Internet Searches for Sexual Harassment and Assault, Reporting, and Training Since the #MeToo Movement Letters RESEARCH LETTER Internet Searches for Sexual Harassment and Assault, Reporting, and Training Since the #MeToo Movement On October 15, 2017, following the public accusations of sexual harassment and assault against film producer Harvey Wein- stein, actress Alyssa Milano encouraged victims to bring the taboo topic out of the shadows by sharing their own stories on social media. #MeToo was tweeted 300 000 times the day af- ter Milano’s post and generated widespread support with scores of accusations made against media, political, and business lead- ers, giving voice to previously unheard victims.1 However, the implications for the victims whose perpetrators are not pub- lic figures is unknown. To fill this knowledge gap, we exam- ined how internet searches for sexual harassment and/or assault changed following #MeToo.2 Methods | We monitored the volume of Google searches origi- nating from the United States that were indicative of sexual harassment and/or assault awareness (all searches including the term “sexual” and the terms “harassment” or “assault”) from January 1, 2010, through June 15, 2018. We further monitored the subset of these searches that focused on seek- ing resources for reporting of sexual harassment and/or assault (searches that also included “report” or “reporting”) and preventive training (searches that also included “train” or “training”). The search volumes were provided as a ratio of all Google searches (per 10 million), thereby adjusting for changes in Google usage over time. Raw search count esti- mates were inferred using Comscore estimates (http://comscore. com). We compared observed search volumes after October 15, 2017, to the counterfactual scenario manufactured from pre- dicted search volumes using the autoregressive integrated mov- ing average (ARIMA) algorithm of Hyndman and Khandakar3 applied to weekly trends from January 1, 2004, to October 14, 2017 (before #MeToo). The ratio of observed and predicted vol- umes with bootstrapped confidence intervals (CIs) were com- puted using R, version 3.5.0 (R Foundation). Because these analyses were based on public aggregate data, institutional re- view board approval was not required. Results | Sexual harassment and/or assault searches were 86% (95% CI, 60%-117%; P < .001) higher than expected from Oc- tober 15, 2017, to June 15, 2018, reaching record highs (Figure). Moreover, observed searches remained higher than expected each week until 8 months after #MeToo began. In absolute terms, the post-#MeToo period corresponded with the great- est number of sexual harassment and/or assault searches ever recorded in the United States, with 40 to 54 million searches from October 15, 2017, to June 15, 2018. Searches related to reporting and preventive training for sexual harassment and/or assault were 30% (95% CI, 23%- 39%; P < .001) higher and 51% (95% CI, 43%-60%; P < .001) higher than predicted from October 15, 2017, to June 15, 2018. Both spiked weeks after #MeToo began and remained greater than expected for all weeks except 1. Discussion | Despite the well-documented evidence that sexual harassment and/or assault has major public health implications,4 it has received little national attention. The #MeToo movement has prompted substantial interest in not only sexual harassment and/or assault, but also actionable out- comes for reporting and prevention. Figure. US Google Searches for Sexual Harassment and/or Assault Awareness, Reporting, and Training 10/15/17 2000 1000 0 R el ev an t Se ar ch es p er 10 M ill io n G oo gl e Se ar ch es , N o. Date Searches greater than expected Observed searches Expected searches Awareness searchesA 06/15/17 09/15/17 12/15/17 03/15/18 06/15/18 50 30 20 10 40 0 R el ev an t Se ar ch es p er 10 M ill io n G oo gl e Se ar ch es , N o. Date Reporting searchesB 06/15/17 09/15/17 12/15/17 03/15/18 06/15/18 40 20 10 30 0 R el ev an t Se ar ch es p er 10 M ill io n G oo gl e Se ar ch es , N o. Date Training searchesC 06/15/17 09/15/17 12/15/17 03/15/18 06/15/18 10/15/17 10/15/17 Weekly Google search volumes are shown. A, All searches that included the terms “sexual” and “assault” or “harassment.” B, The subset of searches that also included the terms “report” or “reporting.” C, The subset of searches that also included the terms “train” or “training.” The dashed vertical line in each graph indicates when #MeToo was first tweeted by Alyssa Milano on October 15, 2017. 258 JAMA Internal Medicine February 2019 Volume 179, Number 2 (Reprinted) jamainternalmedicine.com © 2018 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://comscore.com http://comscore.com http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.5094 Search trends are only proxies for engagement, and sen- tinel surveillance (such as surveys) will clarify these early find- ings. However, our findings demonstrate the power of grass- roots movements to respond to large-scale public health crises. These results suggest that #MeToo may have reduced the stigma of sexual harassment and/or assault as more seek help.5 Public health investments in preventing sexual harass- ment and/or assault is disproportionately small compared with the scale of the problem,6 in part because the problem is hid- den from the public. With millions more persons than ever voic- ing their needs months after #MeToo began, public health lead- ers should respond by investing in enhanced prevention training and improving resources for survivors. Theodore L. Caputi, BS Alicia L. Nobles, PhD, MS John W. Ayers, PhD, MA Author Affiliations: Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts (Caputi); Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla (Nobles, Ayers). Accepted for Publication: August 7, 2018. Corresponding Author: John W. Ayers, PhD, MA, Department of Medicine, University of California, San Diego, 9500 Gilman Dr, Ste 333 Central Research Services Facility (CRSF), 9500 Gilman Drive, La Jolla, CA 92093-0507 (ayers.john.w@gmail.com). Published Online: December 21, 2018. doi:10.1001/jamainternmed.2018.5094 Author Contributions: Dr Ayers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Caputi, Ayers. Acquisition, analysis, or interpretation of data: Caputi, Nobles, Ayers. Drafting of the manuscript: Caputi, Nobles, Ayers. Critical revision of the manuscript for important intellectual content: Caputi, Ayers. Statistical analysis: Caputi. Obtained funding: Caputi. Administrative, technical, or material support: Caputi, Ayers. Conflict of Interest Disclosures: None reported. Funding/Support: This research was funded by the University of California, San Diego, Center for AIDS Research via the National Institutes of Health (P30 AI036214). Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Zacharek S, Dockterman E, Edwards HS. Time person of the year: the silence breakers. Time. 2017. http://time.com/time-person-of-the-year-2017-silence- breakers/. Accessed August 2, 2018. 2. Ayers JW, Althouse BM, Dredze M. Could behavioral medicine lead the web data revolution? JAMA. 2014;311(14):1399-1400. doi:10.1001/jama.2014.1505 3. Khandakar Y, Hyndman RJ. Automatic time series forecasting: the forecast package for R. https://www.jstatsoft.org/article/view/v027i03. Accessed July 29, 2018. 4. Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—national intimate partner and sexual violence survey, United States, 2011. Morbidity and mortality weekly report. 2014. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm. Accessed July 23, 2018. 5. Kennedy AC, Prock KA. “I still feel like I am not normal”: a review of the role of stigma and stigmatization among female survivors of child sexual abuse, sexual assault, and intimate partner violence. Trauma Violence Abuse. 2016;7 (9):8-21. doi:10.1177/1524838016673601 6. Waechter R, Ma V. Sexual violence in America: public funding and social priority. Am J Public Health. 2015;105(12):2430-2437. doi:10.2105/AJPH.2015. 302860 Temporal Trends in Unstable Angina Diagnosis Codes for Outpatient Percutaneous Coronary Interventions Recent health care policy initiatives have focused on reduc- ing misuse or overuse of expensive cardiovascular proce- dures. The appropriate use criteria (AUC) for coronary revascularization were re- leased in 2009 with the aim of reducing inappropriate per- cutaneous coronary interven- tions (PCIs).1 In addition, national efforts to provide hospitals with information about their performance on PCI appropri- ateness began in 2011.2 Since these initiatives were enacted, the volume of PCIs performed for nonacute indications in the United States has declined, as have rates of PCIs considered inappropriate.3,4 Some have declared this a policy success—that the fewer in- appropriate PCIs performed nationally reflect better selec- tion of patients likely to experience improved outcomes. How- ever, it may be that these initiatives incentivized physicians to classify patients with stable chest pain as having unstable angina (UA) to meet AUC. To explore this possibility, we ex- amined trends in PCIs coded for acute indications in the out- patient setting in 3 large and geographically dispersed states. Author Audio Interview Invited Commentary page 261 Figure 1. Proportion of Percutaneous Coronary Interventions (PCIs) Coded for Acute Indications in the Outpatient and Inpatient Settings 10 8 6 4 2 0 Pe rc ut an eo us C or on ar y In te rv en ti on s, % Year Acute outpatient interventionsA 2010 2011 2012 2013 2014 100 80 60 40 20 0 Pe rc ut an eo us C or on ar y In te rv en ti on s, % Year Acute inpatient interventionsB 2010 2011 2012 2013 2014 Michigan Michigan Florida Florida New York New York A, Acute outpatient PCIs. B, Acute inpatient PCIs. Proportions reflect PCIs coded for acute indications in the outpatient setting, or PCIs coded for acute indications in the inpatient setting, divided by total PCIs (acute and nonacute in both outpatient and inpatient settings) for each state by year. Letters jamainternalmedicine.com (Reprinted) JAMA Internal Medicine February 2019 Volume 179, Number 2 259 © 2018 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 mailto:ayers.john.w@gmail.com https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.5094&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.5094 http://time.com/time-person-of-the-year-2017-silence-breakers/ http://time.com/time-person-of-the-year-2017-silence-breakers/ https://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2014.1505&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.5094 https://www.jstatsoft.org/article/view/v027i03 https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm https://dx.doi.org/10.1177/1524838016673601 https://dx.doi.org/10.2105/AJPH.2015.302860 https://dx.doi.org/10.2105/AJPH.2015.302860 https://jamanetwork.com/learning/audio-player/10.1001/jamainternmed.2018.7553/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.5124 https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.5967&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.5124 http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.5124