sexual harassment is an unwelcome deliberate or unintentional action that creates a 
 hostile work environment for the employee . sexual harassment involves the interpretation of a verbal , 
 nonverbal , or physical action against another person and may refer to an action that is 
 not mutually agreed upon or reciprocated by another individual . this behavior interferes 
 with an individual 's work performance and creates an atmosphere of intimidation 
 resulting in a lack of concentration for the victim . workplace gender discrimination is illegal in several countries . in the united states , which is one of 
 the pioneer countries in this kind of legislation , sexual harassment also , gender discrimination was addressed in academic settings by 
 attaching title ix amendments to the educational act of 1972 that forbid institutions 
 receiving federal funds from discriminating on the basis of sex . in brazil , as well as in several 
 countries of latin america , sexual harassment is prohibited by the law through the 
 national penal code , in the chapter of crimes against sexual freedom ; however there is no official 
 recommendation about sexual discrimination in educational environments . research during the past 20 years has revealed that sexual harassment is widespread in 
 general society and in higher education , health profession education , and dental 
 education . a descriptive study on sexual harassment incidence conducted with 
 more than 8 thousand employees from three latin america countries revealed that its 
 incidence varied by country and was found to be around 8.7 - 10% in chile , 4.8% in brazil 
 and 3.5% in argentine . bullying and 
 sexual harassment at school have received recent attention in developed countries , but 
 they have been neglected in latin america . in a general way , there are few data on the prevalence of sexual 
 harassment in developing countries . in the dental field , few studies have been published regarding patients and professors 
 and the sexual harassment claims of their students . there is some evidence that patients may sexually harass their oral 
 health care providers . information 
 from reports from dental and dental hygiene students indicated that such advances do 
 occur and that providers are rarely educated to deal effectively with them . in a study conducted with 300 oregon dentists and 300 dental hygienists , 44% of 
 providers experienced one or more patient verbal advances and up to 23% of providers 
 experienced one or more patient physical advances during a five - year period . given the relative 
 paucity of research on issues associated with sexual harassment in academic settings and 
 especially in dental schools , more studies are needed to assess the frequency , type and 
 etiology of sexual harassment involving patients and students or professors and students 
 in the academic dental environment . a more thorough understanding of the causes of 
 sexual harassment and contributing factors will allow academic institutions to implement 
 preventive measures for a situation that is worrying , but often disguised . accordingly , 
 the purposes of this study were to determine the sexual harassment prevalence in one 
 brazilian dental school and to evaluate the experiences and attitudes of undergraduate 
 dental students in this academic environment . this project was conducted at araatuba dental school , so paulo state 
 university ( unesp ) , brazil . this cross - sectional study assessed the experiences and 
 attitudes of dental students during the clinical phase of their dental education . the 
 hypothesis was that dental students might be harassed by professors , colleagues and , 
 mainly , by patients receiving treatment from the students . data were obtained using an eighteen - item questionnaire that required approximately 15 
 min to be completed . the questionnaire consisted of open and closed questions , which 
 were analyzed through the content analysis technique ( qualitative analysis ) and frequency distribution ( quantitative 
 analysis ) , respectively . this instrument was pre - tested and it was adapted from other 
 studies reporting on sexual harassment in dental schools and dental 
 environments to the local characteristics ( figure 1 ) . three questions requested general information ( gender , 
 age and year of study ) from the students ; eleven questions were about students ' personal 
 experiences with sexual harassment and 4 questions requested information from students 
 who reported they had witnessed someone else being harassed . students were specifically 
 asked if they had been sexually harassed in dental school ; students responding 
 affirmatively were asked to categorize the harasser , and to describe how it occurred . students were also asked if they had witnessed some colleague being sexually harassed at 
 the dental school ; those who answered positively , were asked to categorize the harasser 
 and to describe how it had occurred . a final item asked if they knew what to do in a 
 sexual harassment situation . data collection instrument a pilot study was carried out with 55 students of a single institution , reporting a 
 completion rate of 92% . ten percent of the sample , randomly assigned , filled out the 
 same questionnaire 10 days later . the questionnaire 
 format and students ' answers were verified and discussed among researchers , in order to 
 evaluate the adequacy of the instrument . there were 254 undergraduate students enrolled in the dental school , and all of them 
 were invited to participate in the research . students were informed about the purpose of the study 
 and a signed informed consent form was obtained from each participant . a process was 
 followed that assured student anonymity and the confidentiality of their responses . ten 
 percent of the sample answered twice the questionnaire in order to verify the 
 consistence of answers and an agreement of 89% was observed . this study was implemented with methodology that was consistent with the code of ethics 
 of the world medical association ( declaration of helsinki ) and the research protocol 
 received ethical approval from the research ethics committee of the araatuba 
 dental . data entry and analysis were performed by investigators using the statistic software epi 
 info version 3.2 ( epi info , cdc , atlanta , georgia , usa ) . the statistical analysis 
 included two - sample tests , chi - square and fisher 's exact tests . a 
 p - value of 0.05 was required for statistical significance in 
 all tests . the sexual harassment questionnaire was completed by 208 students ( 82% ) ; 65.9% females 
 and 34.1% males . the mean age of dental students was 22 years old , ranging from 19 to 32 
 years old . the sample was representative of the student population based on the gender 
 ( 70% females and 30% males ) and age ( mean age 23 years old ) in dental education . sexual harassment by the patient or a patient 's relative as the perpetrator was reported 
 by 19 of all respondents - 9.1% of study population , including 8 women and 11 men . out of all male students , 15.5% were harassed at least one 
 time , while 5.9% of all women were harassed . there was a statistically difference 
 significant between the percentage of all female and male subjects in this study who 
 reported they had been sexually harassed ( p=0.04 ) . the probability of 
 male students to be sexually harassed was 3 times as high as that observed for female 
 students ( odds ratio=2.910 ; 95% confidence interval 1.113 - 7.611 ) . sexual harassment experiences reported by dental students who cited the patient as 
 the perpetrator out of 19 students harassed by their patients , 16 concluded the treatment . the remaining 
 3 students refused to treat their patients who were transferred to another dental 
 student for continuation of treatment . the responses to sexual harassment included ignoring , telling the offending person to 
 stop or telling a tutor what had happened ( table 
 2 ) . when students who reported harassment by a patient were asked if they had 
 contributed to occurrence of the sexual harassment incident , 37% said yes , due to a 
 close relationship with the patient , which was misunderstood as intimacy . responses of dental students who reported being sexually harassed by a patient in 
 the dental care settings twelve students ( 5.8% ) were sexually harassed by professors or university staff members 
 including 10 female and 2 male students ( table 
 3 ) . no statistically significant difference in the gender of students harassed by 
 professors or university staff members was observed ; however there was a higher 
 prevalence of females who reported harassment by a professor when compared to male 
 students . the sexual insinuations occurred more frequently at the dental school setting 
 ( 75% ) than in other locations . sexual harassment experiences reported by dental students who cited the professor 
 or the university staff as the perpetrator when asked how they responded to sexual harassment by university staff members , all 
 students reported they ignored the comments and no one filed a complaint . none of the 
 students who did not respond in a receptive manner to the sexual comments of professors 
 was punished . the overall prevalence of sexual harassment in the study population of 208 students was 
 15% ; a total of 32 dental students reported that they had been harassed by a patient or 
 a professor / university staff member ( figure 
 2 ) . distribution ( % ) of dental students sexually harassed according to 
 perpetrators fifty - three ( 25.4% ) out of the 208 students reported that they had witnessed a student 
 colleague being sexually harassed . patients were cited as harassers in 46.6% of the 
 cases , followed by faculty members ( 44.9% ) , university staff members ( 3.4% ) , other 
 dental student ( 3.4% ) and patients ' relatives ( 1.7% ) . responses from harassed students 
 to the situation included feeling embarrassed / terrified ( 36.5% ) , ignoring it ( 26.9% ) , 
 telling the offending person to stop ( 5.8% ) and recommending the harasser ( patient ) to 
 be treated by another student ( 5.8% ) . among students who had witnessed an incident , 
 73.5% did nothing to help the harassed colleagues . according to survey respondents who 
 had witnessed an incident , most of the harassed students contributed to the occurrence 
 of sexual harassment because of their own inappropriate behavior or a close relationship 
 with the patient . regarding to the dental students ' knowledge of legal aspects of sexual harassment , 41.3% 
 did not know what to do if they were harassed . among the students ( 58.7% ) reporting they 
 knew how to act in a sexual harassment situation , 75.6% would recourse to a law suit , 
 look for a police station , make a formal complaint or look for a lawyer ; 13.9% would 
 contact a manager on the university or dental school , such as the dean or a university 
 staff member ; and 7.8% would ignore the situation and would not look for help . this is the first study to survey the sexual harassment experiences of undergraduate 
 students in a dental school in brazil . the prevalence of sexually harassed dental 
 students in our study is similar to that observed in a study conducted at the university 
 of kentucky . when considering the percentage of students that had 
 witnessed a colleague being sexually harassed , the values were also similar to those 
 found by other researchers . although either gender at any position may be the victim of sexual harassment , women who 
 occupy subordinate positions are the most likely targets of these overtures . however , in the present study , men had a higher probability of 
 being sexually harassed than women when the perpetrator was a patient . one of the hypotheses is that nowadays both men and 
 women can be victims of gender discrimination , and not only women , the " fragile sex " , as 
 they were described decades ago . one limitation of this study was that the data depended on the self - report of students , 
 who defined what constitutes sexual harassment differently according to their personal 
 philosophy , values and life experiences . however , at this first moment , the 
 investigators tried not to influence students in their answers , and preferred not to 
 define sexual harassment previously to students report . in a second phase of this 
 project , students will receive training on sexual and cultural discrimination and 
 harassment , and a new survey will be conducted on sexual harassment prevalence and 
 student 's attitudes regarding it . health 
 professionals must be cautious when developing physically close working relationships or 
 using humor , as these behaviors could unintentionally convey sexual overtones . also , 
 clients could confuse these relationships with intimacy , distorting the meaning of 
 patient - professional relation . the results of this study demonstrated that many students 
 did not worry about certain actions such as being subjected to unwanted sexual attention 
 or listening to sexual comments or jokes ; they did not consider these situations to be 
 sexual harassment . the lack of awareness is a strong indication of the necessity of 
 informing dental students and dentists , including faculty members , about the evolving 
 sexual harassment laws and regulations . if dental students were taught sexual harassment 
 prevention and management strategies in the dental educational setting , they would be 
 better prepared to identify illegal behaviors and not tolerate sexual harassment . it is necessary to define and to discuss with the students and professionals the 
 " hostile working environment " . weinstein , in his article , described scenarios , which are 
 used to help defining and identifying harassment . according to the brazilian law this specific characterization for sexual harassment is similarly found in 
 other countries around the world . in this instance , the harasser often occupies a 
 position of power , such as a supervisor or an instructor , to make such demands and to 
 implement a retribution ( punishment or penalty ) if he / she is not satisfied . however , sexual harassment can occur 
 without a relationship of superiority between the individuals involved , e.g. , when the 
 perpetrator is the patient or a relative of the patient and the harassed is the dental 
 student or the dentist . it is difficult for an employee or a student to perform his job 
 adequately in this kind of " hostile working environment " . it is extremely important to 
 prepare the future health professionals to respond to harassing incidents with standards 
 of professionalism , especially when the national laws do not protect against this 
 situation . sexual harassment situations were similar in brazil and other countries , as reported in 
 previous studies . the majority of complaints come from women ; however the number of 
 complaints filed by men is increasing , along with increasing numbers of men filing 
 against female supervisors . two specific situations can be described as most prevalent 
 in the workplace : 1 ) " something for something " ; this is the " you do something for me and i 'll do something 
 for you " type of exchange . this occurs when a job benefit is directly tied to an 
 employee submitting to unwelcome sexual advances . for example , a supervisor promises an 
 employee a raise if she will go out on a date with him , or tells an employee she will be 
 fired if she does n't sleep with him - in the dental environment , this could correspond 
 to sexual favors in exchange for better grades or final approval in the school year . 2 ) hostile environment sexual harassment : this occurs when an employee is subjected to 
 comments of a sexual nature , offensive sexual materials , or unwelcome physical contact 
 as a regular part of the work environment . in a general way , a single isolated incident 
 will not be considered hostile environment harassment unless it is extremely outrageous 
 and egregious conduct . in the present study , the students did not consider a sexual 
 harassment problem being invited for a date or being subjected to some jokes , even if 
 their content was sexually aggressive . a concern is that , in addition to being illegal , these experiences are damaging because 
 they may cause students to become less idealistic and more cynical as they progress 
 through their dental education , and later in their clinical practice . the percentage of victims who actually file formal sexual harassment complaints is 
 extremely low . the brazilian dental 
 students participating in this study failed to report it because of lack of information . the majority of students did not feel professionally prepared to respond to unwanted 
 sexual behaviors and they were not aware of any guidelines or polices in the dental 
 setting that describe how to respond to sexually motivated harassment . high levels of 
 anxiety among dental students have been frequently described in the literature and could 
 be a sign of silent problems , such as sexual harassment situations , which are usually 
 not reported by the involved subjects . taking into account the documented instances of sexual harassment in the health care 
 professions , medical , 
 dental , nursing , and physical therapy schools should develop programs to educate 
 students about this problem . it is essential to help dental students understand what 
 sexual harassment is and what kind of behaviors are tolerated , to clarify what they can 
 do individually in order to reduce the probability of experiencing sexual harassment , 
 and to suggest ways to respond if they do find themselves or another individual in a 
 situation in which sexual harassment is occurring . sexual harassment awareness programs 
 have been developed in medical and 
 dental schools in the united 
 states , and could serve as models for other countries where training programs focusing 
 on sexual and cultural discrimination and harassment are still in their formative stages 
 in higher education institutions . such programs can prepare future professionals to be 
 proactive in providing an appropriate protocol to use whenever they perceive sexual 
 harassment in the workplace . the findings of this study show the prevalence of sexual harassment among dental 
 students at one dental school in brazil . in order of frequency , the harassers were 
 reported to be the patients , relatives of patients and professors , as well as other 
 students . furthermore , it is important to arm students with the knowledge to be 
 proactive in creating an environment that minimizes the probability of sexual harassment 
 by having assertive definitions of acceptable behavior , learning how to anticipate 
 situations , and responding to sexual harassment when it occurs as well as reporting 
 these incidents to appropriate individuals in the dental school .
objectivesexual harassment is unlawful in all work and educational environments in most 
 nations of the world . the goals of this study were to describe the sexual 
 harassment prevalence and to evaluate the experiences and attitudes of 
 undergraduate students in one dental school in brazil.material and methodsan 18-item questionnaire was administered to 254 dental students with a completion 
 rate of 82% ( 208 ) . 
 students were requested to respond to questions about their 
 background and academic level in dental school , their personal experiences with 
 sexual harassment and their observation of someone else being sexually harassed . 
 bivariate statistical analyses were performed.resultsfifteen percent of the students reported being sexually harassed by a patient , by 
 a relative of a patient or by a professor . 
 male students had 3 times higher 
 probability of being sexually harassed than female student [ or=2.910 
 ( 1.113 - 7.611 ) ] . 
 additionally , 25.4% of the students reported witnessing 
 sexual harassment at the school environment . 
 the majority of students did not feel 
 professionally prepared to respond to unwanted sexual behaviors.conclusionthese findings demonstrate that sexual harassment can occur in a dental school 
 setting . 
 there is a need for ongoing sexual harassment education programs for 
 students and university staff . 
 increased knowledge of sexual harassment during 
 graduation can better prepare dental professionals to respond to sexual harassment 
 during their practice .