BEU, Alm.del - 2019-20 - Bilag 383: Orientering af BEU om forskningsresultat om sammenhæng mellem seksuel chikane på arbejde og efterfølgende risiko for selvmord i den svenske arbejdsstyre, fra beskæftigelsesministeren

Beskæftigelsesudvalget 2019-20
BEU Alm.del Bilag 383
Offentligt

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

Work related sexual harassment and risk of suicide and suicide

attempts: prospective cohort study

Linda L Magnusson Hanson,

Anna Nyberg,

Ellenor Mittendorfer-Rutz,

Fredrik Bondestam,

Ida E H Madsen

Stress Research Institute,

Department of Psychology,

Stockholm University, 106 91

Stockholm, Sweden

Division of Insurance Medicine,

Department of Clinical

Neuroscience, Karolinska

Institutet, 171 77 Stockholm,

Sweden

Swedish Secretariat for Gender

Research, Gothenburg University,

405 30 Gothenburg, Sweden

National Research Centre for

the Working Environment, 2100

Copenhagen, Denmark

Correspondence to:

L Magnusson Hanson

[email protected]

(ORCID 0000-0002-2908-1903)

Additional material is published

online only. To view please visit

the journal online.

cite this as:

BMJ2020;370:m2984

http://dx.doi.org/10.1136/bmj.m2984

ABSTRACT

Objective

To analyse the relation between exposure to

workplace sexual harassment and suicide, as well as

suicide attempts.

Design

Prospective cohort study.

setting

Sweden.

ParticiPants

86 451 men and women of working age in paid work

across different occupations responded to a self-report

questionnaire including exposure to work related

sexual harassment between 1995 and 2013. The

analytical sample included 85 205 people with valid

data on sexual harassment, follow-up time, and age.

Main OutcOMe Measures

Suicide and suicide attempts ascertained from

administrative registers (mean follow-up time 13 years).

results

Among the people included in the respective analyses

of suicide and suicide attempts, 125 (0.1%) died

from suicide and 816 (1%) had a suicide attempt

during follow-up (rate 0.1 and 0.8 cases per 1000

person years). Overall, 11 of 4095 participants

exposed to workplace sexual harassment and 114 of

81 110 unexposed participants committed suicide,

and 61/4043 exposed and 755/80 513 unexposed

participants had a record of suicide attempt. In

Cox regression analyses adjusted for a range of

sociodemographic characteristics, workplace sexual

harassment was associated with an excess risk of both

suicide (hazard ratio 2.82, 95% confidence interval

1.49 to 5.34) and suicide attempts (1.59, 1.21 to

2.08), and risk estimates remained significantly

increased after adjustment for baseline health and

certain work characteristics. No obvious differences

between men and women were found.

cOnclusiOns

The results support the hypothesis that workplace

sexual harassment is prospectively associated

with suicidal behaviour. This suggests that suicide

prevention considering the social work environment

may be useful. More research is, however, needed to

determine causality, risk factors for workplace sexual

harassment, and explanations for an association

between work related sexual harassment and suicidal

behaviour.

Accepted:

13 July 2020

WHAT IS ALREADY KNOWN ON THIS TOPIC

Sexual victimisation may lead to suicidal behaviour

However, no population based prospective studies on work related sexual

harassment and suicide or suicide attempts have been conducted

WHAT THIS STUDY ADDS

This large population based cohort study of Swedish men and women indicates

that workplace sexual harassment may be a risk factor for both suicide and

suicide attempts

the

bmj

BMJ

2020;370:m2984 | doi: 10.1136/bmj.m2984

Introduction

Work related sexual harassment (referring to any

unwanted and unwelcome acts or conduct of sexual

nature, whether verbal or non-verbal, experienced

as intimidating, hostile, degrading, humiliating, or

offensive in circumstances related to work)

1 2

has

recently received a lot of attention thanks to the “Me

Too” movement. This movement has put an emphasis

on the widespread occurrence of sexual harassment,

especially work related sexual harassment. Exact

prevalences of work related sexual harassment in the

working population are, however, difficult to estimate,

and previous studies show large discrepancies.

Whereas some reports have found that no less

than 80% of all women and 30% of all men have

experienced work related sexual harassment, other

studies show much lower figures ranging from about

1% to 20%, depending on representativeness, how

sexual harassment was measured, and the time frame,

as well as on cultural context.

3 4

For organisations and the society, sexual harassment

may involve substantial costs associated with turnover

of personnel and absenteeism.

5 6

For individuals,

sexual harassment may take a toll on self-esteem, life

satisfaction, and employment opportunities.

7 8

Work

related sexual harassment may also be associated with

a range of negative health outcomes. Previous literature

has associated workplace sexual harassment with,

for example, physical health symptoms, stress, post-

traumatic stress, sickness absence, and particularly

poorer mental health such as psychological distress,

depression, and anxiety.

2 5 7 9 10

Sexual victimisation

may also lead to suicidal behaviour, through an

increased risk of psychiatric disease and psychosocial

factors such as life events, problematic substance

use/misuse, and risky lifestyle and behaviours,

through behavioural disinhibition, dysregulated mood,

hopelessness, and entrapment.

However, studies,

especially prospective studies, on workplace sexual

harassment and suicidal behaviours are lacking. Many

studies have also been based on convenience samples

or specific occupational groups. To our knowledge, no

population based prospective studies on work related

sexual harassment and suicidal behaviours have been

reported. To rectify this, we did a prospective study

BEU, Alm.del - 2019-20 - Bilag 383: Orientering af BEU om forskningsresultat om sammenhæng mellem seksuel chikane på arbejde og efterfølgende risiko for selvmord i den svenske arbejdsstyre, fra beskæftigelsesministeren

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

on work related sexual harassment and suicide and

suicide attempts in a large sample of Swedish men and

women in paid work.

Methods

study population

This study was based on data from the Swedish Work

Environment Survey (SWES) 1995-2013. SWES is

a biennial cross sectional survey, building on the

Labour Force Survey. Every second year since 1989,

a sample of between 10 000 and 15 000 people aged

16-74 years from the entire Swedish population are

contacted as part of the Labour Force Survey. Those

invited are selected by simple random sampling after

stratification for county, sex, and age and are first

interviewed by phone. Subsequently, the participants

are asked to respond to self-completion questionnaires.

A selected subsample aged 16-64 in paid work, largely

representative of the Swedish workforce, are further

asked to respond to self-completion questionnaires

including a range of questions related to their work

situation, as part of the SWES. Non-participation

in Labour Force Survey and SWES varied between

13% (1995) and 33% (2013) in the initial interviews

and between 23% (1995) and 51% (2013) in the

subsequent phone interviews and questionnaires. In

total, 86 451 participants responded to the SWES self-

completion surveys in 1995-2013. After exclusion of

people with reused personal identification numbers,

missing data on workplace sexual harassment, and

invalid data for the analyses on age at end of follow-up,

the study sample included 85 205 respondents.

sexual harassment

Two questionnaire items about sexual harassment were

used in this study, which were introduced as follows:

“Sexual harassment refers to undesirable advances

or offensive references to what is generally associated

with sexual relations.” The respondents were then

asked to respond to: “Are you subjected to sexual

harassment in your workplace from... 1) superiors

or fellow workers? and 2) other people (eg, patients,

clients, passengers, students)?” The questions were

rated on a seven point Likert-type scale ranging from

not at all during the previous 12 months to every day.

We categorised people who reported that they were

subjected to sexual harassment between once or twice

during the previous 12 months and every day as being

exposed to sexual harassment. We considered those

reporting not being subjected to sexual harassment at

all during the previous 12 months to be unexposed.

We combined these two items into one variable for the

main analyses, indicating any exposure to workplace

sexual harassment during the previous 12 months.

Because most respondents were exposed only once or

twice during the previous 12 months, we did not do

dose-response analyses.

suicide and suicide attempts

We identified suicide and suicide attempts from

the National Patient Register and Causes of Death

personal identification number. The patient register

includes both inpatient and outpatient data (from

2001). We defined people registered with an ICD-

10 (international classification of diseases, version

10) code of X60-X84 (self-inflicted harm) or Y10-Y34

(death with undetermined intent) as the underlying

cause of death as cases of suicide.

13-16

Likewise, we

considered those registered with self-inflicted harm or

harm with undetermined intent in the National Patient

For ICD-8

and ICD-9, we used the corresponding codes E950-

959 and E980-989. For the analyses, we considered

only incident suicide attempts occurring after response

to SWES, excluding people with first attempts before

participation in the survey (dating back to 1964

for inpatient data and 2001 based for outpatient

data). We followed the respondents from the year of

response to SWES questionnaires to the year of either

first registered suicide attempt or suicide, death from

another cause, emigration, or end of follow-up (31

December 2016).

statistical analyses

We estimated the risk of suicide or suicide attempt

by using proportional hazard regression analyses

with age as the underlying time scale. We tested the

proportional hazards assumption by using log-log

plots and interaction between time and exposure, and

we found no deviations from proportionality.

We fitted models assessing the relation both between

workplace sexual harassment and risk of suicide and

between workplace sexual harassment and risk of

suicide attempts. All people with full information on

exposure and outcome were included in the analyses

of suicide. The main analyses of suicide attempts were

carried out in a subsample with no previous suicide

attempts (excluding 649 individuals from the total

study sample) to make sure the exposure preceded

the outcome, but we also did analyses alternatively

adjusting for previous suicide attempts. The analyses

were adjusted for sex, family type, country of birth,

educational level, and income, as these types of factors

have been found to be associated with workplace

sexual harassment and risk factors for suicidal

behaviour.

7 17 18

Information about sex, age, family

situation, country of birth, educational level, and

income came from the longitudinal integration

database for health insurance and labour market

studies (LISA). We used educational level as a

categorical variable with three categories (≤9 years,

10-12 years, and ≥13 years). We categorised baseline

family type as single, divorced, separated, or widowed

without children; single, divorced, separated, or

widowed with children; married or living with partner

without children; or married or living with partner with

children. We categorised country of birth as “Nordic

countries,” “other European countries,” or “other

continents.” In additional analyses, we added poor

mental health at baseline or history of poor mental

health. Poor mental health was measured by baseline

doi: 10.1136/bmj.m2984 |

BMJ

2020;370:m2984 |

the

bmj

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

reports of being tired or listless (“During the past 3

months have you been tired and listless?”) every day,

which we used as an indicator of poor mental health,

and/or a diagnosis of mental disorders as indicated by

ICD-10 F01-99 or ICD-9/ICD-8 290-319 in the National

Patient Register up to the year of survey response.

addition, we adjusted for baseline work characteristics

including job demands and control, measured by

indices for demands and control based on four items

each scored from 0 to 4. We also used an index for

support at work measured with two separate questions

about support from superiors and fellow workers,

scored from 1 to 4, and for descriptive and/or analytical

statistics considered workplace violence and bullying

assessed by the following items: “Are you exposed

to violence or threats of violence in your work?” and

“Are you subjected to personal harassment by means

of malicious words and actions from supervisors

or colleagues?” We also ascertained severe somatic

disease from the National Patient Register (including

inpatient and outpatient data), including myocardial

infarction, congestive heart failure, peripheral

vascular disease, cerebrovascular disease, dementia,

chronic pulmonary disease, rheumatological disease,

peptic ulcer, mild liver disease, diabetes, hemiplegia or

paraplegia, renal disease, any malignancy, moderate

or severe liver disease, metastatic solid tumour,

connective tissue disease, and HIV/AIDS.

A variable

indicating whether any of these illnesses had been

diagnosed before or during the year of survey response

was considered as a potential confounder. The data on

previous or prevalent mental and somatic disorders

dated back to 1994 for inpatient data and 2001 for

outpatient data.

As adverse effects may differ for men and women,

the analyses were also stratified according to sex, and

an interaction term was included in some models,

to assess whether the associations tended to differ

between men and women. We additionally stratified

the analyses by position of the exposed individuals,

as workplace sexual harassment is also linked to

hierarchical power relations and many previous studies

have focused on subordinates.

2 6

We categorised

position as supervisor or subordinate. We regarded

people with supervisory duties as supervisors and

those reporting no supervisory duties as subordinates.

Finally, we analysed sexual harassment from superiors

or fellow workers versus sexual harassment from other

people (for example, patients, clients, passengers,

students) separately. We also did a sensitivity analysis

with suicide and suicide attempts with self-inflicted

harm only. We used SAS Statistical Software 9.4 for all

analyses.

dissemination strategy at the Stress Research Institute

is developed with patient and public involvement.

Results

Overall, 4.8% (4095/85 205) of the included men and

women reported workplace sexual harassment during

the previous 12 months—1.9% (774/40 853) of all

men and 7.5% (3321/44 352) of all women. Those

exposed to workplace sexual harassment tended to

differ from the rest of the study population on several

sociodemographic characteristics (table 1). Among

the exposed participants, a higher proportion were

women and single, divorced, or separated, and a

slightly higher proportion were born outside Europe.

Single or divorced men without children and men born

outside Europe seemed to be disproportionally affected

(supplementary table A). The exposed participants

were also generally younger than the remainder of the

study sample, and their income from work was lower,

especially among women. Furthermore, a higher

proportion of the exposed individuals were found

to have non-supervisory duties and high strain jobs

(characterised by high demands and low control), a

pattern that was most obvious among women. A high

proportion of the exposed participants concurrently

reported exposure to violence or threats of violence

and bullying from superiors or colleagues, which was

especially true for men. Finally, a higher proportion

of the exposed individuals were found to have poor

mental health, among both men and women.

sexual harassment and risk of suicide

We followed the study participants for a total of

1 084 512 person years (mean 13 years). In total, 125

(0.1%) people died from suicide during follow-up (rate:

0.1 cases per 1000 person years), 11 (0.3%) among

people exposed to any workplace sexual harassment

and 114 (0.1%) among those unexposed to workplace

sexual harassment.

In the Cox regression analyses (table 2), the

hazard ratio for completed suicide was 2.23 (95%

confidence interval 1.19 to 4.16) for any workplace

sexual harassment. The hazard ratio was considerably

higher when we adjusted for sex. After adjustment for

sex, birth country, family type, educational level, and

income, the hazard ratio was 2.82 (1.49 to 5.34). This

corresponded to a population attributable fraction of

0.06. Further adjustment for baseline mental health

and working conditions resulted in a more than

twofold higher risk of suicide among people exposed

to workplace sexual harassment (hazard ratios 2.51

(1.29 to 4.90) and 2.47 (1.25 to 4.87), respectively).

As history of somatic disease did not differ notably

between exposed and unexposed participants, we

made no adjustment for somatic disease.

We noted excess risk estimates in both men and

women (table 2), and we found no statistically

significant interaction between workplace sexual

harassment and sex. Similarly, we detected no

statistically significant interaction between workplace

sexual harassment and position (superior versus

Patient and public involvement

No patients were involved in setting the research

question or the outcome measures, nor were they

involved in developing plans for recruitment, design,

and implementation of the study. No patients

were asked for advice on interpretation or writing

up of results. However, part of the research and

the

bmj

BMJ

2020;370:m2984 | doi: 10.1136/bmj.m2984

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

table 1 | Distribution of sociodemographic factors among 85 205 employees in Swedish Work Environment Surveys 1995-2013, according to workplace

sexual harassment. Values are numbers (percentages) unless stated otherwise

Characteristic

Sex:

Male

Female

Mean (SD) age, years

Birth country:

Nordic countries

Other European countries

Elsewhere

Family situation:

Married/living with partner with children

Married/living with partner without children

Single/divorced/separated/widowed with children

Single/divorced/separated/widowed without children

Education:

Primary and lower secondary education

Upper secondary education

University education

Mean (SD) income from work, SEK

Supervisory duties:

Yes

Mean (SD) job demands, scale 0-4

Mean (SD) job control, scale 0-4

Mean (SD) social support, scale 1-4

Exposure to workplace violence:

Yes

Exposure to workplace bullying:

Yes

Baseline poor mental health:

Yes

Baseline somatic disease:

Yes

Suicide:

Yes

Suicide attempt:

Yes

All (n=85 205)

Not exposed to workplace sexual

harassment (n=81 110)

Exposed to workplace sexual

harassment (n=4095)

40 853 (48)

44 352 (52)

43 (11.9)

(n=85 198)

81 288 (95)

2280 (3)

1630 (2)

39 682 (47)

15 451 (18)

6522 (8)

23 550 (28)

(n=83 449)

12 861 (15)

41 295 (49)

29 293 (35)

2 467 210 (1 519 490)

(n=84 919)

59 375 (70)

25 544 (30)

1.7 (1.3)

2.5 (1.3)

1.6 (0.9)

(n=84 951)

73 395 (86)

11 556 (14)

(n=85 002)

77 773 (91)

7229 (9)

(n=84 003)

79 930 (95)

4073 (5)

71 919 (84)

13 286 (16)

85 080 (100)

125 (0)

83 740 (98)

1465 (2)

40 079 (49)

41 031 (51)

43 (11.8)

(n=81 103)

77 415 (95)

2170 (3)

1518 (2)

38 007 (47)

15 066 (19)

6039 (7)

21 998 (27)

(n=80 240)

12 470 (16)

39 186 (49)

28 584 (36)

2 4875 500 (1 533 790)

(n=80 835)

56 454 (70)

24 381 (30)

1.7 (1.3)

2.5 (1.3)

1.6 (0.9)

(n=80 883)

71 415 (88)

9468 (12)

(n=80 929)

74 556 (92)

6373 (8)

(n=X)

962)

(n=79

76 267 (95)

3695 (5)

68 411 (84)

12 699 (16)

80 996 (100)

114 (0)

79 758 (98)

1352 (2)

774 (19)

3321 (81)

37 (11.5)

3873 (95)

110 (3)

112 (3)

1675 (41)

385 (9)

483 (12)

1552 (38)

(n=4005)

391 (10)

2109 (53)

1505 (38)

2 064 420 (1 128 590)

(n=4084)

2921 (71)

1163 (28)

2.1 (1.3)

1.9 (1.3)

1.7 (0.9)

(n=4068)

1980 (49)

2088 (51)

(n=4073)

3217 (79)

856 (21)

(n=4041)

3663 (91)

378 (9)

3508 (86)

587 (14)

4084 (100)

11 (0)

3982 (97)

113 (3)

subordinate), although the risk of suicide seemed

to be more marked among subordinates (table 3),

which may be at least partly due to a higher number

of subordinates (n=59 375

25 544) and prevalence of

sexual harassment among subordinates (4.9% (2921

exposed)

4.6% (1163).

In the total sample, 1.5% (1253/85 189) were

exposed to sexual harassment from superiors or fellow

workers and 3.8% (3247/85 195) were exposed to

sexual harassment from other people (for example,

patients, clients, passengers, students). When we

looked at the association between workplace sexual

harassment perpetrated by superiors or fellow workers

and suicide (table 4), the risk estimate was above

1 but not statistically significant, which may be at

least partly due to low prevalence of exposure and

number of suicide cases in the exposed group (n=2).

The corresponding analyses on sexual harassment by

other people such as clients or customers indicated an

increased risk of suicide (adjusted hazard ratio 3.32,

1.71 to 6.48). The sensitivity analyses on risk of suicide

excluding cases with undetermined intent were similar

to the main findings (supplementary tables B-D).

Workplace sexual harassment and risk of suicide

attempts

Among participants without a previous suicide attempt

(n=84 556), 816 (1%) were found to have a suicide

attempt during follow-up (1 072 312 person years;

rate 0.8, mean follow-up time 13 years)—61/4043

(2%) among people exposed to any workplace sexual

harassment and 755/80 513 (1%) among those

unexposed to workplace sexual harassment.

As for suicide, any workplace sexual harassment

was also associated with an increased risk of suicide

attempt (unadjusted hazard ratio 1.54, 1.19 to 2.01),

and the hazard ratio remained similar after adjustment

for sociodemographic characteristics (1.59, 1.21 to

doi: 10.1136/bmj.m2984 |

BMJ

2020;370:m2984 |

the

bmj

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

table 2 | results from cox regression analyses on workplace sexual harassment stratified by sex, presented as hazard ratios (Hr) and 95% confidence

intervals with and without adjustment for covariates

all

no with

valid data

no of

cases

Hr (95% ci)

no with

valid data

no of

cases

Men

Hr (95% ci)

no with

valid data

Women

no of

cases

Hr (95% ci)

suicide

Model 0*

205

Model 1†

84 238

Model 2‡

83 048

Model 3§

82 860

suicide attempts

Model 0*

84 556

Model 1†

83 600

Model 2‡

82 419

Model 3§

82 233

125

124

121

816

799

786

785

2.23 (1.19 to 4.16)

2.82 (1.49 to 5.34)

2.51 (1.29 to 4.90)

2.47 (1.25 to 4.87)

1.54 (1.19 to 2.01)

1.59 (1.21 to 2.08)

1.55 (1.18 to 2.04)

1.56 (1.18 to 2.05)

40853

40421

39877

39794

40540

40111

39570

39488

397

391

385

384

2.99 (1.09 to 8.18)

2.62 (0.95 to 7.19)

2.62 (0.95 to 7.22)

2.60 (0.92 to 7.34)

1.79 (1.03 to 3.11)

1.80 (1.03 to 3.13)

1.78 (1.02 to 3.11)

1.77 (1.01 to 3.12)

44 353

43 817

43 171

43 066

44 016

43 489

42 849

42 745

419

408

401

3.20 (1.39 to 7.33)

2.94 (1.28 to 6.76)

2.39 (0.98 to 5.80)

2.25 (0.91 to 5.56)

1.49 (1.10 to 2.02)

1.49 (1.09 to 2.02)

1.44 (1.06 to 1.98)

1.47 (1.07 to 2.02)

*Unadjusted analyses.

†Adjusted for sex, birth country, family situation, education, and income at baseline.

‡Adjusted for sex, birth country, family situation, education, income, and poor mental health at baseline.

§Adjusted for sex, birth country, family situation, education, income, demands, control, social support at work, workplace bullying, and poor mental health at baseline.

2.08) (table 2). This corresponded to a population

attributable fraction of 0.03. Moreover, further

adjustment for baseline poor mental and physical

health, as well as working conditions, did not markedly

attenuate the risk estimates, and the risk estimates did

not differ considerably by sex or position (supervisor

versus subordinate). Analyses alternatively adjusting

for previous suicide attempts resulted in lower hazard

ratios. A model adjusting for previous suicide attempt,

sex, birth country, family type, educational level, and

income showed a hazard ratio of 1.25 (1.01 to 1.49)

and a fully adjusted model a hazard ratio of 1.23 (1.00

to 1.52).

When we looked at the association between

workplace sexual harassment perpetrated by superiors

or fellow workers and suicide attempts, the analyses

showed a statistically significant association when the

models were adjusted for sex, birth country, family

type, educational level, and income (table 4). The

corresponding analyses on sexual harassment by other

people such as clients or customers also indicated an

increased risk of suicide attempts (adjusted hazard

ratio 1.74, 1.30 to 2.31).

In sensitivity analyses excluding cases with un-

determined intent, the estimates of association between

workplace sexual harassment and suicide attempts

were stronger (supplementary tables B-D). The hazard

ratio for any exposure to sexual harassment was 2.22

(1.54 to 3.20) in the sensitivity analysis adjusted for

sociodemographic characteristics.

Discussion

This population based cohort study of Swedish men

and women showed an association between workplace

sexual harassment and both suicide and suicide

attempts.

strengths and limitations of study

This study has several major strengths such as

a prospective design and relatively large sample

approximately representative of the Swedish

working population. Prospective cohort studies

typically provide stronger evidence than other

the

bmj

BMJ

2020;370:m2984 | doi: 10.1136/bmj.m2984

observational studies. However, the study also has

limitations, including a risk that sexual harassment is

underreported. In this study, we based our variables on

only one single question, and lower rates of exposure to

sexual harassment tend to be found with one question

than with different questions about particular forms

of behaviour.

3 4

However, a definition was provided

in this study, which may have increased the validity

of the data. Underreporting may have contributed

to an underestimation of associations due to non-

differential misclassification. On the other hand, the

forms of sexual harassment may vary widely, with

some people experiencing light forms such as remarks

whereas others are exposed to severe forms such as

rape. When asked explicitly about sexual harassment,

many respondents seem to consider only severe types

of sexual harassment.

This may be an explanation

for the relatively strong associations in this study.

No assessment of type and severity was available,

however, and we cannot exclude the possibility that

the respondents only witnessed sexual harassment at

their workplace. When comparing effects on wellbeing,

however, some authors have found comparable

effects of less intensive but frequent experiences

such as gender harassment and more intense but

infrequent experiences such as sexual coercion and

unwanted sexual attention.

We also analysed sexual

harassment from superiors or fellow workers and from

others separately and found that sexual harassment

from others was more strongly associated with suicide

than was sexual harassment from superiors and

fellow workers. This finding is surprising in light of

previous Danish analyses, which found that depressive

symptoms were more strongly associated with sexual

harassment from superiors and colleagues than

with sexual harassment from customers or clients.

Although the findings of our study on this point should

be interpreted carefully in light of the limited power,

further research into how and why the consequences

of sexual harassment may differ depending on the

relation to the harasser may be justified.

With respect to the ascertainment of suicide and

suicide attempts, the Swedish registers generally have

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

table 3 | results from cox regression analyses on workplace sexual harassment stratified by occupational position,

presented as hazard ratios (Hr) and 95% confidence intervals with and without adjustment for covariates

supervisor*

no with valid data

no of cases

Hr (95% ci)

no with valid data

subordinate*

no of cases

Hr (95% ci)

suicide

Model 0†

25 544

Model 1‡

25 388

Model 2§

25 089

Model 3¶

25 035

suicide attempts

Model 0†

25 365

Model 1‡

25 210

Model 2§

24 912

Model 3¶

24 859

221

219

217

1.60 (0.38 to 6.70)

1.94 (0.45 to 8.42)

1.04 (0.14 to 7.84)

0.95 (0.12 to 7.30)

1.77 (1.08 to 2.88)

1.98 (1.20 to 3.28)

1.97 (1.19 to 3.26)

1.98 (1.19 to 3.31)

59 375

58 564

57 682

57 548

58 908

58 107

57 233

57 100

593

578

567

566

2.46 (1.23 to 4.94)

3.18 (1.56 to 6.47)

3.06 (1.50 to 6.25)

3.05 (1.47 to 6.33)

1.43 (1.04 to 1.96)

1.42 (1.03 to 1.97)

1.38 (0.99 to 1.92)

*Participants with supervisory duties were regarded as supervisors, those reporting no supervisory duties were regarded as subordinates.

†Unadjusted analyses.

‡Adjusted for sex, birth country, family situation, education, and income at baseline.

§Adjusted for sex, birth country, family situation, education, income, and poor mental health at baseline

¶Adjusted for sex, birth country, family situation, education, income, demands, control, social support at work, workplace bullying, and poor mental

health at baseline.

high completeness and validity.

High agreement for

suicide between death certificates and other sources

of information such as forensic reports, police reports,

and toxicological and histological data has also been

found.

However, the data are likely to cover the most

severe cases. Moreover, the number of false positives

may have been increased by the inclusion of deaths

or diagnoses with undermined intent.

This has on

the other hand been found to reduce under-detection

and incorrect coding, as well as spatial and secular

trends in detection and classification of suicide,

and additional analyses excluding cases with

undetermined intent strengthened the main findings.

In addition, the assessment of suicide attempts may

be more challenging, with a higher risk for under-

ascertainment owing to absence of recorded clinical

care. Non-differential misclassification of the outcome

may have contributed to attenuation of the results.

The analyses were adjusted for some potential

confounding factors including demographic chara-

cteristics and other working conditions, which did

not seem to explain the associations between work-

place sexual harassment and suicide as well as

suicide attempts. However, unmeasured factors such

as evening/night work and precarious employment

are other possible confounders of the associations of

interest. People who are more vulnerable to suicidal

behaviours might be more likely to be employed in

occupations with increased risk of harassment. We also

considered records of pre-existing mental and physical

disease, which included various psychiatric disorders,

substance misuse, and personality disorders. This

strengthens the findings but may on the other hand

lead to an underestimation of the association if poor

mental health and substance misuse act as mediators

of the relation between workplace sexual harassment

and suicidal behaviour. However, we cannot rule out

residual confounding and confounding from other

factors, although only very strong confounding could

completely explain the results. Pre-existing poor

mental health might partly explain the results of the

study, as people with pre-existing poor mental health

are more likely to perceive themselves as harassed

and more likely to be suicidal. We were also unable

to account for certain personality traits such as

neuroticism,

genetic factors, childhood adversities,

and social isolation, which could act as confounders for

the association between workplace sexual harassment

and suicide.

Also, the response rate in SWES has decreased over

time. The non-responders to SWES tend to consist of

a higher proportion of young people, people with

low education and low income, and immigrants. This

attrition may have affected the estimates of prevalence

and risk, and decreases the generalisability of the

results. A major strength of this study on the other

hand is that we had practically no loss to follow-up and

long follow-up time.

strengths and weaknesses in relation to other

studies

To our knowledge, this is the first study to indicate

that workplace sexual harassment increases the risk of

suicidal behaviour in the general working population.

We are aware of only a few previous studies on this topic.

For example, Griffith (2019) showed an association

between workplace sexual harassment and suicide

attempts in the US,

and Jin et al (2018) showed an

association with self-harm in Taiwan.

However, both

of these studies included military personnel only, used

a cross sectional design, and studied only suicide

attempts and not suicide. The cross sectional design

means that their results may have been influenced by

recall bias and common method bias. In this study,

we instead used a prospective design with exposure

assessed by questionnaire but suicide and suicide

attempts ascertained from administrative registers.

This excludes dependent recall bias and reduces the

risk of common method variance. The study is also

based on a large sample representative of different

sectors and occupations in Sweden, with much greater

power than many previous studies on the topic.

Nevertheless, our results are in line with those of the

few previous studies on workplace sexual harassment

doi: 10.1136/bmj.m2984 |

BMJ

2020;370:m2984 |

the

bmj

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

table 4 | results from cox regression analyses on workplace sexual harassment from superiors/fellow workers or

others, presented as hazard ratios (Hr) and 95% confidence intervals with and without adjustment for covariates

Workplace sexual harassment from superiors or fellow

workers

no with valid data

no of cases

Hr (95% ci)

Workplace sexual harassment from other people (eg,

patients, clients, passengers, students)

no with valid data

no of cases

Hr (95% ci)

suicide

Model 0*

Model 1†

Model 2‡

Model 3§

suicide attempts

Model 0*

Model 1†

Model 2‡

Model 3§

85 189

84 223

83 035

82 851

84 540

83 585

82 406

82 224

125

124

121

816

799

786

785

1.28 (0.31 to 5.19)

1.42 (0.35 to 5.78)

1.36 (0.33 to 5.57)

1.22 (0.29 to 5.09)

1.59 (1.02 to 2.48)

1.60 (1.01 to 2.53)

1.56 (0.98 to 2.46)

1.54 (0.97 to 2.46)

85 195

84 228

83 040

82 855

84 546

83 590

82 411

82 228

125

124

121

815

798

785

784

2.55 (1.33 to 4.89)

3.32 (1.71 to 6.48)

2.94 (1.46 to 5.93)

2.93 (1.44 to 5.95)

1.70 (1.28 to 2.25)

1.74 (1.30 to 2.31)

1.70 (1.27 to 2.27)

1.71 (1.27 to 2.29)

*Unadjusted analyses.

†Adjusted for sex, birth country, family situation, education, and income at baseline.

‡Adjusted for sex, birth country, family situation, education, income, and poor mental health at baseline.

§Adjusted for sex, birth country, family situation, education, income, demands, control, social support at work, workplace bullying, and poor mental

health at baseline.

and with results on childhood sexual victimisation and

suicide attempts.

Studies show that people exposed

to sexual abuse and repetitive abuse in childhood are

particularly vulnerable to suicidality in adulthood.

In line with the stress diathesis model, distal factors

such genetics and childhood adversity may have

contributed to a diathesis (a predisposition) to suicidal

behaviour, and an increased risk of suicidal behaviour

could be explained by this diathesis together with

proximal risk factors such as exposure to sexual

harassment.

An interaction between a variety of

biological, clinical, psychological, social, cultural, and

environmental factors can affect the risk of suicide;

most commonly, several risk factors act cumulatively

to increase an individual’s vulnerability to suicidal

behaviour.

12 14

Early life adversities such as sexual

or physical abuse have been connected to a range of

emotional and behavioural changes, related cognitive

deficits, and epigenetic changes. This seems to

increase the risk of development of pathological traits,

emotional dysregulation, altered brain structure, and

impaired executive function, which may increase the

vulnerability to suicidal behaviour.

Childhood abuse

has for instance been found to be strongly associated

with a diagnosis of post-traumatic stress disorder,

involving, for example, extreme fear, helplessness,

persistent arousal, and anxiety, which are risk factors

for suicidality. Workplace sexual harassment has also

been associated with post-traumatic stress disorder,

and it may be associated with similar emotional and

behavioural changes, cognitive deficits, and epigenetic

changes. Workplace sexual harassment is likely to be

associated with other stress responses and could lead

to behavioural risks such as eating disorders and drug

and alcohol misuse,

as well as depressive symptoms,

which may in turn increase the risk of suicide or

suicide attempts.

represent an important risk factor for suicidal

behaviour. This suggests that workplace interventions

focusing on the social work environment and

behaviours could contribute to a decreased burden

of suicide. More research is, however, needed to

determine causality and on risk factors for workplace

sexual harassment and mechanisms explaining the

association between work related sexual harassment

and suicidal behaviour.

Contributors:

LLMH conceived and designed the study, did the

statistical analysis, and drafted the manuscript. All authors provided

critical input to the design and the analysis and interpretation of the

data and revised the manuscript critically. The corresponding author

attests that all listed authors meet authorship criteria and that no

others meeting the criteria have been omitted. LLMH is the guarantor.

Funding:

This study was supported by the Swedish Research Council

for Health, Working Life and Welfare

(#2019-01318). Data collection

and management were also supported by the Swedish Research

Council (#2018-00544). The funders had no role in considering

the study design or in the collection, analysis, or interpretation of

data; writing of the report; or the decision to submit the article for

publication.

Competing interests:

All authors have completed the ICMJE uniform

disclosure form at www.icmje.org/coi_disclosure.pdf and declare:

LLMH received grants from the Swedish Research Council for Health,

Working Life and Welfare during the conduct of the study; no financial

relationships with any organisations that might have an interest in the

submitted work in the previous three years; no other relationships or

activities that could appear to have influenced the submitted work.

Ethical approval:

This study has been approved by the Regional

Research Ethics Board in Stockholm (document numbers: 2012/373-

31/5, 2013/2173–32, 2015/2187–32, 2015/2298–32, and

2017/2535-32). Participants in the Swedish Work Environment

Survey received written information on the survey, and return of the

survey indicated informed consent.

Data sharing:

Relevant data for research purposes from the Swedish

Work Environment Surveys and the Longitudinal Integrated Database

for Health Insurance and Labour Market Studies (LISA) can be

requested from Statistics Sweden. Relevant data for research from

the National Patient Register and Causes of Death Register can be

requested from the National Board of Health and Welfare.

Transparency:

The lead author (the manuscript’s guarantor) affirms

that the manuscript is an honest, accurate, and transparent account of

the study being reported; that no important aspects of the study have

been omitted; and that any discrepancies from the study as planned

(and, if relevant, registered) have been explained.

Dissemination to participants and related patient and public

communities:

There are no plans to disseminate the results of the

research directly to the study participants. Dissemination to the

conclusions and policy implications

All in all, this study supports a prospective association

between workplace sexual harassment and suicidal

behaviour. Workplace sexual harassment may thus

the

bmj

BMJ

2020;370:m2984 | doi: 10.1136/bmj.m2984

RESEARCH

BMJ: first published as 10.1136/bmj.m2984 on 2 September 2020. Downloaded from

http://www.bmj.com/

on 3 September 2020 at National Institute of Occupational Health - DNLA.

Protected by copyright.

population, in general, will be through the Stockholm University

website, seminars/conferences, and the media.

This is an Open Access article distributed in accordance with the

Creative Commons Attribution Non Commercial (CC BY-NC

4.0) license,

which permits others to distribute, remix, adapt, build upon this work

non-commercially, and license their derivative works on different

terms, provided the original work is properly cited and the use is non-

commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Fitzgerald L, Swan S, Magley V. But was it really sexual harassment?

Legal, behavioral and psychological definitions of the workplace

victimization of women. In: O’Donohue W, ed.

Sexual Harassment:

Theory, Research and Treatment. Allyn

& Bacon, 1997: 5-28.

McDonald P. Workplace Sexual Harassment 30 Years on: A Review of

the Literature.

Int J Manag Rev 2012;14:1-17.

doi:10.1111/j.1468-

2370.2011.00300.x

Timmerman G, Bajema C. Incidence and methodology in sexual

harassment research in Northwest Europe.

Womens Stud Int

Forum 1999;22:673-81.

doi:10.1016/S0277-5395(99)00076-X

Nielsen MB, Bjorkelo B, Notelaers G, Einarsen S. Sexual

Harassment: Prevalence, Outcomes, and Gender Differences

Assessed by Three Different Estimation Methods.

J Aggress Maltreat

Trauma 2010;19:252-74.

doi:10.1080/10926771003705056

Willness CR, Steel P, Lee K. A meta-analysis of the antecedents

and consequences of workplace sexual harassment.

Person Psychol 2007;60:127-62.

doi:10.1111/j.1744-

6570.2007.00067.x

Quick JC, McFadyen MA. Sexual harassment: Have we made any

progress?J

Occup Health Psychol 2017;22:286-98.

doi:10.1037/

ocp0000054

Cortina LM, Berdahl JL. Sexual harassment in organizations: A

decade of research in review. In: Barling J, Cooper CL, eds.

Micro

Approaches. SAGE

Publications, 2008: 469-97. (The SAGE Handbook

of Organizational Behavior1.) doi:10.4135/9781849200448.n26

Fitzgerald LF, Drasgow F, Hulin CL, Gelfand MJ, Magley VJ. Antecedents

and consequences of sexual harassment in organizations: a

test of an integrated model.

J Appl Psychol 1997;82:578-89.

doi:10.1037/0021-9010.82.4.578

Nielsen MB, Einarsen S. Prospective relationships between

workplace sexual harassment and psychological distress.

Occup Med

(Lond) 2012;62:226-8.

doi:10.1093/occmed/kqs010

Hogh A, Conway PM, Clausen T, Madsen IE, Burr H. Unwanted sexual

attention at work and long-term sickness absence: a follow-up

BMC Public Health 2016;16:678.

doi:10.1186/

s12889-016-3336-y

Ullman SE. Sexual assault victimization and suicidal behavior

in women: a review of the literature.

Aggress Violent

Behav 2004;9:331-51.

doi:10.1016/S1359-1789(03)00019-3

Turecki G, Brent DA, Gunnell D, et al. Suicide and suicide risk.

Nat Rev

Dis Primers 2019;5:74.

doi:10.1038/s41572-019-0121-0

Linsley KR, Schapira K, Kelly TP. Open verdict v. suicide - importance

to research.

Br J Psychiatry 2001;178:465-8.

doi:10.1192/

bjp.178.5.465

World Health Organization.

Preventing suicide: a global

imperative. World

Health Organization, 2014.

Randall JR, Roos LL, Lix LM, Katz LY, Bolton JM. Emergency

department and inpatient coding for self-harm and suicide attempts:

Validation using clinician assessment data.

Int J Methods Psychiatr

Res 2017;26:e1559.

doi:10.1002/mpr.1559

Naghavi MGlobal Burden of Disease Self-Harm Collaborators. Global,

regional, and national burden of suicide mortality 1990 to 2016:

systematic analysis for the Global Burden of Disease Study 2016.

BMJ 2019;364:l94.

doi:10.1136/bmj.l94

Turecki G, Brent DA. Suicide and suicidal behaviour.

Lancet 2016;387:1227-39.

doi:10.1016/S0140-6736(15)00234-

Batty GD, Kivimäki M, Bell S, et al. Psychosocial characteristics

as potential predictors of suicide in adults: an overview of the

evidence with new results from prospective cohort studies.

Transl

Psychiatry 2018;8:22.

doi:10.1038/s41398-017-0072-8

Bech P. Depressed mood as a core symptom of depression.

Medicographia 2008;94:9-13.

Hvidberg MF, Johnsen SP, Glümer C, Petersen KD, Olesen

AV, Ehlers L. Catalog of 199 register-based definitions of

chronic conditions.

Scand J Public Health 2016;44:462-79.

doi:10.1177/1403494816641553

Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for

defining comorbidities in ICD-9-CM and ICD-10 administrative

data.

Med Care 2005;43:1130-9.

doi:10.1097/01.

mlr.0000182534.19832.83

Sojo V, Wood R, Genat A. Harmful Workplace Experiences and

Women’s Occupational Well-Being: A Meta-Analysis.

Psychol Women

Q 2016;40:10-40.

doi:10.1177/0361684315599346

Friborg MK, Hansen JV, Aldrich PT, et al. Workplace sexual harassment

and depressive symptoms: a cross-sectional multilevel analysis

comparing harassment from clients or customers to harassment

from other employees amongst 7603 Danish employees from 1041

organizations.

BMC Public Health 2017;17:675.

doi:10.1186/

s12889-017-4669-x

Erlangsen A, Qin P, Mittendorfer-Rutz E. Studies of Suicidal Behavior

Using National Registers.

Crisis 2018;39:153-8.

doi:10.1027/0227-

5910/a000552

Allebeck P, Allgulander C, Henningsohn L, Jakobsson SW. Causes of

death in a cohort of 50,465 young men--validity of recorded suicide

as underlying cause of death.

Scand J Soc Med 1991;19:242-7.

doi:10.1177/140349489101900405

Swain RS, Taylor LG, Braver ER, Liu W, Pinheiro SP, Mosholder AD.

A systematic review of validated suicide outcome classification

in observational studies.

Int J Epidemiol 2019;48:1636-49.

doi:10.1093/ije/dyz038

Griffith J. The Sexual Harassment-Suicide Connection in the U.S.

Military: Contextual Effects of Hostile Work Environment and

Trusted Unit Leaders.

Suicide Life Threat Behav 2019;49:41-53.

doi:10.1111/sltb.12401

Jin HT, Lin YC, Strong C. Job stress, sexual harassment, self-harm

behavior, and suicidal ideation among military personnel in Taiwan.

Soc Health Behav 2018;1:11-5.

Zatti C, Rosa V, Barros A, et al. Childhood trauma and suicide

attempt: A meta-analysis of longitudinal studies from the last

decade.

Psychiatry Res 2017;256:353-8.

doi:10.1016/j.

psychres.2017.06.082

Angelakis I, Gillespie EL, Panagioti M. Childhood maltreatment

and adult suicidality: a comprehensive systematic review with

meta-analysis.

Psychol Med 2019;49:1057-78.

doi:10.1017/

S0033291718003823

Wasserman D, ed.

Suicide: An unnecessary death. Oxford

University

Press, 2016. doi:10.1093/med/9780198717393.001.0001

Hailes HP, Yu R, Danese A, Fazel S. Long-term outcomes of childhood

sexual abuse: an umbrella review.

Lancet Psychiatry 2019;6:830-9.

doi:10.1016/S2215-0366(19)30286-X

Web appendix:

Supplementary tables

No commercial reuse: See rights and reprints http://www.bmj.com/permissions

Subscribe: http://www.bmj.com/subscribe