staff, faculty, and those in leadership.
• Attend to the institutional motivation for training , which can impact the effectiveness of the training; for instance, compliance-based approaches have limited positive impact.
• Conduct training using live qualified trainers and offer trainees specific examples of inappropriate conduct. We note that a great deal of sexual harassment training today is offered via an online mini-course or the viewing of a short video.
• Describe standards of behavior clearly and accessibly (e.g., avoiding legal and technical terms).
• To the extent that the training literature provides broad guidelines for creating impactful training that can change climate and behavior, they include the following:
• Establish standards of behavior rather than solely seek to influence attitudes and beliefs. Clear communication of behavioral expectations, and teaching of behavioral skills, is essential.
• Conduct training in adherence to best standards , including appropriate pre-training needs assessment and evaluation of its effectiveness.
• Creating a climate that prevents sexual harassment requires measuring the climate in relation to sexual harassment, diversity, and respect, and assessing progress in reducing sexual harassment.
• Efforts to incentivize systemwide changes, such as Athena SWAN, 1 are crucial to motivating organizations and departments within organizations to make the necessary changes.
• Enacting new codes of conduct and new rules related specifically to conference attendance.
• Including sexual harassment in codes of ethics and investigating reports of sexual harassment. (This is a new responsibility for professional societies, and these organizations are considering how to take into consideration the law, home institutions, due process, and careful reporting when dealing with reports of sexual harassment.)
• Requiring members to acknowledge, in writing, the professional society’s rules and codes of conduct relating to sexual harassment during conference registration and during membership sign-up and renewal.
• Supporting and designing programs that prevent harassment and provide skills to intervene when someone is being harassed.
• Strengthening statements on sexual harassment, bullying, and discrimination in professional societies’ codes of conduct, with a few defining it as research misconduct.
• Factoring in harassment-related professional misconduct into scientific award decisions.
• Professional societies have the potential to be powerful drivers of change through their capacity to help educate, train, codify, and reinforce cultural expectations for their respective scientific, engineering, and medical communities. Some professional societies have taken action to prevent and respond to sexual harassment among their membership. Although each professional society has taken a slightly different approach to addressing sexual harassment, there are some shared approaches, including the following:

___________________

1 Athena SWAN (Scientific Women’s Academic Network). See https://www.ecu.ac.uk/equalitycharters/athena-swan/ .

• There are many promising approaches to changing the culture and climate in academia; however, further research assessing the effects and values of the following approaches is needed to identify best practices:
• Policies, procedures, trainings, and interventions, specifically how they prevent and stop sexually harassing behavior, alter perception of organizational tolerance for sexually harassing behavior, and reduce the negative consequences from reporting the incidents. This includes informal and formal reporting mechanisms, bystander intervention training, academic leadership training, sexual harassment training, interventions to improve civility, mandatory reporting requirements, and approaches to supporting and improving communication with the target.
• Mechanisms for target-led resolution options and mechanisms by which the target has a role in deciding what happens to the perpetrator, including restorative justice practices.
• Mechanisms for protecting targets from retaliation.
• Rehabilitation-focused measures for disciplining perpetrators.
• Incentive systems for encouraging leaders in higher education to address the issues of sexual harassment on campus.

RECOMMENDATIONS

RECOMMENDATION 1: Create diverse, inclusive, and respectful environments.

• Academic institutions and their leaders should take explicit steps to achieve greater gender and racial equity in hiring and promotions, and thus improve the representation of women at every level.
• Academic institutions and their leaders should take steps to foster greater cooperation, respectful work behavior, and professionalism at the faculty, staff, and student/trainee levels, and should evaluate faculty and staff on these criteria in hiring and promotion.
• Academic institutions should combine anti-harassment efforts with civility-promotion programs.
• Academic institutions should cater their training to specific populations (in academia these should include students/trainees, staff, faculty, and those in leadership) and should follow best practices in designing training programs. Training should be viewed as the means of providing the skills needed by all members of the academic community, each of whom has a role to play in building a positive organizational climate focused on safety and respect, and not simply as a method of ensuring compliance with laws.
• Academic institutions should utilize training approaches that develop skills among participants to interrupt and intervene when inappropriate behavior occurs. These training programs should be evaluated to deter

mine whether they are effective and what aspects of the training are most important to changing culture.

• Anti–sexual harassment training programs should focus on changing behavior, not on changing beliefs. Programs should focus on clearly communicating behavioral expectations, specifying consequences for failing to meet these expectations, and identifying the mechanisms to be utilized when these expectations are not met. Training programs should not be based on the avoidance of legal liability.

RECOMMENDATION 2: Address the most common form of sexual harassment: gender harassment.

Leaders in academic institutions and research and training sites should pay increased attention to and enact policies that cover gender harassment as a means of addressing the most common form of sexual harassment and of preventing other types of sexually harassing behavior.

RECOMMENDATION 3: Move beyond legal compliance to address culture and climate.

Academic institutions, research and training sites, and federal agencies should move beyond interventions or policies that represent basic legal compliance and that rely solely on formal reports made by targets. Sexual harassment needs to be addressed as a significant culture and climate issue that requires institutional leaders to engage with and listen to students and other campus community members.

RECOMMENDATION 4: Improve transparency and accountability.

• Academic institutions need to develop—and readily share—clear, accessible, and consistent policies on sexual harassment and standards of behavior. They should include a range of clearly stated, appropriate, and escalating disciplinary consequences for perpetrators found to have violated sexual harassment policy and/or law. The disciplinary actions taken should correspond to the severity and frequency of the harassment. The disciplinary actions should not be something that is often considered a benefit for faculty, such as a reduction in teaching load or time away from campus service responsibilities. Decisions regarding disciplinary actions, if indicated or required, should be made in a fair and timely way following an investigative process that is fair to all sides. 2
• Academic institutions should be as transparent as possible about how they are handling reports of sexual harassment. This requires balancing issues of confidentiality with issues of transparency. Annual reports,

2 Further detail on processes and guidance for how to fairly and appropriately investigate and adjudicate these issues are not provided because they are complex issues that were beyond the scope of this study.

that provide information on (1) how many and what type of policy violations have been reported (both informally and formally), (2) how many reports are currently under investigation, and (3) how many have been adjudicated, along with general descriptions of any disciplinary actions taken, should be shared with the entire academic community: students, trainees, faculty, administrators, staff, alumni, and funders. At the very least, the results of the investigation and any disciplinary action should be shared with the target(s) and/or the person(s) who reported the behavior.

• Academic institutions should be accountable for the climate within their organization. In particular, they should utilize climate surveys to further investigate and address systemic sexual harassment, particularly when surveys indicate specific schools or facilities have high rates of harassment or chronically fail to reduce rates of sexual harassment.
• Academic institutions should consider sexual harassment equally important as research misconduct in terms of its effect on the integrity of research. They should increase collaboration among offices that oversee the integrity of research (i.e., those that cover ethics, research misconduct, diversity, and harassment issues); centralize resources, information, and expertise; provide more resources for handling complaints and working with targets; and implement sanctions on researchers found guilty of sexual harassment.

RECOMMENDATION 5: Diffuse the hierarchical and dependent relationship between trainees and faculty.

Academic institutions should consider power-diffusion mechanisms (i.e., mentoring networks or committee-based advising and departmental funding rather than funding only from a principal investigator) to reduce the risk of sexual harassment.

RECOMMENDATION 6: Provide support for the target.

Academic institutions should convey that reporting sexual harassment is an honorable and courageous action. Regardless of a target filing a formal report, academic institutions should provide means of accessing support services (social services, health care, legal, career/professional). They should provide alternative and less formal means of recording information about the experience and reporting the experience if the target is not comfortable filing a formal report. Academic institutions should develop approaches to prevent the target from experiencing or fearing retaliation in academic settings.

RECOMMENDATION 7: Strive for strong and diverse leadership.

• College and university presidents, provosts, deans, department chairs, and program directors must make the reduction and prevention of sexual

harassment an explicit goal of their tenure. They should publicly state that the reduction and prevention of sexual harassment will be among their highest priorities, and they should engage students, faculty, and staff (and, where appropriate, the local community) in their efforts.

• Academic institutions should support and facilitate leaders at every level (university, school/college, department, lab) in developing skills in leadership, conflict resolution, mediation, negotiation, and de-escalation, and should ensure a clear understanding of policies and procedures for handling sexual harassment issues. Additionally, these skills development programs should be customized to each level of leadership.
• Leadership training programs for those in academia should include training on how to recognize and handle sexual harassment issues, and how to take explicit steps to create a culture and climate to reduce and prevent sexual harassment—and not just protect the institution against liability.

RECOMMENDATION 8: Measure progress.

Academic institutions should work with researchers to evaluate and assess their efforts to create a more diverse, inclusive, and respectful environment, and to create effective policies, procedures, and training programs. They should not rely on formal reports by targets for an understanding of sexual harassment on their campus.

• When organizations study sexual harassment, they should follow the valid methodologies established by social science research on sexual harassment and should consult subject-matter experts. Surveys that attempt to ascertain the prevalence and types of harassment experienced by individuals should adopt the following practices: ensure confidentiality, use validated behavioral instruments such as the Sexual Experiences Questionnaire, and avoid specifically using the term “sexual harassment” in any survey or questionnaire.
• Academic institutions should also conduct more wide-ranging assessments using measures in addition to campus climate surveys, for example, ethnography, focus groups, and exit interviews. These methods are especially important in smaller organizational units where surveys, which require more participants to yield meaningful data, might not be useful.
• Organizations studying sexual harassment in their environments should take into consideration the particular experiences of people of color and sexual- and gender-minority people, and they should utilize methods that allow them to disaggregate their data by race, ethnicity, sexual orientation, and gender identity to reveal the different experiences across populations.
• The results of climate surveys should be shared publicly to encourage transparency and accountability and to demonstrate to the campus community that the institution takes the issue seriously. One option would be for academic institutions to collaborate in developing a central repository for reporting their climate data, which could also improve the ability for research to be conducted on the effectiveness of institutional approaches.
• Federal agencies and foundations should commit resources to develop a tool similar to ARC3, the Administrator-Researcher Campus Climate Collaborative, to understand and track the climate for faculty, staff, and postdoctoral fellows.

RECOMMENDATION 9: Incentivize change.

• Academic institutions should work to apply for awards from the emerging STEM Equity Achievement (SEA Change) program. 3 Federal agencies and private foundations should encourage and support academic institutions working to achieve SEA Change awards.
• Accreditation bodies should consider efforts to create diverse, inclusive, and respectful environments when evaluating institutions or departments.
• Federal agencies should incentivize efforts to reduce sexual harassment in academia by requiring evaluations of the research environment, funding research and evaluation of training for students and faculty (including bystander intervention), supporting the development and evaluation of leadership training for faculty, and funding research on effective policies and procedures.

RECOMMENDATION 10: Encourage involvement of professional societies and other organizations.

• Professional societies should accelerate their efforts to be viewed as organizations that are helping to create culture changes that reduce or prevent the occurrence of sexual harassment. They should provide support and guidance for members who have been targets of sexual harassment. They should use their influence to address sexual harassment in the scientific, medical, and engineering communities they represent and promote a professional culture of civility and respect. The efforts of the American Geophysical Union are especially exemplary and should be considered as a model for other professional societies to follow.
• Other organizations that facilitate the research and training of people in science, engineering, and medicine, such as collaborative field sites (i.e., national labs and observatories), should establish standards of behavior

3 See https://www.aaas.org/news/sea-change-program-aims-transform-diversity-efforts-stem .

and set policies, procedures, and practices similar to those recommended for academic institutions and following the examples of professional societies. They should hold people accountable for their behaviors while at their facility regardless of the person’s institutional affiliation (just as some professional societies are doing).

RECOMMENDATION 11: Initiate legislative action.

State legislatures and Congress should consider new and additional legislation with the following goals:

• Better protecting sexual harassment claimants from retaliation.
• Prohibiting confidentiality in settlement agreements that currently enable harassers to move to another institution and conceal past adjudications.
• Banning mandatory arbitration clauses for discrimination claims.
• Allowing lawsuits to be filed against alleged harassers directly (instead of or in addition to their academic employers).
• Requiring institutions receiving federal funds to publicly disclose results from campus climate surveys and/or the number of sexual harassment reports made to campuses.
• Requesting the National Science Foundation and the National Institutes of Health devote research funds to doing a follow-up analysis on the topic of sexual harassment in science, engineering, and medicine in 3 to 5 years to determine (1) whether research has shown that the prevalence of sexual harassment has decreased, (2) whether progress has been made on implementing these recommendations, and (3) where to focus future efforts.

RECOMMENDATION 12: Address the failures to meaningfully enforce Title VII’s prohibition on sex discrimination.

• Judges, academic institutions (including faculty, staff, and leaders in academia), and administrative agencies should rely on scientific evidence about the behavior of targets and perpetrators of sexual harassment when assessing both institutional compliance with the law and the merits of individual claims.
• Federal judges should take into account demonstrated effectiveness of anti-harassment policies and practices such as trainings, and not just their existence , for use of an affirmative defense against a sexual harassment claim under Title VII.

RECOMMENDATION 13: Increase federal agency action and collaboration.

Federal agencies should do the following:

• Increase support for research and evaluation of the effectiveness of policies, procedures, and training on sexual harassment.
• Attend to sexual harassment with at least the same level of attention and resources as devoted to research misconduct. They should increase collaboration among offices that oversee the integrity of research (i.e., those that cover ethics, research misconduct, diversity, and harassment issues); centralize resources, information, and expertise; provide more resources for handling complaints and working with targets; and implement sanctions on researchers found guilty of sexual harassment.
• Require institutions to report to federal agencies when individuals on grants have been found to have violated sexual harassment policies or have been put on administrative leave related to sexual harassment, as the National Science Foundation has proposed doing. Agencies should also hold accountable the perpetrator and the institution by using a range of disciplinary actions that limit the negative effects on other grant personnel who were either the target of the harassing behavior or innocent bystanders.
• Reward and incentivize colleges and universities for implementing policies, programs, and strategies that research shows are most likely to and are succeeding in reducing and preventing sexual harassment.

RECOMMENDATION 14: Conduct necessary research.

Funders should support the following research:

• The sexual harassment experiences of women in underrepresented and/or vulnerable groups, including women of color, disabled women, immigrant women, sexual- and gender-minority women, postdoctoral trainees, and others.
• Policies, procedures, trainings, and interventions, specifically their ability to prevent and stop sexually harassing behavior, to alter perception of organizational tolerance for sexually harassing behavior, and to reduce the negative consequences from reporting the incidents. This should include research on informal and formal reporting mechanisms, bystander intervention training, academic leadership training, sexual harassment and diversity training, interventions to improve civility, mandatory reporting requirements, and approaches to supporting and improving communication with the target.
• Approaches for mitigating the negative impacts and outcomes that targets experience.
• The prevalence and nature of sexual harassment within specific fields in

science, engineering, and medicine and that follows good practices for sexual harassment surveys.

• The prevalence and nature of sexual harassment perpetrated by students on faculty.
• The amount of sexual harassment that serial harassers are responsible for.
• The prevalence and effect of ambient harassment in the academic setting.
• The connections between consensual relationships and sexual harassment.
• Psychological characteristics that increase the risk of perpetrating different forms of sexually harassing behaviors.

RECOMMENDATION 15: Make the entire academic community responsible for reducing and preventing sexual harassment.

All members of our nation’s college campuses—students, trainees, faculty, staff, and administrators—as well as members of research and training sites should assume responsibility for promoting civil and respectful education, training, and work environments, and stepping up and confronting those whose behaviors and actions create sexually harassing environments.

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Over the last few decades, research, activity, and funding has been devoted to improving the recruitment, retention, and advancement of women in the fields of science, engineering, and medicine. In recent years the diversity of those participating in these fields, particularly the participation of women, has improved and there are significantly more women entering careers and studying science, engineering, and medicine than ever before. However, as women increasingly enter these fields they face biases and barriers and it is not surprising that sexual harassment is one of these barriers.

Over thirty years the incidence of sexual harassment in different industries has held steady, yet now more women are in the workforce and in academia, and in the fields of science, engineering, and medicine (as students and faculty) and so more women are experiencing sexual harassment as they work and learn. Over the last several years, revelations of the sexual harassment experienced by women in the workplace and in academic settings have raised urgent questions about the specific impact of this discriminatory behavior on women and the extent to which it is limiting their careers.

Sexual Harassment of Women explores the influence of sexual harassment in academia on the career advancement of women in the scientific, technical, and medical workforce. This report reviews the research on the extent to which women in the fields of science, engineering, and medicine are victimized by sexual harassment and examines the existing information on the extent to which sexual harassment in academia negatively impacts the recruitment, retention, and advancement of women pursuing scientific, engineering, technical, and medical careers. It also identifies and analyzes the policies, strategies and practices that have been the most successful in preventing and addressing sexual harassment in these settings.

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Skin tone discrimination and birth control avoidance among women in Harris County, Texas: a cross-sectional study

• Kimberly Baker 1 ,
• Susan Tortolero Emery 1 ,
• Evelyn Spike 1 ,
• Jazmyne Sutton 2 &
• Eran Ben-Porath 2  

BMC Public Health volume  24 , Article number:  2375 ( 2024 ) Cite this article

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Introduction

Structural racism plays a major role in reproductive health inequities. Colorism, discrimination based on skin color, may profoundly impact reproductive health access and service delivery. However, quantitative research in this area is limited.

We administered an online survey of women ( n  = 1,299) aged 18–44 from Harris County, Texas to assess the relationship between skin color discrimination and reproductive health service avoidance. The survey included questions on demographics, self-reported skin tone, and dichotomous measures of previous discrimination experiences and avoidance of care because of perceived discrimination. Binary logistic regression was used to examine whether race/ethnicity, skin tone, and previous discrimination experiences were related to avoidance of contraceptive care because of perceived discrimination.

Approximately one-third (31.5%) of the sample classified themselves as non-Hispanic Whites (31.5%), 22.4% as Black, 27.4% as Hispanic and born within the US, and 7.6% as Hispanic born outside of the US. Approximately one-third of women classified themselves in the lightest skin tones, whereas almost one in five women classified themselves in the darkest skin tone palates. Darker skin tones had increasingly greater odds of reporting that they avoided seeking birth control out of a concern for discrimination compared to the lightest skin tone. After adjusting for race/ethnicity and sociodemographic variables (model 3), darker skin tones remained significantly associated with avoiding birth control.

This study demonstrates the role that skin color discrimination plays in negative reproductive health experiences. While this is not surprising given that those with racist ideologies developed the concept of these racial and ethnic categories, the apparent association with darker skin colors and avoidance of seeking birth control provides evidence that structural and individual racism continues to have far-reaching and insidious consequences.

Contraception is recognized for reducing maternal mortality, improving child health, increasing female empowerment, and decreasing poverty. However, not all women equally enjoy the benefits of access to contraception. Addressing colorism within reproductive healthcare has become critically important as the nation becomes increasingly diverse. Focusing on skin tone-based discrimination and its roots in anti-blackness expands our understanding beyond a Black–White binary traditionally applied when addressing racism in healthcare delivery.

Peer Review reports

Racial and ethnic disparities in reproductive health access, services, and outcomes are prevalent [ 1 ]. These disparities are evidenced by the lower use of contraception among Hispanic and non-Hispanic Black women over the last decades, resulting in higher rates of unintended pregnancies and poorer maternal outcomes [ 1 , 2 , 3 ]. Barriers to hormonal contraceptive methods have been well described and include costs, proximity to affordable clinics, lack of over-the-counter access, affordable copays, and patients’ lack of awareness or misconceptions [ 4 , 5 ]. Other factors include healthcare providers’ attitudes, misconceptions, and limited training. For adolescent patients, consent and confidentiality are major barriers [ 4 , 5 ]. Mounting evidence suggests that structural racism may underlie many of these common barriers and extend to the interpersonal and internalized experiences of racism among women seeking care and the type of care provided to them [ 1 , 6 , 7 ].

While scientists have been describing racial and ethnic disparities in reproductive health outcomes, we are slow to acknowledge the underpinnings of these disparities. To understand the underpinnings, we must recognize that racial and ethnic classifications were created in the first place by scientists and others who had racist ideologies. As such, racial and ethnic classifications are complex social constructs with no biological basis and are deeply confounded with the stratification systems that perpetuate structural and individual racism and oppression. By understanding the origins and flaws of these classification systems, researchers can move past simply reporting reproductive health disparities based on race and further address the multiple levels of racism (structural, interpersonal, and internalized) that underlie reproductive health disparities.

One key factor increasingly associated with disparate outcomes in health, housing, and economic mobility is skin color discrimination, also known as colorism [ 8 , 9 ]. Colorism can be defined as discrimination based on the preference and value of people of lighter skin tones and Eurocentric features (straight hair, narrow facial features, e.g.) over darker skin tones, kinky hair, and more stereotypically Afrocentric facial features [ 10 ]. Colorism, an important form of racial discrimination, is garnering increased awareness due to its global prominence and impact on various health outcomes [ 8 , 11 , 12 , 13 , 14 ]. However, the effect colorism has on reproductive healthcare outcomes and contraception access has been overlooked.

Recent qualitative studies document women’s experience of racism and colorism during their healthcare encounters and over their reproductive life experiences. Specifically, women of darker skin tones felt subjugated to lesser treatment when accessing reproductive health services, surfacing long-standing experiences of phenotype discrimination that seldom gets documented in public health research [ 7 , 15 ]. Specifically, women described that racism impacted their ability to obtain timely healthcare services, their frequency of care, and their experiences with the healthcare system. Participants also reported that individual racism, as manifested through interactions with healthcare providers, negatively affected their use of reproductive healthcare services [ 7 ].

Another study suggested that colorism may impact access to prenatal care and delays in care. In this study, a quarter (24.8%) of women had delayed prenatal care, and daily experiences of racism were associated with delayed prenatal care. This association was moderated by self-reported maternal skin tone [ 16 ]. Elucidating the role of racism and colorism is essential in understanding the underlying causes of disparities in contraception use and the interventions that should be implemented to ameliorate these disparities. To determine the association between skin tone, perceived discrimination, and contraception care avoidance, we analyzed survey data collected from a representative sample of 1,299 women in a major southern US city.

The data for this analysis were collected through a cross-sectional survey of N  = 1299 women aged 18 to 44 reached online from February 10 through March 31, 2022. Respondents were recruited through a stratified random address-based sample (ABS) of Harris County, Texas ( n  = 777) and online non-probability-based opt-in panels ( n  = 522). Eligibility criteria included identifying as a woman or as currently able to become pregnant, between the ages of 18 and 44, and living in Harris County, Texas. Data collection was conducted by SSRS, a non-partisan survey research firm.

ABS recruitment involved two waves. The first wave received an initial survey invitation letter and a follow-up postcard a week later. The second wave was recruited four weeks after the follow-up mailing to wave one. The invitation letters included a study-specific URL, QR code, and a toll-free call-in phone number. The letter also listed a unique passcode that respondents needed to log into the survey online or provide to the telephone interviewer. The front side of the letter was in English, and the back was in Spanish. The letters had a one-dollar bill and a quarter included as a non-contingent incentive, while a $10 gift card was offered as contingent on completing the questionnaire. All mailing materials asked that a woman age 18 to 44 living in the household complete the survey. No within household selection method was used. The first wave resulted in 485 completed cases, and 292 respondents came from the second wave of data collection. Most ABS respondents completed the survey online ( n  = 777). Only n  = 33 ABS respondents completed the survey by phone. There were no statistically significant differences by age, race/ethnicity or educational attainment between those who completed the survey online and by phone.

Two third-party non-probability-based web panels, Torfac and Prodege, were utilized to reach additional respondents. Both panels recruit panelists through a variety of online platforms and require “double opt in” where respondents must confirm panel enrollment through a confirmation email after signing up on the panel website. Upon enrollment and through survey activity, demographic information such as age, gender and location information are collected from panelists. This information was used to send targeted email invitations and reminders to panelists likely to qualify for this survey. Panelists must have confirmed their age as under 44 and self-report being a woman living in Harris County, Texas.

Respondents from both the ABS and non-probability sample could complete the survey in English or Spanish. Survey items on discrimination and colorism were adapted from the Everyday Discrimination Scale and the New Immigrant Survey Skin Color Scale [ 17 , 18 ]. The primary outcome of this analysis is whether women avoided birth control because of perceived discrimination. The outcome variable was coded as yes if participants recorded that they experienced discrimination when going to a doctor or health clinic for birth control because of their race/ethnicity or skin tone. The survey also asked about demographic factors, had them rate their skin tone, and if they experienced discrimination because of their race/ethnicity, skin tone, parenthood, marital status, age, sex, or sexual orientation. Skin tone was only assessed for those who completed the online survey ( n  = 1299) and could choose one of 16 pictures of the skin tone that best described themself. The skin tone variable was then collapsed into five categories from lightest to darkest. Using a four-point Likert scale (very easy, somewhat easy, somewhat difficult, or very difficult), women were asked how difficult it was to find a doctor who treats them with dignity and respect when seeking birth control and reproductive healthcare. For the analyses, difficulty in finding a doctor was collapsed into very/somewhat easy compared to somewhat/very difficult. The questionnaire was tested by telephone with six respondents. The respondents completed the full survey. The questionnaire was modified based on their responses and points where they had difficulty answering.

Data management and analysis

The data was cleaned using a computer validation program to locate errors from incorrectly followed skip patterns, out-of-range values, and errors in data field locations. Quality checks were then performed on the final data. The following cases were flagged and reviewed: cases with more than 40% question non-response, cases with a time length less than one-quarter of the mean length by mode, and cases with more than 60% of the answer grids were similar (straight-lining questions). Three cases were removed after being flagged due to two or more issues.

The ABS data was weighted to account for differences in the probability of selection. Data was then weighted to balance the demographic profile of the sample to target parameters. Weighting of the ABS data was accomplished using SPSSINC RAKE, an SPSS extension module that simultaneously balances the distributions of all variables using the GENLOG procedure. The sample was weighted to match population estimates. The weighting parameters were race/ethnicity (Black, Hispanic, Else) by age (18–24, 25–34, 35–44), race/ethnicity by education (less than college, college+), detailed race/ethnicity (White, Black, Hispanic – US Born, Hispanic – Foreign Born, Other), and detailed education (high school or less, some college, college+). The benchmarks were derived from 2021 Current Population Survey (CPS) data [ 19 ]. Weights were trimmed to prevent individual interviews from having too much influence on the results.

Respondents reached through the opt-in panels were younger, with an average age of 30.5 years compared to 33.5 years among ABS respondents. Opt-in panel respondents also tended to have lower levels of educational attainment than those reached through ABS. 31% of opt-in respondents had a four-year college degree or more, compared to 58% of ABS respondents. To reduce selection bias while minimizing design effect within the non-probability sample, SSRS’s stepwise calibration methodology was used to determine a set of non-demographic internal benchmarks to weight the hybrid ABS and non-probability sample [ 20 ]. This calibration method is designed to ensure that estimates from the hybrid sample remain representative of the target population and has been tested across a wide range of healthcare and public opinion surveys. The combined ABS and non-probability samples were then weighted to the same demographic benchmarks used for the ABS sample as well as the internal benchmarks derived from the stepwise calibration.

The data was analyzed using the ‘survey’ package in R with base weights applied to account for the probability of selection. Binary logistic regression was used to examine whether race/ethnicity and skin tone were related to whether women avoided birth control because of perceived discrimination. Crude odds ratios were calculated for each variable. Adjusted odds ratios were calculated to examine whether demographic and other factors explained the relationship between race/ethnicity and the outcome variable (models 2 and 3) and whether these factors explained the relationship between skin tone and the outcome variable (models 3 and 4).

Table 1 displays the characteristics of the study sample, weighted and unweighted. Based on unweighted data, of the 1,299 women in the analysis, 41% were aged 30 and 39. Almost one-third of the sample classified themselves as non-Hispanic Whites (31.5%), 22.4% as Black, 27.4% as Hispanic and born within the US, and 7.6% as Hispanic born and outside of the US. Approximately one-third of women classified themselves in the lightest skin tones, whereas almost one in five women classified themselves in the darkest skin tone palates. Thirty-seven percent said they were single and never married, 14.6% were single and living with a partner, and 41.3% of women reported being married. Almost half (47.6%) reported being college educated. The majority (68.9%) of the sample reported being employed.

Table  2 displays the sample’s self-reported reproductive health experiences unweighted and weighted. Based on weighted data, overall, 14.9% of women aged 18–44 in Harris County said they avoided seeking birth control from a doctor or healthcare provider out of concern that they would be discriminated against or treated poorly because of their race or ethnicity, and 11.1% of women said they avoided seeking birth control out of concern that they would be discriminated against or treated poorly because of their skin tone. One in five women said they had previously experienced discrimination when going to a doctor or health clinic for birth control because of their race/ethnicity (21.1%), and 15.3% said they experienced discrimination when going to a doctor or health clinic for birth control because of their skin tone. One in five women said they had difficulty finding a doctor who treated them with dignity and respect when seeking birth control and reproductive healthcare (21.9%). 43% reported difficulty finding a doctor with a similar background and experiences when seeking birth control and reproductive healthcare.

Table  3 displays the bivariate associations between sociodemographic factors, previous experiences, and avoiding seeking birth control from a doctor or healthcare provider out of concern for discrimination. When compared to women who classified themselves as White, Black women were more than 13 times more likely to report avoiding seeking birth control because of discrimination concerns. Hispanic women born in the US were 8.6 times more likely, and Hispanic women born outside of the US were 14.6 times more likely to report avoiding seeking birth control from a doctor or other healthcare provider because of concern they would be discriminated against for their race, ethnicity, or skin tone. Compared to women classifying themselves in the lightest skin tone, all darker skin tones had increased odds of avoiding seeking birth control out of a concern for discrimination. Women with the two darkest shades of skin tones were 5.9 and 7.6 times more likely to avoid seeking birth control out of concern for discrimination. Those with lower income and those with less education had greater odds of avoiding seeking birth control out of a concern for discrimination than those with the highest income and education. Women who reported a previous experience of discrimination based on race/ethnicity were more than 30 times more likely, and women who reported prior discrimination based on skin tone were 20 times more likely to avoid seeking birth control out of concern they would be discriminated against.

Table  4 displays the multivariate associations between race/ethnicity, skin tone, and avoiding seeking birth control from a doctor or healthcare provider out of concern for discrimination after adjusting for sociodemographic factors. After adjusting for sociodemographic factors, Black women were 12.4 times more likely to avoid seeking birth control compared to non-Hispanic White women, Hispanic women born in the US were 6.5 times more likely to avoid seeking birth control, and Hispanic women born outside the US were 10.3 times more likely to avoid seeking birth control compared to non-Hispanic White women. Darker skin tones had increasingly greater odds of reporting that they avoided seeking birth control out of a concern for discrimination compared to the lightest skin tone. After adjusting for race/ethnicity and sociodemographic variables (model 3), darker skin tones remained significantly associated with avoiding birth control.

This study demonstrates the role that racial and ethnic categories and skin color play in negative reproductive health experiences. While this is not surprising given that the concept of these racial and ethnic categories was developed by those with racist ideologies, the clear association with darker skin colors and avoidance of seeking birth control provides further evidence that structural and individual racism continues to have far-reaching and insidious consequences.

Contraception is known as one of the greatest public health achievements of the 20th century and is recognized for improving the world’s health, reducing maternal mortality, improving child health, increasing female empowerment, and decreasing poverty [ 21 ]. However, not all women equally enjoy the benefits of access to contraception [ 21 ]. Documented disparities in contraception access and reproductive healthcare are multifactorial and complex and include availability and access to healthcare, transportation, health insurance, employment, and education [ 22 ]. These factors are confounded by centuries of structural racism and discrimination. For the past twenty years, studies have documented historical abuse and discrimination in healthcare settings stemming from bias and prejudice against minorities, greater clinical uncertainty when inter- with minority patients, and beliefs or stereotypes held by the provider about the behavior or health of minorities [ 23 ]. In 2020, the Kaiser Family Foundation reported that one in five Black and Hispanic adults said they were personally treated unfairly because of their race or ethnicity while getting healthcare in the past year [ 24 ].

Researchers must move past simply describing racial and ethnic differences in reproductive health and attributing these differences solely to social determinants such as poverty, education, and employment. Instead, colorism must be addressed as a global product of structural racism that impacts interpersonal and internalized experiences of discrimination that will require further study on solutions to address reproductive health inequities. Further, colorism in the American context is unique in that it is inextricably tied to the lasting vestiges of chattel slavery, Jim Crow segregation, and the subsequent policies that kept groups of people segregated and subjugated based on phenotype and ancestry [ 10 ]. We must be able to admit the role that racism rooted in anti-blackness has on reproductive health outcomes and how colorism functions as an agent of this phenomena [ 24 ].

Limitations

The study is conducted exclusively in a large urban southern city, potentially limiting the generalizability of the findings to rural or suburban areas, or even to other urban areas with different socio-economic or cultural contexts. The administration of the online survey might have excluded individuals without internet access or digital literacy.

Additionally, this study includes temporal limitations as polling captures opinions at a specific point in time, which may not reflect changes in public opinion over time. Events occurring after the data collection period can significantly alter public perceptions and attitudes.

By acknowledging these limitations, the study provides a transparent account of potential sources of bias and constraints on the findings, thereby offering a more nuanced interpretation of the results. Future research could aim to address these limitations by incorporating broader geographic samples, longitudinal designs, and methodological triangulation to enhance the robustness and generalizability of the findings.

Conclusions

This study provides colorism as a more specific focus in tackling racism in healthcare delivery now that calls for transforming the quality of care related to trust building and anti-racist practice are present [ 25 ]. Researchers need to test and disseminate strategies to ameliorate harm and ensure well-being for all. Lastly, addressing colorism within reproductive healthcare has become critically important as the nation becomes increasingly diverse. Focusing on skin tone-based discrimination and its roots in anti-blackness expands our understanding beyond a Black–White binary that is traditionally applied when addressing racism in healthcare delivery. Instead, these findings extend further awareness of the discriminatory practices among all people that contribute to a hierarchy based on skin color. We must intentionally develop, test, and disseminate strategies to ameliorate harm and ensure well-being for all.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

address-based sample

Current Population Survey

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KB contributed to the design of the survey and was a major contributor to the writing of the manuscript.STE contributed to the design of the survey, interpreted the statistical output, and contributed to the writing of the manuscript.ES contributed to the survey administration and to the writing of the manuscript.JS and EBP contributed to the data collection and analysis, as well as critical feedback and revisions of the manuscript.

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Baker, K., Emery, S.T., Spike, E. et al. Skin tone discrimination and birth control avoidance among women in Harris County, Texas: a cross-sectional study. BMC Public Health 24 , 2375 (2024). https://doi.org/10.1186/s12889-024-19765-3

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Assessment Survey and evaluation of LGBT-Psychology in Nigeria: current state and recommendations

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• Abayomi O. Olaseni   ORCID: orcid.org/0000-0002-0209-1407 1 &
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There is no gainsaying that individuals with diverse sexual orientations and gender identities are faced with serious socio-legal, and medical discrimination following the enactment of anti-homosexuality law in Nigeria. However, not much is known of the effort of an organized body of psychology in the country to ensure adequate knowledge and competence among Nigerian psychologists. This article, therefore, appraises the stance of Lesbian, Gay, Bisexual, and Transgender (LGBT) psychology in Nigeria in relation to the cardinal quadrants: Advocacy, Education, Research, and Practice. A multi-method design was adopted to sort for both primary and secondary data. Purposive sampling was adopted to involve 124 practicing psychologists. Findings revealed that the Nigerian psychology curriculum limits its scope to sexual and gender disorders (sexual dysfunction, gender dysphoria, and paraphilic disorders) while missing out on sexual and gender diversity content. Furthermore, the outcome shows that not much is documented on the contribution of the field of psychology to the knowledge of LGBT. Many of the participants had a history (and still) working with LGBT clients and did not have formal LGBT-affirmative training. The study concluded that the integration of LGBT psychology is essential for significant achievement in the space of advocacy, education, research, and professional practices.

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Introduction

The psychology profession has numerous sub-fields albeit course contents bore into existence to excavate and further deepen the area of concern or interests. One of the most emerging course contents in psychology is the lesbian, gay, bisexual, and transgender (LGBT Footnote 1 ) psychology. LGBT psychology is a sub-field of psychology developed to research the scientific understanding surrounding the lives and teach a diverse range of psychological and social perspectives of persons with diverse sexual orientations and gender identities (Balsam et al., 2005 ). However, it is important to note that the emergence of LGBT psychology was accompanied by a series of historical global events.

Historically (before the 1950s), sexually and gender diverse (SGD) persons and communities remained targets of hate violence and backlash from privileged heterosexual persons throughout the world; such that victims were regarded as sick and criminals, and not the perpetrators of violence against the SGD populations. Throughout the 50s and 60s, SGD persons and communities continued to be at risk of psychiatric institutionalization, as well as criminal incarceration, and predisposed to other social consequences, such as losing jobs, and child custody, among others (Glassgold et al., 2007 ). Arguably, the breakthrough into the understanding of SGD people and communities started with the submissions of the article titled “The Homosexual in America” by Donald Webster Cory (Pseudo name for Edward Sagarin) in 1951, which paved the way for further scientific research, understanding, and attitudinal change in the United States of America (USA; Sagarin, 1971 ).

Thereafter, research interest began to grow significantly among the populations. In 1956, Evelyn Hooker won a grant from the National Institute of Mental Health to study the psychology of gay men (Hooker, 1956 ). Many scholars across the globe began to expand their niche research interests at that time (Ardila, 2015 ; Hookers, 1956 ). Domination of similar scientifically proven outcomes was reported across different studies, which culminated in the ordination of the first out-gay ministers by the United Church of Christ in 1972; the formation of Parents and Friends of Lesbians and Gays (PFLAG) in the same year; explosion of political actions through the establishment of National Gay and Lesbian Task Force, the Human Rights Campaign; and the election of openly gay and lesbian representatives into the political space (De Waal & Manion, 2006 ; Hooker, 1956 ).

History and responses to LGBT psychology differ from country to country, and there is no exception to Nigerian history. However, the historical processes and attitudes toward same-sexuality and gender diversity are almost the same across countries (Ardila, 2015 ). The current study assessed the historical events of the Nigerian LGBT in tandem with the reports from a Western country (i.e., the USA) and an African country (i.e., South Africa). Below is the historical timelines across the three countries.

Historically, 1950s, 1980s, and 2000s were considered the era of a dark age for SGD persons living in the USA, South Africa, and Nigeria, respectively. In this context, a dark age is characterized by the absence of scientific inquiry about the phenomenon of discussion. At that time, the understanding and knowledge about the SGD populations were informed by religion, socio-cultural, and subjective rational thoughts. Historically, in the case of Nigeria, the dark era started when the Same-Sex Marriage (Prohibition) Act (SSMPA) of 2013 was signed into law in 2014 (Human Rights Watch, 2016; Thoreson & Cook, 2011 ).

The Renaissance period is a period after the Dark Ages, that is characterized by classical sort of knowledge and findings that are scientifically rooted (Copenhaver, 1992 ). The Renaissance period in the USA was contextualized as a post-publication of the finding of Donald Webster (1951) and Evelyn Hooker ( 1956 ). In South Africa, the Renaissance period was ascribed to when the first LGBT + Civil Society Organization (CSO) was established, which involved the initiatives of some pioneering psychologists and volunteers in Cape Town and Johannesburg (De Waal & Manion, 2006 ; Hoad et al., 2005 ; Reddy et al., 2009 ). In Nigeria, several CSOs and Non-governmental Organisations (NGOs) were established to stimulate, educate, and further deepen the rights of the SGD populations in the country. In 2017 for example, a significant increase was reported in heterosexual dispositions toward SGD persons and communities compared to the 2015 survey polls, such that a 07% and 39% opinion increase was reported in the acceptance of SGD communities, and access to basic (healthcare, education, and housing) amenities, respectively (Olamide, 2018 ).

The liberation phase in the USA continued until 1973 when the American Psychiatric Association removed homosexuality as an “illness” classification in its diagnostic manual. Likewise, the American Psychological Association in 1987 published a major revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, where the “ego-dystonic homosexuality” classification was removed. Therefore, most organized bodies of the psychology profession have begun to mobilize support, and sensitization (workshops) for the rationale of the removal of diverse sexual orientations as a disorder. Similarly, the South African government in 2016 acknowledged and signed that LGBT + equality rights, which afforded the country global recognition for its progressive constitution that was the first to include non-discrimination based on diverse sexual orientations in the African continent and fifth in the world (Hoad et al., 2005 ; Judge et al., 2008 ; Nel, 2014 ; Republic of South Africa, 1996). Nigeria seems stuck at the renaissance stage, and not much is documented about the efforts of the organized body of psychology, which explains the persistent problems and challenges confronting the SGD persons and communities to date (Human Rights Watch, 2016).

In Nigeria, there is ambivalence in the global position of an organized body of the psychology profession and the sociopolitical stance. Table 1 below shows the summary of the current social and legal context and the roles of organized institutions.

The Nigerian government passed the anti-homosexuality law on January 7, 2014. The same-sex marriage (prohibition) bill signed into law criminalizes any form of civil union between persons of the same sex, punishable under the law (Okuefuna, 2016 ). The law stipulated that persons engaged in same-sex acts in the country are liable for being imprisoned for 14 years. The law also criminalizes any form of support to persons of diverse sexual orientations. The offense is punishable under the law with 10 years of imprisonment. Similarly, an anti-homosexuality law was earlier adopted in 1999 by twelve northern states (Bauchi, Borno, Gombe, Jigawa, Kaduna, Kano, Katsina, Kebbi, Niger, Sokoto, Yobe, and Zamfara) of Nigeria under the auspice of the Sharia law. The adoption of the Islamic legal systems by the 12 Northern States is a legacy punishment for offenders of the same sexuality among the Muslims in the region.

However, the position of the organized body of psychology and psychiatry posited that people with diverse sexual orientations do not suffer from mental health problems (depathologization) but are minority groups that require support (APA, 2010 : 2016 ; Hooker, 2006). The position of depathologization was reflected in the universally accepted manuals of practice in psychology and psychiatry professions, that is, the DSM-5, and the International Classification of Diseases 10th Revision (ICD-10).

The anti-homosexuality law and the Sharia law were reported to have culminated in various social problems for people with diverse sexual orientations in the country (Human Rights Watch, 2016; Thoreson & Cook, 2011 ). ). The passage of the anti-homosexuality law was immediately followed by legitimized extortions and extensive media reports of high levels of violence, including mob attacks (Human Rights Watch, 2016; Thoreson & Cook, 2011 ). Sexual assaults have also been reported to be on the increase (Adie, 2019 ; Giwa et al., 2020 ).

No formal information is known about the activities of the organized body of psychology in the increase of awareness and provision of affirmative practices that conform to international standards. However, some NGOs in the country provide medical, psychological, and social services to people with diverse sexual orientations. For instance, Diadem Consults, as an NGO provides HIV and healthcare support to SGD persons. Numerous NGOs, such as the Outright Action International, and The Initiative for Equal Rights provide psychosocial support to SGD persons in Nigeria. The proposed imminent solution to the identified gap is the institutionalization of LGBT psychology.

The field of behavioural sciences (such as psychiatry and psychology) is saddled with the core responsibilities of scientifically determining what is normal and abnormal, what is adaptive and maladaptive in fairness to humanity (Glassgold & Drescher, 2007 ). Non-implementation of LGBT Psychology and affirmative practices for professionals in the academic and practice, respectively, contributes significantly to the pathologization, criminalization, and greater stigma experienced by the SGD communities (Matza et al., 2015 ). Knowledge of LGBT psychology is expected not only to advance human rights and development but also to provide means for ensuring and maintaining the mental health of people with diverse sexual orientations and gender identities.

Organized bodies of psychology domiciled in advanced countries have expanded the psychology curriculum that speaks to the reality of complexes in sexuality and gender nonconforming. The understanding and topics around sexualities and gender identities are core to the discipline of psychology, so every psychologist-in-training is saddled with the responsibilities of understanding what sexuality or gender identities are considered adaptive and maladaptive and the psychological rationale of its various classifications. Core to the ethics of the psychology discipline is the well-being of people and groups and the alienation of threats to human well-being (Ardila, 2015 ; Glassgold & Drescher, 2007 ). A large body of research suggests that mental health concerns are common among LGB individuals and often exceed the prevalence rates of the general population (King et al., 2017; World Health Organization [WHO], 2013 ). LGBT + people experience high rates of physical victimization, criminalization, and social exclusion, which appear to contribute to depression, anxiety, and suicidal ideation (Horne et al., 2009 ).

The ambivalent concept of ‘depathologization’ of the same sexuality in the most adopted diagnostic manual in the field of psychology (DSM-5; in Nigeria) and ‘criminalization’ of sexual minorities by the Nigerian government created significant gaps in the teaching curriculum and practice of specialists within the field of behavioral sciences (psychiatry, psychology, etc.). Hence, there is a need for an updated training curriculum, and competent professionals to address numerous intrapsychic factors, such as depression, anxiety, internalized homophobia, and social challenges, such as; victimization/bullying/Hate speech, discrimination, sexual assaults and abuse confronting the LGBT + persons and communities (Adie, 2019 ; Giwa et al., 2020 ; Makanjuola et al., 2018 ; Ogunbanjo et al., 2020).

Theoretical framework

This research is informed by the concepts of the Minority Stress Model (MSM: Meyer, 2003 ). The Minority Stress Model is fast becoming one of the most prominent theoretical and explanatory frameworks of SGD persons and communities. The concept of minority stress derives from several psychosocial theoretical directions, resulting in conflicts between minorities and dominant values, and the social environment experienced by members of minority groups (Meyer, 1995 ). The minority stress theory is that the differences between sexually and gender-diverse individuals and communities can be largely explained by stressors caused by hostile, homo-, bi, and transphobic cultures, often leading to lifelong harassment, abuse, discrimination, and harm (Meyer, 2003 ) and may ultimately affect quadrants of LGBT-Psychology (curriculum, research, outreach, & affirmative knowledge).

There is overwhelming evidence of increased mental health concerns among SGD people and communities, yet there are limited competent mental health providers to meet mental health needs (King et al., 2017; Nel & Victor, 2018; WHO, 2013 ). However, despite the passage of the anti-homosexuality law in 2014 putting pressure on the activities of the non-academic actors, some NGOs have documented much progress in terms of sensitization and provision of medical and psychosocial support, while not much is documented about the activities of the academic actors. The major course designated to bridge the gap in developed (and some developing) countries is LGBT psychology, designed to reconcile the gap between fallible social knowledge and scientific findings.

Clarke et al. ( 2010 ) shed more light on the understanding and contents of LGBT psychology for trainees in the field of behavioural science. Clarke et al. ( 2010 ) identified the following outlines [1] understanding the branch of psychology that is affirmative of LGBT people, [2] understanding the challenge of prejudice and discrimination faced by LGBT people, [3] the privilege of heterosexuality in psychology, and in the broader society, [4] LGBT concerns as legitimate contents in psychological research, 5) provision of a range of psychological perspectives on the lives and experiences of LGBT people, sexualities,, and genders. The perspectives of Clarke et al. (2010) account for both the practice and research gaps in LGBT psychology in Nigeria. The field of psychology and psychiatry housed the reserved right of society and science to define what is abnormal and normal with a sense of fairness, both within and outside the profession (Glassgold & Drescher, 2007).

In sum, the need to advance sexuality and gender knowledge motivates the organized body of psychology to respond to the emerging knowledge gap within the academic space, through the development and integration of LGBT psychology into the conventional psychology curriculum.

The current study set to assess and evaluate the current state of LGBT psychology in Nigeria and its implications for recommendations. The following specific objectives were developed based on the quadrants of LGBT psychology, which are to assess the.

‘Curriculum and Education’ quadrant of LGBT psychology.

‘Research’ quadrant of LGBT psychology.

‘Outreach’ quadrant of LGBT psychology.

‘Professional’ quadrant of LGBT psychology.

Research questions

Does the Nigerian undergraduate curriculum entail LGBT-psychology content compared to what is obtained in the United States of America and South Africa?

To what extent do psychology professionals research LGBT-related matters in Nigeria?

How engaged (outreach) is the organized body of psychology in Nigeria to the LGBT communities?

To what extent are the practicing psychologists caring for LGBT + persons or communities in Nigeria exposed to LGBT + affirmative training?

Study area/settings

The study setting is Nigeria, Africa’s most populous country with over 180 million people, and is in the western part of the African continent (Wright & Okolo, 2018). The Nigerian climate, like most other countries in Africa, has a long history of SGD populations (Alimi, 2015). The popular assumption among Nigerians was that the concept of LGBT is a Western imposition on African communities (Alimi, 2015; Mohammed, 2019). Nigeria also has the most diverse cultures in Africa, with more than 250 local languages.

All dominant tribes in Nigeria had and still have their historical cultural understanding of diverse sexual orientations and gender identities. For example, ancient Yoruba identified sexual minorities (SM) as ‘adofuro’ (a Yoruban word that means someone who engages in anal sex) and gender diverse (GD) individuals as ‘Lakiriboto’ (absence of binary gender assignment at birth due to ambiguous external genitalia) and/or ‘làgbedemeji’ (a person with a combination of penile and vaginal characteristics) (Alimi, 2015). Similarly, a historical reference to Hausa and/or Fulani of Northern Nigeria revealed that northerners identified SGD persons with the descriptive name Yan Daudu (in the Hausa language, meaning that men are considered ‘wives’ to men). The Yan Dauda communities were typically same-sex attracted by the same sex, who thrived (and still thrive) in northern Nigeria (Alimi, 2015). In 2014, the Nigerian government passed into law an anti-homosexuality law against SM in the country (Omilusi, 2021).

Research design/approach

The research utilized a multi-method approach (positivistic & survey) to sort both primary and secondary data used in the study. To conform to the positivist paradigm and the deductive approach. Survey-based questionnaires are preferred for observing populations and answering quantitative research questions (LaDonna et al., 2018). The approaches permit researchers to explore the public documents of the organized body of psychology (including newsletter), approved training curriculum, publications, and survey subset of the population of interest in the country.

Population and sample

The population of the study survey phase is practicing therapists in Nigeria with experience/history of working with LGBT + persons or communities. The study participants are the one hundred twenty-four participants ( n  = 124) practicing therapists who consented to participate in the study. 57.3% ( n  = 71) of the study’s participants were female practitioners, while 42.7 ( n  = 53) self-identified as male practitioners. The participants’ age ranges between 21 and 66 years (mean = 39.5; SD = 05.03). Regarding participants’ sexual orientation, all the participants (100%) self-identified as heterosexuals.

Research tools

The qualitative phase of the synthesized needed information from the benchmark minimum academic standards (BMAS) for undergraduate psychology programs authored by the National Universities Commission (NUC), a governmental body saddled with the responsibilities of regulating and periodically ensuring that the curriculum of psychology teachings in the country is universal and meets the minimum standard as stipulated in the BMAS document.

The questionnaire booklets were made up of widely used and psychometrically sound instruments for the collection of data in the study. The questionnaire was made up of two sections, Section A-C:

Socio-Demographics section that measured respondents’ data such as specialty, gender identity, age, marital status, highest educational attainment, and length of experience.

Checklist of previous experience with LGBT training. This section explored the categorical checklist for participants to tick as applied. The checklists entail a tick for the absence of formal and informal training, a tick for the history of previous formal training (applicable to foreign-trained therapists), and a tick for the history of informal training experience (i.e. training through webinars, conferences, YouTube, etc.).

Self-Efficacy working with LGBT clients was measured using the Lesbian, Gay, and Bisexual Affirmative Counselling Self-Efficacy Inventory (LGB-CSI). LGB-CSI is a 32-item scale developed by Dillon and Worthington (2003) to measure participants’ self-efficacy in performing LGBT+-affirmative psychotherapy in Nigeria. The scale has five dimensions, namely advocacy skills, knowledge application, awareness, assessment, and relationship. LGB-CSI scores are obtained by adding all items of the mentioned subscales. LGB-CSI is a six-point Likert scale with good internal consistency (Cronbach’s α > 0.70).

Data collection and procedures

As the study was a mixture of qualitative and quantitative kinds, qualitative content was recovered from the current benchmark for minimum academic standards (B-MAS), public documents of the Nigerian Psychological Associations, and published qualifying articles on some selected database databases (Google Scholar; PudMed & Elsevier) database between January 30, 2015 (period after the enactment of anti-homosexuality law in Nigeria) and April 2023 (deadline for data collection). The selected articles were LGBT-based publications by researchers / co-researchers affiliated with Nigerian institution(s). However, the quantitative data were retrieved through a set of in-print, structured, and validated questionnaires, which enabled an objective assessment of the constructs of interest in the study. Participants who self-identified as psychologists were included and met other inclusion criteria were included in the study. A detailed informed consent form (stating all ethical requirements) was made available to prospective participants who willingly consented and participated in the study. Participants were recruited using a purposive sampling technique because data collection of this nature is cumbersome to retrieve from the specialist due to the existing anti-homosexuality law in Nigeria. The data collection for the study spans from June 08, 2022, to April 25, 2023.

Showing the numbers of LGBT-related Publications for the year 2015–2022 in Nigeria

Showing the number of psychologists with a history working with LGBT clients in Nigeria.

Data analysis

The document analysis method was adopted for the qualitative phase of the study, while a one-way analysis of covariance was used to test the importance of affirmative training of LGBT in self-efficacy for psychotherapy with SGD populations. Quantitative data were analysed using the statistical package for social sciences (SPSS v.27) and Prism Graph pad (version 16.0).

Results/Outcomes

This section presents the data analyses and results of the study. This section presents the interpretations of the document analyses the four cardinals of LGBT-Psychology and establishes the quantitative findings of the study objectives that established the interplay between the study objectives 1 (curriculum and education) and 4 (professionalism).

Study outcome 1 (curriculum and education)

The finding in study objective 1 that proposed to assess the curriculum and educational quadrant of LGBT psychology in Nigeria was synthesized from the B-MAS for undergraduate psychology programs compared to the psychology curriculum obtained from the United States of America and South Africa as presented in Table 2 .

The results in Table 2 show that related course titles, such as clinical psychology/pathology, contemporary issues in psychology, and psychology of social change, were included in the Nigerian curriculum and training standard as available in South Africa and the USA. However, the Nigerian course contents under clinical psychology/psychopathology cover topics like sexual dysfunction, gender dysphoria, and paraphilic disorder, but the scopes are not expanded and cover topics like sexual and gender diversity and sexual health. Similarly, the course title Contemporary Issues in Psychology does not cover the discussion of diverse sexual orientations and gender identities as a course content just like the curriculum of counterparts within the African continent (e.g. South Africa) and the Western communities (e.g. USA). However, the content of LGBT psychology subsumed under the course title ‘Psychology of social change named social change and identity crises’ was not covered in the Nigerian curriculum despite the inclusion of the psychology of social change in the curriculum.

Furthermore, Table 2 revealed that the Nigerian psychology curriculum does not incorporate LGBT Psychology/Psychology of Sexual and Gender Diversity into the existing training curriculum like what is available in SA and the USA. The LGBT-Psychology/ Psychology of Sexual and Gender Diversity curriculum highlighted the following course contents: [1] historical perspectives of diverse sexual orientations and gender identity [2] LGBT terminology [3] theories of identity development [4] Mental health and well-being of sexual and gender minorities [5] Approaches and ethical approaches to LGBT research [6] Issues that impact LGBTQ + individuals and communities [7] Understanding the role the field of psychology plays in supporting marginalized communities, specifically sexual and gender minorities.

Study outcome 2 (research)

The finding in objective 2 of the study that proposed to assess the research quadrant of LGBT psychology in Nigeria was synthesized from related published articles from 2015 to 2022 in the three main and rated publications (Google Scholar; PudMed & Elsevier) as presented in Fig. 1 .

The descriptive analysis of the synthesized literature as shown in Fig. 1 revealed that the majority (69.2%) of the reviewed articles (e.g. Oginni et al., 2021 ; Mapayi et al., 2016 ; 2022; Sekoni et al., 2022 ; Sekoni et al., 2020 ; Ogunbajo et al., 2021 ; Makanjuola et al., 2018 ; and Oginni et al., 2021 ) were co-published by psychiatrists. The results also revealed that 14.28% of the LGBT-related articles (e.g. Ogunbanjo et al., 2020; Sekoni et al., 2016 ; McKay et al., 2017 ) were co-published by public health specialists, 07.1% of the LGBT-related articles were affiliated with the department of law (e.g. Okuefuna, 2016 ; Arimoro, 2018 ), 03.8% were affiliated with the department of sociology (e.g. Akanle et al., 2019 ), 03.8% of the articles were affiliated with the department of performing theatre (e.g. Okpadah, 2020 ), while none (0%) was affiliated with the department of psychology.

Study outcome 3 (Outreach)

The finding in objective 3 of the study that proposed to assess the outreach quadrant of LGBT psychology in Nigeria was synthesized from previously published flyers/workshops/conferences/outreach/communications issued by the organized body of psychology in Nigeria between 2015 and 2022 as presented in Table 3 .

The results in Table 3 revealed that there was no documented outreach to the LGBT community based on an organized body of psychology in Nigeria. In other words, there was no record of the involvement of the organized body in national discussions, community engagements, or the publication of a position document on LGBT populations. In social media handles, there was no formal LGBT-based broadcast in the newsletters, websites, WhatsApp, and telegram handles of the organized body of psychology. Similarly, there were no LGBT-related topics recorded in the workshop/conference previously organized by the body of psychology between 2015 and 2022.

Study outcome 4 (Professional Practice)

The finding in study objective 4 that proposed to assess the professional practice quadrant of LGBT psychology in Nigeria was synthesized among practicing clinical psychologists caring for LGBT + persons or communities was presented in Figs. 3 and 4 .

Figure 2 revealed that majorityof the participants (81%, n  = 101) reported having previously and/or currently provided psychological services to members of the LGBT communities, while the counterpart minority (19%, n  = 23) reported no history of working with self-disclosed clients

Figure 3 revealed that majority of the participants (91.9%, n  = 114) reported no history of formal and informal LGBT training, while 5.65% ( n  = 07) of the participants had informal LGBT + affirmative training, while 2.42% ( n  = 03) of practicing psychologists had formal LGBT + affirmative training (during their foreign education pursuit) The findings in Figs. 3 and 4 revealed that most of the practicing psychologists who had (or still) attended to LGBT persons and communities had not informed training tailored toward the populations. The findings informed the need to examine the impact of Quadrant 1 (curriculum and education) on Quadrant 4 (Professional Practice) of LGBT psychology. Table 4 examines the influence of the LGBT training experience on self-efficacy in working with LGBT clients The results in Table 4 showed that the effectiveness of psychologists working with LGBT clients was significantly influenced by the experience of LGBT training (F (03,120) = 52.66; p  < 0.01; n p 2 = 0.568). Such that 56.8% (eta value x 100) of the perceived self-efficacy working with LGBT clients was accounted for by previous LGBT training experience. Since the significance was established in the F-value, a post hoc analysis was therefore conducted to determine the magnitude of the F-value (see Fig. 4 )

Showing the distribution of previous training experience on affirmative psychotherapy for the SGD populations

Figure 4 revealed that psychologists with formal LGBT-affirmative training (M = 51.60; SD = 02.67) exhibited greater efficacy working with LGBT clients than counterparts with informal training (M = 38.85; SD = 02.59) and psychologists without formal and informal LGBT-affirmative training (M = 32.25; SD = 01.07). However, there were no significant differences in the efficacy of working with LGBT clients by psychologists without informal/formal training and those with informal pieces of training (MD = 06.60; p  > 0.05).

Scheffe post hoc analysis showing the influence of training experience on self-efficacy working with LGBT clients

The study evaluated the stance of LGBT psychology in Nigeria, and the outcome also revealed that the Nigerian curriculum is somewhat sufficient with that of the reference counterpart in the study (i.e. USA and South Africa), following the enrolment of same courses (such as clinical psychology/pathology, contemporary issues in psychology and psychology of social change) in the Nigerian curriculum and training but the scope are limited and do not cover some important contents like sexual and gender diversity, sexual health, and social change and identity crises. Furthermore, the Nigerian psychology curriculum does not incorporate LGBT Psychology/Psychology of Sexual and Gender Diversity into the existing training curriculum as what is available in SA and the USA. The organized bodies of psychology in some developed and developing communities (such as the USA, UK, Philippines, Canada, Australia, South Africa, etc.) identified overwhelming knowledge and scientific findings of contemporary events of sexualities and gender identity and incorporated the identified knowledge gaps into a stand-alone course entitled ‘LGBT Psychology’ to keep psychology students abreast of the specific knowledge needed to understand human sexual and gender behaviours (Ardila, 2015 ; Clarke et al., 2010 ; Moreno et al., 2020 ) For the second objective, the descriptive outcome established that most of the published articles were co-published by psychiatrists, public health specialists, lawyers, sociologists, and academic artists. However, none of the reviewed articles was published by a psychologist. Research outputs played an important role in the scientific understanding of diverse sexuality and gender, co-morbid mental distress, and lived experiences of LGBT persons and communities, rather than the primitive dispositions that are well-rooted in religious ideology, punishable by death (Morgan & Nerison, 1993 ). In other words, superior arguments through scientific discoveries have changed the narrative of the same sexuality over the years, just like mental health illnesses that were at an early stage attributed to spiritual torments (Hooker, 1956 ; Sagarin, 1951). The finding implied that LGBT psychology has no visible place in the research focus of psychologists in Nigeria. This is evidenced in the the study that none of the authors of published articles on LGBT persons and communities self-identified as a psychologist or member of the Department of Psychology at any higher institution in Nigeria. There is a need to discuss LGBT Psychology at conventions or conferences, to incorporate scientific matters about the SGD populations. Meanwhile, the discussion of LGBT matter and scientific findings contributed significantly to the development of LGBT psychology in countries such as the Philippines (Ofreneo, 2013 ) and South Africa (Nel, 2009 ) The third objective revealed that there were no documented LGBT community-based outreach, broadcast, and/or inclusive LGBT-related themes to workshops/conferences organized by the body of psychology, indicating the passive disposition of the psychology body in national discussions, newsletters, community engagements, or issuance of position paper regarding the SGD populations. Behavioural scientists such as psychologists are the core custodians of community well-being and psychology (PsySSA, 2017 ). Outreach is one of the responsibilities of professionals in taking scientific knowledge from the community members for public interest or further enhancing the community’s mental health and well-being (Smith, 1990 ). Psychologists as experts share knowledge to inform policymakers, engage media on issues of human behaviour, and take principle and formal stands on pressing social issues, especially when behavioural expertise is needed to contribute to debate and decision-making (Cohen et al., 2012 ). Outreach can be done through various social media channels (such as Facebook, newsletter, emails, etc.) or formal outreach (involvement in national discussions, academic conferences, community engagements, etc.). In South Africa, psychologists worked closely with CSOs to sensitize the masses and ensure competence in working with SGD populations (De Waal & Manion, 2006 ; Hoad et al., 2005 ; Reddy et al., 2009 ; Van Zyl & Steyn, 2005 ; Victor & Nel, 2017) The outcome of objective 4 showed that most of the participants reported having previously and/or currently rendered psychological services to members of the LGBT communities, while most also reported having no history of formal and informal LGBT training. In other words, most practicing psychologists lack informed training tailored to the needs of SGD populations. Further research revealed that the effectiveness of psychologists working with LGBT clients was significantly influenced by the LGBT training experience.

Recommendations

Based on the outcome of the study and as behavioural scientists and practitioners, the following recommendations were presented The study recommends that the NUC expand some of the existing course content that talks about sexual disorders and gender identities to discuss the overview and scientific reasons why homosexuality was considered a disorder, while people with diverse sexual orientations were considered a marginalized set of people. The introduction of LGBT Psychology will ensure a good understanding of the history of LGBT psychology, affirmative practices, knowledge of past and current attitudes and behaviours towards LGBT people, including common misconceptions, prejudice, and discrimination, research, and ethics working with LGBT and other identified contents are considered very important to fill the knowledge gap identified The organized body of psychology is encouraged to update the psychology curriculum of Nigeria to bridge the training and theoretical gaps of students studying psychology in Nigeria. The curriculum adjustment will guide to exploration of LGBT issues and concerns in different areas of psychology and other content reported in the results section. In this regard, psychologists’ academic outputs are expected to increase in publications, and thus address the need for more inclusive pedagogical and research practices, which will contribute to the challenging heteronormativity as it was experienced in global communities and South Africa (Nduna et al., 2017 ; Nel, 2009 ). For example, the organized body of psychology in South Africa took a leading role in Africa through the early introduction of LGBT psychology and the development of the Psychological Society of South Africa (PsySSA)’s Affirmative Practice Guidelines for Psychology Professionals, sufficiently promoted by the Specialized Division of Sexuality and Gender. The division focus areas are Research, Training, and Development; Education and Training; Experiential workshops; and Advocacy and Expert opinion (Nel, 2014 ) The implication of adjusted teaching, learning, and research into LGBT psychology also have significant and impactful implications in the ethics and practice guidelines for attending to people with diverse sexual orientations and gender identities. The American Psychology Association (APA) for the USA and the PsySSA for South Africans developed and published an affirmative guideline that assists practicing psychologists to operate within professional conduct and competencies while handling patients who are members of the LGBT community Researchers or psychologists in practice are encouraged to collaborate with scholars from other countries to recognize the relative, cultural, and national specificities of LGBT lives and, in turn, contribute immensely to the international discussion and approach to LGBT psychology.

Limitations

The researchers evaluated and discussed LGBT Psychology in Nigeria, from the unique field of psychology mainly, other disciplines and scholars from different fields should explore and appraise the disposition and contributions to the LGBT course. The use of in-depth interviews and Focus Group Discussions to engage stakeholders in the organized body of psychology or key players in curriculum development may provide a more in-depth understanding of the factors affecting SGD populations and LGBT psychology in Nigeria and proffer potential solutions.

Conclusions

This article has provided information on the development and assessment of LGBT psychology in Nigeria, and what is available in other countries, specifically the USA and South Africa. The study concluded that the Nigerian course contents are sufficient as much as their counterpart nations (USA & SA), however, lacking some important course content (i.e. social change and identity crises; LGBT-Psychology/ Psychology of Sexual and Gender Diversity. The study further established that no LGBT-related published articles from 2015 to 2022 in Nigeria were credited/affiliated with the Department of Psychology. There was no documented outreach to the minority (LGBT) groups by the organized body of psychology. Lastly, the majority of the practicing psychologists reported having previously and/or currently providing psychological services to members of the LGBT communities, without formal and informal LGBT training. This article proposes specific recommendations to facilitate the emergence of LGBT psychology and to help develop the field in Nigeria, as it has already been established in many developed and developing countries as a formal area of psychological science.

Data availability

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

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Acknowledgements

The authors would like to thank the practicing psychologists/counseling psychologists who volunteered to take partake in this study.

Open access funding provided by University of South Africa. The research was independently funded by the researchers. No funding was obtained from external sources for this research.

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Abayomi O. Olaseni

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AOO conceived the research ideas, organized the research, performed the studies, analyzed the data, and drafted the manuscript. JAN co-conceived the research ideas, provided the overall leadership across every role, and revised the entire manuscript. All authors contributed to writing sections of the manuscript and read and approved the submitted version.

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Correspondence to Abayomi O. Olaseni .

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Olaseni, A.O., Nel, J.A. Assessment Survey and evaluation of LGBT-Psychology in Nigeria: current state and recommendations. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06608-y

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Clinician perspectives and recommendations regarding design of clinical prediction models for deteriorating patients in acute care

• Robin Blythe   ORCID: orcid.org/0000-0002-3643-4332 1 ,
• Sundresan Naicker   ORCID: orcid.org/0000-0002-2392-4981 1 ,
• Nicole White   ORCID: orcid.org/0000-0002-9292-0773 1 ,
• Raelene Donovan   ORCID: orcid.org/0000-0003-0737-7719 2 ,
• Ian A. Scott   ORCID: orcid.org/0000-0002-7596-0837 3 , 4 ,
• Andrew McKelliget 2 &
• Steven M McPhail   ORCID: orcid.org/0000-0002-1463-662X 1 , 4  

BMC Medical Informatics and Decision Making volume  24 , Article number:  241 ( 2024 ) Cite this article

Metrics details

Successful deployment of clinical prediction models for clinical deterioration relates not only to predictive performance but to integration into the decision making process. Models may demonstrate good discrimination and calibration, but fail to match the needs of practising acute care clinicians who receive, interpret, and act upon model outputs or alerts. We sought to understand how prediction models for clinical deterioration, also known as early warning scores (EWS), influence the decision-making of clinicians who regularly use them and elicit their perspectives on model design to guide future deterioration model development and implementation.

Nurses and doctors who regularly receive or respond to EWS alerts in two digital metropolitan hospitals were interviewed for up to one hour between February 2022 and March 2023 using semi-structured formats. We grouped interview data into sub-themes and then into general themes using reflexive thematic analysis. Themes were then mapped to a model of clinical decision making using deductive framework mapping to develop a set of practical recommendations for future deterioration model development and deployment.

Fifteen nurses ( n  = 8) and doctors ( n  = 7) were interviewed for a mean duration of 42 min. Participants emphasised the importance of using predictive tools for supporting rather than supplanting critical thinking, avoiding over-protocolising care, incorporating important contextual information and focusing on how clinicians generate, test, and select diagnostic hypotheses when managing deteriorating patients. These themes were incorporated into a conceptual model which informed recommendations that clinical deterioration prediction models demonstrate transparency and interactivity, generate outputs tailored to the tasks and responsibilities of end-users, avoid priming clinicians with potential diagnoses before patients were physically assessed, and support the process of deciding upon subsequent management.

Conclusions

Prediction models for deteriorating inpatients may be more impactful if they are designed in accordance with the decision-making processes of acute care clinicians. Models should produce actionable outputs that assist with, rather than supplant, critical thinking.

• This article explored decision-making processes of clinicians using a clinical prediction model for deteriorating patients, also known as an early warning score.

• Our study identified that the clinical utility of deterioration models may lie in their assistance in generating, evaluating, and selecting diagnostic hypotheses, an important part of clinical decision making that is underrepresented in the prediction modelling literature.

• Nurses in particular stressed the need for models that encourage critical thinking and further investigation rather than prescribe strict care protocols.

Peer Review reports

The number of ‘clinical prediction model’ articles published on PubMed has grown rapidly over the past two decades, from 1,918 articles identified with these search terms published in 2002 to 26,326 published in 2022. A clinical prediction model is defined as any multivariable model that provides patient-level estimates of the probability or risk of a disease, condition or future event [ 1 , 2 , 3 ].

Recent systematic and scoping reviews report a lack of evidence that clinical decision support systems based on prediction models are associated with improved patient outcomes once implemented in acute care [ 4 , 5 , 6 , 7 ]. One potential reason may be that some models are not superior to clinical judgment in reducing missed diagnoses or correctly classifying non-diseased patients [ 8 ]. While improving predictive accuracy is important, this appears insufficient for improving patient outcomes, suggesting that more attention should be paid to the process and justification of how prediction models are designed and deployed [ 9 , 10 ].

If model predictions are to influence clinical decision-making, they must not only demonstrate acceptable accuracy, but also be implemented and adopted at scale in clinical settings. This requires consideration of how they are integrated into clinical workflows, how they generate value for users, and how clinicians perceive and respond to their outputs of predicted risks [ 11 , 12 ]. These concepts are tenets of user-centred design, which focuses on building systems based on the needs and responsibilities of those who will use them. User-centred decision support tools can be designed in a variety of ways, but may benefit from understanding the characteristics of the users and the local environment in which tools are implemented, [ 13 ] the nature of the tasks end-users are expected to perform, [ 14 ] and the interface between the user and the tools [ 15 ].

Prediction models for clinical deterioration

A common task for prediction models integrated into clinical decision support systems is in predicting or recognising clinical deterioration, also known as early warning scores. Clinical deterioration is defined as the transition of a patient from their current health state to a worse one that puts them at greater risk of adverse events and death [ 16 ]. Early warning scores were initially designed to get the attention of skilled clinicians when patients began to deteriorate, but have since morphed into complex multivariable prediction models [ 17 ]. As with many other clinical prediction models, early warning scores often fail to demonstrate better patient outcomes once deployed [ 4 , 18 ]. The clinical utility of early warning scores likely rests on two key contextual elements: the presence of uncertainty, both in terms of diagnosis and prognosis, and the potential for undesirable patient outcomes if an appropriate care pathway is delayed or an inappropriate one is chosen [ 19 ].

The overarching goal of this qualitative study was to determine how prediction models for clinical deterioration, or early warning scores, could be better tailored to the needs of end-users to improve inpatient care. This study had three aims. First, to understand the experiences and perspectives of nurses and doctors who use early warning scores. Second, to identify the tasks these clinicians performed when managing deteriorating patients, the decision-making processes that guided these tasks, and how these could be conceptualised schematically. Finally, to address these tasks and needs with actionable, practical recommendations for enhancing future deterioration prediction model development and deployment.

To achieve our study aims, we conducted semi-structured interviews of nurses and doctors at two large, digitally mature hospitals. We first asked clinicians to describe their backgrounds, perspectives, and experience with early warning scores to give context to our analysis. We then examined the tasks and responsibilities of participants and the decision-making processes that guided these tasks using reflexive thematic analysis, an inductive method that facilitated the identification of general themes. We then identified a conceptual decision-making framework from the literature to which we mapped these themes to understand how they may lead to better decision support tools. Finally, we used this framework to formulate recommendations for deterioration prediction model design and deployment. These steps are presented graphically in a flow diagram (Fig.  1 ).

Schema of study goal, aims and methods

The study was conducted at one large tertiary and one medium-sized metropolitan hospital in Brisbane, Australia. The large hospital contained over 1,000 beds, handling over 116,000 admissions and approximately 150,000 deterioration alerts per year in 2019. Over the same period, the medium hospital contained 175 beds, handling over 31,000 admissions and approximately 42,000 deterioration alerts per year. These facilities had a high level of digital maturity, including fully integrated electronic medical records.

Clinical prediction model for deteriorating patients

The deterioration monitoring system used at both hospitals was the Queensland Adult Deterioration Detection System (Q-ADDS) [ 20 , 21 ]. Q-ADDS uses an underlying prediction model to convert patient-level vital signs from a single time of observation into an ordinal risk score describing an adult patient’s risk of acute deterioration. Vital signs collected are respiratory rate (breaths/minute), oxygen flow rate (L/minute), arterial oxygen saturation (percent), blood pressure (mmHg), heart rate (beats/minute), temperature (degrees Celsius), level of consciousness (Alert-Voice-Pain-Unresponsive) and increased or new onset agitation. Increased pain and urine output are collected but not used for score calculation [ 21 ]. The Q-ADDS tool is included in the supplementary material.

Vital signs are entered into the patient’s electronic medical record, either imported from the vital signs monitoring device at the patient’s bedside or from manual entry by nurses. Calculations are made automatically within Q-ADDS to generate an ordinal risk score per patient observation. Scores can be elevated to levels requiring a tiered escalation response if a single vital sign is greatly deranged, or if several observations are deranged by varying degrees. Scores range from 0 to 8+, with automated alerts and escalation protocols ranging from more frequent observations for lower scores to immediate activation of the medical emergency team (MET) at higher scores.

The escalation process for Q-ADDS is highly structured, mandated and well documented [ 21 ]. Briefly, when a patient’s vital signs meet a required alert threshold, the patient’s nurse is required to physically assess the patient and, depending on the level of severity predicted by Q-ADDS, notify the patient’s doctor (escalation). The doctor is then required to be notified of the patient’s Q-ADDS score, potentially review the patient, and discuss any potential changes to care with the nurse. Both nurses and doctors can escalate straight to MET calls or an emergency ‘code blue’ call (requiring cardiopulmonary resuscitation or assisted ventilation) at any time if necessary.

Participant recruitment

Participant recruitment began in February 2022 and concluded in March 2023, disrupted by the COVID-19 pandemic. Eligibility criteria were nurses or doctors at each hospital with direct patient contact who either receive or respond, respectively, to Q-ADDS alerts. An anticipated target sample size of 15 participants was established prior to recruitment, based on expected constraints in recruitment due to clinician workloads and the expected length of interviews relative to their scope, as guided by prior research [ 22 ]. As the analysis plan involved coding interviews iteratively as they were conducted, the main justification for ceasing recruitment was when no new themes relating to the study objectives were generated during successive interviews as the target sample size was approached [ 23 ].

Study information was broadly distributed via email to nurses and doctors in patient-facing roles across hospitals. Nurse unit managers were followed up during regular nursing committee meetings to participate or assist with recruitment within their assigned wards. Doctors were followed up by face-to-face rounding. Snowball sampling, in which participants were encouraged to refer their colleagues for study participation, was employed whenever possible. In all cases, study authors explained study goals and distributed participant consent forms prior to interview scheduling with the explicit proviso that participation was completely voluntary and anonymous to all but two study authors (RB and SN).

Interview process

We used a reflexive framework method to develop an open-ended interview template [ 24 ] that aligned with our study aims. Interview questions were informed by the non-adoption, abandonment, scale-up, spread and sustainability (NASSS) framework [ 25 ]. The NASSS framework relates the end-user perceptions of the technology being evaluated to its value proposition for the clinical situation to which it is being applied. We selected a reflexive method based on the NASSS for our study as we wanted to allow end-users to speak freely about the barriers they faced when using prediction models for clinical deterioration, but did not limit participants to discussing only topics that could fit within the NASSS framework.

Participants were first asked about their background and clinical expertise. They were then invited to share their experiences and perspectives with using early warning scores to manage deteriorating patients. This was used as a segue for participants to describe the primary tasks required of them when evaluating and treating a deteriorating patient. Participants were encouraged to talk through their decision-making process when fulfilling these tasks, and to identify any barriers or obstacles to achieving those tasks that were related to prediction models for deteriorating patients. Participants were specifically encouraged to identify any sources of information that were useful for managing deteriorating patients, including prediction models for other, related disease groups like sepsis, and to think of any barriers or facilitators for making that information more accessible. Finally, participants were invited to suggest ways to improve early warning scores, and how those changes may lead to benefits for patients and clinicians.

As we employed a reflexive methodology to allow clinicians to speak freely about their perspectives and opinions, answers to interview questions were optional and open-ended, allowing participants to discuss relevant tangents. Separate interview guides were developed for nurses and doctors as the responsibilities and information needs of these two disciplines in managing deteriorating patients often differ. Nurses are generally charged with receiving and passing on deterioration alerts, while doctors are generally charged with responding to alerts and making any required changes to patient care plans [ 4 ]. Interview guides are contained in the supplement.

Due to clinician workloads, member checking, a form of post-interview validation in which participants retrospectively confirm their interview answers, was not used. To ensure participants perceived the interviewers as being impartial, two study authors not employed by the hospital network and not involved in direct patient care (RB and SN) were solely responsible for conducting interviews and interrogating interview transcripts. Interviews were recorded and transcribed verbatim, then re-checked for accuracy.

Inductive thematic analysis

Transcripts were analysed using a reflexive thematic methodology informed by Braun and Clarke [ 26 ]. This method was selected because it facilitated exploring the research objectives rather than being restricted to the domains of a specific technology adoption framework, which may limit generalisability [ 27 ]. Interviews were analysed over five steps to identify emergent themes.

Each interview was broken down into segments by RB and SN, where segments corresponded to a distinct opinion.

Whenever appropriate, representative quotes for each distinct concept were extracted.

Segments were grouped into sub-themes.

Sub-themes were grouped into higher-order themes, or general concepts.

Steps 1 through 4 were iteratively repeated by RB and supervised by SN.

As reflexive methods incorporate the experiences and expertise of the analysts, our goal was to extract any sub-themes relevant to the study aims and able to be analysed in the context of early warning scores, prediction models, or decision support tools for clinical deterioration. The concepts explored during this process were not exhaustive, but repeated analysis and re-analysis of participant transcripts helped to ensure all themes could be interpreted in the context of our three study aims: background and perspectives, tasks and decision-making, and recommendations for future practice.

Deductive mapping to a clinical decision-making framework

Once the emergent themes from the inductive analysis were defined, we conducted a brief scan of PubMed for English-language studies that investigated how the design of clinical decision support systems relate to clinical decision-making frameworks. The purpose of this exercise was to identify a framework against which we could map the previously elicited contexts, tasks, and decision-making of end-users in developing a decision-making model that could then be used to support the third aim of formulating recommendations to enhance prediction model development and deployment.

RB and SN then mapped higher-order themes from the inductive analysis to the decision-making model based on whether there was a clear relationship between each theme and a node in the model (see Results).

Recommendations for improving prediction model design were derived by reformatting the inductive themes based on the stated preferences of the participants. These recommendations were then assessed by the remaining authors and the process repeated iteratively until authors were confident that all recommendations were concordant with the decision-making model.

Participant characteristics

Our sample included 8 nurses and 7 doctors of varying levels of expertise and clinical specialties; further information is contained in the supplement. Compared to doctors, nurse participants were generally more experienced, often participating in training or mentoring less experienced staff. Clinical specialities of nurses were diverse, including orthopaedics, cancer services, medical assessment and planning unit, general medicine, and pain management services. Doctor participants ranged from interns with less than a year of clinical experience up to consultant level, including three doctors doing training rotations and two surgical registrars. Clinical specialties of doctors included geriatric medicine, colorectal surgery, and medical education.

Interviews and thematic analysis

Eleven interviews were conducted jointly by RB and SN, one conducted by RB, and three by SN. Interviews were scheduled for up to one hour, with a mean duration of 42 min. Six higher-order themes were identified. These were: added value of more information; communication of model outputs; validation of clinical intuition; capability for objective measurement; over-protocolisation of care; and model transparency and interactivity (Table  1 ). Some aspects of care, including the need for critical thinking and the informational value of discerning trends in patient observations, were discussed in several contexts, making them relevant to more than one higher-order theme.

Added value of other information

Clinicians identified that additional data or variables important for decision making were often omitted from the Q-ADDS digital interface. Such variables included current medical conditions, prescribed medications and prior observations, which were important for interpreting current patient data in the context of their baseline observations under normal circumstances (e.g., habitually low arterial oxygen saturation due to chronic obstructive pulmonary disease) or in response to an acute stimulus (e.g., expected hypotension for next 4 to 8 h while treatment for septic shock is underway).

“The trend is the biggest thing [when] looking at the data , because sometimes people’s observations are deranged forever and it’s not abnormal for them to be tachycardic , whereas for someone else , if it’s new and acute , then that’s a worry.” – Registrar.

Participants frequently emphasised the critical importance of looking at patients holistically, or that patients were more than the sum of the variables used to predict risk. Senior nurses stressed that prediction models were only one part of patient evaluation, and clinicians should be encouraged to incorporate both model outputs and their own knowledge and experiences in decision making rather than trust models implicitly. Doctors also emphasised this holistic approach, adding that they placed more importance on hearing a nurse was concerned for the patient than seeing the model output. Critical thinking about future management was frequently raised in this context, with both nurses and doctors insisting that model predictions and the information required for contextualising risk scores should be communicated together when escalating the patient’s care to more senior clinicians.

Model outputs

Model outputs were discussed in two contexts. First, doctors perceived that ordinal risk scores generated by Q-ADDS felt arbitrary compared to receiving probabilities of a future event, for example cardiorespiratory decompensation, that required a response such as resuscitation or high-level treatment. However, nurses did not wholly embrace probabilities as outputs, instead suggesting that recommendations for how they should respond to different Q-ADDS scores were more important. This difference may reflect the different roles of alert receivers (nurses) and alert responders (doctors).

“[It’s helpful] if you use probabilities… If your patient has a sedation score of 2 and a respiratory rate of 10 , [giving them] a probability of respiratory depression would be helpful. However , I don’t find many clinicians , and certainly beginning practitioners , think in terms of probabilities.” – Clinical nurse consultant.

Second, there was frequent mention of alert fatigue in the context of model outputs. One doctor and two nurses felt there was insufficient leeway for nurses to exercise discretion in responding to risk scores, leading to many unnecessary alert-initiated actions. More nuance in the way Q-ADDS outputs were delivered to clinicians with different roles was deemed important to avoid model alerts being perceived as repetitive and unwarranted. However, three other doctors warned against altering MET call criteria in response to repetitive and seemingly unchanging risk scores and that at-risk patients should, as a standard of care, remain under frequent observation. Frustrations centred more often around rigidly tying repetitive Q-ADDS outputs to certain mandated actions, leading to multiple clinical reviews in a row for a patient whose trajectory was predictable, for example a patient with stable heart failure having a constantly low blood pressure. This led to duplication of nursing effort (e.g., repeatedly checking the blood pressure) and the perception that prediction models were overly sensitive.

“It takes away a lot of nurses’ critical judgement. If someone’s baseline systolic [blood pressure] is 95 [mmHg] , they’re asymptomatic and I would never hear about it previously. We’re all aware that this is where they sit and that’s fine. Now they are required to notify me in the middle of the night , “Just so you know , they’ve dropped to 89 [below an alert threshold of 90mmHg].“” – Junior doctor.

Validation of clinical intuition

Clinicians identified the ability of prediction models to validate their clinical intuition as both a benefit and a hindrance, depending on how outputs were interpreted and acted upon. Junior clinicians appreciated early warning scores giving them more support to escalate care to senior clinicians, as a conversation starter or framing a request for discussion. Clinicians described how assessing the patient holistically first, then obtaining model outputs to add context and validate their diagnostic hypotheses, was very useful in deciding what care should be initiated and when.

“You kind of rule [hypotheses] out… you go to the worst extreme: is it something you need to really be concerned about , especially if their [score] is quite high? You’re thinking of common complications like blood clots , so that presents as tachycardic… I’m thinking of a PE [pulmonary embolism] , then you do the nursing interventions.” – Clinical nurse manager.

While deterioration alerts were often seen as triggers to think about potential causes for deterioration, participants noted that decision making could be compromised if clinicians were primed by model outputs to think of different diagnoses before they had fully assessed the patient at the bedside. Clinicians described the dangers of tunnel vision or, before considering all available clinical information, investigating favoured diagnoses to the exclusion of more likely causes.

“[Diagnosis-specific warnings are] great , [but] that’s one of those things that can lead to a bit of confirmation bias… It’s a good trigger to articulate , “I need to look for sources of infection when I go to escalate"… but then , people can get a little bit sidetracked with that and ignore something more blatant in front of them. I’ve seen people go down this rabbit warren of being obsessed with the “fact” that it was sepsis , but it was something very , very unrelated.” – Nurse educator.

Objective measurement

Clinicians perceived that prediction models were useful as more objective measures of patients’ clinical status that could ameliorate clinical uncertainty or mitigate cognitive biases. In contrast to the risk of confirmation bias arising from front-loading model outputs suggesting specific diagnoses, prediction models could offer a second opinion that could help clinicians recognise opposing signals in noisy data that, in particular, assisted in considering serious diagnoses that shouldn’t be missed (e.g., sepsis), or more frequent and easily treated diagnoses (e.g., dehydration). Prediction models were also useful when they disclosed several small, early changes in patient status that provided an opportunity for early intervention.

“Maybe [the patient has] a low grade fever , they’re a bit tachycardic. Maybe [sepsis] isn’t completely out of the blue for this person. If there was some sort of tool , that said there’s a reasonable chance that they could have sepsis here , I would use that to justify the option of going for blood cultures and maybe a full septic screen. If [I’m indecisive] , that sort of information could certainly push me in that direction.” – Junior doctor.

Clinicians frequently mentioned that prediction models would have been more useful when first starting clinical practice, but become less useful with experience. However, clinicians noted that at any experience level, risk scoring was considered most useful as a triage/prioritisation tool, helping decide which patients to see first, or which clinical concerns to address first.

“[Doctors] can easily triage a patient who’s scoring 4 to 5 versus 1 to 3. If they’re swamped , they can change the escalation process , or triage appropriately with better communication.” – Clinical nurse manager.

Clinicians also stressed that predictions were not necessarily accurate because measurement error or random variation, especially one-off outlier values for certain variables, was a significant contributor to false alerts and inappropriate responses. For example, a single unusually high respiratory rate generated an unusually high risk score, prompting an unnecessary alert.

Over-protocolisation of care

The sentiment most commonly expressed by all experienced nursing participants and some doctors was that nurses were increasingly being trained to solely react to model outputs with fixed response protocols, rather than think critically about what is happening to patients and why. It was perceived that prediction models may actually reduce the capacity for clinicians to process and internalise important information. For example, several nurses observed their staff failing to act on their own clinical suspicions that patients were deteriorating because the risk score had not exceeded a response threshold.

“We’ve had patients on the ward that have had quite a high tachycardia , but it’s not triggering because it’s below the threshold to trigger… [I often need to make my staff] make the clinical decision that they can call the MET anyway , because they have clinical concern with the patient.” – Clinical nurse consultant.

A source of great frustration for many nurses was the lack of critical thinking by their colleagues of possible causes when assessing deteriorating patients. They wanted their staff to investigate whether early warning score outputs or other changes in patient status were caused by simple, easily fixable issues such as fitting the oxygen mask properly and helping the patient sit up to breathe more easily, or whether they indicated more serious underlying pathophysiology. Nurses repeatedly referenced the need for clinicians to always be asking why something was happening, not simply reacting to what was happening.

“[Models should also be] trying to get back to critical thinking. What I’m seeing doesn’t add up with the monitor , so I should investigate further than just simply calling the code.” – Clinical nurse educator.

Model transparency and interactivity

Clinicians frequently requested more transparent and interactive prediction models. These included a desire to receive more training in how prediction models worked and how risk estimates were generated mathematically, and being able to visualise important predictors of deterioration and the absolute magnitude of their effects (effect sizes) in intuitive ways. For example, despite receiving training in Q-ADDS, nurses expressed frustrations that nobody at the hospital seemed to understand how it worked in generating risk scores. Doctors were interested in being able to visualise the relative size and direction of effect of different model variables, potentially using colour-coding, combined with other contextual patient data like current vital sign trends and medications, and presented on one single screen.

The ability to modify threshold values for model variables and see how this impacted risk scores, and what this may then mean for altering MET calling criteria, was also discussed. For example, in an older patient with an acute ischaemic stroke, a persistently high, asymptomatic blood pressure value is an expected bodily response to this acute insult over the first 24–48 h. In the absence of any change to alert criteria, recurrent alerts would be triggered which may encourage overtreatment and precipitous lowering of the blood pressure with potential to cause harm. Altering the criteria to an acceptable or “normal” value for this clinical scenario (i.e. a higher than normal blood pressure) may generate a lower, more patient-centred risk estimate and less propensity to overtreat. This ability to tinker with the model may also enhance understanding of how it works.

“I wish I could alter criteria and see what the score is after that , with another set of observations. A lot of the time… I wonder what they’re sitting at , now that I’ve [altered] the bit that I’m not concerned about… It would be quite helpful to refresh it and have their score refreshed as the new score.” – Junior doctor.

Derivation of the decision-making model

Guided by the responses of our participants regarding their decision-making processes, our literature search identified a narrative review by Banning (2008) that reported previous work by O’Neill et al. (2005) [ 28 , 29 ]. While these studies referred to models of nurse decision-making, we selected a model (Fig.  2 ) that also appropriately described the responses of doctors in our participant group and matched the context of using clinical decision support systems to support clinical judgement. As an example, when clinicians referenced needing to look for certain data points to give context to a patient assessment, this was mapped to nodes relating to “Current patient data,” “Changes to patient status/data,” and “Hypothesis-driven assessment.”

Decision-making model(Adapted from Neill’s clinical decision making framework [2005] and modified by Banning [2006]) with sequential decision nodes

Mapping of themes to decision-making model

The themes from Table  1 were mapped to the nodes in the decision-making model based on close alignment with participant responses (see Fig.  3 ). This mapping is further explained below, where the nodes in the model are described in parentheses.

Value of additional information for decision-making : participants stressed the importance of understanding not only the data going into the prediction model, but also how that data changed over time as trends, and the data that were not included in the model. (Current patient data, changes to patient status/data)

Format, frequency, and relevance of outputs : participants suggested a change in patient data should not always lead to an alert. Doctors, but not necessarily nurses, proposed outputs displayed as probabilities rather than scores, tying model predictions to potential diagnoses or prognoses. (Changes to patient status/data, hypothesis generation)

Using models to validate but not supersede clinical intuition : Depending on the exact timing of model outputs within the pathway of patient assessment, participants found predictions could either augment or hinder the hypothesis generation process. (Hypothesis generation)

Measuring risks objectively : Risk scores can assist with triaging or prioritising patients by urgency or prognostic risk, thereby potentially leading to early intervention to identify and/or prevent adverse events. (Clinician concerns, hypothesis generation)

Supporting critical thinking and reducing over-protocolised care : by acting as triggers for further assessment, participants suggested prediction models can support or discount diagnostic hypotheses, lead to root-cause identification, and facilitate interim cares, for example by ensuring good fit of nasal prongs. (Provision of interim care, hypothesis generation, hypothesis-driven assessment)

Model transparency and interactivity : understanding how prediction models worked, being able to modify or add necessary context to model predictions, and understanding the relative contribution of different predictors could better assist the generation and selection of different hypotheses that may explain a given risk score. (Hypothesis generation, recognition of clinical pattern and hypothesis selection)

Mapping of the perceived relationships between higher-order themes and nodes in the decision-making model shown in Fig.  2

Recommendations for improving the design of prediction models

Based on the mapping of themes to the decision-making model, we formulated four recommendations for enhancing the development and deployment of prediction models for clinical deterioration.

Improve accessibility and transparency of data included in the model. Provide an interface that allows end-users to see what predictor variables are included in the model, their relative contributions to model outputs, and facilitate easy access to data not included in the model but still relevant for model-informed decisions, e.g., trends of predictor variables over time.

Present model outputs that are relevant to the end-user receiving those outputs, their responsibilities, and the tasks they may be obliged to perform, while preserving the ability of clinicians to apply their own discretionary judgement.

In situations associated with diagnostic uncertainty, avoid tunnel vision from priming clinicians with possible diagnostic explanations based on model outputs, prior to more detailed clinical assessment of the patient.

Support critical thinking whereby clinicians can apply a more holistic view of the patient’s condition, take all relevant contextual factors into account, and be more thoughtful in generating and selecting causal hypotheses.

This qualitative study involving front-line acute care clinicians who respond to early warning score alerts has generated several insights into how clinicians perceive the use of prediction models for clinical deterioration. Clinicians preferred models that facilitated critical thinking, allowed an understanding of the impact of variables included and excluded from the model, provided model outputs specific to the tasks and responsibilities of different disciplines of clinicians, and supported decision-making processes in terms of hypotheses and choice of management, rather than simply responding to alerts in a pre-specified, mandated manner. In particular, preventing prediction models from supplanting critical thinking was repeatedly emphasised.

Reduced staffing ratios, less time spent with patients, greater reliance on more junior workforce, and increasing dependence on automated activation of protocolised management are all pressures that could lead to a decline in clinical reasoning skills. This problem could be exacerbated by adding yet more predictive algorithms and accompanying protocols for other clinical scenarios, which may intensify alert fatigue and disrupt essential clinical care. However, extrapolating our results to areas other than clinical deterioration should be done with caution. An opposing view may be that using prediction models to reduce the burden of routine surveillance may allow redirection of critical thinking skills towards more useful tasks, a question that has not been explored in depth in the clinical informatics literature.

Clinicians expressed interest in models capable of providing causal insights into clinical deterioration. This is neither a function nor capability of most risk prediction models, requiring different assumptions and theoretical frameworks [ 30 ]. Despite this limitation, risk nomograms, visualisations of changes in risk with changes in predictor variables, and other interactive tools for estimating risk may be useful adjuncts for clinical decision-making due to the ease with which input values can be manipulated.

Contributions to the literature

Our research supports and extends the literature on the acceptability of risk prediction models within clinical decision support systems. Common themes in the literature supporting good practices in clinical informatics and which are also reflected in our study include: alert fatigue; the delivery of more relevant contextual information; [ 31 ] the value of patient histories; [ 32 , 33 ] ranking relevant information by clinical importance, including colour-coding; [ 34 , 35 ] not using computerised tools to replace clinical judgement; [ 32 , 36 , 37 ] and understanding the analytic methods underpinning the tool [ 38 ]. One other study has investigated the perspectives of clinicians of relatively simple, rules-based prediction models similar to Q-ADDS. Kappen et al [ 12 ] conducted an impact study of a prediction model for postoperative nausea and vomiting and also found that clinicians frequently made decisions in an intuitive manner that incorporated information both included and absent from prediction models. However, the authors recommended a more directive than assistive approach to model-based recommendations, possibly due to a greater focus on timely prescribing of effective prophylaxis or treatment.

The unique contribution of our study is a better understanding of how clinicians may use prediction models to generate and validate diagnostic hypotheses. The central role of critical thinking and back-and-forth interactions between clinician and model in our results provide a basis for future research using more direct investigative approaches like cognitive task analysis [ 39 ]. Our study has yielded a set of cognitive insights into decision making that can be applied in tandem with statistical best practice in designing, validating and implementing prediction models. [ 19 , 40 , 41 ].

Relevance to machine learning and artificial intelligence prediction models for deterioration

Our results may generalise to prediction models based on machine learning (ML) and artificial intelligence (AI), according to results of several recent studies. Tonekaboni et al [ 42 ] investigated clinician preferences for ML models in the intensive care unit and emergency department using hypothetical scenarios. Several themes appear both in our results and theirs: a need to understand the impact of both included and excluded predictors on model performance; the role of uncertain or noisy data in prediction accuracy; and the influence of trends or patient trajectories in decision making. Their recommendations for more transparent models and the delivery of model outputs designed for the task at hand align closely with ours. The authors’ focus on clinicians’ trust in the model was not echoed by our participants.

Eini-Porat et al [ 43 ] conducted a comprehensive case study of ML models in both adult and paediatric critical care. Their results present several findings supported by our participants despite differences in clinical environments: the value of trends and smaller changes in several vital signs that could cumulatively signal future deterioration; the utility of triage and prioritisation in time-poor settings; and the use of models as triggers for investigating the cause of deterioration.

As ML/AI models proliferate in the clinical deterioration prediction space, [ 44 ] it is important to deeply understand the factors that may influence clinician acceptance of more complex approaches. As a general principle, these methods often strive to input as many variables or transformations of those variables as possible into the model development process to improve predictive accuracy, incorporating dynamic updating to refine model performance. While this functionality may be powerful, highly complex models are not easily explainable, require careful consideration of generalisability, and can prevent clinicians from knowing when a model is producing inaccurate predictions, with potential for patient harm when critical healthcare decisions are being made [ 45 , 46 , 47 ]. Given that our clinicians emphasised the need to understand the model, know which variables are included and excluded, and correctly interpret the format of the output, ML/AI models in the future will need to be transparent in their development and their outputs easily interpretable.

Limitations

The primary limitations of our study were that our sample was drawn from two hospitals with high levels of digital maturity in a metropolitan region of a developed country, with a context specific to clinical deterioration. Our sample of 15 participants may be considered small but is similar to that of other studies with a narrow focus on clinical perspectives [ 42 , 43 ]. All these factors can limit generalisability to other settings or to other prediction models. As described in the methods, we used open-ended interview templates and generated our inductive themes reflexively, which is vulnerable to different types of biases compared to more structured preference elicitation methods with rigidly defined analysis plans. Member checking may have mitigated this bias, but was not possible due to the time required from busy clinical staff.

Our study does not directly deal with methodological issues in prediction model development, [ 41 , 48 ] nor does it provide explicit guidance on how model predictions should be used in clinical practice. Our findings should also not be considered an exhaustive list of concerns clinicians have with prediction models for clinical deterioration, nor may they necessarily apply to highly specialised clinical areas, such as critical care. Our choice of decision making framework was selected because it demonstrated a clear, intuitive causal pathway for model developers to support the clinical decision-making process. However, other, equally valid frameworks may have led to different conclusions, and we encourage more research in this area.

This study elicited clinician perspectives of models designed to predict and manage impending clinical deterioration. Applying these perspectives to a decision-making model, we formulated four recommendations for the design of future prediction models for deteriorating patients: improved transparency and interactivity, tailoring models to the tasks and responsibilities of different end-users, avoiding priming clinicians with diagnostic predictions prior to in-depth clinical review, and finally, facilitating the diagnostic hypothesis generation and assessment process.

Availability of data and materials

Due to privacy concerns and the potential identifiability of participants, interview transcripts are not available. However, interview guides are available in the supplement.

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Acknowledgements

We would like to thank the participants who made time in their busy clinical schedules to speak to us and offer their support in recruitment.

This work was supported by the Digital Health Cooperative Research Centre (“DHCRC”). DHCRC is funded under the Commonwealth’s Cooperative Research Centres (CRC) Program. SMM was supported by an NHMRC-administered fellowships (#1181138).

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RB: conceptualisation, data acquisition, analysis, interpretation, writing. SN: data acquisition, analysis, interpretation, writing. NW: interpretation, writing. RD: data acquisition, interpretation, writing. IS: data acquisition, analysis, interpretation, writing. AM: data acquisition, interpretation, writing. SM: conceptualisation, data acquisition, analysis, interpretation, writing. All authors have approved the submitted version and agree to be accountable for the integrity and accuracy of the work.

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This study was approved by the Metro South Human Research Ethics Committee (HREC/2022/QMS/84205). Informed consent was obtained prior to interview scheduling, with all participants filling out a participant information and consent form. Consent forms were approved by the ethics committee. Participation was entirely voluntary, and could be withdrawn at any time. All responses were explicitly deemed confidential, with only the first two study authors and the participant privy to the research data. Interviews were then conducted in accordance with Metro South Health and Queensland University of Technology qualitative research regulations. For further information, please contact the corresponding author.

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Blythe, R., Naicker, S., White, N. et al. Clinician perspectives and recommendations regarding design of clinical prediction models for deteriorating patients in acute care. BMC Med Inform Decis Mak 24 , 241 (2024). https://doi.org/10.1186/s12911-024-02647-4

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Received : 06 September 2023

Accepted : 23 August 2024

Published : 02 September 2024

DOI : https://doi.org/10.1186/s12911-024-02647-4

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