Microaggressions: How and why do they impact health?

People’s physical and mental health is influenced by a large and diverse array of factors. But how can the attitudes of other people affect individuals’ well-being? In this Special Feature, we examine the impact that microaggressions have on health.

Prof. Derald Wing Sue — a leading psychologist at Columbia University — and his collaborators give the definition of microaggressions as “the everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership.”

The origin of the term “microaggression” dates back to the 1970s, and was coined by African American Harvard University psychiatrist Chester Pierce, specifically in relation to race.

Since then it has expanded to include other marginalized groups including women, LGBTQIA+ people, religious minorities, people with disabilities, and those from low socioeconomic backgrounds.

As conceptualized by Prof. Sue and his colleagues, microaggressions can pertain to three distinct categories:

• microassaults – the most overt form of microaggressions, which come in the form of slights and insults that can be verbal or behavioral

• microinsults — which assert prejudiced stereotypes through insensitive comments that make presumptions about an individual’s intelligence, morality, or belonging to an in-group

• microinvalidations — comments that have the effect of devaluing or denying the lived experience of marginalized people.

Microaggressions may be a result of conscious bias, but they can also reveal unconscious prejudices. Oftentimes a person may deliver a microaggression without consciously admitting that the attitude expressed by their words or actions is discriminatory.

Emerging research suggests that, like more explicit forms of discrimination, this covert type of discrimination has concrete negative impacts on the health of those at the receiving end.

Chronic exposure to microaggressions can have both a direct impact on health, and an indirect impact when it occurs within a system of healthcare.

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Microaggressions’ direct impact on health

When a person experiences stress, it can lead to physiological responses, including elevated blood pressure, increased heart rate, and the secretion of certain hormones, such as cortisol. Discrimination is a social stressor and it acts on the body in the same way.

One impact of this increased stress response was revealed in a study on racial differences in sleep. African American participants who reported experiencing more discrimination achieved less deep slow-wave sleep — the deep state of sleep associated with rest.

Sleep is critical for the healthy physiological functioning of the body, including the immune system, hormone systems, and mental function.

Two separate 2009 analyses of existing research — one from the Journal of Behavioral Medicine, the other from the Psychological Bulletin — examined the link between perceived discrimination and a multitude of physical conditions.

They both concluded that discrimination was a stressor with a negative impact on health and morbidity, particularly hypertension and cardiovascular disease.

Although there is a growing body of scientific literature on the relationships between discrimination and physical health outcomes, more research is needed to show the true impact of different forms of discrimination and discriminatory aggression.

Discrimination is associated with an increased incidence of mental illness, violence, poverty, and inequities in quality of treatment and access to healthcare, all of which have their own impacts on health. Isolating the direct physical impact of microaggressions is challenging when there are so many co-factors at play.

This is compounded by data suggesting that discrimination increases the likelihood of individuals engaging in unhealthy behaviors such as smoking, drinking, or overeating, which may serve as an immediate stress-reducing strategy but are high-risk factors for disease in the long term.

Among the better-understood impacts of microaggressions are those on mental health.

A 2015 investigation into the relationship between microaggressions and suicidal thoughts focused on 405 students from racial and ethnic minorities at a large midwestern university. Participants scored the frequency with which they encountered different types of microaggressions alongside answering questions on their mental well-being.

The trend in the data showed that the more often the students experienced microaggressions, the higher the incidence of suicidal ideation for four out of their six categories of microaggressions.

This corroborated the findings of a study from the previous year across a dataset of 506 adults from various racial groups, which found that higher frequencies of racial microaggressions were a significant predictor of negative mental health amongst the participants, in particular depressive symptoms, anxiety, negative view of the world, and lack of behavioral control.

Microaggressions in healthcare settings

Microaggressions may often be unconscious, but they reveal underlying biases that can impact the treatment of individuals.

A successful relationship between patient and healthcare provider requires trust. When biases are revealed, that trust may be damaged, and the patient may develop a negative association with seeking medical care.

A 2015 study into the healthcare of American Indian patients with diabetes found that more than one in three of the study’s 218 participants had experienced racial microaggressions from their healthcare professionals.

Alongside this, they scored the patients’ depressive symptoms, the incidence of heart attacks, and hospitalizations in the past year. A significant positive correlation emerged between the number of microaggressions experienced and each of the study’s three measures of health and well-being.

For LGBTQIA+ people, one of the most common forms of microaggressions in healthcare is the assumption that people are heterosexual and cisgender.

It is well documented that these communities are at significantly higher risk of tobacco, alcohol and drug misuse, sexually transmitted diseases, psychological distress, and suicide as a result of a higher prevalence of discrimination, rejection, and violence.

If healthcare professionals make assumptions as to patients’ sexuality and gender, this may block the patients’ access to the appropriate health services. Patients may also seek medical attention less readily as a result.

The same trend occurs in mental healthcare settings, too. According to a 2014 study, over half of counseling clients from marginalized racial and ethnic backgrounds reported that they had been subject to microaggressions from their therapists.

The perception of microaggressions negatively correlated to their satisfaction with their counseling and their relationship with their therapists.

To learn more about how these biases arise, Medical News Today spoke to Dr. Elinor Cleghorn, a scholar of medical humanities and author of the book Unwell Women, which chronicles the history of gender bias in healthcare from Ancient Greece through to present times.

“We have a tendency to think about medicine within the framework of science, which annexes it out to this place of impartiality and objectivity,” said Dr. Cleghorn. “In actual fact, the roots of medicine are embedded in society and culture, and because medicine is dealing with the most foundational matters of life and death it has, throughout its history, absorbed and reflected society’s ideas about who we are as people.”

“[Medicine] has really only become the science we understand it to be — an evidence-based science — over the last century […] [before that] we had centuries where practitioners of medicine had to rely on assumptions of who people were, what their bodies did and what they were for,” she explained.

Yet much of this status quo persists to this day, giving rise to systematic discrimination in healthcare settings.

“It made sense to Ancient Greeks that women existed [only] to procreate […] that was ‘science’ to them, it was irrefutable. You begin to create a medical discourse around women’s bodies centered around these presumed facts […] that everything in their health pivoted around their reproductive life,” noted Dr. Cleghorn.

“This has been reiterated and reiterated across the centuries because medicine has always been dominated by male practitioners who have tended, in the most part, to uphold these gender divisions,” she pointed out.

She went on to describe how this historic context may manifest in microaggressions in a healthcare setting in the present day:

“[Microaggressions] can take so many forms, and they’re very intersectional. The microaggressions that [one] might experience as an educated white woman may derive from a historical precedent that those women who worry about their pains must be ‘hysterical’ […] whereas for a woman of color, the perception of her pain carries the burden of [a] different historical context, insofar as she might experience racialized microaggressions emerging through.”

“The majority of doctors, if called out on this, would say ‘of course I don’t believe that Black women are invulnerable to pain,’ but those attitudes have shaped [medical] culture. It’s there because it’s gone unchecked, because the mold in which the science has been forged has not been looked at and remade,” she emphasized.

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How to stop the negative impact

The Institute of Medicine agrees that implicit bias and stereotyping may play a role in the health inequities observed among marginalized groups, and suggests that one strategy to reduce their impact is the recruitment of more healthcare professionals from underrepresented communities.

As with any form of unconscious bias, tackling microaggressions requires critical self-reflection. Training, which increases awareness of one’s own biases, and promotes inter-group contact can be an effective tool in improving patient care.

Providing such training also increases the likelihood of workers feeling able to be open about their own sexuality and gender identity amongst their colleagues, further increasing the opportunity for inter-group contact.

Asked what she felt would help, Dr. Cleghorn cited the value of research:

“One step is using testimonies, voices and experiences of women and other marginalized people in a meaningful research context […] In terms of this issue being studied from a sociological perspective, it’s really new. What we’ve had since the early 2000s are these groundbreaking studies like The Girl Who Cried Pain, which showed that statistically women are much more likely to be prescribed a sedative or an antidepressant when they report chronic pain, whereas men are more likely to be prescribed an analgesic, that women are much more likely to have the cause of pain diagnosed as psychological or emotional, whereas men, [as] physical.”

“Studies [like this] exposed how deep-rooted the issue is, but they also showed how it can be studied! Quite often when we talk about things like microaggressions […] it feels amorphous. To know there are mechanisms by which we can look at these issues critically is really important,” she pointed out.

“That study [The Girl Who Cried Pain] was a combination of patient testimonies, but also things like admission records. It was a real qualitative and quantitative exploration. The more we look at this issue as something that can be studied objectively the more we can move towards undoing it,” concluded Dr. Cleghorn.

Written by Savannah James-Bayly on May 2, 2022 — Fact checked by Anna Guildford, Ph.D.

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