9/11/2022

Addressing Microaggression in Women's Health Care Settings

Author: Yvonne S. Butler Tobah, MD, and Ijeoma Nnodim Opara, MD

Editor: Sireesha Reddy, MD

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Microaggressions are subtle, often recurrent, verbal and nonverbal interactions that are demeaning or engender hostility toward marginalized communities and nondominant groups. Microaggressions may be conscious or unconscious and include several subtypes: microassaults, microinsults, microinvalidations, and environmental microaggressions.

Microassaults are obvious, intentional discriminatory verbal or nonverbal statements or actions intended to offend the recipient. These are the most blatant form of microaggressions, considered "old-fashioned" discrimination. Examples include a patient demanding a White physician or an employee’s refusal to work with a woman or a gender-nonconforming individual.

Microinsults are subtle snubs, humiliation, or demeaning behaviors that may be unintentional. They convey insensitivity and indicate that the recipient's identity, culture, or heritage is "abnormal." Examples include discouraging natural hairstyles worn by individuals of color by implying that it looks unprofessional or refusing to pronounce the non-English names of patients.

Microinvalidations are verbal or nonverbal communications that negate, nullify, or dismiss individuals' thoughts, feelings, or experiential reality. The "alien in one's own land" is an example commonly manifested by asking Asian, Latino/Latina/Latinx Americans, or Americans of African descent where they were born. This assumption communicates exclusion and conveys that the recipient is a perpetual foreigner in their land.

Environmental microaggressions occur when microassaults, microinsults, and microinvalidations are reflected in the culture, climate, norms, or usual processes within a workplace or academia, serving as a reminder that prejudice and bias exist on a systemic level. Examples are medical textbooks depicting only White fetuses or patient education materials representing African American individuals when describing substance abuse.

Microaggressions are also referred to as "everyday racism," as they occur within daily life. They are considered a form of violence. The aggressor may be well-intended and their behavior not overt, but the harm inflicted on the recipient is significant. The effect often outweighs the intent.

The negative implications of microaggressions are severe. Chronic institutional racism contributes to significant adverse physical and mental health outcomes and health care disparities for patients seeking obstetric and gynecologic care. Microaggressions also contribute to stress, depression, burnout, and low performance for medical students, trainees, staff, and faculty from nondominant communities. This negative effect increases with the intersectionality of race, gender, sexual orientation, and other nondominant identities.

Educational frameworks to address microaggressions focus on developing communication strategies modeled around one’s status as the recipient, the source, or a bystander of microaggressions. Institutions can combat environmental or institutional microaggressions through multiple actions:

Implementing dedicated diversity roles
Initiating antiracist reconstitution of policies
Establishing a culture of openness
Increasing diverse representation at all levels of the organization to reflect the community served
Correcting compensation discrepancies
Addressing the minority tax/majority subsidy, which refers to the additional, typically unpaid responsibilities placed on nondominant individuals in an institution as part of efforts to advance diversity
Providing regular and continuing antiracist training for all trainees, faculty, staff, and leaders
Enforcing systems of accountability for preventing and resolving everyday racism

Further Reading:

Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 729: Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care. Obstet Gynecol. 2018 Jan;131(1):e43-e48. doi: 10.1097/AOG.0000000000002459. PMID: 29266079.

Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. JAMA Surg. 2019 Sep 1;154(9):868-872. doi: 10.1001/jamasurg.2019.1648. PMID: 31290954.

Initial Publication: September 2022

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

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