Microaggressions towards LGBT individuals: what about clinical practice?

As clinicians and psychotherapists, we are called to care for the mental health and well-being of the people who come to us. When working with minorities, this also means that we must be aware of the social system we navigate and how social norms, stereotypes, and biases may affect us and the person(s) we take care of in the clinical setting.

A particularly insidious form of subtle bias is microaggressions. Microaggressions have been described as “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional that communicate hostile, derogatory, or negative insults to the target person or group” (Torino et al., 2019). This definition comprises all the key concepts developed within microaggression theorizing. Firstly, microaggressions communicate prejudice and biases delivered implicitly or explicitly through various communication channels (Sue, 2010). Secondly, these aggressions are delivered just because of the marginalized status of the targeted individual or group. And thirdly, these kinds of assaults differ from overt forms of discrimination and violence that occur more sporadically because of their everyday nature.

These subtle forms of prejudice have a detrimental impact on Lesbian, Gay, Bisexual, and Transgender (LGBT) individuals’ mental health and well-being (Owen et al., 2019). The negative effect of microaggressions on the mental health and well-being of LGBT people lies precisely in being repeated on a daily basis. Comments such as “You’re just too sensitive! I’m not transphobic” or “You talk about discrimination all the time” are examples of microaggressions that deny the personal experience, emotions, or thoughts of an individual (Anzani, 2019).

WHAT DO MICROAGGRESSIONS LOOK LIKE IN THE CLINICAL SETTING?

It becomes particularly problematic to reproduce these forms of microaggressive behavior in consultation or therapy. The clinical setting should represent a safe environment where the clients feel safe enough to express their feelings and vulnerabilities. Moreover, if the person has already internalized negative beliefs about their LGBT identity (i.e., internalized transphobia-homophobia), microaggressions in the clinical setting only confirm the belief that something is wrong with them.

Often therapists may ask more questions on the sexual identity of cisgender LGB and transgender clients because they connect the patients’ symptoms with their sexual orientation and gender identity (Anzani et al., 2020; Anzani, Sacchi, Prunas, 2021). The assumption that sexual identity is the cause of their current symptoms contributes to the idea being perpetuated that sexual and gender marginalized identities are inherently “wrong” and problematic, fostering internalization of negative attitudes towards one’s own minority identity. The second fundamental assumption that influences therapists to ask questions about sexual identity relies on stereotypical beliefs about LGBT experiences. Questions regarding how sexual identity was “discovered” and how LGBT individuals manage their sexuality in different social and relational contexts are based on stereotypical assumptions. For example, assuming that sexual identity is a discovery (or a choice) that causes difficulties for the individual is a narrative based on a stereotypical representation of LGBT individuals that does not necessarily reflect the experience of every member of the community.

Other forms of microaggressive behavior in clinical practice might be:

• the avoidance or minimization of marginalized identity (e.g., avoiding to talk about gender or sexuality)
• centering all consultation on marginalized identities alone (e.g., the only issue discussed is the client’s sexual identity)
• making stereotypical assumptions (e.g., based on a person’s appearance)
• expressing cis-heteronormative biases (e.g., ask if a woman has a boyfriend)
• warning of the challenges of being LGBT

The literature suggests a relationship between emotional arousal and/or anxiety and prejudice and stereotypes (Britt et al., 1996; Vescio & Biernat, 1999); clinicians who have greater emotional arousal when facing a patient who belongs to a sexual or gender minority commit more microaggressions (Anzani, Sacchi, Prunas, 2021). Emotional arousal interferes with the clinicians’ process of cognitive evaluation and impression formation. As a result, clinicians have fewer cognitive resources at their disposal and rely more on biases and stereotypes in making judgments (Bodenhausen, 1993). Thus, when confronted with a marginalized group member, some therapists might activate stereotypes that lead to emotional arousal directly detrimental to their judgment. For example, arousal has been shown to reduce the availability of relevant information caused by a narrowed attentional focus (Easterbrook, 1959). Clinicians’ microaggressions might also compromise the creation and maintenance of a therapeutic alliance and cause the dropout of clients.

WHAT CAN WE DO ABOUT IT?

The main guidelines for psychological practice with LGBT clients promote understanding, respect, and support, recognizing the existence of minority stress as an essential factor affecting the mental health of LGBT individuals (American Psychological Association, 2012, 2015; Coleman et al., 2012; Morris et al., 2019). Despite the guidelines that ensure care and protection for the LGBT population, some clinicians continue to demonstrate bias when confronted with a community member as a client (Prunas et al., 2018).

A solid, proactive strategy would be to endorse a paradigm shift from microaggressions to microaffirmations, clearly helpful in providing tangible support and affirmation of LGBT identities (Anzani, Morris, et al., 2019). The first step in this direction could be made by providing adequate knowledge and developing competence among therapists on LGBT issues. In many countries, the educational system offers no good training on gender, sexual diversity, and sexual or gender minorities’ needs for healthcare professionals. As a result, psychologists and healthcare providers are likely still affected by common thinking and societal paradigms rather than focusing on knowledge and skills. A strongly affirmative and supportive practice must be based on adequate and specific training. The microaffirmation model of care recognizes affirmative practices such as acknowledging cisnormativity and its disruption as beneficial. Such practice starts primarily by acknowledging differences in privilege based on people’s identities in the therapeutic relationship through an intersectional perspective.

Reference Article

Anzani, A., Sacchi, S., & Prunas, A. (2021). Microaggressions towards lesbian and transgender women: Biased information gathering when working alongside gender and sexual minorities. Journal of Clinical Psychology

Discussion Questions

1. As clinicians and psychotherapists, to what extent are we aware of the influence of the social environment in which we live?
2. Reflecting on your work as a clinician do you think you have enacted microaggressions? How have you repaired?

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