Please note this is a comparison between Version 2 by Jason Zhu and Version 1 by Irin Saju.
A behavior which is increasing in prevalence is sexual harassment initiated by a client and displayed towards the healthcare professionals and students of these healthcare-related professions. This is termed inappropriate patient sexual behaviour (IPSB). The consequences of IPSB can be significant, including decreased academic and work performance, decreased attention/concentration, reductions in work satisfaction, and a loss of confidence.
The National Academies of Sciences defines sexual harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature 
. The NAS developed a recent report, which stated that there are three types of sexual harassment: sexual coercion, unwanted sexual attention, and gender harassment 
. Sexual coercion includes physical or sexual advances made by an individual, which are reciprocated by the target 
. Unwanted sexual attention entails sexual advances which are unwelcome or offensive to the target 
. Some examples include unwanted touching and persistent sexual advances despite discouragement, or sexual assault 
. Lastly, gender harassment is stated to be the most common type of sexual harassment [1,2]
. Gender harassment is defined as the behavior of one gender conveying an offensive, hostile, or degrading approach to the members of another gender 
Sexual harassment initiated by a client and displayed towards healthcare professionals is termed inappropriate patient sexual behaviour (IPSB) 
. This occurs in physiotherapy and has been increasing in healthcare settings 
. IPSB has been defined as a verbal or physical act of an explicit or perceived sexual nature, which is unacceptable within the social context in which it is carried out 
. This behaviour can vary from sexist remarks to deliberate touch and sexual assault 
. Sexual harassment in physiotherapy commonly identifies the perpetrators of IPSB as patients 
. However, a few studies have stated that there are other potential perpetrators in the physiotherapy workplace—such as a physiotherapist’s co-workers [5,6]
. However, it was found that 83.98% of sexual harassment incidents reported by physiotherapists were carried out by patients, whereas the incidence for other healthcare professionals being the perpetrator was 12.71% 
. Consequently, this review will focus on IPSB.
Multiple studies have found that in physiotherapy, women are more often the victims of sexual harassment than men [1,2,3,7]
. It has also been identified that male clients are more likely than women to be the perpetrators of sexual harassment 
. Research conducted by Weerakoon and O’Sullivan 
indicated that women, in health care settings, view sexual harassment towards them as being due to power inequalities, as opposed to being based on physical attraction. This perception could be due to the historical discrimination of women—such as previously having unequal rights—with women being potentially seen as weak and inferior to the opposite sex.
1.1. Psychological Impact on Physiotherapists/Physiotherapy Students
Experiencing sexual harassment as a student has a significant impact on the students’ academic performance, both immediately and into the future 
. After such an incident, students tend to lack the motivation needed to attend class, receive lower grades, and pay less attention in class 
. For therapists, sexual harassment negatively impacts their work performance, with reduced concentration and a lack of confidence, which reduced their work satisfaction 
. Both physiotherapists and physiotherapy students have also experienced psychological stress after an IPSB incident [8,9]
. The majority of students who had experienced sexual harassment were less likely to report or discuss the incident with their colleagues, family member/s, or their supervisor 
. The reasons for this include emotional barriers, such as feeling embarrassed or ashamed, and cognitive barriers, such as believing that the incident was not appropriate for discussion and not perceiving it to be sufficiently severe to act 
. From this, it is evident that educating students about IPSB and how to respond to it is important to encourage reporting and minimise the negative ramifications. Education is necessary, as evidenced by Ang et al. 
who found that 79% of the students surveyed reported not feeling prepared for such incidents by their education provider. The authors consider that adequate preparation of students for this possibility is important. For this reason, it is necessary to be able to identify precipitants/situational factors and support the development of strategies to manage issues of IPSB, and this is one of the aims of the present systematic review.
1.2. Factors Leading to Sexual Harassment from Patients
The physiotherapy profession often involves an interpersonal relationship with patients, which at times may incorporate the use of remedial touch 
. It also involves being in close proximity to the patients for a variety of reasons, including patient safety 
. Furthermore, partial undressing of patients may be necessary for many physiotherapy interventions 
. All of these factors can increase the risk of physiotherapists experiencing IPSB.
Furthermore, there are health professional attributes that may lead to IPSB. A study conducted by Boissonnault, Cambier, Hetzel, and Plack 
stated that, with regards to IPSB, clinical inexperience was the most predictive factor. This suggests that physiotherapy students may be more at risk of experiencing IPSB due to their lack of experience, as patients may view them as having less power or control in the situation—as opposed to experienced physiotherapists.
There are also client attributes that may lead to IPSB. A study found that patients who act inappropriately with or sexually harassed physiotherapists, were found to be lonely and isolated 
. There are also associations with an inability for the patients to engage in sexual relations when an inpatient in the hospital setting 
. These factors, combined with the close interpersonal relationship a patient has with their physiotherapist, could potentially lead to IPSB.
Other factors that could lead to IPSB may include patients experiencing the side-effects of medications, or a mental illness/psychiatric condition, such as schizophrenia or cognitive impairment/cognitive decline 
. This may lead to patients lacking insight into what might constitute appropriate behavior 
As hypothesized, a high incidence rate of IPSB amongst physiotherapists and physiotherapy students that is between 48–100%. The most used strategy was to ignore the behavior and most of the students highlight the importance of education to help the physiotherapists to manage the IPSB.
These results are in line with others found in different health professions. In a study of female doctors, nurses, and nurse aides working in the medical, surgical, and geriatric wards in three hospitals in central Israel in 2015 
, sexual harassment varied from innuendo (55.1% incidence) to intentions of rape (1.5% incidence). The younger the staff, the more sexual harassment. In the current systematic review, the rates of harassment were not reported in relation to age in any of the articles, so researchers cannot make conclusions based on age. In a sample from the East, of 464 Japanese hospital nurses, 56% had encountered sexual harassment at some point from patients and 24 (5.2%) chose not to answer 
. Registered nurses were at a much higher risk of sexual harassment than were nurse assistants and this was thought to be related to the educational level and awareness of sexual equality possibly increasing the reporting by registered nurses. In the current review, included studies did not report the incidence rates in relation to work seniority of the therapists, and an understanding of sexual equality was not investigated. Interpretation of the harassment and the rate of reporting may also be factors given the findings of Hibino et al. 
. In this study, some participants interpreted a behavior as ‘sexual harassment’ and some not. This might also be related to education levels and/or experience.
According to the included studies, the incidence rate is most likely a result of a patient illness, which may be a mental illness or a behavioural condition, or as a result of the patient demographics, such as increasing age (particularly in male patients); feeling lonely, isolated, or uncertain with their sexuality; and/or the cultural beliefs that deter male patients from receiving directions from female therapists. Another likely reason for the high incidence rate may be due to the close interpersonal relationship that physiotherapists have with their patients 
It is interesting to note the higher rates in physiotherapy in comparison with the referenced nursing studies, given that in nursing and medical roles care sometimes involves breaking many of the social rules governing touch, bodily exposure, and sexuality 
. This could also be true of the physiotherapists working in the area of continence. In the future, it would be interesting to note the type of task being undertaken at the time of the harassment, as this was not recorded in the included studies. Another study conducted by McComas et al. 
stated that the prevalence of sexual harassment among physiotherapists was found to be similar across the acute, rehabilitation, and home care settings. However, severe forms of sexual harassment, such as an attempt to fondle, kiss, or grab, were more often seen in the public rather than the private sector 
One of the most reported strategies that physiotherapists and physiotherapy students used was to ignore the patient and their behaviour. This strategy may seem appropriate and effective in the short-term, but it may likely contribute to the recurrence of IPSB in the long-term. Similarly, for the study by Hibino et al. 
, the majority of their nursing participants tended to remain passive and did not take any definite physical steps to stop the behavior. An alternative strategy mentioned by most participants was to instead distract or redirect the patient. Furthermore, they would let the patient know that the behaviour was inappropriate. Other strategies were to treat the person in a more public space, and a number of changes to the management plan were suggested. Another commonly reported strategy was to report an incident to a superior or employer, which may be an effective strategy, provided that the superior takes action accordingly. It is noted that under-reporting is, however, an issue 
The importance of education about IPSB is highlighted through the suggestions of adding workplace training and curriculum to the undergraduate programs 
. Moreover, inappropriate patient sexual behavior has been found to be an important issue not only in physiotherapy, but also in other workplace and training settings, such as nursing, dental hygiene, or psychiatry [23
to name a few. More generally, sexual harassment is reported in the educational field at all levels—primary, secondary, and superior education—where sexual harassment can be displayed among the students, from the teachers to the students, or from the students to the teachers [26,27,28]
. For example, it has been claimed, in the context of sexual harassment among students, there is a lack of intervention of teachers as a preoccupying concern 
. Studies agree on the need for research and education on the incidence, situational factors, and strategies that can counteract this pervasive problem.
Incorporating knowledge, such as current statistical information regarding the incidence of IPSB, within these programs would help create awareness of sexual harassment in physiotherapy 
. It is also helpful to know the types of patient characteristics that are more likely to initiate incidents of IPSB, so that therapists can be more aware and potentially take precautions, such as treating the person in a more public space. Also, teaching physiotherapists and physiotherapy students the most effective skills/strategies to handle an incident of IPSB may help prevent or minimise the consequences of IPSB, unfortunately however, this was not evaluated in any of the included studies 
This review was limited in that only articles published in English were included, which means that research published in other languages was therefore not consulted. Additional limitations of this review include the subjectivity of the incidence rate and situational factors, as most studies used retrospective research relying on participants’ memory, which could alter an individual’s perception/recall of sexual harassment. Another limitation was that the effectiveness of the strategies used to address IPSB was not clear enough. Furthermore, there are different outcome measures used to assess IPSB, which limits the comparison of the results between the studies, as there could be a discrepancy between the validity and reliability of the different outcome measures. Surveys were also limited by the small populations that they were administered to and the high attrition rates. In the study conducted by Boissonnault et al. 
, an online link was used to distribute the survey to the physiotherapy professionals in the American Physical Therapist Association (APTA), which may not be representative of physiotherapists across the globe. There were also limitations in quality across many of the studies. This may have impacted the validity of the results, and may potentially have limited the ability to make robust conclusions from this literature.
2.2. Future Research
Future research should involve the development and evaluation of an educational intervention, such as pre–post design or use designs like randomised controlled trials. It would be beneficial to decide on a common instrument, which will allow for consistency in the outcome measures being used to assess the incidence rate.
Conducting a pilot testing or statistical analysis is suggested for future studies to ensure the reliability and validity of the outcome measures used. On the other hand, the quality of the studies needs to be improved in the future; pre–post tests or RCTs would address the limitations shown in the quality assessment of the included articles. In particular, the relationship between the researcher and the participants needs to be adequately discussed. Further long-term follow up of interventions could be included, e.g., assessing the students pre- and post-graduation.