Cultivating a fair, inclusive and welcoming work environment has become a priority for many institutions. Those who use overtly hostile, disparaging and threatening language and behaviors directed toward people based on race, gender, religion, sexual orientation, gender identity and disabilities are now being held accountable in the workplace. However, a more subtle and insidious form of prejudice known as microaggressions can perpetuate the same biases and be equally harmful.
The term “microaggression” was coined by Harvard psychiatrist Chester M. Pierce, MD, in a 1970 article in the Journal of the National Medical Association. A contemporary definition of microaggressions, created by Derald Wing Sue et al in 2007, describes them as “subtle snubs, slights and insults directed towards minorities, as well as to women and other historically stigmatized groups, that implicitly communicate or at least engender hostility.”
These intentional or unintentional verbal, behavioral or environmental actions are exercised on a more interpersonal level and may cause feelings of discomfort, devaluation and insecurity in their targets. These nuanced expressions of prejudice are often delivered on a routine basis and can contribute to maintaining existing power structures and to stifle opportunities for groups seeking equity.
Microaggressions are imperfectly understood and there is some degree of subjectivity in that one act may be perceived differently by separate individuals. However, one thing remains constant—microaggressions harm the targets.
What is a microaggression?
Microaggressions are expressed in four principal forms.
Microassaults: Intentional behavior that perpetuates discrimination without the overt intent of being offensive. These are typically addressed to an individual rather than an entire group. For example:
- Telling a racist or sexist joke or story with the disclaimer, “I’m just kidding!”
- A female physician being discouraged from a surgical specialty by implying that call obligations would interfere with her family obligations.
Microinsults: Comments or actions that are unintentionally or subtly discriminatory. These actions “convey rudeness and insensitivity and demean a person’s racial heritage or identity.”1 Microinsults can also pathologize a person’s natural state, such as calling into question appearance, hairstyle, manner or speech. For example:
- “I know your people are very proud of you!”
- “I love your hair! It’s so exotic.”
- “You look so pretty when you wear makeup/smile/get dressed up for work!”
- “We’ve had so many problems with other women/minorities working here in the past, but you’re really smart.”
- “I love having gay people in the section. They’re so much fun!”
- Women and underrepresented minorities (URMs) being mistaken as nonphysicians.
- A team leader not acknowledging the contribution or idea of a woman and lauding the same contribution by a male peer.
- A team leader consistently verbally cutting off minority team members while allowing white counterparts to fully express themselves.
- “Mansplaining” a concept directly to a woman with existing knowledge of the subject.
Microinvalidations: Acts that invalidate, dismiss or undermine thoughts, feelings and experiences of a person. For example:
- A straight person telling a gay colleague that homophobia doesn’t exist anymore since gay people can marry.
- In professional settings, female colleagues being referred to by their first name while male counterparts are referred to with their honorific.
- A URM physician being told by colleagues, “I don’t see color.”
- Leaders insisting that their workplace is a meritocracy when challenged on workforce disparities with objective data.
- Leaders telling aggrieved parties that they’re imagining discrimination or being “overly sensitive.”
- Women leading clinical programs being excluded from strategic decision-making processes while men in similar circumstances are included.
- A team member consistently avoiding being partnered with or speaking to a LGBTQ colleague.
Environmental: Environmental microaggressions are exhibited when microassaults, microinsults and microinvalidations become adopted and expressed in the culture, processes and climate of the workplace. For example:
- Honors and awards being named exclusively after men or white individuals.
- Indifference to a lack of childcare resources promulgating unwelcoming feelings for physicians with young families.
- Leadership denying academic time for staff studying or promoting healthcare disparities, diversity, equity and inclusion in their department.
- Leadership opting not to investigate workplace complaints regarding racism in the workplace.
- Leadership opting to unevenly investigate workplace complaints regarding minorities vs. nonminority counterparts.
Microaggressions can cause the target to exist in a hypervigilant state, always on guard for the next assault, and lead to internalized feelings of professional inadequacy based on their immutable human and cultural characteristics.
While microaggressions may be more difficult to identify than overt forms of discrimination, their aggregated effects create as much stress and harm to the recipients. Microaggressions can cause the target to exist in a hypervigilant state, always on guard for the next assault, and lead to internalized feelings of professional inadequacy based on their immutable human and cultural characteristics. Perceived discrimination contributes to lower self-esteem and is linked to depression and anxiety in its victims.4 Microaggressions are exceedingly challenging for those facing discrimination where there is intersectionality with race, gender, sexual orientation and gender identity. The exacted toll is unacceptable when trying to create a pipeline of necessary talent in medicine.
Microaggressions in real life
The following case examples, submitted anonymously by practicing IRs, provide a real-life look at how subtle discrimination can seep into the workplace every day.
“I served on my medical school’s admissions committee as a liaison from the Student National Medical Association (SNMA). During one meeting, the dean of admissions exclaimed, ‘I knew you were our SNMA representative, but I was surprised to just find out that you’re also one of our best students!’ I accepted her words as a compliment, but I’ve always have held some discomfort that she was surprised that the SNMA representative could also possess academic excellence.”—A Black IR
“In the 1980s, during medical school and internship, we had a lot of patients with end-stage HIV. They were profoundly ill with so much need and so little hope. Every patient, without exception, was the object of a negative comment by someone on the medical team regarding their illness or sexual orientation. Jokes, contempt and indifference were almost routine.
In the 1990s, there was an intense and enduring controversy regarding a local LGBT military service organization that was denied access to march in the city’s annual St. Patrick’s Day parade. Several IR colleagues laughingly discussed the topic and said it was ‘ridiculous’ and ‘totally unnecessary’ for them to disrupt a ‘family day.’
I learned from my peers was that being gay—inside and outside of the hospital—was very much not ok. Gays were regarded as immoral subhumans all having HIV, almost deservingly so, and their presence was considered offensive and threatening to society. This led to a deep schism between my professional life and personal life. I felt unworthy of mentorship and was directionless and without support in my professional development.”—A gay IR
“Every safety report becomes a conversation for me and the Latinx residents, but not for my white colleagues.”—A Black radiology resident
"I was selected to participate in a multi-specialty fellowship case competition that no one from my school had previously attended. The case I chose was an interesting example of adapting existing medical equipment for innovative, non-traditional use in the vascular system. I had performed the case with one of the junior IR faculty earlier in the year. Ultimately, I ended up winning first-place in the case competition.
I returned to my home institution and informed everyone of the award and how well the case was received. The attending seemed genuinely surprised and excited. He said, the case example should be written up for publication. I found out months later that the attending had approached one of my co-fellows to write up the case for submission to an academic journal. The experience shook my self-confidence and made me doubt my abilities vs my worthiness to participate in IR. Afterwards, the attending assured me it was an unintentional oversight and offered to add me to the manuscript, in retrospect. Like so many times before, there seemed to be so many instances where I was tolerated and never truly championed.”—A Black female practicing IR
“I get annoyed when people say to me “I don’t see color” or “I don’t see you as Black.” When they say that to me I think two things: It is impossible to “not see” color. Our movement in our society dictates as such and the ignorance and/or denial is tiring; and I don’t feel seen as my life and existence as an adult is inextricably linked with my Black/African American identity. I love it. I cherish it. I honor it, for better or for worse.
Attendings and colleagues, when hearing my last name have made ‘jokes’ along the lines of: You’re not part of Al Qaeda/ISIS/ISIL, are you? Are you Muslim? Do you believe in Shariah law? What is most frustrating in this present moment is the outright refusal of the field to not unequivocally acknowledge implicit bias and prejudice amongst physicians and scapegoat in addressing diversity and inclusion by just focusing on the patient experience and perspective.” — A Black, Muslim female practicing radiologist
How to be accountable
When microaggressions are encountered, the initial reaction may be to question whether the transgression actually occurred (“Did I mishear him?”) and to discount the behavior (“I’m sure she didn’t mean what she said” or “He must have been tired and misspoke”). Depending on the circumstances, there is risk and danger in the recipient ignoring or engaging the offender. It’s often a “no win” conundrum for the victim.
Structures to confront and dismantle microaggressions encourage dialogue rather than defensiveness. Focusing on what behavior was observed and how that action made the recipient feel is core to this process.
Allies are often bystanders to microaggressions and can be powerful in affecting positive outcomes. By openly acknowledging someone who was interrupted or overlooked, or supporting a wronged colleague, such agents can mitigate some of the deleterious effects of an incident. In that microaggressions are harmful to team members, they are destructive to team cohesion and the shared mission of the group.
As we work to craft a more inclusive and diverse IR workforce, honing our appreciation of this subtle dynamic is essential in dismantling the harmful and very real effects of microaggressions.
References
- Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: Implications for clinical practice.Am Psychol. 2007;62(4):271–286.
- Torres MB, Salles A, Cochran A. Recognizing and reacting to microaggressions in medicine and surgery. JAMA Surg. 2019;154(9):868–
- Pierce CM. Black psychiatry one year after Miami. J Natl Med Assoc. 1970;62(6):471–473.
- Pascoe EA, Smart Richman L. Perceived discrimination and health: A meta-analytic review. Psychol Bull. 2009;135(4):531–
