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Gender Differences in Veterans’ Perceptions of Harassment on Veterans Health Administration Grounds

  • Karen E. Dyer
    Correspondence
    Correspondence to: Karen E. Dyer, PhD, MPH, VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd (151), Los Angeles, CA 90073. Phone: (310) 478-3711; fax: (310) 268-4933.
    Affiliations
    VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
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  • Sharyn J. Potter
    Affiliations
    Department of Sociology, Prevention Innovations Research Center, University of New Hampshire, Durham, New Hampshire
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  • Alison B. Hamilton
    Affiliations
    VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California

    Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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  • Tana M. Luger
    Affiliations
    VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California

    Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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  • Alicia A. Bergman
    Affiliations
    VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
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  • Elizabeth M. Yano
    Affiliations
    VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California

    Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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  • Ruth Klap
    Affiliations
    VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California

    Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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      Abstract

      Purpose

      Stranger harassment at Veterans Health Administration (VA) facilities is prevalent, affecting one in four women veteran VA primary care users. Harassment interferes with health care quality and may result in veterans forgoing or delaying needed care. To better understand this phenomenon, gender-stratified discussion groups were held with men and women veterans. This article examines gender differences in veterans’ perceptions and experiences of harassment on VA grounds.

      Methods

      We conducted a total of 15 discussion groups at four VA medical centers, eight with men (n = 57) and seven with women (n = 38). Transcripts were coded using the constant comparative method and analyzed for overarching themes.

      Results

      Awareness of harassment was not uniformly high among participants. Although women voiced clear understandings and experiences of specific behaviors constituting harassment (e.g., cat-calls, sexual comments), many men expressed confusion about how to differentiate between harassment, “harmless flirting,” and general friendliness; they were unsure which behaviors “cross a line.” Furthermore, men placed the onus on women for setting boundaries, whereas women indicated it was not their responsibility to “train” men about acceptable behavior. Men and women agreed that VA staff hold primary responsibility for preventing and managing harassment.

      Conclusions

      Substantive gender differences in understandings of harassment exist among veteran VA users. To minimize harassment, veterans recommend education of men veteran VA users, and staff-oriented trainings. Privacy, safety, dignity, and security are the cornerstones of women veterans' health care, per VA policy. Harassment undermines these standards, impeding women's access to VA care and compromising both their health outcomes and health care experiences. Understanding harassment through a gendered lens is a critical step in designing comprehensive initiatives that respond to diverse viewpoints and experiences.
      Stranger harassment, also termed street or public harassment, refers to unwanted interactions occurring in public between strangers, and includes both verbal comments/catcalls and non-verbal behaviors such as following, staring, or touching (
      • Logan L.S.
      Street harassment: Current and promising avenues for researchers and activists.
      ,
      Stop Street Harassment (SSH)
      Unsafe and harassed in public spaces: A national street harassment report.
      ). These interactions usually target individuals based on their gender, gender expression, or sexual orientation (
      Stop Street Harassment (SSH)
      Unsafe and harassed in public spaces: A national street harassment report.
      , p. 1). Stranger harassment is prevalent in the United States, with 65%–81% of women experiencing harassment in their lifetime (
      Stop Street Harassment (SSH)
      Unsafe and harassed in public spaces: A national street harassment report.
      ,
      Stop Street Harassment (SSH)
      The facts behind the #MeToo movement: A national study on sexual harassment & assault.
      ). In fact, one-third of young women in a prevalence study reported an almost-daily occurrence of catcalls, whistles, or stares (
      • Fairchild K.
      • Rudman L.A.
      Everyday stranger harassment and women’s objectification.
      ). Although stranger harassment is more pervasive than nonstranger types such as workplace harassment (
      • MacMillan R.
      • Nierobisz A.
      • Welsh S.
      Experiencing the streets: Harassment and perceptions of safety among women.
      ), there is limited legal recourse (
      Stop Street Harassment (SSH)
      Unsafe and harassed in public spaces: A national street harassment report.
      ).
      Negative psychological, social, and physical impacts of stranger harassment are well-documented, and include depression, anxiety, trauma symptoms, self-objectification, sleep disorders, stress, fear, decreased feelings of safety, restricted freedom of movement, and relationship difficulties (
      • Fairchild K.
      • Rudman L.A.
      Everyday stranger harassment and women’s objectification.
      ,
      • Logan L.S.
      Street harassment: Current and promising avenues for researchers and activists.
      ,
      • Miles-McLean H.
      • Liss M.
      • Erchull M.J.
      • Robertson C.M.
      • Hagerman C.
      • Gnoleba M.A.
      • Papp L.J.
      “Stop looking at me!”: Interpersonal sexual objectification as a source of insidious trauma.
      ,
      Stop Street Harassment (SSH)
      Unsafe and harassed in public spaces: A national street harassment report.
      ,
      Stop Street Harassment (SSH)
      The facts behind the #MeToo movement: A national study on sexual harassment & assault.
      ). Frequent sexual objectification can result in cumulative negative effects over time (“insidious trauma”) with outcomes similar to more severe, one-time traumatic events such as sexual assault (
      • Miles-McLean H.
      • Liss M.
      • Erchull M.J.
      • Robertson C.M.
      • Hagerman C.
      • Gnoleba M.A.
      • Papp L.J.
      “Stop looking at me!”: Interpersonal sexual objectification as a source of insidious trauma.
      ).
      • O’Neill A.
      • Sojo V.
      • Fileborn B.
      • Scovelle A.
      • Milner A.
      The #MeToo movement: An opportunity in public health?.
      have framed sexual harassment as a public health problem because it provokes chronic stress that raises risk for a host of physical and mental health ailments, including cardiovascular disease, hypertension, obesity, anxiety, depression, and post-traumatic stress disorder.
      Given that targets of harassment are disproportionately women, and harassers are disproportionately men (
      Stop Street Harassment (SSH)
      The facts behind the #MeToo movement: A national study on sexual harassment & assault.
      ), stranger harassment is an inherently gendered issue. However, limited research to date has explored potential gender differences in perceptions, subjective experiences, and impacts of stranger harassment. Examining gendered experiences of harassment is particularly relevant in the context of Veterans Health Administration (VA) health care. VA has historically served a predominantly male population but is undergoing a transition as more women enter the military and seek VA care after discharge (
      VA National Center for Veterans Analysis and Statistics
      Women veterans report: The past, present, and future of women veterans.
      ). Comprising 7% of the VA population, women are the fastest-growing group of U.S. veterans (
      VA National Center for Veterans Analysis and Statistics
      Women veterans report: The past, present, and future of women veterans.
      ). Although only 5% of stranger harassment occurs in medical settings (
      Stop Street Harassment (SSH)
      The facts behind the #MeToo movement: A national study on sexual harassment & assault.
      ), there is evidence of a much greater prevalence at the VA. Baseline data from a cluster randomized trial in VA women's primary care demonstrated that one-quarter of women veteran primary care users across 12 sites reported experiencing harassment by men veterans at the VA (25.2%; range, 10%–42%;
      • Klap R.
      • Darling J.
      • Hamilton A.
      • Rose D.
      • Dyer K.
      • Canelo I.
      • Yano E.
      Prevalence of stranger harassment of women veterans at veterans affairs medical centers and impacts on delayed and missed care.
      ). Experiencing harassment was associated with feeling unsafe or unwelcome at the VA, and missing or delaying health care (
      • Klap R.
      • Darling J.
      • Hamilton A.
      • Rose D.
      • Dyer K.
      • Canelo I.
      • Yano E.
      Prevalence of stranger harassment of women veterans at veterans affairs medical centers and impacts on delayed and missed care.
      ).
      Recent qualitative research has also found that women veterans experience the VA environment as unwelcoming to women and dislike being “surrounded by men” (
      • Cheney A.M.
      • Dunn A.
      • Booth B.M.
      • Frith L.
      • Curran G.M.
      The intersections of gender and power in women veterans’ experiences of substance use and VA care.
      ,
      • Kehle-Forbes S.
      • Harwood E.
      • Spoont M.
      • Sayer N.
      • Gerould H.
      • Murdoch M.
      Experiences with VHA care: A qualitative study of U.S. women veterans with self-reported trauma histories.
      ). Women veterans who feel unwelcome at the VA are more likely to report delaying or forgoing needed health care in the prior year (
      • Washington D.L.
      • Bean-Mayberry B.
      • Riopelle D.
      • Yano E.M.
      Access to care for women veterans: Delayed healthcare and unmet need.
      ) or to drop out of VA care entirely (
      • Hamilton A.
      • Frayne S.
      • Cordasco K.
      • Washington D.
      Factors related to attrition from VA healthcare use: Findings from the national survey of women veterans.
      ). The VA may be particularly uncomfortable for women with a history of military sexual trauma, for whom the male-dominated environment may cue trauma-related distress and symptoms (
      • Gilmore A.
      • Davis M.
      • Grubaugh A.
      • Resnick H.
      • Birks A.
      • Denier C.
      • Acierno R.
      “Do you expect me to receive PTSD care in a setting where most of the other patients remind me of the perpetrator?”: Home-based telemedicine to address barriers to care unique to military sexual trauma and VA hospitals.
      ,
      • Miles-McLean H.
      • Liss M.
      • Erchull M.J.
      • Robertson C.M.
      • Hagerman C.
      • Gnoleba M.A.
      • Papp L.J.
      “Stop looking at me!”: Interpersonal sexual objectification as a source of insidious trauma.
      ). This finding is particularly concerning given that 49% of women veteran VA users who served during Operations Enduring Freedom and Iraqi Freedom report a military sexual trauma history (
      • Barth S.
      • Kimerling R.
      • Pavao J.
      • McCutcheon S.
      • Batten S.
      • Dursa E.
      • Schneiderman A.
      Military sexual trauma among recent veterans: Correlates of sexual assault and sexual harassment.
      ).
      Thus, the accumulating evidence strongly suggests that harassment can exacerbate gender disparities and inequities in VA health care (and elsewhere). Privacy, safety, dignity, and security are the cornerstones of women veterans' health care, per VA policy; however, these standards are undermined when a segment of the patient population finds the environment unwelcoming, unsafe, or necessary to avoid. On a broader level, harassment limits women's presence in public spaces, “where the work of politics and social change is most likely to take place” (
      • Logan L.S.
      Street harassment: Current and promising avenues for researchers and activists.
      , p. 197); thus, harassment may foster the “invisibility” of women veterans in the VA, which has implications for resource allocation and equal access to comprehensive care. After learning of the prevalence of harassment reported by women veterans in 2015, before the start of the #MeToo movement, leaders in VA's Office of Women's Health Services (WHS) commissioned a project with the overarching aim of piloting and evaluating interventions to reduce harassment (
      • Klap R.
      • Darling J.
      • Hamilton A.
      • Rose D.
      • Dyer K.
      • Canelo I.
      • Yano E.
      Prevalence of stranger harassment of women veterans at veterans affairs medical centers and impacts on delayed and missed care.
      ). To lay the foundation for this initiative and to inform future efforts to address harassment, our team conducted a series of discussion groups with men and women veteran patients that sought to examine gender differences in perceptions, understandings, and experiences/observations of harassment on VA grounds.

      Methods

       Study Setting and Sample

      We conducted a series of gender-stratified discussion groups with men and women veterans at four Veterans Affairs Medical Centers nationwide. Men and women veterans who had ever used VA care were eligible to participate. After local site agreement, recruitment flyers were posted throughout medical center common areas. Participants were also recruited by word of mouth.
      Fifteen discussion groups were conducted between May and July 2016 (eight men's groups and seven women's groups). Groups were conducted by site and scheduled at times that were convenient for veterans. Fifty-seven men and 38 women participated overall (n = 95). On average, discussion groups included six to eight participants each (range, 2–9) and lasted 90 minutes.

       Measures and Procedures

      The study team developed a semistructured moderator's guide with probes that were informed by results from
      • Klap R.
      • Darling J.
      • Hamilton A.
      • Rose D.
      • Dyer K.
      • Canelo I.
      • Yano E.
      Prevalence of stranger harassment of women veterans at veterans affairs medical centers and impacts on delayed and missed care.
      survey of women veteran VA patients, in which women provided extensive open-ended responses about the types of harassment they had experienced on VA grounds. Clinical and research experts reviewed and refined the guide before use. Broadly, questions were designed to elicit patient narratives about 1) their experience and comfort level seeking VA health care, 2) incidents of harassment they had observed or personally experienced at their VA facility, 3) their reaction/response to these incidents, and 4) recommended strategies for addressing harassment. Self-reported sociodemographic information was also collected.
      Staff scheduled discussion groups and site representatives facilitated local approvals and reserved conference rooms. Ground rules for discussion were established at the beginning of each session. Participants were asked not to use last names and reminded that we were interested in everyone's insights and differing perspectives. Specifically, they were told: “Some people naturally tend to talk more than others, but in this limited time we want to hear from everyone, so please don't be offended if I ask someone else to speak up when you indicate that you have something more to share.” After moderators posed general questions about the VA environment of care and how veterans interact at the VA, participants were asked about specific behaviors they may have witnessed or experienced, such as whistling, unsolicited comments, staring or watching, or following. To provide context for the men's groups, participants were told that there has been an increase in the number of women serving in the U.S. military over the past 20 years and a resulting increase in the number of women seeking care at VA; thus, the VA wants to provide care for women veterans in safe and welcoming facilities. Light refreshments were served, and each nonemployee veteran participant received a $50 gift card. The moderators met after each session to debrief and document their observations. WHS provided a determination of nonresearch, indicating that the project was a quality improvement activity. As a result, participants were not required to sign consent forms for the study, but did consent to audio-recordings.

       Data Analysis

      All sessions were audio-recorded and transcribed verbatim. Before formal coding, transcripts were read and summarized by topic by one of the authors (A.B.;
      • Hamilton A.B.
      Qualitative methods in rapid turn-around health services research.
      ). De-identified transcripts were imported into ATLAS.ti (v.7) for coding and analysis. The team developed a preliminary codebook incorporating both a priori and inductive codes. Two qualitative researchers (K.D. and T.L.) coded the transcripts using the constant comparative method (
      • Miles M.B.
      • Huberman A.M.
      Qualitative data analysis: An expanded sourcebook.
      ), with particular attention to comparisons of men's and women's responses. Coding was consensus based, and discrepancies were resolved through meetings and dialogue. Coded segments were then sorted by category and analyzed for overarching themes. Participant sociodemographic data were summarized in Stata Version 13 (StataCorp, College Station, TX).

      Results

      Participant sociodemographic characteristics are summarized in Table 1. On average, men were 56 years old and women were 51. The majority of participants self-identified as either Caucasian or African American, had completed at least some college education, were not working (owing to disability, unemployment, or retirement), and had a service-connected disability. One-third reported being married or partnered.
      Table 1Participant Sociodemographic Characteristics (n = 87)
      Overall participant N is 95; however, demographic information was not collected for one men's group (eight participants).
      VariableWomen (n = 38)Men (n = 49)
      n (%)n (%)
      Age, mean years (SD)51 (1.7)56 (1.8)
      Race
       White/Caucasian21 (55)32 (65)
       African American14 (37)14 (29)
       Other3 (8)3 (6)
      Relationship status
       Married or partnered12 (32)17 (35)
       Divorced or separated18 (47)18 (37)
       Never married8 (21)14 (29)
      Highest level of education
       High school or less2 (5)8 (16)
       Technical/trade1 (3)4 (8)
       Some college or associate's degree16 (42)15 (31)
       Bachelor's degree10 (27)15 (31)
       Postgraduate training8 (22)7 (14)
      Employment
       Working full or part time13 (36)8 (17)
       Disabled and not working7 (19)13 (27)
       Unemployed and looking for work11 (31)17 (35)
       Retired5 (14)10 (21)
       Student
      Student status is not mutually exclusive to other types of employment status.
      6 (17)8 (17)
      Self-rated health status
       Excellent2 (6)4 (8)
       Very good9 (25)11 (23)
       Good16 (44)12 (25)
       Fair8 (22)16 (33)
       Poor1 (3)5 (10)
      Service-connected disability24 (67)37 (77)
      Visit with mental health provider in past year28 (76)44 (92)
      Overall participant N is 95; however, demographic information was not collected for one men's group (eight participants).
      Student status is not mutually exclusive to other types of employment status.
      Four thematic areas arose from discussions: 1) gendered interpretations of harassment, 2) perceived prevalence of harassment, 3) experiences of harassment, and 4) suggestions for addressing harassment. As reflected in Table 2, the following sections highlight both areas of divergence and convergence between men's and women's perspectives, illustrating the powerful ways that gender shapes perceptions and experiences of harassment. Some quotations were minimally edited for readability (e.g., removing utterances such as “um” and “uh”).
      Table 2Gendered Connections Between Overarching Themes
      Primarily among WomenAreas of Overlap between Women's and Men's ResponsesPrimarily among Men
      Definitions
      • Harassment = specific behaviors, comments
      • Considered unwelcome at the VA
      • Lack of understanding, empathy on part of men
      • Sometimes a matter of interpretation
      • Regional differences in meaning of terms (e.g., “baby,” “honey”)
      • Tied to military norms that influence VA culture
      • Biological explanations
      • Often unintentional
      • Overt touching and sexual comments recognized as harassment
      • Confusion, ambiguity about what harassment is: harmless flirting or harassment?
      • Fear of being wrongly accused
      • Shifting social norms, gender role expectations (“times are changing”)
      Perceived prevalence
      • Pervasive problem experienced at VA and elsewhere
      • Almost all women had experienced and/or witnessed harassment
      • Inevitable, contributing to a sense of powerlessness
      • Prevalence of harassment dismissed/downplayed
      • Some but not all men had witnessed harassment
      Experiences
      • Frequent experiences of touching, offensive comments, catcalls, whistles, stares
      • Treated like second-class veterans
      • Used strategies like dressing down to minimize attention
      • Women’s clothing choice is frequently the cause

       Gendered Interpretations of Harassment

      Gendered perspectives were clearly evident in how participants conceptualized what harassment is and how they explained its existence. Drawing on their daily lived experience, women veterans readily identified comments and behaviors they considered harassing or offensive, such as being touched, gawked at, or subjected to catcalls, whistles, or uncomfortable stares. They commented that men are “clueless” about sexual harassment and often unaware that their behavior and comments could be considered offensive or sexist. For example:There's all sorts of confusion [among] the men, some honestly think they're being really nice. (women's group)I'm telling you these people [men], they don't even know that they're harassing people. Then when you tell them, it doesn't really matter to them because every other person around them also thinks it's okay. (women's group)
      At the same time, women generally acknowledged that people interpret comments and behavior differently. For example, terms like “baby” or “honey” are commonly used to address strangers in certain U.S. regions, but can be considered offensive in others. The lack of a consistent definition or understanding of harassment was thus seen to complicate efforts to combat it.Everyone is harassed differently and everyone distinguishes between the different harassments. So what's harassment to you might not be harassment to me, you know. (women's group)
      Thus, women voiced relatively clear understandings of how harassment is defined, yet allowed for potential subjectivity in interpretation, even providing examples of situations more prone to differing interpretations—such as the terms “honey” or “baby.” In contrast, discussion in men's groups reflected significant confusion and ambiguity in defining harassment and how it differs from “harmless flirting” or general friendliness. Men often distinguished between what they regarded as overt and subtle forms of harassment. The overt forms were characterized by unwanted touching or other “black-and-white” aggression, such as following or stalking, and easily identifiable as harassment. Yet, for most participants in the men's group, challenges arose with what they regarded as more “subtle” behaviors, like greetings, stares, or whistles—specifically how to understand or label these behaviors.See, the thing about it is it depends on the person. Because nowadays you say hi to a girl, they might consider that as harassment even though it's not harassment…Because we really don't know. I myself, I don't know. You'll say hi, she might take it the wrong way because I was looking up and down at her but that I'm saying hi, maybe just looking at her shoes. (men's group)I think it's a little difficult because everybody's lines are different, everybody's interpretation of what sexual harassment is—it changes depending on the person. There's a lot of things that are really obvious and stand out, the more over-the-top stuff, but a lot of times it can be subtle. (men's group)
      As a specific example, a man telling a woman to smile provoked very different responses. Generally, men regarded it as unproblematic, whereas women expressed disapproval.I might say [to a stranger], “Hey, you look very nice today. Are you happy? Why don't you smile?,” something like that. Then they'll laugh, take that sad look away and that sour feeling in their heart. (men's group)I don't know how many times—well, you know, “You should smile, you should smile,” and I just look at them like—and just keep going. I'm not negative toward them or anything. I just keep going. (women's group)
      Men pointed to shifting social norms and generational differences surrounding gender expectations, roles, and expected behavior, which added to their confusion.[M]any of the very old veterans have a completely different view of what women's roles are going to be. Boy, when they start talking to each other in the visiting rooms, it's obvious…World War II vets, it's not above them to say a comment to a younger woman in the visiting rooms that's really inappropriate by today's standards. But I don't know how you're going to change that, it's a social issue. (men's group)
      Participants in all men's groups pointed out that some women like being complimented, and people's reactions to attention are different. Thus, men often described women's responses as “unpredictable”; whereas some women might perceive male advances as harassment, men believed that others might welcome or even seek out the attention.Some women are perfectly fine to be approached a certain way, talked to a certain way, and others may have different standards altogether. They may be intimidated, they may be put back by some behaviors that others would consider kind of innocuous. It's kind of difficult…where do you draw the line in terms of, well, “I'm going to report this or I'm going to go to somebody on this?” (men's group)There's got to be a line somewhere. Like, for instance, if he said, “Wow, your lower half looks great in that dress,” that's obviously inappropriate. But if he said “Wow, those glasses are really cool,” I mean you're technically complimenting her but there have actually been cases like that where they claimed harassment. (men's group)
      Men frequently observed that many women veterans have trauma in their past, potentially sparking more extreme reactions than what they believed was warranted. Several women did note that being harassed can trigger them because of prior sexual trauma experienced in the military; however, some men implied that women without a trauma history would not be bothered by the attention, or might even like it, and that potential mental health issues are the only reason for women veterans’ disapproval. In this context, many men expressed a degree of defensiveness that “innocent” behaviors might be unjustly construed as harassment, leaving them vulnerable to social, financial, or legal repercussions. They repeatedly expressed fear of being wrongly accused by “oversensitive” or dishonest women.Because of the way society is, it's sort of like we [men] have to defend ourselves… We're looked at like the enemy. (men's group)They just keep making laws that protect women and I feel that that's good too, but…sometimes things do get, you know, over-exaggerated. It's a shame but that does happen too. (men's group)
      There was at least one participant in nearly every men's group that voiced a desire to learn about which behaviors do and do not constitute harassment, and many men seemed open to assessing their own beliefs. This desire was reflected in genuine questions about the acceptability of certain behaviors; for example, one man asked, “As far as greeting them with a good morning, is that bad?” (men's group). Another reflected:I've got something to think about seriously, about my behaviors, the way I talk, the way I look at women, and all that. (men's group)
      Participants in the women's groups (and to a lesser extent, the men's groups) tied the prevalence of sexual harassment on VA grounds to social norms established in the military, believing that the VA is an extension of a male-dominated military culture characterized by pervasive sexism. Women explained:When you come here as a veteran, all these people get together and they remember what it’s like to be in the military, and they lose their civilian bearing…They like bringing up the old stuff, and then you revert back to when you were younger and you used to say all these things to women that are inappropriate because you're around a bunch of other men that are the same age. (women's group)
      At the same time, VA culture was seen by some participants to be slowly shifting and evolving:I think younger people [are] a little bit more aware [of sexual harassment as a problem]. So it's kind of like starting culturally. But the culture of the military, it's a very big ship that's hard to shift. It's a slow shift. (men's group)I think [the VA] is doing a better job as far as having posters with female veterans and at least make it more clear, if the news isn't clear enough, that there are women that are serving this country, that deserve the same treatment and respect that we as men want. (men's group)
      Some women's comments reflected a sense of inevitability, and thus powerlessness: “There's nothing you can do about it because, basically, it's a man's world—or it's a man's hospital” (women's group). Similarly, both men and women expressed the belief that men are biologically more sexually lustful than women and “hard-wired” toward sexual conquest:These men are looking for girls, women, and whoever. They're on the hunt. You know, men are hunters so they're hunting you every day. (women's group)Well, that's the male instinct or the dominant…guys are guys, I suppose. They get horny and they don't care if it's your grandmother, mother, daughter, sister. They don't care. (men's group)

       Perceived Prevalence of Harassment

      The majority of women veterans reported either personally experiencing harassment or witnessing harassment of other women veterans or VA staff by men on VA grounds. They described explicit incidents and personal impacts, which ranged from minimal effect to extreme distress, depending on the characteristics of the woman describing harassment and the nature of the incident. Although participants in one women's group reported never observing or experiencing harassment on VA grounds, in all other women's groups, most participants regarded it as a pervasive problem and often worse than what they experienced in other public places. As one woman noted: “Every day, every time you come here” (women's group). Others remarked:There's a bunch of guys [in the hospital lobby] that feel the need to make a pass at you every time you walk by. And if you say hi to somebody, it seems like it leaves your lips as “hi,” but by the time it gets to their ear it's like, “Oh, she wants some of this.” No, I was just being respectful. (women's group)Participant 1: “If you come to this VA, you've experienced [harassment].” Participant 2: “Anyone, any VA.” (women's group)
      Men's responses were more varied. There were participants in nearly every men's group who had witnessed and/or heard about harassment at the VA, often describing incidents experienced by loved ones, other patients, or women VA staff. Some men also argued with other participants whose comments they felt crossed a line. However, others either dismissed or downplayed its existence or impact; more than one-half responded that they had never witnessed harassment toward women veterans. Many argued that the situation is no worse than outside the VA, in direct contrast with what many women expressed.Everybody [here] treats everybody with the utmost respect. And we never had—I've never known a woman to complain about a man here or a veteran here sexually harassing them. (men's group)I have seen females on the campus who are attractive and men will talk to them, but I've never seen them harass them. (men's group)
      Importantly, both men and women participants described harassment incidents that took place in front of VA staff who then ignored the behavior. A participant in one of the men's groups described staff observing harassing behavior without intervening: “Everybody saw it, everybody was staying out his way” (men's group). Another noted that staff may be hesitant to intervene due to fear of retaliation:The staff, basically, I would say security and line staff or people just walking the hallways, are I think a bit hesitant because rules and policies of engagement between staff members and public about how do you best approach this…That person can turn around and write you up, or perhaps turn that conversation into a different direction, where it's your word against that person's…So people take an attitude as though they're going to protect their jobs. (men's group)

       Experiences of Harassment

      Women's experiences of harassment at the VA generally fell into two broad categories: sexual and status-related. Regarding the former, women described incidents of inappropriate touching, offensive comments, catcalls, whistles, and stares by male patients. With status-related harassment, women reported that their veteran status was frequently questioned and undermined. Women were often treated like “second-class veterans” by both patients and staff, or were assumed to be wives of veterans visiting the hospital rather than patients themselves.Participant 1: “And then there are the men that don't appreciate women in the military that talk down.” Participant 2: “Yeah, yeah [in the waiting rooms] they'll have a conversation about whether women should be in the military or not and I've been exposed to some of those conversations, more than once. They don't believe we have a stand here, that we belong here. This is their hospital, not ours.” (women's group)Participant 1: “I saw this lady sitting in a wheelchair, she was resting in a wheelchair, and this male DAV rider/driver came up to her and said ‘You can't sit there. That's only for veterans.’ And she goes, ‘I am a veteran.’ She was just sitting there. And I couldn't believe that. I was like, that was just horrible.”Participant 2: “A lot of times the male veterans just say, ‘You're not a veteran. Why are you here? Whaddaya doing here? Is your husband here?’ [others voice agreement].” (women's group)
      Similarly, they described the invisibility of women veterans in the larger VA culture, and the lack of symbols and imagery related to their military service:For me, even coming in the front doors, men and women both served in the military; however, all the pictures on the wall, all the statues you see are men. There's no welcoming atmosphere where women know that we have a place here also. That bothers me, because I know that my fellow sisters from the different branches, we know we put on those boots, and we know some of us went through hell wearing that uniform. (women's group)
      Women described specific coping strategies they use to avoid harassment at VA, such as “dressing down” and disguising their hair with hats (e.g., the “VA uniform”), exclusively attending women-only health clinics, ignoring harassers, and in some instances, confronting or engaging them. As one woman stated, “Yeah, I know not to wear shorts, no spaghetti straps, no tank tops. You cover yourself” (women's group). Another explained:I just kind of avoid men, as best I can. You can kind of tell when that kind of stuff is brewing inside of them, so if I sense it, I'll move away. I definitely wear headphones to avoid unwanted conversation or hearing things I don't want to hear. I sit by myself or in groups of women so that men don't come and sit beside me. It's just like proactive avoidance of them. (women's group)
      Ironically, although these women actively changed clothing to avoid harassment, men (and some women) argued that women brought harassment upon themselves through their clothing choices. In men's groups, clothing was almost always invoked to challenge a woman's right to complain about unwanted male attention. One man asserted:I respect all women but you know sometimes the way some women dress today, they almost ask for it and I'm not being disrespectful, but some women really dress provocatively today. They don't care, they must not care, they know how they look because they look in the mirror a hundred times before they leave the door…They've got to know you've got some responsibility here too. (men's group)
      However, the role of women's dress, or more broadly women's responsibility in provoking harassment, was a contested topic; many participants challenged the idea that clothing contributes to or excuses harassment and saw it as a form of victim blaming. This is reflected in the following exchange between two women:Participant 1: “[So if a woman] comes in here with her titties hanging out—” Participant 2: “She should be able to wear anything she wants—” Participant 1: “She's going to get harassed.” Participant 2: “No. That's like telling a woman if she dresses a certain way to go to church, she's causing a man to lust, and I think that's just bullshit.” (women's group)

       Suggestions for Addressing Harassment

      Table 3 contains quotes illustrating areas of agreement and difference between men and women participants in their suggestions for addressing harassment. Overall, both men and women attributed primary responsibility to hospital staff and VA leadership for minimizing harassment on VA grounds and creating a safe environment for care. Participants did not believe it was patients' role to police other patients' behavior. Other points of convergence between men and women regarding ways to address harassment included stricter enforcement of codes of conduct (either existing or new), more consistent consequences and accountability, and improved reporting avenues. Many participants related the frequency of harassment at the VA to a lack of accountability. They also critiqued the lack of transparency in the reporting process and its perceived ineffectiveness, expressing confusion about how or with whom to report an incident. Participants were skeptical that reporting would result in a satisfactory solution, and several women's groups pointed to possible retaliation or negative repercussions for the complainant: “there is this constant low-level fear of retaliation” (women's group). Several groups called for a greater police presence, although some women were concerned about the effectiveness of VA police with this particular issue.
      Table 3Suggestions for Addressing Harassment: Areas of Agreement and Difference Between Men and Women
      StrategyMen's ExamplesWomen's Examples
      High agreement between men and women
       A.1. Ultimate responsibility for addressing harassment attributed to staff and leadership“Staff has to enforce the rules in which we are all governed by according to policy and procedure and, if staff doesn't do their job, they can't expect us to help them do their job…Staff is the only [people] that has the power to take action against a veteran when they're inappropriate.” (men's group)

      “I think both sides of the party, whether it's women or men, know their boundaries. They try to extend those maybe a little bit too much. But I think ultimately staff are the ones who either allow it or disallow it…Because I mean we're veterans and some of us are a little—we've got issues and sometimes we're not conscious of our behavior. And staff needs to put us in check in a nice way…But that's a staff problem.” (men's group)
      “Women who [live] in [VA] residency programs are totally vulnerable and have to get their care here, [staff] has to be the first line of protection.” (women's group)

      “They need to get rid of staff that's not doing their job. If they're not protecting the patients and not providing them with patient care, and that means a safer environment, they don't need to be employed here, period.” (women's group)

      “… it's really up to the employees here to take a greater stance and be involved versus the patient.” (women's group)
       A.2. Stricter enforcement of codes of conduct

      Consistent consequences and accountability

      Improved reporting venues
      “Veterans in a way know they're safer here than they are on the outside, because on the outside the police and the public will deal with them immediately while here on the inside there's an incredible tolerance of behavior.” (men's group).“The issue is, how do we make a complaint when we're not sure who the person is?...If I'm walking in the hallway, and an offender says something and I want to make a complaint, whose name am I going to put?” (women's group)
      Mixed views among men and women
       B.1. Mixed support for role of VA Police in addressing harassment“We don't know if that person's going to explode or have a weapon or what have you. So the way to quickly subvert that is to have someone you can go to. Again, all patients know who that is, where that is and instead of going directly to that person you call a fireman, you call the police.” (men's group)

      “if you're going to say something, you need to say it really briefly and you just say, ‘Look, I'll call the police.’ That's really all you can do.” (men's group)
      Because VA police are often men veterans themselves, “they stick together” (women's group) and tend to overlook incidents of harassment.

      “You file a complaint yourself at the police station over here on campus. You can go to them and give them a description, ‘This guy, such-and-such, he was sitting over here,’ he could more than likely still be at this.” (women's group)

      “They have police here, so if somebody's physically threatening another resident, and the staff doesn't do anything, then I think then the patient should call the police.” (women's group)
      Differences between men and women
       C.1. Men generally placed the onus on women to set boundaries, while women underscored the importance of educating men.

      However, women wanted guidance on how to respond to harassment safely and effectively.
      “From the experiences that I have knowledge about, female veterans are very well capable of managing and handling themselves. When a veteran says something out of line to them, their responses have been proactive – they put him in his place.” (men's group)“It's really not our responsibility to make sure that men aren't harassing us.” (women's group)

      “With all the awareness that's out there today [about sexual harassment] there should be more, maybe instructional classes about it for male veterans because they never really had to pay attention to it before.” (women's group)

      Participant 1: “Teach us, like, how to be stronger when somebody does harass us and how to address the situation”…Participant 2: “Yeah, it takes me a couple hours to think of something to say.” (women's group)
       C.2. Women tended to appeal to veterans' common military experience, shared identity, and connection.“[There is] this camaraderie in the military and you're at war and you fall and your partner carries you, so if they're going to carry you in war, why can't they carry you when you're not in a war?” (women's group)

      “What I think the men need to learn is that we're not female veterans, we're veterans.” [emphasis added] (women's group)
      Several important distinctions emerged between men's and women's groups. Men generally placed the onus on women to set behavioral boundaries with harassers, noting that women veterans are “tough” and “can handle themselves”. Many seemed to regard men's participation in harassment as fairly innocent and well-intended (e.g., harassers are unaware of their actions or believe that women actually like it), and rarely suggested sexual harassment training as a solution.
      Alternatively, many women underscored the importance of directly educating men patients about what constitutes inappropriate behavior. Women veterans themselves, however, generally did not feel prepared to nor the desire to bear the responsibility for training men about acceptable behavior. Nor did they feel women should be expected to put up with inappropriate behavior, especially while they are at a hospital receiving health care. Many women voiced a desire for coaching on how to personally respond to inappropriate comments and behaviors; they described being at a loss for words in the moment or unsure how to respond effectively and safely.
      Finally, women advocated appealing to veterans’ common military experience, shared identity, and connection beyond gender: for example, reminding men that all veterans are “brothers-and-sisters in arms” and “like a family” with camaraderie, respect, honor, and support. These women believed that reminding men of the “higher ideals” that drew them to the military in the first place would potentially defuse territoriality or the perception of some men that women veterans take away valuable VA resources.

      Discussion

      This article presents men and women veterans' perceptions and experiences of harassment on VA grounds. Extending survey findings by
      • Klap R.
      • Darling J.
      • Hamilton A.
      • Rose D.
      • Dyer K.
      • Canelo I.
      • Yano E.
      Prevalence of stranger harassment of women veterans at veterans affairs medical centers and impacts on delayed and missed care.
      , the majority of women participants described either observing or experiencing harassment by men at the VA, and many men participants confirmed its existence. However, meaningful differences arose in how men and women understood harassment, its sources, and its consequences. Women voiced relatively clear understandings and opinions about specific behaviors constituting harassment, whereas knowledge and attitudes expressed in men's groups were more varied and reflected widespread confusion about the norms and boundaries of appropriate behavior. Although women acknowledged that interpretation can be subjective, this leeway differed in nature from the sense of confusion, and occasionally frustration and fear, that characterized many men's responses. Men frequently observed that women's reactions to men's attention are subjective and individual; thus, men reported difficulty assessing what behavior might cross a line and some expressed defensiveness about being stereotyped or unfairly accused of harassment by “oversensitive” or “dishonest” women, especially those they perceived to have histories of trauma.
      Behaviors considered more “subtle,” and thus more ambiguous, presented the greatest confusion and lack of consensus among male participants, versus overt behaviors that are easily identifiable as harassment (e.g., unwanted touching). This finding echoes prior research demonstrating that men perceive a narrower range of behaviors as constituting sexual harassment than do women (
      • Gordon A.
      • Cohen M.
      • Grauer E.
      • Rogelberg S.
      Innocent flirting or sexual harassment? Perceptions of ambiguous workplace situations.
      ,
      • Herrera M.C.
      • Herrera A.
      • Expósito F.
      Stop harassment! Men’s reactions to victims’ confrontation.
      ), with more ambiguous behaviors accounting for the greatest gender differences in interpretation (
      • Rotundo M.
      • Nguyen D.
      • Sackett P.
      A meta-analytic review of gender differences in perceptions of sexual harassment.
      ). The issue extends beyond patients: in a recent study investigating patient-perpetrated violence in a VA health care system, employees themselves were unsure about which behaviors constituted harassment or abuse and should be reported (
      • Purcell N.
      • Shovein E.
      • Hebenstreit C.
      • Drexler M.
      Violence in a U.S. Veterans Affairs healthcare system: Worker perspectives on prevalence, causes, and contributors.
      ).
      Several authors have attempted to explain why such ambiguity and varying interpretations of harassment exist by arguing that it reflects larger societal forces underlying gender and the social functions that harassment serves. In a linguistic analysis of differing interpretations of “street remarks” as greetings versus harassment,
      • Bailey B.
      Greetings and compliments or street harassment? Competing evaluations of street remarks in a recorded collection.
      argues that street remarks serve to perpetuate male dominance of women in public spaces, and are effective precisely because of their ambiguity. He notes that “in many cases in which men and women give contrasting interpretations of communicative behavior, it is not a matter of interpretation but of power differentials and struggles” (p. 371). Although the literal content of most street remarks in Bailey's study was relatively benign, he argues that in contexts of gender inequality, they represent attempts to engage women “in ways that violate the ground rules of civil interaction,” specifically the American social norm of not addressing strangers as intimates (
      • Bailey B.
      Street remarks to women in five countries and four languages: Impositions of engagement and intimacy.
      , p. 597). For example, although there is regional variation in accepted forms of address, as some of our participants noted, addressing a stranger with a term of endearment usually signifies the subordinate status of the addressee. The unspokenness of this norm can make it difficult for women to articulate with precision why street remarks are offensive or bothersome, and Bailey cautions that framing their meaning merely as matters of interpretation “diverts attention from the ways in which they exercise and reproduce male power over women” (
      • Bailey B.
      Greetings and compliments or street harassment? Competing evaluations of street remarks in a recorded collection.
      , p. 371).
      Similarly, a number of authors (
      • Berdahl J.L.
      Harassment based on sex: Protecting social status in the context of gender hierarchy.
      ,
      • Fairchild K.
      • Rudman L.A.
      Everyday stranger harassment and women’s objectification.
      ) have argued that stranger harassment is an attempt to maintain a dominant social status that is threatened; this sheds light on women veterans’ frequent experience of comments denigrating their veteran status and observation that some men veterans are territorial of VA resources. Others have argued that harassment functions more broadly to enforce traditional gender norms, targeting anyone who deviates from either prescribed feminine or masculine roles (
      • Franke K.
      What’s wrong with sexual harassment?.
      ,
      • Street A.E.
      • Gradus J.L.
      • Stafford J.
      • Kelly K.
      Gender differences in experiences of sexual harassment: Data from a male-dominated environment.
      ). What is clear from our findings is that men veterans often have little understanding of what “benevolent sexism” is nor how they reproduce it within VA settings. Benevolent sexism refers to judgments of women that seem positive on a surface level, but ultimately promote gender inequity because they reflect and perpetuate traditional gender roles and stereotypes (
      • Glick P.
      • Fiske S.T.
      The ambivalent sexism inventory: Differentiating hostile and benevolent sexism.
      ). Women offended by harassing comments or behavior are often faulted for being overly sensitive or emotional (
      • Logan L.S.
      Street harassment: Current and promising avenues for researchers and activists.
      ). Indeed, some men in our study seemed to perceive women, particularly those with trauma histories, as particularly fragile and thus prone to misinterpreting their “well-intentioned” comments.
      These arguments on the social functions of sexual harassment align with recent work on microaggressions, which are based on the proposition that the “manifestation of prejudice and discrimination has changed over the decades from a predominantly overt form to a more subtle, subvert form” (
      • Nadal K.
      • Davidoff K.
      • Davis L.
      • Wong Y.
      • Marshall D.
      • McKenzie V.
      A qualitative approach to intersectional microaggressions: Understanding influences of race, ethnicity, gender, sexuality and religion.
      , p. 147; see also
      • Sue D.W.
      Microaggressions in everyday life: Race, gender and sexual orientation.
      ). Microaggressions related to gender are defined as “intentional and unintentional insults, invalidations, and assaults based on gender [that are] most frequently perpetrated against women and girls” (
      • Gartner R.E.
      • Sterzing P.R.
      Gender microaggressions as a gateway to sexual harassment and sexual assault: Expanding the conceptualization of youth sexual violence.
      , p. 492).
      • Gartner R.E.
      • Sterzing P.R.
      Gender microaggressions as a gateway to sexual harassment and sexual assault: Expanding the conceptualization of youth sexual violence.
      consider these chronic, low-severity acts to occupy one end of the sexual violence continuum; they function as potential gateway mechanisms to more violent offenses and foster a permissive culture normalizing gender-based violence and the sexual objectification of women and girls. Research has found microaggressions to be “equally impactful” on physical and mental health as higher-severity acts (
      • Nadal K.L.
      • Haynes K.
      The effects of sexism, gender microaggressions, and other forms of discrimination on women’s mental health and development.
      ) because of the psychosocial stress imposed by chronic exposure (
      • Gartner R.E.
      • Sterzing P.R.
      Gender microaggressions as a gateway to sexual harassment and sexual assault: Expanding the conceptualization of youth sexual violence.
      ).
      These arguments are relevant when considering the VA health care context. Higher levels of sexual harassment occur in traditionally male-dominated, hierarchical occupations (
      • Buchanan N.
      • Settles I.
      • Hall A.
      • O'Connor R.
      A review of organizational strategies for reducing sexual harassment: Insights from the U.S. military.
      ,
      • Fitzgerald L.F.
      • Magley V.J.
      • Drasgow F.
      • Waldo C.R.
      Measuring sexual harassment in the military: The sexual experiences questionnaire (SEQ-DoD).
      ,
      • Street A.E.
      • Gradus J.L.
      • Stafford J.
      • Kelly K.
      Gender differences in experiences of sexual harassment: Data from a male-dominated environment.
      )—such as the military and, perhaps by extension, the VA (
      • Cheney A.M.
      • Dunn A.
      • Booth B.M.
      • Frith L.
      • Curran G.M.
      The intersections of gender and power in women veterans’ experiences of substance use and VA care.
      ). Both men and women participants in our study linked harassment at the VA to the military culture experienced and “re-created” by veterans, which is further shaped by generational, service era, and regional differences.
      • Cheney A.M.
      • Dunn A.
      • Booth B.M.
      • Frith L.
      • Curran G.M.
      The intersections of gender and power in women veterans’ experiences of substance use and VA care.
      argue that gender inequalities faced by active duty women are mirrored in their VA health care experiences. The comparatively low numbers of women in the VA render them invisible as “suffering subjects”; indeed, women in our study called attention to the lack of images and symbols of women's military service and veteran status. Simultaneously, their low numbers in the VA serve to exaggerate gender boundaries and differences, and facilitate men's perception of women veterans as sexualized and “exotic.”
      Some women tried to minimize harassment by “dressing down” for VA appointments, which echoes strategies that servicewomen use during active duty to reduce their risk of exposure to violence (
      • Cheney A.
      • Reisinger H.
      • Booth B.
      • Mengeling M.
      • Torner J.
      • Sadler A.
      Servicewomen’s strategies to staying safe during military service.
      ). As
      • Cheney A.
      • Reisinger H.
      • Booth B.
      • Mengeling M.
      • Torner J.
      • Sadler A.
      Servicewomen’s strategies to staying safe during military service.
      note, these strategies are effective in the short term by decreasing the immediate threat, but do not challenge victim blaming cultures that facilitate gender-based violence (indeed, victim blaming functions to maintain a gender hierarchy status quo;
      • Kay A.
      • Jost J.
      • Young S.
      Victim derogation and victim enhancement as alternate routes to system justification.
      ,
      • Spaccatini F.
      • Pacilli M.G.
      • Giovannelli I.
      • Roccato M.
      • Penone G.
      Sexualized victims of stranger harassment and victim blaming: The moderating role of right-wing authoritarianism.
      ). Further, these strategies are rooted in sexualized notions of women; eventually, women can come to “treat themselves as objects to be looked at and evaluated” (
      • Cheney A.
      • Reisinger H.
      • Booth B.
      • Mengeling M.
      • Torner J.
      • Sadler A.
      Servicewomen’s strategies to staying safe during military service.
      , p. 3). Sexual objectification facilitates dehumanization of the target (
      • Vaes J.
      • Paladino P.
      • Puvia E.
      Are sexualized women complete human beings? Why men and women dehumanize sexually objectified women.
      ), and is linked to greater acceptance of common rape myths. These myths are rooted in the idea that sexual violence is a crime of attraction and not power, and that women “ask for it” and are complicit in bringing it on themselves (
      • Cheney A.
      • Reisinger H.
      • Booth B.
      • Mengeling M.
      • Torner J.
      • Sadler A.
      Servicewomen’s strategies to staying safe during military service.
      ,
      • Gartner R.E.
      • Sterzing P.R.
      Gender microaggressions as a gateway to sexual harassment and sexual assault: Expanding the conceptualization of youth sexual violence.
      ,
      • Spaccatini F.
      • Pacilli M.G.
      • Giovannelli I.
      • Roccato M.
      • Penone G.
      Sexualized victims of stranger harassment and victim blaming: The moderating role of right-wing authoritarianism.
      ). These narratives were evident in our study, with many men and some women blaming harassment on women's dress choices, minimizing men's responsibility by blaming their biological make-up, or arguing that women are often oversensitive in interpreting comments.
      An interesting contradiction in our study is that, on the one hand, women attributed harassment to military culture, yet they simultaneously advocated referring to that culture in anti-harassment initiatives (e.g., “brothers-and-sisters-in-arms”). This seems to draw on the culturally popular assumption that men would behave better if they learned to empathize with their female family members—mothers, daughters, sisters—and imagined them at risk. This theme has recently been prevalent in the mainstream media with the emergence of the #MeToo movement; public figures frequently reference their daughters as motivation for speaking out against sexual harassment (e.g., “As a father of two daughters…”;
      • Contrera J.
      As ‘the fathers of daughters,’ they were offended by harassment.
      ,
      • Ruttenberg D.
      Paul Ryan and Harvey Weinstein are both ‘fathers of daughters’: Seeing women only as in need of protection is not better than seeing them as prey.
      ). Framing the issue in this way, as women in need of protection by men, reflects a benevolent sexism that poses real limitations on strategies to address harassment because it reinforces traditional gender roles, norms, and stereotypes. On the other hand, psychological research on outgroup dehumanization may lend support to these participants’ suggestions: this line of research holds that humans are unconsciously biased toward assigning a “lower human status” to an outgroup versus their own ingroup (
      • Capozza D.
      • Falvo R.
      • Di Bernardo G.A.
      • Vezzali L.
      • Visintin E.P.
      Intergroup contact as a strategy to improve humanness attributions: A review of studies.
      ). This tendency toward outgroup dehumanization can be reduced by fostering intergroup contact and enhancing perception of similarities and a common membership (
      • Capozza D.
      • Falvo R.
      • Di Bernardo G.A.
      • Vezzali L.
      • Visintin E.P.
      Intergroup contact as a strategy to improve humanness attributions: A review of studies.
      ).

       Implications for Practice and/or Policy

      Unfortunately, guidance on how to address patient-on-patient harassment is limited and in need of development (
      • Klap R.
      • Darling J.
      • Hamilton A.
      • Rose D.
      • Dyer K.
      • Canelo I.
      • Yano E.
      Prevalence of stranger harassment of women veterans at veterans affairs medical centers and impacts on delayed and missed care.
      ). We argue here that understanding the role of gender norms and inequalities underlying harassment provides a context and framework from which to contemplate how best to address it; in other words, gender is an important lens through which leaders of future initiatives should think about harassment. Regarding next steps, points of agreement between men and women included staff's primary responsibility for managing and preventing harassment, as well as more staff training, stricter codes of conduct, improved accountability and reporting procedures, and greater police presence. Groups diverged in their perceptions about women's role: men generally placed the onus on women to set boundaries with harassers, whereas women explicitly asserted that they should not bear responsibility for “training” men about acceptable behavior—pointing to the importance of awareness-raising and sensitivity training for men. Some men did display a curiosity or receptiveness to learn more about behaviors that are considered harassment versus not, which may provide an opening for awareness-focused interventions. Such training should educate men about benevolent sexism in addition to other forms of sexual harassment that they more readily understand (e.g., inappropriate touching, following).
      Findings from this study and others point to the need for interventions focused on organizational culture change.
      • Wesselmann E.
      • Kelly J.
      Cat-calls and culpability: Investigating the frequency and functions of stranger harassment.
      found that men who scored high in “likelihood to harass” were actually “quite attentive” to harassment-related situational norms and behaved accordingly; the authors concluded that interventions targeting perceptions of local norms for stranger harassment would be most beneficial (p. 460).
      • Purcell N.
      • Shovein E.
      • Hebenstreit C.
      • Drexler M.
      Violence in a U.S. Veterans Affairs healthcare system: Worker perspectives on prevalence, causes, and contributors.
      study on violence in a VA health care system highlights how an absence of boundaries and consequences for low-level patient aggression creates a permissive culture that allows for a “general tone of disrespect” and increases the likelihood of physical aggression. Our findings support the existence of a permissive organizational culture; for example, participants expressed general confusion about where and with whom to report offenses and generally did not believe that management would respond or take reports seriously.
      As
      • Odeh A.
      • Bruce T.
      • Krenn D.
      • Ran S.
      A broader perspective for subtle discrimination interventions.
      argue, individual-focused interventions are limited in their ability to decrease subtle discrimination in organizations and risk alienating members of particular groups. Systematic, organizational-level interventions are necessary to have broad impacts on existing “mistreatment climates”; for example, employee training and development programs can be framed positively around building respectful organizational climates, versus oriented toward reducing negative interpersonal behaviors (
      • Odeh A.
      • Bruce T.
      • Krenn D.
      • Ran S.
      A broader perspective for subtle discrimination interventions.
      ,
      • Osatuke K.
      • Moore S.
      • Ward C.
      • Dyrenforth S.
      • Belton L.
      Civility, respect, engagement in the workforce (CREW): Nationwide organization development intervention at veterans health administration.
      ). The VA's initial approach to culture change thus has anchoring in the literature, and would benefit from initiatives to support the development of additional guidance for local leaders, managers, providers, and staff. Because of its goal to change culture and focus on local leadership accountability, the VA did not establish a national-level reporting process for veteran-on-veteran sexual harassment, but hospital directors must set a report and response system.
      One of the primary objectives of VA WHS is to ensure the provision of a safe, sensitive, and inclusive environment for women at VA facilities (
      • Hayes P.M.
      Improving health of veterans through research collaborations.
      ). In August 2017, WHS responded to the initial harassment prevalence findings by commissioning evaluation work to better understand the scope of the issue and launching the End Harassment Campaign, a social norms campaign and employee training program. Research is currently underway to inform development of novel interventions (VA HSR&D Grant No. PPO 18–112; principal investigator, Klap), and to evaluate bystander interventions within VA (M. Relyea, personal communication, July 2018). Additional work is needed to formulate policy guidance and address reporting procedures.

       Study Limitations

      Findings should be interpreted in light of study limitations. First, participants were recruited at four VA sites, potentially limiting generalizability to other health care contexts. Groups were conducted during regular working hours and veterans were paid for participation; thus, the sample may over-represent residents in homeless or substance abuse treatment programs on VA campuses and may trend toward the unemployed. However, this sample composition is fairly consistent with the health care needs present in VA's patient population (
      • Lan C.
      • Fiellin D.
      • Barry D.
      • Bryant K.
      • Gordon A.
      • Edelman E.
      • Marshall B.
      Epidemiology of substance use disorders in U.S. veterans: A systematic review and analysis of assessment methods.
      ,
      • Purcell N.
      • Shovein E.
      • Hebenstreit C.
      • Drexler M.
      Violence in a U.S. Veterans Affairs healthcare system: Worker perspectives on prevalence, causes, and contributors.
      ,
      • Tanielian T.
      • Jaycox L.H.
      Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. RAND center for military health policy research.
      ). Owing to the groups' daytime scheduling, participants are likely representative of the patients actually on campus when women veterans attend their appointments; thus, the sample and site selection align with the project's objective to elicit data from typical VA sites. Second, because the study was advertised in the Veterans Affairs Medical Centers, it recruited current VA users but not nonusers. This strategy misses women who leave or avoid the VA because of prior negative experiences (
      • Hamilton A.
      • Frayne S.
      • Cordasco K.
      • Washington D.
      Factors related to attrition from VA healthcare use: Findings from the national survey of women veterans.
      ), so harassment may actually be underreported in our sample.

      Conclusions

      There is a pressing need to address harassment on VA grounds in light of both clinical implications and evidence that harassment is more likely in contexts with tolerant or ambiguous situational or organizational norms (
      • Buchanan N.
      • Settles I.
      • Hall A.
      • O'Connor R.
      A review of organizational strategies for reducing sexual harassment: Insights from the U.S. military.
      ,
      • Purcell N.
      • Shovein E.
      • Hebenstreit C.
      • Drexler M.
      Violence in a U.S. Veterans Affairs healthcare system: Worker perspectives on prevalence, causes, and contributors.
      ,
      • Wesselmann E.
      • Kelly J.
      Cat-calls and culpability: Investigating the frequency and functions of stranger harassment.
      ). Future initiatives should consider the gendered ways that men and women veterans define harassment, which is further shaped by regional, generational, and military norms and factors, and focus on influencing perceptions of those norms (e.g.,
      • Wesselmann E.
      • Kelly J.
      Cat-calls and culpability: Investigating the frequency and functions of stranger harassment.
      ) to minimize potentially tolerant organizational cultures.

      Acknowledgments

      We are grateful to the veterans who participated in these discussion groups and generously shared their time and experiences with us. We would like to thank Lisa Tarr for scheduling the discussion groups; Chloe Bird, PhD, RAND Corporation, for providing external review of and feedback on earlier versions of this article; and Angela Cohen, MPH, for her project management support.

      Supplementary Data

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      Biography

      Karen E. Dyer, PhD, MPH, is a Medical Anthropologist and Research Health Scientist at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy.
      Sharyn J. Potter, PhD, MPH, is the Executive Director of Research at Prevention Innovations Research Center and Professor in the Department of Sociology, University of New Hampshire.
      Alison B. Hamilton, PhD, MPH, is Chief Officer of Implementation & Policy, VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, and Research Anthropologist in the Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine.
      Tana M. Luger, PhD, MPH, is a Health Psychologist at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy.
      Alicia A. Bergman, PhD, is a Research Health Scientist at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy.
      Elizabeth M. Yano, PhD, MSPH, is Director of the VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, and Adjunct Professor in the Department of Health Policy and Management, UCLA Fielding School of Public Health.
      Ruth Klap, PhD, is a Research Health Scientist at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, and National Consortium Program Manager for the VA Women's Health Research Network.